2018 BCN Advantage Prior Authorization Criteria - bcbsm.com BCN Advantage Prior Authorization Criteria Last updated: April, 2018 BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare

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  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

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    Abstral Actemra Adcirca Adempas Aliqopa Afinitor Afinitor- Disperz Alecensa Alunbrig Amitiza Amitriptyline Ampyra Anadrol-50 Androgel Androderm Aralast NP Aranesp Arcalyst Armodafinil Aubagio Avonex Bavencio Beleodaq Berinert Betaseron Bexarotene Bosulif Briviact Bydureon Byetta Cabometyx Calquence Cayston Cholbam Chorionic Gonadotropin

    Cimzia Cinryze Clomipramine Cometriq Copaxone Cotellic Crinone Cyramza Daliresp Darzalex Doxepin Duopa Dysport Empliciti Epclusa Epogen Erivedge Erleada Esbriet Estradiol Extavia Farydak Fentanyl Oral Fentora Firazyr Forteo Gattex Genotropin Gilenya Gilotrif Glassia Harvoni Hetlioz Humatrope Ibrance Iclusig Idhifa

    Ilaris Imbruvica Imfinzi Imipramine Increlex Inflectra Inlyta Jakafi Juxtapid Kalydeco Kanuma Kineret Kisqali Kisqali Femara Korlym Kuvan Kynamro Kyprolis Lartruvo Lazanda Lenvima Letairis Lidocaine Transdermal Linzess Lonsurf Lynparza Mavyret Mekinist Menest Modafinil Movantik Mozobil Myalept Mylotarg Natpara Nexavar

    Nerlynx Ninlaro Norditropin Novarel Nuplazid Nutropin Nutropin Aq Odomzo Ofev Omnitrope Opsumit Orencia, Orencia Clickject Orenitram Orkambi Otezla Oxandrolone Oxymetholone Pegasys Plegridy Pomalyst Praluent Procrit Procysbi Prolastin C Prolia Promacta Radicava Ravicti Rebif Relistor Remicade Remodulin Repatha Revatio

    Revlimid Rubraca Rydapt Saizen Samsca Serostim Sildenafil Simponi Sirturo Somavert Sovaldi Sprycel Stelara Strensiq Subsys Sutent Sylatron Sylvant SymlinPen Tabloid Tafinlar Tagrisso Tarceva Targretin Tasigna Tecentriq Tecfidera Testim Testosterone Tetrabenazine Thalomid Thioridazine Tracleer Treanda Trimipramine Tysabri

    Uptravi Vecamyl Vectibix Vemlidy Venclexta Verzenio Victoza Vosevi Votrient Xalkori Xeljanz Xgeva Xolair Xtandi Xyrem Yondelis Yervoy Zaleplon Zelboraf Zemaira Zejula Zolinza Zorbtive Zurampic Zydelig Zykadia Zytiga

    H5883_Ph_Apr18PAlist_NM 04262018

  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

    2 of 89

    Actemra Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions Prescribing physician is a rheumatologist

    Coverage duration One Year Other criteria Requires trial of etanercept (Enbrel) and adalimumab (Humira) when these

    medications are FDA labeled for the Part D coverable medically accepted indication.

    Back to Prior Authorization Drug List Adempas Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions None Coverage duration One Year Other criteria None

    Back to Prior Authorization Drug List

  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

    3 of 89

    Afinitor Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions Prescriber is an oncologist Coverage duration One Year Other criteria Coverage is not provided when Affinitor is used in combination with Nexavar

    or Sutent

    Back to Prior Authorization Drug List Aliqopa Effective Date: March 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions None Coverage duration One year Other criteria None

    Back to Prior Authorization Drug List

  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

    4 of 89

    Alecensa Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions None Coverage duration Lifetime Other criteria None

    Back to Prior Authorization Drug List

    Alunbrig Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions None Coverage duration One Year Other criteria None

    Back to Prior Authorization Drug List

  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

    5 of 89

    Amitzia Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info Diagnosis:

    1. Chronic idiopathic constipation (CIC) in adults or 2. Opioid-induced constipation in adults with chronic, non-cancer pain or 3. Irritable bowel syndrome (IBS) with constipation in women

    Age restrictions 18 years of age and older Prescriber restrictions None Coverage duration One Year

    Other criteria Documentation of trial/failure within the last 12 months of: 1. A fiber laxative and 2. One of the following: a stimulant laxative or an osmotic laxative

    Back to Prior Authorization Drug List

    Ampyra Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria Patients with a history of seizure or moderate to severe renal impairment

    defined by a crcl of 50ml/min or less Required med info Initial requests require documentation of a 25 foot timed walk test. Renewal

    requests require documentation of improvement in walking distance of a 25 foot timed walk test compared to pretreatment.

    Age restrictions None Prescriber restrictions Prescriber is a neurologist Coverage duration INITIAL = Three Months

    RENEWAL = One Year

  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

    6 of 89

    Other criteria Initial coverage is provided to improve walking distance in patients with a diagnosis of multiple sclerosis who have the ability to walk a timed 25 foot walk test. renewal criteria: documentation that the member has shown an improvement in walking distance of a 25 foot timed walk test compared to pretreatment.

    Back to Prior Authorization Drug List Transdermal Androgens Androgel, Androderm, Testim, Testipel, Testosterone Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info Documentation of androgen deficiency syndrome confirmed by two morning

    testosterone levels less than 300 ng/dL and at least 2 clinical signs or symptoms specific to androgen deficiency

    Age restrictions None Prescriber restrictions None Coverage duration One Year Other criteria None

    Back to Prior Authorization Drug List

  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

    7 of 89

    ALPHA-1-PROTEINASE INHIBITOR (Aralast NP, Glassia, Prolastin C, Zemaira) Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions None Coverage duration One Year Other criteria None

    Back to Prior Authorization Drug List Arcalyst Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions 12 years of age and older Prescriber restrictions None Coverage duration One Year Other criteria None

    Back to Prior Authorization Drug List

  • 2018 BCN Advantage Prior Authorization Criteria Last updated: May, 2018

    BCN AdvantageSM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

    8 of 89

    Aubagio Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions None Coverage duration One Year Other criteria None

    Back to Prior Authorization Drug List

    Avonex Effective Date: January 1, 2018

    Covered uses All medically accepted indications not otherwise excluded from Part D. Exclusion criteria None Required med info None Age restrictions None Prescriber restrictions None Coverage duration Lifetime Other criteria Non