Preferred Drug List Prior Authorization and Step Therapy ...

Blue Cross Blue Shield of Michigan Blue Care Network Preferred drug List Prior Authorization and step Therapy Coverage Criteria January 2022 Page 1 Revised: 01-01-2022 *For drugs covered under the commercial Blue Cross or BCN medical benefit, please see the Blue Cross and BCN Utilization Management Medical drug List Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

1. Diagnosis of giant cell arteritis 2. Age ≥ 18 years old OR 1. Diagnosis of systemic sclerosis-associated interstitial lung disease (SSc-ILD) 2. Inadequate response to (as evidenced by disease progression - (e.g. worsening of pulmonary function) or not a candidate for either mycophenolate mofetil OR cyclophosphamide Initial approval: 1 year

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