Blue Cross and BCN utilization management medical drug …

1 Blue Cross and bcn utilization management medical drug list For Blue Cross commercial and BCN commercial Revised January 2022. A B C D E F G H I J K L MN O P Q R S T U V W X Y Z. This document outlines the utilization management programs that apply to select medical benefit drugs. These are drugs that require administration by a health care professional. The information on this list applies to: All members who have medical coverage under BCN commercial plans Members whose Blue Cross commercial plans participate in the standard commercial medical drug Prior Authorization Program or are subject to other utilization management requirements related to medical benefit drugs. For information about self-administered drugs that are covered under the pharmacy benefit for Blue Cross and BCN commercial members, see the Pharmacy Services page on our website.

2 medical drug Prior Authorization (PA) Programs These programs help ensure that patients receive medication that is medically necessary and appropriate for their situations. For most medical Submit prior authorization requests through the NovoLogix online tool. This includes requests for chimeric antigen benefit drugs receptor T cells (CAR-T) therapy. For select medical Submit requests to AIM Specialty Health by calling 1-844-377-1278 (BCN) or 1-800-728-8008 (Blue Cross ) or by logging oncology and in to the AIM ProviderPortal. See the medical oncology prior authorization list for Blue Cross commercial fully insured and supportive care drugs BCN commercial members for a comprehensive list of drugs managed by AIM. (other than CAR-T. therapy). Site of care (SOC) Some drugs also have site-of-care requirements.

3 Prior authorization requests for these drugs must indicate that they will program be administered in a lower-cost site of care (such as the physician's office or the member's home), rather than a higher- cost site of care (such as a hospital outpatient facility). Employer-specific The following employer groups have different requirements: medical drug Prior Authorization UAW Retiree medical Benefits Trust PPO Blue Cross and Blue Shield Federal Employee Programs medical drug management program list Program utilization management medical drug list medical oncology prior authorization list 1. Blue Cross and bcn utilization management medical drug list For Blue Cross commercial and BCN commercial Revised January 2022. A B C D E F G H I J K L MN O P Q R S T U V W X Y Z.

4 How to read this list Submit PA requests through columns: See the key below to learn how to determine whether a drug has PA or SOC requirements. Refer to the medical policy router for complete medical drug policies and criteria. When a cell is blank, the drug doesn't have PA or SOC requirements. Key PA requirements apply PA and SOC requirements apply BCN commercial members HMO HMO-SOC. Blue Cross commercial PPO PPO-SOC. members Quantity limits columns: A checkmark ( ) indicates that a drug has quantity limits. See the Blue Cross and BCN Quantity Limits for medical Drugs ( ) document for the specific quantity limit. When a cell is blank, the drug doesn't have quantity limits. Preferred product information column: Lists any preferred products that a member must try and fail before receiving a drug .

5 When a cell is blank, there is no preferred product information for that drug . Note: medical benefit drug policies are a source for Blue Cross and BCN medical policy information. medical policies are not to be used to determine benefits or reimbursement. Refer to the appropriate certificate or contract for benefit information. medical policies are subject to change. Quantity limits See Blue Cross and BCN. Quantity Limits for medical Submit PA requests Drugs ( ) document Procedure through for additional details code Brand name Generic name NovoLogix AIM PPO HMO Preferred product information A. Q2055 Abecma idecabtagene vicleucel PPO.. HMO. J9264 Abraxane paclitaxel PPO. HMO. J3262 Actemra, tocilizumab PPO-SOC. Actemra Actpen . HMO-SOC. 2. Blue Cross and bcn utilization management medical drug list For Blue Cross commercial and BCN commercial Revised January 2022.

6 A B C D E F G H I J K L MN O P Q R S T U V W X Y Z. Quantity limits See Blue Cross and BCN. Quantity Limits for medical Submit PA requests Drugs ( ) document through for additional details Procedure code Brand name Generic name NovoLogix AIM PPO HMO Preferred product information J0800 Acthar Gel corticotropin PPO. HMO. J2997 Activase, Cathflo alteplase recombinant . J2504 Adagen pegademase bovine PPO-SOC.. HMO-SOC. J0791/ Adakveo crizanlizumab-tmca PPO-SOC. C9053 . HMO-SOC. J9042 Adcetris brentuximab vedotin PPO.. HMO. J0172 Aduhelm aducanumab-avwa PPO Coverage of Aduhelm is considered HMO investigational/experimental for all indications J1931 Aldurazyme laronidase PPO-SOC.. HMO-SOC. J9305 Alimta pemetrexed PPO. HMO. J9057 Aliqopa copanlisib PPO.. HMO. J9245 Alkeran melphalan.

7 Hydrochloride J1426 Amondys 45 casimersen PPO Coverage of Amondys 45 is considered HMO investigational/experimental for all indications 3. Blue Cross and bcn utilization management medical drug list For Blue Cross commercial and BCN commercial Revised January 2022. A B C D E F G H I J K L MN O P Q R S T U V W X Y Z. Quantity limits See Blue Cross and BCN. Quantity Limits for medical Submit PA requests Drugs ( ) document through for additional details Procedure code Brand name Generic name NovoLogix AIM PPO HMO Preferred product information J0256 Aralast alpha 1 proteinase PPO-SOC.. inhibitor HMO-SOC. J2793 Arcalyst rilonacept . J1944 Aristada aripiprazole lauroxil . J1943 Aristada Initio aripiprazole lauroxil . J9302 Arzerra of atumumab PPO.. HMO. J1554/ Asceniv immune globulin PPO-SOC.

8 C9072 (human)-slra . HMO-SOC. J9118 Asparlas calasparagase pegol- PPO. mknl . HMO. J2270 Astramorph-PF morphine sulfate/pf . J7504 Atgam lymphocyte immune . globulin J9035/ Avastin bevacizumab PPO Non-pref erred bevacizumab product C9257 HMO Pref erred bevacizumab product(s): Mvasi and Zirabev Note: Intravitreal Avastin does not require authorization for ocular conditions J3145 Aveed testosterone PPO. undecanoate . HMO. J2280 Avelox IV Inj moxifloxacin 100 mg . Q5121 Avsola inf liximab-axxq PPO-SOC Non-pref erred infliximab product . HMO-SOC Pref erred infliximab product: Inf lectra 4. Blue Cross and bcn utilization management medical drug list For Blue Cross commercial and BCN commercial Revised January 2022. A B C D E F G H I J K L MN O P Q R S T U V W X Y Z.

9 Quantity limits See Blue Cross and BCN. Quantity Limits for medical Submit PA requests Drugs ( ) document through for additional details Procedure code Brand name Generic name NovoLogix AIM PPO HMO Preferred product information J0714 Avycaz cef tazidime and . avibactam B. Q0239 bamlanivimab bamlanivimab . J9023 Bavencio avelumab PPO. HMO. J3490/ Baxdela delaf loxacin . C9462. J9032 Beleodaq belinostat . J9036 Belrapzo bendamustine hcl PPO. HMO. J9034 Bendeka bendamustine PPO. hydrochloride HMO. J0490 Benlysta belimumab PPO-SOC.. HMO-SOC. J0179 Beovu brolucizumab PPO.. HMO. J0597 Berinert c-1 esterase PPO-SOC.. HMO-SOC. J9229 Besponsa inotuzumab ozogamicin PPO.. HMO. J9050 Bicnu carmustine . 5. Blue Cross and bcn utilization management medical drug list For Blue Cross commercial and BCN commercial Revised January 2022.

10 A B C D E F G H I J K L MN O P Q R S T U V W X Y Z. Quantity limits See Blue Cross and BCN. Quantity Limits for medical Submit PA requests Drugs ( ) document through for additional details Procedure code Brand name Generic name NovoLogix AIM PPO HMO Preferred product information J1556 Bivigam immune globulin PPO-SOC.. HMO-SOC. J9040 Bleomycin bleomycin sulfate . Sulf ate J9037 Blenrep belantamab mafodotin- PPO. blmf . HMO. J9039 Blincyto blinatumomab PPO. HMO. J2710 Bloxiverz neostigmine . methylsulfate J1740 Boniva ibandronate . J0585 Botox onabotulinumtoxina PPO.. HMO. Q2054 Breyanzi lisocabtagene PPO. maraleucel . HMO. J0567 Brineura cerliponase alfa PPO.. HMO. C. J1566 Carimune NF immune globulin PPO-SOC.. HMO-SOC. J9050 Carmustine carmustine . 6. Blue Cross and bcn utilization management medical drug list For Blue Cross commercial and BCN commercial Revised January 2022.