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Medications

The following medications or classes of medications require prior authorization. Medications may appear more than once.  Please verify you are selecting the medication in the correct category to ensure you download the correct form.  Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in this list may occur. Physicians and pharmacy providers will be notified of any such changes via newsletters and direct mailings.

Medications requiring Prior Authorization

Medications Requiring Step Therapy

 

  • Anti-Depressants  - Patient must try and fail at least one generic antidepressant before a brand name SSRI, NDRI or SNRI will be covered.     

 

 

   

 

  • Cholesterol Lowering Medications  - Patient must try and fail at least one generic HMG Co-A reductase inhibitor (statin) before a brand name HMG Co-A reductase inhibitor will be covered.

 

  • Nasal Steroid - Patient must try and fail a generic nasal steroid before coverage of a brand name nasal steroid will be considered.

 

  • Proton Pump Inhibitor - Brand name PPI’s subject to step therapy requirements. Patients must try and fail a generic lansoprazole or omeprazole before coverage of a brand name PPI will be considered. 

 

  • Sedative Hypnotic - Patient must try and fail a generic sedative hypnotic before coverage of a brand name sedative hypnotic will be considered.

Medications that must be obtained from Specialty Pharmacy (30 Day Supply Limit) 

  • Achtar  - Medical Benefit
  • Actemera(for Rheumatoid Arthritis) – Medical Benefit
  • Amevive  - Medical Benefit          
  • Avonex - Pharmacy Benefit, does not require Prior Authorization          
  • Betaseron - Pharmacy Benefit, does not require Prior Authorization   
  • Cimzia (for Rheumatoid Arthritis) – Pharmacy Benefit
  • Cimzia (for Crohn’s Disease) – Pharmacy Benefit
  • Copaxone - Pharmacy Benefit, does not require Prior Authorization          
  • Enbrel  (For Psoriasis) - Pharmacy Benefit          
  • Enbrel  (For Rheumatoid Arthritis) - Pharmacy Benefit
  • Humira  (For Crohn's Disease) - Pharmacy Benefit          
  • Humira  (For Psoriasis) - Pharmacy Benefit
  • Humira  (For Rheumatoid Arthritis) - Pharmacy Benefit
  • Lucentis - Medical Benefit, does not require Prior Authorization          
  • Lupron/Leuprolide - Medical or Pharmacy Benefit, does not require Prior Authorization          
  • Orencia  - Medical Benefit          
  • Peg-Intron - Pharmacy Benefit, does not require Prior Authorization          
  • Pegasys - Pharmacy Benefit, does not require Prior Authorization                   
  • Rebif - Pharmacy Benefit, does not require Prior Authorization          
  • Rituxan  (when the diagnosis is Rheumatoid Arthritis) - Medical Benefit 
  • Sabril - Pharmacy Benefit
  • Simponi  (for Rheumatoid Arthritis) – Pharmacy Benefit
  • Stelara (for Psoriasis) – Medical Benefit
  • Tysabri  (For Crohn's Disease) - Medical Benefit      
  • Tysabri  (For Multiple Sclerosis) - Medical Benefit

Medications for Dose Optimization and/or Quantity Limits

  • Antimetics  (Anzemet, Emend, Kytril, Zofran) - Patient is limited to 10 tablets unless otherwise authorized.  
  • Asthma Rescue Inhalers  - Patient is limited to two inhalers per 21 days.  
  • Cholesterol Lowering Medications  - Patient is limited to one capsule or tablet per day.                        
  • Estrogen Patches  - Patient is limited to FDA/manufacturer recommended maximum daily dose.    
  • Influenza Therapies  - Patient is limited to one course of treatment per flu season.        
  • Nasal Steroids  - Patient is limited to FDA/manufacturer recommended maximum daily dose.    
  • NSAIDs and Narcotics  - Patient is limited to FDA/manufacturer recommended maximum daily dose.    
  • Stadol Nasal Spray  - Patient is limited to a quantity of eight bottles per 60 days.             
  • Triptan Medications for Migraines  - Quantity limits per fill are based on the manufacturer's recommendation for the number needed to treat three to four headaches per month.  Additional refills may be allowed. 

To submit a prior authorization request for one of these medications, click on the medication name to download the appropriate request form.  For the most timely response, fax the request to 816-502-4915. Requests may also be mailed to:

Blue Cross and Blue Shield of Kansas City
Attention: Pharmacy Services
P.O. Box 419169
Kansas City, MO 64141-2735

Please include any supporting medical information in your fax. Please allow at least two business days from the date of receipt of all necessary information for a determination. To check the status of a prior authorization, call the Customer Service number listed on the member ID card.