May 2016

Ford Motor Company hourly employees to participate in Medical Drug Prior Authorization Program

Beginning July 1, 2016, Ford Motor Company hourly employees will participate in the Medical Drug Prior Authorization Program. Keep in mind that the prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below reflects all medications that are part of the Medical Drug Prior Authorization Program in alphabetical order:

Actemra^®	Depo-Testosterone^®	Immune globulin	Prolia^®
Acthar^® gel	Dysport^®	Kalbitor^®	Ruconest^®
Adagen^®	Elaprase^®	Kanuma™	Signifor^® LAR
Aldurazyme^®	Elelyso™	Krystexxa^®	Simponi^® Aria™
Aralast NP™	Entyvio™	Lemtrada™	Soliris^®
Aveed^®	Fabrazyme^®	Lumizyme^®	Stelara^®
Benlysta^®	Firazyr^®	Makena™	Synagis^®
Berinert^®	Flebogamma^® DIF	Myobloc^®	Testopel^®
Bivigam™	Gammagard^® Liquid or S/D	Myozyme^®	Tysabri^®
Botox^®	Gammaked^®	Naglazyme^®	Vimizim™
Carimune^® NF	Gammaplex^®	Nplate^®	Vpriv^®
Cerezyme^®	Gamunex^® (IV and SubQ)	Nucala^®	Xeomin^®
Cimzia^®	Glassia™	Octagam^®	Xgeva^®
Cinryze^®	Hizentra^®	Orencia^®	Xiaflex^®
Cosentyx™	HyQvia^®	Privigen^®	Xolair^®
Delatestryl^®	Ilaris^®	Prolastin^®-C	Zemaira^®

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.