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April 2017

Two medications to be removed from the Medical Drug Prior Authorization Program

Beginning July 1, 2017, Delatestryl® (testosterone enanthate) and DepoDelatestryl®-Testosterone (testosterone cypionate) will be removed from the required Medical Drug Prior Authorization Program List.

Brand name

HCPCS code

DelatestrylDelatestryl® (testosterone enanthate)

J3121

DepoDelatestryl®-testosterone (testosterone cypionate)

J1071

Below are all the medications that are part of the Medical Drug Prior Authorization Program.

Drug name

Drug name

Drug name

Drug name

Actemra®

Elaprase®              

Kalbitor®

Ruconest®

Acthar® gel

Elelyso™

Kanuma™

Signifor® LAR

Adagen®               

Entyvio™

Krystexxa®

Simponi Aria®

Aldurazyme®       

Exondys 51™

Lemtrada™

Soliris®

Aralast NP™

Fabrazyme®

Lumizyme®

Spinraza™

Aveed®

Firazyr®

Makena®

Stelara®

Benlysta®

Flebogamma® DIF

Myobloc®

Stelara IV®

Berinert®

Gammagard Liquid®

Myozyme®           

Synagis®

Bivigam™

Gammagard® S/D

Naglazyme®        

Testopel®

Botox®

Gammaked®

Nplate®

Tysabri®

Carimune® NF

Gammaplex®

Nucala®

Vimizim™

Cerezyme®

Gamunex®

Octagam®

Vpriv®

Cimzia®

Glassia™

Orencia®

Xeomin®

Cinqair®

Hizentra®

Privigen®

Xgeva®

Cinryze®

HyQvia®

Probuphine®

Xiaflex®

Cosentyx™

Ilaris®

Prolastin®-C

Xolair®

Cuvitru®

Immune globulin

Prolia®

Zemaira®

Dysport®

Inflectra™

Remicade®

Note: The prior authorization requirement doesn’t apply to Federal Employee Program® members.

Blue Cross Blue Shield of Michigan reserves the right to change the prior authorization list at any time.

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 2016 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.