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May 2017
Medical Drug Prior Authorization Program to add Ocrevus™
Beginning June 1, 2017, Ocrevus (ocrelizumab) will be added to the required Medical Drug Prior Authorization Program list. Keep in mind that the prior authorization requirement doesn’t apply to Federal Employee Program® members.
Drug name |
HCPCS code |
Ocrevus™ |
J3490/J3590 |
The following list shows all medications currently in 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® |
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Blue Cross reserves the right to change this list at any time.
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