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July 2017
2 new drugs added to the Medical Drug Prior Authorization Program
Beginning Sept.1, 2017, Brineura™ (cerliponase alfa) and Radicava™ (edaravone) will be added to the commercial 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 |
Brineura™ (cerliponase alfa) |
J3490/J3590 |
Radicava™ (edaravone) |
J3490/J3590 |
The following list shows all medications currently in the Medical Drug Prior Authorization Program:
Drug names |
Actemra® |
Elelyso™ |
Krystexxa® |
Simponi Aria® |
Acthar® gel |
Entyvio™ |
Lemtrada™ |
Soliris® |
Adagen® |
Exondys 51™ |
Lumizyme® |
Spinraza™ |
Aldurazyme® |
Fabrazyme® |
Makena® |
Stelara® |
Aralast NP™ |
Firazyr® |
Myobloc® |
Stelara IV® |
Aveed® |
Flebogamma® DIF |
Myozyme® |
Synagis® |
Benlysta® |
Gammagard Liquid® |
Naglazyme® |
Testopel® |
Berinert® |
Gammagard® S/D |
Nplate® |
Tysabri® |
Bivigam™ |
Gammaked® |
Nucala® |
Vimizim™ |
Botox® |
Gammaplex® |
Ocrevus™ |
Vpriv® |
Carimune® NF |
Gamunex® |
Octagam® |
Xeomin® |
Cerezyme® |
Glassia™ |
Orencia® |
Xgeva® |
Cimzia® |
Hizentra® |
Privigen® |
Xiaflex® |
Cinqair® |
HyQvia® |
Probuphine® |
Xolair® |
Cinryze® |
Ilaris® |
Prolastin®-C |
Zemaira® |
Cosentyx™ |
Immune globulin |
Prolia® |
Zinplava™ |
Cuvitru® |
Inflectra™ |
Remicade® |
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Dysport® |
Kalbitor® |
Ruconest® |
|
Elaprase® |
Kanuma™ |
Signifor® LAR |
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Blue Cross reserves the right to change this list at any time. | 
