The following policies have been permanently moved from the Medical Policy pages to the Prior Review and Limitations page. To locate a policy, search by drug name in the "Drugs that Need Prior Authorization" section.
- Abatacept (Orencia®)
- Aducanumab-avwa (Aduhelm™)
- Alemtuzumab (Lemtrada®)
- Allogeneic Processed Thymus Tissue-agdc (Rethymic®)
- Alpha 1-Antitrypsin Inhibitor Therapy (example: Aralast NP™)
- Anifrolumab-fnia (Saphnelo™)
- Antiemetic Injection Therapy (example: Aloxi®)
- Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy (example: Amondys 45®)
- Belimumab (Benlysta®)
- Bezlotoxumab (Zinplava™)
- Bimatoprost Intracameral Implant (Durysta™)
- Botulinum Toxin Injection (example: Dysport®)
- Brexanolone (Zulresso™)
- Buprenorphine Extended-Release (Sublocade®)
- Burosumab-twza (Crysvita®)
- Canakinumab (Ilaris®)
- CAR-T Therapy (example: Yescarta®)
- Certolizumab pegol (Cimzia®)
- Crizanlizumab (Adakveo®)
- Denosumab (Prolia®, Xgeva®)
- Eculizumab (Soliris®)
- Edaravone (Radicava®)
- Efgartigimod Alfa-fcab (Vyvgart™)
- Emapalumab-lzsg (Gamifant™)
- Enzyme Replacement Therapy (ERT) for Lysosomal Storage Disorders (example: Cerezyme®)
- Eptinezumab-jjmr (Vyepti™)
- Erythropoietin Stimulating Agents (example: Epogen®)
- Esketamine (Spravato®) Nasal Spray
- Evinacumab-dgnb (Evkeeza™)
- Fosdenopterin (Nulibry™)
- Givosiran (Givlaari®)
- Golimumab (Simponi Aria®)
- Guselkumab (Tremfya®)
- Ibalizumab-uiyk (Trogarzo®)
- Immunoglobulin Therapy (example: Asceniv™)
- Inclisiran (Leqvio®)
- Inebilizumab-cdon (Uplizna™)
- Infliximab (Remicade®) and Infliximab Biosimilars
- Injectable and Healthcare Administered Oncology Drugs (example: Abraxane®)
- Injectable Clostridial Collagenase for Fibroproliferative Disorders (example: Xiaflex®)
- Interleukin-5 Antagonists (example: Fasenra®)
- Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee (example: Durolane®)
- Intravenous Iron Replacement Therapy (example: Injectafer®)
- Letermovir (Prevymis™)
- Lumasiran (Oxlumo™)
- Luspatercept-aamt (Reblozyl®)
- Natalizumab (Tysabri®)
- New to Market Specialty Drug PPA Requirements
- Nusinersen (Spinraza®)
- Ocrelizumab (Ocrevus®)
- Ocular Angiogenesis Inhibitor Agents (example: Beovu®)
- Omalizumab (Xolair®)
- Onasemnogene abeparvovec (Zolgensma®)
- Patisiran (Onpattro®)
- Pegcetacoplan (Empaveli™)
- Pegloticase (Krystexxa®)
- Place of Service for Medical Infusions
- Plasminogen, human-tvmh (Ryplazim®)
- Pulmonary Hypertension, Drug Management (example: (Flolan®)
- Ravulizumab-cwvz (Ultomiris®)
- Repository Corticotropin (Acthar® Gel)
- Respiratory Syncytial Virus Prophylaxis (example: Synagis®)
- Rituximab for the Treatment of Rheumatoid Arthritis (example: Truxima®)
- Romiplostim (NPlate®)
- Romosozumab-aqqg (Evenity™)
- Somatostatin Analogs (example: Somatuline® Depot)
- Sutimlimab (Enjaymo™)
- Teprotumumab-trbw (Tepezza™)
- Testosterone Pellet Implantation for Androgen Deficiency (example: Testopel®)
- Tezepelumab-ekko (Tezspire™)
- Tildrakizumab-asmn (Ilumya®)
- Tocilizumab (Actemra®)
- Treatment of Hereditary Angioedema (example: Berinert®)
- Trilaciclib (Cosela™)
- Ustekinumab (Stelara®)
- Vedolizumab (Entyvio®)
- Voretigene neparvovec (Luxturna®)
- White Blood Cell Growth Factors (example: Fulphila®)
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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