Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 The Blue Cross and BCN Requirements for Drugs Covered under the Medical Benefit document outlines the various programs select drugs participate in under your medical coverage. The medical benefit contains drugs that require administration by a healthcare professional. Drugs on this list need to be approved by BCBSM/BCN before you receive them. Various programs include but are not limited to the Prior Authorization Program and the Site of Care program. This list applies to all BCN commercial members with medical coverage, and Blue Cross commercial members that are subject to the PA program. • Prior Authorization Program: This program ensures the medication is medically necessary and appropriate for your situation. For drugs covered under the commercial Blue Cross or BCN pharmacy benefit please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines. • Site of Care Program: This program redirects members’ receiving select injectable or infusible drugs in the outpatient hospital setting to a lower cost, alternate site of care, such as the physician’s office or member’s home. • Oncology Management Program: Medical oncology and supportive care drugs require authorization. Requests can be submitted by calling 1-844-377-1278 or logging into AIM Provider Portal . Blue Cross commercial fully insured and BCN commercial Medical Oncology Prior Authorization list Note: This program does not apply to Blue Cross commercial fully insured members covered through the Federal Employee Program® and the Michigan Education Special Services Association . UAW Retiree Medical Benefits Trust PPO Medical Oncology Prior Authorization list How to read the Blue Cross and BCN Requirements for Drugs Covered under the Medical Benefit: Authorization Summary: criteria listed is not all-inclusive. Please refer to the medical router for the complete medical drug policy and all criteria that may apply. Cell’s that are blank are not applicable. Documentation Required: providers must submit chart notes when submitting an authorization request. If field only says HMO or PPO chart notes are only required for members with that plan. Medical benefit drug policies are a source for BCBSM and BCN medical policy information only. These documents are not to be used to determine benefits or reimbursement. Please reference the appropriate certificate or contract for benefit information. This policy may be updated and therefore subject to change. *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 1 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization Documentation PPO HMO . FDA approved age Affected providers: In network . Prescribed by an oncologist . Have not received prior treatment with any CAR-T therapy (such as Kymriah or Yescarta) despite HCPCS Limit: N/A indication or any other genetically-modified T-cell therapy or are being considered for treatment with any other genetically-modified T-cell therapy NDC NDC Limit . Treatment of patients with relapsed or refractory multiple myeloma 59572-0515-01 1 UN . Must have relapsed or refractory disease after at least 3 prior lines of multiple myeloma therapy 59572-0515-02 1 UN . Patients must have been treated with all of the following: 59572-0515-03 1 UN • An immunomodulatory agent • A proteasome inhibitor • An anti-CD38 antibody . Must have active disease defines by at least one of the following: • Serum M-protein greater or equal to 1.0 g/dL idecabtagene HMO HMO J3590 Abecma • Urine M-protein greater or equal to 200 mg/24 h vicleucel PPO PPO • Serum free light chain (FLC) assay greater or equal to 10 mg/dL provided the serum FLC ratio is abnormal . Patients must not have the following: • ECOG performance status of 2 or greater • Known central nervous system involvement with myeloma • No active infection including hepatitis B, hepatitis C, HIV, or systemic fungal, bacterial, or viral infection • History of class III or IV congestive heart failure (CHF) or severe non-ischemic cardiomyopathy, history of stroke, unstable angina, myocardial infarction, or ventricular arrhythmia within the previous 6 months • Second malignancies in addition to myeloma if the second malignancy has required therapy in the last 3 years or is not in complete remission • Oncology Management Program HMO HMO J9264 Abraxane paclitaxel PPO PPO *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 2 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization Documentation PPO HMO • FDA approved indications Affected providers: In network Rheumatoid arthritis (RA) • FDA approved age • 8 mg/kg every 4 weeks • Diagnosis of rheumatoid arthritis (RA): HCPCS Limit: 800 units Polyarticular juvenile idiopathic arthritis (pJIA) o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include methotrexate, hydroxychloroquine, leflunomide, NDC NDC Limit • <30 kg: 10 mg/kg every 4 sulfasalazine 50242-0135-01 40 ML weeks • Diagnosis of polyarticular juvenile idiopathic arthritis (pJIA) 50242-0136-01 40 ML • > 30 kg: 8 mg/kg every 4 o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless 50242-0137-01 40 ML weeks contraindicated or not tolerated. Examples include methotrexate and leflunomide 50242-0138-01 0.9 ML Systemic juvenile idiopathic • Diagnosis of Still’s disease, including systemic juvenile idiopathic arthritis (sJIA) and adult onset Still’s 50242-0143-01 0.9 ML arthritis (sJIA) • disease (AOSD) 50242-0138-86 0.9 ML < 30 kg: 12 mg/kg every 2 Actemra, HMO HMO J3262 tocilizumab Trial and treatment failure with one of the following: methotrexate, leflunomide, glucocorticoids, or weeks Actemra Actpen o PPO PPO NSAIDs • > 30 kg: 8 mg/kg every 2 • Diagnosis of cytokine release syndrome (CRS) (intravenous formulation only) weeks o Prescribed by or in consultation with an oncologist o Severe or life threatening CRS associated with chimeric antigen receptor (CAR) T cell therapy • Diagnosis of giant cell arteritis (GCA) (subcutaneous formulation only) • Diagnosis of systemic sclerosis-associated interstitial lung disease (SSc-ILD) (subcutaneous formulation only) o Inadequate response to (as evidenced by disease progression - e.g. worsening of pulmonary function) or not a candidate for either mycophenolate mofetil OR cyclophosphamide • Not to be used in combination with other biologics or other targeted DMARDs • Diagnosis of infantile spasms HMO J0800 Acthar Gel corticotropin • Patient is less than 2 years of age PPO • Any additional pertinent medical information Affected providers: In network HCPCS Limit: 100 units NDC NDC Limit J2997 Activase, Cathflo alteplase recombinant 50242-0041-63 50 UN 50242-0041-64 50 UN 50242-0044-13 2 UN 50242-0085-25 1 UN 50242-0085-27 1 UN 50242-0041-10 50 UN *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 3 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization Documentation PPO HMO • Diagnosis of adenosine deaminase (ADA) deficiency in a patient with severe combined immunodeficiency Affected providers: In network Severe Combined disease (SCID) Immunodeficiency Disease • Diagnosis confirmed by evidence