Prior authorization required

Does Bluecross Blueshield Of Tennessee, INC. require prior authorization for Koselugo?

Bluecross Blueshield Of Tennessee, INC. requires prior authorization for Koselugo on every Medicare Part D plan of theirs that covers it.

Every plan from this payer that covers the drug requires authorization before it is dispensed.

By product strength

RxNorm product	Plans covering	Require prior auth	Qty limit	Status
selumetinib 10 MG Oral Capsule [Koselugo]2289424	17 / 17	17	17	Prior authorization required
selumetinib 25 MG Oral Capsule [Koselugo]2289428	17 / 17	17	17	Prior authorization required
selumetinib 5 MG Oral Granules [Koselugo]2723657	17 / 17	17	0	Prior authorization required
selumetinib 7.5 MG Oral Granules [Koselugo]2723661	17 / 17	17	0	Prior authorization required

Product names come from RxNorm (U.S. National Library of Medicine).

Plan-by-plan detail — selumetinib 10 MG Oral Capsule [Koselugo]

Koselugo has 4 products in the corpus; this table is for selumetinib 10 MG Oral Capsule [Koselugo], the one carried on the most plans. The product table above covers every strength.

Plan	Contract	Tier	Prior auth	Step therapy	Qty limit
BlueAdvantage Diamond (PPO)	H7917-009	5	Yes	No	Yes
BlueAdvantage Diamond (PPO)	H7917-010	5	Yes	No	Yes
BlueAdvantage Diamond (PPO)	H7917-011	5	Yes	No	Yes
BlueAdvantage Extra (PPO)	H7917-041	5	Yes	No	Yes
BlueAdvantage Garnet (PPO)	H7917-032	5	Yes	No	Yes
BlueAdvantage Garnet (PPO)	H7917-033	5	Yes	No	Yes
BlueAdvantage Ruby (PPO)	H7917-012	5	Yes	No	Yes
BlueAdvantage Ruby (PPO)	H7917-013	5	Yes	No	Yes
BlueAdvantage Ruby (PPO)	H7917-014	5	Yes	No	Yes
BlueAdvantage Ruby (PPO)	H7917-015	5	Yes	No	Yes
BlueAdvantage Sapphire (PPO)	H7917-030	5	Yes	No	Yes
BlueAdvantage Sapphire (PPO)	H7917-031	5	Yes	No	Yes
BlueAdvantage Sapphire (PPO)	H7917-038	5	Yes	No	Yes
BlueAdvantage Sapphire (PPO)	H7917-040	5	Yes	No	Yes
BlueAdvantage Total Heart and Diabetes (PPO C-SNP)	H7917-044	5	Yes	No	Yes
BlueAdvantage Total Heart and Diabetes (PPO C-SNP)	H7917-045	5	Yes	No	Yes
BlueAdvantage Total Heart and Diabetes Plus (PPO C-SNP)	H7917-046	5	Yes	No	Yes

Source

Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File

Effective: 2026-06-30
Retrieved: 2026-07-19
SHA-256: e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae

We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.

Koselugo at other payers

Or see Koselugo across every payer at once.

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.