PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification ABSTRAL fentanyl citrate oral tablet Analgesics - Opioid ACCU-CHEK TEST STRIP blood glucose test strips Blood Glucose Test Strips ACTEMRA tocilizumab Monoclonal Antibody ACTHAR corticotropin Hormone ACTIMMUNE interferon gamma 1b Interferon ACTIQ fentanyl citrate OTFC Analgesics - Opioid ADAKVEO crizanlizumab-tmca Agents for Sickle Cell Anemia ADCIRCA tadalafil Pulmonary Vasodilator ADEMPAS riociguat Pulmonary Vasodilator ADHANSIA XR methylphenidate Stimulant ADLYXIN lixisenatide Incretin Mimetic Agent ADMELOG/SOLOSTAR insulin lispro [rDNA origin] Human Insulin Analog ADVOCATE TEST STRIP blood glucose test strips Blood Glucose Test Strips ADZENYS ER amphetamine suspension Amphetamine AEROSPAN flunisolide Corticosteroid (Inhaled) AFREZZA insulin Insulin (Inhaled) AIMOVIG erenumab-aooe Migraine – CGRP Receptor Antagonist AIRDUO RESPICLICK fluticasone-salmeterol Beta Adrenergic/Corticosteroid (Inhaled) AJOVY fremanezumab-vfrm Migraine – CGRP Receptor Antagonist AKLIEF trifarotene Anti-Acne AKTIPAK benzoyl peroxide-erythromycin Acne Combination ALBUTEROL SULFATE HFA albuterol Short Acting Beta Adrenergic (Inhaled) ALDARA imiquimod Immunomodulating Agents - Topical ALOGLIPTIN alogliptin Type 2 Diabetes ALOGLIPTIN-METFORMIN alogliptin-metformin Type 2 Diabetes ALTOPREV lovastatin Cholesterol ALTRENO tretinoin Anti-Acne ALVESCO ciclesonide Corticosteroid (Inhaled) ALYQ tadalafil Pulmonary Vasodilator AMPHETAMINE amphetamine suspension Amphetamine AMPHETAMINE amphetamine suspension Amphetamine AMPYRA dalfampridine Multiple Sclerosis Agent AMRIX cyclobenzaprine Skeletal Muscle Relaxant AMZEEQ minocycline hcl Anti-Acne
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification ANAPROX naproxen sodium Nonsteroidal Anti-inflammatory Agents ANAPROX DS naproxen sodium Nonsteroidal Anti-inflammatory Agents ANDRODERM testosterone Topical Testosterone Drug ANDROGEL testosterone Topical Testosterone Drug APADAZ benzhydrocodone-acetaminophen Analgesics – Opioid APIDRA insulin glulisine [rDNA origin] Human Insulin Analog APLENZIN bupropion Antidepressant ARANESP darbepoetin alfa Red Blood Cell Progenitor ARAZLO tazarotene Anti-Acne ARCAPTA NEOHALER indacaterol Beta Adrenergic (Inhaled) ARIKAYCE amikacin sulfate Antibiotics ARMONAIR RESPICLICK fluticasone propionate Corticosteroid (Inhaled) Nonsteroidal Anti-inflammatory Agent ARTHROTEC diclofenac-misoprostol Combination morphine sulfate extended ARYMO ER Analgesics - Opioid release ASCENIV immune globulin-intravenous Intravenous Immune Globulin ascomp with codeine butalbital-aspirin-caffeine-codeine Analgesics - Opioid ASMANEX HFA/ TWISTHALER mometasone Corticosteroid (Inhaled) ATRALIN tretinoin Anti-Acne AURYXIA ferric citrate Phosphate Binder AUSTEDO deutetrabenazine Movement Disorder Therapy AUVI-Q epinephrine Anaphylaxis Therapy Agents morphine sulfate extended AVINZA Analgesics - Opioid release AVITA tretinoin Anti-Acne AXIRON testosterone Topical Testosterone Drug AZEDRA iobenguane i 131 Oncology BAFIERTAM monomethyl fumarate Multiple Sclerosis Agent BELBUCA buprenorphine hcl Analgesics - Opioid belladonna alkaloids-opium belladonna alkaloids-opium Anticholinergic Combination BENLYSTA belimumab Systemic Lupus Erythematosus Agent BENZHYDROCODONE- Analgesics – Opioid benzhydrocodone-acetaminophen ACETAMINOPHEN BERINERT C1 esterase inhibitor Hereditary Angioedema BETHKIS tobramycin Cystic Fibrosis
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification glycopyrrolate-formoterol BEVESPI AEROSPHERE Beta Adrenergic/Anticholinergic (Inhaled) fumarate BIVIGAM immune globulin-intravenous Intravenous Immune Globulin BOTOX onabotulinumtoxinA Specialty Drug budesonide/glycopyrrolate/ Corticosteroid/Beta Adrenergic/Anticholinergic BREZTRI AEROSPHERE formoterol (Inhaled) BRINEURA cerliponase alfa Tripeptidyl Peptidase 1 Deficiency Treatment BRIVIACT brivaracetam Anticonvulsant BROVANA arformoterol tartrate Beta Adrenergic (Nebulized) BRYHALI halobetasol propionate Corticosteroid (Topical) BUDESONIDE-FORMOTEROL budesonide-formoterol fumarate Beta Adrenergic/Corticosteroid (Inhaled) BUNAVAIL buprenorphine-naloxone Controlled Dangerous Substance BUPHENYL sodium phenylbutyrate Nitrogen-Binding Agent BUPROPION XL 450 MG bupropion Antidepressant butalbital compound-codeine butalbital-aspirin-caffeine-codeine Analgesics - Opioid BUTRANS buprenorphine Analgesics - Opioid BYDUREON/BCISE exenatide extended release Incretin Mimetic Agent BYETTA exenatide Incretin Mimetic Agent BYNFEZIA octreotide Somatostatin/Acromegaly CABOMETYX cabozantinib Oncology CAFERGOT ergotamine/caffeine Migraine - Ergot Combinations CAPLYTA lumateperone Antipsychotic CARAC fluorouracil Antineoplastic Antimetabolites - Topical CARETOUCH TEST STRIP blood glucose test strips Blood Glucose Test Strips CARIMUNE NF immune globulin-intravenous Intravenous Immune Globulin carisoprodol compound- carisoprodol-aspirin-codeine Muscle Relaxant Combination codeine carisoprodol-aspirin-codeine carisoprodol-aspirin-codeine Muscle Relaxant Combination CAROSPIR SUSPENSION spironolactone Potassium Sparing Diuretics CAYSTON aztreonam Cystic Fibrosis Nonsteroidal Anti-inflammatory Agents - COX-2 CELEBREX celecoxib Inhibitor CEQUA cyclosporine Dry Eye Agent CERDELGA eliglustat Gaucher’s Disease CEREZYME imiglucerase Gaucher’s Disease CHOLBAM cholic acid Bile Acid
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification CIALIS tadalafil Benign Prostatic Hyperplasia CIMZIA certolizumab pegol Monoclonal Antibody CINQAIR reslizumab Monoclonal Antibody CINRYZE C1 esterase inhibitor Hereditary Angioedema CLEOCIN T clindamycin phosphate Acne Antibiotics CLEVER CHOICE TALK blood glucose test strips Blood Glucose Test Strips CLINDAGEL clindamycin phosphate Acne Antibiotics CLINDAMYCIN PHOSPHATE clindamycin phosphate Acne Antibiotics CLOVIQUE trientine Wilson’s Disease codeine sulfate codeine sulfate Analgesics - Opioid Calcium Channel Blocker-Nonsteroidal Anti- CONSENSI amlodipine-celecoxib inflammatory Combination Agent COSENTYX secukinumab Monoclonal Antibody COTEMPLA XR-ODT methylphenidate Stimulant CRESTOR rosuvastatin Cholesterol CRYSVITA burosumab-twza X-linked Hypophosphatemia Agent Wilson’s Disease/Cystinuria/Rheumatoid CUPRIMINE penicillamine Arthritis CUTAQUIG immune globulin-subcutaneous Subcutaneous Immune Globulin CUVITRU immune globulin-subcutaneous Subcutaneous Immune Globulin D.H.E. 45 dihydroergotamine mesylate Migraine - Ergot Alkaloids and Derivatives DAKLINZA daclatasvir dihydrochloride Hepatitis C DARAPRIM pyrimethamine Antimalarial DAXBIA cephalexin Cephalosporin DAYPRO oxaprozin Nonsteroidal Anti-inflammatory Agents DAYVIGO lemborexant Hypnotic Agent DEMEROL meperidine Analgesics - Opioid DEMSER metyrosine Pheochromocytoma DENAVIR penciclovir Antiviral/Herpes DEXABLISS dexamethasone Glucocorticosteroid DEXPAK dexamethasone Glucocorticosteroid DIACOMIT stiripentol Anticonvulsant DIBENZYLINE phenoxybenzamine Pheochromocytoma DICLOFENAC EPOLAMINE diclofenac epolamine Anti-inflammatory Agents - Topical DILAUDID hydromorphone Analgesics - Opioid
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification DOJOLVI triheptanoin Nutrient - Lipids DOLOPHINE methadone hcl Analgesics - Opioid DOPTELET avatrombopag maleate Thrombopoietic Agent DRIZALMA SPRINKLE duloxetine Antidepressant DUAKLIR PRESSAIR aclidinium-formoterol Beta Adrenergic/Anticholinergic (Inhaled) Nonsteroidal Anti-inflammatory Agent DUEXIS ibuprofen-famotidine Combination DUOBRII halobetasol-tazarotene Corticosteroid Combination (Topical) DUPIXENT dupilumab Atopic Dermatitis – Monoclonal Antibody DURAGESIC PATCH fentanyl Analgesics - Opioid DURLAZA aspirin extended release Antiplatelet DUROLANE sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection DURYSTA bimatoprost Anti-Glaucoma DUZALLO lesinurad-allopurinol Gout Agent DXEVO dexamethasone Glucocorticosteroid DYSPORT abobotulinumtoxinA Specialty Drug EC-NAPROSYN naproxen Nonsteroidal Anti-inflammatory Agents ECOZA econazole Antifungal EDECRIN ethacrynic acid Loop DIuretics EFUDEX fluorouracil Antineoplastic Antimetabolites - Topical EGRIFTA tesamorelin HIV Associated Lipodystrophy ELELYSO taliglucerase alfa Gaucher’s Disease ELIDEL pimecrolimus Immunomodulator EMBEDA morphine-naltrexone Analgesics - Opioid EMBRACE PRO TEST STRIPS blood glucose test strips Blood Glucose Test Strips EMFLAZA deflazacort Corticosteroid EMGALITY galcanezumab-gnlm Migraine – CGRP Receptor Antagonist EMLA lidocaine-prilocaine Local Anesthetics - Topical ENBREL etanercept Monoclonal Antibody ENDARI glutamine Amino Acids – Sickle Cell endocet oxycodone-acetaminophen Analgesics - Opioid ENDODAN oxycodone-aspirin Analgesics - Opioid ENTYVIO vedolizumab Monoclonal Antibody EPCLUSA sofosbuvir-velpatasvir Hepatitis C EPIDIOLEX cannabidiol Anticonvulsant
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification EPOGEN epoetin alfa Red Blood Cell Progenitor ERGOMAR ergotamine Migraine - Ergot Alkaloids and Derivatives ERTACZO sertaconazole Antifungal ESBRIET pirfenidone Pulmonary Fibrosis EUCRISA crisaborole Phosphodiesterase 4 Inhibitor EUFLEXXA sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection EVEKEO ODT amphetamine sulfate Amphetamine EVENCARE MINI GLUCOSE blood glucose test strips Blood Glucose Test Strips TEST STRIP EVENCARE PROVIEW blood glucose test strips Blood Glucose Test Strips EVENITY romosozumab-aqqg Osteoporosis/Bones EVOCLIN clindamycin phosphate Acne Antibiotics EVRYSDI risdiplam Spinal Muscular Atrophy EVZIO naloxone hcl injection Opiate Reversal Agent EVZIO naloxone hcl injection Opiate Reversal Agent hydromorphone hcl extended EXALGO Analgesics - Opioid release EXELDERM sulconazole Antifungal EXONDYS 51 eteplirsen Duchenne Muscular Dystrophy EXTINA ketoconazole Antifungal EZALLOR SPRINKLE rosuvastatin Cholesterol FASENRA benralizumab Monoclonal Antibody FELDENE piroxicam Nonsteroidal Anti-inflammatory Agents FENOPROFEN CALCIUM fenoprofen calcium Nonsteroidal Anti-inflammatory Agents FENORTHO fenoprofen calcium Nonsteroidal Anti-inflammatory Agents FENTANYL PATCH fentanyl Analgesics - Opioid FENTORA fentanyl buccal tablet Analgesics - Opioid FEXMID cyclobenzaprine Skeletal Muscle Relaxant FINTEPLA fenfluramine Anticonvulsant butalbital-acetaminophen- FIORICET-CODEINE Analgesics - Opioid caffeine-codeine FIORINAL-CODEINE butalbital-aspirin-caffiene-codeine Analgesics - Opioid FIRAZYR icatibant Hereditary Angioedema FIRDAPSE amifampridine phosphate Antimyasthenic Agent FLEBOGAMMA immune globulin-intravenous Intravenous Immune Globulin FLECTOR diclofenac epolamine Anti-inflammatory Agents - Topical
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification FLEXERIL cyclobenzaprine Skeletal Muscle Relaxant FLOLAN epoprostenol sodium Pulmonary Vasodilator FLOLIPID simvastatin-suspension Cholesterol FLUOROPLEX fluorouracil Antineoplastic Antimetabolites - Topical FLUOROURACIL 0.5% cream fluorouracil Antineoplastic Antimetabolites - Topical FORA GTEL blood glucose test strips Blood Glucose Test Strips FORADIL AEROLIZER formoterol Beta Adrenergic (Inhaled) FORFIVO XL bupropion Antidepressant FORTAMET metformin Type 2 Diabetes FORTEO teriparatide Osteoporosis/Bones FORTESTA testosterone Topical Testosterone Drug FOSRENOL lanthanum carbonate Phosphate Binder FREESTYLE TEST STRIP blood glucose test strips Blood Glucose Test Strips GALAFOLD migalastat Fabry Disease GAMIFANT emapalumab-lzsg Monoclonal Antibody GAMIMUNE N immune globulin-intravenous Intravenous Immune Globulin GAMMAGARD LIQUID immune globulin-intravenous Intravenous Immune Globulin GAMMAGARD S/D immune globulin-intravenous Intravenous Immune Globulin GAMMAKED immune globulin-intravenous Intravenous Immune Globulin GAMMAPLEX immune globulin-intravenous Intravenous Immune Globulin GAMMAR-P IV immune globulin-intravenous Intravenous Immune Globulin GAMUNEX immune globulin-intravenous Intravenous Immune Globulin immune globulin- GAMUNEX-C Intravenous/Subcutaneous Immune Globulin intravenous/subcutaneous GATTEX teduglutide [rDNA origin] Short Bowel Syndrome GEL-ONE sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection GEL-SYN sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection GENOTROPIN somatropin Growth Hormone GENSTRIP TEST STRIP blood glucose test strips Blood Glucose Test Strips GENVISC 850 sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection GIVLAARI givosiran Hematological Agents – Miscellaneous GLEEVEC imatinib Oncology GLOPERBA colchicine Gout Agent GLUCOPHAGE XR metformin Type 2 Diabetes GLUCOSE TEST STRIP blood glucose test strips Blood Glucose Test Strips
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification GLUMETZA metformin Type 2 Diabetes GOCOVRI amantadine Antiparkinson Dopaminergics GOJJI blood glucose test strips Blood Glucose Test Strips GRALISE gabapentin Postherpetic Neuralgia Agent timothy grass pollen allergen GRASTEK Allergy Immunotherapy extract HAEGARDA C1 esterase inhibitor Hereditary Angioedema HALOBETASOL PROPIONATE halobetasol propionate Corticosteroid (Topical) (foam) HARMONY blood glucose test strips Blood Glucose Test Strips HARVONI ledipasvir-sofosbuvir Hepatitis C bismuth subsalicylate/ HELIDAC Ulcer Therapy metronidazole/tetracycline HEMLIBRA emicizumab-kxwh Hemophilia HETLIOZ tasimelteon Non-24-Hour Sleep-Wake Disorder HIDEX dexamethasone Glucocorticosteroid HIZENTRA immune globulin-subcutaneous Subcutaneous Immune Globulin Restless Legs Syndrome/Postherpetic HORIZANT gabapentin enacarbil Neuralgia HUMALOG insulin lispro [rDNA origin] Human Insulin Analog HUMATROPE somatropin Growth Hormone HUMIRA adalimumab Monoclonal Antibody HUMULIN insulin human [rDNA origin] Human Insulin HYALGAN sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection HYCET hydrocodone-acetaminophen Analgesics – Opioid
HYDROXYPROGESTERONE hydroxyprogesterone Hormone CAPROATE HYMOVIS sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection HYQVIA immune globulin-subcutaneous Subcutaneous Immune Globulin hydrocodone bitartrate extended HYSINGLA ER Analgesics - Opioid release IBRANCE palbociclib Oncology IBUDONE hydrocodone-ibuprofen Analgesics - Opioid IGLUCOSE TEST STRIP blood glucose test strips Blood Glucose Test Strips ILUMYA tildrakizumab-asmn Monoclonal Antibody ILUVIEN fluocinolone acetonide Ophthalmic Steroids
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification IMPAVIDO miltefosine Antileishmanial IMPOYZ clobetasol propionate Corticosteroid (Topical) INBRIJA levodopa Antiparkinson Dopaminergics INCRELEX mecasermin Growth Hormone INDERAL XL propranolol hcl sustained release Beta Blocker INDOCIN indomethacin Nonsteroidal Anti-inflammatory Agents INDOMETHACIN indomethacin Nonsteroidal Anti-inflammatory Agents INFINITY VOICE TEST STRIP blood glucose test strips Blood Glucose Test Strips INFLECTRA infliximab-dyyb Monoclonal Antibody INGREZZA valbenazine Movement Disorder Therapy INNOPRAN XL propranolol hcl sustained release Beta Blocker INSULIN LISPRO insulin lispro [rDNA origin] Human Insulin Analog INVELTYS loteprednol etabonate Ophthalmic Steroids INVOKAMET canagliflozin-metformin Type 2 Diabetes canagliflozin-metformin extended INVOKAMET XR Type 2 Diabetes release INVOKANA canagliflozin Type 2 Diabetes ISTURISA osilodrostat phosphate Cortisol Synthesis Inhibitors IVEEGAM EN immune globulin-intravenous Intravenous Immune Globulin IVIG OR IGIV immune globulin-intravenous Intravenous Immune Globulin JATENZO testosterone undecanoate Oral Testosterone Drug JORNAY PM methylphenidate Stimulant JUBLIA efinaconazole Antifungal JUXTAPID lomitapide Homozygous Familial Hypercholesterolemia JYNARQUE tolvaptan Vasopressin Receptor Antagonist morphine sulfate extended KADIAN Analgesics - Opioid release KALBITOR ecallantide Hereditary Angioedema KALYDECO ivacaftor Cystic Fibrosis KANUMA sebelipase alfa Enzyme KAPSPARGO SPRINKLE metoprolol succinate Beta Blocker KATERZIA amlodipine besylate Calcium Channel Blocker KAZANO alogliptin-metformin Type 2 Diabetes KERYDIN tavaborole Antifungal ketoprofen er ketoprofen extended release Nonsteroidal Anti-inflammatory Agents
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification KETOROLAC TROMETHAMINE ketorolac tromethamine Nonsteroidal Anti-inflammatory Agents KETOROLAC TROMETHAMINE ketorolac tromethamine Nonsteroidal Anti-inflammatory Agents KEVEYIS dichlorphenamide Carbonic Anhydrase Inhibitor KEVZARA sarilumab Monoclonal Antibody KINERET anakinra Monoclonal Antibody KOMBIGLYZE XR saxagliptin-metformin Type 2 Diabetes KORLYM mifepristone Endocrine/Cushing’s Disease KOSELUGO selumetinib MEK Inhibitor KRYSTEXXA pegloticase Gout Agent KUVAN sapropterin Phenylketonuria KYMRIAH tisagenlecleucel Oncology KYNAMRO mipomersen Homozygous Familial Hypercholesterolemia KYNMOBI apomorphine Antiparkinson Dopaminergics LAZANDA NASAL SPRAY fentanyl citrate Analgesics - Opioid LEDIPASVIR-SOFOSBUVIR ledipasvir-sofosbuvir Hepatitis C LEMTRADA alemtuzumab Multiple Sclerosis Agent LETAIRIS ambrisentan Pulmonary Vasodilator LEVALBUTEROL TARTRATE levalbuterol tartrate Short Acting Beta Adrenergic (Inhaled) HFA LEVORPHANOL levorphanol tartrate Analgesics - Opioid LEXETTE halobetasol propionate Corticosteroid (Topical) LIBERTY TEST STRIP blood glucose test strips Blood Glucose Test Strips LICART diclofenac epolamine Anti-inflammatory Agents – Topical lidocaine ointment 5% lidocaine Local Anesthetics - Topical LIDODERM lidocaine Topical Anesthetic LIVALO pitavastatin calcium Cholesterol LOCORT dexamethasone Glucocorticosteroid LODINE etodolac Nonsteroidal Anti-inflammatory Agents LONHALA glycopyrrolate Anticholinergic lorcet (hd/plus) hydrocodone-acetaminophen Analgesics - Opioid LORTAB hydrocodone-acetaminophen Analgesics - Opioid LOVAZA omega-3-acid ethyl esters Omega-3 Fatty Acid LUCEMYRA lofexidine Agents for Narcotic Withdrawal LULICONAZOLE luliconazole Antifungal LUMIGAN bimatoprost Anti-Glaucoma
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification LUTATHERA lutetium lu 177 dotatate Oncology LUXTURNA voretigene neparvovec-rzyl Inherited Retinal Disease LUZU luliconazole Antifungal LYRICA CR pregabalin extended release Postherpetic Neuralgia Agent LYUMJEV insulin lispro [rDNA origin] Human Insulin Analog MAKENA hydroxyprogesterone Hormone MAVENCLAD cladribine Multiple Sclerosis Agent MAVYRET glecaprevir-pibrentasvir Hepatitis C MENTAX butenafine Antifungal MEPSEVII vestronidase alfa-vjbk Mucopolysaccharidosis VII Treatment Agent methadose methadone hcl Analgesics - Opioid METHYLPHENIDATE ER 72 MG methylphenidate Stimulant MICRODOT XTRA blood glucose test strips Blood Glucose Test Strips migergot ergotamine-caffeine Migraine - Ergot Combinations MIGRANAL dihydroergotamine mesylate Migraine - Ergot Alkaloids and Derivatives MINOCYCLINE HCL ER minocycline hcl er Tetracycline MINOLIRA ER minocycline hcl Tetracycline MIRCERA pegylated epoetin beta Red Blood Cell Progenitor MOBIC meloxicam Nonsteroidal Anti-inflammatory Agents MONOVISC sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection morphine sulfate extended MORPHABOND ER Analgesics - Opioid release morphine sulfate morphine sulfate Analgesics - Opioid MOTEGRITY prucalopride succinate Chronic Idiopathic Constipation Agents morphine sulfate controlled and MS CONTIN Analgesics - Opioid extended release MULPLETA lusutrombopag Thrombopoietic Agent MYALEPT metreleptin Leptin Analog MYOBLOC rimabotulinumtoxinB Specialty Drug NAFTIN naftifine Antifungal NALFON fenoprofen calcium Nonsteroidal Anti-inflammatory Agents NALOCET oxycodone-acetaminophen Analgesics - Opioid NALOXONE HCL naloxone hcl injection Opiate Reversal Agent naproxen sodium controlled and NAPRELAN Nonsteroidal Anti-inflammatory Agents extended release NAPROSYN naproxen Nonsteroidal Anti-inflammatory Agents
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification NATESTO testosterone Topical Testosterone Drug NATPARA parathyroid hormone Parathyroid Agent NESINA alogliptin Type 2 Diabetes NEURONTIN gabapentin Postherpetic Neuralgia/Anticonvulsant NEXLETOL bempedoic acid Cholesterol NEXLIZET bempedoic acid/ezetimibe Cholesterol NITYR nitisinone Hereditary Tyrosinemia Type 1 NOCDURNA (sublingual) desmopressin Vasopressin Analogue NOCTIVA (nasal spray) desmopressin Vasopressin Analogue NORCO hydrocodone-acetaminophen Analgesics - Opioid NORDITROPIN somatropin Growth Hormone NORGESIC FORTE orphenadrine-aspirin-caffeine Muscle Relaxant Combinations NORTHERA droxidopa Neurogenic Orthostatic Hypotension NOURIANZ istradefylline Antiparkinson Adenosine Receptor Antagonist NUCALA mepolizumab Monoclonal Antibody NUCYNTA tapentadol hcl Analgesics - Opioid NUCYNTA ER tapentadol hcl extended release Analgesics - Opioid dextromethorphan hydrobromide- NUEDEXTA Pseudobulbar Affect quinidine sulfate NURTEC ODT rimegepant Migraine – CGRP Receptor Antagonist NUTROPIN somatropin Growth Hormone NUTROPIN AQ somatropin Growth Hormone NUVIGIL armodafinil CNS Stimulant OCALIVA obeticholic acid Bile Acid Analog OCREVUS ocrelizumab Monoclonal Antibody OCTAGAM immune globulin-intravenous Intravenous Immune Globulin ODACTRA dust mite mixed extract Allergy Immunotherapy OFEV nintedanib Pulmonary Fibrosis OLUMIANT baricitinib Janus Kinase Inhibitor OLYSIO simeprevir Hepatitis C OMNITROPE somatropin Growth Hormone ONE TOUCH TEST STRIP blood glucose test strips Blood Glucose Test Strips ONE TOUCH ULTRA TEST blood glucose test strips Blood Glucose Test Strips STRIP ONGLYZA saxagliptin Type 2 Diabetes
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification ONMEL itraconazole Antifungal ONPATTRO patisiran sodium Small Interfering RNA Agent ONSOLIS fentanyl soluble film Analgesics - Opioid Migraine Therapy – Selective Serotonin ONZETRA XSAIL sumatriptan succinate Agonists OPANA oxymorphone hcl Analgesics - Opioid oxymorphone hcl extended OPANA ER Analgesics - Opioid release OPSUMIT macitentan Pulmonary Vasodilator sweet vernal-orchard-perennial ORALAIR rye-timothy-kentucky blue grass Allergy Immunotherapy mixed pollens allergen extract ORAVIG miconazole Antifungal ORENCIA/CLICKJECT abatacept Monoclonal Antibody ORENITRAM/ER treprostinil Pulmonary Vasodilator ORFADIN nitisinone Heredeitary Tyrosinemia Type 1 Estrogen-Progestin-Gonadotropin-Releasing ORIAHNN elagolix/estradiol/norethisterone Hormone receptor antagonist Gonadotropin-Releasing Hormone receptor ORILISSA elagolix sodium antagonist ORKAMBI lumacaftor-ivacaftor Cystic Fibrosis orphengesic forte orphenadrine-aspirin-caffeine Muscle Relaxant Combinations ORTHOVISC high molecular weight hyaluronan Hyaluronic Acid Derivative for Joint Injection ORTIKOS budesonide Glucocorticosteroid OSMOLEX ER amantadine Antiparkinson Dopaminergics OTEZLA apremilast Phosphodiesterase Inhibitor Rheumatoid Arthritis/Polyarticular Juvenile OTREXUP methotrexate Idiopathic Arthritis/Psoriasis OXAYDO oxycodone hcl Analgesics - Opioid OXBRYTA voxelotor Agents for Sickle Cell Anemia OXERVATE cenegermin-bkbj Ophthalmic Nerve Growth Factors OXISTAT oxiconazole Antifungal OXYCODONE ER† oxycodone hcl extended release Analgesics - Opioid oxycodone-ibuprofen oxycodone-ibuprofen Analgesics - Opioid OXYCONTIN† oxycodone hcl extended release Analgesics - Opioid OZEMPIC semaglutide Incretin Mimetic Agent OZOBAX baclofen Skeletal Muscle Relaxant
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification OZURDEX dexamethasone Ophthalmic Steroids PALFORZIA peanut powder-dnfp Allergy Immunotherapy PALYNZIQ pegvalise-pqpz Phenylketonuria PANZYGA immune globulin-intravenous Intravenous Immune Globulin PEGASYS peginterferon alfa-2a Interferon PEG-INTRON peginterferon alfa-2b Interferon PENNSAID diclofenac sodium Anti-inflammatory Agents - Topical PERCOCET oxycodone-acetaminophen Analgesics - Opioid PERCODAN oxycodone-aspirin Analgesics - Opioid PERFOROMIST formoterol fumarate Beta Adrenergic (Nebulized) PHOSLO calcium acetate Phosphate Binder PHOSLYRA calcium acetate Phosphate Binder POLYGAM S/D immune globulin-intravenous Intravenous Immune Globulin PONSTEL mefenamic acid Nonsteroidal Anti-inflammatory Agents PRADAXA dabigatran etexilate Anticoagulant PRALUENT alirocumab Cholesterol PRECISION SOF-TACT TEST blood glucose test strips Blood Glucose Test Strips STRIP PRECISION XTRA TEST STRIP blood glucose test strips Blood Glucose Test Strips PREMIER TEST STRIP blood glucose test strips Blood Glucose Test Strips PRILOSEC DR omeprazole Proton Pump Inhibitor PRIMLEV oxycodone-acetaminophen Analgesics - Opioid PRIVIGEN immune globulin-intravenous Intravenous Immune Globulin PRO VOICE V8-V9 TEST STRIP blood glucose test strips Blood Glucose Test Strips PROAIR DIGIHALER albuterol Short Acting Beta Adrenergic (Inhaled) PROCRIT epoetin alfa Red Blood Cell Progenitor PROCYSBI cysteamine bitartrate Nephropathic Cystinosis Agent PRODIGY TEST STRIP blood glucose test strips Blood Glucose Test Strips profeno fenoprofen calcium Nonsteroidal Anti-inflammatory Agents PROGRAF GRANULES tacrolimus Immunosuppressants prolate oxycodone-acetaminophen Analgesics – Opioid PROLIA denosumab Osteoporosis/Bones PROMACTA eltrombopag olamine Thrombopoietic Agent PROTOPIC tacrolimus Immunomodulator PROVENGE sipuleucel-T Oncology
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification PROVENTIL HFA albuterol Short Acting Beta Adrenergic (Inhaled) PROVIGIL modafinil CNS Stimulant prudoxin doxepin Antipruritics - Topical PULMICORT FLEXHALER budesonide Corticosteroid (Inhaled) QBREXZA glycopyrronium tosylate Primary Axillary Hyperhidrosis QMIIZ ODT meloxicam Nonsteroidal Anti-inflammatory Agents QTERN empagliflozin-linagliptin Type 2 Diabetes QUDEXY XR topiramate extended release Anticonvulsant QUTENZA capsaicin Topical Anesthetic RADICAVA edaravone Amyotrophic Lateral Sclerosis (ALS) Agent short ragweed pollen allergen RAGWITEK Allergy Immunotherapy extract RAVICTI glycerol phenylbutyrate Nitrogen-Binding Agent RAYALDEE calcifediol Vitamin D3 analog RAYOS prednisone Corticosteroid REBLOZYL luspatercept-aamt Erythroid Maturation Agent RELAFEN DS nabumetone Nonsteroidal Anti-inflammatory Agents RELEXXII methylphenidate Stimulant RELION TEST STRIP blood glucose test strips Blood Glucose Test Strips REMICADE infliximab Monoclonal Antibody REMODULIN treprostinil sodium Pulmonary Vasodilator RENAGEL sevelamer Phosphate Binder RENFLEXIS infliximab-abda Monoclonal Antibody RENVELA sevelamer carbonate Phosphate Binder REPATHA evolocumab Cholesterol reprexain hydrocodone-ibuprofen Analgesics - Opioid RESTASIS/MULTIDOSE cyclosporine Dry Eye Agent RETACRIT epoetin alfa-epbx Red Blood Cell Progenitor RETIN-A tretinoin Anti-Acne RETIN-A MICRO tretinoin Anti-Acne RETISERT fluocinolone acetonide Ophthalmic Steroids REVATIO sildenafil citrate Pulmonary Vasodilator REVCOVI elapegademase-lvlr Adenosine Deaminase SCID Treatment Agent
REVLIMID lenalidomide Oncology
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification Migraine Therapy – Selective Serotonin REYVOW lasmiditan succinate Agonists RHOFADE oxymetazoline Rosacea Agent RHOPRESSA netarsudil dimesylate Rho Kinase Inhibitors RINVOQ ER upadacitinib Janus Kinase Inhibitor RIOMET ER metformin Type 2 Diabetes RITUXAN rituximab Monoclonal Antibody RITUXAN HYCELA rituximab-hyaluronidase Monoclonal Antibody ROCKLATAN netarsudil-latanoprost Kinase Inhibitors - Combinations roxicet oxycodone-acetaminophen Analgesics - Opioid ROXICODONE oxycodone hcl Analgesics - Opioid ROXYBOND oxycodone hcl Analgesics – Opioid
C1 esterase inhibitor RUCONEST Hereditary Angioedema (recombinant) RUXIENCE rituximab-pvvr Monoclonal Antibody RUZURGI amifampridine Antimyasthenic Agent RYBELSUS semaglutide Incretin Mimetic Agent RYCLORA dexchlorpheniramine maleate Antihistamine RYVENT carbinoxamine Antihistamine SABRIL vigabatrin Anticonvulsant SAIZEN/SAIZENPREP somatropin Growth Hormone SAVAYSA edoxaban Anticoagulant SECUADO asenapine Antipsychotic SEEBRI NEOHALER glycopyrrolate Anticholinergic SENSIPAR cinacalcet Parathyroid Agent SEROSTIM somatropin Growth Hormone SEYSARA sarecycline Tetracycline SIGNIFOR pasireotide Somatostatin/Cushing’s Disease SIGNIFOR LAR pasireotide Somatostatin/Acromegaly SIKLOS hydroxyurea Agents for Sickle Cell Anemia SILIQ brodalumab Monoclonal Antibody SIMPONI golimumab Monoclonal Antibody SIMVASTATIN simvastatin-suspension Cholesterol SITAVIG acyclovir Antiviral/Herpes SKYRIZI risankizumab-rzaa Monoclonal Antibody
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification SODIUM HYALURONATE sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection SOFOSBUVIR-VELPATASVIR sofosbuvir-velpatasvir Hepatitis C Antineoplastic or Premalignant Lesions - Topical SOLARAZE diclofenac NSAID SOLIQUA insulin glargine-lixisenatide Human Insulin Analog SOLOSEC secnidazole Amebicides SOVALDI sofosbuvir Hepatitis C SPINRAZA nusinersen Spinal Muscular Atrophy SPRAVATO esketamine Antidepressant SPRITAM levetiracetam Anticonvulsant SPRIX ketorolac tromethamine Nonsteroidal Anti-inflammatory Agents SPRYCEL dasatinib Oncology STEGLUJAN ertugliflozin-sitagliptin Type 2 Diabetes STELARA ustekinumab Monoclonal Antibody STRENSIQ asfotase alfa Hypophosphatasia STRIANT testosterone Topical Testosterone Drug SUBOXONE SL TABLET buprenorphine-naloxone Controlled Dangerous Substance SUBSYS fentanyl sublingual spray Controlled Dangerous Substance SUBUTEX buprenorphine Controlled Dangerous Substance SULCONAZOLE sulconazole Antifungal SUNOSI solriamfetol Dopamine/Norepinephrine Reuptake Inhibitor SUPARTZ sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection SUTENT sunitinib Oncology SYMDEKO tezacaftor-ivacaftor Cystic Fibrosis SYMLIN pramlintide Amylin Analogue SYMPAZAN clobazam Anticonvulsant SYMPROIC naldemedine tosylate Opioid Induced Constipation SYNAGIS palivizumab Monoclonal Antibody SYNALGOS-DC aspirin-caffeine-dihydrocodeine Analgesics - Opioid SYNDROS dronabinol Antiemetics SYNVISC hylan GF 20 Hyaluronic Acid Derivatives for Joint Injection SYNVISC-ONE hylan GF 20 Hyaluronic Acid Derivatives for Joint Injection SYPRINE trientine Wilson’s Disease TAKHZYRO lanadelumab-fiyo Monoclonal Antibody TALTZ ixekizumab Monoclonal Antibody
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification TANZEUM albiglutide Incretin Mimetic Agent TAPERDEX dexamethasone Glucocorticosteroid TAVALISSE fostamatinib Spleen Tyrosine Kinase Inhibitor TECHNIVIE ombitasvir-paritaprevir-ritonavir Hepatitis C TEGSEDI inotersen sodium Antisense Oligonucleotide inhibitor Agent TEPEZZA teprotumumab Thyroid Eye Disease TERIPARATIDE teriparatide Osteoporosis/Bones TESTIM testosterone Topical Testosterone Drug TESTOSTERONE testosterone Topical Testosterone Drug TEV-TROPIN somatropin Growth Hormone TIGLUTIK riluzole Amyotrophic Lateral Sclerosis (ALS) Agent TIROSINT-SOL levothyroxine Thyroid Hormone TIVORBEX indomethacin Nonsteroidal Anti-inflammatory Agents TOBI/TOBI PODHALER tobramycin Cystic Fibrosis TOLAK fluorouracil Antineoplastic Antimetabolites - Topical tolmetin tolmetin sodium Nonsteroidal Anti-inflammatory Agents TOPIRAMATE ER topiramate extended release Anticonvulsant Migraine Therapy – Selective Serotonin TOSYMRA sumatriptan succinate Agonists TRACLEER bosentan Pulmonary Vasodilator TRAMADOL HCL tramadol hcl Analgesics - Opioid TREMFYA guselkumab Monoclonal Antibody TRETIN-X tretinoin Anti-Acne acetaminophen-caffeine- TREZIX Analgesics - Opioid dihydrocodeine TRIKAFTA elexacaftor-tezacaftor-ivacaftor Cystic Fibrosis TRIMPEX trimethoprim Anti-Infective Agents TRIVISC sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection TROKENDI XR topiramate extended release Anticonvulsant TRULANCE plecanatide Chronic Idiopathic Constipation Agents TRULICITY dulaglutide Incretin Mimetic Agent TRUXIMA rituximab-abbs Monoclonal Antibody TUDORZA PRESSAIR aclidinium Anticholinergic (Inhaled) TURALIO pexidartinib Tyrosine Kinase Inhibitor TYLENOL WITH CODEINE acetaminophen-codeine Analgesics - Opioid
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification TYMLOS abaloparatide Osteoporosis/Bones TYSABRI natalizumab Monoclonal Antibody TYVASO treprostinil Pulmonary Vasodilator UBRELVY ubrogepant Migraine – CGRP Receptor Antagonist ULTOMIRIS ravulizumab-cwvz Complement Inhibitors UNISTRIP1 blood glucose test strips Blood Glucose Test Strips UPTRAVI selexipag Pulmonary Vasodilator UTIBRON NEOHALER Indacaterol-glycopyrrolate Beta Adrenergic/Anticholinergic (Inhaled) VECAMYL mecamylamine hydrochloride Hypertension VELETRI epoprostenol sodium Pulmonary Vasodilator VELPHORO sucroferric oxyhydroxide Phosphate Binder VELTIN tretinoin-clindamycin Anti-Acne VENTAVIS iloprost Pulmonary Vasodilator VERASENS TEST STRIP blood glucose test strips Blood Glucose Test Strips verdrocet hydrocodone-acetaminophen Analgesics - Opioid vicodin (es/hp) hydrocodone-acetaminophen Analgesics - Opioid VICOPROFEN hydrocodone-ibuprofen Analgesics - Opioid VICTOZA liraglutide Incretin Mimetic Agent ombitasvir-paritaprevir-ritonavir- VIEKIRA PAK/XR Hepatitis C dasabuvir VIGADRONE vigabatrin Anticonvulsant naproxen-esomeprazole Nonsteroidal Anti-inflammatory Agent VIMOVO magnesium Combination VISCO-3 sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection VIVAGUARD INO blood glucose test strips Blood Glucose Test Strips VIVLODEX meloxicam Nonsteroidal Anti-inflammatory Agents VOGELXO testosterone Topical Testosterone Drug VOLTAREN diclofenac sodium Anti-inflammatory Agents - Topical VOLTAREN-XR diclofenac sodium Nonsteroidal Anti-inflammatory Agents VOSEVI sofosbuvir-velpatasvir-voxilaprevir Hepatitis C VPRIV velaglucerase alfa Gaucher’s Disease VUMERITY diroximel fumerate Multiple Sclerosis Agent VYEPTI eptinezumab-jjmr Migraine – CGRP Receptor Antagonist VYNDAMAX tafamidis Transthyretin Stabilizers VYNDAQEL tafamidis meglumine Transthyretin Stabilizers
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification VYONDYS-53 golodirsen Duchenne Muscular Dystrophy VYZULTA latanoprostene Anti-Glaucoma WAKIX pitolisant Narcolepsy WAVESENSE TEST STRIP blood glucose test strips Blood Glucose Test Strips WELLBUTRIN SR/XL bupropion Antidepressant XADAGO safinamide mesylate Antiparkinson Monoamine Oxidase Inhibitor XALATAN latanoprost Anti-Glaucoma XARTEMIS XR oxycodone-acetaminophen Analgesics - Opioid Acute Lymphoblastic Leukemia/Polyarticular XATMEP methotrexate Jevnile Idiopathic Arthritis XCOPRI cenobamate Anticonvulsant XELJANZ/XR tofacitinib Janus Kinase Inhibitor XELPROS latanoprost Anti-Glaucoma XEMBIFY immune globulin-subcutaneous Subcutaneous Immune Globulin XENAZINE tetrabenazine Huntington’s Chorea XEOMIN incobotulinumtoxinA Specialty Drug XERMELO telotristat etiprate Carcinoid Syndrome Diarrhea XGEVA denosumab Oncology/Bones XHANCE fluticasone propionate Nasal Steroids for Nasal Polyps XIAFLEX collagenase clostridium Cord Injection XIMINO minocycline hcl er Tetracycline XODOL hydrocodone-acetaminophen Analgesics - Opioid XOLAIR omalizumab Monoclonal Antibody XOLEGEL ketoconazole Antifungal XOLOX oxycocodone-acetaminophen Analgesics - Opioid XOPENEX HFA levalbuterol Short Acting Beta Adrenergic (Inhaled) XTAMPZA ER oxycodone extended release Analgesics - Opioid XULTOPHY insulin degludec-liraglutide Insulin/Incretin Mimetic Agent XURIDEN uridine triacetate granule Hereditary Orotic Aciduria xylon hydrocodone-ibuprofen Analgesics - Opioid XYOSTED testosterone enanthate Subcutaneous Testosterone Drug XYREM sodium oxybate Narcolepsy YESCARTA axicabtagene ciloleucel Oncology YUPELRI revefenacin Anticholinergic YUTIQ fluocinolone acetonide Ophthalmic Steroids
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Revised 09/20
As part of our drug utilization management program, members must request and receive prior authorization for certain prescription drugs in order to use their prescription drug benefits. Below is a list of drugs that currently require prior authorization. This list will be updated periodically as new drugs that require prior authorization are introduced. As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. The Schedule of Benefits contains a list of drug categories that require prior authorization. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians must call ESI to obtain an authorization. (1-800-842-2015).
Drug Name Generic Name Drug Classification zamicet hydrocodone-acetaminophen Analgesics - Opioid ZAVESCA miglustat Gaucher’s Disease ZELNORM tegaserod Irritable Bowel Syndrome - Constipation Migraine Therapy – Selective Serotonin ZEMBRACE SYMTOUCH sumatriptan injection Agonists ZEPATIER elbasvir-grazoprevir Hepatitis C ZEPOSIA ozanimod Multiple Sclerosis Agent ZERVIATE cetirizine Ophthalmic Antiallergic ZIANA tretinoin-clindamycin Anti-Acne ZILRETTA triamcinolone acetonide Glucocorticosteroid – Intra-articular ZILXI minocycline hcl Rosacea Agent ZINBRYTA daclizumab Monoclonal Antibody ZINPLAVA bezlotoxumab Bacterial Monoclonal Antibodies ZIOPTAN tafluprost Anti-Glaucoma ZIPSOR diclofenac potassium Nonsteroidal Anti-inflammatory Agents ZODEX dexamethasone Glucocorticosteroid hydrocodone bitartrate extended ZOHYDRO ER Analgesics - Opioid release ZOLGENSMA onasemnogene abeparvovec-xioi Spinal Muscular Atrophy ZOMACTON somatropin Growth Hormone ZONACORT dexamethasone Glucocorticosteroid ZONALON doxepin Antipruritics - Topical ZORBTIVE somatropin Growth Hormone ZORVOLEX diclofenac Nonsteroidal Anti-inflammatory Agents ZOVIRAX CREAM/OINTMENT acyclovir Antiviral/Herpes ZTLIDO PATCH lidocaine Topical Anesthetic ZULRESSO brexanolone Antidepressant ZURAMPIC lesinurad Uric Acid Transporter 1 Inhibitor ZYFLO zileuton Asthma Therapy ZYFLO CR zileuton controlled release Asthma Therapy ZYPITAMAG pitavastatin magnesium Cholesterol
04HQ3249 R09/20 †Quantities greater than 90 per month may require prior authorization.
Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company