DTF Prior Authorization Drug List

The following is a list of the prescribed drugs included in your prior authorization program and is comprehensive as of the date of publication. Express Scripts Canada® makes every effort to ensure this list is updated regularly.

Please note that prior authorization applies to the brand drug and its generic alternatives (if available). As of July 22, 2021 Drug Chemical Ingredient ABSTRAL fentanyl ACTEMRA tocilizumab ADALIMUMAB adalimumab ADCIRCA tadalafil ADDYI flibanserin ADEMPAS riociguat AFINITOR everolimus AIMOVIG erenumab AJOVY fremanezumab ALECENSARO alectinib ALUNBRIG brigatinib AMGEVITA adalimumab ARZERRA ofatumumab AUBAGIO teriflunomide AVASTIN bevacizumab AVSOLA infliximab BALVERSA erdafitinib BANZEL rufinamide BAVENCIO avelumab BENLYSTA belimumab BESPONSA inotuzumab ozogamicin BEOVU brolucizumab BOSULIF bosutinib BOTOX onabotulinumtoxinA BRAFTOVI encorafenib BRENZYS etanercept BRUKINSA zanubrutinib BUDESONIDE budesonide CABLIVI caplacizumab CABOMETYX cabozantinib CALQUENCE acalabrutinib CAPRELSA vandetanib CARBAGLU carglumic acid CERDELGA eliglustat 1 © Express Scripts Canada. All rights reserved.

CEQUA cyclosporine CIMZIA certolizumab CINQAIR reslizumab COPAXONE Glatiramer acetate COSENTYX secukinumab COTELLIC cobimetinib CRESEMBA isavuconazole CRYSVITA burosumab CUVPOSA glycopyrrolate CYRAMZA ramucirumab CYSTADROPS cysteamine DAKLINZA daclatasvir DAURISMO glasdegib DEMYLOCAN decitabine DIACOMIT stiripentol DOJOLVI triheptanoin DUODOPA levodopa/carbidopa DUPIXENT dupilumab DYSPORT THERAPEUTIC abobotulinumtoxinA EGRIFTA tesamorelin EMGALITY galcanezumab ENBREL etanercept ENSPRYNG satrailizumab ENTYVIO vedolizumab EPCLUSA sofosbuvir/velpatasvir ERELZI etanercept ERIVEDGE vismodegib ERLEADA apalutamide ESBRIET pirfenidone EVENITY romosozumab EVRYSDI risdiplam EYLEA aflibercept FABRAZYME agalsidase beta FAMPYRA fampridine FASENRA benralizumab FENTORA fentanyl FIRAZYR icatibant FIRDAPSE amifampridine phosphate FORTEO teriparatide GALAFOLD migalastat GALEXOS simeprevir GAZYVA obinutuzumab GENOTROPIN somatropin GILENYA fingolimod 2 © Express Scripts Canada. All rights reserved.

GIOTRIF afatinib dimaleate GIVLAARI givosiran HADLIMA adalimumab HANZEMA alitretinoin HARVONI sofosbuvir/ledipasvir HIZENTRA human immunoglobulin HOLKIRA PAK ombitasvir/paritaprevir/ritonavir/dasabuvir HULIO adalimumab HUMATROPE somatropin HUMIRA adalimumab HYRIMOZ adalimumab IBAVYR ribavirin IBRANCE palbociclib ICLUSIG ponatinib IDACIO adalimumab IDHIFA enasidenib ILARIS canakinumab ILUMYA tildrakizumab IMBRUVICA ibrutinib IMFINZI durvalumab INCRELEX mecasermin INFLECTRA infliximab INLYTA axitinib INQOVI decitabine/cedazuridine INSPRA eplerenone INVOKANA canagliflozin IRESSA gefitinib JAKAVI ruxolitinib JETREA ocriplasmin JINARC tolvaptan KALYDECO ivacaftor KESIMPTA ofatumumab KEVZARA sarilumab KEYTRUDA pembrolizumab KISQALI ribociclib KUVAN sapropterin KYNMOBI apomorphine LEMTRADA alemtuzumab LENVIMA lenvatinib mesylate LIBTAYO cemiplimab LONSURF trifluridine/tipiracil LORBRENA lorlatinib LOVENOX enoxaparin sodium LUCENTIS ranibizumab LYNPARZA olaparib 3 © Express Scripts Canada. All rights reserved.

MACUGEN pegaptanib sodium MAVENCLAD cladribine MAVIRET glecaprevir/pibrentasvir MAYZENT siponimod MDK-NITISINONE nitisinone MEKINIST trametinib MEKTOVI binimetinib MOVAPO apomorphine MVASI bevacizumab NERLYNX neratinib NEXAVAR sorafenib NINLARO ixazomib citrate NITISINONE TABLETS nitisinone NORDITROPIN somatropin NPLATE romiplostim NUBEQA darolutamide NUCALA mepolizumab NUTROPIN AQ somatropin OCALIVA obeticholic acid OCREVUS ocrelizumab ODOMZO sonidegib OFEV nintedanib OLUMIANT baricitinib OMNITROPE somatropin OMVYENCE infliximab ONPATTRO patisiran OPDIVO nivolumab OPSUMIT macitentan ORENCIA abatacept ORFADIN nitisinone ORKAMBI ivacaftor/lumacaftor OSNUVO teriparatide OTEZLA apremilast OXERVATE cenegermin PIQRAY alpelisib POMALYST pomalidomide PONVORY ponsimod PRALUENT alirocumab PREVYMIS letermovir PROCYSBI mercaptamine bitartrate PROLASTIN-C alpha-1 proteinase inhibitor QINLOCK ripretinib RADICAVA edaravone RAVICTI glycerol phenylbutyrate

4 © Express Scripts Canada. All rights reserved.

REBLOZYL luspatercept RELISTOR methylnaltrexone bromide REMICADE infliximab REMSIMA infliximab RENFLEXIS infliximab REPATHA evolocumab REPLAGAL agalsidase alfa RETEVMO selpercatinib REVATIO sildenafil REVESTIVE teduglutide REVLIMID lenalidomide REVOLADE eltrombopag RIABNI rituximab RINVOQ upadacitinib RITUXAN, RITUXAN SC rituximab RIXIMYO rituximab ROZLYTREK entrectinib RUXIENCE rituximab RUZURGI amifampridine RYDAPT midostaurin SAIZEN somatropin SAMSCA tolvaptan SATIVEX delta-9-tetrahydrocannabinol-cannabidiol SENSIPAR cinacalcet SEROSTIM somatropin SIGNIFOR, SIGNIFOR LAR pasireotide SILIQ brodalumab SIMPONI golimumab SKYRIZI risankizumab SOVALDI sofosbuvir SPRAVATO esketamine SPRYCEL dasatinib monohydrate STELARA ustekinumab STIVARGA regorafenib STRAMUCIN mupirocin SUNVEPRA asunaprevir SUTENT sunitinib SYMDEKO tezacaftor/ivacaftor TAFINLAR dabrafenib TAGRISSO osimertinib TAKHZYRO lanadelumab TALTZ ixekizumab TALZENNA talazoparib TARCEVA erlotinib

5 © Express Scripts Canada. All rights reserved.

TASIGNA nilotinib TAVALISSE fostamatinib TECENTRIQ atezolizumab TECFIDERA dimethyl fumarate TECHNIVIE ombitasvir/paritaprevir/ritonavir TEGSEDI inotersen TEMODAL temozolomide TEPMETKO tepotinib THALOMID thalidomide THYROGEN thyrotropin alfa TOCTINO alitretinoin TREANDA bendamustine TREMFYA guselkumab TRIKAFTA elexacaftor/tezacaftor/ivacaftor TRUXIMA rituximab TUKYSA tucatinib TYKERB lapatinib TYSABRI natalizumab UPTRAVI selexipag VECTIBIX panitumumab VEMLIDY tenofovir alafenamide VENCLEXTA venetoclax VERZENIO abemaciclib VIDAZA azacitidine VITRAKVI larotrectinib VIZIMPRO dacomitinib VOLIBRIS ambrisentan VOSEVI sofosbuvir/velpatasvir/voxilaprevir VOTRIENT pazopanib VYEPTI eptinezumab VYNDAQEL tafamidis meglumine XALKORI crizotinib XELJANZ, XELJANZ XR tofacitinib XEOMIN incobotulinumtoxinA XERMELO telotristat ethyl XIAFLEX collagenase Clostridium histolyticum XIIDRA lifitigrast XOLAIR omalizumab XOSPATA gilteritinib XTANDI enzalutamide YERVOY ipilimumab ZAVESCA miglustat ZAXINE rifaximin ZEJULA niraparib ZELBORAF vemurafenib 6 © Express Scripts Canada. All rights reserved.

ZEMAIRA alpha-1 proteinase inhibitor ZEPATIER elbasvir/grazoprevir ZEPOSIA ozanimod HCL ZINBRYTA daclizumab beta ZIRABEV bevacizumab ZOLINZA vorinostat ZYDELIG idelalisib ZYKADIA ceritinib ZYTIGA abiraterone

7 © Express Scripts Canada. All rights reserved.