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ESC Prior Authorization Program Drug List

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ESC Prior Authorization Program Drug List 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 June 17, 2021 Drug Chemical ingredient ABSTRAL fentanyl ACTEMRA tocilizumab ADALIMUMAB adalimumab ADCIRCA tadalafil ADDYI flibanserin ADEMPAS riociguat AFINITOR/AFINITOR DISPERZ everolimus AIMOVIG erenumab AJOVY fremanezumab ALECENSARO alectinib ALPHA1-PROTEINASE INHIBITOR alpha1-proteinase inhibitor ALUNBRIG brigatinib AMGEVITA adalimumab ARZERRA ofatumumab AUBAGIO teriflunomide AVASTIN bevacizumab AVSOLA infliximab BALVERSA erdafitinib BANZEL rufinamide BAVENCIO avelumab BENLYSTA belimumab BEOVU brolucizumab BESPONSA inotuzumab ozogamicin BIO-TROPIN somatropin BOSULIF bosutinib BOTOX onabotulinumtoxinA BRENZYS etanercept BRUKINSA zanubrutinib CABLIVI caplacizumab 1 © Express Scripts Canada. All rights reserved. Drug Chemical ingredient CABOMETYX cabozantinib CALQUENCE acalabrutinib CAPRELSA vandetanib CARBAGLU carglumic acid CERDELGA eliglustat tartrate CIMZIA certolizumab CINQAIR reslizumab COPAXONE Glatiramer acetate COSENTYX secukinumab COTELLIC cobimetinib CRESEMBA isavuconazonium sulfate CRYSVITA burosumab CUVPOSA glycopyrrolate CYRAMZA ramucirumab CYSTADROPS cysteamine hcl DACOGEN decitabine 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 2 © Express Scripts Canada. All rights reserved. Drug Chemical ingredient FAMPYRA fampridine FASENRA benralizumab FENTORA fentanyl FIRAZYR icatibant FIRDAPSE amifampridine phosphate FORTEO teriparatide GALAFOLD migalastat hydrochloride GALEXOS simeprevir GAZYVA obinutuzumab GENOTROPIN somatropin GILENYA fingolimod GIOTRIF afatinib dimaleate GIVLAARI givosiran HADLIMA adalimumab HANZEMA alitretinoin HARVONI sofosbuvir/ledipasvir HIZENTRA immune globulin HOLKIRA PAK ombitasvir/paritaprevir/ritonavir/dasabuvir HULIO adalimumab HUMATROPE somatropin HUMIRA adalimumab HYRIMOZ adalimumab IBAVYR ribavirin IBRANCE palbociclib ICLUSIG ponatinib IDACIO adalimumab IDHIFA enasidenib mesylate ILARIS canakinumab ILUMYA tildrakizumab IMBRUVICA ibrutinib IMFINZI durvalumab INFLECTRA infliximab INLYTA axitinib INQOVI cedazuridine-decitabine INREBIC fedratinib HCL IRESSA gefitinib JAKAVI ruxolitinib JETREA ocriplasmin 3 © Express Scripts Canada. All rights reserved. Drug Chemical ingredient JINARC tolvaptan JUXTAPID lomitapide KALYDECO ivacaftor KESIMPTA ofatumumab KEVZARA sarilumab KEYTRUDA pembrolizumab KINERET anakinra KISQALI ribociclib succinate KUVAN sapropterin KYNMOBI apomorphine HCL LEMTRADA alemtuzumab LENVIMA lenvatinib LIBTAYO cemiplimab LONSURF trifluridine/tipiracil HCL LORBRENA lorlatinib LUCENTIS ranibizumab LYNPARZA olaparib MACUGEN pegaptanib sodium MAVENCLAD cladribine MAVIRET glecaprevir-pibrentasvir MAYZENT siponimod MDK-NITISINONE nitisinone MEKINIST trametinib MOVAPO apomorphine HCL MVASI bevacizumab NERLYNX neratinib NEXAVAR sorafenib NINLARO ixazomib citrate NITISINONE TAB nitisinone NORDITROPIN SIMPLEXX / NORDITROPIN NORDIFLEX somatropin NPLATE romiplostim NUBEQA darolutamide NUCALA mepolizumab NUTROPIN / NUTROPIN AQ / NUTROPIN AQ NUSPIN somatropin OCALIVA obeticholic acid OCREVUS ocrelizumab ODOMZO sonidegib OFEV nintedanib 4 © Express Scripts Canada. All rights reserved. Drug Chemical ingredient 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 PHEBURANE sodium phenylbutyrate PIQRAY alpelisib POMALYST pomalidomide PONVORY ponesimod PRALUENT alirocumab PREVYMIS letermovir PROCYSBI mercaptamine bitartrate PROLASTIN alpha1-proteinase inhibitor QINLOCK ripretinib RAVICTI glycerol phenylbutyrate REBLOZYL luspatercept RELISTOR methylnaltrexone bromide REMICADE infliximab REMSIMA infliximab REPATHA evolocumab REPLAGAL agalsidase alfa REVATIO sildenafil REVESTIVE teduglutide REVLIMID lenalidomide REVOLADE eltrombopag RIABNI rituximab RINVOQ upadacitinib RITUXAN / RITUXAN SC rituximab RIXIMYO rituximab ROZLYTREK entrectinib RUXIENCE rituximab 5 © Express Scripts Canada. All rights reserved. Drug Chemical ingredient RUZURGI amifampridine RYDAPT midostaurin SAIZEN somatropin SAMSCA tolvaptan SATIVEX delta-9-tetrahydrocannabinol—cannabidiol SEROSTIM somatropin SIGNIFOR / SIGNIFOR LAR pasireotide SILIQ brodalumab SIMPONI golimumab SKYRIZI risankizumab SOMAVERT pegvisomant SOVALDI sofosbuvir SPRAVATO esketamine SPRYCEL dasatinib monohydrate STELARA ustekinumab STIVARGA regorafenib SUNOSI Solriamfetol hcl SUTENT sunitinib SYMDEKO tezacaftor-ivacaftor TAFINLAR dabrafenib TAGRISSO osimertinib TAKHZYRO lanadelumab TALTZ ixekizumab TALZENNA talazoparib TARCEVA erlotinib TASIGNA nilotinib TAVALISSE fostamatinib TECENTRIQ atezolizumab TECFIDERA dimethyl fumarate TEGSEDI inotersen sodium TEMODAL temozolomide THALOMID thalidomide TOCTINO alitretinoin TREANDA bendamustine TREMFYA guselkumab TRUXIMA rituximab TUKYSA tucatinib TYKERB lapatinib 6 © Express Scripts Canada. All rights reserved. Drug Chemical ingredient TYSABRI natalizumab UPTRAVI selexipag VECTIBIX panitumumab VENCLEXTA venetoclax VERZENIO abemaciclib VIDAZA azacitidine VIMIZIM elosulfase alfa VITRAKVI larotrectinib VIZIMPRO dacomitnib VOLIBRIS ambrisentan VOSEVI sofosbuvir/velpatasvir/voxilap VOTRIENT pazopanib VYEPTI eptinezumab VYNDAQEL tafamidis meglumine XALKORI crizotinib XELJANZ tofacitinib XEOMIN incobotulinumtoxinA XERMELO telotristat etiprate XIAFLEX collagenase clostridium histolyticum XOLAIR omalizumab XOSPATA gilteritinib fumarate XTANDI enzalutamide YERVOY ipilimumab ZAVESCA miglustat ZAXINE rifaximin ZELBORAF vemurafenib ZEMAIRA alpha1-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. .
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