Prior Authorization Programs for Members on the Basic Drug List, Basic Annual Drug List, Enhanced Drug List Or Enhanced Annual Drug List

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Prior Authorization Programs for Members on the Basic Drug List, Basic Annual Drug List, Enhanced Drug List or Enhanced Annual Drug List

Drug Category* Prescription Drugs within the Category* Non-Specialty Prior Authorization Actinic Keratosis Diclofenac Gel: Solaraze/ diclofenac gel

Fluorouracil Cream: Carac, Efudex, Efudex Cream Kit, Fluoroplex, Fluorouracil Cream, Tolak

Imiquimod Cream: Aldara, Zyclara/ imiquimod

Ingenol Gel: Picato Afrezza Afrezza Alternative Dosage Carafate suspension Tiglutik † Form Naprosyn suspension Amifampridine Firdapse Ruzurgi (formerly Firdapse)† Androgens/Anabolic Steroids Anadrol-50 Jatenzo Androderm Methitest Androgel/ testosterone Natesto Android/ methyltestosterone Oxandrin Androxy Striant Aveed Testim Axiron/ testosterone solution Testopel danazol Testred/ methyltestosterone Delatestryl Vogelxo Depo-Testosterone Xyosted Fortesta Antifungal Agents Cresemba Tolsura† Noxafil Vfend/ voriconazole Antifungal Agents – Jublia Penlac/ ciclopirox Onychomycosis Kerydin Sporanox Onmel Bonjesta/Diclegis Bonjesta Diclegis/ doxylamine - pyridoxine Calcitonin Gene-Related Aimovig Emgality Peptide (CGRP) Ajovy Cannabidiol Epidiolex Circadian Rhythm Disorders Hetlioz Combination NSAIDs Consensi Vimovo (formerly Combination GI 1 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 1019 Protectants) Duexis Yosprala Erectile Dysfunction Caverject Muse (ED) Cialis/ tadalafil Staxyn Edex Stendra Levitra/ vardenafil Viagra/sildenafil Human Fibrinogen Fibryga RiaSTAP Concentrate† Hyperhidrosis† Qbrexza Hyperpolarization-Activated Corlanor Cyclic Nucleotide-Gated (HCN) Channel Blocker Hypoactive Sexual Addyi Desire Disorder (HSDD) (formerly Addyi) Insulin Agents Admelog Humalog Mix 50/50 Apidra Humulin R U-100 Humalog Humulin N Humalog Junior KwikPen Humulin 70/30 Humalog KwikPen U200 Humalog Mix 75/25 Keveyis Keveyis Metformin ER Fortamet/ metformin extended-release Glumetza/ metformin extended- release Multisource Brand AirDuo Respiclick Narcolepsy Nuvigil Provigil Neuropathy Lyrica CR Nocturia Nocdurna† Noctiva Northera Northera Ophthalmic Cequa Xiidra Immunomodulators Restasis Opioid Antidote Evzio Opioid Induced Movantik Symproic Constipation Relistor Oral Tetracycline Derivatives Doxycycline products: Acticlate/generic doxycycline, Adoxa, Doryx (and (formerly generic equivalents), Doryx MPC (and generic equivalents), Doxycycline, Doxycycline/Minocycline) Monodox, Oracea, Targadox, Vibramycin

Minocycline products: Minocin, minocycline tablet, Minocycline SR (and generic equivalents), Minolira, Solodyn (and generic equivalents), Ximino

Tetracycline products: Seysara

Orilissa† Orilissa Pseudobulbar Affect Nuedexta Rayos Rayos Regranex Regranex Selective Serotonin Inverse Nuplazid Agonist (SSIA) Therapeutic Alternatives Absorica Librax

Allzital Locort Amrix Lorzone Aplenzin Naprelan Ativan Nesina Auvi-Q Noritate Azelex Oseni Bupap Pandel Cambia Sitavig Cardizem CD Spritam Carospir Taperdex Pak Chlorzoxazone/ Parafon Forte Tivorbex Cuprimine Vanatol LQ Daraprim Vanos Dexpak Vivlodex Diflorasone/Psorcon cream† Wellbutrin XL diflorasone ointment† Zegerid/ omeprazole-sodium Durlaza bicarbonate Dutoprol† Zipsor Dxevo Zodex Pak Fenoprofen Zonacort Fexmid/ cyclobenzaprine Zorvolex Kazano Zyflo Kenalog spray† Zyflo CR/ zileuton CR Levorphanol Topical Doxepin Doxepin cream Zonalon Prudoxin Topical Lidocaine Lidoderm/ lidocaine patch Synera† lidocaine ointment Ztlido Pliaglis† Topiramate ER Qudexy XR/Topiramate ER Trokendi XR Transmucosal Immediate Abstral Lazanda Release Fentanyl Actiq/ fentanyl lozenge Subsys Fentora Vascepa† Vascepa Vitamin B12 Deficiency Nascobal

Specialty Prior Authorization

Arikayce† Arikayce

Benlysta Benlysta Biologic Immunomodulators Actemra subcutaneous Remicade (Rheumatoid Cimzia Renflexis Arthritis/Psoriasis) Cosentyx Siliq Enbrel Simponi Entyvio Simponi ARIA Humira Skyrizi Humira Starter Kit Stelara Ilumya Stelara IV Inflectra Taltz 3

Kevzara Tremfya Kineret Xeljanz Olumiant Xeljanz XR Orencia subcutaneous Cerdelga Cerdelga Cystic Fibrosis Kalydeco Symdeko Orkambi Emflaza Emflaza Enzyme Deficiency Kuvan Palynziq Erythropoiesis Stimulating Aranesp Procrit Agents (ESAs) Epogen Retacrit Mircera Fabry Disease† Galafold Growth Hormone/ Egrifta Egrifta Omnitrope Genotropin Saizen Humatrope Serostim Norditropin Zomacton Nutropin AQ Zorbtive H.P. Acthar (Pituitary Hormone) H.P. Acthar Gel hATTR Amyloidosis Tegsedi Neuropathy† Hemlibra Hemlibra Hemophilia Factor VIII, IX Adynovate Idelvion Afstyla Jivi Alprolix Rebinyn Eloctate Hepatitis B and C Daklinza Sofosbuvir/Velpatasvir Epclusa Sovaldi Harvoni Technivie Ledipasvir/Sofosbuvir Viekira Pak Mavyret Viekira XR Olysio Vosevi Pegasys Zepatier Peg-Intron Hereditary Berinert Ruconest Angioedema Firazyr/ icatibant Takhzyro Haegarda Huntington’s Disease Austedo Xenazine/ tetrabenazine / Tardive Dyskinesia Ingrezza Hypercholesterolemia Juxtapid Praluent Kynamro Repatha Idiopathic Pulmonary Fibrosis Esbriet Ofev (IPF) Inherited Autoinflammatory Arcalyst Disorders Interleukin-4 (IL-4) Inhibitors Dupixent (formerly Injectable Atopic Dermatitis) Interleukin-5 (IL-5) Nucala 4

Inhibitors Korlym Korlym Multiple Sclerosis Ampyra Myalept Myalept Natpara Natpara Neurotrophic Oxervate Keratitis† Ocaliva Ocaliva Osteoporosis Forteo Tymlos Otezla Otezla Parkinson’s Disease Gocovri Osmolex ER Polycystic Kidney Disease Jynarque Procysbi† Procysbi Pulmonary Arterial Adcirca/ tadalafil Revatio Hypertension (PAH) Adempas Tracleer/ bosentan Letairis/ ambrisentan Tyvaso Opsumit Uptravi Orenitram Ventavis Self-Administered Oncology Afinitor Ninlaro Afinitor Disperz Odomzo Alecensa Piqray Alunbrig Pomalyst Balversa Revlimid Bosulif Rubraca Braftovi Rydapt Cabometyx Sprycel Calquence Stivarga Caprelsa Sutent Cometriq Sylatron Copiktra Tafinlar Cotellic Tagrisso Daurismo Talzenna Erivedge Tarceva/ erlotinib Erleada Targretin/ bexarotene Farydak Tasigna Gilotrif Temodar/ temozolomide Gleevec/ imatinib Thalomid Hexalen Tibsovo Hycamtin Tretinoin (oral) Ibrance Tykerb Iclusig Venclexta Idhifa Verzenio Imbruvica Vitrakvi Inlyta Vizimpro Iressa Votrient Jakafi Xalkori Kisqali Xeloda/ capecitabine Kisqali Femara Pack Xopata Lenvima Xpovio 5

Lonsurf Xtandi Lorbrena Yonsa Lynparza Zejula Lysodren Zelboraf Matulane Zolinza Mekinist Zydelig Mektovi Zykadia Nerlynx Zytiga/ abiraterone Nexavar Short Bowel Syndrome Gattex Sickle Cell Disease Endari Sodium Oxybate Xyrem (formerly Xyrem) Strensiq Strensiq Thrombopoietin Receptor Doptelet Promacta Agonists Mulpleta Tavalisse Urea Cycle Disorders Buphenyl/ sodium phenylbutyrate Ravicti

If you have any questions, call the number on the back of your member ID card.

*Third-party brand names are the property of their respective owners. These programs are subject to change from time to time and additional drugs may be added to the categories listed.

† Select plans only at this time. This change will not apply to the annual drug lists until 1/1/20.