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Prescription Drugs Requiring Prior Authorization PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION Revised 10/16 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 Controlled Dangerous Substance Accu-Chek Test Strips blood glucose test strips Blood Glucose Test Strips Actemra tocilizumab Monoclonal Antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate OTFC Controlled Dangerous Substance Adcirca tadalafil Pulmonary Vasodilator Adempas riociguat Pulmonary Vasodilator Adlyxin lixisenatide Type 2 Diabetes Advocate Test Strips blood glucose test strips Blood Glucose Test Strips Aerospan** flunisolide Corticosteroids (Inhaled) Afrezza insulin Insulin (inhaled) Ampyra dalfampridine Multiple Sclerosis Agent Altoprev** lovastatin Cholesterol Alvesco** ciclesonide Corticosteroids (Inhaled) Amrix** cyclobenzaprine Skeletal Muscle Relaxant Androderm testosterone Topical Testosterone Drug Androgel testosterone Topical Testosterone Drug Apidra insulin glulisine [rDNA origin] Human Insulin Analog Aplenzin** bupropion Antidepressant Aranesp darbepoetin alfa Red Blood Cell Progenitor Arcapta Neohaler** indacaterol Beta Adrenergic (Inhaled) Asmanex HFA/Twisthaler** mometasone Corticosteroid (Inhaled) Atralin tretinoin Anti-Acne Auryxia ferric citrate Phosphate Binder Avita tretinoin Anti-Acne Axiron testosterone Topical Testosterone Drug Benlysta belimumab Lupus Berinert C1 esterase inhibitor Hereditary Angioedema Betaseron interferon beta-1b Multiple Sclerosis Agent Bethkis** tobramycin Cystic Fibrosis Bevespi Aerosphere glycopyrrolate/formoterol fumarate Beta Adrenergic/Anticholinergic (inhaled) Bivigam immune globulin-intravenous Intravenous Immune Globulin Boniva Syringe ibandronate Osteoporosis/Bones 04HQ3249 R10/16 *Removing from Prior Authorization list effective for 1/1/2017 **Addition to Prior Authorization list effective for 1/1/2017 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION Revised 10/16 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 Botox onabotulinumtoxinA Specialty Drug Briviact brivaracetam Anticonvulsant Brovana** aformoterol tartrate Beta Adrenergic (Nebulized) Bunavail buprenorphine/naloxone Controlled Dangerous Substance Bydureon exenatide ER Incretin Mimetic Agent Byetta exenatide Incretin Mimetic Agent Carimune NF immune globulin-intravenous Intravenous Immune Globulin Cayston** aztreonam Cystic Fibrosis Cholbam cholic acid Bile Acid Cialis tadalafil Benign Prostatic Hyperplasia Cimzia certolizumab pegol Anti-Tumor Necrosis Factor Drug Cinryze C1 esterase inhibitor Hereditary Angioedema Cinqair reslizumab Monoclonal Antibody Cosentyx secukinumab Interleukin-17 Receptor Antagonist Crestor** rosuvastatin Cholesterol Cuprimine** penicillamine Wilson’s Disease/Cystinuria/Rheumatoid Arthritis Cuvitru immune globulin-subcutaneous Subcutaneous Immune Globulin Daklinza daclatasvir dihydrochloride Hepatitis C Daraprim** pyrimethamine Antimalarial Denavir** penciclovir Antiviral/Herpes Dulera** mometasone/formoterol Beta Adrenergic/Corticosteroid (Inhaled) Durlaza aspirin ER Antiplatelet Dysport onabotulinumtoxinA Specialty Drug Ecoza** econazole Antifungal Edarbi azilsartan Hypertension Edarbyclor azilsartan/chlorthalidone Hypertension Egrifta tesamorelin HIV Associated Lipodystrophy Embrace Pro Test Strips blood glucose test strips Blood Glucose Test Strips Elidel** tacrolimus Immunomodulator Enbrel etanercept Anti-Tumor Necrosis Factor Drug Entyvio vedolizumab Monoclonal Antibody Epclusa sofosbuvir/velpatasvir Hepatitis C Epogen epoetin alfa Red Blood Cell Progenitor Ertaczo** sertaconazole Antifungal 04HQ3249 R10/16 *Removing from Prior Authorization list effective for 1/1/2017 **Addition to Prior Authorization list effective for 1/1/2017 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION Revised 10/16 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 Esbriet pirfenidone Pulmonary Fibrosis Evencare Mini Glucose Test blood glucose test strips Blood Glucose Test Strips Strips Euflexxa sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection Evzio** naloxone hcl injection Opiate Reversal Agent Exelderm** sulconazole Antifungal Exondyx 51 eteplirsen Duchenne Muscular Dystrophy Extina** ketoconazole Antifungal Farxiga** dapagliflozin Type 2 Diabetes Fentora fentanyl buccal tablet Controlled Dangerous Substance Fexmid** cyclobenzaprine Skeletal Muscle Relaxant Firazyr icatibant Hereditary Angioedema Flexeril** cyclobenzaprine Skeletal Muscle Relaxant Flolan epoprostenol sodium Pulmonary Vasodilator Flebogamma immune globulin-intravenous Intravenous Immune Globulin 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 Strips blood glucose test strips Blood Glucose Test Strips 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 teduglitide [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 04HQ3249 R10/16 *Removing from Prior Authorization list effective for 1/1/2017 **Addition to Prior Authorization list effective for 1/1/2017 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION Revised 10/16 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 Genstrip Test Strips blood glucose test strips Blood Glucose Test Strips GenVisc 850 sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection Glucose Test Strip blood glucose test strips Blood Glucose Test Strips Glucophage XR** metformin Type 2 Diabetes Glumetza** metformin
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