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 Type 2 Diabetes Gralise** gabapentin Postherpetic Neuralgia Agent timothy grass pollen allergen Grastek Allergy Immunotherapy extract Harvoni ledipasvir/sofosbuvir Hepatitis C NS5A/Polymerase Inhibitor Hetlioz tasimelteon Non-24-Hour Sleep-Wake Disorder Hizentra immune globulin-subcutaneous Subcutaneous Immune Globulin Horizant** gabapentin enacarbil Restless Legs Syndrome/Postherpetic 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 Hymovis sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection Hyqvia immune globulin-subcutaneous Subcutaneous Immune Globulin Impavido miltefosine Antileishmanial Increlex mecasermin Growth Hormone Iveegam EN immune globulin-intravenous Intravenous Immune Globulin IVIG or IGIV immune globulin-intravenous Intravenous Immune Globulin Jentadueto/XR* linagliptin/metformin Type 2 Diabetes Jublia** efinaconazole Antifungal Juxtapid lomitapide Homozygous Familial Hypercholesterolemia Kalbitor ecallantide Hereditary Angioedema Kalydeco ivacaftor Cystic Fibrosis Kanuma selbelipase alfa Enzyme Kazano alogliptin/metformin Type 2 Diabetes Kerydin** tavaborole Antifungal Keveyis diclorphenamide Carbonic Anhydrase Inhibitor Kombiglyze XR** saxagliptin/metformin Type 2 Diabetes Korlym mifepristone Endocrine/Cushing’s Disease
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 Krystexxa pegloticase Gout Kuvan sapropterin Phenylketonuria Kynamro mipomersen Homozygous Familial Hypercholesterolemia Lazanda Nasal Spray fentanyl citrate Controlled Dangerous Substance Lemtrada alemtuzumab Multiple Sclerosis Letairis ambrisentan Pulmonary Vasodilator Liberty Test Strip blood glucose test strips Blood Glucose Test Strips Lidoderm lidocaine Topical Anesthetic Livalo** pitavastatin calcium Cholesterol Lovaza omega-3-acid ethyl esters Omega-3 Fatty Acid Lumigan bimatoprost Anti-Glaucoma Luzu** luliconazole Antifungal Makena hydroxyprogesterone Hormone Mentax** butenafine Antifungal Mircera pegylated epoetin beta Red Blood Cell Progenitor Monovisc sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection Myalept metreleptin Leptin Analog Myobloc rimabotulinumtoxinB Specialty Drug Naftifine** naftifine Antifungal Naftin** naftifine Antifungal Natesto testosterone Topical Testosterone Drug Nesina alogliptin Type 2 Diabetes Neurontin** gabapentin Postherpetic Neuralgia/Anticonvulsant Norditropin somatropin Growth Hormone Northera droxidopa Neurogenic Orthostatic Hypotension Nucala mepolizumab Monoclonal Antibody Nutropin somatropin Growth Hormone Nutropin AQ somatropin Growth Hormone Nuvigil armodafinil CNS Stimulant Ocaliva obeticholic acid Bile Acid Analog Octagam immune globulin-intravenous Intravenous Immune Globulin Ofev nintedanib Pulmonary Fibrosis Olysio simeprevir Hepatitis C Protease Inhibitor Omnitrope 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 One Touch Test Strips blood glucose test strips Blood Glucose Test Strips One Touch Ultra Test Strips blood glucose test strips Blood Glucose Test Strips Onglyza** saxagliptin Type 2 Diabetes Onmel itraconazole Antifungal Onsolis fentanyl soluble film Controlled Dangerous Substance Opsumit macitentan Pulmonary Vasodilator sweet vernal, orchard, perennial rye, timothy and kentucky blue Oralair Allergy Immunotherapy grass mixed pollens allergen extract Oravig** miconazole Antifungal Orencia / Clickject abatacept Selective Co-Stimulation Modulator for RA Orenitram treprostinil Pulmonary Vasodilator Orkambi lumacaftor/ivacaftor Cystic Fibrosis Orthovisc high molecular weight hyaluronan Hyaluronic Acid Derivative for Joint Injection Otezla apremilast Phosphodiesterase Inhibitor Arthritis/Polyarticular Juvenile Idiopathic Arthritis/ Otrexup** methotrexate Psoriasis Oxycontin- quantities oxycodone extended release Controlled Dangerous Substance greater than 90 per month Oxistat** oxiconazole Antifungal Pegasys peginterferon alfa-2a Interferon Peg-Intron peginterferon alfa-2b Interferon Perforomist** formoterol fumarate Beta Adrenergic (nebulized) PhosLo calcium acetate Phosphate Binder Phoslyra calcium acetate Phosphate Binder Pradaxa** dabigatran etexilate Anticoagulant Praluent alirocumab Cholesterol Precision SOF-TACT Test blood glucose test strips Blood Glucose Test Strips Strips Precision Xtra Test Strips blood glucose test strips Blood Glucose Test Strips Polygam S/D immune globulin-intravenous Intravenous Immune Globulin Privigen immune globulin-intravenous Intravenous Immune Globulin Prestige Test Strips blood glucose test strips Blood Glucose Test Strips Procrit epoetin alfa Red Blood Cell Progenitor Procysbi cysteamine bitartrate Nephropathic Cystinosis Agent
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 Prodigy Test Strips blood glucose test strips Blood Glucose Test Strips Prolia denosumab Osteoporosis/Bones Protopic** tacrolimus Immunomodulator Provenge sipuleucel-T Oncology Proventil HFA** albuterol Short Acting Beta Adrenergic (inhaled) Provigil modafinil CNS Stimulant Pulmicort Flexhaler** budesonide Corticosteroid (Inhaled) Qudexy XR** topiramate extended release Anticonvulsant Qutenza capsaicin Topical Anesthetic short ragweed pollen allergen Ragwitek Allergy Immunotherapy extract Rasuvo** methotrexate Rheumatoid Arthritis/ Psoriasis Rayos** prednisone Corticosteroid Reclast zoledronic acid Osteoporosis/Bones Relion Test Strips blood glucose test strips Blood Glucose Test Strips Remicade infliximab Monoclonal Antibody Remodulin treprostinil sodium Pulmonary Vasodilator Renagel sevelamer Phosphate Binder Renvela sevelamer Phosphate Binder Repatha evolocumab Cholesterol Restasis** cyclosporine Anti-Inflammatory/Immunomodulator Retin-A tretinoin Anti-Acne Retin-A Micro tretinoin Anti-Acne Revatio sildenafil citrate Pulmonary Vasodilator Rituxan rituximab Monoclonal Antibody C1 esterase inhibitor Ruconest Hereditary Angioedema (recombinant) Sabril vigabatrin Anticonvulsant Saizen somatropin Growth Hormone Savaysa** edoxaban Anticoagulant Seebri Neohaler** glycopyrrolate Anticholinergic Serostim somatropin Growth Hormone Signifor pasireotide Somatostatin/Cushing’s Disease Signifor LAR pasireotide Somatostatin/Acromegaly Simponi golimumab Anti-Tumor Necrosis Factor Drug
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 Sitavig** acyclovir Antiviral/Herpes Sovaldi sofosbuvir Hepatitis C Polymerase Inhibitor Spritam levetiracetam Anticonvulsant Stelara ustekinumab Anti-Tumor Necrosis Factor Drug Stiolto Respimat** tiotropium bromide/olodaterol Beta Adrenergic/Anticholinergic (Inhaled) Strensiq asfotase alfa Hypophosphatasia Striant testosterone Topical Testosterone Drug Subutex** buprenorphine Controlled Dangerous Substance Suboxone SL Film buprenorphine and naloxone Controlled Dangerous Substance Suboxone SL Tablets buprenorphine and naloxone Controlled Dangerous Substance Subsys fentanyl sublingual spray Controlled Dangerous Substance Supartz sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection SureStep Test Strips blood glucose test strips Blood Glucose Test Strips Symlin pramlintide Amylin Analogue Synagis palivizumab Monoclonal Antibody 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 Taltz ixekizumab Monoclonal Antibody Tanzeum albiglutide Incretin Mimetic Agent Technivie ombitasvir, paritaprevir, ritonavir Hepatitis C Testim testosterone Topical Testosterone Drug Tev-Tropin somatropin Growth Hormone Tobi/Tobi Podhaler** tobramycin Cystic Fibrosis Topiramate ER** topiramate extended release Anticonvulsant Tracleer bosentan Pulmonary Vasodilator Tradjenta* linagliptin Type 2 Diabetes Travatan Z travoprost Anti-Glaucoma Travoprost travoprost Anti-Glaucoma Tresiba* insulin degludec Insulin Tretin-X tretinoin Anti-Acne Trokendi XR** topiramate extended release Anticonvulsant Trulicity dulaglutide Incretin Mimetic Agent Tudorza Pressair** aclidinium Anticholinergic (Inhaled)
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 Tyvaso treprostinil Pulmonary Vasodilator Tysabri natalizumab Monoclonal Antibody Unistrip1 blood glucose test strips Blood Glucose Test Strips Uptravi selexipag Pulmonary Vasodilator Utibron Neohaler** indacaterol/glycopyrrolate Beta Adrenergic/Anticholinergic (Inhaled) Vascepa icosapent ethyl Omega-3 Fatty Acid Vecamyl** mecamylamine hydrochloride Antihypertensive Veletri epoprostenol sodium Pulmonary Vasodilator Velphoro sucroferric oxyhydroxide Phosphate Binder Veltin tretinoin/clindamycin Anti-Acne Ventavis iloprost Pulmonary Vasodilator Victoza liraglutide Incretin Mimetic Agent ombitasvir/paritaprevir/ritonavir/ Viekira Pak/XR Hepatitis C dasabuvir Vogelxo testosterone Testosterone Replacement WaveSense Test Strips blood glucose test strips Blood Glucose Test Strips Wellbutrin SR/XL** bupropion Antidepressant Xalatan latanoprost Anti-Glaucoma Xeljanz/XR tofacitinib Janus Kinase Inhibitor Xenazine tetrabenazine Huntington’s Chorea Xeomin incobotulinumtoxinA Specialty Drug Xgeva denosumab Oncology/Bones Xiaflex collagenase clostridium Cord Injection Xigduo XR** dapagliflozin Type 2 Diabetes Xiidra lifitegrast Dry Eye Disease Xolair omalizumab Monoclonal Antibody Xolegel** ketoconazole Antifungal Xopenex HFA** albuterol Short Acting Beta Adrenergic (Inhaled) Xuriden uridine triacetate granule Hereditary Orotic Aciduria Xyrem** sodium oxybate Narcolepsy Zepatier elbasvir/grazoprevir Hepatitis C Ziana tretinoin/clindamycin Anti-Acne Zinbryta daclizumab Monoclonal Antibody Zioptan tafluprost Anti-Glaucoma
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 Zomacton somatropin Growth Hormone Zometa zoledronic acid Oncology/Bones Zorbtive somatropin Growth Hormone Zovirax cream/ointment** acyclovir Antiviral/Herpes Zubsolv buprenorphine and naloxone Controlled Dangerous Substance Zyflo/Zyflo CR** zileuton Asthma Therapy
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