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Prior Approval Drug List

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Prior Approval Drug List BCBSVT Formulary Prior Approval List As of: April 21, 2021 Helpful Tip: To search for a specific drug, use the find feature (Ctrl + F) Trade Name Chemical/Biological Name Class Prior Authorization Program FUSILEV LEVOLEUCOVORIN CALCIUM ADJUNCTIVE AGENTS UNCLASSIFIED DRUG PRODUCTS KHAPZORY LEVOLEUCOVORIN ADJUNCTIVE AGENTS UNCLASSIFIED DRUG PRODUCTS LEVOLEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM ADJUNCTIVE AGENTS UNCLASSIFIED DRUG PRODUCTS VISTOGARD URIDINE TRIACETATE ADJUNCTIVE AGENTS UNCLASSIFIED DRUG PRODUCTS ACTHAR CORTICOTROPIN ADRENAL HORMONES HORMONES BELRAPZO BENDAMUSTINE HCL ALKYLATING AGENTS ANTINEOPLASTICS BENDAMUSTINE HCL BENDAMUSTINE HCL ALKYLATING AGENTS ANTINEOPLASTICS BENDEKA BENDAMUSTINE HCL ALKYLATING AGENTS ANTINEOPLASTICS MELPHALAN FLUFENAMIDE INJECTION FOR INTRAVENOUS PEPAXTO ALKYLATING AGENTS ANTINEOPLASTICS USE TREANDA BENDAMUSTINE HCL ALKYLATING AGENTS ANTINEOPLASTICS DAW (DISPENSE AS WRITTEN) ALL CUSTOM EVKEEZA EVINACUMAB‐DGNB INJECTION ANGIOPOIETIN LIKE 3 INHIBITOR HOMOZYGOUS FAMILIAL HYPERCHOL BELVIQ LORCASERIN HCL ANOREXIANTS ANTI‐OBESITY DRUGS BELVIQ XR LORCASERIN HCL ANOREXIANTS ANTI‐OBESITY DRUGS CONTRAVE ER NALTREXONE HCL/BUPROPION HCL ANOREXIANTS ANTI‐OBESITY DRUGS DIETHYLPROPION HCL DIETHYLPROPION HCL ANOREXIANTS ANTI‐OBESITY DRUGS DIETHYLPROPION HCL ER DIETHYLPROPION HCL ANOREXIANTS ANTI‐OBESITY DRUGS LOMAIRA PHENTERMINE HCL ANOREXIANTS ANTI‐OBESITY DRUGS PHENDIMETRAZINE TARTRATE PHENDIMETRAZINE TARTRATE ANOREXIANTS ANTI‐OBESITY DRUGS QSYMIA PHENTERMINE/TOPIRAMATE ANOREXIANTS ANTI‐OBESITY DRUGS SAXENDA LIRAGLUTIDE ANOREXIANTS ANTI‐OBESITY DRUGS ABIRATERONE ACETATE ABIRATERONE ACETATE ANTIANDROGENS ANTINEOPLASTICS ERLEADA APALUTAMIDE ANTIANDROGENS ANTINEOPLASTICS NUBEQA DAROLUTAMIDE ANTIANDROGENS ANTINEOPLASTICS XTANDI ENZALUTAMIDE ANTIANDROGENS ANTINEOPLASTICS YONSA ABIRATERONE ACET,SUBMICRONIZED ANTIANDROGENS ANTINEOPLASTICS ZYTIGA ABIRATERONE ACETATE ANTIANDROGENS ANTINEOPLASTICS DIACOMIT STIRIPENTOL ANTICONVULSANTS CNS DRUGS EPIDIOLEX CANNABIDIOL (CBD) ANTICONVULSANTS CNS DRUGS LYRICA CR PREGABALIN ANTICONVULSANTS UNCLASSIFIED DRUG PRODUCTS BELLADONNA & OPIUM OPIUM/BELLADONNA ALKALOIDS ANTIDIARRHEALS ANALGESICS FASLODEX FULVESTRANT ANTIESTROGENS ANTINEOPLASTICS FULVESTRANT FULVESTRANT ANTIESTROGENS ANTINEOPLASTICS FOLOTYN PRALATREXATE ANTIMETABOLITES ANTINEOPLASTICS ONUREG AZACITADINE ANTIMETABOLITES ANTINEOPLASTICS VIDAZA AZACITIDINE ANTIMETABOLITES ANTINEOPLASTICS GOCOVRI AMANTADINE HCL ANTIPARKINSONISM AGENTS ANTIPARKINSON DRUGS INBRIJA LEVODOPA ANTIPARKINSONISM AGENTS ANTIPARKINSON DRUGS OSMOLEX ER AMANTADINE HCL ANTIPARKINSONISM AGENTS ANTIPARKINSON DRUGS COSENTYX 150MG SECUKINUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS COSENTYX 300MG SECUKINUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS ILUMYA TILDRAKIZUMAB‐ASMN ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS ORENCIA ABATACEPT SC INJECTION ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS OTEZLA APREMILAST TABLETS ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS SILIQ BRODALUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS SKYRIZI (2 SYRINGES) KIT RISANKIZUMAB‐RZAA ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS STELARA USTEKINUMAB ANTIPSORIATIC / ANTISEBORRHEIC IMMUNOSUPPRESSANTS TALTZ AUTOINJECTOR IXEKIZUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ AUTOINJECTOR (2 PACK) IXEKIZUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ AUTOINJECTOR (3 PACK) IXEKIZUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ SYRINGE IXEKIZUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TREMFYA GUSELKUMAB ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS LEMTRADA ALEMTUZUMAB INJECTION CD52‐DIRECTED CYTOLYTIC MONOCLONAL ANTIBODY MULTIPLE SCLEROSIS COSELA TRILACICLIB INJECTION FOR INTRAVENOUS USE CDK INHIBITOR ANTINEOPLASTICS ACETAMINOPHEN W/CODEINE ACETAMINOPHEN WITH CODEINE COMBINATION NARCOTIC /ANALGESICS ANALGESICS APADAZ BENZHYDROCODONE/ACETAMINOPHEN COMBINATION NARCOTIC /ANALGESICS ANALGESICS ASCOMP WITH CODEINE CODEINE/BUTALBITAL/ASA/CAFFEIN COMBINATION NARCOTIC /ANALGESICS ANALGESICS ASPIRIN WITH CODEINE ASPIRIN/CODEINE PHOSPHATE COMBINATION NARCOTIC /ANALGESICS ANALGESICS BENZHYDROCODONE‐ACETAMINOPHEN BENZHYDROCODONE/ACETAMINOPHEN COMBINATION NARCOTIC /ANALGESICS ANALGESICS BUTALBITAL/CAFF/APAP/CODEINE BUTALBIT/ACETAMIN/CAFF/CODEINE COMBINATION NARCOTIC /ANALGESICS ANALGESICS DVORAH ACETAMINOPHEN/CAFF/DIHYDROCOD COMBINATION NARCOTIC /ANALGESICS ANALGESICS FIORICET WITH CODEINE BUTALBIT/ACETAMIN/CAFF/CODEINE COMBINATION NARCOTIC /ANALGESICS ANALGESICS HYDROCODONE BIT‐IBUPROFEN HYDROCODONE/IBUPROFEN COMBINATION NARCOTIC /ANALGESICS ANALGESICS HYDROCODONE W/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN COMBINATION NARCOTIC /ANALGESICS ANALGESICS LORCET HYDROCODONE/ACETAMINOPHEN COMBINATION NARCOTIC /ANALGESICS ANALGESICS LORCET HD HYDROCODONE/ACETAMINOPHEN COMBINATION NARCOTIC /ANALGESICS ANALGESICS MARGESIC #3 ACETAMINOPHEN WITH CODEINE COMBINATION NARCOTIC /ANALGESICS ANALGESICS NALOCET OXYCODONE HCL/ACETAMINOPHEN COMBINATION NARCOTIC /ANALGESICS ANALGESICS OXYCODONE HCL‐IBUPROFEN IBUPROFEN/OXYCODONE HCL COMBINATION NARCOTIC /ANALGESICS ANALGESICS TYLENOL W/CODEINE ACETAMINOPHEN WITH CODEINE COMBINATION NARCOTIC /ANALGESICS ANALGESICS VUMERITY DIROXIMEL FUMARATE ORAL COPAXONE MISCELLANEOUS NEUROLOGICAL THERAPYMULTIPLE SCLEROSIS ARIPIPRAZOLE FOR EXTENDEDRELEASE INJECTABLE ABILIFY MAINTENA CUSTOM CUSTOM SUSPENSION FOR INTRAMUSCULAR USE APOKYN APOMORPHINE HYDROCHLORIDE INJCTION CUSTOM PARKINSON'S DISEASE CIALIS FOR BENIGN PROSTATIC HYPERTROPHY ONLY TADALAFIL CUSTOM CUSTOM COMPOUNDED* MEDICATIONS CUSTOM CUSTOM DISPENSE AS WRITTEN ‐ DAW BRAND‐ NAME DRUGS WITH GENERICS AVAILABLE CUSTOM CUSTOM ENTERAL NUTRITION AND MEDICAL FOOD CUSTOM CUSTOM Blue Cross and Blue Shield of Vermont Formulary *For compounds costing $300 or more Prior Approval List As of: 04/21/2021 | Rev: 04/21/2021 Trade Name Chemical/Biological Name Class Prior Authorization Program HIGH DOSE OPIOIDS CUSTOM CUSTOM INNOHEP TINZAPARIN CUSTOM CUSTOM LUTATHERA LUTETIUM LU 177 DOTATATE CUSTOM CUSTOM LUVERIS LUTROPIN ALFA CUSTOM CUSTOM IMMEDIATE RELEASE/ LONG ACTING IN OPIOID NAÏVE OPIOID NAIVE CUSTOM CUSTOM PERSON PRALUENT ALICROCUMAB CUSTOM CUSTOM PROVENGE SIPULEUCEL‐T CUSTOM CUSTOM REBETOL ROBAVIRIN CUSTOM CUSTOM REPATHA EVOLOCUMAB CUSTOM CUSTOM SEROQUEL QUETIAPINE CUSTOM CUSTOM VIDAZA AZACITIDINE INJECTIONS CUSTOM CUSTOM VIMIZIM ELOSULFASE ALFA CUSTOM CUSTOM VPRIV VELAGLUCERASE ALFA CUSTOM CUSTOM YONDELIS TRABECTEDIN CUSTOM CUSTOM ZOMACTRA HIGH CUSTOM CUSTOM ARANESP DARBOEPOETIN ALFA ERYTHROID STIMULANTS COLONY STIMULATING FACTORS EPOGEN EPOETIN ALFA ERYTHROID STIMULANTS COLONY STIMULATING FACTORS MIRCERA EPOETIN BETA ERYTHROID STIMULANTS COLONY STIMULATING FACTORS REBLOZYL LUSPATERCEPT‐AAMT ERYTHROID STIMULANTS UNCLASSIFIED DRUG PRODUCTS RETACRIT EPOETIN ALFA‐EPBX ERYTHROID STIMULANTS COLONY STIMULATING FACTORS DANYELZA® NAXITAMAB‐GQGK INJECTION GD2 BINDING MONOCLONAL ANTIBODY ANTINEOPLASTIC UNITUXIN® DINUTUXIMAB INJECTION FOR INTRAVENOUS INJECTION GD2 BINDING MONOCLONAL ANTIBODY ANTINEOPLASTIC ORGOVYX™ RELUGOLIX TABLETS GNRH RECEPTOR ANTAGONIST ANTIEOPLASTIC ORILISSA ELAGOLIX SODIUM GONADOTROPIN & RELATED AGENTS HORMONES GENOTROPIN SOMATROPIN GROWTH HORMONES HORMONES NORDITROPIN FLEXPRO SOMATROPIN GROWTH HORMONES HORMONES NUTROPIN AQ NUSPIN SOMATROPIN GROWTH HORMONES HORMONES OMNITROPE SOMATROPIN GROWTH HORMONES HORMONES SAIZEN SOMATROPIN GROWTH HORMONES HORMONES SAIZENPREP SOMATROPIN GROWTH HORMONES HORMONES SEROSTIM SOMATROPIN GROWTH HORMONES HORMONES ZOMACTON SOMATROPIN GROWTH HORMONES HORMONES ZORBTIVE SOMATROPIN GROWTH HORMONES HORMONES AIMOVIG AUTOINJECTOR ERENUMAB‐AOOE HEADACHE THERAPY ANALGESICS AJOVY FREMANEZUMAB‐VFRM HEADACHE THERAPY ANALGESICS EMGALITY GALCANEZUMAB‐GNLM HEADACHE THERAPY ANALGESICS EMGALITY SYRINGE GALCANEZUMAB‐GNLM HEADACHE THERAPY ANALGESICS DOPTELET AVATROMBOPAG MALEATE HEMOSTATICS COLONY STIMULATING FACTORS MULPLETA LUSUTROMBOPAG HEMOSTATICS COLONY STIMULATING FACTORS NPLATE ROMIPLOSTIM HEMOSTATICS COLONY STIMULATING FACTORS WILATE ANTIHEMOPHILIC FACTOR/VWF HEMOSTATICS BLOOD HETLIOZ TASIMELTEON HYPNOTIC AGENTS SEDATIVE/HYPNOTICS ZEPOSIA OZANIMOD IMMUNOMODULATOR MULTIPLE SCLEROSIS GAMIFANT EMAPALUMAB‐LZSG IMMUNOSUPPRESSANT DRUGS IMMUNOSUPPRESSANTS EXTAVIA INTERFERON BETA‐1B INTERFERONS CNS DRUGS PEGASYS PEGINTERFERON ALFA‐2A INTERFERONS ANTIVIRALS PLEGRIDY PEGINTERFERON BETA‐1A INTERFERONS CNS DRUGS REBIF INTERFERON BETA‐1A/ALBUMIN INTERFERONS CNS DRUGS REBIF REBIDOSE INTERFERON BETA‐1A/ALBUMIN INTERFERONS CNS DRUGS AYVAKIT AVAPRITINIB TABLET KINASE INHIBITOR ANTINEOPLASTICS TEPMETKO® TEPOTINIB TABLETS KINASE INHIBITOR ANTI‐NEOPLASTIC JUXTAPID LOMITAPIDE MESYLATE LIPID LOWERING/CHOLESTEROL CARDIOVASCULAR NEXLETOL BEMPEDOIC ACID ORAL LIPID LOWERING/CHOLESTEROL HYPERLIPIDEMIA NEXLIZET BEMPEDOIC ACID/EZETIMIBE ORAL LIPID LOWERING/CHOLESTEROL HYPERLIPIDEMIA PRALUENT PEN ALIROCUMAB LIPID LOWERING/CHOLESTEROL CARDIOVASCULAR REPATHA PUSHTRONEX EVOLOCUMAB LIPID LOWERING/CHOLESTEROL CARDIOVASCULAR REPATHA SURECLICK EVOLOCUMAB LIPID LOWERING/CHOLESTEROL CARDIOVASCULAR REPATHA SYRINGE EVOLOCUMAB LIPID LOWERING/CHOLESTEROL CARDIOVASCULAR ABECMA IDECABTAGENE VICLEUCEL INJECTION MISELLANEOUS ANTI‐NEOPLASTIC ADCETRIS BRENTUXIMAB INJECTION MISCELLANEOUS ANTINEOPLASTICS AMONDYS 45 CASIMERSIN INTRAVENOUS INFUSION MISCELLANEOUS MUSCULAR DYSTROPHY ARZERRA OFATUZUMAB INJECTION MISCELLANEOUS ANTINEOPLASTICS BLENREP BELANTAMAB MAFODOTIN‐BLMF MISCELLANEOUS ANTINEOPLASTICS LISOCABTAGENE MARALEUCEL SUSPENSION FOR BREYANZI MISCELLANEOUS ANTI‐NEOPLASTIC INTRAVENOUS INFUSION DACOGEN DECITABIN INJECTION MISCELLANEOUS
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