BCBSVT Open Formulary Prior Approval List As of: 10/27/2020 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 TREANDA BENDAMUSTINE HCL ALKYLATING AGENTS ANTINEOPLASTICS DAW (DISPENSE AS WRITTEN) ALL CUSTOM 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 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 CUSTOM 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 HIGH DOSE OPIOIDS CUSTOM CUSTOM INNOHEP TINZAPARIN CUSTOM CUSTOM LUTATHERA LUTETIUM LU 177 DOTATATE CUSTOM CUSTOM LUVERIS LUTROPIN ALFA CUSTOM CUSTOM
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program IMMEDIATE RELEASE/ LONG ACTING IN OPIOID NAÏVE OPIOID NAIVE CUSTOM CUSTOM PERSON PEGASYS PEGYLATED INTERFERON ALFA 2A CUSTOM CUSTOM PEG‐INTRON PEGYLATED INTERFERON ALFA 2A CUSTOM CUSTOM 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 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 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 SARCLISA ISATUXIMAB INJECTION MISCELLAENOUS ANTINEOPLASTICS ADCETRIS BRENTUXIMAB INJECTION MISCELLANEOUS ANTINEOPLASTICS ARZERRA OFATUZUMAB INJECTION MISCELLANEOUS ANTINEOPLASTICS BLENREP BELANTAMAB MAFODOTIN‐BLMF MISCELLANEOUS ANTINEOPLASTICS DACOGEN DECITABIN INJECTION MISCELLANEOUS ANTINEOPLASTICS GIVLAARI GIVOSIRAN INJECTION MISCELLANEOUS HEPATOLOGY HALAVEN ERIBULIN MESYLATE INJECTION MISCELLANEOUS ANTINEOPLASTICS TRASTUZUMAB‐PKRB INJECTION FOR INTRAVENOUS HERZUMA MISCELLANEOUS ANTINEOPLASTICS INFUSION KANJINTI TRASTUZUMAB‐ANNS INJECTION MISCELLANEOUS ANTINEOPLASTICS KOSELUGO SELUMETINIB CAPSULES MISCELLANEOUS ANTINEOPLASTICS TRASTUZUMAB‐DKST INJECTION FOR INTRAVENOUS OGIVRI MISCELLANEOUS ANTINEOPLASTICS INFUSION TRASTUZUMAB‐DTTB INJECTION FOR INTRAVENOUS ONTRUZANT MISCELLANEOUS ANTINEOPLASTICS INFUSION PEMAZYRE PEMIGATINIB TABLETS MISCELLANEOUS ANTINEOPLASTICS THIOTEPA INJECTION FOR IV, INTRACAVITARY OR TEPADINE MISCELLANEOUS ANTINEOPLASTICS INTRAVESICAL USE TEPEZZA TEPROTUMUMAB INJECTION MISCELLANEOUS OPTHALMOLOGY TORISEL TEMSIROLIMUS INJECTION MISCELLANEOUS ANTINEOPLASTICS TRASTUZUMAB‐QYYP INJECTION FOR INTRAVENOUS TRAZIMERA MISCELLANEOUS ANTINEOPLASTICS INFUSION TRISENOX ARSENIC TRIOXIDE INJECTION MISCELLANEOUS ANTINEOPLASTICS TUKYSA TUCATINIB TABLETS MISCELLANEOUS ANTINEOPLASTICS VALCHLOR MECHLORETHAMINE GEL FOR TOPICAL USE MISCELLANEOUS ANTINEOPLASTICS VALSTAR VALRUBICIN SOLUTION FOR INTRAVESICAL USE MISCELLANEOUS ANTINEOPLASTICS VYEPTI EPTINEZUMAB INJECTION MISCELLANEOUS MIGRAINE VYXEOS DAUNORUBICIN AND CYTARABINE LIPOSOME FOR INJECTION MISCELLANEOUS ANTINEOPLASTICS ZALTRAP ZIV‐AFLIBERCEPT INJECTION MISCELLANEOUS ANTINEOPLASTICS ARALAST NP ALPHA‐1‐PROTEINASE INHIBITOR MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS CERDELGA ELIGLUSTAT TARTRATE MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS CHEMET SUCCIMER MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program CRYSVITA BUROSUMAB‐TWZA MISCELLANEOUS AGENTS BIOLOGICALS DEFERASIROX DEFERASIROX MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS DMAE DEANOL MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS ELELYSO TALIGLUCERASE ALFA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS EXJADE DEFERASIROX MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS FABRAZYME AGALSIDASE BETA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS FERRIPROX DEFERIPRONE MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS GALAFOLD MIGALASTAT HCL MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS GLASSIA ALPHA‐1‐PROTEINASE INHIBITOR MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS JADENU DEFERASIROX MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS JADENU SPRINKLE DEFERASIROX MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS JYNARQUE TOLVAPTAN MISCELLANEOUS AGENTS DIURETICS MIGLUSTAT MIGLUSTAT MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS NITISINONE NITISINONE MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS NITYR NITISINONE MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS NOCDURNA DESMOPRESSIN ACETATE MISCELLANEOUS AGENTS HORMONES NOCTIVA DESMOPRESSIN ACETATE MISCELLANEOUS AGENTS HORMONES PALYNZIQ PEGVALIASE‐PQPZ MISCELLANEOUS AGENTS BIOLOGICALS ALPHA‐1‐PROTEINASE INHIBITOR LYOPHILIZED POWDER AND PROLASTIN‐C MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS SOLUTION RECLAST ZOLEDRONIC ACID/MANNITOL‐WATER MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS REVCOVI ELAPEGADEMASE‐LVLR MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS SAMSCA TOLVAPTAN MISCELLANEOUS AGENTS DIURETICS SOLIRIS ECULIZUMAB MISCELLANEOUS AGENTS BLOOD STRENSIQ ASFOTASE ALFA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS SYNAREL NAFARELIN ACETATE MISCELLANEOUS AGENTS HORMONES ULTOMIRIS RAVULIZUMAB‐CWVZ MISCELLANEOUS AGENTS BLOOD VIMIZIM ELOSULFASE ALFA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS VPRIV VELAGLUCERASE ALFA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS XIAFLEX COLLAGENASE CLOSTRIDIUM HIST. MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS ZAVESCA MIGLUSTAT MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS ZEMAIRA ALPHA‐1‐PROTEINASE INHIBITOR MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL‐WATER MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE MISCELLANEOUS ANALGESICS ANALGESICS DUROLANE HYALURONATE SODIUM, STABILIZED MISCELLANEOUS ANALGESICS ANTIARTHRITICS EUFLEXXA HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS GEL‐ONE HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS GELSYN‐3 HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS GENVISC 850 HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS HYMOVIS HYALURONATE,MOD.,NON‐CROSSLINK MISCELLANEOUS ANALGESICS ANTIARTHRITICS MONOVISC HYALURONATE SODIUM, STABILIZED MISCELLANEOUS ANALGESICS ANTIARTHRITICS NALBUPHINE HCL NALBUPHINE HCL MISCELLANEOUS ANALGESICS ANALGESICS NUCYNTA ER TAPENTADOL HCL MISCELLANEOUS ANALGESICS ANALGESICS ORTHOVISC HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS PENTAZOCINE AND NALOXONE HCL PENTAZOCINE HCL/NALOXONE HCL MISCELLANEOUS ANALGESICS ANALGESICS SODIUM HYALURONATE 1% INJECTION HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS SUPARTZ FX HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS SYNVISC HYLAN HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS SYNVISC‐ONE HYLAN HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS TRAMADOL HCL TRAMADOL HCL MISCELLANEOUS ANALGESICS ANALGESICS TRAMADOL HCL ER TRAMADOL HCL MISCELLANEOUS ANALGESICS ANALGESICS TRAMADOL HCL‐ACETAMINOPHEN TRAMADOL HCL/ACETAMINOPHEN MISCELLANEOUS ANALGESICS ANALGESICS TRILURON HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS TRIVISC HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS VISCO‐3 HYALURONATE SODIUM MISCELLANEOUS ANALGESICS ANTIARTHRITICS NUPLAZID PIMAVANSERIN TARTRATE MISCELLANEOUS ANTIDEPRESSANTS PSYCHOTHERAPEUTIC DRUGS SPRAVATO ESKETAMINE HCL MISCELLANEOUS ANTIDEPRESSANTS PSYCHOTHERAPEUTIC DRUGS ZULRESSO BREXANOLONE MISCELLANEOUS ANTIDEPRESSANTS PSYCHOTHERAPEUTIC DRUGS ARIKAYCE AMIKACIN LIPOSOMAL/NEB.ACCESSR MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS BETHKIS TOBRAMYCIN MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS KITABIS PAK TOBRAMYCIN/NEBULIZER MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS LINEZOLID LINEZOLID MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS SIVEXTRO TEDIZOLID PHOSPHATE MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS TOBI TOBRAMYCIN IN 0.225% SOD CHLOR MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS TOBI PODHALER TOBRAMYCIN MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS TOBRAMYCIN SULFATE TOBRAMYCIN IN 0.225% SOD CHLOR MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS ADAKVEO CRIZANLIZUMAB‐TMCA MISCELLANEOUS ANTINEOPLASTIC DRUGS BLOOD AFINITOR EVEROLIMUS MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS AFINITOR DISPERZ EVEROLIMUS MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ALECENSA ALECTINIB HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ALIQOPA COPANLISIB DI‐HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ALUNBRIG BRIGATINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ASPARLAS CALASPARGASE PEGOL‐MKNL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS AVASTIN BEVACIZUMAB INJECTION FOR INTRAVENOUS INJECTION MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BALVERSA ERDAFITINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BAVENCIO AVELUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BELEODAQ BELINOSTAT MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BESPONSA INOTUZUMAB OZOGAMICIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BEXAROTENE BEXAROTENE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BLINCYTO BLINATUMOMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BOSULIF BOSUTINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BRAFTOVI ENCORAFENIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BRUKINSA ZANUBRUTINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS CABOMETYX CABOZANTINIB S‐MALATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS CALQUENCE ACALABRUTINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS CARMUSTINE CARMUSTINE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program COMETRIQ CABOZANTINIB S‐MALATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS COPIKTRA DUVELISIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS COTELLIC COBIMETINIB FUMARATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS CYRAMZA RAMUCIRUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS DARZALEX DARATUMUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS DARZALEX FASPRO DARATUMUMAB/HYALURONIDASE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS DAURISMO GLASDEGIB MALEATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ELIGARD LEUPROLIDE ACETATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ELZONRIS TAGRAXOFUSP‐ERZS MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS EMPLICITI ELOTUZUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ERBITUX CETUXIMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ERIVEDGE VISMODEGIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ERLOTINIB HCL ERLOTINIB HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ERWINAZE ASPARAGINASE (ERWINIA CHRYSAN) MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS FARYDAK PANOBINOSTAT LACTATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS FENSOLVI LEUPROLIDE ACETATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS FIRMAGON DEGARELIX MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS GAVRETO PRALSETINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS GAZYVA OBINUTUZUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS GILOTRIF AFATINIB DIMALEATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS GLEEVEC IMATINIB MESYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS HERCEPTIN TRASTUZUMAB INTRAVENOUS INFUSION MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS HERCEPTIN HYLECTA TRASTUZUMAB‐HYALURONIDASE‐OYSK MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS HYCAMTIN TOPOTECAN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IBRANCE PALBOCICLIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ICLUSIG PONATINIB HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IDHIFA ENASIDENIB MESYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IMATINIB MESYLATE IMATINIB MESYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IMBRUVICA IBRUTINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IMFINZI DURVALUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IMLYGIC TALIMOGENE LAHERPAREPVEC MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INLYTA AXITINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INQOVI DECITABINE/CEDAZURIDINE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INREBIC FEDRATINIB DIHYDROCHLORIDE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IRESSA GEFITINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IXEMPRA IXABEPILONE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS JAKAFI RUXOLITINIB PHOSPHATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS JELMYTO MITOMYCIN URETERAL GEL (PYELOCALYCEAL) MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS JEVTANA CABAZITAXEL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KADCYLA ADO‐TRASTUZUMAB EMTANSINE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TRASTUZUMAB‐ANNS INJECTION FOR INTRAVENOUS KANJINTI MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INFUSION KEYTRUDA PEMBROLIZUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KEYTRUDA PEMBROLIZUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KISQALI RIBOCICLIB SUCCINATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KISQALI FEMARA CO‐PACK RIBOCICLIB SUCCINATE/LETROZOLE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KYMRIAH TISAGENLECLEUCEL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KYPROLIS CARFILZOMIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LENVIMA LENVATINIB MESYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LIBTAYO CEMIPLIMAB‐RWLC MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LONSURF TRIFLURIDINE/TIPIRACIL HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LORBRENA LORLATINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LUMOXITI MOXETUMOMAB PASUDOTOX‐TDFK MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LUPRON DEPOT LEUPROLIDE ACETATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LUPRON DEPOT‐PED LEUPROLIDE ACETATE MISCELLANEOUS ANTINEOPLASTIC DRUGS HORMONES LYNPARZA OLAPARIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS MEKINIST TRAMETINIB DIMETHYL SULFOXIDE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS MEKTOVI BINIMETINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS MONJUVI TAFASITAMAB‐CXIX INJECTION FOR INTRAVENOUS USE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BEVACIZUMAB‐AWWB INJECTION FOR INTRAVENOUS MVASI MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INFUSION MYLOTARG GEMTUZUMAB OZOGAMICIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS NERLYNX NERATINIB MALEATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS NEXAVAR SORAFENIB TOSYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS NILANDRON NILUTAMIDE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS NINLARO IXAZOMIB CITRATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ODOMZO SONIDEGIB PHOSPHATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS OGIVRI TRASTUZUMAB‐DKST MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ONCASPAR PEGASPARGASE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ONIVYDE IRINOTECAN LIPOSOMAL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS OPDIVO NIVOLUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS OPDIVO NIVOLUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS PERJETA PERTUZUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS PHESGO PERTUZUMAB/TRASTUZUMAB/HYALURONIDASE INJECTION MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS PIQRAY ALPELISIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS POLIVY POLATUZUMAB VEDOTIN‐PIIQ MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS POMALYST POMALIDOMIDE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS PORTRAZZA NECITUMUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS POTELIGEO MOGAMULIZUMAB‐KPKC MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS PROLEUKIN ALDESLEUKIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS QINLOCK REPRITINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS QINLOCK RIPRETINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RETEVMO SELPERCATINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS REVLIMID LENALIDOMIDE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RITUXAN RITUXIMAB FOR INTRAVENOUS INFUSION MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program RITUXAN HYCELA RITUXIMAB/HYALURONIDASE,HUMAN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ROMIDEPSIN ROMIDEPSIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ROZLYTREK ENTRECTINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RUBRACA RUCAPARIB CAMSYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RUXIENCE RITUXIMAB‐OVVR IV INJECTION MISCELLENEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RYDAPT MIDOSTAURIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS SIGNIFOR LAR PASIREOTIDE PAMOATE MISCELLANEOUS ANTINEOPLASTIC DRUGS HORMONES SPRYCEL DASATINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS STIVARGA REGORAFENIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS SUPPRELIN LA HISTRELIN ACETATE MISCELLANEOUS ANTINEOPLASTIC DRUGS HORMONES SUTENT SUNITINIB MALATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS SYLATRON PEGINTERFERON ALFA‐2B MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS SYLVANT SILTUXIMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS SYNRIBO OMACETAXINE MEPESUCCINATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TABRECTA CAPMATINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TAFINLAR DABRAFENIB MESYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TAGRISSO OSIMERTINIB MESYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TALZENNA TALAZOPARIB TOSYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TARCEVA ERLOTINIB HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TARGRETIN BEXAROTENE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TASIGNA NILOTINIB HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TAZVERIK TAZEMETOSTAT MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BREXUCABTAGENE AUTOLEUCEL SUSPENSION FOR TECARTUS MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INTRAVENOUS INJECTION TECENTRIQ ATEZOLIZUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS THALOMID THALIDOMIDE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTIBIOTICS TIBSOVO IVOSIDENIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TRELSTAR TRIPTORELIN PAMOATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TRIPTODUR TRIPTORELIN PAMOATE MISCELLANEOUS ANTINEOPLASTIC DRUGS HORMONES TRODELVY SACITUZUMAB GOVITECAN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TRUXIMA RITUXIMAB‐ABBS INJECTION FOR INTRAVEOUS USE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TURALIO PEXIDARTINIB HYDROCHLORIDE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TYKERB LAPATINIB DITOSYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VANTAS HISTRELIN ACETATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VECTIBIX PANITUMUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VENCLEXTA VENETOCLAX MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VENCLEXTA STARTING PACK VENETOCLAX MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VERZENIO ABEMACICLIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VITRAKVI LAROTRECTINIB SULFATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VIZIMPRO DACOMITINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VOTRIENT PAZOPANIB HCL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS XALKORI CRIZOTINIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS XERMELO TELOTRISTAT ETIPRATE MISCELLANEOUS ANTINEOPLASTIC DRUGS GASTROINTESTINAL XGEVA DENOSUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS XOSPATA GILTERITINIB FUMARATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS XPOVIO SELINEXOR MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS YERVOY IPILIMUMAB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS YESCARTA AXICABTAGENE CILOLEUCEL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS YONDELIS TRABECTEDIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ZEJULA NIRAPARIB TOSYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ZEPZELCA LURBINECTEDIN INJECTION MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BEVACIZUMAB‐BVZR INJECTION FOR INTRAVENOUS ZIRABEV MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INFUSION ZOLINZA VORINOSTAT MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ZYDELIG IDELALISIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS QUETIAPINE FUMARATE QUETIAPINE FUMARATE MISCELLANEOUS ANTIPSYCHOTICS PSYCHOTHERAPEUTIC DRUGS SEROQUEL QUETIAPINE FUMARATE MISCELLANEOUS ANTIPSYCHOTICS PSYCHOTHERAPEUTIC DRUGS EPCLUSA SOFOSBUVIR/VELPATASVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS HARVONI LEDIPASVIR/SOFOSBUVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS LEDIPASVIR‐SOFOSBUVIR LEDIPASVIR/SOFOSBUVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS MAVYRET GLECAPREVIR/PIBRENTASVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS SOFOSBUVIR‐VELPATASVIR SOFOSBUVIR/VELPATASVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS SOVALDI SOFOSBUVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS VIEKIRA PAK OMBITA/PARITAP/RITON/DASABUVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS VOSEVI SOFOSBUVIR/VELPATAS/VOXILAPREV MISCELLANEOUS ANTIVIRALS ANTIVIRALS ZEPATIER ELBASVIR/GRAZOPREVIR MISCELLANEOUS ANTIVIRALS ANTIVIRALS VYNDAMAX TAFAMIDIS MISCELLANEOUS CARDIOVASCULAR AGENTS UNCLASSIFIED DRUG PRODUCTS VYNDAQEL TAFAMIDIS MEGLUMINE MISCELLANEOUS CARDIOVASCULAR AGENTS UNCLASSIFIED DRUG PRODUCTS ADVATE ANTIHEMOPHIL.FVIII,FULL LENGTH MISCELLANEOUS COAGULATION AGENTS BLOOD ADYNOVATE ANTIHEMO.FVIII,FULL LENGTH PEG MISCELLANEOUS COAGULATION AGENTS BLOOD AFSTYLA ANTIHEM.FVIII,SIN‐CHN,B‐DM TRU MISCELLANEOUS COAGULATION AGENTS BLOOD ALPHANATE ANTIHEMOPHILIC FACTOR/VWF MISCELLANEOUS COAGULATION AGENTS BLOOD CABLIVI CAPLACIZUMAB‐YHDP MISCELLANEOUS COAGULATION AGENTS BLOOD ELOCTATE ANTIHEMOPHILIC FACTOR FC FUSION PROTEIN MISCELLANEOUS COAGULATION AGENTS BLOOD ESEROCOT ANTIHEMOPHILIC FACTOR GLYCOPEGYLATED MISCELLANEOUS COAGULATION AGENTS BLOOD HELIXATE ANTIHEMOPHILIC FACTOR MISCELLANEOUS COAGULATION AGENTS BLOOD HEMLIBRA EMICIZUMAB‐KXWH MISCELLANEOUS COAGULATION AGENTS BLOOD HEMOFIL‐MANTIHEMOPHILIC FACTOR, HUMAN MISCELLANEOUS COAGULATION AGENTS BLOOD ANTIHEMOPHILIC FACTOR/ VON WILLEBRAND FACTOR HUMATE‐P MISCELLANEOUS COAGULATION AGENTS BLOOD COMPLEX INJECTION JIVI FVIII REC,B‐DOM DELET PEG‐AUCL MISCELLANEOUS COAGULATION AGENTS BLOOD KOATE ANTIHEMOPHILIC FACTOR, HUMAN MISCELLANEOUS COAGULATION AGENTS BLOOD KOGENATE FS ANTIHEMOPHILIC FACTOR MISCELLANEOUS COAGULATION AGENTS BLOOD KOVALTRY ANTIHEMOPHIL.FVIII,FULL LENGTH MISCELLANEOUS COAGULATION AGENTS BLOOD MONOCLATE‐PANTIHEMOPHILIC FACTOR MISCELLANEOUS COAGULATION AGENTS BLOOD NOVOEIGHT ANTIHEMOPH.FVIII,B‐DOM TRUNCAT MISCELLANEOUS COAGULATION AGENTS BLOOD
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program NUWIQ ANTIHEMOPH.FVIII,HEK B‐DELETE MISCELLANEOUS COAGULATION AGENTS BLOOD RECOMBINATE ANTIHEMOPHILIC FACTOR MISCELLANEOUS COAGULATION AGENTS BLOOD TAVALISSE FOSTAMATINIB DISODIUM MISCELLANEOUS COAGULATION AGENTS UNCLASSIFIED DRUG PRODUCTS XYNTHA ANTIHEMOPH.FVIII,B‐DOMAIN DEL MISCELLANEOUS COAGULATION AGENTS BLOOD XYNTHA SOLOFUSE ANTIHEMOPH.FVIII,B‐DOMAIN DEL MISCELLANEOUS COAGULATION AGENTS BLOOD DUPIXENT DUPILUMAB MISCELLANEOUS DERMATOLOGICALS IMMUNOSUPPRESSANTS QBREXZA GLYCOPYRRONIUM TOSYLATE MISCELLANEOUS DERMATOLOGICALS SKIN PREPS ANTIINFLAM.TUMOR NECROSIS AVSOLA INFLIXIMAB‐AXXQ INTRAVENOUS INFUSION MISCELLANEOUS GASTROINTESTINAL AGENTS FACTOR INHIBITING AGENTS ANTIINFLAM.TUMOR NECROSIS CIMZIA CERTOLIZUMAB PEGOL MISCELLANEOUS GASTROINTESTINAL AGENTS FACTOR INHIBITING AGENTS ENTYVIO VEDOLIZUMAB MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL ANTIINFLAM.TUMOR NECROSIS INFLECTRA INFLIXIMAB‐DYYB INTRAVENOUS INFUSION MISCELLANEOUS GASTROINTESTINAL AGENTS FACTOR INHIBITING AGENTS OCALIVA OBETICHOLIC ACID MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL ANTIINFLAM.TUMOR NECROSIS REMICADE INFLIXIMAB INTRAVENOUS INFUSION MISCELLANEOUS GASTROINTESTINAL AGENTS FACTOR INHIBITING AGENTS ANTIINFLAM.TUMOR NECROSIS RENFLEXIS INFLIXIMAB‐ABDA INTRAVENOUS INFUSION MISCELLANEOUS GASTROINTESTINAL AGENTS FACTOR INHIBITING AGENTS AMPYRA DALFAMPRIDINE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS AUBAGIO TERIFLUNOMIDE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS AUSTEDO DEUTETRABENAZINE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS AVONEX INTERFERON BETA‐1A MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS BAFIERTAM MONOMETHYL FUMARATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS BETASERON INTERFERON BETA‐1B MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS COPAXONE GLATIRAMER ACETATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS EVRYSDI RISDIPLAM ORAL SOLUTION MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS EXONDYS 51 ETEPLIRSEN MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS GILENYA FINGOLIMOD HCL MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS GLATIRAMER ACETATE GLATIRAMER ACETATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS GLATOPA GLATIRAMER ACETATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS INGREZZA VALBENAZINE TOSYLATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS INGREZZA INITIATION PACK VALBENAZINE TOSYLATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS KESIMPTA OFATUMUMAB MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS MAVENCLAD CLADRIBINE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS MAYZENT SIPONIMOD MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS OCREVUS OCRELIZUMAB MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS ONPATTRO PATISIRAN SODIUM,LIPID COMPLEX MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS SPINRAZA NUSINERSEN SODIUM/PF MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS TECFIDERA DIMETHYL FUMARATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS TEGSEDI INOTERSEN SODIUM MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS TETRABENAZINE TETRABENAZINE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS TYSABRI NATALIZUMAB MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS VILTEPSO VILTOLARSEN MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS VUMERITY DIROXIMEL FUMARATE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS XENAZINE TETRABENAZINE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS ZOLGENSMA ONASEMNOGENE ABEPARVOVEC‐XIOI MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS ARGININE ARGININE MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O AXONA NUT.TX,METAB.DIS, MV‐MINS NO.2 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O BETAQUIK MEDIUM CHAIN TRIGLYCERIDES MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O COMPLEX MSUD NUTRIT. TX, MSUD WITHOUT IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O CYCLINEX‐1 INF.FORMULA,UREA CYCLE DISORDR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O CYCLINEX‐2 NUT.THERAPY,UREA CYCLE DISORDR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O CYTO ARG ARGININE MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O CYTO RALA R‐LIPOIC ACID MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O EAA NUT.TX FOR PKU WITH IRON NO.13 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O EO28 SPLASH NUT.TX.IMPAIRED DIGESTIVE FXN MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O GA‐1 ANAMIX EARLY YEARS INF FOR, GLUTAR ACID I/DHA/ARA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O GERBER EXTENSIVE HA INF FORM,SP.MET,LF,IRON/B.ANIM MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O GLUTARADE GA‐1NUT TX, GA 1/FLAXSEED/FIBER MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O GLUTAREX‐1INF FORM, GLUTARIC ACIDURIA I MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O GLUTAREX‐2 NUT.THERAP.GLUTARIC ACIDURIA 1 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O GLYTACTIN 10 PE COMPLETE NUTRITIONAL TX FOR PKU, NO.62 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O GLYTACTIN SWIRL 15 PE NUTRITIONAL TX FOR PKU NO.69 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O HCU ANAMIX EARLY YEARS INF.FORM,METAB,IRON METHION‐FR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O HCU ANAMIX NEXT NUT.TX,METABOLIC DIS,METHIO‐FR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O HCU EASY NUT.TX,METABOLIC DIS,METHIO‐FR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O HOMINEX‐1 INF.FORM,METAB,IRON METHION‐FR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O HOMINEX‐2 NUT.TX,METABOLIC DIS,METHIO‐FR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O ISOVACTIN AA PLUS 20 PE NUT TX FOR ISOVALERIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O IVA ANAMIX EARLY YEARS INF FORM, ISOVAL IRON/DHA/ARA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O IVA ANAMIX NEXT INF. FORM, ISOVALERIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O I‐VALEX‐1INF. FORM, ISOVALERIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O I‐VALEX‐2NUT TX FOR ISOVALERIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O KETONEX‐1INFANT FORMULA WITH IRON, MSUD MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O KETONEX‐2 NUTRIT.THERAPY, MSUD WITH IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O LANAFLEX NUT.TX FOR PKU WITH IRON NO.25 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O LEUCINE LEUCINE MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O LEU‐FREE COOLER NUT.TX,METAB.DIS,LEUCINE‐FREE MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O LIPISTART NUT.TX.IMPAIRED DIGESTIVE FXN MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O LIQUIGEN MEDIUM CHAIN TRIGLYCERIDES MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O LOPHLEX NUT. TX FOR PKU WITH IRON NO.7 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O MCT PRO‐CAL NUT.TX.IMPAIRED DIGESTIVE FXN MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O METHIONAID NUT.TX,METABOLIC DIS,METHIO‐FR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O MMA‐PA ANAMIX EARLY YEARS INF FORM, PROPIONIC AC/DHA/ARA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O MMA‐PA ANAMIX NEXT INFANT FORM,PROPIONIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program MONOGEN NUT.TX.IMPAIRED DIGEST FXN/MCT MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O MSUD AID NUTRIT.THERAPY, MSUD WITH IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O MSUD ANAMIX EARLY YEARS INFANT FORMULA WITH IRON, MSUD MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O MSUD EASY NUTRIT. TX, MSUD WITHOUT IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O MSUD EXPRESS COOLER NUTRIT.THERAPY, MSUD WITH IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O NEOCATE JUNIOR NUT.TX.IMPAIRED DIGESTIVE FXN MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O NUTRAMIGEN DHA‐ARA INF.FORMULA,IRON,SP.MET.LAC‐FR MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PERIFLEX INFANT INFANT FORM.FOR PKU,IRON NO.4 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PERIFLEX LQ PKU NUT.TX FOR PKU WITH IRON NO.2 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENACTIN AA PLUS 20 PE NUT.TX FOR PKU WITH IRON NO.59 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENEX‐1INFANT FORMULA PKU,IRON NO.2 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENEX‐2NUT.THERAPY FOR PKU, IRON NO.1 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENYLADE NUTRITIONAL TX FOR PKU NO.31 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENYLADE ESSENTIAL NUT.TX FOR PKU WITH IRON NO.35 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENYLADE GMP NUT.TX FOR PKU WITH IRON NO.57 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENYLADE GMP MIX‐IN NUT. TX FOR PKU,NO.66 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENYLADE MTE NUTRITIONAL TX FOR PKU NO.31 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENYLADE PHEBLOC NUTRITIONAL TX FOR PKU NO.33 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHENYLADE60 NUT.TX FOR PKU WITH IRON NO.27 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PHLEXY‐VITS NUTRITIONAL SUPPLEMENT MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PKU COOLER 10 NUT.TX FOR PKU WITH IRON NO.4 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PKU COOLER 15 NUT.TX FOR PKU WITH IRON NO.4 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PKU COOLER 20 NUT.TX FOR PKU WITH IRON NO.4 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PKU PERIFLEX EARLY YEARS INFANT FORM.FOR PKU,IRON NO.4 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PKU SPHERE20 NUTRITIONAL TX FOR PKU NO.67 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PORTAGEN NUT.TX.IMPAIRED DIGEST FXN/MCT MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PRODUCT 3232A INFANT FORM,IRON,LAC‐FR,HYPOAL MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PROMACTIN AA PLUS 20 PE NUT. TX FOR PROPIONIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PRO‐PHREE INFANT FORMULA, METABOLIC,IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PROPIMEX‐1INFANT FORM,PROPIONIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PROPIMEX‐2NUT. TX FOR PROPIONIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PURAMINO JR NUT.TX.IMPAIRED DIGESTIVE FXN MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O PURAMINO TODDLER NUT.TX.IMPAIRED DIGESTIVE FXN MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O RENA START NUT.TX,IMPAIRED RENAL FXN,WHEY MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O TYR ANAMIX EARLY YEARS INF FORM FOR TYROSINEMIA, IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O TYR ANAMIX NEXT NUT TX FOR TYROSINEMIA W‐IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O TYREX‐1INF FORM FOR TYROSINEMIA, IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O TYREX‐2NUT TX FOR TYROSINEMIA W‐IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O ULTRIENT 1.5 WITH ENFIT NUTRITIONAL SUPPLEMENT MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O VILACTIN AA PLUS 20 PE NUTRIT.THERAPY, MSUD WITH IRON MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O XLEU MAXAMUM NUT TX FOR ISOVALERIC ACIDEMIA MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O XPHE MAXAMUM NUT. TX FOR PKU WITH IRON NO.6 MISCELLANEOUS NUTRITION PRODUCTS ELECT/CALORIC/H2O BEOVU BROLUCIZUMAB‐DBLL MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS EYLEA AFLIBERCEPT MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS LUCENTIS RANIBIZUMAB INTRAVITREAL INJECTION MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS LUXTURNA VORETIGENE NEPARVOVEC‐RZYL MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS MACUGEN PEGAPTANIB SODIUM MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS OXERVATE CENEGERMIN‐BKBJ MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS ADDYI FLIBANSERIN MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS ARMODAFINIL ARMODAFINIL MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS VYLEESI BREMELANOTIDE ACETATE MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS WAKIX PITOLISANT HCL MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS CNS DRUGS ADCIRCA TADALAFIL MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR ADEMPAS RIOCIGUAT MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR ALYQ TADALAFIL MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR AMBRISENTAN AMBRISENTAN MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR BERINERT C1 ESTERASE INHIBITOR MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS BOSENTAN BOSENTAN MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR CINQAIR RESLIZUMAB MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS CINRYZE C1 ESTERASE INHIBITOR MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS ESBRIET PIRFENIDONE MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS FASENRA BENRALIZUMAB MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS FASENRA PEN BENRALIZUMAB MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS FIRAZYR ICATIBANT ACETATE MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS HAEGARDA C1 ESTERASE INHIBITOR MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS ICATIBANT ICATIBANT ACETATE MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS KALBITOR ECALLANTIDE MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS KALYDECO IVACAFTOR MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS LETAIRIS AMBRISENTAN MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR NUCALA MEPOLIZUMAB MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS OFEV NINTEDANIB ESYLATE MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS OPSUMIT MACITENTAN MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR ORKAMBI LUMACAFTOR/IVACAFTOR MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS REVATIO SILDENAFIL CITRATE MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR RUCONEST C1 ESTERASE INHIBITOR, RECOMB MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS SILDENAFIL CITRATE SILDENAFIL CITRATE MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR SYMDEKO TEZACAFTOR/IVACAFTOR MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS TAKHZYRO LANADELUMAB‐FLYO MISCELLANEOUS PULMONARY AGENTS BIOLOGICALS TRACLEER BOSENTAN MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR TRIKAFTA ELEXACAFTOR/TEZACAFTOR/IVACAFT MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS TYVASO TREPROSTINIL/NEBULIZER/ACCESOR MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR VENTAVIS ILOPROST TROMETHAMINE MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR XOLAIR OMALIZUMAB MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS ACTEMRA TOCILIZUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS IMMUNOSUPPRESSANTS ACTEMRA ACTPEN TOCILIZUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS IMMUNOSUPPRESSANTS BENLYSTA IV (PA required effective 08‐15‐2020) BELIMUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS UNCLASSIFIED DRUG PRODUCTS
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program BENLYSTA SQ BELIMUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS UNCLASSIFIED DRUG PRODUCTS CUPRIMINE PENICILLAMINE MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS DEPEN PENICILLAMINE MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS D‐PENAMINE PENICILLAMINE MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS ANTIINFLAM.TUMOR NECROSIS ENBREL ETANERCEPT SC INJECTION MISCELLANEOUS RHEUMATOLOGICAL AGENTS FACTOR INHIBITING AGENTS ANTIINFLAM.TUMOR NECROSIS HUMIRA ADALIMUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS FACTOR INHIBITING AGENTS ANTIINFLAM.TUMOR NECROSIS HUMIRA PEDIATRIC ADALIMUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS FACTOR INHIBITING AGENTS KEVZARA SARILUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS IMMUNOSUPPRESSANTS KINERET ANAKINRA SC INJECTION MISCELLANEOUS RHEUMATOLOGICAL AGENTS IMMUNOSUPPRESSANTS OLUMIANT BARICITINIB MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS OLUMIANT BARICITINIB TABLETS MISCELLANEOUS RHEUMATOLOGICAL AGENTS IMMUNOSUPPRESSANTS ORENCIA ABATACEPT MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS ORENCIA CLICKJECT ABATACEPT MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS PENICILLAMINE PENICILLAMINE MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS RINVOQ ER UPADACITINIB MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS ANTIINFLAM.TUMOR NECROSIS SIMPONI GOLIMUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS FACTOR INHIBITING AGENTS ANTIINFLAM.TUMOR NECROSIS SIMPONI ARIA GOLIMUMAB MISCELLANEOUS RHEUMATOLOGICAL AGENTS FACTOR INHIBITING AGENTS XELJANZ TOFACITINIB CITRATE MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS XELJANZ XR TOFACITINIB CITRATE MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS TADALAFIL TADALAFIL MISCELLANEOUS UROLOGICALS UNCLASSIFIED DRUG PRODUCTS CARISOPRODOL‐ASPIRIN‐CODEINE CARISOPRODOL/ASPIRIN/CODEINE MUSCLE RELAXANTS & ANTISPASMODIC AGENTS ANALGESICS FULPHILA PEGFILGRASTIM‐JMDB INJECTION FOR SUBCUTANEOUS MYELOID STIMULANTS COLONY STIMULATING FACTORS GRANIX TBO‐FILGRASTIM MYELOID STIMULANTS COLONY STIMULATING FACTORS PEGFILGRASTIM INJECTION FOR SUBCUTANEOUS USE (INCLUDES SINGLE‐DOSE PREFILLED SYRINGES FOR MANUAL NEULASTA MYELOID STIMULANTS COLONY STIMULATING FACTORS USE AND SINGLE‐DOSE PREFILLED SYRINGE CO‐PACKAGED WITH THE ON‐BODY INJECTOR) FILGRASTIM INJECTION FOR SUBCUTANEOUS OR NEUPOGEN MYELOID STIMULANTS COLONY STIMULATING FACTORS INTRAVENOUS USE FILGRASTIM INJECTION FOR SUBCUTANEOUS OR NIVESTYM MYELOID STIMULANTS COLONY STIMULATING FACTORS INTRAVENOUS USE NIVESTYM FILGRASTIM‐AAFI MYELOID STIMULANTS COLONY STIMULATING FACTORS NYVEPRIA PEGFILGRASTIM‐APGF INJECTION FOR SUBCUTANEOUS USE MYELOID STIMULANTS COLONY STIMULATING FACTORS UDENYCA PEGFILGRASTIM‐CBQV INJECTION FOR SUBCUTANEOUS USE MYELOID STIMULANTS COLONY STIMULATING FACTORS ZARXIO FILGRASTIM MYELOID STIMULANTS COLONY STIMULATING FACTORS FILGRASTIM‐SNDZ INJECTION FOR SUBCUTANEOUS OR ZARXIO MYELOID STIMULANTS COLONY STIMULATING FACTORS INTRAVENOUS USE ZIEXTENZO PEGFILGRASTIM‐BMEZ INJECTION FOR SUBCUTANEOUS USE MYELOID STIMULANTS COLONY STIMULATING FACTORS LUCEMYRA LOFEXIDINE HCL NARCOTIC ANTAGONISTS UNCLASSIFIED DRUG PRODUCTS ABSTRAL FENTANYL CITRATE NARCOTICS ANALGESICS ALFENTANIL HYDROCHLORIDE ALFENTANIL HCL NARCOTICS ANALGESICS ARYMO ER MORPHINE SULFATE NARCOTICS ANALGESICS BELBUCA BUPRENORPHINE HCL NARCOTICS ANALGESICS BUPRENEX BUPRENORPHINE HCL NARCOTICS ANALGESICS BUPRENORPHINE HYDROCHLORIDE BUPRENORPHINE HCL NARCOTICS ANALGESICS CODEINE PHOSPHATE CODEINE PHOSPHATE NARCOTICS UNCLASSIFIED DRUG PRODUCTS CODEINE SULFATE CODEINE SULFATE NARCOTICS ANALGESICS DEMEROL MEPERIDINE HCL/PF NARCOTICS ANALGESICS DIHYDROCODEINE BITARTRATE DIHYDROCODEINE BITARTRATE NARCOTICS UNCLASSIFIED DRUG PRODUCTS DISKETS METHADONE HCL NARCOTICS ANALGESICS DOLOPHINE HCL METHADONE HCL NARCOTICS ANALGESICS DSUVIA SUFENTANIL CITRATE NARCOTICS ANALGESICS DURAMORPH MORPHINE SULFATE/PF NARCOTICS ANALGESICS FENTANYL CITRATE FENTANYL CITRATE NARCOTICS UNCLASSIFIED DRUG PRODUCTS FENTANYL CITRATE‐STERILE WATER FENTANYL CITRATE/PF NARCOTICS ANALGESICS HYDROCODONE BITARTRATE HYDROCODONE BITARTRATE NARCOTICS UNCLASSIFIED DRUG PRODUCTS HYDROMORPHONE HCL HYDROMORPHONE HCL NARCOTICS UNCLASSIFIED DRUG PRODUCTS HYDROMORPHONE HCL‐WATER HYDROMORPHONE HCL IN WATER/PF NARCOTICS ANALGESICS HYSINGLA ER HYDROCODONE BITARTRATE NARCOTICS ANALGESICS INFUMORPH MORPHINE SULFATE/PF NARCOTICS ANALGESICS INNOVAR FENTANYL CITRATE/DROPERIDOL NARCOTICS ANALGESICS KADIAN MORPHINE SULFATE NARCOTICS ANALGESICS LEVORPHANOL TARTRATE LEVORPHANOL TARTRATE NARCOTICS UNCLASSIFIED DRUG PRODUCTS METHADONE HCL METHADONE HCL NARCOTICS ANALGESICS METHADOSE METHADONE HCL NARCOTICS ANALGESICS MITIGO MORPHINE SULFATE/PF NARCOTICS ANALGESICS MORPHABOND ER MORPHINE SULFATE NARCOTICS ANALGESICS MORPHINE SULFATE ER MORPHINE SULFATE NARCOTICS ANALGESICS OXYCODONE HCL ER OXYCODONE HCL NARCOTICS ANALGESICS REMIFENTANIL HCL REMIFENTANIL HCL NARCOTICS ANALGESICS ROXICODONE OXYCODONE HCL NARCOTICS ANALGESICS SUBSYS FENTANYL NARCOTICS ANALGESICS ULTIVA REMIFENTANIL HCL NARCOTICS ANALGESICS XTAMPZA ER OXYCODONE MYRISTATE NARCOTICS ANALGESICS LOVAZA OMEGA 3 FATTY ACID PRODUCTS OMEGA 3 FATTY ACID TRIGLYCERIDE VASCEPA OMEGA 3 FATTY ACID PRODUCTS OMEGA 3 FATTY ACID TRIGLYCERIDE PEANUT [ARACHIS HYPOGAEA] ALLERGEN POWDER‐DNFP PALFORZIA ORAL IMMUNOTHERAPY ALLERGEN IMMUNOTHERAPY FOR ORAL ADMINISTRATION EVENITY ROMOSOZUMAB‐AQQG OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS EVENITY (2 SYRINGES) ROMOSOZUMAB‐AQQG OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS FORTEO TERIPARATIDE OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020 Trade Name Chemical/Biological Name Class Prior Authorization Program IBANDRONATE SODIUM IBANDRONATE SODIUM OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS PROLIA DENOSUMAB OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS TYMLOS ABALOPARATIDE OSTEOPOROSIS THERAPY HORMONES AZEDRA DOSIMETRIC IOBENGUANE IODINE‐131 RADIOPHARMACEUTICALS ANTINEOPLASTICS AZEDRA THERAPEUTIC IOBENGUANE IODINE‐131 RADIOPHARMACEUTICALS ANTINEOPLASTICS LUTATHERA LUTETIUM LU 177 DOTATATE RADIOPHARMACEUTICALS UNCLASSIFIED DRUG PRODUCTS NURTEC (RIMEGEPANT ORAL) RECEPTOR AGONIST MIGRAINE REYVOW LASMIDITAN TABLET RECEPTOR AGONIST MIGRAINE UBRELVY UBROGEPANT TABLET RECEPTOR AGONIST MIGRAINE LUPANETA PACK LEUPROLIDE/NORETHINDRONE ACET SPECIALIZED OB/GYN DRUGS HORMONES ALTRENO TRETINOIN THERAPY FOR ACNE SKIN PREPS ATRALIN TRETINOIN THERAPY FOR ACNE SKIN PREPS AVITA TRETINOIN THERAPY FOR ACNE SKIN PREPS CLINDAMYCIN PHOS‐TRETINOIN CLINDAMYCIN/TRETINOIN THERAPY FOR ACNE SKIN PREPS MIRVASO BRIMONIDINE TARTRATE THERAPY FOR ACNE SKIN PREPS RHOFADE OXYMETAZOLINE HCL THERAPY FOR ACNE SKIN PREPS TRETINOIN TRETINOIN THERAPY FOR ACNE SKIN PREPS TRETINOIN MICROSPHERE TRETINOIN MICROSPHERES THERAPY FOR ACNE SKIN PREPS TRETIN‐XTRETINOIN/EMOL 9/SKIN CLEANSR1 THERAPY FOR ACNE SKIN PREPS ASCENIV IMMUNE GLOBULIN,GAMMA(IGG)SLRA VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS BIVIGAM IMMUN GLOB G(IGG)/GLY/IGA OV50 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS BOTOX ONABOTULINUMTOXINA VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS CARIMUNE NF IMMUNE GLOB INTRAVENOUS (HUMAN), NANOFILTERED VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS CUTAQUIG IMMUN GLOB G(IGG)‐HIPP/MALTOSE VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS CUVITRU IMMUN GLOB G(IGG)/GLY/IGA OV50 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS DYSPORT ABOBOTULINUMTOXINA VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS FLEBOGAMMA DIF IMM GLOB G (IGG)/SORB/IGA 0‐50 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMMAGARD LIQUID IMMUN GLOB G(IGG)/GLY/IGA OV50 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMMAKED IMMUNE GLOBUL G/GLY/IGA AVG 46 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMMAPLEX IMMUNE GLOBULIN INTRAVENOUS VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMUNEX‐C IMMUNE GLOBUL G/GLY/IGA AVG 46 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS HIZENTRA IMMUN GLOB G(IGG)/PRO/IGA 0‐50 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS HYQVIA IGG/HYALURONIDASE,RECOMBINANT VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS MYOBLOC RIMABOTULINUMTOXINB VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS OCTAGAM IMMUNE GLOBULIN INTRAVENOUS VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS PANZYGA IMMUN GLOB G(IGG)‐IFAS/GLYCINE VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS PRIVIGEN IMMUN GLOB G(IGG)/PRO/IGA 0‐50 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS SIPULEUCEL‐T PROVENGE SIPULEUCEL‐T/LACTATED RINGERS VACCINES & MISCELLANEOUS IMMUNOLOGICALS ANTINEOPLASTICS XEMBIFY IMMUNE GLOBULIN,GAMMA(IGG)KLHW VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS XEOMIN INCOBOTULINUMTOXINA VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS EPOPROSTENOL SODIUM EPOPROSTENOL SODIUM (GLYCINE) VASODILATORS CARDIOVASCULAR FLOLAN EPOPROSTENOL SODIUM (GLYCINE) VASODILATORS CARDIOVASCULAR ORENITRAM ER TREPROSTINIL DIOLAMINE VASODILATORS CARDIOVASCULAR REMODULIN TREPROSTINIL SODIUM VASODILATORS CARDIOVASCULAR TREPROSTINIL TREPROSTINIL SODIUM VASODILATORS CARDIOVASCULAR UPTRAVI SELEXIPAG VASODILATORS CARDIOVASCULAR
Blue Cross and Blue Shield of Vermont Open Formulary *For compounds costing $300 or more Prior Approval List As of: 10/27/2020 | Rev: 10/27/2020