DTF Prior Authorization Drug List The following is a list of the prescribed drugs included in your prior authorization program and is comprehensive as of the date of publication. Express Scripts Canada® makes every effort to ensure this list is updated regularly. Please note that prior authorization applies to the brand drug and its generic alternatives (if available). As of July 23, 2020 Drug Chemical Ingredient ABSTRAL fentanyl ACTEMRA tocilizumab ADCIRCA tadalafil ADEMPAS riociguat AFINITOR everolimus AIMOVIG erenumab AJOVY fremanezumab ALECENSARO alectinib ALUNBRIG brigatinib ARZERRA ofatumumab AUBAGIO teriflunomide AVASTIN bevacizumab AVSOLA infliximab BALVERSA erdafitinib BANZEL rufinamide BAVENCIO avelumab BENLYSTA belimumab BESPONSA inotuzumab ozogamicin BEOVU brolucizumab BOSULIF bosutinib BOTOX onabotulinumtoxinA BRENZYS etanercept BUDESONIDE budesonide CABLIVI caplacizumab CABOMETYX cabozantinib CALQUENCE acalabrutinib CAPRELSA vandetanib CARBAGLU carglumic acid CERDELGA eliglustat CIMZIA certolizumab CINQAIR reslizumab COSENTYX secukinumab COTELLIC cobimetinib CRESEMBA isavuconazole 1 © Express Scripts Canada. All rights reserved. CRYSVITA burosumab CUVPOSA glycopyrrolate CYRAMZA ramucirumab CYSTADROPS cysteamine DAKLINZA daclatasvir DAURISMO glasdegib DEMYLOCAN decitabine DIACOMIT stiripentol DUODOPA levodopa/carbidopa DUPIXENT dupilumab DYSPORT THERAPEUTIC abobotulinumtoxinA EGRIFTA tesamorelin EMGALITY galcanezumab ENBREL etanercept ENTYVIO vedolizumab EPCLUSA sofosbuvir/velpatasvir ERELZI etanercept ERIVEDGE vismodegib ERLEADA apalutamide ESBRIET pirfenidone EVENITY romosozumab EYLEA aflibercept FABRAZYME agalsidase beta FAMPYRA fampridine FASENRA benralizumab FENTORA fentanyl FIRAZYR icatibant FORTEO teriparatide GALAFOLD migalastat GALEXOS simeprevir GAZYVA obinutuzumab GENOTROPIN somatropin GILENYA fingolimod GIOTRIF afatinib dimaleate HADLIMA adalimumab HANZEMA alitretinoin HARVONI sofosbuvir/ledipasvir HIZENTRA human immunoglobulin HOLKIRA PAK ombitasvir/paritaprevir/ritonavir/dasabuvir HUMATROPE somatropin HUMIRA adalimumab IBAVYR ribavirin IBRANCE palbociclib ICLUSIG ponatinib 2 © Express Scripts Canada. All rights reserved. IDHIFA enasidenib ILARIS canakinumab IMBRUVICA ibrutinib IMFINZI durvalumab INFLECTRA infliximab INLYTA axitinib INSPRA eplerenone INVOKANA canagliflozin IRESSA gefitinib JAKAVI ruxolitinib JETREA ocriplasmin JINARC tolvaptan KALYDECO ivacaftor KEVZARA sarilumab KEYTRUDA pembrolizumab KISQALI ribociclib KUVAN sapropterin LEMTRADA alemtuzumab LENVIMA lenvatinib mesylate LIBTAYO cemiplimab LONSURF trifluridine/tipiracil LORBRENA lorlatinib LOVENOX enoxaparin sodium LUCENTIS ranibizumab LYNPARZA olaparib MACUGEN pegaptanib sodium MAVENCLAD cladribine MAVIRET glecaprevir/pibrentasvir MAYZENT siponimod MDK-NITISINONE nitisinone MEKINIST trametinib MOVAPO apomorphine MVASI bevacizumab NERLYNX neratinib NEXAVAR sorafenib NINLARO ixazomib citrate NITISINONE TABLETS nitisinone NORDITROPIN somatropin NPLATE romiplostim NUBEQA darolutamide NUCALA mepolizumab NUTROPIN AQ somatropin OCALIVA obeticholic acid OCREVUS ocrelizumab 3 © Express Scripts Canada. All rights reserved. OFEV nintedanib OLUMIANT baricitinib OMNITROPE somatropin ONPATTRO patisiran OPDIVO nivolumab OPSUMIT macitentan ORENCIA abatacept ORFADIN nitisinone ORKAMBI ivacaftor/lumacaftor OSNUVO teriparatide OTEZLA apremilast OXERVATE cenegermin PIQRAY alpelisib POMALYST pomalidomide PRALUENT alirocumab PREVYMIS letermovir PROCYSBI mercaptamine bitartrate PROLASTIN-C alpha-1 proteinase inhibitor RADICAVA edaravone RAVICTI glycerol phenylbutyrate RELISTOR methylnaltrexone bromide REMICADE infliximab RENFLEXIS infliximab REPATHA evolocumab REPLAGAL agalsidase alfa REVATIO sildenafil REVESTIVE teduglutide REVLIMID lenalidomide REVOLADE eltrombopag RINVOQ upadacitinib RITUXAN, RITUXAN SC rituximab RIXIMYO rituximab ROZLYTREK entrectinib RUXIENCE rituximab RYDAPT midostaurin SAIZEN somatropin SAMSCA tolvaptan SATIVEX delta-9-tetrahydrocannabinol-cannabidiol SENSIPAR cinacalcet SEROSTIM somatropin SIGNIFOR, SIGNIFOR LAR pasireotide SILIQ brodalumab SIMPONI golimumab SKYRIZI risankizumab 4 © Express Scripts Canada. All rights reserved. SOVALDI sofosbuvir SPRAVATO esketamine SPRYCEL dasatinib monohydrate STELARA ustekinumab STIVARGA regorafenib STRAMUCIN mupirocin SUNVEPRA asunaprevir SUTENT sunitinib SYMDEKO tezacaftor/ivacaftor TAFINLAR dabrafenib TAGRISSO osimertinib TAKHZYRO lanadelumab TALTZ ixekizumab TALZENNA talazoparib TARCEVA erlotinib TASIGNA nilotinib TECENTRIQ atezolizumab TECFIDERA dimethyl fumarate TECHNIVIE ombitasvir/paritaprevir/ritonavir TEGSEDI inotersen TEMODAL temozolomide THALOMID thalidomide THYROGEN thyrotropin alfa TOCTINO alitretinoin TREANDA bendamustine TREMFYA guselkumab TRUXIMA rituximab TYKERB lapatinib TYSABRI natalizumab UPTRAVI selexipag VECTIBIX panitumumab VEMLIDY tenofovir alafenamide VENCLEXTA venetoclax VERZENIO abemaciclib VIDAZA azacitidine VITRAKVI larotrectinib VIZIMPRO dacomitinib VOLIBRIS ambrisentan VOSEVI sofosbuvir/velpatasvir/voxilaprevir VOTRIENT pazopanib VYNDAQEL tafamidis meglumine XALKORI crizotinib XELJANZ, XELJANZ XR tofacitinib XEOMIN incobotulinumtoxinA 5 © Express Scripts Canada. All rights reserved. XERMELO telotristat ethyl XIAFLEX collagenase Clostridium histolyticum XIIDRA lifitigrast XOLAIR omalizumab XOSPATA gilteritinib XTANDI enzalutamide YERVOY ipilimumab ZAVESCA miglustat ZAXINE rifaximin ZEJULA niraparib ZELBORAF vemurafenib ZEMAIRA alpha-1 proteinase inhibitor ZEPATIER elbasvir/grazoprevir ZINBRYTA daclizumab beta ZIRABEV bevacizumab ZOLINZA vorinostat ZYDELIG idelalisib ZYKADIA ceritinib ZYTIGA abiraterone 6 © Express Scripts Canada. All rights reserved. .