Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval
Restricted Use Drug -A Prescription Medication or Drug that may require Prior Approval and/or be subject to a limited dispensing amount. Key Definitions F
Formulary Drug
NF
Non-Formulary Drug
A Brand Name or Generic Prescription Drug that has been determined to be safe, therapeutically effective, high quality, and cost-effective as determined by a committee of Physicians and Pharmacists based on current data. A Prescription Medication or Drug that is not a Formulary Drug
CONTRACEPTIVES: Oral contraceptives, if covered, are covered for females only. Prior approval (PA) required for males. Oral contraceptives may be excluded from coverage under the drug benefit. In all cases, plan inclusions/exclusions determine specific coverage. The following List of Drugs represents the drugs requiring Prior Approval (PA) • Specific criteria must be met before medication is covered under the pharmacy benefit. If a prior approval is granted, the drug will be allowed at the Formulary benefit level. • Both brand name drugs and generic equivalents require Prior Approval. • Please see separate documents for drugs requiring Prior Approval, due to a Utilization Management Quantity Limit or a Step Therapy edit.
CATEGORY
ACNE & SKIN: Prior approval (PA) required for age >40
ANTIBIOTICS ANTIFUNGALS
AUTOIMMUNE INFLAMMATORY DISORDERS
BRAND DRUG NAME ATRALIN, AVITA , RETIN-A, TRETIN-X DERMAPAK PLUS DIFFERIN EPIDUO FABIOR TAZORAC VELTIN ZIANA ZYVOX*
GENERIC DRUG NAME TRETINOIN TRETINOIN-ZINC OXIDE ADAPALENE ADAPALENE-BENZOYL PEROXIDE TAZAROTENE TAZAROTENE CLINDAMYCIN-TRETINOIN CLINDAMYCIN-TRETINOIN LINEZOLID*
*Initial therapy of 28 doses will be covered to ensure that therapy is not delayed while the prior approval request is being reviewed.
NOXAFIL VFEND ACTEMRA AMEVIVE ARCALYST CIMZIA COSENTYX ENBREL ENTYVIO HUMIRA ILARIS KINERET ORENCIA OTEZLA REMICADE RITUXAN
Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association
POSACONAZOLE VORICONAZOLE TOCILIZUMAB ALEFACEPT RILONACEPT CERTOLIZUMAB SECUKINUMAB ETANERCEPT VEDOLIZUMAB ADALIMUMAB CANAKINUMAB ANAKINRA ABATACEPT APREMILAST INFLIXIMAB RITUXIMAB
Updated 1/1/17 Page 1 of 6 Information subject to change
Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval CATEGORY
CANCER— ORALLY ADMINISTERED
BRAND DRUG NAME
GENERIC DRUG NAME
SIMPONI/SIMPONI ARIA STELARA TALTZ XELJANZ, XELJANZ XR ALECENSA AFINITOR/AFINITOR DISPERZ BOSULIF CAPRELSA CABOMETYX COMETRIQ COTELLIC ERIVEDGE FARYDAK GILOTRIF GLEEVEC HYCAMTIN IBRANCE ICLUSIG IMBRUVICA INLYTA IRESSA JAKAFI LENVIMA LONSURF LYNPARZA MEKINIST NEXAVAR NINLARO ODOMZO POMALYST REVLIMID SPRYCEL STIVARGA SUTENT TAFINLAR TAGRISSO TARCEVA TARGRETIN TASIGNA TEMODAR THALOMID TYKERB VENCLEXTA VOTRIENT XALKORI
GOLIMUMAB USTEKINUMAB IXEKIZUMAB TOFACITINIB ALECTINIB EVEROLIMUS BOSUTINIB VANDETANIB CABOZANTINIB CABOZANTINIB S-MAL COBIMETINIB VISMODEGIB PANOBINOSTAT LACTATE AFATINIB DIMALEATE IMATINIB MESYLATE TOPOTECAN PALBOCICLIB PONATINIB IBRUTINIB AXITINIB GEFITINIB RUXOLITINIB LENVATINIB MESYLATE TRIFLURIDINE-TIPIRACIL OLAPARIB TRAMETINIB SORAFENIB IXAZOMIB SONIDEGIB POMALIDOMIDE LENALIDOMIDE DASATINIB REGORAFENIB SUNITINIB DABRAFENIB OSIMERTINIB ERLOTINIB BEXAROTENE NILOTINIB TEMOZOLOMIDE THALIDOMIDE LAPATINIB VENETOCLAX PAZOPANIB CRIZOTINIB
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Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval CATEGORY
CANCER—INJECTABLE
CYSTIC FIBROSIS
ENZYME DEFICIENCIES
GROWTH HORMONES
HEPATITIS C
HEREDITARY ANGIOEDEMA (HAE) IDIOPATHIC IMMUNE THROM-BOCYTOPENIC PURPURA (ITP) INSULIN
BRAND DRUG NAME
GENERIC DRUG NAME
XELODA XTANDI ZELBORAF ZOLINZA ZYDELIG ZYKADIA ZYTIGA AVASTIN KADCYLA HERCEPTIN KYPROLIS PERJETA RITUXAN SYNRIBO XOFIGO CAYSTON KALYDECO ORKAMBI CARBAGLU ELELYSO KUVAN LUMIZYME, MYOZYME ORFADIN STRENSIQ SUCRAID VIMIZIM VPRIV ZAVESCA GENOTROPIN, HUMATROPE, NORDITROPIN, NUTROPIN/NUTROPIN AQ, OMNITROPE, SAIZEN, SEROSTIM, TEVTROPIN, ZORBTIVE INCRELEX OLYSIO HARVONI SOVALDI EPCLUSA ZEPATIER BERINERT CINRYZE FIRAZYR KALBITOR RUCONEST NPLATE
CAPECITABINE ENZALUTAMIDE VEMURAFENIB VORINOSTAT IDELALISIB CERITINIB ABIRATERONE BEVACIZUMAB ADO-TRASTUZUMAB EMTANSINE TRASTUZUMAB CARFILZOMIB PERTUZUMAB RITUXIMAB OMACETAXINE RADIUM RA 223 DICHLORIDE AZTREONAM IVACAFTOR LUMACAFTOR-IVACAFTOR CARGLUMIC ACID TALIGLUCERASE ALFA SAPROPTERIN ALGLUCOSIDASE ALFA NITISINONE ASFOTASE ALFA SACROSIDASE ELOSULFASE ALFA VELAGLUCERASE ALFA MIGLUSTAT
PROMACTA
ELTROMBOPAG
AFREZZA
INSULIN, INHALED
Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association
SOMATROPIN MECASERMIN SIMEPRIVIR LEDIPASVIR-SOFOSBUVIR SOFOSBUVIR SOFOSBUVIR-VELPATASVIR ELBASVIR-GRAZOPREVIR C1 ESTERASE INHIBITOR (HUMAN) C1 ESTERASE INHIBITOR (HUMAN) ICATIBANT ACETATE ECALLANTIDE C1 ESTERASE INHIBITOR (RECOMBINANT) ROMIPLOSTIM
Updated 1/1/17 Page 3 of 6 Information subject to change
Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval CATEGORY
LUNG DISORDERS
MEN’S HEALTH: A PA required for females. B Not covered for females.
MULTIPLE SCLEROSIS
PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS (PCSK9S)
PULMONARY HYPERTENSION
BRAND DRUG NAME
GENERIC DRUG NAME
APIDRA HUMALOG 50/50 HUMALOG 75/25 HUMALOG HUMULIN 70/30 HUMULIN N HUMULIN R HUMULIN R U-500 ACTIMMUNE ARALAST NP, PROLASTIN-C, ZEMAIRA CINQAIR ESBRIET GLASSIA NUCALA OFEV XOLAIR AVODARTB ELIGARD A PROSCARB STRIANT A
INSULIN GLULISINE INSULIN LISPRO INSULIN LISPRO INSULIN LISPRO REGULAR INSULIN; ISOPHANE INSULIN (NPH) ISOPHANE INSULIN (NPH) REGULAR INSULIN REGULAR INSULIN INTERFERON GAMMA-1B ALPHA1-PROTEINASE INHIBITOR RESILIZUMAB PIRFENIDONE ALPHA1-PROTEINASE INHIBITOR MEPOLIZUMAB NINTEDANIB OMALIZUMAB DUTASTERIDEB LEUPROLIDE ACETATE SUBCUTANEOUS INJ KITA FINASTERIDE B TESTOSTERONE BUCCALA
VANTAS A
HISTRELIN ACETATE IMPLANT KITA
AUBAGIO AVONEX BETASERON COPAXONE EXTAVIA GILENYA GLATOPA LEMTRADA PLEGRIDY REBIF TECFIDERA TYSABRI ZINBRYTA
TERIFLUNOMIDE INTERFERON β-1a INTERFERON β-1b GLATIRAMER INTERFERON β-1b FINGOLIMOD GLATIRAMER ALEMTUZUMAB PEGINTERFERON BETA-1A INTERFERON β-1a DIMETHYL FUMARATE NATALIZUMAB DACLIZUMAB
PRALUENT
ALIROCUMAB
REPATHA
EVOLOCUMAB
ADCIRCA ADEMPAS FLOLAN LETAIRIS OPSUMIT ORENITRAM REMODULIN REVATIO
TADALAFIL RIOCIGUAT EPOPROSTENOL AMBRISENTAN MACITENTAN TREPROSTINIL TREPROSTINIL SILDENAFIL
Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association
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Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval CATEGORY
OTHERS
BRAND DRUG NAME
GENERIC DRUG NAME
TRACLEER TYVASO UPTRAVI VELETRI VENTAVIS
BOSENTAN TREPOSTINOL SELEXIPAG EPOPROSTENOL ILOPROST
APOKYN
APOMORPHINE
BANZEL
RUFINAMIDE
BENLYSTA
BELIMUMAB
CERDELGA
ELIGLUSTAT TARTRATE
CEREZYME
IMIGLUCERASE
CHENODAL
CHENODIOL
DARAPRIM
PYRIMETHAMINE
FORTEO
TERIPARATIDE
GRASTEK
TIMOTHY GRASS POLLEN ALLERGEN EXTRACT
HETLIOZ
TASIMELTEON
INJECTAFER
FERRIC CARBOXYMALTOSE
JETREA
OCRIPLASMIN
JUXTAPID
LOMITAPIDE
NORTHERA
DROXIDOPA
OCALIVA
OBETICHOLIC ACID
ORALAIR
MIXED GRASS POLLENS ALLERGEN EXTRACT
H P ACTHAR GEL
CORTICOTROPIN INJ GEL
RAGWITEK
SHORT RAGWEED POLLEN ALLERGEN EXTRACT
RELISTOR
METHYLNALTREXONE
RITUXAN
RITUXIMAB
SAMSCA
TOLVAPTAN
SENSIPAR
CINACALCET
SYNAGIS
PALIVIZUMAB IM SOLUTION
SUPPRELIN LA
HISTRELIN ACETATE
XENAZINE
TETRABENAZINE
Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association
Updated 1/1/17 Page 5 of 6 Information subject to change
Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval
Drugs with Benefit Quantity Limits: The following list represents the drugs subject to a limited dispensing amount. ANTIBIOTICS
BRAND NAME
GENERIC NAME
FORMULARY STATUS
ZYVOX
LINEZOLID
F
MULTIPLE SCLEROSIS BRAND NAME
GENERIC NAME
AMPYRA
DALFAMPRIDINE
BRAND NAME
GENERIC NAME
CIALIS 10 mg, 20 mg LEVITRA STAXYN STENDRA VIAGRA CIALIS Once-Daily Use 2.5 mg, 5 mg
TADALAFIL VARDENAFIL VARDENAFIL AVANAFIL SILDENAFIL
ERECTILE DYSFUNCTION, ORAL
TADALAFIL
Quantity Limit Initial therapy of 28 doses will be covered to ensure that therapy is not delayed while the prior approval request is being reviewed.
FORMULARY Quantity Limit STATUS NF 2 tabs/day Daily and as-needed use prescriptions are not allowed concomitantly FORMULARY Quantity Limit STATUS NF A member can receive up to a NF combined total of 18 tablets per A Combined Total of 18 NF 90 days. The claims system tablets per 90 Days will not allow any quantity >18 NF in any 90-day claims period. NF NF
Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association
1 tab/day
Updated 1/1/17 Page 1 of 6 Information subject to change