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

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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