Prescription Drug List Temporary 90-day Removal of PA and ST Coverage Requirements
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1 Prescription List Temporary 90-day Removal of PA and ST Coverage Requirements To facilitate transition to Blue Shield plans, prior authorization and step therapy requirements for the following drugs may be temporarily removed within the first 90 days of enrollment. To promote safety, age, gender and quantity (e.g., number of pills, tablets, inhalers, syringes, vials) dispensing requirements will not be removed. Acanya Actonel 5mg, 35mg Actoplus Met XR Aczone Adcirca Adempas Adlyxin Aerospan Afinitor, Afinitor Disperz alogliptin (Nesina) alogliptin/metformin (Kazano) alogliptin/pioglitazone (Oseni) Amitiza amlodipine/atorvastatin (Caduet) amlodipine/valsartan (Exforge) Amrix Antara 30mg, 90mg capsule Aplenzin Aptiom Arcapta armodafinil (Nuvigil) Asmanex Aubagio Avandamet Avandia Banzel Basaglar Kwikpen Benzefoam, Benzefoam Ultra benzoyl peroxide 5.3% foam (Benzefoam) benzoyl peroxide 9.8% foam (Benzefoam Ultra) Pulmonary hypertension Asthma Renal cell cancer, Brain cancer, Neuroendocrine tumor, Breast cancer Chronic constipation, Irritable bowel syndrome, CAD, High cholesterol Muscle spasm High cholesterol or triglyceride Seizure Various sleep disorders such as narcolepsy, obstructive sleep apnea, shift work sleep disorder Asthma Multiple Sclerosis Page 1 of 6
2 benzoyl peroxide towelette (Triaz) benzoyl peroxide 5%/clindamycin 1% gel w pump (Benzaclin) Betaseron bimatoprost 0.03% drops (Lumigan) Binosto Bosulif Brintellix Buphenyl Bydureon Byetta Byalson calcipotriene/betamethasone ointment (Taclonex) Cambia candesartan (Atacand) candesartan-hctz (Atacand HCT) Caprelsa Carbaglu Cardura XL clonidine er (Kapvay) Coreg CR Corlanor Cuvposa cyclobenzaprine 7.5mg tablet (Fexmid) Cycloset Daliresp darifenacin (Enablex) Desvenlafaxine ER Dipentum donepezil 23mg (Aricept) Durlaza dutasteride/tamsulosin (Jalyn) Dutoprol Edarbi Edarbyclor Edluar Elidel Eliquis Emadine Entresto Epiduo, Epiduo Forte eprosartan 600mg (Teveten) Erivedge ethacrynic acid (Edecrin) Exforge HCT Extavia Farxiga fenofibrate (Fenoglide, Lipofen) Multiple Sclerosis Glaucoma Specific blood cancer (CML) Urea cycle disorder Psoriasis Migraine Thyroid cancer Rare urea cycle disorder (NAGS deficiency) Benign prostatic hyperplasia Attention deficit hyperactivity disorder Heart failure Heart failure Chronic drooling in children Muscle spasm Alzheimer s disease Coronary artery disease Benign prostatic hyperplasia Insomnia Allergic skin condition such as atopic dermatitis Atrial fibrillation Allergic conjunctivitis Heart failure Edema Multiple Sclerosis High cholesterol or triglyceride Page 2 of 6
3 fenofibrate, micronized (Antara) Ferriprox Fetzima fluvastatin (Lescol, Lescol XL) fluvoxamine er (Luvox CR) Foradil Forfivo XL Fycompa Gelnique Giazo Gilotrif Glyxambi Gralise guanfacine er (Intuniv) Horizant ibandronate (Boniva) imatinib (Gleevec) Imbruvica Inlyta Invokamet, Invokamet XR Invokana Janumet, Janumet XR Januvia Jardiance Jentadueto, Jentadueto XR Khedezla Kombiglyze XR Korlym lamivudine tablet (Epivir HBV) lamotrigine er, and odt (Lamictal XR, Lamictal ODT) (non start kit) Letairis Levemir Liptruzet Livalo Lyrica Mekinist mesalamine (Asacol HD) metformin extended-release (Glumetza, Fortamet) modafinil (Provigil) Myrbetriq Naprelan CR Nexavar Oleptro ER High cholesterol or triglyceride Thalassemia High cholesterol and triglyceride Social anxiety disorder, Obsessive compulsive disorder Asthma, Seizure Lung cancer Post herpetic neuralgia Attention deficit hyperactivity disorder Restless leg syndrome Various FDA approved cancer and other blood disorders Mantle cell lymphoma Advanced renal cell carcinoma Cushing s syndrome Hepatitis B High cholesterol and triglycerides High cholesterol Diabetic peripheral neuropathy; Post herpetic neuralgia; Partial seizures; Fibromyalgia Various sleep disorders such as narcolepsy, obstructive sleep apnea, shift work sleep disorder Inflammatory conditions Renal and liver cancers such as advanced renal cell carcinoma, and non-resectable hepatocellular carcinoma Page 3 of 6
4 olmesartan (Benicar) olmesartan/amlodipine (Azor) olmesartan/amlodipine/hctz (Tribenzor) olmesartan/hctz (Benicar HCT) omega-3 acid ethyl esters (Lovaza) High triglycerides Onexton vulgaris Onfi Seizure Onglyza Opsumit Orfadin Tyrosinemia Type 1 Oxtellar XR Oxytrol Pacnex HP Pacnex LP paliperidone (Invega) Schizophrenia Pennsaid Osteoarthritis of the knee Pentasa Pexeva pioglitazone/glimepiride (Duetact) pioglitazone/metformin (Actoplus Met) Pomalyst Multiple myeloma Pradaxa Atrial fibrillation Prestalia p Qudexy XR quetiapine er (Seroquel XR) Schizophrenia, Bipolar mania, Ranexa Chest pain Rapaflo Benign prostatic hyperplasia (BPH) Ravicti Urea cycle disorder Rayaldee Hyperparathyroidism repaglinide/metformin (Prandimet) Retin-A Micro 0.08% Revatio suspension risedronate 35mg (Atelvia) risedronate 5mg, 35mg, 150mg (Actonel) Rosula 10%-4.5% Wash and other inflammatory skin conditions Rozerem Insomnia Rytary Parkinson s disease Savella (non titration pack) Fibromyalgia Seebri Neohaler Selzentry HIV infection Sensipar Secondary hyperparathyroidism sildenafil tab (Revatio) sodium phenylbutyrate powder Urea cycle disorder (Buphenyl) Soliqua Sorilux Spiriva, Spiriva Respimat Psoriasis, Asthma Page 4 of 6
5 Sprycel Stiolto Respimat Stivarga Striverdi Respimat sulfacetamide 8%/sulfur 4% suspension (Sumaxin TS) Sumaxin TS Sutent Symlin, Symlinpen Synjardy tacrolimus ointment (Protopic) Tafinlar Tanzeum Tarceva Tasigna Tekamlo Tekturna, Tekturna HCT telmisartan (Micardis) telmisartan/amlodipine (Twynsta) telmisartan/hctz (Micardis HCT) tetrabenazine (Xenazine) Thalomid tolterodine (Detrol) tolterodine er (Detrol LA) Toviaz Tracleer Tradjenta Tresiba Flextouch Treximet Triglide Trokendi XR Trulicity Tykerb Tyzeka Uloric Ultravate 0.05% Lotion Uramaxin GT Utibron Neohaler Valchlor Vascepa Vesicare Victoza Viibryd (non titration pack) Vimovo Vimpat Vivlodex Votrient Vraylar (non-dose pack) Specific types of leukemia such as CML, ALL Colorectal cancer and other inflammatory skin conditions and other inflammatory skin conditions Renal and certain stomach cancers Atopic dermatitis Lung and pancreatic cancer Specific type of leukemia such as Ph+ CML Chorea related to Huntington s Disease Leprosy, Multiple myeloma Migraine High cholesterol and triglyceride Specific type of metastatic breast cancer Hepatitis B Gout Plaque Psoriasis Nail problems Mycosis fungoides High triglyceride Arthritis Osteoarthritis Renal cancer Schizophrenia, Bipolar mania Page 5 of 6
6 Vytorin Xalkori Xtandi Xultophy Zelboraf Ziana Zipsor Zolinza Zontivity Zorvolex Zurampic Zykadia Zytiga High cholesterol and triglycerides Lung cancer Prostate cancer Mild to moderate pain Cutaneous T-cell lymphoma (CTCL) Reduce the risk of heart attack or stroke Mild to moderate pain Gout Lung cancer Prostate cancer Last updated: March 2017 Page 6 of 6
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SOURCE:
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