2021 FEP Prior Approval Drug List

A Abilify Mycite Absorica (Brand Only) Abstral Aciphex (generic only) Actemra Acthar Gel Actimmune Actiq Aczone++ Adakveo Adcetris Adcirca Adderall/Adderall XR Adempas Adhansia XR Adzenys XR/ Adzenys ER solution Aemcolo Afinitor Afrezza Aimovig Aklief Akynzeo Ala Scalp Lotion 2% (hydrocortisone)+ Albenza Alcortin A (generic only) Alcovate Cream, Ointment 0.05% (alclometasone dipropionate)+

Aldara (brand only) Aldurazyme Alecensa Alferon-N Allzital Aloxi (palonosetron) Alprostadil Powder/Injection Altinac Altreno Alunbrig Ambien/Ambien CR Ameluz Gel Amerge Amitiza Amondys 45 amphetamine salt combo Ampyra (generic only) Amzeeq++ Anadrol-50 Androderm AndroGel Android Androxy Apexicon E Cream 0.05% (diflorasone diacetate)+

Rev. 9 30.21

2021 FEP Prior Approval Drug List

Apokyn Aptensio XR Aquoral

Aralast NP

Aranesp Arazlo Arcalyst Arikayce Arymo ER Arzerra Asceniv Asparlas Atgam Atralin Aubagio Austedo Avastin Aveed Avita Avonex Avsola Axert Axiron Ayvakit

B Baclofen Powder

Bactroban 2% cream, nasal

ointment, ointment

(mupirocin)++ Bafiertam

Balversa Baraclude (brand only) Bavencio Baxdela Belbuca Beleodaq Belsomra Bendeka Benlysta Beovu Berinert Besponsa Betaseron Bivigam Blenrep Blincyto Bocasal Bonjesta bortezomib Bosulif Botox Braftovi Bravelle Bronchitol Brukinsa Bunavail

Buphenyl buprenorphine SL Buprenorphine inj butorphanol Butrans Bylvay Bynfezia Pen

C Cabometyx

Calquence Capex Shampoo 0.01% (fluocinolone acetonide)+

Caphosol Caprelsa Carbaglu carisoprodol products cefotaxime sodium IV ceftriaxone IV Celecoxib Powder Celebrex Ceprotin Cequa Cerdelga Cerezyme Cesamet Cetrotide Chenodal Cholbam Cholestyramine resin Cialis (2.5 mg & 5 mg)* Ciclodan 0.77% cream /Loprox 0.77% cream (ciclopirox)++ Ciclodan nail lacquer 8% topical solution / Penlac nail lacquer 8% Topical Solution (ciclopirox)++

Cimzia Cinqair Cinryze Cinvanti Clindamax 1% gel, lotion / Cleocin T 1% gel, lotion / Glindagel 1% gel (clindamycin)++ Clobetasol Powder Clobex Lotion, Shampoo, Spray 0.05% /Clodan Shampoo 0.05%/(clobetasol propionate)

Cloderm Cream 0.10% (clocortolone pivalate)+ Clomid clomiphene citrate powder Clotrimazole 1% cream++

Codeine Tablets Colistimethate IV Cometriq Compound High Dollar Limit Concerta Continuous Glucose Monitors (CGM)

Continuous glucose monitor supplies

Conzip (generic only)

Copaxone Copegus Copiktra Cordran Cream 0.025% (flurandrenolide), Cordran Cream, Lotion, Ointment 0.05%, Cordran Tape 4mcg (flurandrenolide)+

Corlanor Cormax Solution 0.05% (clobetasol propionate)+

Corticosporin cream (neomycin 3.5mg/1g, polymyxin B 10,000IU/1g, hydrocortisone 0.5%)++

Corticosporin ointment (neomycin 3.5mg/1g, polymyxin B 5,000IU/1g, bacitracin 400IU/1g, hydrocortisone 1%)++

Cosentyx Cotellic Cotempla XR Cresemba Crinone Crysvita Cutaquig Cutivate Cream, Lotion 0.05% / Cutivate Ointment 0.005% (fluticasone propionate)+ Cuvitru Cyclobenzaprine Powder Cyclocort Cream, lotion, Ointment 0C.y1r%am(azmacinonide)+

D Dalmane Daptomycin IV Daraprim Darzalex Darzalex Faspro Daurismo Daytrana Dayvigo

Delatestryl Demerol Demser Depo-Testosterone Derma-smooth /FS body oil 0.01%/ Derma-smooth /FS scalp oil 0.01% (fluocinolone acetonide)+

Dermatop Cream, Ointment 0.1% (prednicarbate)+

Desonate Gel 0.05% Desonide Cream Lotion, Ointment 0.05% Desowen Lotion 0.05% (desonide)+

Desoxyn (generic only) Dexedrine Dexilant Dexmethylphenidate Dextroamphetamine Diabetes test strips Diacomit Diclegis Diclofenac Powder Differin Dilaudid Diprosone Cream, Lotion, Ointment 0.05% /Diprolene AF Cream, Gel, Lotion, Ointment 0.05% (betamethasone dipropionate)+

Dojolvi Dolophine Doptelet Doral Dovonex Cream 0.005% (calcipotriene) Doxepin Cream 5% Doxycycline IV Duobrii Lotion Dupixent Duragesic (fentanyl)

Durlaza

Durolane

Dyanavel XR Dysport

E Econazole 1% cream++ Econazole Powder Ecoza Edluar Egrifta Elaprase Elelyso

Rev. 9 30.21

2021 FEP Prior Approval Drug List

Eligard Elocon Cream, Ointment, Solution 0.1% (mometasone furoate)+

Embeda Emend Emflaza Emgality Emgel 2% gel (erythromycin)++

Emla Empaveli Empliciti Emverm Enbrel Endari Endometrin Enhertu Enstilar Foam 0.005/0.064% (calcipotriene and betamethasone dipropionate) Enspryng

Entresto Entyvio Epclusa Epidiolex Epiduo Gel Episil Epogen Erbitux Erivedge Erleada Erlotinib (generic Tarceva) Ertaczo Erwinaze

Erythromycin 2% solution++

Esbriet Esgic/ Esgic plus estazolam

eszopiclone Eucrisa Euflexxa Evekeo/Evekeo ODT Evenity Evoclin++ Evomela Evrysdi Evzio Exalgo Exelderm Exjade Exondys 51

Extavia Eylea Eysuvis

F Fabior Foam Fabrazyme Farxiga Farydak Fasenra Faslodex (brand only) Fenoprofen powder Fensolvi Fentanyl inj Fentanyl patches Fentanyl powder Fentora Ferriprox / Ferprx 2-Day Finacea Fintepla Fioricet /Fioricet with codeine Fiorinal /Fiorinal with codeine

Firazyr Firdapse Firmagon Flebogamma Flolan flurazepam Flurbiprofen powder Fluticasone Powder Fluoxymesterone Powder Focalin/Focalin XR Follistim AQ Fortamet Forteo Fortesta Fotivda Frova Fulphila

G Gabapentin Gabapentin Powder Galafold Gamastan S/D Gammagard Gammaked Gammaplex Gamunex Ganirelix Gattex Gavreto Gazyva Gelclair

Gel-One Gel-Syn 3 Gelx Genotropin

Gentamicin IV Gentamicin 0.1% cream/

ointment++ Genvisc Gilenya Gilotrif Givlaari Glassia Gleevec Gloperba Glumetza (generic only)

Glyxambi Gocovri Gonal-F/Gonal-F RFF Granisetron injection Granix Grastek

H Haegarda Halaven Halcion Halog Cream, Ointment, Solution 0.1% (halcinonide)+

Harvoni HCG powder Hemady Hepsera (brand only) Herceptin Herceptin Hylecta Herzuma Hetlioz Hizentra Humatrope Humira Hyalgan Hyaluronate Compounding

Powder Hydrocortisone Cream,

Lotion, Ointment 1%, 2.5%+ Hydromorphone Hymovis Hyqvia Hysingla ER

I Ibrance Ibuprofen Powder Iclusig Idhifa Ilaris Ilumya Imbruvica Imcivree Imfinzi Imitrex Imlygic

Impeklo+ Impoyz Cream 0.025% (clobetasol proprionate)+

Inbrija Increlex Infergen Inflectra Ingrezza Inlyta Inqovi Inrebic Intermezzo Intron-A Invokamet/ Invokamet XR Invokana

Iressa Istodax Isturisa

J Jadenu Jakafi Jardiance Jatenzo Jemperli Jevtana Jublia Juxtapid Jynarque

K Kadcyla Kadian Kalbitor Kalydeco Kanjinti Kanuma Kapidex Kepivance Kerydin Kesimpta Ketalar Ketamine powder Ketoconazole Ketoconazole Powder Ketoconazole 2% shampoo++

Ketodan 2% foam / Extina (generic only) 2% foam (Kkeettoopcroonfeanzopleo)w+d+er Keveyis Kevzara Keytruda Kineret Kisqali/ Kisqali-Femara Klisyri Korlym Koselugo

Rev. 9 30.21

2021 FEP Prior Approval Drug List

Krystexxa Kuvan Kynamro Kynmobi Kyprolis Kytril (granisetron)

L Lemtrada Lenvima Letairis Leukine Levulan Lidex-E Cream 0.05%/ Lidex Gel, Ointment, Solution, Cream 0.05% (fluocinonide)+

Lidocaine injection Lidocaine Powder Lidocaine Topical ointment

Lidoderm LifEMS Naloxone Linzess Locoid Cream, Lipocream, Lotion, Ointment, Solution 0.1% (hydrocortisone butyrate)+ Lokelma Lonsurf Loprox 0.77% gel, suspension (ciclopirox)++

Lorbrena Lotrisone 1%/0.05% cream, lotion (clotrimazole, betamethasone)++ Lucemyra Lucentis Lumakras Lumizyme Lumoxiti Lunesta

Lupkynis

Lupron Depot Luxiq Foam 0.12% (betamethasone valerate)+

Luzu Lynparza Lyrica Lysodren

M Marinol Marqibo Mavenclad Mavyret Maxalt/Maxalt MLT Mayzent

Medical foods Mekinist Mektovi Meloxicam Powder Menopur Meperidine Mepsevii Metadate CD/Metadate ER

metformin ER (generic Glumetza) Methadone Methadose Methamphetamine Methitest Methylin/Methylin ER Methylphenidate Methyltestosterone Powder Metrocream 0.75% cream / Rosadan 0.75% cream (metronidazole)++ Micort-HC Cream 2.5% (hydrocortisone acetate)+

Migranal nasal spray Mircera Mirvaso Moderiba Mometasone Powder

Monovisc Morphine

Motegrity Movantik Mozobil MS Contin Mucotrol Mugard Mulpleta Mupirocin Powder Mvasi Myalept Mycapssa Mydayis Mylotarg

Myobloc Mytesi

N Naftin 1% gel, cream (naftifine) / Naftin 2% gel, cream (naftifine)++

Naglazyme Nalbuphine inj Naproxen powder Nascobal Natesto nasal gel Natpara

Nayzilam Neo-Synalar 0.5%/0.025% cream (neomycin, fluocinolone)++

Nerlynx Neulasta Neupogen Neutrasal Nexavar Nexium (generic only) Nexletol Nexlizet Nexviazyme Nilandron (brand only) Ninlaro Nivestym Nizoral 2% cream (ketoconazole)++

Nocdurna Noctiva Nolix Cream, Lotion 0.05% (flurandrenolide)+ Norditropin Noritate Northera Nourianz Novarel Noxafil Nplate Nubeqa Nucala Nucynta/Nucytna ER Nuedexta Numoisyn Nuplazid Nurtec Nutropin Nuvigil

Nuzyra Nydamax 0.75% gel / Rosadan 0.75% gel (metronidazole)++

Nystatin 100,000 unit/g cream, ointment++

Nystatin (Nystop/ Nyamyc) Powder

Nystatin-Triamcinolone 100,000 unit/g-0.1% cream, ointment++

Nyvepria

O Ocaliva Ocrevus Octagam

Odactra Odomzo Ofev Ogivri Olumiant Olux Foam 0.05% Olux E Emulsion Foam 0.05% (clobetasol propionate)+ (generic only)

Omeclamox-Pak Omnitrope Oncaspar Onivyde Onsolis Ontruzant Onureg Onzetra Xsail

Opana/Opana ER

Opdivo Opioid cough medications Opioid powders Opsumit Oralair Oramagic Rx Orencia Orenitram Orgovyx Oriahnn Orilissa Orkambi Orladeyo Orthovisc Osmolex ER Otezla Otrexup Ovace/Ovace Plus wash 10% gel/cleansing gel and liquid++ Ovidrel Oxandrin Oxbryta Oxistat Oxecta Oxervate Ocxycodone Oxycontin ER

Oxymorphone Ozobax

P Padcev

Palforzia

Palynziq Pandel Cream 0.1% (hydrocortisone probutate)+

Rev. 9 30.21

2021 FEP Prior Approval Drug List

Panzyga Papaverine Powder Parsabiv Pegasys Peg-Intron

Pemazyre

penicillin G potassium IV Pentazocine-Naloxone (Talwin) Pepaxto

Perjeta Phentolamine powder Phesgo Piqray Plegridy Pliaglis Polivy Pomalyst

Ponvory

Portrazza Poteligeo Praluent Pregnyl Prevacid (generic only) Prevpac Prevymis Prilocaine powder Privigen Probuphine ProCentra Procrit Procysbi progesterone in oil progesterone powder Prolastin-C Prolia Promacta Prometrium Prosom Protonix (generic only) Provigil Psorcon Cream, Ointment 0.05% (diflorasone)+ (generic only)

Pulmozyme Pylera

Q Qbrexza Qdolo Qinlock Qtern Quillichew ER Quillivant XR Qutenza

R Radicava Ragwitek Rasuvo Ravicti Rayos Rebetol Rebif Reblozyl Reclast (band only) RediTrex Refissa Regranex Relenza Relistor Relpax Remicade Remodulin Renflexis Renova (0.05%)** Repatha Repatha PushTronex Repronex Restasis

Restoril

Retacrit

Retevmo

Retin-A/Retin-A Micro Retin A Micro Pump Revatio/Revatio IV Revatio oral suspension Revcovi Revlimid Rezurock Riabni Ribapak Ribasphere Ribatab Ribavirin Rinvoq Riomet IR Ritalin/Ritalin LA/Ritalin SR

Rituxan Rituxan Hycela Rhofade 1% cream Roxybond Rozerem Rozlytrek Rubraca Ruconest Ruxience Ruzurgi Rybrevant Rydapt

S Sabril

Saizen

Salicept SalivaMax Salivate Rx Samsca

Sancuso (granisetron) patches

Sandostatin (brand only)

Sandostatin LAR

Santyl Ointment Sarclisa Savella Segluromet Sernivo Spray 0.05% (betamethasone dipropionate)+

Sensipar Serophene

Serostim Signifor/Signifor LAR Siklos Sildenafil Powder Siliq

Simponi / Simponi Aria Sivextro Skyrizi Sodium Hyaluronate 20mg/2ml Sodium sulfacetamide 10% liquid++ Solaraze Soliris Soliqua Soma Soma Compound Soma Compound

with Codeine

Somatuline Depot Sonata Soolantra Sorilux Sovaldi Spravato Sprix Sprycel Sporanox Stadol (Butorphanol) Steglatro Steglujan Stelara Stivarga Strensiq Streptomycin IV

Striant Sublocade Suboxone Subsys sumatriptan Sumatriptan powder Sunosi Supartz Supprelin/Supprelin LA Sustol ER Injection (granisetron) Sutent Sylvant Symdeko Symproic Synagis Synalar Cream, Ointment, Solution 0.01% /Synalar Cream, Ointment 0.025% (fluocinolone acetonide)+

Synarel Syndros Synjardy/ Synjardy XR Synribo Synvisc/Synvisc-One

T Tabrecta Taclonex Ointment (generic only), Suspension 0.005/0.064% (calcipotriene and betamethasone dipropionate) Tadalafil Powder Tafinlar Tagrisso Takhzyro Talicia Taltz Talzenna Tamiflu Targretin Tasigna Tasmar (generic only) Tavalisse Tazorac Tazarotene powder Tazverik Tecentriq Tecfidera Tegsedi temazepam

Temodar (brand only)

Rev. 9 30.21

2021 FEP Prior Approval Drug List

Temovate-E Cream 0.05% Temovate Cream, Gel, Ointment, Solution 0.05% (clobetasol propionate)+

Tencon Tepezza Tepmetko Terbutaline Testim Testopel

Testosterone Compounding Powders Testosterone Injectable Agents Testosterone Oral Agents Testred

Tetravex Texacort Solution 2.5% (hydrocortisone)+

Thiola/Thiola EC Tibsovo Tikosyn (brand only) Tizanidine Powder Tobramycin IV Tobramycin Powder tolcapone (generic only) Topicort Cream, Gel, Ointment, Spray 0.05% 0.25% (desoximetasone)+

Topiramate Powder Tosymra Nasal Spray Tracleer

Tramadol Powder Tramadol/Tramadol ER Trazimera Treanda Trelstar / Trelstar LA Tremfya Tretin-X Treximet Triamcinolone Cream, Lotion, Ointment Spray 0.025%, 0.05%, 0.1%, 0.5% Triderm Cream 0.1%, 0.5% Kenalog aerosol spray 0.147 mg/ml (triamcinolone acetonide)+

triazolam Tridesilon Cream 0.05%/ Verdeso Foam 0.05%(desonide)+

Trijardy XR Trikafta

Triluron Triptodur TriVisc Trodelvy Trogarzo

Trulance Truseltiq Tukysa Turalio Truxima

Tuxarin ER Tykerb Tymlos Tysabri Tyvaso

U Udenyca Ukoniq Uloric Ultomiris Ultracet Ultram/Ultram ER Ultravate Cream, Lotion, Ointment 0.05% (halobetasol propionate)+

Upneeq Uptravi

V Valchlor Valcyte Valisone Cream, Lotion, Ointment 0.01% (betamethasone valerate)+

Valtoco Vanatol LQ Vancomycin IV Vancomycin Powder Vantas Varubi Vectibix

Velcade Veletri Veltassa Veltin Venclexta Ventavis Verdeso Foam 0.05% (desonide)+

Verzenio Vfend

Viberzi Viltepso Vimizim

Visco-3

Vitrakvi

Vizimpro

Vogelxo Voltaren Gel 1% (diclofenac sodium)

Vosevi

Votrient VPRIV Vumerity Vusion topical ointment++ Vyepti Vyndamax Vyndaqel

Vyondys 53

Vyvanse Vyxeos

W Wakix Wescort Cream, Ointment 0.2% (hydrocortisone valerate)+

Winlevi Wynzora

X Xalkori Xartemis XR Xcopri Xeljanz/ Xeljanz XR Xeloda (brand only) Xembify Xenazine Xenleta Xeomin Xepi Xermelo Xgeva Xhance Xiaflex Xifaxan Xiidra Xigduo XR Xofluza Xolair Xospata Xpovio Xtampza ER Xtandi

Xultophy

Xuriden Xylocaine Xyosted Xyrem Xywav

Y Yervoy

Yondelis

Yonsa Z

zaleplon Zaltrap Zarxio Zavesca Zegerid (generic only) Zejula

2021 FEP Prior Approval Drug List

Zelboraf Zelnorm Zemaira Zembrace SymTouch Zenzedi Zepatier Zeposia Zepzelca Ziana Ziextenzo Zilxi ++

Zirabev Zofran (ondansetron) Zohydro ER Zokinvy Zoladex Zolinza Zolpidem Zolpimist Zomacton (Tev-Tropin) Zomig/Zomig ZMT Zomitriptan Powder

Zorbtive Zubsolv Zyclara Zydelig Zykadia Zyprexa Relprevv Zytiga

Zyvox

Specialty medications are in bold print. Non-Specialty medications are not bolded.

* Cialis 2.5mg and Cialis 5mg are a covered benefit with prior approval, Cialis 10mg and Cialis 20mg are NOT covered benefits under the plan. ** Renova 0.02% is NOT a covered benefit as its only FDA approved indication is for cosmetic use. +These medications can be found under Topical Corticosteroids ++These medications can be found under Topical Antifungals and Antibiotics

The medicine names listed in this document are the registered and/or unregistered trademarks of third-party pharmaceutical companies. These trademarks are included for informational purposes only and are not intended to imply or suggest any affiliation with such third-party companies.

Learn About Prior Approval

For certain prescription medicines, the Service Benefit Plan Pharmacy Programs must determine whether the medicine is related to a service or condition that is covered before benefits can be approved. We also evaluate whether the medicine is prescribed in accordance with generally accepted medical practices.

The prior approval program ensures members have access to appropriate quantities of medicine either by requiring prior approval of a medicine before benefits can be paid or by making available a set amount of medicine within a specific timeframe, known as a quantity allowance.

According to the terms of your coverage, prior approval is required for certain services and supplies and must be renewed periodically. This is outlined in the Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005 or RI 71-017), your official statement of benefits.

For prescription drugs and covered medical supplies, prior approval is required if the medication

? may be used outside the Food & Drug Administration or manufacturer's guidelines; ? requires completion of diagnostic procedures to maximize the therapeutic benefits; ? may be used to treat conditions or illnesses not covered by the Plan; ? has unique dosing and/or administration requirements; or ? has a high potential for adverse effects and/or abuse.

How to Obtain Prior Approval

FEP Clinical Call Center

Your physician's office can contact our clinical call center toll-free at 1-877-727-3784 between the hours of 7 a.m. and 9 p.m., Eastern Time, Monday through Friday and request prior approval or quantity increases. This phone number is for physicians' offices only.

Paper-based Process

Rev. 9 30.21

FEP Prior Approval Program

The Service Benefit Plan recognizes some members and physicians prefer to use a paper-based process to obtain prior approval. You or your physician can request the appropriate form by calling the Retail Pharmacy Program Customer Care Unit toll-free at 1-800-624-5060 or printing the form from ./forms. Scroll down to Prior Approval Pharmacy Forms box and click on the link. Then scroll down on the Prior Approval Page to select the form for your specific medication. Fax or mail the completed request to the number or address in the upper right-hand corner of the form. Please allow up to five business days for processing.

Prior Approval Status

You can verify the status of your prior approval request by logging on to our secure Web site. Follow the instructions above to access Caremark's Pharmacy Site. Once you have registered and logged in, select the Plan and Benefits tab, then Coverage exceptions on the left-side navigation bar. Please allow up to 24 hours for physician phoned-in requests or two to five business days for paper-based requests.

?2015 Blue Cross and Blue Shield Association and CVS Caremark

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