BB&T Prior Authorization Program Drug List

Transcription

1 BB&T Prior Authorization Program Drug List Prior authorization programs are designed to support BB&T prior authorization and medical exception initiatives. Prior authorization and medical exceptions apply qualitative and quantitative standards to determine drug coverage by the pharmacy benefit. Express Scripts offers prior authorization review services 24 hours a day, 365 days a year. Requests are made through the Contact Center to ensure that physicians and pharmacists have quick, easy access to prior authorization information. BRAND NAME Abstral Actemra Actiq Adcirca Amevive Ampyra Aranesp GENERIC NAME oral transmucosal fentanyl drugs tocilizumab oral transmucosal fentanyl drugs tadalafil alefacept dalfampridine darbepoetin alfa Arcalyst rilonacept Atralin

2 Avita Avonex Berinert Betaseron Boniva IV Botox Carimune NF Nanofiltered Chenodal Cerezyme Cimzia Cinryze Copaxone Diflucan Dysport Egrifta Eligard Enbrel Epogen Erbitux Euflexxa Extavia Fabrazyme topical retinoin interferon beta-1a injection C1 esterase inhibitor interferon beta-1b injection bisphosphonates IV botulinum toxin type A chenodol imiglucerase certolizumab pegol for injection C1 esterase inhibitor glatiramer injection fluconazole abobbotulinumtoxina tesamorelin for injection Leuprolide etanercept epoetin alfa cetuximb interferon beta-1b injection agalsidase beta

3 Fentora Firazyr Flebogamma Flolan Forteo Gammagard Liquid Gammagard S/D Gammaked Gamunex-C Gamunex-C Gamunex Genotropin Gleevec Herceptin Hizentra Humatrope Humira Hyalgan Ilaris Incivek Increlex Iveegam EN Kalbitor Kalydeco Kineret Krystexxa oral transmucosal fentanyl drugs icatibant epoprostenol inection teriparatide immune globulin subcutaneous immun globulin intravenous imatinib mesylate trastuzumab immune globulin subcutaneous adalimumab njection) canakinumab telaprevir Mecasermin ecallantide Ivacaftor anakinra pegloticase

4 Korlym mifepristone Kuvan sapropterin dihydrochloride Letairis Ambrisntan Lazanda fentanyl nasal spray Lidoderm lidocaine transdermal Lupron Leuprolide Makena hydroxyprogesterone caproate Myobloc botulinum toxin type B Neulasta pegfilgrastim Neupogen filgrastim Norditropin Nplate romiplostim Nutropin AQ Nutropin Nuvigil armodafinil Octagam Omnitrope Onsolis fentanyl citrate Orencia abatacept Orthovisc Pegasys peginterferon alfa-2a PEG-Intron peginterferon alfa -2b Polygam Perjeta pertuzumab Procrit epoetin alfa Prolastin, Aralast, Zemaira alpha 1 -proteinase inhibitor

5 Prolia Promacta Provigil Rebif Reclast Regranex Remicade Remodulin Retin-A /Micro Revatio Rituxan Saizen Samsca Selzentry Serostim Simponi Somavert Sprycel Stelara Supartz Subsys Synagis Synvisc Tasigna Tazorac denosumab eltrombopag olamine modafinil interferon beta-1a injection bisphosphonates IV Becaplermin infliximab treprostinil injection sildenafil rituxamab tolvaptan maraviroc golimumab injection pegvisomant dasatinib ustekinumab fentanyl sublingual palivizumab nilotinib tazarotene

6 Tev-Tropin Topamax Tracleer Tretin-X Tykerb Tysabri Tyvaso Vectibix Ventavis Victrelis Vivaglobin Vivaglobin Xalkori Xenazine Xeomin Xolair Zelboraf Ziana Zonegran Zorbtive topiramate bosentan lapatinib natalizumab injection treprostinil inhalation panitumumab iloprost boceprevir immune globulin SC immune globulin subcutaneous Crizotinib tetrabenazine incobotulinumtoxima omalizumab vemurafenib zonisamide Members may call Express Scripts with any questions at Physicians can call the PA Hotline at