Blue Cross Blue Shield Vermont: Prescription Drug Prior Approval List

Prescription Drug Prior Approval
We require Prior Approval for certain categories of medications: those without a National Drug Code (NDC) number and drugs that have been on the market less than 12 months. Your doctor must consult the guidelines, and submit the appropriate form.

(Updated 5/5/08) # = added to list 1/1/08 * = added effective 5/5/08

Drug Name	Guidelines	Form
Amevive #	Amevive Guidelines	Amevive Prior Approval Form
Antagon #	Antagon Guidelines	Antagon Approval Form
Apokyn #	Apokyn Guidelines	Apokyn Prior Approval Form
Aranesp #	Aranesp Guidelines	Aranesp Prior Approval Form
Arixtra	Arixtra Guidelines	Arixtra Prior Approval Form
Avastin #	Avastin Guidelines	Avastin Prior Approval Form
Avonex #	Avonex Guidelines	Avonex Prior Approval Form
Baraclude	Baraclude Guidelines	Baraclude Prior Approval Form
Betaseron #	Betaseron Guidelines	Betaseron Prior Approval Form
Botox	Botox Guidelines	Botox Prior Approval Form
Bravelle #	Bravelle Guidelines	Bravelle Approval Form
Byetta	Byetta Guidelines	Byetta Prior Approval Form
Bystolic	Bystolic Guidelines	Bystolic Prior Approval Form
Cetrotide #	Cetrotide Guidelines	Cetrotide Approval Form
Copaxone #	Copaxone Guidelines	Copaxone Approval Form
Copegus	Copegus Guidelines	Copegus Approval Form
Emend	Emend Guidelines	Emend Approval Form
Enbrel	Enbrel Guidelines	Enbrel Approval Form
Epogen #	Epogen Guidelines	Epogen Approval Form
Erbitux	Erbitux Guidelines	Erbitux Approval Form
Exforge	Exforge Guidelines	Exforge Approval Form
Exubera	Exubera Guidelines	Exubera Approval Form
Fertinex #	Fertinex Guidelines	Fertinex Approval Form
Flolan	Flolan Guidelines	Flolan Approval Form
Follistim #	Follistm Guidelines	Follistm Approval Form
Fragmin	Fragmin Guidelines	Fragmin Approval Form
Genotropin	Genotropin Guidelines	Genotropin Approval Form
Gleevec	Gleevec Guidelines	Gleevec Approval Form
GnRHa #	GnRHa Guidelines	GnRHa Approval Form
Gonal-FRFP #	Gonal-FRFP Guidelines	Gonal-FRFP Approval Form
Hepsera #	Hepsera Guidelines	Hepsera Approval Form
Humatrope	Humatrope Guidelines	Humatrope Approval Form
Humira	Humira Guidelines	Humira Approval Form
Innohep	Innohep Guidelines	Innohep Approval Form
Iressa	Iressa Guidelines	Iressa Approval Form
Kineret #	Kineret Guidelines	Kineret Approval Form
Lamisil #	Lamisil Guidelines	Lamisil Approval Form
Letairis	Letairis Guidelines	Letairis Prior Approval Form
Lovenox	Lovenox Guidelines	Lovenox Approval Form
Meridia #	Meridia Guidelines	Meridia Approval Form
Nexavar	Nexavar Guidelines	Nexavar Approval Form
Norditropin	Norditropin Guidelines	Norditropin Approval Form
Novarel #	Novarel Guidelines	Novarel Approval Form
Nutropin	Nutropin Guidelines	Nutropin Approval Form
Nutropin AQ	Nutropin AQ Guidelines	Nutropin AQ Approval Form
Ovidrel #	Ovidrel Guidelines	Ovidrel Prior Approval Form
Orencia	Orencia Guidelines	Orencia Approval Form
Pegasys	Pegasys Guidelines	Pegasys Approval Form
Peg-Intron	Peg-Intron Guidelines	Peg-Intron Approval Form
Pergonal #	Pergonal Guidelines	Pergonal Prior Approval Form
Pristiq *	Guidelines Pending	Pristiq Prior Approval Form
Procrit #	Procrit Guidelines	Procrit Approval Form
Pregnyl #	Pregnyl Guidelines	Pregnyl Prior Approval Form
Profasi #	Profasi Guidelines	Profasi Prior Approval Form
Protropin	Protropin Guidelines	Protropin Prior Approval Form
Rebetol	Rebetol Guidelines	Rebetol Approval Form
Rebif #	Rebif Guidelines	Rebif Approval Form
Retin-A for members over age 41 #	N/A	Retin-A Approval Form
Repronex #	Repronex Guidelines	Repronex Prior Approval Form
Revatio	Revatio Guidelines	Revatio Approval Form
Revlimid	Revlimid Guidelines	Revlimid Approval Form
Rituxan	Rituxan Guidelines	Rituxan Approval Form
Saizen	Saizen Guidelines	Saizen Approval Form
Serostim	Serostim Guidelines	Serostim Approval Form
Spiriva	Spiriva Guidelines	Spiriva Approval Form
Soliris	Soliris Guidelines	Soliris Approval Form
Somatrem	Somatrem Guidelines	Somatrem Approval Form
Somatropin	Somatropin Guidelines	Somatropin Approval Form
Sporanox/Itraconazole #	Sporanox Guidelines	Sporanox Approval Form
Sprycel	Sprycel Guidelines	Sprycel Approval Form
Sutent	Sutent Guidelines	Sutent Approval Form
Synarel #	Synarel Guidelines	Synarel Approval Form
Tarceva	Tarceva Guidelines	Tarceva Approval Form
Tekturna	Tekturna Guidelines	Tekturna Approval Form
Temodar	Temodar Guidelines	Temodar Approval Form
Tracleer	Tracleer Guidelines	Tracleer Approval Form
Tykerb	Tykerb Guidelines	Tykerb Approval Form
Tysabri	Tysabri Guidelines	Tysabri Approval Form
Ventavis	Ventavis Guidelines	Ventavis Approval Form
Veramyst	Veramyst Guidelines	Veramyst Approval Form
Vidaza	Vidaza Guidelines	Vidaza Approval Form
Vyvanse	Vyvanse Guidelines	Vyvanse Approval Form
Xolair #	Xolair Guidelines	Xolair Approval Form
Xenical #	Xenical Guidelines	Xenical Prior Approval Form
Xyzal	Xyzal Guidelines	Xyzal Approval Form
Zolinza	Zolinza Guidelines	Zolinza Approval Form
Zorbtive	Zorbtive Guidelines	Zorbtive Approval Form
Zyvox #	Zyvox Guidelines	Zyvox Approval Form

Compounded Medications #	N/A	Compounded Medications Approval Form
"Dispense as written" #	N/A	Dispense as Written Approval Form
Medications without NDC	N/A	N/A
Medications on market less than 12 months	N/A	N/A