Blue Cross Blue Shield Vermont: Catamount Prescription Drug Prior Approval

Catamount BlueSM 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) # = new to list as of 5/5/08

Drug Name	Guidelines	Form
Amevive	Amevive Guidelines	Amevive Prior 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
Byetta	Byetta Guidelines	Byetta Prior Approval Form
Bystolic	Bystolic Guidelines	Bystolic Prior 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
Flolan	Flolan Guidelines	Flolan Approval Form
Fragmin	Fragmin Guidelines	Fragmin Approval Form
Genotropin	Genotropin Guidelines	Genotropin Approval Form
Gleevec	Gleevec Guidelines	Gleevec 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 Approval Form
Lovenox	Lovenox Guidelines	Lovenox Approval Form
Nexavar	Nexavar Guidelines	Nexavar Approval Form
Norditropin	Norditropin Guidelines	Norditropin Approval Form
Nutropin	Nutropin Guidelines	Nutropin Approval Form
Orencia	Orencia Guidelines	Orencia Approval Form
Pegasys	Pegasys Guidelines	Pegasys Approval Form
Peg-Intron	Peg-Intron Guidelines	Peg-Intron Approval Form
Pristiq #	Guidelines Pending	Pristiq Approval Form
Procrit	Procrit Guidelines	Procrit Approval Form
Protropin	Protropin Guidelines	Protropin Approval Form
Revatio	Revatio Guidelines	Revatio Approval Form
Revlimid	Revlimid Guidelines	Revlimid Approval Form
Rebetol	Rebetol Guidelines	Rebetol Approval Form
Rebif	Rebif Guidelines	Rebif Approval Form
Retin-A for members over age 41	Retin-A Guidelines	Retin-A Approval Form
Rituxan	Rituxan Guidelines	Rituxan Approval Form
Saizen	Saizen Guidelines	Saizen Approval Form
Serostim	Serostim Guidelines	Serostim Approval Form
Soliris	Soliris Guidelines	Soliris Approval Form
Somatrem	Somatrem Guidelines	Somatrem Approval Form
Spiriva	Spiriva Guidelines	Spiriva Approval Form
Sporanox/Itraconazole	Sporanox Guidelines	Sporanox Approval Form
Sprycel	Sprycel Guidelines	Sprycel Approval Form
Sutent	Sutent Guidelines	Sutent 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
Vyvanse	Vyvanse Guidelines	Vyvanse Approval Form
Xolair	Xolair Guidelines	Xolair 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