2018 Service Benefit Plan Specialty Drug List
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- Rodger Stanley
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1 2018 Service Benefit Plan Specialty Drug List If you are a member or health care provider and have questions, please call , or visit fepblue.org/pharmacy. Specialty drugs are prescribed to treat people with complex conditions such as multiple sclerosis, hemophilia, hepatitis C and rheumatoid arthritis. These high cost drugs also have one or more of the following traits: they are injected or infused (but some may be taken by mouth); they have unique storage or shipment needs; more education and support is needed to help patients use the drugs properly, and they are usually not stocked at retail pharmacies. This list of specialty drugs is updated and is subject to change. Changes may appear prior to their effective date. For drug-specific coverage information, please call the number listed above Monday-Friday from 7 a.m. to 9 p.m., or Saturday/Sunday from 8 a.m. to 6:30 p.m. ET. Please Note: The self-injectable formulation of the drugs with an asterisk are only covered under the pharmacy benefit. A ALUNBRIG (PA)¹ BERINERT (PA) ABRAXANE Amifostine BESPONSA (PA)¹ ACTEMRA (PA) AMPYRA (PA) BETASERON (PA)* ACTIMMUNE (PA)* APLIGRAF^ BETHKIS ADAGEN APOKYN*¹ Bexarotene (PA) ADCETRIS (PA) ARALAST NP (PA) BICNU ADCIRCA (PA) ARANESP (PA) BIVIGAM (PA) Adefovir Dipivoxil ARCALYST (PA)*¹ Bleomycin ADEMPAS (PA)¹ ARRANON BLINCYTO (PA)¹ Adriamycin ARZERRA (PA) BORTEZOMIB (PA) Adrucil AUBAGIO (PA) BOSULIF (PA) ADVATE AUSTEDO (PA) BOTOX (PA) ADYNOVATE AVASTIN (PA) BRAVELLE (PA) AFINITOR (PA) AVEED (PA) BRINEURA (PA)^ AFSTYLA AVONEX (PA)* BUPHENYL (PA) ALDURAZYME (PA) Azacitidine C ALECENSA (PA) B CABOMETYX (PA) ALFERON N (PA)¹ BARACLUDE CALQUENCE (PA)¹ ALIMTA BAVENCIO (PA)¹ CAMPTOSAR ALIQOPA (PA)^ BEBULIN Capecitabine ALKERAN BELEODAQ (PA) CAPRELSA (PA)¹ ALPHANATE BENDEKA (PA) CARBAGLU (PA)¹ ALPHANINE SD BENEFIX Carboplatin ALPROLIX BENLYSTA (PA) CARIMUNE (PA)
2 CAYSTON DOXIL CEPROTIN (PA)¹ Doxorubicin CERDELGA (PA) DUPIXENT (PA) CEREZYME (PA) DUROLANE (PA)¹ CETROTIDE (PA) DYSPORT (PA) CHOLBAM (PA)¹ E CHORIONIC GONADOTROPIN EGRIFTA (PA) (PA) ELAPRASE (PA) CIMZIA (PA)* ELELYSO (PA)¹ CINQAIR (PA) ELIGARD (PA) CINRYZE (PA)¹ ELITEK Cisplatin ELLENCE Cladribine ELOCTATE Clofarabine EMFLAZA (PA)¹ CLOLAR EMPLICITI (PA) COAGADEX¹ ENBREL (PA)* COMETRIQ (PA)¹ ENDARI (PA)¹ COPAXONE (PA)* Entecavir COPEGUS (PA) ENTYVIO (PA) CORIFACT EPCLUSA (PA) CORTICOTROPHIN¹ Epirubicin COSENTYX (PA) EPOGEN (PA) COSMEGEN Epoprostenol (PA)¹ COTELLIC (PA) EPOPROSTENOL STERILE CUVITRU (PA)¹ DILUENT¹ Cyclophosphamide ERBITUX (PA) CYRAMZA (PA)¹ ERIVEDGE (PA) CYSTADANE¹ ERLEADA (PA) CYSTAGON¹ ERWINAZE (PA)¹ CYSTARAN ESBRIET (PA) Cytarabine ETHYOL CYTOGAM ETOPOPHOS CYTOVENE Etoposide D EUFLEXXA (PA) Dacarbazine EVOMELA (PA) DACOGEN EXJADE (PA) Dactinomycin EXONDYS 51 (PA)¹ DAKLINZA (PA) EXTAVIA (PA)* DARZALEX (PA) EYLEA (PA) Daunorubicin F DAUNOXOME FABRAZYME (PA) Decitabine FARYDAK (PA) Deferoxamine FASENRA (PA) DEPOCYT FASLODEX DESFERAL FEIBA Dexrazoxane FERRIPROX (PA)¹ Docetaxel FIBRYGA¹ Dofetilide FIRAZYR (PA)* FIRMAGON FLEBOGAMMA (PA) FLOLAN (PA)¹ FLOLAN STERILE DILUENT¹ FLOXURIDINE Fludarabine Fluorouracil FOLLISTIM AQ (PA) FOLOTYN FORTEO (PA)* FUSILEV FUZEON* G GAMASTAN S/D (PA) GAMMAGARD (PA) GAMMAKED (PA) GAMMAPLEX (PA) GAMUNEX-C (PA) Ganciclovir GANIRELIX (PA) GATTEX (PA)¹ GAZYVA (PA) GEL-ONE (PA) GELSYN-3 (PA) Gemcitabine GEMZAR GENOTROPIN (PA)* GENVISC 850 (PA) GILENYA (PA) GILOTRIF (PA)¹ GLASSIA (PA) Glatiramer (PA)* Glatopa (PA)* GLEEVEC (PA) GONAL-F (PA) GRANIX (PA) H H.P. ACTHAR (PA)* HAEGARDA (PA) HALAVEN (PA) HARVONI (PA) HELIXATE FS (PA) HEMLIBRA HEMOFIL M HEPAGAM B HEPSERA HERCEPTIN (PA)
3 HETLIOZ (PA) HIZENTRA (PA) HUMATE-P HUMATROPE (PA)* HUMIRA (PA)* HYALGAN (PA) HYCAMTIN HYDROXYPROGESTERONE HYMOVIS (PA) HYPERHEP B S/D HYPERRHO S/D HYQVIA (PA) I IBRANCE (PA) ICLUSIG (PA)¹ IDAMYCIN Idarubicin IDELVION IDHIFA (PA) IFEX Ifosfamide ILARIS (PA) Imatinib (PA) IMBRUVICA (PA)¹ IMFINZI (PA)¹ IMLYGIC (PA) INCRELEX (PA)* INFLECTRA (PA) INGREZZA (PA)¹ INLYTA (PA) INTRON A (PA) IRESSA (PA)¹ Irinotecan ISTODAX (PA) IXEMPRA IXINITY J JADENU (PA) JAKAFI (PA) JETREA (PA) JEVTANA (PA) JUXTAPID (PA)¹ K KADCYLA (PA) KALBITOR (PA)¹ KALYDECO (PA) KANUMA (PA) KEPIVANCE (PA) KEVZARA (PA) KEYTRUDA (PA) KINERET (PA)¹ KISQALI (PA) KITABIS KOATE KOGENATE FS KORLYM (PA)¹ KOVALTRY KRYSTEXXA (PA) KUVAN (PA) KYLEENA KYMRIAH (PA)^ KYNAMRO (PA) KYPROLIS (PA) L LARTRUVO (PA)¹ LEMTRADA (PA) LENVIMA (PA)¹ LETAIRIS (PA) LEUKINE (PA) Leuprolide (PA) Levoleucovorin LILETTA¹ Lipodox LONSURF (PA) LUCENTIS (PA) LUMIZYME (PA) LUPANETA LUPRON DEPOT (PA) LUXTURNA (PA)^ LYNPARZA (PA)¹ M MACUGEN (PA) MAKENA MARQIBO (PA)¹ MATULANE MAVYRET (PA) MEKINIST (PA) Melphalan MENOPUR (PA) MEPSEVII (PA)¹ Mesna MESNEX MICRHOGAM MIRCERA (PA)¹ MIRENA Mitomycin Mitoxantrone Moderiba (PA) MONOCLATE-P MONONINE MONOVISC (PA) MOZOBIL MUSTARGEN Mutamycin MYALEPT (PA)¹ MYLOTARG (PA)¹ MYOBLOC (PA) N NABI-HB NAGLAZYME (PA) NATPARA (PA) NAVELBINE NERLYNX (PA)¹ NEULASTA (PA) NEUPOGEN (PA) NEXAVAR (PA) NEXPLANON¹ NINLARO (PA) NIPENT NITYR¹ NORDITROPIN (PA)* NORTHERA (PA) NOVAREL (PA) NOVOEIGHT NOVOSEVEN NPLATE (PA) NUCALA (PA) NULOJIX NUPLAZID (PA) NUTROPIN AQ (PA)* NUWIQ O OCALIVA (PA) OCREVUS (PA) OCTAGAM (PA) Octreotide ODOMZO (PA) OFEV (PA) OLYSIO (PA) OMNITROPE (PA)* ONCASPAR
4 ONIVYDE (PA)¹ OPDIVO (PA) OPSUMIT (PA) ORALAIR (PA) ORENCIA (PA) ORENITRAM ER (PA)¹ ORFADIN¹ ORKAMBI (PA) ORTHOVISC (PA) OTEZLA (PA) OVIDREL (PA) Oxaliplatin P Paclitaxel Pamidronate PARSABIV (PA) PEGASYS (PA) PEG-INTRON (PA) PERJETA (PA) PHOTOFRIN^ PLEGRIDY (PA) POMALYST (PA) PORTRAZZA (PA)¹ PRALUENT (PA) PREGNYL (PA) PREVYMIS (PA) PRIALT PRIVIGEN (PA) PROCRIT (PA) PROCYSBI (PA)¹ PROFILNINE PROLASTIN-C (PA)¹ PROLEUKIN PROLIA (PA) PROMACTA (PA) PROVENGE (PA)^ PULMOZYME (PA) PURIXAN R RADICAVA (PA) RAVICTI (PA) REBETOL (PA) REBIF (PA)* REBINYN RECLAST RECOMBINATE REMICADE (PA) REMODULIN (PA)¹ RENFLEXIS (PA) REPATHA (PA) REVATIO (PA) REVLIMID (PA) RHOGAM RHOPHYLAC RIASTAP Ribasphere (PA) Ribavirin (PA) RITUXAN (PA) RITUXAN HYCELA (PA) RIXUBIS ROMIDEPSIN (PA) RUBRACA (PA)¹ RUCONEST (PA)¹ RYDAPT (PA) S SABRIL (PA) SAIZEN (PA)* SAMSCA SANDOSTATIN SANDOSTATIN LAR (PA) SENSIPAR (PA) SEROSTIM (PA)* SIGNIFOR (PA)¹ Sildenafil (PA) SILIQ (PA) SIMPONI (PA)* SKYLA Sodium Phenylbutyrate (PA) SOLESTA SOLIRIS (PA) SOMATULINE DEPOT (PA) SOMAVERT SOVALDI (PA) SPINRAZA (PA)^ SPRYCEL (PA) STELARA (PA) STIMATE STIVARGA (PA) STRENSIQ (PA)¹ SUBLOCADE (PA) SUPARTZ FX (PA) SUPPRELIN LA (PA) SUTENT (PA) SYLATRON (PA) SYMDEKO (PA) SYNAGIS (PA) SYNRIBO (PA)¹ SYNVISC (PA) T TAFINLAR (PA) TAGRISSO (PA)¹ TALTZ (PA) TARCEVA (PA) TARGRETIN (PA) TASIGNA (PA) TAXOTERE TECENTRIQ (PA) TECFIDERA (PA) TECHNIVIE (PA) TEMODAR Temozolomide TEPADINA TESTOPEL (PA) Tetrabenazine (PA) THALOMID THERACYS Thiotepa THYROGEN TICE BCG TIKOSYN TOBI Tobramycin Toposar Topotecan TORISEL TOTECT TRACLEER (PA) TREANDA (PA) TRELSTAR (PA) TREMFYA (PA) TRETTEN¹ TRIPTODUR (PA)¹ TRISENOX TROGARZO (PA) TYKERB (PA) TYMLOS (PA) TYSABRI (PA) TYVASO (PA)¹ U UPTRAVI (PA)¹ UVADEX
5 V VALCHLOR (PA)¹ VALSTAR VANTAS (PA) VARIZIG VECTIBIX (PA) VELCADE (PA) VELETRI (PA)¹ VEMLIDY VENCLEXTA (PA)¹ VENTAVIS (PA)¹ VERZENIO (PA) VIDAZA VIEKIRA (PA) VIEKIRA XR (PA) Vigabatrin (PA) VIMIZIM (PA) VINBLASTINE Vincasar Vincristine Vinorelbine VISCO-3 (PA) VISUDYNE VIVITROL VONVENDI¹ VORAXAZE VOSEVI (PA) VOTRIENT (PA) VPRIV (PA) W WILATE WINRHO SDF X XALKORI (PA) XELJANZ (PA) XELJANZ XR (PA) XELODA XENAZINE (PA) XEOMIN (PA) XERMELO (PA)¹ XGEVA (PA) XIAFLEX (PA)¹ XOLAIR (PA) XTANDI (PA) XYNTHA Y YERVOY (PA) YESCARTA (PA)^ YONDELIS (PA) Z ZALTRAP (PA) ZANOSAR ZARXIO (PA) ZAVESCA (PA)¹ ZEJULA (PA)¹ ZELBORAF (PA) ZEMAIRA (PA)¹ ZEPATIER (PA) ZILRETTA (PA)¹ ZINECARD ZOLADEX (PA) Zoledronic Acid ZOLINZA (PA) ZOMACTON (PA) ZOMETA ZORBTIVE (PA)* ZORTRESS ZYDELIG (PA)¹ ZYKADIA (PA) ZYTIGA (PA)
6 2018 Limited Distribution Drug List Limited Distribution Drugs (LDD): In some cases, a manufacturer may limit the number of pharmacies it allows to carry (or distribute) a Limited Distribution Drug. Or sometimes a condition of the Food and Drug Administration s (FDA) drug approval process may require a drug to be in the LDD category. Limited distribution helps the manufacturer carefully keep track of drugs that have special dosing or lab monitoring requirements, or that need to be followed very closely to ensure that any risks that are associated with the LDD are minimized. You may get the Limited Distribution Drugs listed below through a specific Preferred retail pharmacy with the Specialty Drug Pharmacy Program copayments under the Standard Option and Basic Option. Please contact the Specialty Pharmacy Program at for assistance with finding the appropriate pharmacy. A DUROLANE K ADEMPAS E KALBITOR ALFERON N ELELYSO KINERET ALUNBRIG EMFLAZA KORLYM APOKYN ENDARI L ARCALYST EPOPROSTENOL LARTRUVO B EPOPROSTENOL STERILE LENVIMA BAVENCIO DILUENT LILETTA BESPONSA ERWINAZE LYNPARZA BLINCYTO EXONDYS 51 M C F MARQIBO CALQUENCE FERRIPROX MEPSEVII CAPRELSA FIBRYGA MIRCERA CARBAGLU FLOLAN MYALEPT CEPROTIN FLOLAN STERILE DILUENT MYLOTARG CHOLBAM G N CINRYZE GATTEX NERLYNX COAGADEX GILOTRIF NEXPLANON COMETRIQ I NITYR CORTICOTROPHIN ICLUSIG O CUVITRU IMBRUVICA ONIVYDE CYRAMZA IMFINZI ORENITRAM ER CYSTADANE INGREZZA ORFADIN CYSTAGON IRESSA P D J PORTRAZZA JUXTAPID
7 PROCYSBI PROLASTIN-C R REMODULIN RUBRACA RUCONEST S SIGNIFOR STRENSIQ SYNRIBO T TAGRISSO TRETTEN TRIPTODUR TYVASO U UPTRAVI V VALCHLOR VELETRI VENCLEXTA VENTAVIS VONVENDI X XERMELO XIAFLEX Z ZAVESCA ZEJULA ZEMAIRA ZILRETTA ZYDELIG
8
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