Headline Specialty pharmacy drug list

Transcription

1 Headline Effective January 1, 2017 BriovaRx, the OptumRx specialty pharmacy, provides comprehensive support services, including access to pharmacists around the clock, for high-cost oral and injectable medications used to treat rare and complex conditions. In addition, your medications will be shipped to you at no extra cost. OptumRx optumrx.com

2 Characteristics of specialty medications Specialty medications are defined as high-cost oral or injectable medications used to treat rare and complex conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds found within the body. Medications must have at least one of the following characteristics in order to be classified as a specialty medication by BriovaRx: High cost Typically priced at more than $1,000 per 30-day supply. High complexity Biotechnology products Medications that treat ultra rare conditions Medications that are included in a specialty therapeutic drug class strategy High-touch medications that require: Temperature control or other special handling and shipping requirements (e.g., refrigerated or frozen shipping) Ongoing management by a pharmacist and/or physician specializing in treating the condition Focused, in-depth education including how to administer injections, adhere to the treatment protocol, and manage side effects Protein or protein-based molecular entities

3 Alpha-1 Glassia PA Ammonia detoxicants Ravicti PA Anticonvulsants Onfi PA Antilipemic agents Juxtapid PA Kynamro PA Repatha Antiviral Actimmune Adefov Dipiv Alferon N Baraclude Copegus PA Daklinza Epclusa Hepsera Infergen PA Intron-A PA * Olysio Pegasys PA * Peg-Intron PA Rebetol PA Ribapak PA Ribasphere PA Ribatab PA Ribavirin PA * * Sovaldi Synagis PA Tyzeka Victrelis Viekira XR PA Zepatier PA Asthma Xolair PA Birth control Implanon Mirena Nexplanon Cancer Abraxane Adcetris PA Adriamyc Adriamycin Adrucil Afinitor PA Afinitor Dis PA Alecensa PA Alimta Alkeran Amifostine Arranon Arzerra PA Avastin Azacitidine Bendeka Bicnu Bleomycin Bosulif ST Busulfex Cabometyx PA Camptosar Capecitabine Caprelsa PA Carboplatin Cerubidine Cisplatin Cladribine Clolar Cometriq PA Cosmegen Cyclophosph Cyclophospha Cytarabine Dacarbazine Dacogen PA Dactinomycin Daunorubicin Daunoxome Decitabine PA Dexrazoxane Docefrez Docetaxel Doxil Doxorubicin Eligard Ellence Eloxatin Elspar Epirubicin Erbitux PA Erivedge PA Erwinaze Ethyol Etopophos Etoposide Evomela Faslodex Firmagon PA Floxuridine Fludara Fludarabine Fluorouracil Folotyn PA Fusilev Gablofen Gemcitabine Gemzar Gilotrif PA Gleevec PA * Halaven PA Herceptin PA Hycamtin Iclusig Idamycin PFS Idarubicin Ifex Ifosfamide Inlyta PA Irinotecan Istodax PA Ixempra Kit Jakafi PA Jevtana PA Kadcyla PA Kepivance Kyprolis PA Lenvima PA Leuprolide PA Lipodox Lipodox 50 Lupaneta Kit PA Lupr Dep-Ped PA * Lupron Depot PA * Marqibo Mekinist PA Melphalan Mercaptopuri Mesna Mesnex PA Prior authorization required ST Step therapy * Preferred 3

4 Mitomycin Mitomycin C Mitoxantron PA Mustargen Navelbine Nexavar PA Nipent Oncaspar Oxaliplatin Paclitaxel Pamidronate Pentostatin Perjeta PA Photofrin Pomalyst PA Portrazza PA Proleukin provenge Revlimid PA Rituxan Sprycel Stivarga PA Supprelin LA Sutent PA Sylatron PA Synribo PA Tafinlar PA Tarceva PA Targretin PA * Tasigna Taxotere Tecentriq PA Temodar PA Temozolomide PA Teniposide Thalomid PA Theracys Thiotepa Tice Bcg Toposar Topotecan Torisel Totect Treanda PA Trelstar LA ST Trelstar Mix ST Tretinoin Trisenox Tykerb PA Vantas ST Vectibix Velcade PA Venclexta PA Vidaza Vinblastine Vincasar PFS Vincristine Vinorelbine Votrient PA Xalkori PA Xeloda Xgeva PA Xtandi Yervoy PA Zaltrap PA Zanosar Zelboraf PA Zevalin Zinecard Zoladex * Zolinza PA Zytiga PA Chemotherapy Protectant Xuriden PA Enzyme replacement/ modifiers Carbaglu Kanuma PA Orfadin Enzyme therapy Adagen Aldurazyme PA Aralast NP PA Cerezyme PA Elaprase PA Elelyso PA Fabrazyme PA Kuvan Kuvan Powder Lumizyme PA Myozyme PA Naglazyme PA Procysbi Prolastin-C PA Vimizim Inj Vpriv PA Zavesca PA Zemaira PA Gastrointestinal agents Gattex PA Ocaliva PA Solesta Sucraid Gout Krystexxa PA Growth hormone Genotropin Humatrope Increlex PA Norditropin Nutropin Nutropin AQ Omnitrope * Saizen Serostim PA Tev-Tropin Zorbtive PA * * * Hematological agents Advate Alphanate Alphanine SD Aranesp PA * Afstyla Bebulin Bebulin VH Benefix Berinert PA Cinryze PA Corifact Epogen PA Feiba NF Feiba VH Firazyr PA Idelvion Helixate FS Hemofil M 4 OptumRx optumrx.com

5 Humate-P Kalbitor PA Koate-DVI Kogenate FS Leukine PA Monoclate-P Mononine Mozobil PA Neulasta PA Neumega PA Neupogen PA Novoseven RT Nplate PA Omontys PA Procrit PA * Profilnine Promacta PA Recombinate Rixubis Tretten Inj Wilate Xyntha Xyntha Solof Hemophilia Afstyla Vonvendi HIV Abacavir * Aptivus * Atripla * Combivir Complera * Crixivan * Didanosine * Descovy Edurant * Egrifta PA Emtriva * Epivir Epivir HBV * Epzicom * Fuzeon Intelence * Invirase * Isentress * Kaletra * Lamivud/Zido * Lamivudine * Lexiva * Nevirapine * Norvir * Odefsey Prezista * Rescriptor * Retrovir Reyataz * Selzentry PA * Stavudine * Stribild * Sustiva * Tivicay * Trizivir Truvada * Videx * Videx EC Viracept * Viramune Viramune XR Viread * Zerit Ziagen Zidovudine * Hormones and hormone modifiers Acthar HP PA Acthrel Octreotide PA Samsca Sandostatin PA Sensipar Signifor PA Somatuline PA Somavert PA Thyrogen Huntington s disease Xenazine PA Immune globulin Atgam Bivigam PA Carimune NF PA Cytogam Flebogamma PA Gamastan S/D PA Gammagard PA Gammagard SD PA Gammaked PA Gammaplex PA Gamunex-C PA Hizentra PA Hyperrab S/D Hyperrho S/D Imogam Rabie Micrhogam PL Octagam PA Privigen PA Rhogam Plus Rhophylac Soliris Winrho SDF Immunomodulator Benlysta PA Infertility Bravelle Cetrotide Chor Gonadot PA Delalutin PA Follistim AQ Ganirelix AC * Gonal-f * Gonal-f RFF Makena PA * Menopur PA Novarel PA Ovidrel Pregnyl PA * Repronex PA PA, ST * PA Prior authorization required ST Step therapy * Preferred 5

6 Inflammatory conditions Iron overload Musculoskeletal agents Osteoarthritis Actemra Arcalyst PA * Cimzia * Cimzia Prefl Enbrel Enbrel Srclk * Humira * Humira Pen Ilaris PA Kineret Orencia Otrexup Injection PA Remicade PA * Simponi * Stelara Taltz Xeljanz Xeljanz XR Exjade Ferriprox PA Multiple sclerosis Ampyra PA * Aubagio * Avonex Avonex Pen Avonex Prefl * Betaseron * Copaxone Extavia Gilenya Rebif Rebif Rebido PA Rebif Titrtn PA * Tecfidera Tysabri PA Zinbryta * * Botox PA Dysport PA Myobloc PA Xeomin PA Xiaflex Zoledronic Zometa Narcolepsy Xyrem PA Ophthalmic agents Cystaran PA Eylea Jetrea Lucentis Macugen Visudyne Euflexxa PA Gelsyn-3 PA Gel-One Hyalgan Hymovis PA Orthovisc PA Supartz Synvisc PA * Synvisc One PA * Osteoporosis Forteo PA * Prolia PA Reclast Pain management Prialt Qutenza 6 OptumRx optumrx.com

7 Parkinson s disease Apokyn PA Pregnancy Makena Pulmonary hypertension Adcirca PA Epoprostenol PA Flolan PA Letairis PA * Opsumit PA Remodulin PA Revatio PA Sildenafil PA Tracleer PA * Tyvaso PA Tyvaso Refil PA Tyvaso Start PA Uptravi PA Veletri PA Ventavis PA Recombinant Human Leptin Analog Alprolix Respiratory agents Bethkis Neb ST Cayston PA Cinqair PA Kalydeco PA Pulmozyme Tobi ST Tobi Podhalr ST Tobramycin Neb ST Substance abuse treatment agents Vivitrol PA Transplant Astagraf XL Cellcept Cellcept IV Cyclosporine * Gengraf Hecoria Mycophenolate * Myfortic Neoral Nulojix PA Prograf Rapamune Sandimmune Sirolimus Tabs Tacrolimus Zortress PA PA Prior authorization required ST Step therapy * Preferred 7

8 Specialty Pharmacy Drug List About OptumRx OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. BriovaRx is our specialty pharmacy. Our high-quality, integrated services deliver optimal member outcomes, superior savings and outstanding customer service. We are an Optum TM company a leading provider of integrated health services. Learn more at optum.com. To fill a prescription for a specialty medication on this list, please call or visit optumrx.com. This specialty pharmacy drug list may not be a complete representation of all available specialty medications; this list is subject to change at any time without prior notice. Non-specialty alternatives may be a recommended first-line therapy to treat your condition. Please consult your physician. optumrxsales@optum.com optumrx.com 2300 Main Street, Irvine, CA All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners OptumRx, Inc. ORX2700_170101