specialty drug list ph-anr07rev022119...f = formulary pa = prior authorization ql = quantity limit...
TRANSCRIPT
Specialty Drug List
F = Formulary PA = Prior Authorization QL = Quantity Limit
ST = Step Therapy AL = Age Limit V01.01.2019
1
Drug Tier Status Notes
Antimalarials
Daraprim Specialty PA
Glycopeptide Antibiotics
vancomycin intravenous recon soln 1,000 mg, 10
gram, 5 gram, 500 mg, 750 mg
Specialty
Antineoplastic - CYP17 (17 Alpha-Hydroxylase/C17, 20-Lyase) Inhibitor
Yonsa Specialty PA
Zytiga Specialty PA; QL
Antineoplastic - Alkylating Agent - Triazenes
temozolomide Specialty PA
Antineoplastic - Antimetabolites - Pyrimidine Analog Combinations
Lonsurf Specialty PA
Antineoplastic - Epipodophyllotoxins
etoposide oral Specialty PA
Antineoplastic - Estrogens
Emcyt Specialty PA
Antineoplastic - Hedgehog Pathway Inhibitor
Erivedge Specialty PA; QL
Odomzo Specialty PA
Antineoplastic - Histone Deacetylase (HDAC) Inhibitors
Farydak Specialty PA
Zolinza Specialty PA
Antineoplastic - Interferons
Intron A injection Specialty PA
Antineoplastic - Janus Kinase (JAK) Inhibitors
Jakafi Specialty PA; QL
Antineoplastic - mTOR Kinase Inhibitors
Afinitor Disperz Specialty PA; QL
Afinitor oral tablet 10 mg, 2.5 mg, 5 mg Specialty PA; QL
Afinitor oral tablet 7.5 mg Specialty PA
F = Formulary PA = Prior Authorization QL = Quantity Limit
ST = Step Therapy AL = Age Limit V01.01.2019
2
Drug Tier Status Notes
Antineoplastic - Mutant Isocitrate Dehydrogenase 1 (mIDH1) Inhibitors
Tibsovo Specialty PA
Antineoplastic - Mutant Isocitrate Dehydrogenase 2 (mIDH2) Inhibitors
Idhifa Specialty PA
Antineoplastic - Retinoids
tretinoin (chemotherapy) Specialty PA
Antineoplastic - Selective Retinoid X Receptor Agonists
Targretin oral Specialty
Antineoplastic - Thalidomide Analogs
Revlimid oral capsule 10 mg, 15 mg, 25 mg, 5 mg Specialty PA; QL
Revlimid oral capsule 2.5 mg, 20 mg Specialty PA
Antineoplastic - Topoisomerase I Inhibitors
Hycamtin oral Specialty PA
Adempas Specialty PA; QL
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists
Letairis Specialty PA; QL
Tracleer oral tablet Specialty PA; QL
Tracleer oral tablet for suspension Specialty PA; AL
Minerals And Electrolytes - Magnesium
magnesium sulfate injection Specialty
Androgen - Single Agents
testosterone cypionate Specialty
Insulin-Like Growth Factor-1 (IGF-1)
Increlex Specialty PA
Somatostatic Agents
octreotide acetate injection solution 1,000
mcg/mL, 100 mcg/mL, 200 mcg/mL, 50 mcg/mL
Specialty PA
Multiple Sclerosis Agents
Multiple Sclerosis Agent - Interferons
Avonex (with albumin) Specialty PA; QL
F = Formulary PA = Prior Authorization QL = Quantity Limit
ST = Step Therapy AL = Age Limit V01.01.2019
3
Drug Tier Status Notes
Avonex intramuscular pen injector kit Specialty PA; QL
Avonex intramuscular syringe kit Specialty PA; QL
Multiple Sclerosis Agent - Others
glatiramer Specialty PA; QL
Glatopa subcutaneous syringe 20 mg/mL Specialty PA; QL
Tecfidera Specialty PA; QL
Multiple Sclerosis Agent - Potassium Channel Blocker
Ampyra Specialty PA
Multiple Sclerosis Agent - Sphingosine 1-Phosphate Receptor Modulator
Gilenya oral capsule 0.5 mg Specialty PA; QL
Cystic Fibrosis - Inhaled Aminoglycosides
Bethkis Specialty PA
Kitabis Pak Specialty
Tobi Podhaler Specialty PA
tobramycin in 0.225 % NaCl Specialty PA
tobramycin with nebulizer Specialty PA
Cystic Fibrosis - Inhaled Monobactams
Cayston Specialty PA
Mucolytics
Pulmozyme Specialty PA; QL
4
Index
A Adempas ................................. 2
Afinitor ................................... 1
Afinitor Disperz...................... 1
Ampyra ................................... 3
Avonex ................................... 3
Avonex (with albumin) .......... 2
B Bethkis .................................... 3
C Cayston ................................... 3
D Daraprim................................. 1
E Emcyt ..................................... 1
Erivedge ................................. 1
etoposide................................. 1
F Farydak ................................... 1
G Gilenya ................................... 3
glatiramer ............................... 3
Glatopa ................................... 3
H Hycamtin ................................ 2
I Idhifa ...................................... 2
Increlex ................................... 2
Intron A .................................. 1
J Jakafi ...................................... 1
K Kitabis Pak ............................. 3
L Letairis .................................... 2
Lonsurf ................................... 1
M magnesium sulfate .................. 2
O octreotide acetate .................... 2
Odomzo .................................. 1
P Pulmozyme ............................. 3
R Revlimid ................................. 2
T Targretin ................................. 2
Tecfidera ................................. 3
temozolomide ......................... 1
testosterone cypionate ............ 2
Tibsovo ................................... 2
Tobi Podhaler ......................... 3
tobramycin in 0.225 % NaCl .. 3
tobramycin with nebulizer ...... 3
Tracleer ................................... 2
tretinoin (chemotherapy) ........ 2
V vancomycin ............................. 1
Y Yonsa ...................................... 1
Z Zolinza .................................... 1
Zytiga ...................................... 1