standard formulary specialty drug list · 2020. 7. 30. · magellanrx.com . standard formulary...

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Standard Formulary Specialty Drug List Our Specialty Pharmacy provides patients with comprehensive support services and coordinated delivery related to high-cost oral, inhaled or injectable specialty medications, used to treat complex conditions. We are your single source for high-touch patient care management to control side effects, patient support and education to ensure compliance or continued treatment, and specialized handling and distribution of medications directly to the patient or care provider. Specialty medications may be covered under either the medical or pharmacy benefit. Please consult your insurance documentation to determine which benefit covers these medications. This list is updated with new information each quarter. Characteristics of Specialty Medications “Specialty” medications are defined as high-cost oral or injectable medications used to treat complex chronic conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds found within the body. High-touch patient care management is usually required to control side effects and ensure compliance. Specialized handling and distribution are also necessary to ensure appropriate medication administration. Medications must have at least one of the following characteristics in order to be classified as a specialty medication by Magellan Rx Management.

High Cost High-cost medications are typically priced at more than $670 per 30-day supply; including self-administered injectables, professionally-administered injectables/infusions, and oral medications.

High Complexity • Biotechnology products • Orphan or Ultra-Orphan drugs • Medications that are included in a specialty therapeutic drug class strategy

High Touch • Medications that require temperature control or other special handling/shipping requirements (i.e., refrigerated or

frozen shipping) • Medications that require ongoing drug management by a pharmacist and/or physician specializing in treating the

member’s condition • Medications that require focused, in-depth member education, compliance monitoring, side effect management and,

often, injection technique education

KEY:

Generics: Lower case italic. For example, tobramycin

Brands: All capital letters. For example, HUMIRA

QL: Quantity Limits apply under some benefits. Check your plan document for coverage details.

PA: Prior Authorization needed under some benefits. Check your plan document for coverage details.

PS: Preferred Specialty

PS1: Preferred Specialty first-line

PS2: Preferred Specialty second-line

2 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219

DRUG NAME QL PA PS PS1 PS2

ANALGESICS PRIALT

ANTIARTHRITICS DUROLANE X ELITEK EUFLEXXA X X GEL-ONE X GENVISC 850 X HYALGAN X HYMOVIS X KINERET X X KRYSTEXXA X X MONOVISC X OLUMIANT X X ORENCIA X X X ORENCIA CLICKJECT X X X ORTHOVISC X OTEZLA X X X RINVOQ ER X X X sodium hyaluronate SUPARTZ FX X SYNVISC X X SYNVISC-ONE X X TRILURON TRIVISC X XELJANZ X X X XELJANZ XR X X X

ANTIASTHMATICS FASENRA X X FASENRA PEN X X


NUCALA X X X XOLAIR X X

ANTIBIOTICS ARIKAYCE X X BETHKIS X CAYSTON X KITABIS PAK X THALOMID X X TOBI X TOBI PODHALER X tobramycin X XENLETA X

ANTICOAGULANTS ARIXTRA enoxaparin sodium fondaparinux sodium FRAGMIN IPRIVASK LOVENOX

ANTIFUNGALS TOLSURA X

ANTIHYPERGLYCEMICS KORLYM X

ANTIINFECTIVES/MISCELLANEOUS IMPAVIDO

ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS

CIMZIA X X X ENBREL X X ENBREL MINI X X ENBREL SURECLICK X X



HUMIRA X X X HUMIRA PEDIATRIC CROHN'S X X X

HUMIRA PEN X X X HUMIRA PEN CROHN'S-UC-HS X X X

HUMIRA PEN PSOR-UVEITS-ADOL HS X X X

HUMIRA(CF) X X X HUMIRA(CF) PEDIATRIC CROHN'S X X X

HUMIRA(CF) PEN X X X HUMIRA(CF) PEN CROHN'S-UC-HS X X X

HUMIRA(CF) PEN PSOR-UV-ADOL HS X X X

INFLECTRA X X X REMICADE X X RENFLEXIS X X X SIMPONI X X X SIMPONI ARIA X X X

ANTINEOPLASTICS ABRAXANE X ACTIMMUNE X ADCETRIS X ADRIAMYCIN adrucil AFINITOR X X AFINITOR DISPERZ X X ALECENSA X X ALFERON N ALIMTA X ALKERAN


ALUNBRIG X X ARRANON arsenic trioxide ARZERRA X AVASTIN X azacitidine BALVERSA X X BCG (TICE STRAIN) BELEODAQ X bendamustine hcl bexarotene X BICNU bleomycin sulfate BLINCYTO bortezomib X BOSULIF X X X BRAFTOVI X busulfan BUSULFEX CABOMETYX X X CALQUENCE X X CAMPATH X CAMPTOSAR capecitabine X CAPRELSA X X carboplatin carmustine cisplatin cladribine clofarabine



CLOLAR COMETRIQ X X COPIKTRA X COSMEGEN COTELLIC X X cyclophosphamide X CYRAMZA X cytarabine dacarbazine DACOGEN dactinomycin DARZALEX X daunorubicin hcl DAURISMO X X decitabine DOCEFREZ docetaxel DOXIL doxorubicin hcl doxorubicin hcl liposome

ELIGARD X ELLENCE ELZONRIS X EMCYT epirubicin hcl ERBITUX X ERIVEDGE X X ERLEADA X X erlotinib hcl X X ERWINAZE


ETOPOPHOS etoposide EVOMELA FARYDAK X FASLODEX X X FIRMAGON X floxuridine fludarabine phosphate fluorouracil FOLOTYN X fulvestrant X X GAZYVA X gemcitabine hcl GEMZAR GILOTRIF X X GLEEVEC X X X HALAVEN X HERCEPTIN X HERCEPTIN HYLECTA X HEXALEN X HYCAMTIN X IBRANCE X X ICLUSIG X X IDAMYCIN PFS idarubicin hcl IDHIFA X X IFEX ifosfamide ifosfamide-mesna imatinib mesylate X X X



IMBRUVICA X X INLYTA X X X INREBIC X X INTRON A X IRESSA X X irinotecan hcl ISTODAX X IXEMPRA X JAKAFI X X JEVTANA X X KADCYLA X KANJINTI X X KEYTRUDA X KISQALI X X KISQALI FEMARA CO-PACK X X

KYPROLIS X LENVIMA X X leuprolide acetate X LONSURF X X LORBRENA X X LUMOXITI X LUPRON DEPOT X LYNPARZA X LYSODREN MARQIBO X MATULANE MEKINIST X X MEKTOVI X melphalan hcl mitomycin


mitoxantrone hcl X MUSTARGEN mutamycin MVASI X X MYLERAN MYLOTARG NAVELBINE NERLYNX X X NEXAVAR X X NILANDRON nilutamide NINLARO X X NIPENT NUBEQA X X X ODOMZO X X ONCASPAR OPDIVO X oxaliplatin paclitaxel PERJETA X PHOTOFRIN PIQRAY X X POLIVY X X POMALYST X X PROLEUKIN X PROVENGE X X PURIXAN X REVLIMID X X RITUXAN X RITUXAN HYCELA X



romidepsin X ROZLYTREK X X RUBRACA X X RYDAPT X X SPRYCEL X X STIVARGA X X SUTENT X X X SYLATRON X SYLVANT X SYNRIBO X TABLOID TAFINLAR X X TAGRISSO X X TALZENNA X TARCEVA X X TARGRETIN X TASIGNA X X TAXOTERE TECENTRIQ X TEMODAR X temozolomide X temsirolimus X X teniposide thiotepa TIBSOVO X toposar topotecan hcl TORISEL X X TREANDA X TRELSTAR X


tretinoin X TRISENOX TURALIO X X TYKERB X X UNITUXIN X UVADEX VALCHLOR X X valrubicin VALSTAR VANTAS X VECTIBIX X VELCADE X VENCLEXTA X X VENCLEXTA STARTING PACK X X

VERZENIO X X VIDAZA vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate VITRAKVI X X VIZIMPRO X VOTRIENT X X XALKORI X X XELODA X X XOSPATA X X XPOVIO X X XTANDI X X YERVOY X YONSA X X



ZALTRAP X ZANOSAR ZEJULA X X ZELBORAF X X ZEVALIN ZOLADEX X ZOLINZA X X ZYDELIG X X ZYKADIA X X ZYTIGA X X X

ANTIPARKINSON DRUGS APOKYN X X DUOPA X X GOCOVRI X X INBRIJA X X OSMOLEX ER X X

ANTIVIRALS abacavir X abacavir-lamivudine X abacavir-lamivudine-zidovudine X

adefovir dipivoxil APTIVUS atazanavir sulfate X ATRIPLA BARACLUDE X X BIKTARVY cidofovir CIMDUO X COMBIVIR COMPLERA


COPEGUS X X CRIXIVAN CYTOVENE DAKLINZA X X DELSTRIGO DESCOVY X didanosine X DOVATO X EDURANT efavirenz X EMTRIVA entecavir X EPCLUSA X X X EPIVIR EPIVIR HBV EPZICOM EVOTAZ fosamprenavir calcium X FUZEON X ganciclovir ganciclovir sodium GENVOYA HARVONI X X X HEPSERA X X INTELENCE INVIRASE ISENTRESS ISENTRESS HD JULUCA X KALETRA



lamivudine lamivudine hbv lamivudine-zidovudine X ledipasvir-sofosbuvir X X X LEXIVA lopinavir-ritonavir X MAVYRET X X X moderiba X X nevirapine X nevirapine er X NORVIR ODEFSEY OLYSIO X X PEGASYS X PEGASYS PROCLICK X PEGINTRON X PIFELTRO PREVYMIS X PREZCOBIX PREZISTA REBETOL X X RESCRIPTOR RETROVIR REYATAZ ribasphere X X RIBASPHERE RIBAPAK X X ribavirin X X ritonavir X SELZENTRY sofosbuvir-velpatasvir X X X


SOVALDI X X X stavudine X STRIBILD SUSTIVA SYMFI X SYMFI LO X SYMTUZA SYNAGIS X TECHNIVIE X X tenofovir disoproxil fumarate X

TIVICAY TRIUMEQ TRIZIVIR TRUVADA VEMLIDY X X VIDEX VIDEX EC VIEKIRA PAK X X VIEKIRA XR X X VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VOSEVI X X X ZEPATIER X X ZERIT ZIAGEN zidovudine X



AUTONOMIC DRUGS BOTOX X BOTOX COSMETIC X DYSPORT X X JEUVEAU X MYOBLOC X NORTHERA X X XEOMIN X

BIOLOGICALS BIVIGAM X CARIMUNE NF NANOFILTERED X

CUTAQUIG X CUVITRU X CYTOGAM FLEBOGAMMA DIF X GAMASTAN X GAMASTAN S-D X GAMMAGARD LIQUID X GAMMAGARD S-D X GAMMAKED X GAMMAPLEX X GAMUNEX-C X HEPAGAM B HIZENTRA X HYPERHEP B S-D HYPERRAB HYPERRAB S-D HYPERRHO S-D HYPERTET S-D HYQVIA X


HYQVIA IG COMPONENT X

IMOGAM RABIES-HT KEDRAB MICRHOGAM ULTRA-FILTERED PLUS

NABI-HB OCTAGAM X ORALAIR PALYNZIQ X X PANZYGA X PRIVIGEN X RHOGAM ULTRA-FILTERED PLUS

RHOPHYLAC TAKHZYRO X X VARIZIG WINRHO SDF XEMBIFY X

BLOOD ACTIVASE ADVATE X ADYNOVATE X AFSTYLA X ALPHANATE X ALPHANINE SD ALPROLIX X ATRYN BEBULIN X BENEFIX X CABLIVI CATHFLO ACTIVASE



COAGADEX X CORIFACT CYKLOKAPRON ELOCTATE X ENDARI X X FEIBA NF X HELIXATE FS X HEMLIBRA X X HEMOFIL M X HUMATE-P X IDELVION X IXINITY X KOATE X KOGENATE FS X KOVALTRY X MONOCLATE-P MONONINE X NOVOEIGHT X NOVOSEVEN RT X NUWIQ X OBIZUR X PROFILNINE X RECOMBINATE X RECOTHROM RIASTAP RIXUBIS X SIKLOS SOLIRIS X THROMBATE III tranexamic acid


tranexamic acid-nacl TRETTEN X ULTOMIRIS X VONVENDI X WILATE X XYNTHA X XYNTHA SOLOFUSE X

CARDIAC DRUGS dofetilide TIKOSYN

CARDIOVASCULAR ADCIRCA X X ADEMPAS X X alyq X X ambrisentan X X bosentan X X epoprostenol sodium FLOLAN X HEMANGEOL JUXTAPID X X KYNAMRO X X LETAIRIS X X OPSUMIT X X ORENITRAM ER X X PRALUENT PEN X X X REMODULIN X REPATHA PUSHTRONEX X X X

REPATHA SURECLICK X X X REPATHA SYRINGE X X X REVATIO X X



sildenafil citrate X X tadalafil X X TRACLEER X X treprostinil X TYVASO X X TYVASO INSTITUTIONAL START KIT

X X

TYVASO REFILL KIT X X TYVASO STARTER KIT X X UPTRAVI X X VECAMYL X VELETRI X VENTAVIS X X

CNS DRUGS AMPYRA X X AUBAGIO X X AUSTEDO X X AVONEX X X X AVONEX PEN X X X BETASERON X X X clobazam X COPAXONE X X X dalfampridine er X X DIACOMIT X X EPIDIOLEX X EXTAVIA X X FIRDAPSE X GILENYA X X X glatiramer acetate X X X glatopa X X


INGREZZA X X INGREZZA INITIATION PACK X X

MAVENCLAD X MAYZENT X X X ONFI X PLEGRIDY X X X PLEGRIDY PEN X X X REBIF X X REBIF REBIDOSE X X RUZURGI X X SABRIL X X SYMPAZAN X X TECFIDERA X X X tetrabenazine X vigabatrin X X XENAZINE X ZINBRYTA X X

COLONY STIMULATING FACTORS ARANESP X X DOPTELET X EPOGEN X FULPHILA X GRANIX X LEUKINE X MIRCERA X MOZOBIL X NEULASTA X NEUPOGEN X NIVESTYM X NPLATE X



PROCRIT X PROMACTA X RETACRIT X X UDENYCA X ZARXIO X

CONTRACEPTIVES KYLEENA X LILETTA MIRENA X NEXPLANON PARAGARD T 380-A SKYLA X

DIAGNOSTIC MACRILEN X

DIURETICS JYNARQUE X X SAMSCA X X

EENT PREPS bevacizumab X CYSTARAN X X EYLEA X X ILUVIEN X LUCENTIS X X MACUGEN X X OXERVATE X X OZURDEX X RETISERT X YUTIQ

ELECT/CALORIC/H2O FERAHEME


FERRLECIT INFED INJECTAFER NUTRESTORE sod ferric gluconate complex

TRIFERIC VENOFER XURIDEN

GASTROINTESTINAL BUPHENYL CESAMET X X CHENODAL CHOLBAM X X CINVANTI EMEND X ENTYVIO X X fosaprepitant dimeglumine X

GATTEX X granisetron hcl KEPIVANCE MYTESI OCALIVA X X ondansetron hcl ondansetron hcl-0.9% nacl

ondansetron hcl-d5w RAVICTI X X SUCRAID X VARUBI X X XERMELO X



ZOFRAN

HORMONES ACTHAR X ACTHREL X AVEED X CETROTIDE X X chorionic gonadotropin X EGRIFTA X X EMFLAZA X FOLLISTIM AQ X ganirelix acetate X GONAL-F X X GONAL-F RFF X X GONAL-F RFF REDI-JECT X X

hydroxyprogesterone caproate X X

INCRELEX X LUPRON DEPOT (LUPANETA) X

LUPRON DEPOT-PED X MAKENA X X MENOPUR X X MIACALCIN MYALEPT X NATPARA X NORDITROPIN FLEXPRO X X

NOVAREL X octreotide acetate X OVIDREL X X PREGNYL X


SANDOSTATIN X X SANDOSTATIN LAR DEPOT X X

SEROSTIM X X SIGNIFOR X SIGNIFOR LAR X X SOMATULINE DEPOT X X STIMATE SUPPRELIN LA X SYNAREL X testopel X TYMLOS X X ZORBTIVE X X

IMMUNOSUPPRESSANTS ACTEMRA X X X ACTEMRA ACTPEN X X X ASTAGRAF XL X X ATGAM CELLCEPT cyclosporine cyclosporine modified DUPIXENT X X X ENVARSUS XR X X GAMIFANT X gengraf KEVZARA X X mycophenolate mofetil mycophenolic acid MYFORTIC NEORAL NULOJIX X



PROGRAF RAPAMUNE SANDIMMUNE sirolimus STELARA X X X tacrolimus ZORTRESS X

MISCELLANEOUS ADAGEN ALDURAZYME X amifostine ARALAST NP X ARCALYST X BENLYSTA X BERINERT X BONIVA X CARBAGLU CERDELGA X X CEREZYME X CINRYZE X clovique X CYSTADANE CYSTAGON X X deferasirox X dexrazoxane X DILUENT FOR ELITEK doxercalciferol ELAPRASE X ELELYSO X X ESBRIET X X


ETHYOL EVENITY X EVENITY (2 SYRINGES) X EXJADE X FABRAZYME X FERRIPROX X FIRAZYR X FORTEO X FUSILEV GALAFOLD X GLASSIA X HAEGARDA X X HECTOROL HICON HYQVIA HY COMPONENT X

ibandronate sodium icatibant X ILARIS X X JADENU X JADENU SPRINKLE X KALBITOR X KALYDECO X X KEVEYIS X X KHAPZORY KUVAN X leucovorin calcium levoleucovorin calcium LUMIZYME X lumoxiti iv soln stabilizer X



mesna MESNEX METASTRON miglustat X NAGLAZYME X nitisinone X NITYR X OFEV X X ORAFATE ORFADIN X ORKAMBI X X pamidronate disodium paricalcitol PROCYSBI X X PROLASTIN C X PROLIA X X PROTHELIAL PULMOZYME X X QUADRAMET RAYALDEE RECLAST REVCOVI RUCONEST X X SENSIPAR X X sodium iodide i-131 sodium phenylbutyrate SOMAVERT STRENSIQ X X SUBLOCADE X X SYMDEKO X X


SYPRINE X TAVALISSE X TEGSEDI X trientine hcl X TYBOST TYSABRI X X VIMIZIM VISTOGARD VISUDYNE VIVITROL X VORAXAZE VPRIV X VYNDAMAX X X VYNDAQEL X X XGEVA X X XIAFLEX X XOFIGO X ZAVESCA X ZEMAIRA X ZEMPLAR X ZINECARD X zoledronic acid ZOMETA

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

SOLESTA

PSYCHOTHERAPEUTIC DRUGS NUPLAZID X X SPRAVATO X X VYLEESI X X



SEDATIVE/HYPNOTICS HETLIOZ X X XYREM X X

SKIN PREPS COSENTYX (2 SYRINGES) X X

COSENTYX PEN X X COSENTYX PEN (2 PENS) X X

COSENTYX SYRINGE X X QUTENZA SILIQ X SKYRIZI X X X


SKYRIZI (2 SYRINGES) KIT X X X

TALTZ AUTOINJECTOR X X X TALTZ AUTOINJECTOR (2 PACK) X X X

TALTZ AUTOINJECTOR (3 PACK) X X X

TALTZ SYRINGE X X X TALTZ SYRINGE (2 PACK) X X X

TALTZ SYRINGE (3 PACK) X X X

TREMFYA X X X

THYROID PREPS THYROGEN X

standard formulary specialty drug list · 2020. 7. 30. · magellanrx.com . standard formulary...

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