Paramount Advantage Formulary Specialty Pharmacy List
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1 Paramount Advantage Formulary Specialty Pharmacy List Note: When these products are self-administered they are covered as part of the Paramount Advantage pharmacy benefit, and should be obtained at a pharmacy that is part of Paramount's Specialty Pharmacy Network. Brand Name Generic Name Brand Name Generic Name Antiviral PA Growth Disorder PA Copegus ribavirin Sandostatin octreotide Fuzeon enfuviritide Somatuline Depot lanreotide Hepsera adefovir Somavert pegvisomant Incivek telapravir Infergen interferon alfacon-1 Growth Hormone PA Intron A interferon alpha-2b Accretropin somatropin Pegasys peginterferon alfa-2a Genotropin somatropin PEG-Intron peginterferon alfa-2b Geref sermorelin acetate Rebetol ribavirin Humatrope human growth hormone Rebetron interferon alfa-2b Increlex mecasermin RibaPak ribavirin Norditropin somatropin Ribasphere ribavirin Nutropin somatropin Roferon A interferon alfa-2a Nutropin AQ somatropin Virazole ribavirin Omnitrope somatropin Sylatron peginterferon alfa-2b Saizen somatropin Synagis palivizumab Serostim somatropin Victrelis boceprevir Tev-tropin somatropin Zorbtive somatropin Autoimmune Disorders PA Actemra tocilizumab Hemophilia Benlysta belimumab Advate Factor VIII (recomb) Cimzia certolizumab pegol Alphanate Factor VIII (human) Enbrel etanercept Alphanate/vWF Factor VIII (human)/vwf Humira adalimumab Alphanine SD Factor IX (human) Kineret anakinra Bebulin VH Factor IX complex (human) Orencia abatacept Benefix Factor IX (recomb) Remicade infliximab Feiba VH apcc Factor VIII Rituxan rituximab Genarc Factor VIII (recomb) Simponi golimumab Helixate FS Factor VIII (recomb) Hemofil-M Factor VIII (human) Colony Stimulating Factors Humate-P Factor VIII/vWF (human) Leukine sargramostim Koate-DVI Factor VIII (human) Mozobil PA plerixafor Kogenate FS Factor VIII (recomb) Neulasta PA pegfilgrastim Monoclate-P Factor VIII (human) Neupogen filgrastim Mononine Factor IX (human) Novoseven RT Factor VIIa (recomb) Erythropoiesis-Stimulating Agents PA Profilnine SD Factor IX complex (human) Aranesp darbepoetin alfa Proplex T Factor IX (human) Epogen epoetin alfa Recombinate Factor VIII (recomb) Procrit epoetin alfa Refacto Factor VIII (recomb) Wilate Factor VIII/vWF (human) Growth Factor (Human) Xyntha Factor VIII (recomb) Neumega oprelvekin (ril-11) Specialty drugs include both brand-name drug and any generic equivalent. The list is subject to change without notice. Page 1 PA Prior Authorization based on clinical criteria required prior to payment Revised: 2011-Sept
2 Paramount Advantage Formulary Specialty Pharmacy List Brand Name Generic Name Brand Name Generic Name Immune Deficiency Multiple Indications Atgam lymphocyte immune globulin Actimmune PA interferon gamma-1b Carimune NF PA IVIG lyophilized Depo-testosterone testosterone cypionate Flebogamma DIF PA IVIG nonlyophilized Lupron PA leuprolide Gammagard PA immune globulin Lupron Depot PA leuprolide depot Gammaplex PA immune globulin Recothrom PA topical thrombin Gamunex PA or Gamunex C PA IVIG nonlyophilized Hizentra PA SubQ immune globulin Multiple Sclerosis PA Privigen PA immune globulin Ampyra dalfampirdine Thymoglobulin immune globulin (rabbit) Avonex interferon beta-1a Vivaglobin PA SubQ immune globulin Betaseron interferon beta-1b Copaxone glatiramer acetate Extavia interferon beta-1b Rebif interferon beta-1a Stelara ustekinumab Metabolic Bone Disorder PA Tysabri natalizumab Sensipar cinacalcet Forteo teriparatide Oncology Prolia denusomab Afinitor PA everolimus Eligard PA leuprolide Emcyt PA estramustine Metabolic Disorders Gleevec PA imatinib Adagen PA (orphan drug) pegademase bovine Hycamtin PA (oral) topotecan Aldurazyme PA laronidase Iressa PA gefitinib Arcalyst PA rilonacept Lupron PA leuprolide Berinert PA C1-esterase inhibitor Lupron Depot PA leuprolide depot Buphenyl sodium phenylbutyrate Nexavar PA sorafenib Ceredase PA aglucerase Novantrone PA mitoxantrone Cerezyme PA imiglucerase Panretin PA (orphan drug) alitretinoin 0.1% gel Cinryze PA C1-esterase inhibitor Revlimid PA lenalidomide Desferal PA deferoxamine Sandostatin PA octreotide Elaprase PA idursulfase Sandostatin Depot PA octreotide depot Exjade PA deferasirox Sprycel PA dasatinib Fabrazyme PA agalsidase beta Sutent PA sunitinib Ganirelix PA ganirelix Tarceva PA erlotinib Myozyme PA alglucosidase alfa Targretin PA bexarotene Nplate PA romiplostim Tasigna PA nilotinib Orfadin PA nitisinone Temodar PA temozolomide Promacta PA eltrombopag Thalomid PA thalidomide Samsca PA tolvaptan Tykerb PA lapatinib Soliris PA eculizumab Vandetanib PA vandetanib Sucraid PA sacrosidase Toposar etoposide Vivitrol naltrexone Vesanoid PA tretinoin Xenazine PA tetrabenazine Xeloda PA capecitabine Zavesca PA miglustat Zolinza PA vorinostat Specialty drugs include both brand-name drug and any generic equivalent. The list is subject to change without notice. Page 2 PA Prior Authorization based on clinical criteria required prior to payment Revised: 2011-Sept
3 Paramount Advantage Formulary Specialty Pharmacy List Brand Name Generic Name Brand Name Generic Name Neurological/Muscular Disorders Pulmonary Hypertension PA Apokyn apomorphine Adcirca tadalafil Botox PA botulinum toxin type A Flolan epoprostenol H.P. Acthar PA corticotropin Letairis ambrisentan Myobloc PA botulinum toxin type B Remodulin treprostinil Rilutek PA riluzole Revatio sildenafil Xeomin PA incobotulinumtoxin A Tracleer bosentan Xyrem PA sodium oxybate Tyvaso treprostinil inhaled Ventavis iloprost Psoriasis PA Respiratory Disorders PA 8-MOP systemic methoxsalen Aralast (NP) alpha, antitrypsin Amevive alefacept Glassia alpha-1 proteinase inhibitor Soriatane acitretin Prolastin alpha, antitrypsin Xolair omalizumab Zemaira alpha, antitrypsin Specialty drugs include both brand-name drug and any generic equivalent. The list is subject to change without notice. Page 3 PA Prior Authorization based on clinical criteria required prior to payment Revised: 2011-Sept
4 Paramount Medicaid Formularies Specialty Pharmacy Alphabetical Listing Brand Name (generic) criteria Brand Name (generic) criteria 8-MOP (systemic methoxsalen) PA Desferal (deferoxamine) PA Accretropin (somatropin rdna) PA Elaprase (idursulfase) PA Actemra (tocilizumab) PA Eligard (leuprolide) PA Actimmune (interferon gamma-1b) PA Emcyt (estramustine) PA Adagen (pegademase bovine) PA Enbrel (etanercept) PA Adcirca (tadalafil) PA Epogen (erythropoietin) PA Advate (Factor VIII) Exjade (deferasirox) PA Afinitor (everolimus) PA Extavia (interferon beta-1b) PA Aldurazyme (laronidase) PA Fabrazyme (agalsidase beta) PA Alphanate (Factor VIII) Feiba VH (apcc Factor VIII) Alphanate/vWF (Factor VIII/vWF) Flebogamma DIF (IVIG nonlyophilized) PA Alphanine SD (Factor IX) Flolan (generic epoprostenol) PA Amevive (alefacept) PA Forteo (teriparatide) PA Ampyra (dalfampirdine) PA Fuzeon (enfuviritide) PA Apokyn (apomorphine) Gammagard (immune globulin) PA Aralast NP (alpha1-proteinase inhibitor) PA Gammaplex (immune globulin) PA Aranesp (darbepoetin alfa) PA Gamunex (IVIG nonlyophilized) PA Arcalyst (rilonacept) PA Gamunex C (IVIG nonlyophilized) PA Atgam (lymphocyte immune globulin (equine)) Ganirelix (ganirelix) PA Avonex (interferon beta-1a) PA Genarc (Factor VIII) Bebulin VH (Factor IX complex) Genotropin (somatropin) PA Benefix (Factor IX) Geref (sermorelin acetate) PA Benlysta (belimumab) PA Glassia (alpha-1 proteinase inhibitor) PA Berinert (C1 esterase inhibitor) PA Gleevec (imatinib) PA Betaseron (interferon beta-1b) PA H.P. Acthar (corticotropin) PA Botox (botulinum toxin type A) PA Helixate FS (Factor VIII) Buphenyl (sodium phenylbutyrate) Hemofil-M (Factor VIII) Carimune NF (IVIG lyopholized) PA Hepsera (adefovir) PA Ceredase (aglucerase) PA Hizentra (IVIG) PA Cerezyme (imiglucerase) PA Humate-P (Factor VIII/vWF) Cimzia (certolizumab) PA Humatrope (human growth hormone) PA Cinryze (C1-esterase inhibitor) PA Humira (adalimumab) PA Copaxone (glatiramer acetate) PA Hycamtin (topotecan) PA Copegus (ribavirin) PA Incivek (telapravir) PA Depo-testosterone (testosterone cypionate) Increlex (mecasermin) PA Specialty drugs include both brand-name drug and any generic equivalent. List is subject to change without notice. Page 4 PA Prior Authorization based on clinical criteria required prior to payment 2011-Sept
5 Paramount Medicaid Formularies Specialty Pharmacy Alphabetical Listing Brand Name (generic) criteria Brand Name (generic) criteria Infergen (interferon alfacon-1) PA Prolastin (alpha1-proteinase inhibitor) PA Intron A (interferon alpha-2b) PA Prolia (denosumab) PA Iressa (gefitinib) PA Promacta (eltrombopag) PA Kineret (anakinra) PA Proplex T (Factor IX) Koate-DVI (Factor VIII) Rebetol (ribavirin) PA Kogenate FS (Factor VIII) Rebetron (interferon alfa-2b ) PA Letairis (ambrisentan) PA Rebif (interferon beta-1a) PA Leukine (sargramostim) Recombinate (Factor VIII) Lupron (leuprolide) PA Recothrom (topical thrombin) PA Lupron Depot (leuprolide depot) PA Refacto (Factor VIII) Monoclate-P (Factor VIII) Remicade (infliximab) PA Mononine (Factor IX) Remodulin (treprostinil) PA Mozobil (plerixafor) PA Revatio (sildenafil) PA Myobloc (botulinum toxin type B) PA Revlimid (lenalidomide) PA Myozyme (alglucosidase alfa) PA RibaPak (ribavirin) PA Neulasta (pegfilgrastim) PA Ribasphere (ribavirin) PA Neumega (oprelvekin) Rilutek (riluzole) PA Neupogen (filgrastim) PA Rituxan (rituximab) PA Nexavar (sorafenib) PA Roferon-A (interferon alfa-2a) PA Norditropin (somatropin) PA Saizen (somatropin) PA Novantrone (mitoxantrone) PA Samsca (tolvaptan) PA Novoseven RT (Factor VIIa) Sandostatin (octreotide) PA Nplate (romiplostim) PA Sandostatin Depot (octreotide depot) PA Nutropin (somatropin) PA Sensipar (cinacalcet) PA Nutropin AQ (somatropin) PA Serostim (somatropin) PA Omnitrope (somatropin) PA Simponi (golimumab) PA Orencia (abatacept) PA Soliris (eculizumab) PA Orfadin (nitisinone) PA Somatuline Depot (lanreotide) PA Panretin (alitretinoin 0.1% gel) PA Somavert (pegvisomant) PA PEG-Intron (peginterferon alfa-2b) PA Soriatane (acitretin ) PA Pegasys (peginterferon alfa-2a) PA Sprycel (dasatinib) PA Privigen (immune globulin) PA Stelara (ustekinumab) PA Procrit (erythropoietin) PA Sucraid (sacrosidase) PA Profilnine SD (Factor IX complex) Sutent (sunitinib) PA Specialty drugs include both brand-name drug and any generic equivalent. List is subject to change without notice. Page 5 PA Prior Authorization based on clinical criteria required prior to payment 2011-Sept
6 Paramount Medicaid Formularies Specialty Pharmacy Alphabetical Listing Brand Name (generic) criteria Brand Name (generic) criteria Sylatron (peginterferon alfa-2b) PA Vesanoid (tretinoin) PA Synagis (palivizumab) PA Victrelis (boceprevir) PA Tarceva (erlotinib) PA Virazole (ribavirin) PA Targretin (bexarotene) PA Vivaglobin (Subcut. immune globulin) PA Tasigna (nilotinib) PA Vivitrol (naltrexone inj.) Temodar (temozolomide) PA Wilate (Factor VIII/vWF(human)) Tev-tropin (somatropin) PA Xeloda (capecitabine) PA Thalomid (thalidomide) PA Xenazine (tetrabenazine) PA Thymoglobulin (immune globulin (rabbit)) Xyntha (Factor VIII) Toposar (etoposide) Xeomin (incobotulinumtoxin A) PA Tracleer (bosentan) PA Xolair (omalizumab) PA Tykerb (lapatinib) PA Xyrem (sodium oxybate) PA Tysabri (natalizumab) PA Zavesca (miglustat) PA Tyvaso (treprostinil) PA Zemaira (alpha-1 proteinase inhibitor) PA Vandetanib (vandetanib) PA Zolinza (vorinostat) PA Ventavis (iloprost) PA Zorbtive (somatropin) PA Specialty drugs include both brand-name drug and any generic equivalent. List is subject to change without notice. Page 6 PA Prior Authorization based on clinical criteria required prior to payment 2011-Sept
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