Specialty Pharmacy Program Drug List



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Transcription:

Specialty Pharmacy Program Drug List The Specialty Pharmacy Program covers certain drugs commonly referred to as high-cost Specialty Drugs. To receive in-network benefits/coverage for these drugs, these drugs must be dispensed through a select group of contracted specialty pharmacies or your medical provider. Please call the BCBSLA Customer Service number on the back of your member ID card for information about our contracted specialty pharmacies. All specialty drugs listed below are limited to the retail day supply listed in your benefit plan (typically a 30-day supply). Inclusion on this list does not imply benefits. Please refer to your benefit plan for a complete list of benefits, including specific exclusions, limitations and member cost-sharing amounts you are responsible for such as a deductible, copayment and coinsurance. Brand Name Generic Name Drug Classification 8-MOP methoxsalen Psoralen Actemra SC tocilizumab Monoclonal Antibody/Arthritis Acthar corticotropin Adrenocortical insufficiency Actimmune interferon gamma 1b Interferon Adcirca tadalafil Pulmonary Arterial Hypertension Adempas riociguat Chronic Thromboembolic Pulmonary Hypertension/ Pulmonary Arterial Hypertension Afinitor everolimus Oncology Alferon interferon alfa-n3 Interferon Ampyra ER dalfampridine Multiple Sclerosis Aptivus tipranavir HIV/AIDS Apokyn apomorphine Parkinson's Disease Aranesp darbepoetin alfa Red blood cell progenitor Arcalyst rilonacept Interleukin Blocker/ CAPS Atripla efavirenz/emtricitabine/tenofovir HIV/AIDS Aubagio teriflunomide Multiple Sclerosis Avonex interferon beta-1a Multiple Sclerosis Baraclude entecavir Hepatitis B Berinert C1 esterase inhibitor Hereditary Angioedema Betaseron beta-interferon 1B Multiple Sclerosis Bosulif bosutinib Oncology Buphenyl sodium phenylbutyrate Nitrogen-binding Agent Caprelsa vandetanib Oncology Carbaglu carglumic acid Endocrine Agent Cayston aztreonam lysine Cystic Fibrosis Cetrotide cetrorelix Specialized OB/GYN Chemet succimer Chelating Agent Chenodal chenodiol Gallstone Solubilizing Agent

Cimzia certolizumab pegol Anti Tumor Necrosis Factor Drug Cinryze C1 esterase inhibitor Hereditary Angioedema Combivir lamivudine/zidovudine* HIV/AIDS Cometriq cabozantinib s-malate Oncology Complera emtricitabine/rilpivirine/tenofovir HIV/AIDS Copaxone glatiramer acetate Multiple Sclerosis Copegus ribavirin* Hepatitis C Cystadane betaine Homocystinuria Cystaran cysteamine Cystine-depleting Agent Daklinza dackatasvur dihydrochloride Hepatitis C DDAVP nasal desmopressin* Vasopressin Analogue spray/rhinal tube Edurant rilpivirine HIV/AIDS Egrifta tesamorelin Growth Hormonee Emtriva emtricitabine HIV/AIDS Enbrel etanercept Anti tumor necrosis factor drug/arthritis/psoriasis Epivir lamivudine* HIV/AIDS Epivir-HBV lamivudine* Hepatitis B Epogen epoetin alfa Red blood cell progenitor Epzicom abacavir/lamivudine HIV/AIDS Erbitux cetuximab Oncology Erivedge vismodegib Oncology Erwinaze asparaginase Oncology Exjade deferasirox Chelating agent Extavia interferon beta-1b Interferon Ferriprox deferiprone Iron overload Fertinex urofollitropin Ovulatory Stimulants Firazyr icatibant Hereditary Angioedema Follistim AQ follitropin beta Ovulatory Stimulants Forteo teriparatide Parathyroid Hormone for Osteoporosis/Bones Fulyzaq crofelemer HIV/AIDS Fuzeon enfuvirtide HIV/AIDS Ganirelix gonadotropin-releasing hormone Specialized OB/GYN antagonist Gattex glucagon-like peptide 2 analog Gastrointestinal Genotropin somatropin Growth Hormone Gleevec imatinib Oncology Gilenya fingolimod Multiple Sclerosis Gilotrif afatinib Oncology Page 2 of 7

Gonal-F follitropin alfa Ovulatory Stimulants Gonal-F RFF follitropin alfa Ovulatory Stimulants Harvoni ledipasvir/sofosbuvir Hepatitis C Hemangeol propranolol Proliferating Infantile Hemangioma Hepsera adefovir dipivoxil Hepatitis B Hetlioz tasimelteon Sedative/Hypnotic Hexalen altretamine Oncology Humatrope somatropin Growth Hormone Humira adalimumab Monoclonal Antibody/Arthritis/Psoriasis/ Crohns/Ankylosing Spondilitis Ibrance palbociclib Oncology Iclusig ponatinib Oncology Imbruvica ibrutinib Oncology Ilaris canakinumab Interleukin Blocker Incivek telaprevir Hepatitis C Increlex mecasermin Growth Hormone Infergen interferon alfacon-1 Interferon Intelence etravirine HIV/AIDS Intron-A interferon alfa-2b Interferon Invirase saquinavir HIV/AIDS Iressa getfitinib Oncology Isentress raltegravir HIV/AIDS Jakafi ruxolitinib Oncology Juxtapid lomitapide Hypercholesterolemia Kaletra lopinavir/ritonavir HIV/AIDS Kalydeco ivacaftor Respiratory Keveyis dichlorphenamide Carbonic Anhydrase Inhibitor Kineret anakinra Immunologic Agents Korlym mifepristone Endocrine/Cushing s disease Kuvan sapropterin dihydrochloride Phenylketonuria Kynamro mipomersen Hypercholesterolemia Lenvima lenvatinib Oncology Letairis ambrisentan Pulmonary Arterial Hypertension leucovorin leucovorin* Folinic Acid for Anemia Lexiva amprenavir HIV/AIDS Lomustine lomustine Oncology Lonsurf trifluridine/tipiracil HCl Oncology Lupron (all products) leuprolide Gonadotropin-releasing hormone analog Luveris lutropin alfa Ovulatory Stimulants Page 3 of 7

Lynparza olaparib Oncology Lysodren mitotane Oncology Makena hydroxyprogesterone Hormone Matulane procarbazine Oncology Mekinist trametinib Oncology Menopur menotropins Ovulatory Stimulants Moderiba ribavirin* Antiviral for Hepatitis C Myalept metreleptin Leptin Analog Neumega oprelvekin Interleukin for platelets Neupogen filgrastim Colony Stimulating Factor for use with chemotherapy Nexavar sorafenib Oncology Norditropin somatropin Growth Hormone (all products) Northera droxidopa Neurogenic Orthostatic Hypotension Norvir ritonavir HIV/AIDS Novarel human chorionic gonadotropin Specialized OB/GYN Nutropin (all products) somatropin Page 4 of 7 Growth Hormone Odomzo sonidegib phosphate Oncology Olysio simeprevir Hepatitis C Omnitrope somatropin Growth Hormone Opsumit macitentan Pulmonary Arterial Hypertension Orencia SC abatacept Selective costimulation modulator for RA Orenitram treprostinil Pulmonary Arterial Hypertension Orfadin nitisinone Tyrosinemia Type 1 Otezla apremilast Psoriatic Arthritis Otrexup methotrexate Arthritis/Polyarticular Juvenile Idiopathic Arthritis/Psoriasis Ovidrel choriogonadotropin alfa Specialized OB/GYN Oxsoralen methoxsalen Psoralen Oxsoralen-Ultra methoxsalen Psoralen Panretin gel alitretinoin HIV/AIDS Pegasys peginterferon alfa-2a Hepatitis C Peg-Intron peginterferon alfa-2b Hepatitis C Plegridy peginterferon beta-1a Multiple sclerosis Pomalyst pomalidomide Oncology Praluent alirocumab PCSK-9 inhibitor Pregnyl chorionic gonadotropin Specialized OB/GYN

Prezista darunavir HIV/AIDS Procrit epoetin alfa Red blood cell progenitor Profasi chorionic gonadotropin Specialized OB/GYN Promacta eltrombopag olamine Thrombopoietic Agents Pulmozyme dornase alfa Cystic Fibrosis Qutenza Capsaicin Postherpetic Neuralgia Ravicti glycerol phenylbutyrate Nitrogen-binding Agent Rebetol ribavirin* Hepatitis C Rebif interferon beta-1a Multiple Sclerosis Relistor methylnaltrexone bromide Specialty GI drug Repatha evolocumab PCSK-9 inhibitor Rescriptor delavirdine HIV/AIDS Retrovir zidovudine* HIV/AIDS Revatio sildenafil* Pulmonary Arterial Hypertension Revlimid lenalidomide Oncology Reyataz atazanavir HIV/AIDS Ribapak ribavirin* Antiviral for Hepatitis C ribasphere ribavirin* Antiviral for Hepatitis C Ribatab ribavirin* Antiviral for Hepatitis C Rilutek riluzole* Sclerosis Roferon-A interferon alfa-2a recombinant Interferon Sabril vigabatrin Anticonvulsant Saizen somatropin Growth Hormone Sandostatin octreotide Acromegaly, Carcinoid Syndrome, VIPomas Selzentry maraviroc HIV/AIDS Serostim somatropin HIV/AIDS Signifor pasireotide Somatostatin/Cushing s disease Simponi golimumab Anti-tumor necrosis factor drug Sirturo bedaquiline Tuberculosis Somavert pegvisomant Acromegaly Sovaldi sofosbuvir Hepatitis C Sprycel dasatinib Oncology Stelara ustekinumab Interleukin Blocker Stimate nasal desmopressin Vasopressin Analogue spray Stivarga regorafenib Oncology Strensiq asfotase alfa Hypophosphatasia Stribild elvitegravir/cobicistat/emtricitabine/ tenofovir HIV/AIDS Page 5 of 7

Sucraid sacrosidase Enzyme replacement Sustiva efavirenz HIV/AIDS Sutent sunitinib Oncology Sylatron peginterferon alfa-2b Oncology Synribo omacetaxine Oncology Tafinlar dabrafenib Oncology Tarceva erlotinib Oncology Targretin bexarotene Oncology Targretin gel bexarotene Oncology Tasigna nilotinib Oncology Tecfidera dimethyl fumarate Multiple Sclerosis Technivie ombitasvir, paritaprevir, ritonavir Hepatitis C Temodar temozolomide Oncology Tev-Tropin somatropin Growth Hormone Thalomid thalidomide Oncology Tivicay dolutegravir HIV/AIDS Tobi tobramycin for inhalation Anti-infective (Cystic Fibrosis) Tobi Podhaler tobramycin for inhalation Anti-infective (Cystic Fibrosis) Tracleer bosentan Pulmonary Arterial Hypertension Triumeq dolutegravir/abacavir/lamivudine HIV/AIDS Trizivir abacavir/lamivudine/zidovudine HIV/AIDS Truvada emtricitabine/tenofovir HIV/AIDS Tybost cobicistat HIV/AIDS Tykerb lapatinib Oncology Tysabri natalizumab Monoclonal Antibody/Multiple Sclerosis Tyvaso treprostinil Pulmonary Arterial Hypertension Tyzeka telbivudine Hepatitis B Valchlor mechlorethamine Oncology Vandetanib vandetanib Oncology Vecamyl mecamylamine Hypertension Ventavis iloprost Pulmonary Arterial Hypertension VePesid etoposide Oncology Versacloz clozapine Antipsychotic agent Victrelis boceprevir Hepatitis C Videx/EC didanosine* HIV/AIDS Viracept nelfinavir HIV/AIDS Viramune nevirapine* HIV/AIDS Viread tenofovir HIV/AIDS Page 6 of 7

Votrient pazopanib Oncology Xalkori crizotinib Oncology Xeljanz tofacitinib Immunologic Agent Xeloda capecitabine Oncology Xenazine tetrabenazine Huntington's disease Xtandi enzalutamide Oncology Xyrem gamma hydroxybutyrate Cataplexy Zavesca miglustat Gaucher Disease Zecuity sumatriptan succinate Anti-Migraine Zelboraf vemurafenib Oncology Zerit stavudine* HIV/AIDS Ziagen abacavir* HIV/AIDS Zolinza vorinostat Oncology Zorbtive somatropin Growth Hormone Zydelig Idelaisib Oncology Zytiga abiraterone acetate Oncology Page 7 of 7

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