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State and Specialty Pharmacy Drug Reimbursement Rates

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State and Specialty Pharmacy Drug Reimbursement Rates State and Specialty Pharmacy Drug Reimbursement The following table lists specialty pharmacy drug reimbursement rates. ForwardHealth defines specialty drugs as drugs requiring comprehensive patient care services, clinical management, and product support services. Drugs that meet ForwardHealth’s definition of specialty drugs will be reimbursed using the following rates. However, these rates do not apply to specialty drugs purchased through the federal 340B Drug Discount Program, which will be reimbursed according to the 340B ingredient cost reimbursement methodology. If ForwardHealth uses State Maximum Allowable Cost (SMAC) reimbursement in the future, the SMAC reimbursement rates will be published in this table. Effective 11/01/2020 EAC* EAC* Label Generic Name - Label - Generic ANEMIA/NEUTROPENIA DRUGS ARANESP DARBEPOETIN ALFA IN POLYSORBAT -1.0% EPOGEN EPOETIN ALFA -1.6% FULPHILA PEGFILGRASTIM-JMDB -1.0% GRANIX TBO-FILGRASTIM -1.0% MIRCERA METHOXY PEG-EPOETIN BETA -0.4% NEULASTA PEGFILGRASTIM -1.0% NEUPOGEN FILGRASTIM -1.0% NIVESTYM FILGRASTIM-AAFI -1.0% PROCRIT EPOETIN ALFA -1.6% RETACRIT EPOETIN ALFA-EPBX -1.0% UDENYCA PEGFILGRASTIM-CBQV -1.0% ZARXIO FILGRASTIM-SNDZ -1.0% ZIEXTENZO PEGFILGRASTIM-BMEZ -1.0% ANTICOAGULANT DRUGS ARIXTRA FONDAPARINUX SODIUM -3.0% -50.0% FONDAPARINUX SODIUM FONDAPARINUX SODIUM -50.0% FRAGMIN DALTEPARIN SODIUM,PORCINE -0.4% THROMBATE III ANTITHROMBIN III (PLASMA DER) -0.4% ANTI-INFECTIVE DRUGS ABELCET AMPHOTERICIN B LIPID COMPLEX -0.4% AMBISOME AMPHOTERICIN B LIPOSOME -0.4% ANCOBON FLUCYTOSINE -0.4% -1.0% AVYCAZ CEFTAZIDIME/AVIBACTAM -0.4% CRESEMBA ISAVUCONAZONIUM SULFATE -0.4% CUBICIN DAPTOMYCIN -0.4% -1.0% CUBICIN RF DAPTOMYCIN -0.4% -1.0% DALVANCE DALBAVANCIN HCL -0.4% DAPTOMYCIN DAPTOMYCIN -1.0% FLUCYTOSINE FLUCYTOSINE -1.0% IMPAVIDO MILTEFOSINE -0.4% LINEZOLID IN 0.9% SODIUM CHLOR LINEZOLID IN 0.9% SODIUM CHLOR -0.4% LINEZOLID IN DEXTROSE 5% LINEZOLID IN DEXTROSE 5% -40.0% LINEZOLID ORAL LINEZOLID ORAL -40.0% ORBACTIV ORITAVANCIN DIPHOSPHATE -0.4% PENTAM 300 PENTAMIDINE ISETHIONATE -0.4% -1.0% PENTAMIDINE ISETHIONATE PENTAMIDINE ISETHIONATE -1.0% SIVEXTRO TEDIZOLID PHOSPHATE -0.4% SYNERCID QUINUPRISTIN/DALFOPRISTIN -0.4% VIBATIV TELAVANCIN HCL -0.4% ZYVOX IN DEXTROSE 5% LINEZOLID IN DEXTROSE 5% -0.4% -40.0% ZYVOX ORAL LINEZOLID ORAL -0.4% -40.0% BLOOD CELL DEFICIENCY DRUGS DOPTELET AVATROMBOPAG MALEATE -0.4% LEUKINE SARGRAMOSTIM -0.4% MULPLETA LUSUTROMBOPAG -0.4% NPLATE ROMIPLOSTIM -0.4% PROMACTA ELTROMBOPAG OLAMINE -0.4% ENDOCRINE DISORDER DRUGS BYNFEZIA OCTREOTIDE ACETATE -0.4% MYALEPT METRELEPTIN -0.4% MYCAPSSA OCTREOTIDE ACETATE -0.4% OCTREOTIDE ACETATE OCTREOTIDE ACETATE -30.0% SANDOSTATIN OCTREOTIDE ACETATE -30.0% SIGNIFOR PASIREOTIDE DIASPARTATE -0.4% SOMATULINE DEPOT LANREOTIDE ACETATE -0.4% SOMAVERT PEGVISOMANT -0.4% ENZYME DEFICIENCY DRUGS ADAGEN PEGADEMASE BOVINE 1.0% ALDURAZYME LARONIDASE 1.0% AMMONUL SODIUM BENZOATE/SOD PHENYLACET 1.0% -10.0% CARBAGLU CARGLUMIC ACID 1.0% CERDELGA ELIGLUSTAT TARTRATE 1.0% FABRAZYME AGALSIDASE BETA 1.0% GALAFOLD MIGALASTAT HCL 1.0% KUVAN SAPROPTERIN DIHYDROCHLORIDE -0.7% MEPSEVII VESTRONIDASE ALFA-VJBK 1.0% MIGLUSTAT MIGLUSTAT -10.0% NAGLAZYME GALSULFASE 1.0% NITYR NITISINONE 1.0% ORFADIN NITISINONE 1.0% PALYNZIQ PEGVALIASE-PQPZ 1.0% SODIUM BENZOATE/SOD PHENYLACET SODIUM BENZOATE/SOD PHENYLACET -10.0% STRENSIQ ASFOTASE ALFA 1.0% ZAVESCA MIGLUSTAT 1.0% -10.0% State and Specialty Pharmacy Drug Reimbursement GROWTH HORMONE DRUGS EGRIFTA SV TESAMORELIN ACETATE -1.6% GENOTROPIN SOMATROPIN -1.6% HUMATROPE SOMATROPIN -1.6% INCRELEX MECASERMIN -1.6% NORDITROPIN FLEXPRO SOMATROPIN -1.6% NUTROPIN AQ NUSPIN SOMATROPIN -1.6% OMNITROPE SOMATROPIN -1.6% SAIZEN SOMATROPIN -1.6% SAIZEN-SAIZENPREP SOMATROPIN -1.6% SEROSTIM SOMATROPIN -1.6% ZOMACTON SOMATROPIN -1.6% ZORBTIVE SOMATROPIN -1.6% HEMOPHILIA DRUGS ADVATE ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% ADYNOVATE ANTIHEMO.FVIII,FULL LENGTH PEG -12.0% AFSTYLA ANTIHEM.FVIII,SIN-CHN,B-DM TRU -15.0% ALPHANATE ANTIHEMOPHILIC FACTOR/VWF -20.0% ALPHANINE SD FACTOR IX -20.0% ALPROLIX FACTOR IX REC, FC FUSION PROTN -4.0% BENEFIX FACTOR IX HUMAN RECOMBINANT -15.0% COAGADEX COAGULATION FACTOR X -10.0% CORIFACT FACTOR XIII -10.0% ELOCTATE ANTIHEMOPH.FVIII REC,FC FUSION -9.0% ESPEROCT FVIII REC,B-DOM TRUNC PEG-EXEI -10.0% FEIBA NF ANTI-INHIBITOR COAGULANT COMP. -15.0% HELIXATE FS ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% HEMLIBRA EMICIZUMAB-KXWH -6.0% HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN -20.0% HUMATE-P ANTIHEMOPHILIC FACTOR/VWF -15.0% IDELVION FACTOR IX RECOM,ALBUMIN FUSION -3.0% IXINITY FACTOR IX HUMAN RECOMB,THR 148 -5.0% JIVI FVIII REC,B-DOM DELET PEG-AUCL -10.0% KOATE ANTIHEMOPHILIC FACTOR, HUMAN -15.0% KOGENATE FS ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% KOVALTRY ANTIHEMOPHIL.FVIII,FULL LENGTH -20.0% MONONINE FACTOR IX -20.0% NOVOEIGHT ANTIHEMOPH.FVIII,B-DOM TRUNCAT -15.0% NOVOSEVEN RT COAGULATION FACTOR VIIA,RECOMB -12.0% NUWIQ ANTIHEMOPH.FVIII,HEK B-DELETE -12.0% OBIZUR ANTIHEMOPHILIC FVIII,REC PORC 0.0% PROFILNINE FACTOR IX CPLX(PCC)NO4,3FACTOR -10.0% REBINYN FACTOR IX HUMAN REC,PEGYLATED -5.0% RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC -15.0% RIASTAP FIBRINOGEN -10.0% RIXUBIS FACTOR IX HUMAN RECOMBINANT -15.0% STIMATE DESMOPRESSIN ACETATE 0.0% TRETTEN FACTOR XIII A-SUBUNIT,RECOMB -10.0% VONVENDI VON WILLEBRAND FACTOR -10.0% WILATE ANTIHEMOPHILIC FACTOR/VWF -15.0% XYNTHA ANTIHEMOPH.FVIII,B-DOMAIN DEL -20.0% XYNTHA SOLOFUSE ANTIHEMOPH.FVIII,B-DOMAIN DEL -20.0% HEPATITIS DRUGS ADEFOVIR DIPIVOXIL ADEFOVIR DIPIVOXIL -10.0% BARACLUDE SOLUTION ENTECAVIR SOLUTION -0.4% BARACLUDE TABLET ENTECAVIR TABLET -0.4% -40.0% ENTECAVIR TABLET ENTECAVIR TABLET -40.0% EPCLUSA SOFOSBUVIR/VELPATASVIR -1.6% EPIVIR HBV SOLUTION LAMIVUDINE SOLUTION -0.4% EPIVIR HBV TABLET LAMIVUDINE TABLET -2.5% -60.0% HARVONI LEDIPASVIR/SOFOSBUVIR -1.6% HEPSERA ADEFOVIR DIPIVOXIL -0.4% -10.0% INTRON A INTERFERON ALFA-2B,RECOMB. -0.4% LAMIVUDINE TABLET LAMIVUDINE TABLET -60.0% LEDIPASVIR-SOFOSBUVIR LEDIPASVIR/SOFOSBUVIR -1.6% MAVYRET GLECAPREVIR/PIBRENTASVIR -3.0% MODERIBA RIBAVIRIN -50.0% PEGASYS PEGINTERFERON ALFA-2A -1.6% PEGINTRON PEGINTERFERON ALFA-2B -1.6% RIBASPHERE RIBAVIRIN -50.0% SOFOSBUVIR-VELPATASVIR SOFOSBUVIR/VELPATASVIR -1.6% SOVALDI SOFOSBUVIR -1.6% VEMLIDY TENOFOVIR ALAFENAMIDE -0.4% VOSEVI SOFOSBUVIR/VELPATAS/VOXILAPREV -3.0% ZEPATIER ELBASVIR/GRAZOPREVIR -1.6% HEREDITARY ANGIOEDEMA DRUGS BERINERT C1 ESTERASE INHIBITOR -0.4% CINRYZE C1 ESTERASE INHIBITOR -0.4% FIRAZYR ICATIBANT ACETATE -0.4% -1.0% HAEGARDA C1 ESTERASE INHIBITOR -0.4% ICATIBANT ACETATE ICATIBANT ACETATE -1.0% RUCONEST C1 ESTERASE INHIBITOR, RECOMB -0.4% TAKHZYRO LANADELUMAB-FLYO -0.4% IMMUNE DEFICIENCY DRUGS ACTIMMUNE INTERFERON GAMMA-1B,RECOMB. -0.4% ASCENIV IMMUNE GLOBULIN,GAMMA(IGG)SLRA -20.0% BIVIGAM IMMUN GLOB G(IGG)/GLY/IGA OV50 -0.4% CUTAQUIG IMMUN GLOB G(IGG)-HIPP/MALTOSE -0.4% State and Specialty Pharmacy Drug Reimbursement IMMUNE DEFICIENCY DRUGS CONT. CUVITRU IMMUN GLOB G(IGG)/GLY/IGA OV50 -5.0% FLEBOGAMMA DIF IMM GLOB G (IGG)/SORB/IGA 0-50 -5.0% GAMMAGARD LIQUID IMMUN GLOB G(IGG)/GLY/IGA OV50 -20.0% GAMMAKED IMMUNE GLOBUL G/GLY/IGA AVG 46 -20.0% GAMMAPLEX IMMUN GLOB G(IGG)/GLY/IGA 0-50 -20.0% GAMMAPLEX IMMUN GLOB G/SORB/GLY/IGA 0-50 -20.0% GAMUNEX-C IMMUNE GLOBUL G/GLY/IGA AVG 46 -20.0% HIZENTRA IMMUN GLOB G(IGG)/PRO/IGA 0-50 -20.0% HYQVIA IGG/HYALURONIDASE,RECOMBINANT -20.0% OCTAGAM IMMUN GLOBG(IGG)/MALT/IGA OV50 -20.0% PANZYGA IMMUN GLOB G(IGG)-IFAS/GLYCINE -0.4% PRIVIGEN IMMUN GLOB G(IGG)/PRO/IGA 0-50 -20.0% XEMBIFY IMMUNE GLOBULIN,GAMMA(IGG)KLHW -5.0% LIPITROPICS, OTHER DRUGS JUXTAPID LOMITAPIDE MESYLATE -0.4% PRALUENT PEN ALIROCUMAB -0.4% REPATHA PUSHTRONEX EVOLOCUMAB -0.4% REPATHA SURECLICK EVOLOCUMAB -0.4% REPATHA SYRINGE EVOLOCUMAB -0.4% MISC.: IRON DEFICIENCY DRUGS FERAHEME FERUMOXYTOL -0.4% MISC: HYPOCALCEMIA DRUGS CALCITRIOL CALCITRIOL -10.0% MISC: IRON OVERLOAD DRUGS DEFERASIROX DEFERASIROX -1.0% EXJADE DEFERASIROX -0.4% -1.0% FERRIPROX DEFERIPRONE -0.4% FERRIPROX (2 TIMES A DAY) DEFERIPRONE -0.4% JADENU DEFERASIROX -0.4% -1.0% JADENU SPRINKLE DEFERASIROX -0.4% MISCELLANEOUS: INJECTABLE & OTHER ROUTE DRUGS GATTEX TEDUGLUTIDE -0.4% RAVICTI GLYCEROL PHENYLBUTYRATE -0.4% MULTIPLE SCLEROSIS DRUGS AMPYRA DALFAMPRIDINE -1.6% -30.0% AUBAGIO TERIFLUNOMIDE -1.0% AVONEX INTERFERON BETA-1A -1.6% AVONEX INTERFERON BETA-1A/ALBUMIN -1.6% AVONEX PEN INTERFERON BETA-1A -1.6% BAFIERTAM MONOMETHYL FUMARATE -1.6% BETASERON INTERFERON BETA-1B -1.6% COPAXONE GLATIRAMER ACETATE -2.6% -30.0% DALFAMPRIDINE DALFAMPRIDINE -30.0% EXTAVIA INTERFERON BETA-1B -1.6% GILENYA FINGOLIMOD HCL -2.6% GLATIRAMER ACETATE GLATIRAMER ACETATE -30.0% GLATOPA GLATIRAMER ACETATE -2.6% -30.0% KESIMPTA PEN OFATUMUMAB -1.6% MAVENCLAD CLADRIBINE -1.6% MAYZENT SIPONIMOD -1.6% PLEGRIDY PEGINTERFERON BETA-1A -1.6% PLEGRIDY PEN PEGINTERFERON BETA-1A -1.6% REBIF INTERFERON BETA-1A/ALBUMIN -1.6% REBIF REBIDOSE INTERFERON BETA-1A/ALBUMIN -1.6% TECFIDERA DIMETHYL FUMARATE -1.6% VUMERITY DIROXIMEL FUMARATE -1.6% ZEPOSIA OZANIMOD HYDROCHLORIDE -1.6% ONCOLOGY - ADJUNCT THERAPY DRUGS ANZEMET DOLASETRON MESYLATE -0.4% LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM -1.0% MESNEX MESNA -0.4% VARUBI ROLAPITANT HCL -0.4% ZOLEDRONIC ACID ZOLEDRONIC ACID -20.0% ZOMETA ZOLEDRONIC ACID -0.4% -20.0% ZUPLENZ ONDANSETRON -0.4% ONCOLOGY - ORAL DRUGS ABIRATERONE ACETATE ABIRATERONE ACETATE -10.0% AFINITOR EVEROLIMUS -0.4% AFINITOR EVEROLIMUS -0.4% -1.0% AFINITOR DISPERZ EVEROLIMUS -0.4% ALECENSA ALECTINIB HCL -0.4% ALKERAN MELPHALAN -0.4% -10.0% ALUNBRIG BRIGATINIB -0.4% AYVAKIT AVAPRITINIB -0.4% BALVERSA ERDAFITINIB -0.4% BEXAROTENE
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