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Medical Benefit Specialty Drug List

A Abraxane Advate Aimovig Alphanate/Von Aranesp Avonex Actemra Advate H Ajovy Willebrand Arcalyst Azacitidine Acthar HP Advate L Aldurazyme Alphanine SD Aredia Azedra Actimmune Advate M Alferon N Alprolix Arranon Adagen Advate SH Alimta Arzerra Adcetris Advate UH Aliqopa Andexxa Atgam Adriamycin Adynovate Alkeran Apokyn Avastin Adrucil Afstyla Alphanate Aralast NP Aveed

B TOP Bavencio Beleodaq Berinert Bicnu Bortezomib Busulfex Bebulin Bendeka Besponsa Bivigam Botox Bebulin VH Benefix Betaseron Bleomycin Sulfate Bravelle Immuno Benlysta Bevacizumab Blincyto Brineura

C TOP Calcium Folinate Cellcept Chorionic Cladribine Copaxone Cyclophosphamide Campath Ceprotin Gonadotropin Clolar Corifact Cyclosporine Camptosar Ceredase Cimzia Coagadex Cosentyx Cyramza Carboplatin Cerezyme Cinqair Colistimethate Cosmegen Cytarabine Carimune NF Cerubidine Cinryze Coly-Mycin M Crysvita Cytogam Nanofiltered Cetrotide Cisplatin Parenteral Cuvitru

D TOP Dacarbazine Desferal Mesylate Doxil Dupixent Dacogen Daunoxome Mesylate Dexrazoxane Durolane Dactinomycin Decitabine Depocyt Docefrez Doxorubicin Dysport Darzalex Desferal Docetaxel Liposome

E TOP Egrifta Ellence Emgality Epogen Ethyol Exondys 51 Elaprase Eloctate Empliciti Epoprostenol Etopophos Extavia Elelyso Eloxatin Enbrel Sodium Etoposide Eylea Eligard Elspar Entyvio Erbitux Euflexxa Elitek Elzonris Erwinaze Evomela

F TOP Fabrazyme Feiba VH Immuno Flebogamma Fludarabine Folotyn Fuzeon Fasenra Fibryga Flebogamma DIF Phosphate Forteo Faslodex Firazyr Flolan Fluorouracil Fulphila Feiba Nf Firmagon Floxuridine Follistim AQ Fusilev

G TOP Gablofen Gammaked Ganite Gemcitabine Glatiramer Acetate Granix Gamastan S-D Gammaplex Gattex Gemzar Glatopa Gamifant Gamunex Gazyva Genotropin Gliadel Gammagard Liquid Gamunex-C Gel-One Genvisc 850 Gliadel Wafer Gammagard S-D Ganirelix Acetate Gelsyn-3 Glassia Gonal-F

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H TOP Haegarda Hemofil M Humate-P Hycamtin Hymovis Halaven Hepagam B Humatrope Hydroxy- Hyperhep B S-D Helixate FS Herceptin Humira progesterone Hyperrho S-D Hemlibra Hizentra Hyalgan Caproate Hyqvia

I TOP Idamycin PFS Ifex Ilaris Imfinzi Inflectra Istodax Idarubicin Ifosfamide Ilumya Imlygic Intron A Ixempra Idelvion Ifosfamide- Iluvien Increlex Irinotecan Ixinity

J TOP Jetrea Jevtana Jivi

K TOP Kadcyla Kepivance Khapzory Kogenate FS Kynamro Kalbitor Kevzara Kineret Kovaltry Kyprolis Kanuma Keytruda Koate-DVI Krystexxa

L TOP Lartruvo Leucovorin Leuprolide Acetate Lioresal Intrathecal Lucentis Lupaneta Pack Lemtrada Calcium Leustatin Lipodox Lumizyme Lupron Depot Leukine Libtayo Lipodox 50 Lumoxiti Lupron Depot-Ped

M TOP Macugen Menopur Micrhogam Ultra- Mitoxantrone Mozobil Mylotarg Makena Mepsevii Filtered Pl Monoclate-P Mugard Myobloc Marqibo Mesna Mircera Mononine Mustargen Myozyme Melphalan Mesnex Mitomycin Monovisc Myalept

N TOP Nabi-HB Neulasta Nivestym Novarel Nucala Nutropin AQ Naglazyme Neumega Norditropin Novoeight Nulojix Nuspin Natpara Neupogen Flexpro Novoseven RT Nutropin AQ Nuwiq Navelbine Nipent Novantrone Nplate

O TOP Obizur Octreotide Acetate Oncaspar Ontak Orthovisc Ozurdex Ocrevus Omnitrope Onivyde Opdivo Ovidrel Octagam Omontys Onpattro Orencia Oxaliplatin

P TOP Paclitaxel Panzyga Pentostatin Plegridy Privigen Prograf Palynziq Parsabiv Perjeta Portrazza Probuphine Prolastin C Pamidronate Pegasys Photofrin Poteligeo Implant Kit Proleukin Disodium Pegasys Proclick Photrexa Praluent Procrit Prolia Panhematin Pegintron Photrexa Viscous Pregnyl Profilnine Provenge

Q TOP Quadramet

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R TOP Radicava Reclast Renflexis Retisert Rhogam Ultra- Rituxan Rebif Recombinate Repatha Retrovir Filtered Plus Rituxan-Hycela Rebif Rebidose Remicade Repronex Revatio Rhophylac Rixubis Rebinyn Remodulin Retacrit Revcovi Riastap Ruconest

S TOP Saizen Serostim Simponi Somavert Supartz Synagis Sandimmune Signifor Simponi Aria Spinraza Supartz FX Synribo Sandostatin Signifor LAR Solesta Stelara Supprelin LA Synvisc Sandostatin LAR Sildenafil Citrate Soliris Strensiq Sylatron Synvisc-One DEPOT Siliq Somatuline Depot Sublocade Sylvant

T TOP Takhzyro Temodar Thymoglobulin Totect Tremfya Tymlos Taltz Teniposide Thyrogen Treanda Tretten Tysabri Taxotere Tepadina Toposar Trelstar Triptodur Tecentriq Testopel Topotecan Trelstar Depot Trisenox Tegsedi Thiotepa Torisel Trelstar LA Trogarzo

U TOP Udenyca Ultomiris Unituxin Uvadex

V TOP Valstar Vectibix Vimizim Vinorelbine Vivaglobin Vpriv Vantas Velcade Vinblastine Sulfate Tartrate Vivitrol Vumon Varithena Veletri Vincasar PFS Visco-3 Vonvendi Vyxeos Varizig Vidaza Vincristine Sulfate Visudyne Voraxaze

W TOP Wilate Winrho SDF

X TOP Xeomin Xgeva Xiaflex Xolair Xyntha Xyntha Solofuse

Y TOP Yervoy Yondelis Yutiq

Z TOP Zaltrap Zarxio Zinbryta Zinplava Zoledronic Acid Zometa Zanosar Zemaira Zinecard Zoladex Zomacton Zorbtive