Colorado 4th Tier Medication List
Brand Name Generic Name Drug Category Actemra Tocilizumab Immunomodulator Acthar HP Corticotropin Endocrine agent Actimmune Interferon gamma 1b Immunomodulator Alferon Interferon alfa N3 Immunomodulator Amevive Alefacept Immunomodulator Ampyra Dalfampridine Potassium channel blocker (multiple sclerosis) Aranesp Darbepoetin Hematopoietic Arixtra Fondiparinux Anticoagulant Avonex, Rebif Interferon beta-1a Immunomodulator (multiple sclerosis) Betaseron, Extavia Interferon beta-1b Immunomodulator (multiple sclerosis) Cimzia Certolizumab Immunomodulator Copaxone Glatiramer acetate Immunomodulator (multiple sclerosis) Egrifta Tesamorelin Endocrine agent Enbrel Etanercept Immunomodulator Epogen, Procrit Erythropoetin Hematopoietic Extavia Interferon beta-1b Immunomodulator (multiple sclerosis) Forteo Teriparatide Parathyroid hormone Fragmin Dalteparin Anticoagulant (low molecular weight heparin) Fuzeon Enfuvirtide Antiretroviral Gilenya Fingolimod Immunomodulator (multiple sclerosis) Genotropin, Humatrope, Norditropin, Somatropin Growth hormone Nutropin, Nutropin AQ, Nutropin Depot, Omnitrope, Saizen, Serostim, Serostim LQ, Tev-Tropin, Zorbtive Humira Adalimumab Immunomodulator Incivek Telaprevir Antiviral (Hepatitis C) Infergen Interferon alfacon-1 Immunomodulator Innohep Tinzaparin Anticoagulant (low molecular weight heparin) Intron-A Interferon alfa 2b Immunomodulator Kineret Anakinra Immunomodulator Leukine Sargramostim (GM-CSF) Hematopoietic Lovenox, Enoxaparin Enoxaparin Anticoagulant (low molecular weight heparin)
Colorado 4th Tier Medication List
Brand Name Generic Name Drug Category Makena Hydroxyprogesterone Caproate Endocrine agent (pre-term birth) Miacalcin injection Calcitonin Polypeptide hormone (bone loss prevention) Neulasta Pegfilgrastim Hematopoietic Neumega Oprelvekin Hematopoietic Neupogen Filgrastim (G-CSF) Hematopoietic Orencia Abatacept Immunomodulator Pegasys Peginterferon alfa 2a Immunomodulator Peg-Intron Peginterferon alfa 2b Immunomodulator Prolia Denosumab Osteoporosis agent Remicade Infliximab Immunomodulator Roferon-A Interferon alfa 2a Immunomodulator Simponi Golimumab Immunomodulator Somavert Pegvisomant Growth hormone antagonist Stelara Ustekinumab Immunomodulator Sylatron Pebinterferon alfa 2b Anticancer agent (melanoma) Thyrogen Thyrotropin alfa Diagnostic aid (thyroid function) Victrelis Boceprevir Antiviral (Hepatitis C) Xgeva Denosumab Immunomodulator Xolair Omalizumab Monoclonal antibody (anti-asthmatic)
Updated as of July 2011. This list is subject to change. For the most recent list, please go to Anthem.com or contact Customer Service at the number on your ID card. Inclusion of a drug on this list is not a guarantee of coverage and certain drugs may require Prior Authorization. Please refer to the member’s certificate of coverage.