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The Empire Plan Prescription Drug Program Specialty Pharmacy Program Drug List for Advanced Flexible Formulary

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The Empire Plan Prescription Drug Program Specialty Pharmacy Program Drug List for Advanced Flexible Formulary April 2020 The Empire Plan Prescription Drug Program Specialty Pharmacy Program Drug List for Advanced Flexible Formulary If you are an enrollee or health care provider, please contact CVS Specialty® at 1-855-264-3238 or visit empireplanrxprogram.com. With more than 40 years of specialty phar macy experience, CVS S pecialty provides proactive quality care and service. We have a network of pharmacies that includes those with Joint Commission and URAC accreditation. The Joint Commission and URAC are nationally recognized s ymbols of quality that reflect an organization’s c ommitment to meet high standards of quality and safety. Coverage under the Empire Plan Prescription Drug Program requires that the following medications be ordered from CVS Specialty. ACROMEGALY ATOPIC DERMATITIS HEMATOPOIETICS Stimate Lupaneta Pack 2 octreotide acetate Dupixent Mozobil* Tretten* Lupron Depot 1 Vonvendi* (SANDOSTATIN) Natpara* HEMOPHILIA, Sandostatin LAR CARDIAC DISORDERS Wilate Supprelin LA* 4 2 2 Somatuline Depot* dofetilide (TIKOSYN)1, VON WILLEBRAND Xyntha Trelstar Somavert* DISEASE & ELATED Vantas CRYOPYRIN-ASSOCIATED BLEEDING HEPATITIS C Zoladex PERIODIC SYNDROMES ALCOHOL DISORDERS Epclusa Arcalyst DEPENDENCY * Advate Harvoni IMMUNE DEFICIENCIES Ilaris* Adynovate 2 & RELATED DISORDERS Vivitrol PegIntron Asceniv* Afstyla Rebetol Solution AMYLOIDOSIS CYSTIC FIBROSIS Alphanate RibaPak Bivigam* Bethkis ribasphere Cuvitru Onpattro* Cayston* AlphaNine SD RibaTab Cytogam Vyndamax* Kitabis Pak* Alprolix ribavirin caps GamaSTAN S/D Vyndaqel* Pulmozyme Bebulin 1 tobramycin nebulizer1 BeneFIX (REBETOL) Gammagard Liquid ALPHA-1 ANTITRYPSIN Coagadex* ribavirin tabs Gammagard S/D 1 DEFICIENCY ELECTROLYTE Corifact* (MODERIBA) Gammaked Aralast NP* DISORDER Eloctate Sovaldi Gammaplex* Samsca* Glassia* Feiba NF Vosevi Gamunex C Zemaira* Fibryga HepaGam B GASTROINTESTINAL Helixate FS HEREDITARY Hizentra* ANEMIA DISORDERS – OTHER ANGIOEDEMA HyperHEP B 2 Hemlibra Aranesp Gattex* Hemofil M Berinert* HyperRHO S/D Epogen Ocaliva* Humate-P Cinryze* HyQvia Reblozyl* Solesta* 2 Idelvion Haegarda* MICRhoGAM Retacrit Ixinity icatibant acetate* Nabi-HB GOUT Kovaltry (FIRAZYR*)1 Octagam ANTICOAGULANTS Krystexxa* 1 Koate Kalbitor* Panzyga enoxaparin (LOVENOX) Koate-DVI Ruconest* Privigen GROWTH HORMONE 2 Kogenate FS RhoGAM ANTIEMETICS & RELATED Anzemet Monoclate-P HIV MEDICATIONS DISORDERS Rhophylac granisetron (KYTRIL) 1 Mononine Egrifta* 4 Grow th Hormone Varizig Fuzeon palonosetron (ALOXI) 1 Disorders NovoEight* Vivaglobin* 2 Genotropin NovoSeven WinRho SDF ASTHMA HORMONAL Humatrope NovoSeven RT Xembify* Cinqair* Nuwiq THERAPIES Serostim* Aveed* Dupixent Obizur* Zorbtive Eligard Fasenra* Profilnine SD IMMUNE (IDIOPATHIC) IGF-1 Deficiency Rebinyn Firmagon THROMBOCYTOPENIA Nucala* Increlex* Recombinate leuprolide acetate Xolair* PURPURA RiaSTAP 1 (LUPRON) Doptelet* Rixubis April 2020 *4 Nplate tetrabenazine Khapzory imatinib meseylate PSORIASIS 1 1 Promacta* (XENAXINE*) Kyprolis* (GLEEVEC) Cosentyx* Levoleucovorin4 Inlyta* Enbrel INFECTIOUS DISEASE MULTIPLE SCLEROSIS Lumoxiti* Inrebic* Humira Actimmune Ampyra* Mitoxantrone4 Iressa* Inflectra 4 Alferon N Aubagio* Mvasi* Jakafi* Otezla 2 Otrexup Avonex Mylotarg* Kisqali INFERTILITY Rasuvo Kisqali Cetrotide Betaseron Ogivri* 4 Remicade chorionic gonadotropin Gilenya Oncaspar Femara Co-Pack 1 Renflexis* (NOVAREL, PREGNYL) glatiramer acetate Opdivo* Lenvima* Stelara Ganirelix Acetate (COPAXONE 4 Perjeta* Lonsurf* Gonal-F 1 40MG,glatopa) Polivy* Lorbrena* PULMONARY Gonal-F RFF Lemtrada* Portrazza* Mekinist* ARTERIAL Menopur Mavenclad* 4 Proleukin Mugard*4 HYPERTENSION Ovidrel Mayzent* 4 Rituxan Nerlynx* Adempas* Ocrevus* Rituxan Hycela* Nexavar* ambrisentan* 4 INFLAMMATORY Plegridy* Romidepsin (LETAIRIS*)1 4 Ninlaro* BOWEL DISEASE 2 Sylatron Rebif Nubeqa* bosentan* 1 Entyvio Tecfidera* Sylvant* (TRACLEER*) Odomzo* Humira Tysabri* Tecentriq* epoprostenol sodium* 4 Pomalyst* Inflectra Vumerity* 1 Temodar (FLOLAN*) Purixan* Remicade Temsirolimus Opsumit* Revlimid* Renflexis* NEUTROPENIA 4 (TORISEL) Rozlytrek* Orenitram* Stelara Granix 1 Tepadina Rubraca* tadalafil (ADCIRCA) Tysabri* Leukine Thyrogen* Rydapt treprostinil sodium* Neulasta 1 4 Sprycel (REMODULIN*) IRON OVERLOAD Treanda Ziextenzo* Stivarga Tyvaso* deferasirox* Truxima* * 1 valrubicin Sutent Uptravi* (EXJADE*/JADENU*) ONCOLOGY – 1, 4 Tafinlar (VALSTAR) * Veletri* deferoxamine 3 INJECTABLE 4 Tagrisso* 1 *4 Vectibix Ventavis* (DESFERAL) Adcetris 4 Talzenna* *4 Velcade Arzerra Tasigna PULMONARY LIPID DISORDERS Xgeva temozolidine Asparlas* 4 DISORDERS – OTHER Kynamro* 4 Yervoy 1 Avastin (TEMODAR) Esbriet* 1,4 Yondelis* azacitidine (VIDAZA) Thalomid Ofev* LYSOSOMAL STORAGE *4 Zaltrap DISORDERS Bavencio* Tykerb* zoledronic acid RARE DISORDERS – Aldurazyme* Beleodaq* Verzenio* 1 OTHER Cerdelga* Bendeka* (ZOMETA) Vitrakvi* Crysvita* Cerezyme* Besponsa* Vizimpro* Gamifant* ONCOLOGY – Cystagon* Blincyto* 4 ORAL/TOPICAL Votrient* Elaprase* Bortezomib RENAL DISEASE Alunbrig* Xalkori* Elelyso* Cyramza* Parsabiv* bexarotene Xtandi* Sensipar Fabrazyme* Darzalex* 1 Yonsa* (TARGRETIN) RESPIRATORY Kanuma* decitabine Zelboraf* 1,4 Bosulif SYNCYTIAL VIRUS Lumizyme* (DACOGEN) Zolinza Cabometyx* Synagis miglustat Empliciti* Cometriq* Zydelig* 4 Naglazyme Erbitux Zykadia* * capecitabine RETINAL DISORDERS Evomela* 1 Vimizim* (XELODA) Zytiga* Eylea* VPRIV* Folotyn4 Cotellic* Iluvien* Fusilev4 Daurismo* PAROXYSMAL Lucentis* Gazyva*4 Erivedge MENTAL HEALTH * NOCTURNAL Macugen* Halaven4 Erleada* CONDITIONS HEMOGLOBINURIA Visudyne* Zulresso* Herceptin4 erlotinib Soliris* 4 hydrochloride* Ultomiris* Herceptin Hylecta RHEUMATOID (TARCEVA*)1 MOVEMENT DISORDERS Imfinzi* ARTHRITIS *4 everolimus PHENYLKETONURIA Apokyn* Intron A Actemra * 2 Kuvan* Austedo *4 (AFINITOR) Istodax Palynziq* Enbrel 4 Farydak* Inbrija* Ixempra Humira Jevtana4 Hycamtin* Inflectra Northera* PRE-TERM BIRTH Kadcyla4 Ibrance* Orencia Nuplazid* Makena* Kanjinti* IDHIFA* Otrexup Soliris* Keytruda* Rasuvo April 2020 Remicade SYSTEMIC LUPUS Renflexis* ERYTHEMATOSUS Xeljanz Benlysta TRANSPLANT SEIZURE DISORDERS Epidiolex* Astagraf XL H.P. Acthar Gel* cyclosporine (gengraf, NEORAL, vigabatrin powder* SANDIMMUNE)1 (SABRIL POWDER*) 1 Envarsus XR vigabatrin tabs* Nulojix 1 (SABRIL TABS*) Prograf Injectable Zortress SICKLE CELL DISEASE UREA CYCLE Adakveo DISORDERS Oxbryta* Buphenyl* Ravicti* SLEEP DISORDER sodium phenylbutyrate * Wakix* I f you are an enrollee or health care provider, please contact CVS Specialty at 1-855-264-3238 or visit empirepla n rx pr ogr a m.c o m. 1 Lowercase type indicates generic name and availability; lowercase type within parentheses indicates trademark generics listed only when no brand is available; products in all capital letters within parentheses indicate brand names of generic products. 2 Multiple dosage formulations and/or injectable devices are available. 3 Call CVS Specialty at 1-877-769-7447 for specific medications available through CVS Specialty. Listing is subject to change. 4 Certain specialty drugs may be obtained at your local retail network pharmacy or through CVS Specialty. * Indicates Limited Distribution products distributed by CVS Specialty. Products distributed by CVS Specialty, as well as products covered by a plan member’s prescription and medical benefit plan, may change from time to time. In addition, a member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private he alth information. ©2020 CVS Specialty. All rights reserved. 75-48110A 041420 Empire Plan Specialty Pharmacy Drug List .
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