Pharmacy Specialty Drug Policies

As of 11/01/2019

Defer to https://hmsa.com/portal/PROVIDER/prc_Search_Drug_Formularies_by_Coverage_Codes.htm in order to find your formulary plan using your 3 digit DRUG Coverage Code. The formularies will be listed https://hmsa.com/portal/PROVIDER/zav_PHARM-FORMULARY.htm.

Afinitor (everolimus) Alecensa (alectinib) Alunbrig (brigatinib) Ampyra (dalfampridine) Aubagio (teriflunomide) Austedo (deutetrabenazine) Balversa (erdafitinib) Bethkis (tobramycin) Bosulif (bosutinib) Braftovi (encorafenib) Buphenyl (phenylbutyrate) Cabometyx (cabozantinib) Calquence (acalabrutinib) Caprelsa (vandetanib) Carbaglu (carglumic acid) Cayston (aztreonam) Cerdelga (eligustat) Cholbam (cholic acid) Cometriq (cabozantinib) Copiktra (duvelisib) Cotellic (cobimetinib) Cystagon (cysteamine bitartrate) Cystaran (cysteamine) Daklinza (daclatasvir) Daurismo (gladegib) Doptelet (avatrombopag) Emflaza (deflazacort) Endari (L-glutamine) Epclusa (sofosbuvir/velpatasvir) Epidiolex (cannabidiol) Erivedge (vismodegib) Erleada (apalutamide) Esbriet (pirfenidone) Exjade (deferasirox) Farydak (panobinostat) Ferriprox (deferiprone) Firdapse (amifampridine) Galafold (migalastat) Gilenya (fingolimod) Gilotrif (afatinib) Gleevec (imatinib) Harvoni (ledipasvir/sofosbuvir) Hetlioz (tasimelteon) Hycamtin (topotecan) Ibrance (palbociclib) Iclusig (ponatinib) Idhifa (enasidenib) Imbruvica (ibrutinib) Inbrija (levodopa) Ingrezza (valbenazine) Inlyta (axitinib) Inrebic (fedratinib) Iressa (gefitinib) Jadenu (deferasirox) Jakafi (ruxolitinib) Juxtapid (lomitapide) Jynarque (tolvaptan) Kalydeco (ivacaftor) Keveyis (diclofenamide) Kisqali (ribociclib) Kisqali Femara Co-Pack (ribociclib and letrozole) Korlym (mifepristone) Kuvan (sapropterin) Lenvima (lenvatinib) Lonsurf (trifluridine and tipiracil) Lorbrena (lorlatinib) Lynparza (olaparib) Macrilen (macimorelin) Mavenclad (cladribine) Mavyret (glecaprevir/pibrentasvir) Mayzent (siponimod) Mekinist (trametinib) Mektovi (binimetinib) Nerlynx (neratinib) Nexavar (sorafenib) Ninlaro (ixazomib) Nityr (nitisinone) Northera (droxidopa) Nubeqa (darolutamide) Nuplazid (pimavanserin) Ocaliva (obeticholic acid) Odomzo (sonidegib) Ofev (nintedanib) Olumiant (baricitinib) Olysio (simeprevir) Orfadin (nitisinone) Orkambi (lumacaftor/ivacaftor) Orilissa (elagolix) Otezla (apremilast) Oxervate (cenegerim-bkbj) Piqray (alpelisib) Pomalyst (pomalidomide) Procysbi (cysteamine bitartrate) Promacta (eltrombopag) Pulmozyme (dornase alfa) Ravicti (glycerol phenylbutyrate) Revlimid (lenalidomide) Rinvoq (upadacitinib) Rozlytrek (entrectinib) Rubraca (rucaparib) Ruzurgi (amifampridine) Rydapt (midostaurin) Sabril (vigabatrin) Samsca (tolvaptan) Sensipar (cincalcet) Sovaldi (sofosbuvir) Sprycel (dasatinib) Stimate (desmopressin acetate) - QUEST Stivarga (regorafenib) Sutent (sunitinib) Symdeko (tezacaftor/ivacaftor and ivacaftor) Tafinlar (dabrafenib) Tagrisso (osimertinib) Talzenna (talazoparib) Tarceva (erlotinib) Targretin (bexarotene) Tasigna (nilotinib) Tavalisse (fostamatinib - disodium hexahydrate) Tecfidera (dimethyl fumarate) Technivie (ombitasvir/paritaprevir/ritonavir) Temodar (temozolomide) Thalomid (thalidomide) Tibsovo Tikosyn (dofetilide) TOBI (tobramycin) Turalio (pexidartinib) Tykerb (lapatinib) Uptravi (selexipag) Valchlor (mechlorethamine) Venclexta (ventoclax) Verzenio (abemaciclib) Viekira Pak/Viekira XR (ombitasvir/paritaprevir/ritonavir) Vitrakvi (larotrectinib) Vizimpro (dacomitinib) Vosevi (sofosbuvir/velpatasvir/voxilaprevir) Votrient (pazopanib) Vyndaqel-Vyndamax (tafamidis meglumine - tafamidis) Wakix (pitolisant) Xalkori (crizotinib) Xatmep (methotrexate) Xeljanz/Xeljanz XR (tofacitinib) Xeloda (capecitabine) Xenazine (tetrabenazine) Xermelo (telotristat ethyl) Xospata (gilteritinib) Xpovio (selinexor) Xtandi (enazlutamide) Xyrem (sodium oxybate) Yonsa (abiraterone) Zavesca (migulstat) Zejula (niraparib) Zelboraf (vemurafenib) Zepatier (elbasvir/grazoprevir) Zolinza (vorinostat) Zydelig (idelalisib) Zykadia (certinib) Zytiga (abiraterone)