Specialty Pharmacy Drug List Our Specialty Pharmacy provides patients with comprehensive support services and coordinated delivery related to high-cost oral, inhaled or injectable specialty medications, used to treat complex conditions. We are your single source for high-touch patient care management to control side effects, patient support and education to ensure compliance or continued treatment, and specialized handling and distribution of medications directly to the patient or care provider. Specialty medications may be covered under either the medical or pharmacy benefit. Please consult your insurance documentation to determine which benefit covers these medications. We offer a broad specialty medication list containing nearly 500 drugs, covering 42 therapeutic categories and specialty disease states. This list is updated with new information each quarter. Characteristics of Specialty Medications “Specialty” medications are defined as high-cost oral or injectable medications used to treat complex chronic conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds found within the body. High-touch patient care management is usually required to control side effects and ensure compliance. Specialized handling and distribution are also necessary to ensure appropriate medication administration. Medications must have at least one of the following characteristics in order to be classified as a specialty medication by Magellan Rx Management. High Cost High Complexity High Touch High-cost medications are • Biotechnology products¥ • Medications that require temperature control or other special typically priced at more than • Orphan or Ultra-Orphan drugs handling/shipping requirements (i.e., refrigerated or frozen shipping) $1,000 per 30-day supply; • Medications that are included • Medications that require ongoing drug management by a pharmacist including self-administered in a specialty therapeutic drug and/or physician specializing in treating the member’s condition injectables, professionally- class strategy • Medications that require focused, in-depth member education, † administered injectables/ compliance monitoring, side effect management and, often, infusions, and oral medications injection technique education Generics: Lower case italic. For example, dexferrum Brands: All capital letters. For example, HUMIRA QL: Quantity Limits apply under some benefits. Check your plan document for coverage details. PA: Prior Authorization needed under some benefits. Check your plan document for coverage details. Anemia Asthma CAMPTOSAR epirubicin IFEX ARANESP ‡ PA XOLAIR PA capecitabine ERBITUX PA ifosfamide dexferrum CAPRELSA PA ERIVEDGE PA IMBRUVICA PA EPOGEN PA Birth Control carboplatin ERWINAZE INLYTA PA FERAHEME IMPLANON CERUBIDINE ETHYOL IRESSA PA, QL ferrlecit MIRENA cisplatin ETOPOPHOS irinotecan MIRCERA PA NEXPLANON cladribine etoposide ISTODAX PA OMONTYS PARAGARD T 380-A CLOLAR FARYDAK PA IXEMPRA PROCRIT ‡ PA SKYLA COMETRIQ PA FASLODEX JAKAFI PA COSMEGEN FIRMAGON PA JEVTANA PA sodium ferric gluconate Cancer/Chemotherapy VENOFER cyclophosphamide floxuridine KADCYLA PA ABRAXANE PA CYRAMZA PA FLUDARA KEYTRUDA PA ADCETRIS PA Anticoagulants cytarabine fludarabine KYPROLIS PA adriamycin ADEMPAS PA dacarbazine fluorouracil LENVIMA ‡ PA, QL adrucil ARIXTRA DACOGEN FOLOTYN PA LEUCOVORIN CALCIUM INJ AFINITOR PA enoxaparin DACTINOMYCIN FUSILEV LEUSTATIN ALIMTA PA IPRIVASK daunorubicin GABLOFEN LYNPARZA PA ALKERAN fondaparinux DAUNOXOME GAZYVA PA lipodox amifostine FRAGMIN decitabine gemcitabine MARQIBO PA ARRANON INNOHEP DEPOCYT GEMZAR MATULANE ARZERRA PA LOVENOX dexrazoxane PA GILOTRIF PA MEKINIST PA AVASTIN PA DOCEFREZ GLEEVEC* ‡ PA melphalan Antilipemic Agents azacitidine docetaxel HALAVEN PA mercaptopurine KYNAMRO PA BELEODAQ PA DOXIL HERCEPTIN PA mesna JUXTAPID PA BEXXAR doxorubicin hcl HYCAMTIN PA MESNEX PRALUENT ‡ PA, QL BICNU ELLENCE IBRANCE ‡ PA mitomycin REPATHA ‡ PA, QL bleomycin sulfate ELOXATIN ICLUSIG PA mitoxantrone TIKOSYN BOSULIF PA ELSPAR IDAMYCIN PFS MOZOBIL PA BUSULFEX EMCYT idarubicin hcl MUSTARGEN CAMPATH PA † Administered by a healthcare professional or in a healthcare setting ¥ Protein or protein-based molecular entities ‡ Preferred Specialty Product © 2016 Magellan Rx Management. All rights expressly reserved. This publication may not be reproduced in whole or part by any means whatsoever without express written permission of the copyright owner. MRX0367_0116 MYLERAN VESANOID Endocrine and Growth Hormone and THROMBATE III NAVELBINE VIDAZA Metabolic Agents Related Disorders tranexamic acid NEXAVAR ‡ PA, QL vinblastine sulfate ACTHREL PA GENOTROPIN PA TRETTEN PA NILANDRON PA, QL vincasar pfs AVEED PA HUMATROPE PA WILATE NIPENT vincristine sulfate KORLYM PA INCRELEX PA XYNTHA ‡ ODOMZO PA, QL vinorelbine tartrate LYSODREN NORDITROPIN ‡ PA ONCASPAR VORAXAZE MYALEPT PA NOVOEIGHT PA Hepatitis B adefovir dipivoxil OPDIVO PA VOTRIENT PA, QL EGRIFTA PA, QL NUTROPIN PA BARACLUDE QL oxaliplatin VUMON octreotide PA NUTROPIN AQ PA entecavir QL paclitaxel XALKORI PA, QL SAMSCA PA, QL OMNITROPE PA EPIVIR HBV ‡ pentostatin XELODA ‡ SANDOSTATIN PA SAIZEN PA lamivudine tab PERJETA PA XGEVA PA, QL SANDOSTATIN LAR PA SEROSTIM PA, QL NABI-HB PHOTOFRIN XOFIGO PA SENSIPAR SOMAVERT THROMBATE III POMALYST PA, QL XTANDI PA, QL SIGNIFOR PA TECHNIVIE PA, QL HEPAGAM B PROLEUKIN PA YERVOY PA SOMATULINE PA TEV-TROPIN PA HYPERHEP B S-D PROVENGE PA ZALTRAP PA SOMAVERT PA ZOMACTON ‡ PA HEPSERA ‡ PURIXAN PA ZANOSAR SYNAREL ZORBTIVE PA, QL TYZEKA REVLIMID PA, QL ZELBORAF PA, QL TESTOPEL PA Hemophilia and RITUXAN PA ZEVALIN THYROGEN Hepatitis C SIGNIFOR LAR PA ZINECARD PA Related Bleeding ACTIMMUNE SPRYCEL PA, QL ZOLADEX ‡ PA Enzyme Replacement Disorders ACTIVASE ALFERON N STIVARGA PA, QL ZOLINZA PA, QL (Alpha 1) ADVATE COPEGUS PA SUPPRELIN LA ZYDELIG PA, QL ADAGEN ALPHANATE DAKLINZA PA, QL SUTENT PA, QL ZYKADIA PA, QL ALDURAZYME PA ALPHANINE S/D HARVONI ‡ PA, QL SYLATRON PA ZYTIGA ‡ PA ARALAST PA ALPROLIX PA INCIVEK ‡ PA, QL SYNRIBO PA ELAPRASE PA ATRYN PA INFERGEN PA TABLOID Crohn’s Disease ELELYSO PA BEBULIN VH INTRON A PA TAFINLAR PA, QL CIMZIA PA, QL GLASSIA PA BENEFIX moderiba PA TARCEVA PA, QL HUMIRA ‡ PA, QL FABRAZYME PA BERINERT PA OLYSIO PA, QL TARGRETIN PA REMICADE ‡ PA KUVAN PA, QL PEG INTRON ‡ PA TARGRETIN GEL TYSABRI PA LUMIZYME PA CINRYZE PA PEGASYS PA TASIGNA ‡ PA, QL MYOZYME PA CORIFACT Cystic Fibrosis REBETOL PA TAXOTERE NAGLAZYME PA CYKLOKAPRON BETHKIS PA ribatab PA TEMODAR ‡ PA NATPARA ‡ PA ELOCTATE PA CAYSTON ribapak tablets kit PA temozolomide PA ORFADIN PA FEIBA NF ESBRIETA PA ribasphere PA teniposide ORKAMBI ‡ PA, QL FIRAZYR PA KALYDECO PA, QL ribavirin PA THALOMID PA, QL PROCYSBI HELIXATE FS KITABIS PA SOVALDI ‡ PA, QL THERACYS PROLASTIN PA HEMOFIL-M OFEV PA, QL TECHNIVIE PA, QL THIOTEPA SOLESTA HUMATE-P PULMOZYME PA, QL VIEKIRA PA, QL TICE BCG VIMIZIM IXINITY PA TOBI VICTRELIS PA, QL toposar ZEMAIRA PA KALBITOR PA TOBI PODHALER topotecan KOATE-DVI tobramycin nebu soln Gastrointestinal HIV/AIDS TORISEL PA, QL KOGENATE FS Agents abacavir TOTECT PA LYSTEDA QL Cytomegalovirus CHOLBAM ‡ PA, QL abacavir sulfate TREANDA PA MONOCLATE-P Vaccines GATTEX PA abacavir sulfate/lamivudine/ tretinoin PA, QL MONONINE zidovudine CYTOGAM SUCRAID TRISENOX PA NOVOSEVEN RT APTIVUS ‡ TYKERB ‡ PA, QL Dystonia Gaucher Disease OBIZUR ATRIPLA ‡ PROFILNINE UNITUXIN ‡ PA BOTOX PA CERDELGA PA, QL COMBIVIR RECOMBINATE UVADEX DYSPORT PA CEREZYME PA COMPLERA ‡ RECOTHROM VALCHLOR PA, QL MYOBLOC PA VPRIV PA CRIXIVAN ‡ RIASTAP VALSTAR XIAFLEX ZAVESCA PA didanosine VANTAS zoledronic RIXUBIS EDURANT ‡ VECTIBIX PA RUCONEST PA EMTRIVA ‡ VELCADE PA STIMATE EPIVIR ‡ © 2016 Magellan Rx Management. All rights expressly reserved. This publication may not be reproduced in whole or part by any means whatsoever without express written permission of the copyright owner. MRX0367_0116 EPZICOM ‡ Hyperparathyroidism Infertility Narcolepsy Pain Management FUZEON QL doxercalciferol BRAVELLE PA XYREM PA, QL LIORESAL INT INTELENCE ‡ HECTOROL CETROTIDE ‡ PA PRIALT INVIRASE ‡ ZEMPLAR CHORIONIC Nausea QUTENZA ISENTRESS ‡ GONADOTROPIN PA AKYNZEO PA KALETRA ‡ Immune Deficiency BENLYSTA PA ALOXI Parkinson Disease lamivudine BIVIGAM PA ENDOMETRIN VAGINAL ‡ ANZEMET QL APOKYN PA lamivudine/ zidovudine CARIMUNE NF PA GANIRELIX CESAMET PA Psoriasis LEXIVA ‡ FLEBOGAMMA PA GONAL-F ‡ PA EMEND QL COSENTYX PA nevirapine GAMASTAN S/D PA GONAL-F RFF ‡ PA granisetron ENBREL ‡ PA, QL NORVIR GAMMAGARD PA MAKENA ‡ PA ONDANSETRON HCL INJ HUMIRA ‡ PA, QL PREZISTA ‡ GAMMAGARD SD PA MENOPUR PA SANCUSCO QL REMICADE ‡ PA RESCRIPTOR GAMMAKED PA novarel PA ZOFRAN INJ RASUVO PA,QL RETROVIR GAMMAPLEX PA OVIDREL ‡ PA Neuromuscular STELARA PA, QL REYATAZ ‡ GAMUNEX PA pregnyl PA Blocking Agent SELZENTRY ‡ PA HIZENTRA PA REPRONEX PA XEOMIN PA Pulmonary stavudine HYPERRAB S/D Hypertension HYPERRHO S/D Iron Overload STRIBILD Neutropenia ADCIRCA PA, QL HYPERTET S/D EXJADE SUSTIVA ‡ GRANIX PA epoprostenol PA HYQVIA PA FERRIPROX PA TIVICAY LEUKINE PA FLOLAN PA IMOGAM RABIES TRIUMEQ PA Miscellaneous NEULASTA‡ PA LETAIRIS ‡ PA, QL MICRHOGAM PL TRIZIVIR AMYVID NEUPOGEN‡ PA OPSUMIT PA, QL OCTAGAM PA TRUVADA ‡ BENLYSTA PA ZARXIO PA, QL ORENITRAM PA PRIVIGEN PA TYBOST ‡ PA CARBAGLU REMODULIN PA SOLIRIS Ophthalmic VIDEX ‡ cidofovir REVATIO PA, QL VIDEX EC EYLEA Immune Globulins — CRESEMBA INJ ‡ PA sildenafil 20mg PA, QL VIRACEPT ‡ JETREA PA Obstetrics CYSTAGON TRACLEER ‡ PA, QL VIRAMUNE LUCENTIS RHOGAM PLUS CYTOVENE TYVASO PA, QL VIRAMUNE XR ‡ MACUGEN RHOPHYLAC ELITEK VELETRI