SPECIALTY MEDICATIONS available through Accredo Health Group, Inc., Medco’s specialty pharmacy Call toll-free (800) 803-2523, 8:00 a.m. to 8:00 p.m., eastern time, Monday through Friday, to confirm that your medication is covered. Effective as of July 1, 2011 Abraxane® (paclitaxel protein-bound particles) Berinert® (C 1 esterase inhibitor [human])* (PA) (QD) Actemra ™ (tocilizumab) (PA) Betaseron® (interferon beta-1b) (PA) Actimmune® (interferon gamma-1b) (PA) Botox® (botulinum toxin type A) (PA) Adagen® (pegademase bovine) Carbaglu ™ (carglumic acid) Adcirca® (tadalafil) (ST) (QD) Carimune® NF (immune globulin intravenous [human]) (PA) Advate® (antihemophilic factor [recombinant]) (CPA) Cerezyme® (imiglucerase) (CPA) (ST) Afinitor® (everolimus) (PA) (QD) Cimzia® (certolizumab pegol) (ST) Aldurazyme® (laronidase) (CPA) Copaxone® (glatiramer acetate) (PA) Alphanate® (antihemophilic factor [human]) (CPA) Copegus® (ribavirin) (ST) AlphaNine® SD (coagulation factor IX [human]) (CPA) Corifact® (factor XIII [human]) (CPA) Amevive® (alefacept) (PA) Cystadane® (betaine) Ampyra ™ (dalfampridine) (PA) CytoGam® (cytomegalovirus immune globulin Apokyn® (apomorphine hydrochloride) (PA) (QD) intravenous [human])* (CPA) Aralast® (alpha[1]-proteinase inhibitor [human]) Cytovene® IV (ganciclovir sodium)* Aranesp® (darbepoetin alfa) (PA) Dacogen® (decitabine) Arcalyst® (rilonacept) (PA) (QD) Dysport® (abobotulinumtoxinA) (PA) Arixtra® (fondaparinux sodium)* Egrifta ™ (tesamorelin) (PA) Arranon® (nelarabine) Elaprase® (idursulfase) (CPA) Arzerra® (ofatumumab) Eligard® (leuprolide acetate) ATryn® (antithrombin [recombinant])* Enbrel® (etanercept) (PA) Avastin® (bevacizumab) (PA) (QD) Enoxaparin sodium (GENERIC )* Avonex® (interferon beta-1a) (PA) Epogen® (epoetin alfa) (PA) Bebulin® VH (factor IX complex) (CPA) Epoprostenol sodium (GENERIC ) (ST) BeneFIX® (coagulation factor IX [recombinant]) (CPA) Erbitux® (cetuximab) (PA) (QD) Benlysta® (belimumab) Euflexxa® (sodium hyaluronate) (QD) *Specialty drug is available through Accredo Health Group, Inc., Medco’s specialty pharmacy, for long-term use and through participating retail pharmacies for short-term/emergency use. The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. Exjade® (deferasirox) Hyalgan® (sodium hyaluronate) (QD) Extavia® (interferon beta-1b) (PA) Hycamtin® capsules (topotecan) Fabrazyme® (agalsidase beta) (CPA) HyperRho® S/D (Rh o[D] immune globulin [human])* Feiba® VH (anti-inhibitor coagulant complex) (CPA) Incivek ™ (telaprevir) Firmagon ® (degarelix) Increlex® (mecasermin [rDNA origin]) (PA) Flebogamma® (immune globulin [human]) (PA) Infergen® (interferon alfacon-1) (PA) Flolan® (epoprostenol sodium) (ST) Innohep® (tinzaparin sodium)* Folotyn ™ (pralatrexate) Intron® A (interferon alfa-2b) (PA) Forteo® (teriparatide [rDNA origin]) (ST) Iprivask® (desirudin)* Fragmin® (dalteparin sodium)* Istodax® (romidepsin) (PA) (QD) Fuzeon® (enfuvirtide) Ixempra® (ixabepilone) GamaSTAN ® S/D (immune globulin [human]) * Jevtana® (cabazitaxel) (PA) (QD) Gammagard® Liquid (immune globulin [human]) (PA) Kineret® (anakinra) (PA) Gammagard® S/D (immune globulin [human]) (PA) Koate®-DVI (antihemophilic factor [human]) (CPA) Gammaplex® (immune globulin [human]) (PA) Kogenate® FS (antihemophilic factor [recombinant]) (CPA) Gamunex® (immune globulin [human]) (PA) Krystexxa ™ (pegloticase) (ST) (QD) Ganciclovir (GENERIC )* Kuvan® (sapropterin dihydrochloride) (PA) Genotropin® (somatropin [rDNA origin]) (PA) Letairis® (ambrisentan) (ST) Gilenya ™ (fingolimod) (PA) Leukine® (sargramostim) (PA) Glassia ™ (alpha [1]-proteinase inhibitor [human]) Leuprolide acetate (GENERIC )* Gleevec® (imatinib mesylate) (PA) (QD) Lovenox® (enoxaparin sodium)* Halaven ™ (eribulin mesylate) Lucentis® (ranibizumab) Helixate® FS (antihemophilic factor [recombinant]) (CPA) Lumizyme ™ (alglucosidase alfa) (CPA) Hemofil® M (antihemophilic factor [human]) (CPA) Lupron Depot® (leuprolide acetate) Herceptin® (trastuzumab) (ST) Lupron Depot-PED® (leuprolide acetate) Hizentra ™ (immune globulin subcutaneous [human]) (PA) Luveris® (lutropin alfa) H.P. Acthar® Gel (corticotropin)* (PA) Macugen® (pegaptanib sodium injection) Humate-P® (antihemophilic factor/von Willebrand factor complex [human]) (CPA) Makena ™ (hydroxyprogesterone caproate) (CPA) Humatrope® (somatropin [rDNA origin]) (PA) MICRhoGAM® (Rh o[D] immune globulin [human])* Humira® (adalimumab) (PA) Mitoxantrone HCl (GENERIC ) *Specialty drug is available through Accredo Health Group, Inc., Medco’s specialty pharmacy, for long-term use and through participating retail pharmacies for short-term/emergency use. The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. Monoclate-P® (antihemophilic factor [human]) (CPA) Procrit® (epoetin alfa) (PA) Mononine® (coagulation factor IX [human]) (CPA) Profilnine® SD (factor IX complex [human]) (CPA) Mozobil® (plerixafor)* (QD) Proleukin® (aldesleukin)* Myobloc® (botulinum toxin type B) (PA) Prolia ™ (denosumab) (PA) (QD) Myozyme® (alglucosidase alfa) (CPA) Promacta® (eltrombopag) (PA) Naglazyme® (galsulfase) (CPA) Pulmozyme® (dornase alfa) Neulasta® (pegfilgrastim)* (PA) Qutenza® (capsaicin) Neumega® (oprelvekin) (PA) Rebetol® (ribavirin) (ST) Neupogen® (filgrastim) (PA) Rebif® (interferon beta-1a) (PA) Nexavar® (sorafenib) (PA) (QD) Recombinate ™ (antihemophilic factor [recombinant]) (CPA) (PA) Norditropin® (somatropin [rDNA origin]) (PA) Remicade® (infliximab) Remodulin® (treprostinil sodium) (ST) Norditropin/Nordiflex® (somatropin [rDNA origin]) (PA) Retisert® (fluocinolone acetonide) (PA) (QD) Novantrone® (mitoxantrone HCl) (PA) Revatio® injection (sildenafil citrate) (ST) (QD) NovoSeven® RT (coagulation factor VIIa [recombinant]) (CPA) Revatio® tablets (sildenafil citrate) (ST) (QD) Nplate® (romiplostim)* (PA) Revlimid® (lenalidomide) (PA) (QD) Nutropin® (somatropin [rDNA origin]) (PA) RhoGAM® (RH o[D] immune globulin [human])* Nutropin AQ® (somatropin [rDNA origin]) (PA) Rhophylac® (RH o[D] immune globulin intravenous Octagam® (immune globulin intravenous [human]) (PA) [human])* Octreotide acetate (GENERIC ) RiaSTAP® (fibrinogen)* Oforta ™ (fludarabine) RibaPak® (GENERIC ) Omnitrope® (somatropin) (PA) Ribasphere® (GENERIC ) Orencia® (abatacept) (PA) Ribavirin (GENERIC ) Orfadin® (nitisinone) Rituxan® (rituximab) (PA) OrthoVisc® (hyaluronate sodium) (QD) Sabril® (vigabatrin)* Ozurdex ™ (dexamethasone) Saizen® (somatropin [rDNA origin]) (PA) Pegasys® (peginterferon alfa-2a) (PA) Samsca® (tolvaptan)* PEG-Intron® (peginterferon alfa-2b) (PA) Sandostatin® (octreotide acetate) PEG-Intron® Redipen® (peginterferon alfa-2b) (PA) Sandostatin LAR® (octreotide/IM) Prialt® (ziconotide) Sensipar® (cinacalcet hydrochloride) (PA) Privigen® (immune globulin intravenous [human]) (PA) Serostim® (somatropin [rDNA origin]) (PA) *Specialty drug is available through Accredo Health Group, Inc., Medco’s specialty pharmacy, for long-term use and through participating retail pharmacies for short-term/emergency use. The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. Simponi ™ (golimumab) (ST) Vectibix® (panitumumab) (PA) Soliris® (eculizumab) (PA) Velcade® (bortezomib) Somatuline Depot® (lanreotide) Veletri® (epoprostenol sodium) Somavert® (pegvisomant) (PA) Ventavis® (iloprost) (ST) (QD) Spryce l® (dasatinib) (PA) (QD) Victrelis ™ (boceprevir) Stelara ™ (ustekinumab) (PA) (QD) Vidaza® (azacitidine) (PA) (QD) Stimate® (desmopressin acetate) Vivitrol® (naltrexone) Supartz® (sodium hyaluronate) (QD) Votrient® (pazopanib) (PA) (QD) Supprelin® LA (histrelin acetate) Vpriv ™ (velaglucerase alfa) (PA) Sutent® capsules (sunitinib malate) (PA) (QD) Wilate® (von Willebrand factor/coagulation factor VIII complex [human]) (CPA) Sylatron ™ (peginterferon alfa-2b) (PA) WinRho SDF® (Rh o[D] immune globulin intravenous Synagis® (palivizumab) (PA) (QD) [human])* Synvisc® (hylan G-F 20) (QD) Xeloda® (capecitabine)* Tarceva® (erlotinib) (PA) (QD) Xenazine® (tetrabenazine) (PA) (QD) Tasigna® (nilotinib) (PA) (QD) Xeomin® (incobotulinumtoxinA) (PA) Temodar® capsules (temozolomide) (PA) Xgeva ™ (denosumab) Temodar® injection (temozolomide) (PA) Xiaflex ™ (collagenase clostridium histolyticum) Tev-Tropin® (somatropin [rDNA origin]) (PA) Xolair® (omalizumab) (PA) (QD) Thalomid® (thalidomide) (PA) Xyntha® (antihemophilic factor [recombinant]) (CPA) Tobi® (tobramycin) (ST) (QD) Yervoy ™ (ipilimumab)