2021 specialty drug list - welldynerx.adaptiverx.com

2021 Specialty Drug List

Specialty medicines treat complex and chronic (long-term) conditions. Examples include multiple sclerosis,hepatitis C, HIV and cancer. Depending on the condition and prescribed therapy, these drugs may be taken bymouth, through a vein, or by injection. Specialty medicines often require specialty handling such as refrigeration.The following specialty medications are covered by WellDyne. This list is not all-inclusive and is subject to changewithout notice.

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

IMCIVREEPA, QL

WAKIXPA, QL

ALLERGENICEXTRACTS/BIOLOGICALS MISC

ADAGENPA

AMINOGLYCOSIDES

ARIKAYCEPA, QL

BETHKISPA, QL

KITABIS PAKPA, QL

TOBI PODHALERPA, QL

TOBIQL

TOBRAMYCINPA, QL

ZEMDRIPA, QL

ANALGESICS - ANTI-INFLAMMATORY

ARCALYSTPA

ENBREL MINIPA, QL

ENBREL SURECLICKPA, QL

ENBRELPA, QL

HUMIRA PEDIATRIC CROHNSSTARTPA

HUMIRA PEN-CD/UC/HSSTARTERPA, QL

HUMIRA PEN-PEDIATRIC UCSTARTPA, QL

HUMIRA PEN-PS/UV/ADOL HSSTARTPA

HUMIRA PEN-PSOR/UVEITSTARTERPA, QL

HUMIRA PENPA

HUMIRAPA, QL

ILARISPA

OTEZLAPA, QL

RASUVOPA, QL

RINVOQPA, QL

XELJANZ XRPA, QL

XELJANZPA, QL

ANALGESICS - NONNARCOTIC

clonidine hcl (analgesia)DURACLONPRIALT

ANALGESICS - OPIOID

PROBUPHINE IMPLANT KITPA, QL

SUBLOCADEPA, QL

ANTI-INFECTIVE AGENTS - MISC.

CAYSTONPA, QL

colistimethate sodium (cba)COLY-MYCIN MIMPAVIDOPA, QL

KIMYRSAPA

ORBACTIVPA, QL

VIBATIV

ANTIARRHYTHMICS

dofetilideTIKOSYN

ANTIASTHMATIC ANDBRONCHODILATOR AGENTS

CINQAIRPA

FASENRA PENPA, QL

FASENRAPA, QL

NUCALAPA

XOLAIRPA

ANTICONVULSANTS

DIACOMITPA, QL

EPIDIOLEXPA

FINTEPLAPA, QL

SABRILPA, QL

vigabatrinPA, QL

vigadronePA, QL

ANTIDEPRESSANTS

SPRAVATO (56 MG DOSE)PA, QL

SPRAVATO (84 MG DOSE)PA, QL

ZULRESSOPA

ANTIDIABETICS

KORLYMPA, QL

ANTIDOTES AND SPECIFICANTAGONISTS

ANDEXXABRIDIONPA

deferasirox granulesPA

deferasiroxPA

deferipronePA

deferoxamine mesylatePA

DESFERALPA

EXJADEPA

FERRIPROX TWICE-A-DAYPA

FERRIPROXPA

JADENU SPRINKLEPA

VISTOGARDPA, QL

VIVITROLPA, QL

ANTIHYPERLIPIDEMICS

EVKEEZAPA

JUXTAPIDPA, QL

KYNAMROPA, QL

PRALUENTPA, QL

REPATHA PUSHTRONEXSYSTEMPA, QL

REPATHA SURECLICKPA, QL

REPATHAPA, QL

ANTIHYPERTENSIVES

metyrosinePA, QL

ANTIMYASTHENIC/CHOLINERGIC AGENTS

RUZURGIPA, QL

ANTIMYCOBACTERIAL AGENTS

SIRTUROQL

ANTINEOPLASTICS ANDADJUNCTIVE THERAPIES

ABECMAPA

abiraterone acetatePA, QL

ABRAXANEACTIMMUNEPA

ADCETRISPA

ADRIAMYCINadrucilAFINITOR DISPERZPA, QL

AFINITORPA, QL

ALECENSAPA, QL

ALFERON NALIMTAALIQOPAPA, QL

ALKERANPA

ALUNBRIGPA, QL

ARRANONarsenic trioxideARZERRAPA

ASPARLASPA

AYVAKITPA, QL

azacitidinePA

AZEDRA DOSIMETRICAZEDRA THERAPEUTICBALVERSAPA, QL

BAVENCIOPA

BELEODAQBELRAPZOPA

BENDAMUSTINE HCLPA

BENDEKAPA

BESPONSAPA, QL

bexarotenePA

BICNUBLENREPPA

BLEO 15Kbleomycin sulfateBLINCYTOPA

BORTEZOMIBPA

BOSULIFPA, QL

BRAFTOVIPA, QL

BREYANZIPA

BRUKINSAPA, QL

busulfanBUSULFEXCABOMETYXPA, QL

CAMPATHPA

CAMPTOSAR

capecitabinePA

CAPRELSAPA, QL

carboplatincarmustineCISPLATINcladribineclofarabineCLOLARCOMETRIQ (100 MG DAILY DOSE)PA,

QL

COMETRIQ (140 MG DAILY DOSE)PA,

QL

COMETRIQ (60 MG DAILY DOSE)PA, QL

COPIKTRAPA, QL

COSELAPA

COSMEGENCOTELLICPA, QL

CYCLOPHOSPHAMIDECYRAMZAPA

cytarabine (pf)CYTARABINEDACARBAZINEDACOGENPA

dactinomycinDANYELZAPA, QL

DARZALEX FASPROPA

DARZALEXPA

DAUNORUBICIN HCLDAURISMOPA, QL

decitabineDOCETAXEL (NON-ALCOHOL)DOCETAXELDOXILdoxorubicin hcl liposomalDOXORUBICIN HCLELIGARDPA, QL

ELLENCEELZONRISPA

EMCYTEMPLICITIPA

ENHERTUPA

epirubicin hclERBITUXPA

ERIVEDGEPA, QL

ERLEADAPA, QL

erlotinib hclPA, QL

ERWINASEERWINAZEETHYOLETOPOPHOSETOPOSIDEeverolimusPA, QL

EVOMELAPA

FARYDAKPA, QL

FASLODEXFIRMAGON (240 MG DOSE)QL

(Continued)

The rights of the drug names appearing on this Specialty Drug List, whether or not appearing in connection with the trademark symbol, belong exclusively to their owners.©2021 WellDyne. All Rights Reserved


FIRMAGONPA, QL

floxuridinefludarabine phosphatefluorouracilFOLOTYNFOTIVDAPA, QL

FULVESTRANTFUSILEVGAVRETOPA, QL

GAZYVAPA

GEMCITABINE HCLGEMZARGILOTRIFPA, QL

GLEOSTINEPA

GLIADEL WAFERHALAVENPA

HERZUMAPA

HYCAMTINPA

HYDROXYPROGESTERONECAPROATEPA, QL

IBRANCEPA, QL

ICLUSIGPA, QL

IDAMYCIN PFSidarubicin hclIDHIFAPA, QL

IFEXIFOSFAMIDEimatinib mesylatePA, QL

IMBRUVICAPA, QL

IMFINZIPA

IMLYGICPA

INFUGEMINLYTAPA, QL

INQOVIPA, QL

INREBICPA, QL

INTRON APA

IRESSAPA, QL

IRINOTECAN HCLIXEMPRA KITJAKAFIPA, QL

JEMPERLIPA, QL

JEVTANAPA

KADCYLAPA

KANJINTIPA

KEPIVANCEKEYTRUDAPA

KHAPZORYKISQALI (200 MG DOSE)PA, QL

KISQALI (400 MG DOSE)PA, QL

KISQALI (600 MG DOSE)PA, QL

KISQALI FEMARA (400 MG DOSE)PA,

QL

KISQALI FEMARA (600 MG DOSE)PA,

QL

KISQALI FEMARA(200 MG DOSE)PA,

QL

KOSELUGOPA, QL

KYMRIAHPA, QL

KYPROLISPA

lapatinib ditosylatePA, QL

LARTRUVOPA

LENVIMA (10 MG DAILY DOSE)PA, QL








LEUCOVORIN CALCIUMleuprolide acetatePA

levoleucovorin calcium pfLEVOLEUCOVORIN CALCIUMLIBTAYOPA, QL

lipodox 50LONSURFPA

LORBRENAPA, QL

LUMAKRASPA, QL

LUMOXITIPA

LUPRON DEPOT (1-MONTH)PA, QL




LYNPARZAPA, QL

LYSODRENPA, QL

MARGENZAPA

MARQIBOMATULANEPA

MEKINISTPA, QL

MEKTOVIPA, QL

melphalan hclmelphalanPA

mesnaMESNEXMITOMYCINmitoxantrone hclPA

MONJUVIPA

MUSTARGENmutamycinMVASIPA

MYLERANPA

MYLOTARGPA

NAVELBINENERLYNXPA, QL

NEXAVARPA, QL

NINLAROPA, QL

NIPENTNUBEQAPA, QL

ODOMZOPA, QL

OGIVRIPA

ONCASPARONIVYDEPA

ONUREGPA, QL

OPDIVOPA, QL

ORGOVYXPA, QL

OXALIPLATINPACLITAXELPADCEVPA

paraplatinPEMAZYREPA, QL

PEPAXTOPA

PERJETAPA

PHESGOPA, QL

PHOTOFRINPA

PIQRAY (200 MG DAILY DOSE)PA, QL



POLIVYPA

POMALYSTPA, QL

PORTRAZZAPA

POTELIGEOPA

PROLEUKINPROVENGEPA

PURIXANQINLOCKPA, QL

RETEVMOPA, QL

RIABNIPA

ROMIDEPSINPA

ROZLYTREKPA, QL

RUBRACAPA, QL

RUXIENCEPA

RYBREVANTPA

RYDAPTPA, QL

SARCLISAPA

SPRYCELPA, QL

STIVARGAPA, QL

SUTENTPA, QL

SYLATRONPA

SYNRIBOPA

TABLOIDTABRECTAPA, QL

TAFINLARPA, QL

TAGRISSOPA, QL

TALZENNAPA, QL

TARCEVAPA, QL

TARGRETINPA

TASIGNAPA, QL

TAXOTERETAZVERIKPA, QL

TECARTUSPA

TECENTRIQPA, QL

TEMODARPA

temozolomidePA

temsirolimusPA

TENIPOSIDETEPADINATEPMETKOPA, QL

thiotepaTIBSOVOPA, QL

TICE BCGtoposarTOPOTECAN HCLTORISELPA

TRAZIMERAPA

TREANDATRELSTAR MIXJECTPA, QL

TRISENOXTRODELVYPA

TRUSELTIQ (100MG DAILY DOSE)PA,

QL

TRUSELTIQ (125MG DAILY DOSE)PA,

QL

TRUSELTIQ (50MG DAILY DOSE)PA, QL

TRUSELTIQ (75MG DAILY DOSE)PA, QL

TRUXIMAPA

TUKYSAPA, QL

TURALIOPA, QL

TYKERBPA, QL

UKONIQPA, QL

UNITUXINUVADEXvalrubicinVALSTARVANTASPA, QL

VECTIBIXPA

VELCADEPA

VENCLEXTA STARTING PACKPA, QL

VENCLEXTAPA, QL

VERZENIOPA, QL

VIDAZAPA

VINBLASTINE SULFATEvincasar pfsVINCRISTINE SULFATEvinorelbine tartrateVITRAKVIPA, QL

VIZIMPROPA, QL

VOTRIENTPA, QL

VYXEOSPA

WELIREGPA, QL

XALKORIPA, QL

XELODAXOFIGOPA, QL

XOSPATAPA, QL

XPOVIO (100 MG ONCE WEEKLY)PA, QL


XPOVIO (40 MG TWICE WEEKLY)PA, QL





XTANDIPA, QL

YERVOYPA

YESCARTAPA, QL

YONDELISPA

YONSAPA, QL

ZALTRAPPA

ZANOSARZEJULAPA, QL

ZELBORAFPA, QL

ZEPZELCAPA

ZIRABEVPA

ZOLADEXPA, QL

ZOLINZAPA, QL

ZYDELIGPA, QL

ZYKADIAPA, QL

ZYNLONTAPA

ANTIPARKINSON AND RELATEDTHERAPY AGENTS

APOKYNPA, QL

DUOPAINBRIJAPA, QL

ANTIPSYCHOTICS/ANTIMANICAGENTS

(Continued)



ANTIVIRALS

abacavir sulfate-lamivudineQL

abacavir sulfateQL

abacavir-lamivudine-zidovudineQL

adefovir dipivoxilPA, QL

APTIVUSQL

atazanavir sulfateQL

ATRIPLAQL

BARACLUDEPA, QL

BIKTARVYQL

CABENUVAQL

CIMDUOQL

COMBIVIRQL

COMPLERAQL

COPEGUSPA, QL

CRIXIVANQL

DELSTRIGOQL

DESCOVYQL

DIDANOSINEQL

DOVATOQL

EDURANTQL

efavirenz-emtricitab-tenofovirQL

efavirenz-lamivudine-tenofovirQL

efavirenzQL

emtricitabine-tenofovir dfQL

emtricitabineQL

EMTRIVAQL

entecavirPA, QL

EPCLUSAPA, QL

EPIVIR HBVQL

EPIVIRQL

EPZICOMQL

EVOTAZQL

fosamprenavir calciumQL

FUZEONPA, QL

GENVOYAQL

HEPSERAQL

INTELENCEQL

INVIRASEQL

ISENTRESS HDQL

ISENTRESSQL

JULUCAQL

KALETRAQL

lamivudine-zidovudineQL

lamivudineQL

LEXIVAQL

lopinavir-ritonavirQL

MAVYRETPA, QL

MODERIBA (1000 MG PACK)PA, QL




moderibaPA, QL

NEVIRAPINE ERQL

nevirapineQL

NORVIRQL

ODEFSEYQL

PEG-INTRON REDIPENPA

PEGASYS PROCLICKPA, QL

PEGASYSPA, QL

PEGINTRONPA, QL

PIFELTROQL

PREVYMISPA, QL

PREZCOBIXQL

PREZISTAQL

REBETOLPA, QL

RESCRIPTORQL

RETROVIRQL

REYATAZQL

RIBASPHERE RIBAPAK (1000PACK)PA, QL




RIBASPHEREPA, QL

ribavirinPA, QL

ritonavirQL

RUKOBIAPA, QL

SELZENTRYQL

STAVUDINEQL

STRIBILDQL

SUSTIVAQL

SYMFI LOQL

SYMFIQL

SYMTUZAQL

TEMIXYSQL

tenofovir disoproxil fumarateQL

TIVICAY PDQL

TIVICAYQL

TRIUMEQQL

TRIZIVIRQL

TROGARZOPA, QL

TRUVADAQL

TYBOSTQL

VEMLIDYPA, QL

VIDEX ECQL

VIDEXQL

VIRACEPTQL

VIRAMUNE XRQL

VIRAMUNEQL

VIRAZOLEVIREADQL

VOCABRIAQL

VOSEVIPA, QL

ZERITQL

ZIAGENQL

zidovudineQL

CARDIOVASCULAR AGENTS -MISC.

ADCIRCAPA, QL

ADEMPASPA, QL

alyqPA, QL

ambrisentanPA, QL

bosentanPA, QL

epoprostenol sodiumPA

FLOLANPA

LETAIRISPA, QL

OPSUMITPA, QL

ORENITRAMPA, QL

REMODULINPA

REVATIOPA, QL

sildenafil citratePA, QL

tadalafil (pah)PA, QL

TRACLEERPA, QL

treprostinilPA

TYVASO REFILLPA

TYVASO STARTERPA

TYVASOPA

UPTRAVIPA, QL

VELETRIPA

VENTAVISPA, QL

VYNDAMAXPA, QL

VYNDAQELPA, QL

CHEMICALS

ARSENIC TRIOXIDEDIMETHYL FUMARATEPA, QL

FLOXURIDINELEUPROLIDE ACETATEPA

RIBAVIRINPA, QL

SILDENAFIL CITRATEPA, QL

SIROLIMUSPA

SODIUM PHENYLBUTYRATEPA

THIOTEPA

CORTICOSTEROIDS

EMFLAZAPA

DERMATOLOGICALS

BOTOX COSMETICCOSENTYX (300 MG DOSE)PA

COSENTYX SENSOREADY (300MG)PA

COSENTYX SENSOREADY PENPA

COSENTYXPA

DUPIXENTPA, QL

FLUOROURACILSCENESSEPA, QL

SKYRIZI (150 MG DOSE)PA, QL

SKYRIZIPA, QL

STELARAPA, QL

TREMFYAPA, QL

VALCHLORPA

DIAGNOSTIC PRODUCTS

MACRILENPA, QL

THYROGENPA

DIURETICS

KEVEYISPA, QL

ENDOCRINE AND METABOLICAGENTS - MISC.

ACTHARPA

ALDURAZYMEPA

BONIVAPA, QL

BRINEURAPA

BUPHENYLPA

BYNFEZIA PENPA

CARBAGLUPA

CETROTIDEPA

CHORIONIC GONADOTROPINcinacalcet hclPA

CRYSVITAPA

DESMOPRESSIN ACETATEEGRIFTA SVEGRIFTAPA, QL

ELAPRASEPA

EVENITYPA, QL

FABRAZYMEPA

FENSOLVI (6 MONTH)PA, QL

FORTEOPA, QL

GALAFOLDPA, QL

ganirelix acetatePA

GENOTROPIN MINIQUICKPA

GENOTROPINPA

GONAL-F RFF REDIJECTGONAL-F RFFGONAL-FHCGibandronate sodiumPA, QL

INCRELEXPA

ISTURISAPA, QL

JYNARQUEPA, QL

KANUMAPA

KUVANPA

LUMIZYMEPA

LUPANETA PACKPA, QL

LUPRON DEPOT-PED (1-MONTH)PA, QL

LUPRON DEPOT-PED (3-MONTH)PA,

QL

MENOPURMEPSEVIIPA

MYALEPTPA

MYCAPSSAPA, QL

NAGLAZYMEPA

NATPARAPA, QL

NEXVIAZYMEPA

nitisinonePA

NITYRPA

NORDITROPIN FLEXPROPA

NOVARELNULIBRYPA

OCTREOTIDE ACETATEPA

ORFADINPA

ORILISSAPA, QL

OVIDRELPA

PALYNZIQPA

PAMIDRONATE DISODIUMPARSABIVPA

PREGNYLPROLIAPA, QL

RAVICTIPA, QL

RECLASTQL

REVCOVIPA

SAMSCAPA, QL

SANDOSTATIN LAR DEPOTPA, QL

SANDOSTATINPA

sapropterin dihydrochloridePA

SENSIPARPA

SEROSTIMPA

(Continued)



SIGNIFOR LARPA, QL

SIGNIFORPA, QL

sodium phenylbutyratePA

SOMATULINE DEPOTPA, QL

SOMAVERTPA

STIMATESTRENSIQPA

SUPPRELIN LAPA, QL

SYNARELPA

TEPEZZAPA, QL

TOLVAPTANPA, QL

TRIPTODURPA, QL

TYMLOSPA, QL

VIMIZIMPA

XGEVAPA, QL

XURIDENPA, QL

ZOLEDRONIC ACIDPA, QL

ZOMETAPA

ZORBTIVEPA

ESTROGENS

MYFEMBREEPA, QL

ORIAHNNPA, QL

GASTROINTESTINAL AGENTS -MISC.

AVSOLAPA

BYLVAY (PELLETS)PA, QL

BYLVAYPA, QL

CHENODALPA

CHOLBAMPA

ENTYVIOPA, QL

GATTEXPA

INFLECTRAPA

OCALIVAPA, QL

REMICADEPA

RENFLEXISPA

XERMELOPA, QL

GENITOURINARY AGENTS -MISCELLANEOUS

CYSTAGONPA

OXLUMOPA

PROCYSBIPA

THIOLA ECPA

THIOLAPA

GOUT AGENTS

KRYSTEXXAPA

HEMATOLOGICAL AGENTS -MISC.

ADVATEADYNOVATEAFSTYLAALPHANATE/VWFCOMPLEX/HUMANALPHANATEALPHANINE SDALPROLIXBEBULINBENEFIXBERINERTPA

CABLIVIPA, QL

CEPROTINCINRYZEPA

COAGADEXCORIFACTDEFITELIOPA

ELOCTATEEMPAVELIPA, QL

ESPEROCTFEIBAFIBRYGAFIRAZYRPA

GIVLAARIPA

HAEGARDAPA

HELIXATE FSHEMLIBRAPA

HEMOFIL MHUMATE-Picatibant acetatePA

IDELVIONIXINITYJIVIPA

KALBITORPA

KCENTRAKOATE-DVIKOATEKOGENATE FS BIO-SETKOGENATE FSKOVALTRYMONOCLATE-PMONONINENOVOEIGHTNOVOSEVEN RTNUWIQOBIZURORLADEYOPA, QL

PROFILNINE SDPROFILNINEREBINYNRECOMBINATERIASTAPRIXUBISRUCONESTPA

sajazirPA

SEVENFACTSOLIRISPA

TAKHZYROPA, QL

TAVALISSEPA, QL

THROMBATE IIITRETTENULTOMIRISPA, QL

VONVENDIWILATEXYNTHA SOLOFUSEXYNTHA

HEMATOPOIETIC AGENTS

ADAKVEOPA

ARANESP (ALBUMIN FREE)PA

CERDELGAPA, QL

CEREZYMEPA

DOPTELETPA, QL

ENDARIPA, QL

EPOGENPA

FULPHILAPA, QL

GRANIXPA

INJECTAFERPA

LEUKINEPA

miglustatQL

MIRCERAPA

MOZOBILPA, QL

MULPLETAPA, QL

NEUPOGENPA

NIVESTYMPA

NPLATEPA

NYVEPRIAPA

OXBRYTAPA, QL

PROCRITPA

PROMACTAPA, QL

REBLOZYLPA

RETACRITPA

VPRIVPA

ZARXIOPA

ZAVESCAPA, QL

ZIEXTENZOPA

HYPNOTICS/SEDATIVES/SLEEPDISORDER AGENTS

HETLIOZ LQPA, QL

HETLIOZPA, QL

MIGRAINE PRODUCTS

AIMOVIG (140 MG DOSE)PA, QL

AIMOVIGPA, QL

AJOVYPA, QL

EMGALITY (300 MG DOSE)PA, QL

EMGALITYPA, QL

NURTECPA, QL

UBRELVYPA, QL

VYEPTIPA, QL

MISCELLANEOUS THERAPEUTICCLASSES

BENLYSTAPA, QL

cloviqueQL

CUPRIMINEPA, QL

D-PENAMINEENSPRYNGPA, QL

GAMIFANTPA

LUPKYNISPA, QL

NULOJIXPA

penicillaminePA, QL

RAPAMUNEPA

REVLIMIDPA, QL

REZUROCKPA, QL

SAPHNELOPA

SOLESTAPA

SYLVANTPA

SYPRINEQL

THALOMIDPA

trientine hclQL

UPLIZNAPA, QL

XIAFLEXPA

ZOKINVYPA, QL

MUSCULOSKELETAL THERAPYAGENTS

BACLOFENDUROLANEPA

EUFLEXXAPA, QL

GABLOFENGELSYN-3PA, QL

LIORESALMONOVISCPA, QL

ORTHOVISCPA, QL

NASAL AGENTS - SYSTEMIC ANDTOPICAL

SINUVAPA, QL

NEUROMUSCULAR AGENTS

AMONDYS 45PA

BOTOXPA

DYSPORTPA

EVRYSDIPA, QL

EXONDYS 51PA

MYOBLOCPA

RADICAVAPA

SPINRAZAPA

VILTEPSOPA

VYONDYS 53PA

XEOMINPA

NUTRIENTS

DOJOLVIPA

OPHTHALMIC AGENTS

AMVISC PLUSPA

AMVISCPA

BEOVUPA, QL

BEVACIZUMABPA, QL

BIOLONPA

CYSTADROPSPA, QL

CYSTARANPA, QL

DEXTENZAPA

DEXYCUPA, QL

DUOVISCPA

EYLEAPA

HEALON DUET PROPA

HEALON GV PROPA

HEALON GVPA

HEALON PROPA

HEALON5 PROPA

HEALON5PA

HEALONPA

HYALURONIDASE (INTRAOCULAR)PA

ILUVIENPA

JETREAQL

LUCENTISPA

LUXTURNAPA, QL

MACUGENPA, QL

OXERVATEPA, QL

OZURDEXQL

PHOTREXA VISCOUSPHOTREXA-PHOTREXA VISCOUSKIT

(Continued)



PROVISCPA

RETISERTPA

SHELLGELPA

VISUDYNEPA

YUTIQPA

PASSIVE IMMUNIZING ANDTREATMENT AGENTS

ASCENIVPA

BIVIGAMPA

CARIMUNE NFPA

CUVITRUPA

CYTOGAMETESEVIMABPA, QL

FLEBOGAMMA DIFPA

GAMASTANPA

GAMMAGARD S/D LESS IGAPA

GAMMAGARDPA

GAMMAPLEXPA

GAMUNEX-CPA

HIZENTRAPA

HYPERRHO S/DHYQVIAPA

MICRHOGAM ULTRA-FILTEREDPLUSOCTAGAMPA

PANZYGAPA

PRIVIGENPA

RHOGAM ULTRA-FILTERED PLUSRHOPHYLACSYNAGISPA

WINRHO SDFXEMBIFYPA

ZINPLAVAPA, QL

PROGESTINS

MAKENAPA, QL

PSYCHOTHERAPEUTIC ANDNEUROLOGICAL AGENTS - MISC.

AMPYRAPA, QL

AUBAGIOPA, QL

AUSTEDOPA, QL

AVONEX PENPA, QL

AVONEX PREFILLEDPA, QL

AVONEXPA, QL

BAFIERTAMPA, QL

BETASERONPA, QL

dalfampridine erPA, QL

dimethyl fumarate starter packPA, QL

GILENYAPA, QL

glatiramer acetatePA, QL

glatopaPA, QL

INGREZZAPA, QL

KESIMPTAPA, QL

LEMTRADAPA, QL

MAVENCLAD (10 TABS)PA, QL







MAYZENT STARTER PACKPA

MAYZENTPA, QL

OCREVUSPA, QL

ONPATTROPA

PLEGRIDY STARTER PACKPA, QL

PLEGRIDYPA, QL

PONVORY STARTER PACKPA, QL

PONVORYPA, QL

REBIF REBIDOSE TITRATIONPACKPA, QL

REBIF REBIDOSEPA, QL

REBIF TITRATION PACKPA, QL

REBIFPA, QL

TEGSEDIPA

tetrabenazinePA, QL

TYSABRIPA, QL

VUMERITY (STARTER)PA, QL

VUMERITYPA, QL

VYLEESIPA, QL

XENAZINEQL

XYREMPA, QL

XYWAVPA, QL

ZEPOSIA 7-DAY STARTER PACKPA,

QL

ZEPOSIA STARTER KITPA, QL

ZEPOSIAPA, QL

ZINBRYTAPA

RESPIRATORY AGENTS - MISC.

ARALAST NPPA

BRONCHITOL TOLERANCE TESTPA,

QL

BRONCHITOLPA, QL

ESBRIETPA, QL

GLASSIAPA

KALYDECOPA, QL

OFEVPA, QL

ORKAMBIPA, QL

PROLASTIN-CPA

PULMOZYMEPA, QL

SYMDEKOPA, QL

TRIKAFTAPA, QL

ZEMAIRAPA

THYROID AGENTS

SODIUM IODIDE I-131PA

VASOPRESSORS

NORTHERAPA, QL

Products covered by a member’s prescription benefit plan may change from time to time. Preferred brand products are listed in UPPERCASE LETTERS, generic productsare listed in lower-cased italics, and other products listed are non-preferred. Specialty medications are covered based on member’s benefit plan design, regardless oftheir appearance on this document. Additionally, medications listed in this document may require prior authorization.PA = Prior Authorization RequiredST = Step Therapy RequiredQL = Quantity Level Required


2021 specialty drug list - welldynerx.adaptiverx.com

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