Specialty Drug List

F = Formulary PA = Prior Authorization QL = Quantity Limit

ST = Step Therapy AL = Age Limit V01.01.2019

1

Drug Tier Status Notes

Antimalarials

Daraprim Specialty PA

Glycopeptide Antibiotics

vancomycin intravenous recon soln 1,000 mg, 10

gram, 5 gram, 500 mg, 750 mg

Specialty

Antineoplastic - CYP17 (17 Alpha-Hydroxylase/C17, 20-Lyase) Inhibitor

Yonsa Specialty PA

Zytiga Specialty PA; QL

Antineoplastic - Alkylating Agent - Triazenes

temozolomide Specialty PA

Antineoplastic - Antimetabolites - Pyrimidine Analog Combinations

Lonsurf Specialty PA

Antineoplastic - Epipodophyllotoxins

etoposide oral Specialty PA

Antineoplastic - Estrogens

Emcyt Specialty PA

Antineoplastic - Hedgehog Pathway Inhibitor

Erivedge Specialty PA; QL

Odomzo Specialty PA

Antineoplastic - Histone Deacetylase (HDAC) Inhibitors

Farydak Specialty PA

Zolinza Specialty PA

Antineoplastic - Interferons

Intron A injection Specialty PA

Antineoplastic - Janus Kinase (JAK) Inhibitors

Jakafi Specialty PA; QL

Antineoplastic - mTOR Kinase Inhibitors

Afinitor Disperz Specialty PA; QL

Afinitor oral tablet 10 mg, 2.5 mg, 5 mg Specialty PA; QL

Afinitor oral tablet 7.5 mg Specialty PA

F = Formulary PA = Prior Authorization QL = Quantity Limit

ST = Step Therapy AL = Age Limit V01.01.2019

2

Drug Tier Status Notes

Antineoplastic - Mutant Isocitrate Dehydrogenase 1 (mIDH1) Inhibitors

Tibsovo Specialty PA

Antineoplastic - Mutant Isocitrate Dehydrogenase 2 (mIDH2) Inhibitors

Idhifa Specialty PA

Antineoplastic - Retinoids

tretinoin (chemotherapy) Specialty PA

Antineoplastic - Selective Retinoid X Receptor Agonists

Targretin oral Specialty

Antineoplastic - Thalidomide Analogs

Revlimid oral capsule 10 mg, 15 mg, 25 mg, 5 mg Specialty PA; QL

Revlimid oral capsule 2.5 mg, 20 mg Specialty PA

Antineoplastic - Topoisomerase I Inhibitors

Hycamtin oral Specialty PA

Adempas Specialty PA; QL

Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists

Letairis Specialty PA; QL

Tracleer oral tablet Specialty PA; QL

Tracleer oral tablet for suspension Specialty PA; AL

Minerals And Electrolytes - Magnesium

magnesium sulfate injection Specialty

Androgen - Single Agents

testosterone cypionate Specialty

Insulin-Like Growth Factor-1 (IGF-1)

Increlex Specialty PA

Somatostatic Agents

octreotide acetate injection solution 1,000

mcg/mL, 100 mcg/mL, 200 mcg/mL, 50 mcg/mL

Specialty PA

Multiple Sclerosis Agents

Multiple Sclerosis Agent - Interferons

Avonex (with albumin) Specialty PA; QL

F = Formulary PA = Prior Authorization QL = Quantity Limit

ST = Step Therapy AL = Age Limit V01.01.2019

3

Drug Tier Status Notes

Avonex intramuscular pen injector kit Specialty PA; QL

Avonex intramuscular syringe kit Specialty PA; QL

Multiple Sclerosis Agent - Others

glatiramer Specialty PA; QL

Glatopa subcutaneous syringe 20 mg/mL Specialty PA; QL

Tecfidera Specialty PA; QL

Multiple Sclerosis Agent - Potassium Channel Blocker

Ampyra Specialty PA

Multiple Sclerosis Agent - Sphingosine 1-Phosphate Receptor Modulator

Gilenya oral capsule 0.5 mg Specialty PA; QL

Cystic Fibrosis - Inhaled Aminoglycosides

Bethkis Specialty PA

Kitabis Pak Specialty

Tobi Podhaler Specialty PA

tobramycin in 0.225 % NaCl Specialty PA

tobramycin with nebulizer Specialty PA

Cystic Fibrosis - Inhaled Monobactams

Cayston Specialty PA

Mucolytics

Pulmozyme Specialty PA; QL

4

Index

A Adempas ................................. 2

Afinitor ................................... 1

Afinitor Disperz...................... 1

Ampyra ................................... 3

Avonex ................................... 3

Avonex (with albumin) .......... 2

B Bethkis .................................... 3

C Cayston ................................... 3

D Daraprim................................. 1

E Emcyt ..................................... 1

Erivedge ................................. 1

etoposide................................. 1

F Farydak ................................... 1

G Gilenya ................................... 3

glatiramer ............................... 3

Glatopa ................................... 3

H Hycamtin ................................ 2

I Idhifa ...................................... 2

Increlex ................................... 2

Intron A .................................. 1

J Jakafi ...................................... 1

K Kitabis Pak ............................. 3

L Letairis .................................... 2

Lonsurf ................................... 1

M magnesium sulfate .................. 2

O octreotide acetate .................... 2

Odomzo .................................. 1

P Pulmozyme ............................. 3

R Revlimid ................................. 2

T Targretin ................................. 2

Tecfidera ................................. 3

temozolomide ......................... 1

testosterone cypionate ............ 2

Tibsovo ................................... 2

Tobi Podhaler ......................... 3

tobramycin in 0.225 % NaCl .. 3

tobramycin with nebulizer ...... 3

Tracleer ................................... 2

tretinoin (chemotherapy) ........ 2

V vancomycin ............................. 1

Y Yonsa ...................................... 1

Z Zolinza .................................... 1

Zytiga ...................................... 1