Mandatory Specialty Drug List - Premera Blue Cross
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Mandatory Specialty Drug List BRAND NAME GENERIC NAME ABIRATERONE ACETATE ABIRATERONE ACETATE ABRAXANE* PACLITAXEL PROTEIN‐BOUND ACTEMRA TOCILIZUMAB ACTEMRA* TOCILIZUMAB ACTEMRA ACTPEN TOCILIZUMAB ACTHAR CORTICOTROPIN ACTIMMUNE INTERFERON GAMMA‐1B,RECOMB. ADCETRIS* BRENTUXIMAB VEDOTIN ADEMPAS RIOCIGUAT ADYNOVATE* ANTIHEMO.FVIII,FULL LENGTH PEG AFINITOR EVEROLIMUS AFINITOR DISPERZ EVEROLIMUS AFSTYLA* ANTIHEM.FVIII,SIN‐CHN,B‐DM TRU ALDURAZYME* LARONIDASE ALECENSA ALECTINIB HCL ALPHANATE* ANTIHEMOPHILIC FACTOR/VWF ALPHANINE SD* FACTOR IX ALPROLIX* FACTOR IX REC, FC FUSION PROTN AMBRISENTAN AMBRISENTAN AMPYRA DALFAMPRIDINE APOKYN APOMORPHINE HCL ARALAST NP* ALPHA‐1‐PROTEINASE INHIBITOR ARANESP DARBEPOETIN ALFA IN POLYSORBAT ARCALYST RILONACEPT ARRANON* NELARABINE ARZERRA* OFATUMUMAB ASCENIV* IMMUNE GLOBULIN,GAMMA(IGG)SLRA AUBAGIO TERIFLUNOMIDE AUSTEDO DEUTETRABENAZINE AVASTIN* BEVACIZUMAB AVONEX INTERFERON BETA‐1A/ALBUMIN AVONEX INTERFERON BETA‐1A AVONEX PEN INTERFERON BETA‐1A AVSOLA* INFLIXIMAB‐AXXQ AZACITIDINE* AZACITIDINE BAFIERTAM MONOMETHYL FUMARATE BEBULIN* FACTOR IX CPLX(PCC)NO6,3FACTOR BELRAPZO* BENDAMUSTINE HCL Depending on your pharmacy plan, drugs on this list may be required to be filled only at preferred, in‐ network, specialty pharmacies. This may be because: • Distribution of the drug is restricted by the manufacturer • The drug requires patient education, provider coordination, or special handling Specialty pharmacies provide additional care beyond standard retail pharmacies. This includes access to specialized: • Pharmacists • Reimbursement experts • Patient advocates *Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization. Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Transcript of Mandatory Specialty Drug List - Premera Blue Cross
Mandatory Specialty Drug List
BRAND NAME GENERIC NAMEABIRATERONE ACETATE ABIRATERONE ACETATEABRAXANE* PACLITAXEL PROTEIN‐BOUNDACTEMRA TOCILIZUMABACTEMRA* TOCILIZUMABACTEMRA ACTPEN TOCILIZUMABACTHAR CORTICOTROPINACTIMMUNE INTERFERON GAMMA‐1B,RECOMB.ADCETRIS* BRENTUXIMAB VEDOTINADEMPAS RIOCIGUATADYNOVATE* ANTIHEMO.FVIII,FULL LENGTH PEGAFINITOR EVEROLIMUSAFINITOR DISPERZ EVEROLIMUSAFSTYLA* ANTIHEM.FVIII,SIN‐CHN,B‐DM TRUALDURAZYME* LARONIDASEALECENSA ALECTINIB HCLALPHANATE* ANTIHEMOPHILIC FACTOR/VWFALPHANINE SD* FACTOR IXALPROLIX* FACTOR IX REC, FC FUSION PROTNAMBRISENTAN AMBRISENTANAMPYRA DALFAMPRIDINEAPOKYN APOMORPHINE HCLARALAST NP* ALPHA‐1‐PROTEINASE INHIBITORARANESP DARBEPOETIN ALFA IN POLYSORBATARCALYST RILONACEPTARRANON* NELARABINEARZERRA* OFATUMUMABASCENIV* IMMUNE GLOBULIN,GAMMA(IGG)SLRAAUBAGIO TERIFLUNOMIDEAUSTEDO DEUTETRABENAZINEAVASTIN* BEVACIZUMABAVONEX INTERFERON BETA‐1A/ALBUMINAVONEX INTERFERON BETA‐1AAVONEX PEN INTERFERON BETA‐1AAVSOLA* INFLIXIMAB‐AXXQAZACITIDINE* AZACITIDINEBAFIERTAM MONOMETHYL FUMARATEBEBULIN* FACTOR IX CPLX(PCC)NO6,3FACTORBELRAPZO* BENDAMUSTINE HCL
Depending on your pharmacy plan, drugs on this list may be required to be filled only at preferred, in‐
network, specialty pharmacies.
This may be because:
• Distribution of the drug is restricted by the manufacturer
• The drug requires patient education, provider coordination, or special handling
Specialty pharmacies provide additional care beyond standard retail pharmacies. This includes access to
specialized:
• Pharmacists
• Reimbursement experts
• Patient advocates
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
BENDAMUSTINE HCL* BENDAMUSTINE HCLBENDEKA* BENDAMUSTINE HCLBENEFIX* FACTOR IX HUMAN RECOMBINANTBENLYSTA* BELIMUMABBENLYSTA* BELIMUMABBEOVU* BROLUCIZUMAB‐DBLLBERINERT* C1 ESTERASE INHIBITORBESPONSA* INOTUZUMAB OZOGAMICINBETASERON INTERFERON BETA‐1BBIVIGAM* IMMUN GLOB G(IGG)/GLY/IGA OV50BOSENTAN BOSENTANBOSULIF BOSUTINIBBRAFTOVI ENCORAFENIBBRONCHITOL MANNITOLCABOMETYX CABOZANTINIB S‐MALATECAPECITABINE CAPECITABINECARBAGLU CARGLUMIC ACIDCARGLUMIC ACID CARGLUMIC ACIDCAYSTON AZTREONAM LYSINECERDELGA ELIGLUSTAT TARTRATECEREZYME* IMIGLUCERASECETROTIDE CETRORELIX ACETATECHORIONIC GONADOTROPIN CHORIONIC GONADOTROPIN, HUMANCIMZIA CERTOLIZUMAB PEGOLCINRYZE* C1 ESTERASE INHIBITORCOPAXONE GLATIRAMER ACETATECORIFACT* FACTOR XIIICOSENTYX PEN SECUKINUMABCOSENTYX SYRINGE SECUKINUMABCOSENTYX PEN (2 PENS) SECUKINUMABCOSENTYX (2 SYRINGES) SECUKINUMABCOTELLIC COBIMETINIB FUMARATECRINONE PROGESTERONE, MICRONIZEDCRYSVITA* BUROSUMAB‐TWZACUTAQUIG* IMMUN GLOB G(IGG)‐HIPP/MALTOSECUVITRU* IMMUN GLOB G(IGG)/GLY/IGA OV50CYRAMZA* RAMUCIRUMABCYTOGAM* CYTOMEGALOVIRUS IMMUNE GLOBULNDACOGEN* DECITABINEDALFAMPRIDINE ER DALFAMPRIDINEDARZALEX* DARATUMUMABDARZALEX FASPRO* DARATUMUMAB‐HYALURONIDASE‐FIHJDAURISMO GLASDEGIB MALEATEDDAVP* DESMOPRESSIN ACETATEDECITABINE* DECITABINEDEFERASIROX DEFERASIROXDESMOPRESSIN ACETATE* DESMOPRESSIN ACETATEDIMETHYL FUMARATE DIMETHYL FUMARATEDOJOLVI TRIHEPTANOINDOPTELET AVATROMBOPAG MALEATEDROXIDOPA DROXIDOPADUOPA* CARBIDOPA/LEVODOPADUPIXENT SYRINGE DUPILUMAB
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
DUPIXENT PEN DUPILUMABDUROLANE* HYALURONATE SODIUM, STABILIZEDDURYSTA* BIMATOPROSTDYSPORT* ABOBOTULINUMTOXINAEGRIFTA* TESAMORELIN ACETATEEGRIFTA SV* TESAMORELIN ACETATEELAPRASE* IDURSULFASEELELYSO* TALIGLUCERASE ALFAELOCTATE* ANTIHEMOPH.FVIII REC,FC FUSIONEMFLAZA DEFLAZACORTEMPLICITI* ELOTUZUMABENBREL ETANERCEPTENBREL MINI ETANERCEPTENBREL SURECLICK ETANERCEPTENDARI GLUTAMINEENDOMETRIN PROGESTERONE, MICRONIZEDENHERTU* FAM‐TRASTUZUMAB DERUXTECN‐NXKIENSPRYNG SATRALIZUMAB‐MWGEENTYVIO* VEDOLIZUMABEPCLUSA SOFOSBUVIR/VELPATASVIREPIDIOLEX CANNABIDIOL (CBD)EPOGEN EPOETIN ALFAEPOPROSTENOL SODIUM* EPOPROSTENOL SODIUM (GLYCINE)EPOPROSTENOL SODIUM* EPOPROSTENOL SODIUMERBITUX* CETUXIMABERIVEDGE VISMODEGIBERLEADA APALUTAMIDEERLOTINIB HCL ERLOTINIB HCLESBRIET PIRFENIDONEESPEROCT* FVIII REC,B‐DOM TRUNC PEG‐EXEIEVENITY ROMOSOZUMAB‐AQQGEVENITY (2 SYRINGES) ROMOSOZUMAB‐AQQGEVEROLIMUS EVEROLIMUSEVRYSDI RISDIPLAMEXJADE DEFERASIROXEXTAVIA INTERFERON BETA‐1BEYLEA* AFLIBERCEPTFABRAZYME* AGALSIDASE BETAFARYDAK PANOBINOSTAT LACTATEFASENRA BENRALIZUMABFASENRA PEN BENRALIZUMABFEIBA NF* ANTI‐INHIBITOR COAGULANT COMP.FIRAZYR ICATIBANT ACETATEFIRMAGON* DEGARELIX ACETATEFLOLAN* EPOPROSTENOL SODIUM (GLYCINE)FOLLISTIM AQ FOLLITROPIN BETA,RECOMBFOLOTYN* PRALATREXATEFORTEO TERIPARATIDEGALAFOLD MIGALASTAT HCLGAMMAGARD LIQUID* IMMUN GLOB G(IGG)/GLY/IGA OV50GAMMAGARD S‐D* IMMUN GLOB G/GLY/GLUC/IGA 0‐50GAMMAKED* IMMUNE GLOBUL G/GLY/IGA AVG 46GAMMAPLEX* IMMUN GLOB G(IGG)/GLY/IGA 0‐50
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
GAMMAPLEX* IMMUN GLOB G/SORB/GLY/IGA 0‐50GAMUNEX‐C* IMMUNE GLOBUL G/GLY/IGA AVG 46GANIRELIX ACETATE GANIRELIX ACETATEGATTEX TEDUGLUTIDEGAVRETO PRALSETINIBGAZYVA* OBINUTUZUMABGEL‐ONE* HYALURONATE SOD, CROSS‐LINKEDGENOTROPIN SOMATROPINGILENYA FINGOLIMOD HCLGILOTRIF AFATINIB DIMALEATEGIVLAARI* GIVOSIRAN SODIUMGLASSIA* ALPHA‐1‐PROTEINASE INHIBITORGLATIRAMER ACETATE GLATIRAMER ACETATEGLATOPA GLATIRAMER ACETATEGLEEVEC IMATINIB MESYLATEGONAL‐F FOLLITROPIN ALFA, RECOMBINANTGONAL‐F RFF FOLLITROPIN ALFA, RECOMBINANTGONAL‐F RFF REDI‐JECT FOLLITROPIN ALFA, RECOMBINANTHAEGARDA C1 ESTERASE INHIBITORHALAVEN* ERIBULIN MESYLATEHARVONI LEDIPASVIR/SOFOSBUVIRHEMLIBRA EMICIZUMAB‐KXWHHERCEPTIN* TRASTUZUMABHERCEPTIN HYLECTA* TRASTUZUMAB‐HYALURONIDASE‐OYSKHERZUMA* TRASTUZUMAB‐PKRBHETLIOZ TASIMELTEONHETLIOZ LQ TASIMELTEONHIZENTRA* IMMUN GLOB G(IGG)/PRO/IGA 0‐50HUMATE‐P* ANTIHEMOPHILIC FACTOR/VWFHUMATROPE SOMATROPINHUMIRA ADALIMUMABHUMIRA PEDIATRIC CROHN'S ADALIMUMABHUMIRA PEN ADALIMUMABHUMIRA PEN CROHN'S‐UC‐HS ADALIMUMABHUMIRA PEN PSOR‐UVEITS‐ADOL HS ADALIMUMABHUMIRA(CF) ADALIMUMABHUMIRA(CF) PEDIATRIC CROHN'S ADALIMUMABHUMIRA(CF) PEN ADALIMUMABHUMIRA(CF) PEN CROHN'S‐UC‐HS ADALIMUMABHUMIRA(CF) PEN PEDIATRIC UC ADALIMUMABHUMIRA(CF) PEN PSOR‐UV‐ADOL HS ADALIMUMABHYCAMTIN TOPOTECAN HCLHYMOVIS* HYALURONATE,MOD.,NON‐CROSSLINKHYQVIA* IGG/HYALURONIDASE,RECOMBINANTIBRANCE PALBOCICLIBIDELVION* FACTOR IX RECOM,ALBUMIN FUSIONIDHIFA ENASIDENIB MESYLATEILARIS* CANAKINUMAB/PFILUMYA* TILDRAKIZUMAB‐ASMNILUVIEN* FLUOCINOLONE ACETONIDEIMATINIB MESYLATE IMATINIB MESYLATEIMFINZI* DURVALUMABINCRELEX MECASERMIN
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
INFLECTRA* INFLIXIMAB‐DYYBINFLIXIMAB* INFLIXIMABINLYTA AXITINIBINQOVI DECITABINE/CEDAZURIDINEINREBIC FEDRATINIB DIHYDROCHLORIDEINTRON A* INTERFERON ALFA‐2B,RECOMB.IRESSA GEFITINIBISTODAX* ROMIDEPSINIXEMPRA* IXABEPILONEIXINITY* FACTOR IX HUMAN RECOMB,THR 148JADENU DEFERASIROXJADENU SPRINKLE DEFERASIROXJAKAFI RUXOLITINIB PHOSPHATEJEMPERLI* DOSTARLIMAB‐GXLYJEVTANA* CABAZITAXELJIVI* FVIII REC,B‐DOM DELET PEG‐AUCLJUXTAPID LOMITAPIDE MESYLATEKADCYLA* ADO‐TRASTUZUMAB EMTANSINEKALBITOR* ECALLANTIDEKALYDECO IVACAFTORKANJINTI* TRASTUZUMAB‐ANNSKANUMA* SEBELIPASE ALFAKESIMPTA PEN OFATUMUMABKEVZARA SARILUMABKISQALI RIBOCICLIB SUCCINATEKISQALI FEMARA CO‐PACK RIBOCICLIB SUCCINATE/LETROZOLEKRYSTEXXA* PEGLOTICASEKUVAN SAPROPTERIN DIHYDROCHLORIDELAPATINIB LAPATINIB DITOSYLATELARTRUVO* OLARATUMABLEDIPASVIR‐SOFOSBUVIR LEDIPASVIR/SOFOSBUVIRLEMTRADA* ALEMTUZUMABLENVIMA LENVATINIB MESYLATELETAIRIS AMBRISENTANLONSURF TRIFLURIDINE/TIPIRACIL HCLLORBRENA LORLATINIBLUCENTIS* RANIBIZUMABLUMAKRAS SOTORASIBLUMIZYME* ALGLUCOSIDASE ALFALUPANETA PACK* LEUPROLIDE/NORETHINDRONE ACETLUXTURNA* VORETIGENE NEPARVOVEC‐RZYLLYNPARZA OLAPARIBMACRILEN MACIMORELIN ACETATEMACUGEN* PEGAPTANIB SODIUMMAVENCLAD CLADRIBINEMAVYRET GLECAPREVIR/PIBRENTASVIRMAYZENT SIPONIMODMEKINIST TRAMETINIB DIMETHYL SULFOXIDEMEKTOVI BINIMETINIBMENOPUR MENOTROPINSMEPSEVII* VESTRONIDASE ALFA‐VJBKMIGLUSTAT MIGLUSTATMITOXANTRONE HCL* MITOXANTRONE HCL
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
MODERIBA RIBAVIRINMONONINE* FACTOR IXMONOVISC* HYALURONATE SODIUM, STABILIZEDMOZOBIL* PLERIXAFORMULPLETA LUSUTROMBOPAGMVASI* BEVACIZUMAB‐AWWBMYALEPT METRELEPTINMYLOTARG* GEMTUZUMAB OZOGAMICINMYOBLOC* RIMABOTULINUMTOXINBNAGLAZYME* GALSULFASENATPARA PARATHYROID HORMONENERLYNX NERATINIB MALEATENEXAVAR SORAFENIB TOSYLATENEXPLANON* ETONOGESTRELNEXVIAZYME* AVALGLUCOSIDASE ALFA‐NGPTNINLARO IXAZOMIB CITRATENITISINONE NITISINONENITYR NITISINONENORDITROPIN FLEXPRO SOMATROPINNORTHERA DROXIDOPANOURIANZ ISTRADEFYLLINENOVAREL CHORIONIC GONADOTROPIN, HUMANNOVOEIGHT* ANTIHEMOPH.FVIII,B‐DOM TRUNCATNOVOSEVEN RT* COAGULATION FACTOR VIIA,RECOMBNPLATE* ROMIPLOSTIMNUBEQA DAROLUTAMIDENUCALA MEPOLIZUMABNUPLAZID PIMAVANSERIN TARTRATENUTROPIN AQ NUSPIN SOMATROPINNUWIQ* ANTIHEMOPH.FVIII,HEK B‐DELETEOCALIVA OBETICHOLIC ACIDOCREVUS* OCRELIZUMABOCTAGAM* IMMUN GLOBG(IGG)/MALT/IGA OV50ODOMZO SONIDEGIB PHOSPHATEOFEV NINTEDANIB ESYLATEOGIVRI* TRASTUZUMAB‐DKSTOLUMIANT BARICITINIBOMNITROPE SOMATROPINONUREG AZACITIDINEOPDIVO* NIVOLUMABOPSUMIT MACITENTANORENCIA ABATACEPTORENCIA* ABATACEPT/MALTOSEORENCIA CLICKJECT ABATACEPTORENITRAM ER TREPROSTINIL DIOLAMINEORKAMBI LUMACAFTOR/IVACAFTOROTEZLA APREMILASTOVIDREL CHORIOGONADOTROPIN ALFAOXBRYTA VOXELOTOROXERVATE CENEGERMIN‐BKBJOZURDEX* DEXAMETHASONEPADCEV* ENFORTUMAB VEDOTIN‐EJFVPALYNZIQ PEGVALIASE‐PQPZ
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
PEGASYS PEGINTERFERON ALFA‐2APEGASYS PROCLICK PEGINTERFERON ALFA‐2APEGINTRON PEGINTERFERON ALFA‐2BPERJETA* PERTUZUMABPHESGO* PERTUZUMAB‐TRASTUZUMAB‐HY‐ZZXFPIQRAY ALPELISIBPLEGRIDY PEN PEGINTERFERON BETA‐1APLEGRIDY PEGINTERFERON BETA‐1APOLIVY* POLATUZUMAB VEDOTIN‐PIIQPOMALYST POMALIDOMIDEPONVORY PONESIMODPORTRAZZA* NECITUMUMABPREGNYL CHORIONIC GONADOTROPIN, HUMANPRIVIGEN* IMMUN GLOB G(IGG)/PRO/IGA 0‐50PROCRIT EPOETIN ALFAPROCYSBI CYSTEAMINE BITARTRATEPROFILNINE* FACTOR IX CPLX(PCC)NO4,3FACTORPROGESTERONE* PROGESTERONEPROLEUKIN* ALDESLEUKINPROLIA DENOSUMABPROMACTA ELTROMBOPAG OLAMINEPULMOZYME DORNASE ALFARAVICTI GLYCEROL PHENYLBUTYRATEREBETOL RIBAVIRINREBIF INTERFERON BETA‐1A/ALBUMINREBIF REBIDOSE INTERFERON BETA‐1A/ALBUMINREBINYN* FACTOR IX HUMAN REC,PEGYLATEDRECOMBINATE* ANTIHEMOPHILIC FACTOR, HUM RECREMICADE* INFLIXIMABREMODULIN* TREPROSTINIL SODIUMRENFLEXIS* INFLIXIMAB‐ABDARETACRIT* EPOETIN ALFA‐EPBXRETEVMO SELPERCATINIBRETISERT* FLUOCINOLONE ACETONIDEREVATIO* SILDENAFIL CITRATEREVATIO SILDENAFIL CITRATEREVLIMID LENALIDOMIDERIABNI* RITUXIMAB‐ARRXRIASTAP* FIBRINOGENRIBASPHERE RIBAVIRINRIBASPHERE RIBAPAK RIBAVIRINRIBAVIRIN RIBAVIRINRINVOQ UPADACITINIBRITUXAN* RITUXIMABRITUXAN HYCELA* RITUXIMAB/HYALURONIDASE,HUMANRIXUBIS* FACTOR IX HUMAN RECOMBINANTROZLYTREK ENTRECTINIBRUBRACA RUCAPARIB CAMSYLATERUCONEST* C1 ESTERASE INHIBITOR, RECOMBRUXIENCE* RITUXIMAB‐PVVRRYBREVANT* AMIVANTAMAB‐VMJWRYDAPT MIDOSTAURINSABRIL VIGABATRIN
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
SAIZEN SOMATROPINSAIZEN‐SAIZENPREP SOMATROPINSAJAZIR ICATIBANT ACETATESAMSCA TOLVAPTANSANDOSTATIN LAR DEPOT* OCTREOTIDE ACETATE,MI‐SPHERESSAPROPTERIN DIHYDROCHLORIDE SAPROPTERIN DIHYDROCHLORIDESCEMBLIX ASCIMINIB HYDROCHLORIDESEROSTIM SOMATROPINSEVENFACT* COAGULATION VIIA,RECOMB‐JNCWSILIQ BRODALUMABSIMPONI GOLIMUMABSIMPONI ARIA* GOLIMUMABSKYRIZI (2 SYRINGES) KIT RISANKIZUMAB‐RZAASKYRIZI PEN RISANKIZUMAB‐RZAASKYRIZI RISANKIZUMAB‐RZAASOFOSBUVIR‐VELPATASVIR SOFOSBUVIR/VELPATASVIRSOLIRIS* ECULIZUMABSOMATULINE DEPOT* LANREOTIDE ACETATESOMAVERT PEGVISOMANTSOVALDI SOFOSBUVIRSPINRAZA* NUSINERSEN SODIUM/PFSPRYCEL DASATINIBSTELARA* USTEKINUMABSTELARA USTEKINUMABSTIMATE DESMOPRESSIN ACETATESTIVARGA REGORAFENIBSUNITINIB MALATE SUNITINIB MALATESUPPRELIN LA* HISTRELIN ACETATESUTENT SUNITINIB MALATESYLVANT* SILTUXIMABSYMDEKO TEZACAFTOR/IVACAFTORSYNAGIS* PALIVIZUMABSYNVISC* HYLAN G‐F 20SYNVISC‐ONE* HYLAN G‐F 20TABRECTA CAPMATINIB HYDROCHLORIDETAFINLAR DABRAFENIB MESYLATETAGRISSO OSIMERTINIB MESYLATETAKHZYRO LANADELUMAB‐FLYOTALTZ AUTOINJECTOR (2 PACK) IXEKIZUMABTALTZ AUTOINJECTOR (3 PACK) IXEKIZUMABTALTZ AUTOINJECTOR IXEKIZUMABTALTZ SYRINGE IXEKIZUMABTALZENNA TALAZOPARIB TOSYLATETARCEVA ERLOTINIB HCLTASIGNA NILOTINIB HCLTECENTRIQ* ATEZOLIZUMABTECFIDERA DIMETHYL FUMARATETEGSEDI INOTERSEN SODIUMTEMODAR TEMOZOLOMIDETEMODAR* TEMOZOLOMIDETEMOZOLOMIDE TEMOZOLOMIDETEMSIROLIMUS* TEMSIROLIMUSTEPEZZA* TEPROTUMUMAB‐TRBW
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
TERIPARATIDE TERIPARATIDETETRABENAZINE TETRABENAZINETHALOMID THALIDOMIDETHYROGEN* THYROTROPIN ALFATIOPRONIN TIOPRONINTOLVAPTAN TOLVAPTANTORISEL* TEMSIROLIMUSTRACLEER BOSENTANTRAZIMERA* TRASTUZUMAB‐QYYPTREANDA* BENDAMUSTINE HCLTREMFYA GUSELKUMABTREPROSTINIL* TREPROSTINIL SODIUMTRETTEN* FACTOR XIII A‐SUBUNIT,RECOMBTRIKAFTA ELEXACAFTOR/TEZACAFTOR/IVACAFTTRUXIMA* RITUXIMAB‐ABBSTYKERB LAPATINIB DITOSYLATETYMLOS ABALOPARATIDETYSABRI* NATALIZUMABTYVASO TREPROSTINILTYVASO REFILL KIT TREPROSTINIL/NEB ACCESSORIESTYVASO STARTER KIT TREPROSTINIL/NEBULIZER/ACCESORTYVASO INSTITUTIONAL START KIT TREPROSTINIL/NEBULIZER/ACCESORULTOMIRIS* RAVULIZUMAB‐CWVZUPLIZNA* INEBILIZUMAB‐CDONUPTRAVI SELEXIPAGUPTRAVI* SELEXIPAGVALCHLOR MECHLORETHAMINE HCLVANTAS* HISTRELIN ACETATEVECTIBIX* PANITUMUMABVELCADE* BORTEZOMIBVELETRI* EPOPROSTENOL SODIUMVENTAVIS ILOPROST TROMETHAMINEVERZENIO ABEMACICLIBVIDAZA* AZACITIDINEVIGABATRIN VIGABATRINVIMIZIM* ELOSULFASE ALFAVISUDYNE* VERTEPORFINVITRAKVI LAROTRECTINIB SULFATEVIZIMPRO DACOMITINIBVONVENDI* VON WILLEBRAND FACTORVOSEVI SOFOSBUVIR/VELPATAS/VOXILAPREVVOTRIENT PAZOPANIB HCLVPRIV* VELAGLUCERASE ALFAVUMERITY DIROXIMEL FUMARATEVYNDAMAX TAFAMIDISVYNDAQEL TAFAMIDIS MEGLUMINEWAKIX PITOLISANT HCLWILATE* ANTIHEMOPHILIC FACTOR/VWFXALKORI CRIZOTINIBXELJANZ TOFACITINIB CITRATEXELJANZ XR TOFACITINIB CITRATEXELODA CAPECITABINEXEMBIFY* IMMUNE GLOBULIN,GAMMA(IGG)KLHW
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally coveredunder the medical benefit, not the pharmacy benefit. They may also require prior authorization.
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association
017542 (02-17-2022)
Mandatory Specialty Drug ListBRAND NAME GENERIC NAME
XENAZINE TETRABENAZINEXEOMIN* INCOBOTULINUMTOXINAXGEVA* DENOSUMABXOLAIR* OMALIZUMABXTANDI ENZALUTAMIDEXYNTHA* ANTIHEMOPH.FVIII,B‐DOMAIN DELXYNTHA SOLOFUSE* ANTIHEMOPH.FVIII,B‐DOMAIN DELYERVOY* IPILIMUMABYONSA ABIRATERONE ACET,SUBMICRONIZEDZALTRAP* ZIV‐AFLIBERCEPTZAVESCA MIGLUSTATZELBORAF VEMURAFENIBZEMAIRA* ALPHA‐1‐PROTEINASE INHIBITORZEPATIER ELBASVIR/GRAZOPREVIRZEPOSIA OZANIMOD HYDROCHLORIDEZIRABEV* BEVACIZUMAB‐BVZRZOLADEX* GOSERELIN ACETATEZOLGENSMA* ONASEMNOGENE ABEPARVOVEC‐XIOIZOLINZA VORINOSTATZOMACTON SOMATROPINZORBTIVE SOMATROPINZYDELIG IDELALISIBZYKADIA CERITINIBZYTIGA ABIRATERONE ACETATE
*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization. Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association
017542 (02-17-2022)
037398 (07-01-2021) An independent licensee of the Blue Cross Blue Shield Association
Discrimination is Against the Law
Premera Blue Cross Blue Shield of Alaska (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free: 855-332-4535, Fax: 425-918-5592, TTY: 711, Email [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Language Assistance
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УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки.
Телефонуйте за номером 800-508-4722 (телетайп: 711).
เรยีน: ถา้คณุพดูภาษาไทยคณุสามารถใชบ้รกิารช่วยเหลือทางภาษาไดฟ้ร ี โทร 800-508-4722 (TTY: 711).
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.(711: والبكم الصم هاتف رقم ) 800-508-4722 برقم اتصل. بالمجان لك تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا: ملحوظة
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-508-4722 (TTY: 711).
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-508-4722 (ATS : 711).
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ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 800-508-4722 (TTY: 711).
.د یر یبگ تماس 508-800-(TTY: 711) 4722 با. باشد ی م فراهم شما ی برا گان یرا بصورت ی زبان لات یتسه د،یکن یم گفتگو فارسی زبان به اگر: توجه
