Specialty medication list - Moda Health · Specialty medication list An evidence-based pharmacy...
Transcript of Specialty medication list - Moda Health · Specialty medication list An evidence-based pharmacy...
Specialty medication list
An evidence-based pharmacy
program that works for you
All specialty medications, including those listed below, require prior authorization before
they can be dispensed.
Prior authorization (PA) is the process a member follows to obtain approval from Moda
Health before we can process payment for a specific medication. To request PA for your
specialty medication, please contact our Pharmacy Customer Service and we’ll work directly
with your healthcare provider to complete this process. If you do not have the required
authorization, we may deny payment for your medication.
For a complete list of drugs that require authorization log in to your myModa account at
modahealth.com (after your effective date of coverage). Or, call us toll free at 800-913-4311.
Please note that we update this list as new medications enter the market and it is subject to
change. You must access specialty medications through the exclusive specialty pharmacy. To
enroll with Ardon Health Specialty Pharmacy, call toll free at 855-425-4085.
2018.2 (4/2/2018).
For prior effective dates, please contact Moda Health. 2 modahealth.com
Brand Name Dosage
Abilify Maintena Suser Vial
Abilify Maintena Suser Syr
Actemra Vial
Actemra Syringe
Actimmune Vial
Adefovir Dipivoxil Tablet
Adempas Tablet
Advate Vial
Adynovate Vial
Afinitor Tablet
Afinitor Disperz Tab Susp
Afstyla Vial
Alecensa Capsule
Alferon N Vial
Alimta Vial
Alkeran Tablet
Alphanate Vial
Alphanine SD Vial
Alprolix Vial
Alunbrig Tab Ds Pk
Alunbrig Tablet
Amicar Solution
Amicar (1000 mg) Tablet
Aminocaproic Acid Vial
Ampyra Tab ER 12h
Amvisc Syringe
Amvisc Plus Syringe
Anzemet Tablet
Anzemet Vial
Apokyn Cartridge
Aralast NP Vial
Aranesp Vial
Aranesp Syringe
Arcalyst Vial
Aristada Suser Syr
Atryn Vial
Aubagio Tablet
Austedo Tablet
Aveed Vial
Avelox IV Piggyback
Avonex Kit
Avonex Syringekit
Avonex Syringe
Brand Name Dosage
Avonex Pen Pen Injctr
Avonex Pen Pen Ij Kit
Azactam Vial
Aztreonam Vial
Baraclude Tablet
Baraclude Solution
Bebulin Vial
Benefix Kit
Benlysta Auto Injct
Benlysta Syringe
Benlysta Vial
Berinert Kit
Berinert Vial
Betaseron Vial
Betaseron Kit
Bethkis Ampul-Neb
Bexarotene Capsule
Bosulif Tablet
Botox Vial
Brevibloc IV Soln
Brevibloc Vial
Buphenyl Powder
Buphenyl Tablet
Bupivacaine HCl Els Pmp Fr
Cabometyx Tablet
Calcium Gluconate-0.9% Nacl Plast. Bag
Calquence Capsule
Camptosar Vial
Capecitabine Tablet
Caprelsa Tablet
Carbaglu Tab Disper
Carboplatin Vial
Carimune Nf Nanofiltered Vial
Caverject Vial
Caverject Kit
Cayston Vial-Neb
Cefazolin Sodium-Dextrose Piggyback
Cefazolin Sodium-Dextrose Froz.Piggy
Ceftazidime Piggyback
Ceprotin Vial
Cerdelga Capsule
Cerezyme Vial
Chenodal Tablet
2018.2 (4/2/2018).
For prior effective dates, please contact Moda Health. 3 modahealth.com
Brand Name Dosage
Cholbam Capsule
Chorionic Gonadotropin Vial
Cimzia Kit
Cimzia Syringekit
Cinryze Vial
Coagadex Vial
Cometriq (100 mg/day And 140 mg/day) Capsule
Copaxone Syringe
Copegus Tablet
Corifact Kit
Cosentyx (2 Syringes) Syringe
Cosentyx Pen Pen Injctr
Cosentyx Pen (2 Pens) Pen Injctr
Cosentyx Syringe Syringe
Cotellic Tablet
Cuvitru Vial
Cyclophosphamide Vial
Cyklokapron Vial
Cystadane Powder
Cystagon Capsule
Cystaran Drops
Cytarabine Vial
Daklinza Tablet
Ddavp Ampul
Ddavp Vial
Desmopressin Acetate Ampul
Desmopressin Acetate Vial
Dexamethasone-0.9% Nacl Piggyback
Dexrazoxane Vial
Dilaudid-Hp Vial
Diphenhydramine-0.9% Nacl Piggyback
Docefrez Vial
Docetaxel Vial
Dupixent Syringe
Dysport Vial
Edex Kit
Eligard Syringe
Elitek Vial
Ellence Vial
Eloctate Vial
Emcyt Capsule
Emend Vial
Emflaza Tablet
Brand Name Dosage
Enbrel Cartridge
Enbrel Vial
Enbrel Syringe
Enbrel Pen Injctr
Entecavir Tablet
Epclusa Tablet
Epinephrine-D5w Plast. Bag
Epirubicin HCl Vial
Epivir HBV Tablet
Epivir HBV Solution
Epogen Vial
Erivedge Capsule
Esbriet Capsule
Esbriet Tablet
Esmolol HCl Vial
Etoposide Capsule
Exjade Tab Disper
Extavia Vial
Extavia Kit
Fabrazyme Vial
Fareston Tablet
Farydak Capsule
Feiba Nf Vial
Fentanyl Citrate Vial
Fentanyl Citrate Plast. Bag
Fentanyl Citrate Pca Syring
Fentanyl Citrate Syringe
Fentanyl Citrate Ampul
Fentanyl Citrate-0.9% Nacl Plast. Bag
Fentanyl Citrate-0.9% Nacl Syringe
Fentanyl Citrate-0.9% Nacl Vial
Fentanyl Citrate-0.9% Nacl Pca Syring
Fentanyl Citrate-0.9% Nacl Pump Resvr
Fentanyl Citrate-D5w Pca Syring
Fentanyl Citrate-D5w Plast. Bag
Fentanyl-Bupivacaine-0.9% Nacl Plast. Bag
Fentanyl-Bupivacaine-0.9% Nacl Pump Resvr
Fentanyl-Ropivacaine-0.9% Nacl Plast. Bag
Fentanyl-Ropivacaine-0.9% Nacl Pump Resvr
Ferriprox Tablet
Ferriprox Solution
Firazyr Syringe
Firmagon Vial
2018.2 (4/2/2018).
For prior effective dates, please contact Moda Health. 4 modahealth.com
Brand Name Dosage
Fludarabine Phosphate Vial
Folotyn Vial
Forteo Pen Injctr
Fuzeon Vial
Gablofen Vial
Gamastan S-D Vial
Gammagard S-D Vial
Gammaked Vial
Gamunex-C Vial
Gattex Kit
Gemcitabine HCl Vial
Gemzar Vial
Genotropin Cartridge
Genotropin Syringe
Geodon Vial
Gilenya Capsule
Gilotrif Tablet
Glassia Vial
Glatiramer Acetate Syringe
Glatopa Syringe
Gleevec Tablet
Gleostine Capsule
Glycopyrrolate Syringe
Granisetron HCl Tablet
Granisetron HCl Vial
Granix Syringe
H.P. Acthar Vial
Haegarda Vial
Haldol Decanoate 100 Ampul
Haldol Decanoate 50 Ampul
Haloperidol Decanoate Vial
Haloperidol Decanoate Ampul
Haloperidol Decanoate 100 Ampul
Haloperidol Lactate Vial
Harvoni Tablet
Healon5 Syringe
Helixate FS Vial
Hemlibra Vial
Hemofil M Vial
Heparin Flush Kit
Heparin Sodium-0.9% Nacl IV Soln
Hepsera Tablet
Hetlioz Capsule
Brand Name Dosage
Hexalen Capsule
Hizentra Vial
Humate-P Vial
Humatrope Vial
Humatrope Cartridge
Humira Syringekit
Humira Pediatric Crohn's Syringekit
Humira Pen Pen Ij Kit
Humira Pen Crohn-UC-HS Starter Pen Ij Kit
Humira Pen Psoriasis-Uveitis Pen Ij Kit
Hycamtin Vial
Hycamtin Capsule
Hydromorph-Bupivac-0.9% Nacl Pump Resvr
Hydromorphone HCl Vial
Hydromorphone HCl-0.9% Nacl Pca Syring
Hydromorphone HCl-0.9% Nacl Pca Vial
Hydromorphone HCl-0.9% Nacl Plast. Bag
Hydromorphone HCl-D5w Pca Syring
Hydroxyprogesterone Caproate Vial
Hyqvia Vial
Hyqvia Hy Component Vial
Hyqvia Ig Component Vial
Ibrance Capsule
Iclusig Tablet
Idelvion Vial
Idhifa Tablet
Ifex Vial
Ifosfamide Vial
Imatinib Mesylate Tablet
Imbruvica Capsule
Imbruvica Tablet
Imipenem-Cilastatin Sodium Vial
Impavido Capsule
Increlex Vial
Ingrezza Capsule
Inlyta Tablet
Intron A Vial
Invega Sustenna Syringe
Iressa Tablet
Irinotecan HCl Vial
Ixempra Vial
Ixinity Vial
Jadenu Tablet
2018.2 (4/2/2018).
For prior effective dates, please contact Moda Health. 5 modahealth.com
Brand Name Dosage
Jadenu Sprinkle Gran Pack
Jakafi Tablet
Juxtapid Capsule
Kalydeco Tablet
Kalydeco Gran Pack
Keveyis Tablet
Kevzara Syringe
Kineret Syringe
Kisqali Tablet
Koate Vial
Koate-Dvi Vial
Kogenate FS Vial
Korlym Tablet
Kovaltry Vial
Kuvan Tablet Sol
Kuvan Powd Pack
Kynamro Syringe
Lamivudine (100mg) Tablet
Lamivudine HBV Tablet
Lenvima Capsule
Letairis Tablet
Leukeran Tablet
Leukine Vial
Leuprolide Acetate Vial
Leuprolide Acetate Kit
Levaquin Piggyback
Levetiracetam-Nacl Piggyback
Levofloxacin-D5w Piggyback
Levophed Bitartrate Vial
Levothyroxine Sodium Vial
Lidocaine HCl Syringe
Lidocaine HCl Vial
Lidocaine HCl Ampul
Lioresal Intrathecal Ampul
Lomustine Capsule
Lonsurf Tablet
Lucentis Vial
Lupaneta Pack Kt Syr Tab
Lupron Depot Syringekit
Lupron Depot (Lupaneta) Syringekit
Lupron Depot-Ped Kit
Lupron Depot-Ped Syringekit
Lynparza Capsule
Brand Name Dosage
Magnesium Sulfate-0.9% Nacl Piggyback
Makena Auto Injt
Makena Vial
Matulane Capsule
Mavyret Tablet
Mekinist Tablet
Melphalan Tablet
Meperidine HCl-0.9% Nacl Pca Syring
Meropenem Vial
Merrem Vial
Mesna Vial
Mesnex Vial
Mesnex Tablet
Methadone HCl Vial
Methoxsalen (NDC 68682-0065-10) Cap Lq Rap
Mircera Syringe
Mitomycin Vial
Moderiba Tablet
Moderiba Tab Ds Pk
Monoclate-P Vial
Mononine Vial
Morphine Sulfate Cartridge
Morphine Sulfate-0.9% Nacl Pca Syring
Morphine Sulfate-0.9% Nacl Plast. Bag
Morphine Sulfate-0.9% Nacl Syringe
Morphine Sulfate-0.9% Nacl Pump Resvr
Morphine Sulfate-0.9% Nacl Pca Vial
Myalept Vial
Myleran Tablet
Myobloc Vial
Natpara Cartridge
Neostigmine Methylsulfate Vial
Nerlynx Tablet
Neulasta Syringe
Neulasta Syr W/ Inj
Neumega Vial
Neupogen Syringe
Neupogen Vial
Nexavar Tablet
Nexplanon Implant
Nexterone Plast. Bag
Nilandron Tablet
Nilutamide Tablet
2018.2 (4/2/2018).
For prior effective dates, please contact Moda Health. 6 modahealth.com
Brand Name Dosage
Ninlaro Capsule
Nityr Tablet
Norditropin Flexpro Pen Injctr
Norditropin Nordiflex Pen Injctr
Norepinephrine Bitar-0.9% Nacl Plast. Bag
Norepinephrine Bitartrate Vial
Northera Capsule
Novarel Vial
Novoeight Vial
Novoseven Rt Vial
Nplate Vial
Nuplazid Tablet
Nutropin AQ Cartridge
Nutropin AQ Nuspin Pen Injctr
Nuwiq Vial
Obizur Vial
Ocaliva Tablet
Octagam Vial
Octreotide Acetate Vial
Octreotide Acetate Ampul
Octreotide Acetate Syringe
Odomzo Capsule
Ofev Capsule
Olanzapine Vial
Olysio Capsule
Omnitrope Cartridge
Omnitrope Vial
Ondansetron HCl Vial
Ondansetron HCl Syringe
Opsumit Tablet
Orencia Syringe
Orencia Clickject Auto Injct
Orenitram ER Tablet ER
Orfadin Oral Susp
Orfadin (2 mg, 5 mg And 10 mg) Capsule
Orkambi Tablet
Otezla Tab Ds Pk
Otezla Tablet
Oxaliplatin Vial
Pamidronate Disodium Vial
Pegasys Vial
Pegasys Syringe
Pegasys Proclick Pen Injctr
Brand Name Dosage
Pegintron Kit
Pegintron Redipen Pen Ij Kit
Phenylephrine HCl-0.9% Nacl Plast. Bag
Piperacillin-Tazobactam Vial Port
Piperacillin-Tazobactam Vial
Plegridy Syringe
Plegridy Pen Pen Injctr
Pomalyst Capsule
Potassium Phosphate-0.9% Nacl Plast. Bag
Praluent Pen Pen Injctr
Praluent Syringe Syringe
Pregnyl Vial
Prevymis
Prialt Vial
Primaxin Vial
Primaxin Vial Port
Procrit Vial
Procysbi Cap Dr Spr
Profilnine Vial
Prolastin C Vial
Prolia Syringe
Promacta Tablet
Pulmozyme Solution
Ravicti Liquid
Rebetol Capsule
Rebetol Solution
Rebif Syringe
Rebif Rebidose Pen Injctr
Rebinyn Vial
Recombinate Vial
Relistor Tablet
Relistor Vial
Relistor Syringe
Remodulin Vial
Repatha Pushtronex Wear Injct
Repatha Sureclick Pen Injctr
Repatha Syringe Syringe
Revlimid Capsule
Ribasphere Capsule
Ribasphere Tablet
Ribasphere Ribapak Tab Ds Pk
Ribatab Tab Ds Pk
Ribavirin Tablet
2018.2 (4/2/2018).
For prior effective dates, please contact Moda Health. 7 modahealth.com
Brand Name Dosage
Ribavirin Capsule
Rilutek Tablet
Riluzole Tablet
Risperdal Consta Syringe
Rixubis Vial
Ropivacaine HCl Els Pmp Hr
Ropivacaine HCl Els Pmp Lr
Ropivacaine HCl Syringe
Ropivacaine HCl-0.9% Nacl Pump Resvr
Ropivacaine HCl-0.9% Nacl Els Pmp Hr
Ropivacaine HCl-0.9% Nacl Plast. Bag
Rubraca Tablet
Ruconest Vial
Rydapt Capsule
Sabril Tablet
Sabril Powd Pack
Saizen Vial
Saizen Cartridge
Saizen-Saizenprep Cartridge
Sancuso Patch Tdwk
Sandostatin Ampul
Sandostatin Vial
Sandostatin Lar Kit
Sandostatin Lar Depot Vial
Serostim Vial
Signifor Ampul
Siliq Syringe
Simponi Syringe
Simponi Pen Injctr
Simulect Vial
Sirturo Tablet
Sodium Phenylbutyrate Powder
Sodium Phenylbutyrate Tablet
Soltamox Solution
Somatuline Depot Syringe
Somavert Vial
Sovaldi Tablet
Sprycel Tablet
Stelara Vial
Stelara Syringe
Stivarga Tablet
Strensiq Vial
Sutent Capsule
Brand Name Dosage
Sylatron Kit
Synagis Vial
Synarel Spray
Synribo Vial
Tabloid Tablet
Tafinlar Capsule
Tagrisso Tablet
Taltz Autoinjector Auto Injct
Taltz Autoinjector (2 Pack) Auto Injct
Taltz Autoinjector (3 Pack) Auto Injct
Taltz Syringe Syringe
Taltz Syringe (2 Pack) Syringe
Taltz Syringe (3 Pack) Syringe
Tarceva Tablet
Targretin Gel (Gram)
Targretin Capsule
Tasigna Capsule
Taxotere Vial
Tecfidera Capsule Dr
Technivie Tablet
Temodar Capsule
Temozolomide Capsule
Tetrabenazine Tablet
Thalomid Capsule
Thrombate Iii Vial
Tobi Podhaler Capsule
Tobi Podhaler Cap W/Dev
Topotecan HCl Vial
Tracleer Tablet
Tracleer Tab Susp
Tranexamic Acid Vial
Treanda Vial
Trelstar Syringe
Trelstar Vial
Tremfya Syringe
Tretten Vial
Tykerb Tablet
Tymlos Pen Injctr
Tyvaso Ampul-Neb
Tyvaso Institutional Start Kit Ampul-Neb
Tyvaso Refill Kit Ampul-Neb
Tyvaso Starter Kit Ampul-Neb
Uptravi Tablet
2018.2 (4/2/2018).
For prior effective dates, please contact Moda Health. 8 modahealth.com
Brand Name Dosage
Uptravi Tab Ds Pk
Valchlor Gel (Gram)
Vecamyl (NDC 45043-0558-40) Tablet
Vemlidy Tablet
Venclexta Tablet
Venclexta Starting Pack Tab Ds Pk
Ventavis Ampul-Neb
Verzenio Tablet
Vibativ Vial
Viekira Pak Tab Ds Pk
Viekira XR Tab Bp 24h
Vinblastine Sulfate Vial
Vinorelbine Tartrate Vial
Vistogard Gran Pack
Vivitrol Sus ER Rec
Vonvendi Vial
Vosevi Tablet
Votrient Tablet
Wilate Vial
Xalkori Capsule
Xeljanz Tablet
Xeljanz XR Tab ER 24h
Xeloda Tablet
Xenazine Tablet
Xermelo Tablet
Xgeva Vial
Xolair Vial
Xtandi Capsule
Xuriden Gran Pack
Brand Name Dosage
Xylocaine Vial
Xylocaine IV Ampul
Xylocaine-Mpf Vial
Xyntha Vial
Xyntha Solofuse Syringe
Xyrem Solution
Yervoy Vial
Zaltrap Vial
Zarxio Syringe
Zavesca Capsule
Zejula Capsule
Zelboraf Tablet
Zemaira Vial
Zepatier Tablet
Zinbryta Syringe
Zinecard Vial
Zoladex Implant
Zolinza Capsule
Zolpimist Spray/Pump
Zomacton Vial
Zometa Pggybk Btl
Zorbtive Vial
Zortress Tablet
Zosyn Vial
Zydelig Tablet
Zykadia Capsule
Zyprexa Vial
Zyprexa Relprevv Vial
Zytiga Tablet
This document is provided for informational purposes only, and is intended as a quick reference. For cost and further
details of the coverage, including exclusions, any reduction or limitations and the terms under which the policy may be
continued in force, contact your producer or Moda Health.
Copyright © 2014 Moda, Inc. All Rights Reserved. Health plans in Oregon, Alaska and Washington provided by Moda Health Plan, Inc. Health plans in California provided by Moda Health Plan, Inc. dba Moda
Health Insurance.
Effective 1/2/2013. For prior effective dates, please contact Moda Health.
Effective 1/2/2013. For prior effective dates, please contact Moda Health.