US Specialty Specialty Drug List 2020 · v usspecialtycare.com ©2020. us specialty, powered by...

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ACROMEGALY SANDOSTATIN LARPA QL

SOMATULINE DEPOT‡ PA QL

SOMAVERT‡ PA

octreotidePA (SANDOSTATIN)

ADRENAL GLAND DISORDERS KORLYM* PA QL

SIGNIFORPA QL

SIGNIFOR LARPA QL

ALCOHOL/OPIOID DEPENDENCE VIVITROLPA

ALLERGIC ASTHMA CINQAIR‡ PA

FASENRA‡ PA

NUCALA‡ PA

XOLAIR‡ PA

ALPHA-1 ANTITRYPSIN DEFICIENCY ARALAST NP‡ PA

GLASSIA‡ PA

PROLASTIN-C‡ PA

ZEMAIRA‡ PA

AMYLOIDOSIS ONPATTRO‡ PA QL

VYNDAMAX* PA QL

VYNDAQEL* PA QL

ANALGESIC/PAIN PRIALT clonidine injectable (DURACLON)

ANEMIA ARANESPPA

EPOGENPA

MIRCERAPA

PROCRITPA

RETACRITPA

ANTI-INFECTIVES ARIKAYCE‡ PA QL

ANTIDOTES ANDEXXABRIDIONPA

VISTOGARD‡ PA QL

XURIDEN* PA QL

ANTIPARASITICS IMPAVIDOPA QL

ZINPLAVAPA QL

ATOPIC DERMATITIS DUPIXENT‡ PA QL

ANTICOAGULANTS THROMBATE III

BLOOD DISORDERS HEMLIBRA‡ PA

JIVI‡ PA

SOLIRIS‡ PA

BOTULINUM TOXINS BOTOXPA

DYSPORT* PA

MYOBLOCPA

XEOMIN‡ PA

CARDIAC DISORDERS dofetilide (TIKOSYN)

CHOREA - HUNTINGTON'S DISEASE AUSTEDO‡ PA QL

COAGULATION DISORDERS CEPROTIN‡

US Specialty Specialty Drug List 2020

Therapy Class Brand Name Generic Name


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US Specialty - Specialty Drug List 2020US Specialty - Specialty Drug List 2020

CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES

ARCALYST‡ PA

ILARIS‡ PA

KINERET* PA

CYSTIC FIBROSIS BETHKIS‡ PA QL

CAYSTON‡ PA QL

KALYDECO‡ PA QL

KITABIS PAK‡ PA QL

ORKAMBI‡ PA QL

PULMOZYME‡ PA QL

SYMDEKO* PA QL

TRIKAFTA* PA QL

TOBI PODHALER‡ PA QL

colistimethate (COLY-MYCIN M)tobramycin nebulizer ‡ PA QL (TOBI NEBULIZER)

CYSTINE-DEPLETING AGENTS CYSTAGON‡ PA

CYSTARAN* PA QL

PROCYSBI* PA

DUCHENNE MUSCULAR DYSTROPHY (DMD)

EMFLAZA* PA

EXONDYS 51* PA

ELECTROLYTE DISORDERS SAMSCA‡ PA QL

ENZYME DISORDERS ADAGEN* PA

BRINEURAPA QL

CARBAGLU* PA

KANUMA‡ PA

MEPSEVII* PA

NITYR* PA

ORFADIN‡ PA

STRENSIQ‡ PA

nitisinone (ORFADIN)

FECAL INCONTINENCE SOLESTA‡ PA

GASTROINTESTINAL DISORDERS - OTHER

CHOLBAM‡ PA

GATTEX‡ PA

XERAVAPA QL

GOUT KRYSTEXXA‡ PA

GROWTH HORMONE & RELATED DISORDERS

GENOTROPINPA

HUMATROPEPA

INCRELEX‡ PA

MACRILEN‡ PA QL

NORDITROPINPA

NUTROPIN AQPA

NUTROPIN NUSPINPA

OMNITROPEPA

SAIZENPA

SEROSTIM‡ PA

ZOMACTONPA

ZORBTIVEPA

HEMATOPOIETICS MOZOBIL‡ PA QL

HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED BLEEDING DISORDERS

ADVATE‡

ADYNOVATE*AFSTYLA*



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ALPHANATE/VON WILLEBRAND*ALPHANINE SD*ALPROLIX*BEBULIN*BENEFIX*COAGADEX‡

CORIFACT‡

ELOCTATE*FEIBA*HELIXATE FS*HEMOFIL M*HUMATE-P*IDELVION*IXINITY*KCENTRA*KOATE*KOATE-DVI*KOGENATE FS*KOVALTRY*MONOCLATE-P*MONONINE*NOVOEIGHT‡

NOVOSEVEN RT*NUWIQ*OBIZUR‡

PROFILNINE SD*REBINYN‡

RECOMBINATE*RIASTAP‡

RIXUBIS*STIMATETRETTEN‡

VONVENDI‡

WILATE*XYNTHA*

HEPATITIS BARACLUDE SOLNPA QL

DAKLINZAPA QL

EPCLUSAPA QL

HARVONIPA QL

INTRON-A‡ PA

MAVYRETPA QL

OLYSIOPA QL

PEGASYSPA QL

PEG-INTRONPA QL

REBETOL SOLNPA QL

RIBAPAKPA QL

RIBASPHEREPA QL

RIBATABPA QL

adefovir PA QL (HEPSERA)entecavir PA QL (BARACLUDE)lamivudineQL (EPIVIR HBV)ribavirin caps PA QL (REBETOL)ribavirin tabsPA QL (COPEGUS, MODERIBA)tenofovir DF QL (VIREAD)



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HEPATITIS (continued) SOVALDIPA QL

TECHNIVIEPA QL

VEMLIDYPA QL

TYZEKAPA QL

VIEKIRA PAK/VIEKIRA XRPA QL

VOSEVIPA QL

ZEPATIERPA QL

HEREDITARY ANGIOEDEMA BERINERT‡ PA

CINRYZE‡ PA

FIRAZYR‡ PA

HAEGARDA‡ PA

KALBITOR‡ PA

RUCONEST‡ PA

TAKHZYRO‡ PA QL

icatibant acetate‡ (FIRAZYR)

HIV/AIDS APTIVUSQL

ATRIPLAQL

BIKTARVYQL

CIMDUOQL

COMPLERAQL

CRIXIVANQL

DELSTRIGOQL

DESCOVYQL

DOVATOPA QL

EDURANTQL

EGRIFTA‡ PA QL

EMTRIVAQL

EVOTAZQL

FUZEONPA QL

GENVOYAQL

INTELENCEQL

INVIRASEQL

ISENTRESSQL

ISENTRESS HDQL

JULUCAQL

KALETRAQL

LEXIVAQL

ODEFSEYQL

PIFELTROQL

PREZCOBIXQL

PREZISTAQL

RESCRIPTORQL

RETROVIR INJECTABLEQL

SELZENTRYQL

STRIBILDQL

SYMFI LOQL

SYMFIQL

SYMTUZAQL

TIVICAYQL

abacavirQL (ZIAGEN)abacavir-lamivudineQL (EPZICOM)abacavir-lamivudine-zidovudineQL (TRIZIVIR)atazanavirQL (REYATAZ)didanosine QL (VIDEX, VIDEX EC)efavirenzQL (SUSTIVA)fosamprenavir QL (LEXIVA)lamivudineQL (EPIVIR)lamivudine-zidovudineQL (COMBIVIR)lopinavir-ritonavir solnQL (KALETRA)nevirapineQL (VIRAMUNE, VIRAMUNE XR)ritonavirQL (NORVIR) stavudineQL (ZERIT)tenofovir DF QL (VIREAD)zidovudineQL (RETROVIR)



(Continued)


HIV/AIDS (continued) TRIUMEQQL

TROGARZO‡ PA QL

TRUVADAQL

TYBOSTQL

VIDEX SOLUTIONQL

VIRACEPTQL

HORMONAL THERAPIES ELIGARDPA QL

FIRMAGONPA QL

LUPANETA PACKPA QL

LUPRON DEPOTPA QL

ORILISSAPA QL

NATPARA‡ PA QL

SUPPRELIN LA‡ PA QL

SYNARELPA

TRIPTODUR‡ PA QL

TRELSTARPA QL

VANTASPA QL

ZOLADEXPA QL

leuprolide acetatePA (Lupron)

IMMUNE DEFICIENCIES & RELATED DISORDERS

BIVIGAM‡ PA

CARIMUNE NFPA

CUTAQUIG* PA

CUVITRU‡ PA

CYTOGAMFLEBOGAMMA‡ PA

GAMASTAN S/D‡ PA

GAMMAGARD LIQUID‡ PA

GAMMAGARD S/D‡ PA

GAMMAKEDPA

GAMMAPLEX‡ PA

GAMUNEX CPA

HIZENTRA‡ PA

HYPERRHO S/DHYQVIA‡ PA

MICRHOGAMOCTAGAMPA

PANZYGAPA

PRIVIGENPA

RHOGAMRHOPHYLICWINRHO SDFXEMBIFYPA

ACQUIRED THROMBOTIC AND IMMUNE (IDIOPATHIC) THROMBOCYTOPENIA PURPURA

CABLIVI‡ PA QL

DOPTELET‡ PA QL

MULPLETAPA QL

NPLATE‡ PA

PROMACTA‡ PA QL

TAVALISSE‡ PA QL

INFECTIOUS DISEASE ACTIMMUNE‡

ALFERON N*PREVYMISPA QL



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INFERTILITY BRAVELLECETROTIDEPA

CHORIONIC GONADOTROPINFOLLISTIM AQGONAL-F, GONAL-F RFFMENOPURNOVARELOVIDRELPA

PREGNYL

ganirelix acetatePA

INFLAMMATORY BOWEL DISEASE CIMZIAPA QL

ENTYVIO‡ PA QL

HUMIRAPA

INFLECTRAPA

REMICADEPA

RENFLEXISPA

SIMPONIPA

STELARAPA QL

TYSABRI‡ PA QL

IRON OVERLOAD EXJADE‡ PA

FERRIPROX‡ PA

JADENU‡ PA

deferasiroxPA (EXJADE) deferoxaminePA (DESFERAL)

LIPID DISORDERS JUXTAPID* PA QL

KYNAMRO‡ PA QL

PRALUENT‡ PA QL

REPATHAPA QL

LIPODYSTROPHY MYALEPT* PA

LIPOSOMAL STORAGE DISORDERS ALDURAZYME‡ PA

CERDELGA‡ PA QL

CEREZYME‡ PA

ELAPRASE‡ PA

ELELYSO* PA

FABRAZYME‡ PA

GALAFOLD* PA QL

LUMIZYME‡ PA

NAGLAZYME‡ PA

VIMIZIM‡ PA

VPRIV‡ PA

miglustat* PA QL (ZAVESCA)

MENTAL HEALTH CONDITIONS SPRAVATO* PA QL

ZULRESSO* PA

MIGRAINE AGENTS AIMOVIGPA QL

AJOVYPA QL

EMGALITYPA QL

MISCELLANEOUS CHENODAL‡

CRYSVITA‡ PA

DEFITELIOPA

DEXTENZAPA

FIRDAPSE‡ PA QL



(Continued)


MISCELLANEOUS (continued) GAMIFANT* PA

HCGHETLIOZ‡ PA QL

JETREA* QL

KEPIVANCEKEVEYIS‡ PA QL

OCALIVA‡ PA QL

ONPATTRO* PA QL

OXERVATE* PA QL

PHOTREXA*REVCOVI* PA

RUZURGI* PA QL

SYLVANT‡ PA

VYLEESI* PA QL

XIAFLEX‡ PA

YUTIQ* PA

MOVEMENT DISORDERS APOKYN‡ PA QL

DUOPA*GABLOFENINBRIJA‡ PA QL

INGREZZA‡ PA QL

LIORESAL INTRATHECALNORTHERA‡ PA QL

NUPLAZID‡ PA QL

RADICAVA* PA

SPINRAZA* PA

TIGLUTIK‡ PA QL

tetrabenazine‡ PA QL (XENAZINE)riluzole‡ PA QL (RILUTEK)

MULTIPLE SCLEROSIS AUBAGIOPA QL

AVONEX‡ PA QL

BETASERONPA QL

EXTAVIAPA QL

GILENYAPA QL

LEMTRADA‡ PA QL

MAVENCLAD* PA QL

MAYZENT* PA QL

OCREVUS‡ PA QL

PLEGRIDY‡ PA QL

REBIFPA QL

TECFIDERA‡ PA QL

TYSABRI‡ PA QL

dalfampridine ER‡ PA QL (AMPYRA)glatiramer acetatePA QL (COPAXONE)mitoxantronePA (NOVANTRONE)

NARCOLEPSY XYREM‡ PA QL

NARCOTIC ANTAGONISTS PROBUPHINE IMPLANT* PA QL

SUBLOCADE* PA QL

NEUTROPENIA GRANIXPA

FULPHILAPA QL

LEUKINEPA QL

NEULASTAPA QL



(Continued)


NEUTROPENIA (continued) NEUPOGENPA

NIVESTYMPA

UDENYCAPA

ZARXIOPA

ONCOLOGY - INJECTABLE ADCETRIS‡ PA

ALIMTAALIQOPA* PA QL

ARRANONARZERRA‡ PA

AVASTIN‡ PA

AZEDRABAVENCIO‡ PA

BELEODAQ‡

BENDEKA‡ PA

BESPONSAPA QL

BLINCYTO* PA

CAMPATH* PA

CYRAMZA‡ PA

DARZALEX‡ PA

ELZONRISPA

EMPLICITI‡ PA

ERBITUXPA

ERWINAZE*EVOMELA‡ PA

FASLODEXFOLOTYNGAZYVA‡ PA

GLIADEL WAFERHALAVENPA

HERCEPTIN‡ PA

HERCEPTIN HYLECTA‡ PA

IMFINZI‡ PA

IMLYGICPA

INFUGEMINTRON-A‡ PA

ISTODAX‡ PA

IXEMPRAJEVTANA‡ PA

KADCYLA‡ PA

KANJINTI‡

KEYTRUDA‡ PA

KHAPZORYKYMRIAH* PA QL

KYPROLIS‡ PA

LARTRUVO* PA

LIBTAYO‡ PA QL

LUMOXITI‡ PA QL MITOMYCINMUSTARGEN

amifostine (ETHYOL)arsenic trioxide (TRISENOX)azacitidinePA (VIDAZA)bleomycin (BLEO)busulfan (BUSULFEX) carboplatincarmustine (BICNU)cisplatincladribineclofarabine (CLOLAR)cyclophosphamidecytarabine (DEPOCYT)dacarbazinedactinomycin (COSMEGEN)daunorubicin decitabine* PA (DACOGEN)docetaxel (DOCEFREZ, TAXOTERE)doxorubicin (ADRIAMYCIN)doxorubicin liposomal (DOXIL)epirubicin (ELLENCE)etoposide (ETOPOPHOS)floxuridinefludarabinefluorouracil (ADRUCIL)fulvestrant (FASLODEX)idarubicin (GEMZAR)idarubicin (IDAMYCIN)ifosfamide (IFEX)irinotecan (CAMPTOSAR)levoleucovorin (FUSILEV)melphalanPA (ALKERAN)mesna (MESNEX)mitoxantronePA (ALKERAN)oxaliplatinpaclitaxel (ABRAXANE)pamidronate (AREDIA)temsirolimusPA

topotecan‡ (HYCAMTIN)valrubicin (VALSTAR)vinblastinevincristine (MARQIBO, VINCASAR)vinorelbine (NAVELBINE)zoledronic acidPA (ZOMETA)



(Continued)


ONCOLOGY - INJECTABLE (continued) MVASI‡ PA QL

MYLOTARG‡ PA

ONCASPAR*ONIVYDE‡

OPDIVO‡ PA

PERJETA‡ PA

PHOTOFRINPA

POLIVY‡ PA

PORTRAZZA* PA

POTELIGEO‡ PA

PROLEUKINPROVENGE* PA

RITUXAN‡ PA

RITUXAN HYCLEA‡ PA

SYLATRON‡ PA

SYNRIBOPA

TECENTRIQ‡ PA QL

TEMODARTENIPOSIDETEPADINATHERACYSTHYROGEN‡ PA

TICE BCGTORISELPA

TREANDATRISENOXUNITUXINUVADEXVALSTARVECTIBIXPA

VELCADEPA

VYXEOSPA

XGEVAPA

XOFIGO* PA QL

YERVOY‡ PA

YESCARTA* PA

YONDELIS‡ PA

ZALTRAP‡ PA

ZANOSARZOLGENSMAPA QL

ONCOLOGY - ORAL/TOPICAL AFINITOR‡ PA QL

ALECENSA‡ PA QL

ALUNBRIG‡ PA QL

BALVERSA‡ PA QL

BOSULIF‡ PA QL

BRAFTOVI* PA QL

CABOMETYX‡ PA QL

CALQUENCE‡ PA QL

abiraterone 250 mgPA QL (ZYTIGA)bexarotenePA (TARGRETIN)capecitabinePA (XELODA)cyclophosphamideerlotinibPA QL (TARCEVA)imatinib mesylatePA QL (GLEEVEC)temozolomidePA (TEMODAR)



(Continued)


ONCOLOGY - ORAL/TOPICAL CAPRELSA‡ PA QL

COMETRIQ* PA QL

COPIKTRA‡ PA QL

COTELLIC‡ PA QL

DAURISMO‡ PA QL EMCYTERIVEDGE‡ PA QL

ERLEADA‡ PA QL

FARYDAK‡ PA QL

GLEOSTINEPA QL

GILOTRIF* PA QL

HYCAMTIN‡ PA

IBRANCE‡ PA QL

ICLUSIG‡ PA QL

IDHIFA‡ PA QL

IMBRUVICA‡ PA QL

INLYTA‡ PA QL

INREBIC* PA QL

IRESSA‡ PA QL

JAKAFI‡ PA QL

KISQALIPA QL

KISQALI FEMARA CO-PACKPA QL

LENVIMA‡ PA QL

LORBRENA‡ PA QL

LONSURF‡ PA

LYNPARZA‡ PA QL

LYSODRENPA QL

MATULANE‡ PA

MEKINIST‡ PA QL

MEKTOVI* PA QL

MYLERANPA

NERLYNX‡ PA QL

NEXAVAR‡ PA QL

NINLARO‡ PA QL

NUBEQA* PA QL

ODOMZO‡ PA QL

PIQRAY‡ PA QL

POMALYST ‡ PA QL

PURIXAN ‡

REVLIMID‡ PA QL

ROZLYTREK‡ PA QL

RUBRACA‡ PA QL

RYDAPT PA QL

SPRYCELPA QL

STIVARGA‡ PA QL

SUTENT ‡ PA QL

TABLOID‡

TAFINLAR‡ PA QL

TAGRISSO‡ PA QL



(Continued)


ONCOLOGY - ORAL/TOPICAL (continued)

TALZENNA* PA QL

TARCEVA‡ PA QL

TARGRETINPA

TASIGNAPA QL

THALOMID‡ PA

TIBSOVO‡ PA QL

TURALIOPA QL

TYKERB‡ PA

VALCHLOR‡ PA

VENCLEXTA‡ PA QL

VERZENIO‡ PA QL

VITRAKVI‡ PA QL

VIZIMPRO‡ PA QL

VOTRIENT‡ PA QL

XALKORI‡ PA QL

XERMELO‡ PA QL

XOSPATA‡ PA QL

XPOVIOPA QL

XTANDI‡ PA QL

YONSA‡ PA QL

ZEJULA‡ PA QL

ZELBORAF‡ PA QL

ZOLINZAPA QL

ZYDELIG‡ PA QL

ZYKADIA‡ PA QL

ZYTIGA‡ PA QL

OSTEOARTHRITIS DUROLANEPA QL

EUFLEXXAPA QL

GEL-ONEPA QL

GELSYN-3‡ PA QL

GENVISC 850‡ PA QL

HYALGANPA QL

HYMOVIS‡ PA QL

MONOVISCPA QL

ORTHOVISCPA QL

SUPARTZPA QL

SYNVISCPA QL

SYNVISC ONEPA QL

VISCO-3PA QL

OSTEOPOROSIS EVENITYPA QL

FORTEOPA QL

PROLIAPA QL

TYMLOSPA QL

intravenous ibandronatePA QL (BONIVA)zoledronic acidPA QL (RECLAST)

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA

SOLIRIS‡ PA

ULTOMIRISPA QL

PHENYLKETONURIA KUVAN‡ PA

PALYNZIQ‡ PA

PRE-TERM BIRTH MAKENA‡ PA QL hydroxyprogesterone caproate



(Continued)


PSORIASIS COSENTYX‡ PA

ENBRELPA QL

HUMIRAPA

ILUMYAPA QL

INFLECTRAPA

OTEZLA‡ PA QL

OTREXUPPA QL

RASUVOPA QL

REMICADEPA

RENFLEXIS‡ PA

SILIQ‡ PA QL

SKYRIZIPA QL

STELARAPA QL

TALTZ‡ PA QL

TREMFYAPA QL

PSORIATIC ARTHRITIS COSENTYX‡ PA

ENBRELPA QL

HUMIRAPA

INFLECTRAPA

OTEZLAPA QL

ORENCIAPA QL

REMICADEPA

RENFLEXISPA

SIMPONIPA

STELARAPA QL

TALTZ‡ PA QL

PULMONARY ARTERIAL HYPERTENSION

ADEMPAS‡ PA QL

OPSUMIT‡ PA QL

ORENITRAM‡ PA QL

TYVASO‡ PA

UPTRAVI‡ PA QL

VENTAVIS‡ PA QL

ambrisentan‡ PA (LETAIRIS)bosentan‡ PA (TRACLEER)epoprostenol ‡ PA (FLOLAN, VELETRI)sildenafil citratePA QL (REVATIO)tadalafilPA QL (ADCIRCA)treprostinil‡ (REMODULIN)

PULMONARY DISORDERS - OTHER ESBRIET‡ PA QL

OFEV‡ PA QL

RENAL DISEASE CUPRIMINEPA

JYNARQUE‡ PA

PARSABIV‡ PA

THIOLA‡

THIOLA EC‡ PA

ZEMDRIPA QL

cinacaletPA( SENSIPAR)penicillamine (CUPRIMINE)

RESPIRATORY SYNCYTIAL VIRUS SYNAGIS‡ PA QL

VIRAZOLEPA

RETINAL DISORDERS AMVISCPA

DEXYCUPA QL

EYLEA‡ PA

HEALONPA

ILUVIEN‡ PA




RETINAL DISORDERS (CONTINUED) LUCENTIS‡ PA

LUXTURNA* PA QL

MACUGEN‡ PA QL

OZURDEX‡ QL

PROVISCPA

RETISERT‡ PA

VISUDYNE‡ PA

RHEUMATOID ARTHRITIS ACTEMRA‡ PA

CIMZIAPA QL

ENBRELPA QL

HUMIRAPA

INFLECTRAPA

KEVZARA‡ PA QL

KINERET* PA

OLUMIANTPA QL

ORENCIAPA QL

OTREXUPPA QL

RASUVOPA QL

REMICADEPA

RENFLEXISPA

RINVOQPA QL

RITUXAN‡ PA

SIMPONIPA

SIMPONI ARIAPA

XELJANZ, XELJANZ XRPA QL

SEIZURE DISORDERS DIACOMIT‡ PA QL

EPIDIOLEX‡ PA

H.P. ACTHAR GEL‡ PA

SABRIL‡ PA QL

vigabatrin pak‡ PA QL (SABRIL)vigadrone‡ PA QL (SABRIL)

SICKLE CELL DISEASE ENDARI‡ PA QL

SYSTEMIC LUPUS ERYTHEMATOSUS BENLYSTA‡ PA

TRANSPLANT NULOJIX‡

UREA CYCLE DISORDERS RAVICTI‡ PA QL sodium phenylbutrate‡ PA (BUPHENYL)

WILSON'S DISEASE CUPRIMINEPA trientinePA QL (SYPRINE)

Products covered by a member’s prescription benefit plan may change from time to time. Specialty medications are covered based on member’s benefit plan design, regardless of their appearance on this document. Please consult your plan documents for specific information. Brand name medications are listed in all CAPS and generic products in lowercase italics.

‡ Indicates Limited Distribution products that are dispensed by US Specialty Pharmacy or one of its specialty pharmacy partners.

* Indicates Limited Distribution products that are not dispensed by US Specialty Pharmacy or one of its specialty pharmacy partners.

Bolded products may have a percentage copay, in accordance with your plan documents.

PA = Prior Authorization Required QL = Quantity Level Limit


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