Horizon Blue Cross Blue Shield of New Jersey

Horizon Blue Cross Blue Shield of New Jersey
Specialty Pharmacy Drug Management List
Definition of specialty medications: Specialty medications are generally prescribed for people with complex or ongoing medical conditions
such as multiple sclerosis, hemophilia, hepatitis C and rheumatoid arthritis. These high cost medications also have one or more of the
following characteristics: injected or infused, but some may be taken by mouth; unique storage or shipment requirements; additional
education and support required from a health care professional; and usually not stocked at retail pharmacies.
Autoimmune
ACTEMRA SC
ARCALYST
1,2
1
ENBREL
HUMIRA
1,2
KINERET
2
OTEZLA
STELARA
1,2
XELJANZ
1,2
TEMODAR
temozolomide
1,2
1,2
LEUKINE
1,2
NEULASTA
1,2
NEUMEGA
1,2
XELODA
1,2
ZORBTIVE
INCIVEK
1,2
INFERGEN
1,2
ZYDELIG
1,2
INTRON-A
1
ZYKADIA
1,2
MODERIBA
2
Cystic Fibrosis
TRELSTAR DEPOT / LA / MIX
2
2
BETHKIS
CAYSTON
BOSULIF
1,2
capecitabine
ERIVEDGE
1,2
1,2
ETOPOSIDE
GILOTRIF
GLEEVEC
1,2
HEXALEN
ICLUSIG
1
TOBI
TOBI PODHALER
tobramycin
1
BUPHENYL
CARBAGLU
1
CERDELGA
1,2
1,2
KUVAN
1
1
1,2
ORFADIN
JAKAFI
1,2
PROCYSBI
MATULANE
2
Enzyme Deficiencies
INLYTA
LYSODREN
2
RAVICTI
1,2
sodium phenylbutyrate
AVONEX
2
GILENYA
1,2
1
drug categories may require MND.
If MND is required, it is important
that you or your doctor initiate a
2
start your review, please have your
doctor fax 1-877-243-6930.
1,2
ADCIRCA
1,2
for certain drugs to ensure that
LETAIRIS
1,2
2
they are prescribed and dispensed
1,2
within the proper safety standards
OPSUMIT
1
for dosage and/or the length of
ORENITRAM
1,2
time you use the drug. These
1,2
REVATIO
2
sildenafil citrate
SOVALDI
1,2
1,2
TRACLEER
standards are established from a
2
number of sources, such as Food
and Drug Administration product
labeling, medical literature,
dispensing patterns and generally
accepted standards of medical
practice. If your specialty
medication prescription requires
you to exceed the dispensing
limit, you will be notified. You or
your doctor can request an
exception.
Others
EGRIFTA
1,2
FUZEON
2
ACTIMMUNE
APOKYN
2
ELIGARD
2
1,2
1,2
Immunosuppressants
EXJADE
ASTAGRAF XL
FIRAZYR
1,2
CELLCEPT
FORTEO
1,2
cyclosporine
KYNAMRO
GENGRAF
leuprolide acetate
HECORIA
LUPANETA
mycophenolate mofetil
Dispensing Limits Apply -
Horizon BCBSNJ monitors claims
1,2
1,2
2
1,2
RIBAPAK
VICTRELIS
review as soon as possible. To
2
1,2
TECFIDERA
Medical Necessity Determination
(MND) Required - Select drugs or
2
ADEMPAS
HIV
Key
2
2
EXTAVIA
1,2
ribavirin
2
CYSTAGON
1,2
IMBRUVICA
PULMOZYME
1,2
2
REBETOL
RIBATAB
2
2
1,2
HYCAMTIN
1,2
PEG-INTRON
RIBASPHERE
1,2
KALYDECO
Cancer – Oral
AFINITOR / DISPERZ
2
1,2
Pulmonary Hypertension
1,2
PEGASYS
SYPRINE2
VALCHLOR 1
REBIF REBIDOSE
OLYSIO
1,2
2
2
Multiple Sclerosis
REBIF
1,2
SOMAVERT
ZORTRESS
PLEGRIDY
1,2
1,2
Cancer– Injectable
1,2
1,2
2
1
SOMATULINE DEPOT
TACROLIMUS
COPAXONE
1,2
HARVONI
1,2
SIGNIFOR
SANDIMMUNE
BETASERON
Hepatitis C
ZOLINZA
ZYTIGA
SYLATRON
1,2
1,2
SANDOSTATIN / LAR
RAPAMUNE
AUBAGIO
1,2
COPEGUS
ZELBORAF
1,2
PROMACTA
1,2
1,2
1,2
1,2
SEROSTIM
SAMSCA
PROGRAF
AMPYRA
TEV-TROPIN
1,2
XALKORI
XTANDI
1,2
PROCRIT
1,2
VOTRIENT
1,2
NEUPOGEN
1,2
1
TYKERB
1,2
1,2
SAIZEN
SABRIL
sirolimus
1,2
OMNITROPE
1,2
THALOMID
HUMATROPE
NUTROPIN / AQ
1,2
TASIGNA
1,2
1,2
NORDITROPIN
TARGRETIN
1,2
GENOTROPIN
INCRELEX
1,2
TARCEVA
Blood Modifiers
EPOGEN
1,2
2
1,2
NEORAL
Growth Hormones
1,2
octreotide acetate
MYFORTIC
2
ZAVESCA
1,2
TAFINLAR
SIMPONI ARIA
ARANESP
1,2
1,2
SUTENT
1,2
XENAZINE
NORTHERA
mycophenolic acid dr
1,2
1,2
STIVARGA
1,2
SUCRAID
1,2
SPRYCEL
1,2
SIMPONI
NEXAVAR
REVLIMID
1,2
ORENCIA
1,2
1,2
POMALYST
1,2
CIMZIA
MEKINIST
1,2
2
LUPRON DEPOT / PED
HorizonBlue.com
2
This list is subject to change without notice.
This document contains prescription brand name drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with Horizon BCBSNJ or the Blue Cross and Blue
Shield Association. The list of drugs subject to Prior Authorization or Quantity Limits is subject to change. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and
Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name, symbols and Making
Healthcare Work®are registered marks of Horizon Blue Cross Blue Shield of New Jersey.
4220-A NJ © Prime Therapeutics LLC 11/1/14 Prime Therapeutics LLC is an independent company providing pharmacy benefit management and specialty pharmacy services for Blue Cross Blue Shield of New Jersey
members. Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC.