MHBP QL & PA Drug List

Specialty Drug List
Specialty drugs may require prior authorization and may need to be obtained from the
CVS/caremark Specialty Pharmacy. Contact CaremarkConnect toll-free at 1-800-237-2767
for Specialty Pharmacy service.
For Your Information: This is a summary of specialty medications for MHBP. It does not guarantee coverage. Listed products are for informational
purposes only and are not intended to replace the clinical judgment of the prescriber. Due to the large number of available medicines, this list may
not be all inclusive and may change without notice. Dispensing Limits, Specialty Pharmacy dispensing and/or Prior Authorization requirements
apply to all brand and generic equivalents listed below. Products distributed and therapies covered by CVS/caremark may change or expand from
time to time. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical
manufacturers not affiliated with CVS/caremark.
In addition, a plan member’s specific benefit plan design may not cover certain products or categories, regardless of their appearance on this
document. The member’s prescription benefit plan may have a different copay or coinsurance for products on the list. Before making a final
decision, please read the 2015 official Plan brochure, RI 71-007 (Standard Option and Value Plan) or RI 71-016 (Consumer Option). All benefits are
subject to the definitions, limitations, and exclusions set forth in the 2015 official Plan brochure.
Medications listed may be FDA (Food & Drug Administration) approved for more than one indication. Please check with your prescriber regarding
specific questions for your indication.
Generic products are listed in lowercase italics.
┼
Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
∞ Step Therapy, also referred to as Specialty Preferred Drug Step Therapy, is a program through the prescription benefit that encourages use of
clinically appropriate and lowest net-cost specialty medications within select therapeutic categories.
* Specialty Medication through the pharmacy benefit must be obtained through CVS/caremark Specialty Pharmacy. If you are a plan member or
health care provider, please contact CaremarkConnect® toll-free at 1-800-237-2767 or visit www.cvscaremarkspecialtyrx.com.
§ Medication not covered under medical benefit. Contact CVS/caremark for pharmacy benefits. This program, also referred to as Medical Benefit
Management, provides consistent quality by moving select specialty drugs to the pharmacy benefit for dispensing and clinical management.
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
√
Medication not
covered under
§
medical benefit
√
abacavir
NO
Abraxane
YES ‡
Actemra
YES
┼
Acthar Gel
YES
┼
√
√
Actimmune
YES
┼
√
√
Revised 01/06/2015
‡
Step
Therapy ∞
√
√
Page 1 of 16
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Adagen
YES
┼
‡
Adcetris
YES
┼
‡
Adcirca
YES
┼
adefovir
NO
Adempas
YES
Adriamycin PFS
YES ‡
Adriamycin RDF
YES ‡
Advate
YES
Afinitor
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
√
√
√
√
√
√
┼
√
√
YES
┼
√
√
Aldurazyme
YES
┼
‡
Alferon-N
YES
┼
‡
Alimta
YES ‡
Alphanate
YES
┼
√
√
Alphanine SD
YES
┼
√
√
Alprolix
YES
┼
√
√
Amevive
YES
┼
Ampyra
YES
┼
√
√
Apokyn
YES
┼
√
√
Aptivus
NO
√
√
Aralast
YES
┼
√
Aranesp
YES
┼
√
√
Arcalyst
YES
┼
√
√
Arixtra
NO
Arzerra
YES
Astagraf XL
NO
√
√
Atripla
NO
√
√
Aubagio
YES
┼
√
√
Avastin
YES
┼
‡
Aveed
YES
┼
‡
Avonex
YES
┼
┼
┼
‡
Step
Therapy ∞
√
√
‡
√
√
√
√
Revised 01/06/2015
Page 2 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication not
covered under
§
medical benefit
YES
Baraclude
NO
Bebulin VH
YES
┼
Beleodaq
YES
┼
Benefix
YES
┼
Benlysta
YES
┼
‡
√
Berinert
YES
┼
‡
√
Betaseron
YES
┼
√
√
Bethkis
YES
┼
√
√
Bexxar
YES ‡
Bivigam
YES
┼
‡
√
Blincyto
YES
┼
‡
√
Bosulif
YES
┼
Botox
YES
┼
Bravelle
YES
┼
√
√
Buphenyl
YES
┼
√
√
capecitabine
YES
┼
√
√
Caprelsa
YES
┼
‡
Carbaglu
YES
┼
‡
Campath
YES ‡
Camptosar
YES ‡
Carimune NF
YES
┼
‡
Cayston
YES
┼
‡
CellCept
NO
Ceprotin
‡
√
√
√
√
√
√
√
‡
Step
Therapy ∞
√
azacitidine
┼
‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
√
√
√
√
√
√
YES
┼
‡
√
Cerdelga
YES
┼
‡
√
Ceredase
YES
┼
‡
√
Cerezyme
YES
┼
‡
√
Cetrotide
YES
┼
‡
√
chorionic gonadotropin
YES
┼
√
√
√
Revised 01/06/2015
Page 3 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Cimzia
YES
┼
Cinryze
YES
┼
Clolar
YES ‡
Combivir
NO
Cometriq
YES
Complera
NO
Copaxone
YES
Copegus
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
√
‡
Medication not
covered under
§
medical benefit
√
√
√
√
┼
√
√
YES
┼
√
√
Corifact
YES
┼
√
√
Crixivan
NO
√
√
cyclosporine
NO
√
√
Cyramza
YES
Cystadane
NO
Cystagon
YES
┼
√
√
Cystaran
YES
┼
‡
Cytogam
YES
┼
‡
Dacogen
YES
┼
‡
DDAVP
YES
┼
‡
decitabine
YES
┼
‡
deferoxamine
YES
┼
‡
√
Desferal
YES
┼
‡
√
Desmopressin
YES
┼
‡
didanosine
NO
Doxil
┼
√
√
√
┼
Step
Therapy ∞
‡
‡
√
√
YES
┼
‡
Dysport
YES
┼
‡
Edurant
NO
Egrifta
√
√
√
YES
┼
‡
√
Elaprase
YES
┼
‡
√
Elelyso
YES
┼
‡
Eligard
YES
┼
‡
√
√
Revised 01/06/2015
Page 4 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
√
√
√
√
√
√
√
√
Eloctate
YES
Elspar
YES ‡
Emtriva
NO
Enbrel
YES
enoxaparin sodium
NO
entecavir
NO
Entyvio
YES
Epivir
NO
√
√
Epivir HBV
NO
√
√
Epogen
YES
┼
√
√
epoprostenol sodium
YES
┼
Epzicom
NO
Erbitux
YES
┼
Erivedge
YES
┼
Erwinase
YES ‡
Esbriet
YES
┼
Euflexxa
YES
┼
√
Exjade
YES
┼
√
√
Extavia
YES
┼
√
√
Eylea
YES
┼
‡
√
Fabrazyme
YES
┼
‡
√
Faslodex
YES ‡
Feiba NF
YES
┼
√
√
Feiba VH
YES
┼
√
√
Ferriprox
YES
┼
Firazyr
YES
┼
√
√
Firmagon
YES
┼
‡
√
Flebogamma
YES
┼
‡
√
Flolan
YES
┼
Follistim AQ
YES
┼
┼
┼
┼
‡
‡
Step
Therapy ∞
√
√
√
√
√
√
‡
‡
√
‡
√
√
√
Revised 01/06/2015
Page 5 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Folotyn
YES
fondaparinux
NO
Forteo
YES
Fragmin
NO
Fusilev
YES
┼
Fuzeon
YES
┼
Gamastan S/D
YES
┼
‡
√
Gammagard
YES
┼
‡
√
Gammagard SD
YES
┼
‡
√
Gammaked
YES
┼
‡
√
Gammaplex
YES
┼
‡
√
Gamunex
YES
┼
‡
√
Gamunex-C
YES
┼
‡
√
ganirelix
YES
┼
Gattex
YES
┼
‡
Gazyva
YES
┼
‡
Gel-One
YES
┼
‡
Gemzar
YES ‡
Gengraf
NO
Genotropin
┼
Medication not
covered under
§
medical benefit
Step
Therapy ∞
‡
┼
√
√
√
√
‡
√
√
√
√
√
√
YES
┼
√
√
Gilenya
YES
┼
√
√
Gilotrif
YES
┼
‡
Glassia
YES
┼
‡
Gleevec
YES
┼
√
√
Gonal-F
YES
┼
√
√
√
Gonal-F RFF
YES
┼
√
√
√
Gonal-F RFF Pen
YES
┼
√
√
√
Granix
YES
┼
‡
Halaven
YES
┼
‡
Harvoni
YES
┼
‡
√
√
√
Revised 01/06/2015
Page 6 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
√
√
YES
┼
√
√
Hemofil M
YES
┼
√
√
HepaGam B
NO
Hepsera
NO
√
√
√
Herceptin
YES
┼
Hetlioz
YES
┼
Hizentra
YES
┼
HP Acthar Gel
YES
┼
√
√
Humate-P
YES
┼
√
√
Humatrope
YES
┼
√
√
Humira
YES
┼
√
√
Hyalgan
YES
┼
Hycamtin
YES
┼
√
HyperHep B
NO
HyperRho S/D
NO
HyQvia
YES
┼
‡
√
√
√
Iclusig
YES
┼
‡
Ilaris
YES
┼
‡
√
Iluvien
YES
┼
‡
√
Imbruvica
YES
┼
‡
Immune Globulins
YES
┼
‡
√
Implanon
YES
┼
‡
√
Increlex
YES
┼
√
√
Infergen
YES
┼
√
√
Inlyta
YES
┼
√
√
Intelence
NO
√
√
Intron A
YES
Invirase
NO
√
√
Iprivask
NO
Hecoria
NO
Helixate FS
┼
Step
Therapy ∞
‡
√
‡
‡
√
√
√
‡
Revised 01/06/2015
Page 7 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Isentress
NO
Istodax
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
√
√
√
√
YES
┼
‡
Ixempra
YES
┼
‡
Jakafi
YES
┼
Jetrea
YES
┼
‡
Jevtana
YES
┼
‡
Juxtapid
YES
┼
‡
Kadcyla
YES
┼
‡
Kalbitor
YES
┼
‡
Kaletra
NO
Kalydeco
YES
Kepivance
YES ‡
Keytruda
YES
┼
Kitabis Pak
YES
┼
Kineret
YES
┼
Koate-DVI
YES
┼
√
√
Kogenate FS
YES
┼
√
√
Korlym
YES
┼
‡
Krystexxa
YES
┼
‡
Kuvan
YES
┼
Kynamro
YES
┼
‡
√
Kyprolis
YES
┼
‡
√
lamivudine
NO
√
√
lamivudine/zidovudine
NO
√
√
Lemtrada
YES
┼
Letairis
YES
┼
Leukine
YES
┼
‡
√
Leuprolide
YES
┼
‡
√
Lexiva
NO
Lovenox
NO
┼
‡
Step
Therapy ∞
√
√
√
√
√
√
√
‡
√
√
√
‡
√
√
√
√
√
√
√
Revised 01/06/2015
Page 8 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
Lucentis
YES
┼
‡
√
Lumizyme
YES
┼
‡
√
Lupaneta
YES
┼
‡
√
Lupron
YES
┼
‡
√
Lupron Depot
YES
┼
‡
√
Lynparza
YES
┼
‡
Macugen
YES
┼
‡
√
Makena
YES
┼
‡
√
Marqibo
YES ‡
Mekinist
YES
┼
√
√
Menopur
YES
┼
√
√
methotrexate injectable
NO
MicRhogam
NO
Mirena
YES
┼
‡
√
√
√
mitoxantrone
YES
┼
‡
Moderiba
YES
┼
√
√
Monoclate-P
YES
┼
√
√
Mononine
YES
┼
√
√
Monvisc
YES
┼
‡
√
Mozobil
YES
┼
‡
√
MuGard
YES
┼
‡
√
Myalept
YES
┼
‡
mycophenolate
NO
√
√
mycophenolate mofetil
NO
√
√
mycophenolic acid
NO
√
√
Myfortic
NO
√
√
Myobloc
YES
┼
‡
√
Myozyme
YES
┼
‡
√
Nabi HB
NO
Naglazyme
YES
‡
√
√
┼
Step
Therapy ∞
Revised 01/06/2015
Page 9 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Neoral
NO
Neulasta
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
√
YES
┼
‡
√
Neumega
YES
┼
‡
√
Neupogen
YES
┼
‡
√
nevirapine
NO
Nexavar
YES
┼
Nexplanon
YES
┼
Norditropin
YES
┼
Northera
YES
┼
Norvir
NO
Novantrone
YES ‡
Novarel
YES
Nov-Onxol
YES ‡
Novoseven RT
YES
Nplate
YES
Nulojix
NO
Nutropin
‡
√
√
√
√
√
√
√
√
√
√
┼
√
√
┼
√
YES
┼
√
√
√
Nutropin AQ
YES
┼
√
√
Obizur
YES
┼
‡
√
Octagam
YES
┼
‡
√
octreotide acetate
YES
┼
‡
√
Ofev
YES
┼
‡
Oforta
YES
┼
‡
Olysio
YES
┼
√
√
Omnitrope
YES
┼
√
√
Omontys
YES
┼
Oncaspar
YES ‡
Opdivo
YES
┼
Opsumit
YES
┼
Orencia
YES
┼
┼
Step
Therapy ∞
√
√
√
‡
Medication not
covered under
§
medical benefit
√
‡
√
√
‡
√
√
√
Revised 01/06/2015
Page 10 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
√
Medication not
covered under
§
medical benefit
Step
Therapy ∞
√
Orenitram
YES
┼
Orfadin
YES
┼
Orthovisc
YES
┼
√
Otezla
YES
┼
√
Otrexup
YES
┼
‡
√
Ovidrel
YES
┼
‡
√
Ozurdex
NO
Paraplatin
YES ‡
Pegasys
YES
┼
√
√
Pegasys Proclick
YES
┼
√
√
Peg-Intron
YES
┼
√
√
Perjeta
YES
┼
‡
Plegridy
YES
┼
‡
Pomalyst
YES
┼
√
√
Pregnyl
YES
┼
√
√
Prezista
NO
√
√
Prialt
YES
┼
‡
Privigen
YES
┼
‡
Procrit
YES
┼
Procysbi
YES
┼
Profilnine SD
YES
┼
Prograf
NO
Prolastin C
YES
┼
‡
Proleukin
YES
┼
‡
Prolia
YES
┼
‡
Promacta
YES
┼
Provenge
YES
┼
Pulmozyme
YES
┼
Purixan
YES
┼
Rapamune
NO
‡
√
√
√
√
√
√
√
√
√
√
√
√
‡
√
√
√
√
√
√
√
‡
‡
Revised 01/06/2015
Page 11 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
√
Rasuvo
YES
┼
Ravicti
YES
┼
√
√
Rebetol
YES
┼
√
√
Rebif
YES
┼
√
√
Reclast
YES
┼
Recombinate
YES
┼
√
√
Refacto
YES
┼
√
√
Remicade
YES
┼
Remodulin
YES
┼
√
√
Repronex
YES
┼
√
√
Rescriptor
NO
√
√
Retisert
NO
Retrovir
NO
√
√
√
Revatio
YES
┼
√
√
Revlimid
YES
┼
√
√
Reyataz
NO
√
√
Rhogam
NO
Rhophylac
NO
RiaSTAP
YES
┼
√
√
√
√
Ribapak
YES
┼
√
√
Ribasphere
YES
┼
√
√
Ribatab
YES
┼
√
√
ribavirin
YES
┼
√
√
Rituxan
YES
┼
Rixubis
YES
┼
√
√
Rubex
YES ‡
Ruconest
YES
┼
Sabril
YES
┼
√
√
Saizen
YES
┼
√
√
Samsca
YES
┼
‡
‡
Step
Therapy ∞
√
√
√
√
‡
‡
√
√
Revised 01/06/2015
Page 12 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Sandimmune
NO
Sandostatin
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
√
YES
┼
‡
√
Sandostatin LAR
YES
┼
‡
√
Selzentry
NO
Sensipar
Medication not
covered under
§
medical benefit
Step
Therapy ∞
√
√
√
YES
┼
√
√
Serostim
YES
┼
√
√
Signifor
YES
┼
‡
sildenafil 20mg
YES
┼
‡
√
Simponi
YES
┼
‡
√
√
Simponi Aria
YES
┼
‡
√
√
sirolimus
NO
Skyla
YES
┼
sodium phenylbutyrate
YES
┼
√
Solesta
NO
Soliris
YES
┼
√
√
Somatuline Depot
YES
┼
Somavert
YES
┼
Sovaldi
YES
┼
√
√
Sprycel
YES
┼
√
√
stavudine
NO
√
√
Stelara
YES
┼
‡
√
Stimate
YES
┼
‡
√
Stivarga
YES
┼
Stribild
NO
Supartz
YES
┼
‡
√
Supprelin LA
YES
┼
‡
√
Sustiva
NO
Sutent
YES
┼
Sylatron
YES
┼
‡
Sylvant
YES
┼
‡
√
‡
‡
√
√
‡
√
√
√
√
√
√
√
√
√
√
√
√
√
Revised 01/06/2015
Page 13 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Synagis
YES
┼
‡
√
Synribo
YES
┼
‡
√
Synvisc
YES
┼
‡
√
tacrolimus
NO
Tafinlar
Medication not
covered under
§
medical benefit
√
√
YES
┼
√
√
Tarceva
YES
┼
√
√
Targretin
YES
┼
√
√
Tasigna
YES
┼
√
√
Taxol
YES ‡
Taxotere
YES ‡
Tecfidera
YES
┼
√
√
Temodar
YES
┼
√
√
temozolomide
YES
┼
√
√
Tev-tropin
YES
┼
√
√
Thalomid
YES
┼
√
√
Thyrogen
NO
Tikosyn
YES
┼
√
√
√
Tivicay
NO
√
√
Tobi
YES
┼
√
√
Tobi Podhaler
YES
┼
√
√
tobramycin inh soln
YES
┼
√
√
Torisel
YES
┼
Tracleer
YES
┼
√
√
Treanda
YES
┼
‡
Trelstar
YES
┼
‡
Tretten
YES
┼
Triumeq
NO
Trizivir
‡
√
√
√
NO
√
√
√
Truvada
NO
√
√
Tybost
NO
Tykerb
YES
√
√
√
┼
Step
Therapy ∞
Revised 01/06/2015
Page 14 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
√
√
Tysabri
YES
┼
Tyvaso
YES
┼
Tyzeka
NO
Valchlor Gel
YES
┼
‡
Valstar
YES
┼
‡
vandetanib
YES
┼
‡
Vantas
YES
┼
‡
Varithena
NO
Varizig
YES
┼
‡
Vectibix
YES
┼
‡
Velcade
YES
┼
‡
Veletri
YES
┼
√
√
Ventavis
YES
┼
√
√
Victrelis
YES
┼
√
√
Vidaza
YES
┼
Videx
NO
Videx EC
NO
Viekira Pak
YES
┼
Vimizim
YES
┼
Viracept
NO
√
√
Viramune
NO
√
√
Viramune XR
NO
√
√
Viread
NO
√
√
Visudyne
YES
Vitekta
NO
Vivaglobin
‡
Step
Therapy ∞
√
√
√
√
√
√
√
√
√
√
√
‡
┼
‡
YES
┼
‡
Vivitrol
YES
┼
‡
Voraxaze
YES ‡
Votrient
YES
┼
VPRIV
YES
┼
√
√
√
√
‡
√
√
Revised 01/06/2015
Page 15 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Prior
Authorization
Required (SGM)
┼ ‡
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
Medication not
covered under
§
medical benefit
┼
√
√
YES
┼
√
√
√
Xeljanz
YES
┼
√
√
Xeloda
YES
┼
√
√
Xenazine
YES
┼
√
√
Xeomin
YES
┼
‡
√
Xgeva
YES
┼
‡
√
Xiaflex
NO
Xolair
YES
┼
‡
√
√
Xtandi
YES
┼
√
√
Xyntha
YES
┼
√
√
Yervoy
YES
┼
‡
Zaltrap
YES
┼
‡
Zavesca
YES
┼
‡
Zelboraf
YES
┼
√
√
Zemaira
YES
┼
Zemplar
YES ‡
Zerit
NO
Zevalin
YES ‡
Ziagen
Wilate
YES
WinRho SDF
NO
Xalkori
‡
√
√
√
√
NO
√
√
zidovudine
NO
√
√
Zoladex
YES
┼
‡
√
zoledronic acid
YES
┼
‡
√
Zolinza
YES
┼
Zometa
YES
┼
Zorbtive
YES
┼
Zortress
NO
Zydelig
YES
┼
Zykadia
YES
┼
√
‡
Step
Therapy ∞
√
√
√
√
√
√
√
√
‡
Revised 01/06/2015
Page 16 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.
Specialty Drug List
Medication Name
Zytiga
Prior
Authorization
Required (SGM)
┼ ‡
YES
┼
Medication
Obtained through
CVS/caremark
Specialty
Pharmacy*
√
Medication not
covered under
§
medical benefit
Step
Therapy ∞
√
Revised 01/06/2015
Page 17 of 17
┼ Prior Authorization, also referred to as Specialty Guideline Management (SGM), is required through CVS/caremark when obtained through the
pharmacy benefit. The SGM program promotes safe and appropriate utilization of specialty drugs by applying evidence based guidelines before
and throughout the course of therapy.
‡ Certain medications may require prior authorization by the MHBP/Aetna Clinical Department when obtained through a medical provider or
outpatient clinic. Please contact 1-800-410-7778.