GHP Family Specialty Drug List/Procedure. Prior Authorization required if marked. Contact the Pharmacy Department.

Transcription

1 GHP Family Specialty Drug List/Procedure Medical Management: Phone: (800) option 2 Fax: (570) Pharmacy Customer Service: Phone: (855) Fax: (570) Drugs included in Geisinger Health Plan Specialty Pharmacy Drug Program Prior Authorization required if marked. Contact the Medical Management Department. Prior Authorization required if marked. Contact the Pharmacy Department. Specialty Pharmacy Provider Status per GHP Pharmacy Abilify Maintena X Voluntary CS, D, B, C, V, Actemra IV X Voluntary CS, D, B, Actemra Self Injectable X Mandatory CS, D, B, Actimmune X Mandatory A, B, V, Adcetris A, B, C, D, Adcirca A, CS, D,, V Adempas X Mandatory A Adcetris Voluntary D, B, Adcirca X Mandatory Advate A, D, B, C, V, Adynovate Mandatory * B, C, Afstyla Mandatory * A, B, C, D, Alecensa X Mandatory A, Alphanate Mandatory * A, D, B, V,

2 Alphanine SD V, Alunbrig X Mandatory A, CS Ampyra X Mandatory A, D, B, Apokyn X Mandatory A, B, Aralast X Mandatory A, D, B, Aranesp Voluntary A, CS, D, B, C, V, Arcalyst X Mandatory A, B, Aristada X Voluntary CS, B, C, D, Aubagio X (7 mg only) Mandatory A, CS, D Austedo X Mandatory Avastin Voluntary A, CS, C, D, BW, Avonex Mandatory A, CS, D, B, C, V, Bebulin VH Mandatory * D, B, V, Benefix Mandatory * A, D, B, V, Benlysta X Voluntary A, C, D, B,, V Berinert X Mandatory A, B, D,, V, Betaseron Mandatory A, CS, D, B, C, Bethkis X Mandatory A, D, C, V, Bosulif X Mandatory A, CS, D, V, Botox X Voluntary A, D, B, C, V, Cabometyx X Mandatory A, CS, D, Caprelsa X Mandatory Cayston X Mandatory, A Cerezyme X Mandatory A, D, B, C, V, Chenodal X Mandatory Dohmen Cholbam X Mandatory Dohmen Cimzia Mandatory * A, CS, D, B, Cinqair X Voluntary Cinryze X Mandatory A, B,

3 Cometriq X Mandatory D, Copaxone Mandatory A, CS, D, B, C, V, Cosentyx X Mandatory A, CS, D, C, V, Cotellic X Mandatory A, CS, D, Cuvitru X Voluntary A, D, Cystadane X Mandatory Cystagon Mandatory A, B,, CVS Caremark Cytogam X Voluntary A, B, CS, C, Daklinza X Mandatory A, C, D, CS, B, Duopa Voluntary A, Dupixent X Voluntary A, CS, D, C, V, B, Dysport Voluntary A, D, C,, lelyso X Mandatory A, B, C,, Dohmen loctate Mandatory * A, D, V, mflaza X Mandatory nbrel X Mandatory A, CS, D, B, BW, C, V, ndari ntyvio X Voluntary A, D, C, V, pclusa X Mandatory A, C, CS, D, B, V,, pogen Voluntary A, CS, D, B, C, V, rivedge X Mandatory A, CS, D, B, sbriet X Mandatory A, D,, CS uflexxa Voluntary A, D, B, C, V,, CS xondys 51 X Voluntary xtavia Mandatory A, CS, D, B, C,

4 Farydak X Mandatory B,, A, C, D Feiba Mandatory * A, B, V, Ferriprox X Mandatory, Dohmen Firazyr X Mandatory A, CS, D, B, V, Flolan X Mandatory A, B, Forteo X Mandatory A, CS, D, B, C, V, Fuzeon Mandatory A, CS, D, B, C, V, Gammagard X Voluntary A, D, B, C, V, Gamunex X Voluntary A, D, B, V, Gattex X Mandatory A, B, Gazyva X Voluntary A, D, Genotropin X Mandatory A, CS, D, B, C, V, Gilenya Mandatory A, CS, D, B, C, V, Gilotrif X Mandatory A, Glassia X Mandatory A, D, Glatiramer Acetate A, CS, C, D, Glatopa Mandatory A, C, CS, D, B, H.P. Acthar X Mandatory A, B, Haegarda X Mandatory A Harvoni X Mandatory A, CS, D, Helixate FS V, Hemofil M V, Hetlioz X Mandatory A, D, Hizentra X Voluntary A, D, B, C, V, Humate-P V, Humatrope X Mandatory A, D, B, C, V, Humira X Mandatory A, CS, D, B, C, V,

5 Hycamtin Mandatory CS, D, B, V, Hyqvia X Voluntary A, Ibrance X Mandatory A, CS, D, Iclusig X Mandatory Idelvion Mandatory * A, B,, C, D Idhifa X Mandatory A, D Ilaris X Mandatory A, B, Imatinb A, CS, D,, V, Imbruvica X Mandatory CS, D, Ingrezza X Mandatory Inflectra X Voluntary B, C,,, A, CS, D Inlyta X Mandatory A, CS, D, B, Intron-A Voluntary CS, D, B, Invega Sustenna X Voluntary CS, D, B, C, V, Invega Trinza X Voluntary CS, B, V,, Iressa X Mandatory A, D, Ixinity Mandatory * A, B,, D Jadenu X Mandatory A, D, CS, B, C, Jakafi X Mandatory A, D, B, Juxtapid X Mandatory A, Dohmen Kadcyla X Voluntary A, C, D, Kalydeco X Mandatory A, B, D,, Cystic Fibrosis Services Keveyis X Mandatory D, Kevzara X Mandatory A, CS, C, D, Kineret X Mandatory B, BW, D, Kisqali X Mandatory A, D, B, CS, V, C, Kitabis Pak X Mandatory A, CS, D,

6 Koate-DVI V, Kogenate FS Mandatory * A, D, B, V, Korlym X Mandatory B, V,, Dohmen Kovaltry Kuvan X Mandatory A, B,, Kynamro X Mandatory A, B, Lemtrada X Voluntary A, D, Lenvima X Mandatory A, Letairis X Mandatory A, B, Lonsurf X Mandatory A, D Lovenox X Voluntary A, CS, D, B, V, Lucentis Voluntary A, B Lumizyme X Mandatory A, B, C,, Lupaneta X Voluntary A, B, CS, V, Lupron Depot Voluntary A, CS, D, B, C, V, Lynparza X Mandatory A, Makena X Voluntary CS, D, B, Matulane Mandatory B, Mavyret X Mandatory A, CS, C, D, m V Mekinist X Mandatory A, CS, D, B, C, V, Monoclate-P V, Mononine Mandatory * A, D, B, V, Myalept X Mandatory A, Natpara X Mandatory A, Nerlynx X Mandatory A, D Neulasta Voluntary A, CS, D, C, V, Neupogen Voluntary A, CS, D, B,

7 Nexavar X Mandatory A, D, B Ninlaro X Mandatory CS, D, B,, V, A, C, Nityr X Mandatory D Norditropin X Mandatory A, CS, D, B, V, Northera X Mandatory A Novoseven RT Mandatory * A, B, V,, Nucala X Voluntary A, D, C, Nulojix X Voluntary A, D, C, V, Nuplazid X Mandatory A, Nutropin AQ X Mandatory A, CS, D, B, Nuwiq Mandatory * A, D, C, Ocaliva X Mandatory A, Ocrevus X Voluntary A, CS, D, V Odomzo X Mandatory A, D, Ofev X Mandatory A, Olysio X Mandatory A, B, CS, D,, Orencia IV X Voluntary CS, D, BW, C, V, Orencia Self- Administered X Mandatory A, CS, D, Orenitram X Mandatory A, Orfadin X Mandatory Dohmen Orkambi X Mandatory A, D, Otezla X Mandatory A, CS, D, C, V, Oxaliplatin Voluntary C, D, B, V, PegIntron Mandatory A, CS, D, B,, Pegasys Mandatory A, CS, D, B, BW, V,, Perjeta Voluntary A, CS, D, B, C, Plegridy Mandatory A, CS, D,

8 Pomalyst X Mandatory A, D, B Praluent X Mandatory CS, C, V,, Prialt X Voluntary D, B, Procrit Voluntary A, CS, D, B, Procysbi X Mandatory A, B, Profilnine Mandatory * A, B, V, Prolastin-C X Mandatory B,, Dohmen Prolia X Voluntary A, CS, C, D,, V Promacta X Voluntary A, CS, D, B, V, Pulmozyme X Mandatory A, CS, D,, V Rasuvo X Mandatory CS, D,, V Ravicti X Mandatory A, B, Rebif Mandatory A, CS, D, B, C, V, Reclast Mandatory A, CS, D, B, C, V, Recombinate V, Remicade X Voluntary A, CS, D, B, Remodulin X Mandatory A, B, Renflexis X Voluntary CS Repatha X Mandatory CS, C, V,, Revlimid X Mandatory A, D, B Rhogam Voluntary A, D, B, C, V, Risperdal Consta X Voluntary CS, D, B, C, V, Rituxan X Voluntary A, CS, C, D, BW, Rituxan Hycela X Voluntary A, CS, C Rubraca X Mandatory Rydapt X Mandatory A, CS, C, D,, V Sabril X Mandatory A, B,

9 Saizen X Mandatory A, D, B, CS, C, V, Samsca A, Sandostatin LAR X Voluntary A,, CS, D, V Signifor X Mandatory A, B, Siliq X Mandatory Simponi (selfadministered) X Voluntary CS, D, B, C, Solesta X Voluntary A, B, Soliris X Mandatory D, B, V, Somatuline Depot X Mandatory A, D, B,, Somavert X Mandatory A, Sovaldi X Mandatory A, CS, D, B, V, Spinraza X Voluntary A, Sprycel X Voluntary CA, S, D, B, C, Stelara Mandatory * CS, D, C, V, Stivarga X Mandatory A, D, Strensiq X Mandatory (NCPDP ) Sucraid X Mandatory A, B, Supprelin LA X Mandatory A, D, B, C, Sustol X Voluntary D,, CS, C Sutent X Mandatory A, CS, D Sylatron X Mandatory A, CS, D, B, Synagis X Voluntary A, D, B Synvisc Voluntary A, D, B, C,, CS, V Tafinlar X Mandatory A, CS, D, B, C, V, Tagrisso X Mandatory A, D, Taltz X Mandatory D, B, C, Tarceva X Mandatory A, CS, D, B, Tasigna X Mandatory A, CS, C, V, D, B, Tecfidera Mandatory CS, D, B,

10 Technivie X Mandatory A, CS, D, C, Thalomid X Mandatory A, D, Thiola X Mandatory V,, Dohmen Thyrogen Voluntary A, D, B, C, V, Tobi/Tobi Podhaler X Mandatory A, B, D, V,, CF Services Tracleer X Mandatory A, B, Tremfya X Mandatory A, CS, C, D,, V Triptodur RPx Tykerb X Mandatory A, CS, D, B, V, Tymlos X Mandatory A, CS, C,, V Tysabri X Mandatory A, B, Tyvaso X Mandatory A, C, B, Uptravi X Mandatory A, Valchlor X Mandatory A, Veletri X Mandatory A, Veltassa X Mandatory A,, CS, Venclexta X Mandatory C, D Ventavis X Mandatory A, B, Verzenio X Mandatory CS Viekira Pak X Mandatory A, CS, D, B, Viekira XR X Mandatory A, CS, D, B, Vivitrol Voluntary A, CS, D, B, C, V, Vosevi X Mandatory A, CS, C, D, Votrient X Mandatory A, CS, D, B, C, V, VPRIV X Voluntary A, D, C,, WinRho X Voluntary A, D, B, Xadago X Mandatory CS, C,, V

11 Xalkori X Mandatory CS, D, B Xeljanz X Mandatory A, CS, C, D, Xeljanz XR X Mandatory A, CS, C, D, Xenazine X Mandatory A, B, V, Xermelo X Mandatory D, Xolair X Mandatory A, B, CS, Xtandi X Mandatory A, D, B Xyrem X Mandatory Yervoy X Voluntary A, D, B, C, V, Zaltrap X Voluntary A, D, B, V, Zarxio Mandatory * A, CS, D, C B, Zavesca X Mandatory A, B, Zejula X Mandatory D Zelboraf X Mandatory A, CS, D, B, Zemaira X Mandatory A, D, B, Zepatier X Mandatory A, CS, D, B, C, V, Zinbryta X Mandatory D, Zomacton X Mandatory A, D, B Zorbtive X Mandatory A, D, B,, Zydelig X Mandatory D, Zykadia X Mandatory A, D, B, C, Zyprexa Relprevv X Voluntary CS, D, B, C, V, Zytiga X Mandatory A, CS, D, B, V, *Use of the Specialty Pharmacy Drug Program is mandatory only when medication will be selfadministered by the member at home. Use of the Specialty Pharmacy Drug Program is not mandatory if the physician elects to buy and bill the medication. Last Updated 2/8/2018 KY: A= Accredo

12 CS = Caresite Specialty D= Diplomat B= Bank s BW= Boothwyn C= Curexa V= Value = mpire = PANTHRx (NCPDP )