Specialty Drug List - Effective 7/1/2015

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Specialty Drug List - Effective 7/1/2015 Drug Name Formulary Tier J-Code Therapeutic Class Medical Billing Allowed Pharmacy Billing Allowed Coverage Restricted through Specialty Pharmacy abacavir

1 Specialty Drug List - Effective 7/1/2015 Drug Name Formulary Tier J-Code Therapeutic Class Medical Billing Allowed Pharmacy Billing Allowed Coverage Restricted through Specialty Pharmacy abacavir Tier 4 no code Antiviral X ABRAXANE Tier 4 J9264 Antineoplastics X X X ACTEMRA** Tier 4 J3262 Analgesic, Anti-inflammatory or Antipyretic X X X ACTIMMUNE** Tier 4 J9216 Anti-infective agents X X X ADCIRCA Tier 4 no code Cardiovascular therapy agents X AFINITOR Tier 4 J7527 Antineoplastics X X X ALDURAZYME** Tier 4 J1931 Enzyme Replacement Therapy X ALKERAN Tier 4 J8600 Antineoplastics X ALOXI Tier 4 J2469 Chemotherapeutic adjuvants X Alprostadil Tier 4 J0270 Genitourinary therapy X Amifostine IV Tier 4 J0207, J0270 Chemotherapeutic adjuvants X AMPYRA** Tier 4 no code Multiple Sclerosis agents X X APOKYN** Tier 4 J0364 Central Nervous System agents X X X APTIVUS Tier 4 no code Antiviral X ARALAST** Tier 4 J0256 Respiratory Therapy Agents X X ARANESP Tier 4 J0881/2 Hematological agents X X X ARCALYST** Tier 4 J2793, J2794 Analgesic, Anti-inflammatory or Antipyretic X X X ARIXTRA Tier 4 J1652 Hematological agents X X ARRANON Tier 4 J9261 Antineoplastics X X X ARZERRA Tier 4 J9302 Antineoplastics X X ATRIPLA Tier 4 no code Antiviral X AUBAGIO** Tier 4 no code Multiple Sclerosis agents X X AVONEX Pen Tier 4 J1826, Q3025 Multiple Sclerosis agents X X AVONEX PFS Tier 4 J1826, Q3025 Multiple Sclerosis agents X X AVONEX SDV Tier 4 J1826, Q3025 Multiple Sclerosis agents X X BARACLUDE Tier 4 no code Anti-infective agents X X BENLYSTA* Tier 4 Q2044, J0490 Analgesic, Anti-inflammatory or Antipyretic X X X BETASERON Tier 4 J1830 Multiple Sclerosis agents X X BIVIGAM Tier 4 J1556 Immunodeficiency X bleomycin sulfate Tier 4 J9040 Antineoplastics X BOSULIF** Tier 4 no code Antineoplastics X X X BOTOX Tier 4 J0585 NEUROMUSCULAR AGENTS X BRAVELLE Tier 4 J3355 Endocrine X Partial Fill Requirement

2 BUPHENYL Tier 4 no code Genitourinary therapy X BYDUREON Tier 4 no code Endocrine X BYETTA Tier 4 no code Endocrine X CAMPTOSAR Tier 4 J9206 Antineoplastics X CAPRELSA** Tier 4 no code Antineoplastics CARBAGLU** Tier 4 no code Metabolic Modifiers X X X CAYSTON** Tier 4 no code Anti-infective agents X X CELLCEPT Tier 4 J7517 Immunosuppresive agents X X CELLCEPT IV Tier 4 J7517 Immunosuppresive agents X CERDELGA** Tier 4 no code Enzyme Replacement Therapy X X CEREZYME Tier 4 J1786 Enzyme Replacement Therapy X CETROTIDE Tier 4 no code Endocrine X X CIMZIA Tier 4 J0718 Gastrointestinal therapy agents X X X cladribine Tier 4 J9065 Antineoplastics X CLOLAR Tier 4 J9027 Antineoplastics X X X COMBIVIR Tier 4 no code Antiviral X COMETRIQ** Tier 4 no code Antineoplastics X X X X COMPLERA Tier 4 no code Antiviral X COPAXONE KIT 20MG/ML Tier 4 J1595 Multiple Sclerosis agents X X COPEGUS Tier 4 no code Anti-infective agents X X CRIXIVAN Tier 4 no code Antiviral X cyclosporine Inj Tier 4 J7502, J7515 Immunosuppresive agents X CYRAMZA** Tier 4 no code Antineoplastics X CYSTAGON** Tier 4 no code Genitourinary therapy X X CYSTARAN** Tier 4 no code Ophthalmic agents x X CYTOVENE Tier 4 J7310, J1570 Antiviral X dacarbazine Tier 4 J9130 Antineoplastics X daunorubicin HCL Tier 4 J9150 Anitbiotics X deferoxamine mesylate Tier 4 J0895 Heavy Metal Antagonists X DEPO-TESTOSTERONE Tier 4 J1070, J1080 Endocrine X X DESFERAL Tier 4 J0895 Antidotes and other reversal agents X dexrazoxane Tier 4 J1190 Cardiovascular therapy agents X didanosine Tier 4 no code Antiviral X DOXIL Tier 4 no code Antibiotics X doxorubicin hcl and doxorubicin liposome Tier 4 J9000 Antineoplastics X DYSPORT** Tier 4 J0586 Neuromuscular Agents X EDURANT Tier 4 no code Antivirals X EGRIFTA** Tier 4 no code Endocrine X ELAPRASE** Tier 4 J1743 Enzyme Replacement Therapy X ELELYSO** Tier 4 C9294 Metabolic Disease Enzyme Replacement agents X X X ELIGARD Tier 4 J9217 Endocrine X X X ELLENCE Tier 4 J9178 Antibiotics X ELSPAR Tier 4 J9020 Antineoplastics X

3 EMEND Tier 4 J8501, J1453 Chemotherapeutic adjuvants X EMTRIVA Tier 4 no code Antiviral X ENBREL Tier 4 J1438 Analgesic, Anti-inflammatory or Antipyretic X X ENTYVIO Tier 4 no code Analgesic, Anti-inflammatory or Antipyretic episone CRE Tier 4 no code Dermatologicals X EPIVIR Tier 4 no code Antiviral X EPIVIR HBV Tier 4 no code Antiviral X EPOGEN Tier 4 J0885 J0886, Q4081 Hematological agents X X X epoprostenol sodium Tier 4 J1325, S0155 Cardiovascular therapy agents X EPZICOM Tier 4 no code Antiviral X ERBITUX Tier 4 J9055 Antineoplastics X ERIVEDGE** Tier 4 no code Antineoplastics X X X X ETHYOL Tier 4 J0207 Chemotherapy Rescue EXJADE** Tier 4 no code Hematological agents X EXTAVIA Tier 4 no code Multiple Sclerosis agents X X FABRAZYME** Tier 4 J0180 Enzyme Replacement Therapy X FASLODEX Tier 4 J9395 Hormone Agent X FERRIPROX** Tier 4 no code Antidotes and other reversal agents X X FIRAZYR Tier 4 J1744 Cardiovascular therapy agents X X FIRMAGON Tier 4 J9155 GnRH receptor antagonist--endocrine X FLEBOGAMMA DIF Tier 4 J1572 Immunodeficiency X FLOLAN** Tier 4 J1325 Cardiovascular therapy agents X X FLOXURIDINE Tier 4 J9200 Antineoplastics X FLUDARA Tier 4 J9185 Antineoplastics X FLUDARABINE PHOSPHATE Tier 4 J9185 Antineoplastics X fluorouracil IV Tier 4 J9190 Antineoplastics X FOLLISTIM AQ Tier 4 S0128 Fertility Regulators X FOLOTYN Tier 4 J9307 Antineoplastics X X FORTEO Tier 4 J3110 Endocrine X X X FRAGMIN Tier 4 J1645 Hematological agents X X GAMASTAN SD Tier 4 J1460, J1560 Immunodeficiency X GAMUNEX-C Tier 4 J1561 Immunodeficiency X GAMMAGARD Tier 4 J1569 Immunodeficiency X GAMMAGARD S/D less IgA Tier 4 J1569 Immunodeficiency X GAMMAGARD SD Tier 4 J1569 Immunodeficiency X GAMMAKED Tier 4 J1561 Immunodeficiency X GAMMAPLEX Tier 4 J1557 Immunodeficiency x x X GASTROCROM Tier 4 no code Gastrointestinal therapy agents X GAZYVA** Tier 4 J9301 Antineoplastics X Gemcitabine HCL Tier 4 J9201 Antineoplastics X GEMZAR Tier 4 J9201 Antineoplastics X GENOTROPIN & GENOTROPIN MINIQUICK Tier 4 J2941 Endocrine X X GILENYA** Tier 4 no code Multiple Sclerosis agents X X GILOTRIF** Tier 4 no code Enzyme Inhibitors X X

4 GLASSIA** Tier 4 J0257 Respiratory Therapy Agents X X X glatopa Tier 4 no code Multiple Sclerosis agents X X GLEEVEC Tier 4 S0088 Antineoplastics X X X GONAL-F Tier 4 S0126 Fertility Regulators X GONAL-F RFF Tier 4 S0126 Fertility Regulators X H.P. ACTHAR Tier 4 J0800 Corticotropin X HALAVEN Tier 4 J9179 Antineoplastics X X HARVONI Tier 4 no code Hepatitis C X X X HEPSERA Tier 4 no code Anti-infective agents X X HEXALEN Tier 4 no code Antineoplastics X HIZENTRA** Tier 4 J1559 Biologicals X X HUMATROPE & HUMATROPE COMBO PAK Tier 4 J2941 Endocrine X X HUMIRA Tier 4 J0135 Analgesic, Anti-inflammatory or Antipyretic X X HYALGAN Tier 4 J7321 Locomotor system X X X HYCAMTIN ** Tier 4 J8705, J9351 Antineoplastics X X HYPERHEP B S/D Tier 4 no code Immunodeficiency X HYPERRHO S/D and S/D Mini Dose PFS Tier 4 J2788 Immunosuppresive agents X ICLUSIG** Tier 4 no code Antineoplastics X X X ILARIS** Tier 4 J0638 Analgesic, Anti-inflammatory or Antipyretic x X X IMBRUVICA** Tier 4 no code Antineoplastics X X X X INCRELEX** Tier 4 J2170 Endocrine X X X INFERGEN Tier 4 J9212 Anti-infective agents X X X INLYTA** Tier 4 no code Antineoplastics X X X INTELENCE Tier 4 no code Antiviral X INTRON A HSAF Tier 4 J9214, J9215 Antineoplastics X INTRON-A** Tier 4 J9214, J9215 Antineoplastics X X X INTRON-A with Diluent Tier 4 J9214, J9215 Antineoplastics X X X INVIRASE Tier 4 S0140 Antiviral X ISENTRESS Tier 4 no code Antiviral X ISTODAX Tier 4 J9315 Antineoplastics X X X JAKAFI** Tier 4 no code Antineoplastics X X X JEVTANA Tier 4 C9399, J9043 Antineoplastics X X X KADCYLA** Tier 4 J9354 Antineoplastics X X X KALBITOR** Tier 4 J1290 Cardiovascular therapy agents X X KALETRA Tier 4 no code Antiviral X KALYDECO** Tier 4 no code Cystic Fibrosis X X KEPIVANCE Tier 4 J2425 Gastrointestinal therapy agents X X X KINERET Tier 4 J3490 Analgesic, Anti-inflammatory or Antipyretic X X X KITABIS PAK** Tier 4 no code Anti-infective agents X X KUVAN** Tier 4 no code Metabolic Modifiers X X LETAIRIS** Tier 4 no code Cardiovascular therapy agents X X LEUKINE SOL Tier 4 J2820 Hematological agents X X X LEXIVA Tier 4 no code Antiviral X LUMIZYME** Tier 4 J0220, J0221 Enzyme Replacement Therapy X

5 LUPRON DEPOT Tier 4 J9217, J9218, J1950 Endocrine X X X LUPRON DEPOT-PED Tier 4 J9217, J9218, J1950 Endocrine X LYSODREN Tier 4 no code Antineoplastics X MAKENA** Tier 4 J1725 Progestins X X X MEKINIST** Tier 4 no code Enzyme Inhibitors X X melphalan hcl Tier 4 J9245, J8600 Antineoplastics X MENOPUR Tier 4 S0122 Endocrine X mesna Tier 4 J9209 Chemotherapeutic adjuvants X MESNEX Tier 4 J9209 Chemotherapeutic adjuvants X MICRHOGAM ULTRA FILTERED PLUS Tier 4 J2788 Immune Globulin X MITOMYCIN Tier 4 J9280 Antineoplastics X mitoxantrone Tier 4 J9293 Antineoplastics X MODERIBA 800 and 1200 Dose Paks Tier 4 no code Antiviral X MOZOBIL Tier 4 J2562 Hematological agents X X X MUSTARGEN Tier 4 J9230 Antineoplastics X MYALEPT** Tier 4 no code Metabolic Modifiers X X MYCAMINE Tier 4 J2248 Anti-infective agents X X mycophenolate Tier 4 J7517 Immunosuppresive agents X MYFORTIC Tier 4 J7518 Immunosuppresive agents X MYOZYME** Tier 4 J0220 Metabolic Modifiers X X NABI-HB Tier 4 CPT Biologicals X X X NAGLAZYME** Tier 4 J1458 Metabolic Disease Enzyme Replacement agents X X X NAVELBINE Tier 4 J9390 Antineoplastics X X X NEORAL Tier 4 J7502, J7515 Immunosuppresive agents X NEULASTA Tier 4 J2505 Hematological agents X X X NEUMEGA Tier 4 J2355 Hematological agents X X X NEUPOGEN Tier 4 J1442, J1446 Hematological agents X X X NEVIRAPINE Tier 4 no code Antiviral X NEXAVAR** Tier 4 no code Antineoplastics X X X NIVATOPIC PLUS Tier 4 no code Dermatologicals X NORDITROPIN Tier 4 J2941 Endocrine X X NORVIR Tier 4 no code Antiviral X NOXAFIL Tier 4 no code anti-infective agents X NULOJIX Tier 4 J0485 Immunosuppresive agents X X X NUTROPIN Tier 4 J7189 Endocrine X X NUTROPIN AQ PEN Tier 4 J2941 Endocrine X NUTROPIN AQ NuSpin Tier 4 J2941 Endocrine X OCTAGAM Tier 4 J1568 Immunodeficiency X octreotide acetate Tier 4 J2354 Chemotherapeutic adjuvants X OMNITROPE Crtg Tier 4 J2941 Endocrine X OMNITROPE Tier 4 J2941 Endocrine X X ondansetron Tier 4 J2405 Chemotherapeutic adjuvants X ondansetron IV Tier 4 J2405 Chemotherapeutic adjuvants X

6 ORENCIA Tier 4 J0129 Analgesic, Anti-inflammatory or Antipyretic X X X OTEZLA** Tier 4 no code Analgesic, Anti-inflammatory or Antipyretic X X paclitaxel Tier 4 J9264, J9267 Antineoplastics X PAMIDRONATE DISODIUM Tier 4 J2430 Chemotherapeutic adjuvants X PEGASYS Tier 4 S0145, S0148 Anti-infective agents X X X PEGASYS Proclick Tier 4 S0145, S0148 Anti-infective agents X PEG-INTRON and PEG-INTRON Redipen and RedipeTier 4 J9214, J9215 Anti-infective agents X X X PENTAM 300 Tier 4 J2545 Anti-infective agents X PERJETA** Tier 4 J9306 Antineoplastics X X X polyethylene glycol 3350 Tier 4 no code Laxatives X POMALYST** Tier 4 no code Antineoplastics X X X PREZISTA Tier 4 no code Antiviral X PRIVIGEN Tier 4 J1459 Immunodeficiency X PROCRIT Tier 4 J0886 J0885, Q4081 Hematological agents X X X PROGRAF ORAL Tier 4 J7507 Immunosuppresive agents X X PROLASTIN - C** Tier 4 J0256 Respiratory Therapy Agents PROLEUKIN Tier 4 J9015 Antineoplastics X X X PROLIA Tier 4 J0897 Endocrine X X PROMACTA** Tier 4 no code Hematological agents X X PROSTIN VR PEDIATRIC Tier 4 J0270 Immunodeficiency X PULMOZYME Tier 4 J7639 Respiratory Therapy Agents X X X RAPAMUNE Tier 4 J7520 Immunosuppresive agents X REBETOL TIER 4 No Code Anti-infective agents X X REBIF Tier 4 J1826, Q3028 Multiple Sclerosis agents X X REBIF REBIDOSE TITRATION PACK Tier 4 J1826, Q3028 Multiple Sclerosis agents X RECLAST Tier 4 J3489 Bisphosphonates X X X RELISTOR Tier 4 J2212 Antidotes and other reversal agents X REMICADE Tier 4 J1745 Analgesic, Anti-inflammatory or Antipyretic X X X REMODULIN** Tier 4 J3285 Cardiovascular therapy agents X X RETROVIR IV Tier 4 J3485, S0104 Antiviral X RETROVIR Syrup Tier 4 J3485, S0104 Antiviral X REVATIO Tier 4 S0090 Cardiovascular therapy agents X X REVLIMID** Tier 4 no code Antineoplastics X X REYATAZ Tier 4 no code Antiviral X RHOGAM ULTRA FILTERED PLUS Tier 4 J2788, J2790 Immunodeficiency X RHOPHYLAC Tier 4 J2790, J2791 Immunosuppresive agents X RIBASPHERE and RIBASPHERE RIBAPAK Tier 4 no code Anti-infective agents X X RIBATAB Tier 4 no code Anti-infective agents X RIBAVIRIN Tier 4 no code Anti-infective agents X X RITUXAN Tier 4 J9310 Antineoplastics X X X SABRIL** Tier 4 no code Central Nervous System agents X X SAIZEN Tier 4 J2941 Endocrine X X SAMSCA** Tier 4 no code Cardiovascular therapy agents X X SANDOSTATIN Tier 4 J2353, J2354 Endocrine X X X

7 SENSIPAR Tier 4 no code Endocrine X X SEROSTIM** Tier 4 J2941 Endocrine X X X SIGNIFOR** Tier 4 J3490 Endocrine X X sildenafil citrate Tier 4 S0090 Vasodilator X SIMPONI Tier 4 no code Analgesic, Anti-inflammatory or Antipyretic X X SOMATULINE DEPOT Tier 4 J1930 Endocrine X X X SOMAVERT** Tier 4 J2505 Endocrine X X X SOVALDI Tier 4 no code Anti-infective agents X X X SPRYCEL Tier 4 J8999 Antineoplastics X X X stavudine Tier 4 no code Antiviral X STELARA Tier 4 J3357 Dermatological X X STIVARGA** Tier 4 no code Antineoplastics X X X SUSTIVA Tier 4 no code Antiviral X SUTENT** Tier 4 no code Antineoplastics X X X SYLATRON** Tier 4 no code Antineoplastics X X X SYNAGIS** Tier 4 no code Biologicals X X X SYNAREL Tier 4 no code Endocrine X X X SYNRIBO Tier 4 C9297, J9999 Antineoplastics X X X SYNVISC Tier 4 J7325 Locomotor system X X X tacrolimus Tier 4 J7507, J7508 Immunosuppresive agents X TAFINLAR** Tier 4 no code Antineoplastics X X X TARCEVA** Tier 4 no code Antineoplastics X X X TARGRETIN Tier 4 no code Dermatological X X X TASIGNA Tier 4 no code Antineoplastics X X X TECFIDERA** Tier 4 no code Multiple Sclerosis agents X X TEMODAR Tier 4 J8700, J9328 Antineoplastics X X testosterone cypionate Tier 4 J1071 Endocrine X X TEV-TROPIN Tier 4 no code Endocrine X X THALOMID** Tier 4 no code Anti-infective agents X X TOBI** Tier 4 J7682 Anti-infective agents X X X tobramycin** Tier 4 J7682 Anti-infective agents X X X TOPOTECAN HCL Tier 4 J8705, J9351 Antineoplastics X TORISEL Tier 4 J9330 Antineoplastics X X X TOTECT Tier 4 J1190 Chemotherapeutic adjuvants X TRACLEER** Tier 4 no code Cardiovascular therapy agents X X TREANDA Tier 4 J9033 Antineoplastics X X X TRELSTAR Tier 4 J3315 GnRH receptor antagonist--endocrine X TRELSTAR MIXJET Tier 4 J3315 GnRH receptor antagonist--endocrine X TRUVADA Tier 4 no code Antiviral X TYGACIL Tier 4 J3243 Anti-infective agents X X TYKERB** Tier 4 no code Antineoplastics X X TYSABRI** Tier 4 J2323 Multiple Sclerosis agents X X X TYZEKA Tier 4 no code Anti-infective agents X X X VANTAS Tier 4 J1645, J9225 Endocrine X X X

8 VASOTEC Tier 4 no code Ace Inhibitor X VELETRI Tier 4 J1325 Cardiovascular therapy agents X X VENTAVIS** Tier 4 Q4074 Cardiovascular therapy agents X X X VICTOZA Tier 4 no code Endocrine X VICTRELIS Tier 4 no code Anti-infective agents X X VIDAZA Tier 4 J9025 Antineoplastics X X X VIDEX EC Tier 4 S0137 Antiviral X VIMIZIM** Tier 4 j1322 Endocrine X vincristine sulfate Tier 4 J9370, J9371 Antineoplastics X vinorelbine tartrate Tier 4 J9390 Vinorelbine X VIRACEPT Tier 4 no code Antiviral X VIRAMUNE and VIRAMUNE XR Tier 4 no code Antiviral X VOTRIENT** Tier 4 no code Antineoplastics X X X VPRIV** Tier 4 J3385 Metabolic Disease Enzyme Replacement agents X X WINRHO SDF LIQUID Tier 4 J2788, J2791, J2792 Immunosuppresive agents X XALKORI** Tier 4 no code Antineoplastics X X X XCLAIR Tier 4 no code Dermatologicals X X XELJANZ Tier 4 no code Analgesic, Anti-inflammatory or Antipyretic X X XELODA Tier 4 J8520/8521 Antineoplastics X X XENAZINE** Tier 4 no code Central Nervous System agents X X XEOMIN Tier 4 J0588 Neuromuscular Agents X XGEVA Tier 4 J0897 Endocrine x X X XIAFLEX** Tier 4 J0775 Locomotor system X X X XOLAIR** Tier 4 J2357 Respiratory Therapy Agents X X X XTANDI** Tier 4 no code Antineoplastics X X X XYREM** Tier 4 no code Central Nervous System agents X X YERVOY Tier 4 J9228 Antineoplastics X X X ZAVESCA** Tier 4 no code Metabolic Modifiers X X ZELBORAF** Tier 4 no code Antineoplastics X X X ZEMAIRA** Tier 4 J0256 Respiratory Therapy Agents X X ZERIT Tier 4 no code Antiviral X ZIAGEN Tier 4 no code Antiviral X zidovudine Tier 4 no code Antiviral X ZINECARD Tier 4 J1190 Chemotherapeutic adjuvants X X ZOFRAN Tier 4 J2405, Q0162, S0119 Chemotherapeutic adjuvants X ZOLADEX Tier 4 J9202 Antineoplastics X X X ZOLINZA Tier 4 no code Antineoplastics X X X ZOMETA Tier 4 J3489 Endocrine X X X ZORBTIVE Tier 4 J2941 Endocrine X X ZORTRESS Tier 4 J8561 Immunosuppresive agents X X ZYDELIG** Tier 4 no code Antineoplastics X ZYKADIA** Tier 4 no code Antineoplastics X X X ZYTIGA** Tier 4 no code Antineoplastics X X X

9 NOTES: Drugs listed on this Specialty Drug List are subject to 20% coinsurance. After the member has met their maximum out of pocket for their plan in a single year, then the plan pays 100% of the cost of the drug. Please consult your Summary of Benefits for details. Specialty Prescriptions can be faxed to Diplomat Specialty Pharmacy at: For Benefit Verification, Eligibility, and the most current "Specialty Drug List" contact Catamaran Rx at All drugs on this list may be subject to Prior Authorization. An initial 14 day supply of drugs mandated to Specialty Pharmacy may be dispensed by a retail pharmacy if needed immediately and requested by the member. The Prominence Health Plan Partial Fill Program consists of a limit on the initial 3 months of selected medications to a 14 or 15 day supply. These specific medications are targeted for the program due to high discontinuation rate, poor response, adverse effects, and/or noncompliance. **Denotes Limited Distribution Drugs that Diplomat is not currently in network to supply.

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

GHP Family Specialty Drug List/Procedure Medical Management: Phone: (800) 544-3907 option 2 Fax: (570) 271-5534 Pharmacy Customer Service: Phone: (855) 552-6028 Fax: (570) 271-5610 Drugs included in Geisinger