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.