View the specialty drug list
Specialty Preferred Drug List Effective 1/1/2015 Drug Name Drug List Status Therapeutic Class Available Through acitretin Specialty Tier 1 Psoriasis Fairview Specialty Pharmacy ACTEMRA SQ * Specialty Tier 2 Inflammatory Diseases Fairview Specialty Pharmacy ACTIMMUNE Specialty Tier 1 Immunological Fairview Specialty Pharmacy ADAGEN Specialty Tier 2 Enzyme Deficiencies Walgreens Specialty Pharmacy ADCIRCA* Specialty Tier 1 Pulmonary Hypertension Fairview Specialty Pharmacy adefovir dipivoxil (Hepsera) Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy ADEMPAS Specialty Tier 1 Pulmonary Hypertension Accredo Health OR Caremark Tier 2 Antineoplastic Fairview Specialty Pharmacy AMEVIVE * Specialty Tier 2 Dermatological Agents Fairview Specialty Pharmacy AMPYRA* Specialty Tier 1 Walgreens Specialty Pharmacy APOKYN * QL Specialty Tier 1 Multiple Sclerosis Central Nervous System Agents ARANESP * Specialty Tier 1 Fairview Specialty Pharmacy ARCALYST* Specialty Tier 1 Blood and Coagulation Interleukin Receptor Antagonist AUBAGIO ST, QL Specialty Tier 1 Multiple Sclerosis Walgreens Specialty Pharmacy AVONEX ST Specialty Tier 1 Multiple Sclerosis Fairview Specialty Pharmacy entecavir (BARACLUDE) Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy BETASERON ST Specialty Tier 1 Multiple Sclerosis Fairview Specialty Pharmacy BETHKIS Specialty Tier 2 Antiinfectives Fairview Specialty Pharmacy BOSULIF Tier 2 Antineoplastic Fairview Specialty Pharmacy BRAVELLE Specialty Tier 1 Infertility Fairview Specialty Pharmacy capecitabine (Xeloda) Tier 1 Antineoplastic Fairview Specialty Pharmacy CAPRELSA Tier 2 Antineoplastic Biologics, Inc. AFINITOR ‡ Accredo Health CARBAGLU* Specialty Tier 1 CAYSTON Specialty Tier 1 Aniinfectives Cayston Access Program CERDELGA Specialty Tier 2 Endocrine Metabolic Agent Fairview Specialty Pharmacy CETROTIDE Specialty Tier 1 Infertility Fairview Specialty Pharmacy CHENODAL* Specialty Tier 2 Bile Salts Chenodal Total Care Program chorionic gonadotropin Specialty Tier 2 Infertility Fairview Specialty Pharmacy CIMZIA* Specialty Tier 2 Inflammatory Diseases Fairview Specialty Pharmacy CINRYZE * Specialty Tier 1 Enzyme Deficiencies Caremark, CuraScript, OR Accredo Health colistimethate sodium Specialty Tier 1 Antiinfective Fairview Specialty Pharmacy COLY-MYCIN M PARENTERAL Specialty Tier 2 Antiinfective Fairview Specialty Pharmacy Tier 2 Antineoplastic Diplomat Specialty Pharmacy COPAXONE Specialty Tier 1 Multiple Sclerosis Fairview Specialty Pharmacy COPAXONE 40MG Specialty Tier 1 Multiple Sclerosis Fairview Specialty Pharmacy COPEGUS Specialty Tier 2 Antiinfectives Fairview Specialty Pharmacy CYSTARAN Specialty Tier 1 Opthalmologic Walgreens Specialty Pharmacy COMETRIQ Hyperammonemia agent Walgreens Specialty Pharmacy Accredo Health * = PRIOR AUTHORIZATION REQUIRED, ST = Step Therapy, QL = Quantity Limits, = Not subject to specialty prescription drug copay; will collect the applicable outpatient prescription drug copay as outlined in member Certificate of Coverage. ‡ = Oral Oncology Split Fill Program. Prior authorization may be required to obtain coverage for select drugs on this list. Generic drugs will be dispensed when available. Brand name drugs may be subject to the non-Preferred benefit if the generic becomes available. Brand name drugs listed in ALL CAPS. Select drugs on this list may be excluded under your specific plan design. Please refer to your coverage document to determine specific benefit levels. If you have questions, please call the Medica Customer Service number listed on the back of your ID card. This list is subject to change. © 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC. Last Updated: 10/24/14 Specialty Preferred Drug List Effective 1/1/2015 Drug Name Drug List Status Therapeutic Class Available Through EGRIFTA* Specialty Tier 2 Endocrine-Metabolic Agent Walgreens Specialty Pharmacy ELIGARD Specialty Tier 2 Hormone Antagonist Fairview Specialty Pharmacy ENBREL * Specialty Tier 1 Inflammatory Diseases Fairview Specialty Pharmacy EPOGEN * Specialty Tier 1 Blood and Coagulation Fairview Specialty Pharmacy Tier 2 Antineoplastic Fairview Specialty Pharmacy ESBRIET * Specialty Tier 2 Respiratory Agent Diplomat Specialty Pharamcy EXJADE * Specialty Tier 1 Chelation Agents Fairview Specialty Pharmacy EXTAVIA ST Specialty Tier 1 Fairview Specialty Pharmacy FIRAZYR * Specialty Tier 1 Multiple Sclerosis Bradykinin Receptor Antagonist FIRMAGON Specialty Tier 2 Hormone Antagonist Fairview Specialty Pharmacy FOLLISTIM AQ Specialty Tier 1 Fairview Specialty Pharmacy FORTEO * Specialty Tier 1 Infertility Hormones and Related Agents FUZEON * Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy GANIRELIX ACETATE Specialty Tier 2 Infertility Fairview Specialty Pharmacy GENOTROPIN * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy GILENYA QL Specialty Tier 1 Multiple Sclerosis GILOTRIF * Tier 2 Antineoplastic Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Accredo Health GLEEVEC Tier 2 Antineoplastic Fairview Specialty Pharmacy GONAL-F Specialty Tier 2 Infertility Fairview Specialty Pharmacy GRANIX Specialty Tier 1 Blood and Coagulation Fairview Specialty Pharmacy HARVONI * Specialty Tier 2 Antiinfectives Fairview Specialty Pharmacy Tier 2 Antineoplastic Fairview Specialty Pharmacy H.P. ACTHAR GEL * Specialty Tier 2 Hormone Agonist Fairview Specialty Pharmacy HUMATROPE * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy HUMIRA * Specialty Tier 1 Inflammatory Diseases Fairview Specialty Pharmacy Tier 2 Fairview Specialty Pharmacy Specialty Tier 1 Antineoplastic Interleukin Receptor Antagonist Tier 2 Antineoplastic Fairview Specialty Pharmacy INCIVEK* Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy INCRELEX * Specialty Tier 1 Growth Hormones Fairview Specialty Pharmacy INFERGEN Specialty Tier 1 Antiinfectives INLYTA Tier 2 Antineoplastic Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) INTRON A Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy IRESSA Tier 2 Antineoplastic Curascript or Accredo Health JAKAFI Tier 2 Antineoplastic Fairview Specialty Pharmacy JUXTAPID * Specialty Tier 1 Lipid Lowering Agent Juxtapid REMS Program KALYDECO * Specialty Tier 1 Endocrine-Metabolic Agent Fairview Specialty Pharmacy ERIVEDGE HEXALEN HYCAMTIN ILARIS* IMBRUVICA Fairview Specialty Pharmacy Fairview Specialty Pharmacy Caremark * = PRIOR AUTHORIZATION REQUIRED, ST = Step Therapy, QL = Quantity Limits, = Not subject to specialty prescription drug copay; will collect the applicable outpatient prescription drug copay as outlined in member Certificate of Coverage. ‡ = Oral Oncology Split Fill Program. Prior authorization may be required to obtain coverage for select drugs on this list. Generic drugs will be dispensed when available. Brand name drugs may be subject to the non-Preferred benefit if the generic becomes available. Brand name drugs listed in ALL CAPS. Select drugs on this list may be excluded under your specific plan design. Please refer to your coverage document to determine specific benefit levels. If you have questions, please call the Medica Customer Service number listed on the back of your ID card. This list is subject to change. © 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC. Last Updated: 10/24/14 Specialty Preferred Drug List Effective 1/1/2015 Drug Name Drug List Status Therapeutic Class Available Through KINERET * Specialty Tier 1 Dermatological Agents Fairview Specialty Pharmacy KORLYM * Specialty Tier 2 Hormone Antagonist Curascript or Accredo Health KUVAN Specialty Tier 1 Metabolic Enzyme Fairview Specialty Pharmacy KYNAMRO * Specialty Tier 1 Lipid Lowering Agent Walgreens Specialty Pharmacy lamivudine (Epivir HBV) Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy LETAIRIS Specialty Tier 1 Pulmonary Hypertension Walgreens Specialty Pharmacy LEUKINE Specialty Tier 1 Blood and Coagulation Fairview Specialty Pharmacy leuprolide Specialty Tier 1 Fairview Specialty Pharmacy LUPANETA PACK Specialty Tier 2 Hormone Antagonist Hormones and Related Agents LUPRON DEPOT Specialty Tier 1 Hormone Antagonist Fairview Specialty Pharmacy LUVERIS Fairview Specialty Pharmacy Specialty Tier 2 Infertility Fairview Specialty Pharmacy LYSODREN Tier 2 Antineoplastic Fairview Specialty Pharmacy MAKENA * QL Specialty Tier 1 Endocrine Metabolic Agent Fairview Specialty Pharmacy MATULANE Tier 2 Antineoplastic Walgreens Specialty Pharmacy MEKINIST * Tier 2 Antineoplastic Fairview Specialty Pharmacy MENOPUR Specialty Tier 1 Infertility Fairview Specialty Pharmacy MYALEPT * Specialty Tier 2 Endocrine Metabolic Agent Accredo Health NEULASTA Specialty Tier 1 Blood and Coagulation Fairview Specialty Pharmacy NEUMEGA Specialty Tier 1 Blood and Coagulation Fairview Specialty Pharmacy NEUPOGEN Specialty Tier 1 Blood and Coagulation NEXAVAR ‡ Tier 2 Antineoplastic Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) NILANDRON Tier 2 Antineoplastic Fairview Specialty Pharmacy NORDITROPIN * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy NORDITROPIN FLEXPRO * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy NORDITROPIN NORDIFLEX * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy NOVAREL Specialty Tier 2 Infertility Fairview Specialty Pharmacy NUTROPIN * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy NUTROPIN AQ * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy octreotide acetate Specialty Tier 1 Endocrine Metabolic Agent OFEV * Specialty Tier 2 Respiratory Agent Fairview Specialty Pharmacy Acro Pharmaceutical Services OR Advanced Care Scripts OLYSIO * Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy OMNITROPE * Specialty Tier 1 Growth Hormones Fairview Specialty Pharmacy OPSUMIT Specialty Tier 1 Pulmonary Hypertension Caremark OR Accredo Health ORENCIA SQ * Specialty Tier 2 Inflammatory Diseases Fairview Specialty Pharmacy ORENITRAM ER * Specialty Tier 2 Pulmonary Hypertension Walgreens Specialty Pharmacy OTEZLA * Specialty Tier 2 Inflammatory Diseases Fairview Specialty Pharmacy OVIDREL Specialty Tier 2 Infertility Fairview Specialty Pharmacy * = PRIOR AUTHORIZATION REQUIRED, ST = Step Therapy, QL = Quantity Limits, = Not subject to specialty prescription drug copay; will collect the applicable outpatient prescription drug copay as outlined in member Certificate of Coverage. ‡ = Oral Oncology Split Fill Program. Prior authorization may be required to obtain coverage for select drugs on this list. Generic drugs will be dispensed when available. Brand name drugs may be subject to the non-Preferred benefit if the generic becomes available. Brand name drugs listed in ALL CAPS. Select drugs on this list may be excluded under your specific plan design. Please refer to your coverage document to determine specific benefit levels. If you have questions, please call the Medica Customer Service number listed on the back of your ID card. This list is subject to change. © 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC. Last Updated: 10/24/14 Specialty Preferred Drug List Effective 1/1/2015 Drug Name Drug List Status Therapeutic Class Available Through PEGASYS * Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy PEG-INTRON * Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy PEG-INTRON REDIPEN * Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy PLEGRIDY ST Specialty Tier 1 Multiple Sclerosis Tier 2 Antineoplastic Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) PREGNYL Specialty Tier 1 Infertility Fairview Specialty Pharmacy PROCRIT * Specialty Tier 1 Blood and Coagulation Fairview Specialty Pharmacy PROCYSBI Specialty Tier 2 Renal-Urologic Agent Accredo Health PROFASI Specialty Tier 2 Fairview Specialty Pharmacy PROLIA* Specialty Tier 1 Infertility Hormones and Related Agents PROMACTA* Specialty Tier 1 Blood and Coagulation Fairview Specialty Pharmacy PULMOZYME Specialty Tier 1 Respiratory RAVICTI * Specialty Tier 1 Hyperammonemia REBETOL SOLUTION Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy Fairview Specialty Pharmacy Accredo Health OR Caremark Fairview Specialty Pharmacy Accredo Health OR Caremark REBIF Specialty Tier 1 Multiple Sclerosis Fairview Specialty Pharmacy RELISTOR Specialty Tier 1 Opioid Antagonist Fairview Specialty Pharmacy REPRONEX Specialty Tier 1 Infertility Fairview Specialty Pharmacy REVATIO * Specialty Tier 1 Pulmonary Hypertension REVLIMID Tier 2 Antineoplastic Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) RIBASPHERE Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy ribavirin Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy ROFERON-A Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy SABRIL* Specialty Tier 1 Anticonvulsant Accredo Health SAIZEN * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy SANDOSTATIN Specialty Tier 2 Endocrine Metabolic Agent Fairview Specialty Pharmacy SANDOSTATIN LAR Specialty Tier 1 Endocrine Metabolic Agent Fairview Specialty Pharmacy SEROSTIM * Specialty Tier 2 Growth Hormones Walgreens Specialty Pharmacy SILDENAFIL 20MG * Specialty Tier 1 Pulmonary Hypertension Fairview Specialty Pharmacy SIGNIFOR * Specialty Tier 2 Hormone Antagonist Accredo Health SIMPONI* Specialty Tier 2 Inflammatory Diseases Fairview Specialty Pharmacy SOMATULINE DEPOT Specialty Tier 1 Fairview Specialty Pharmacy SOMAVERT Specialty Tier 2 Endocrine Metabolic Agent Growth Hormone Receptor Antagonist Walgreens Specialty Pharmacy SOVALDI * Specialty Tier 1 Antiinfective Fairview Specialty Pharmacy SPRYCEL ‡ Tier 2 Antineoplastic STIVARGA Tier 2 Antineoplastic Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) Specialty Tier 2 Psoriasis Fairview Specialty Pharmacy POMALYST , ST STELARA * Fairview Specialty Pharmacy Specialty Tier 2 SUCRAID Gastrointestinal Accredo Health * = PRIOR AUTHORIZATION REQUIRED, ST = Step Therapy, QL = Quantity Limits, = Not subject to specialty prescription drug copay; will collect the applicable outpatient prescription drug copay as outlined in member Certificate of Coverage. ‡ = Oral Oncology Split Fill Program. Prior authorization may be required to obtain coverage for select drugs on this list. Generic drugs will be dispensed when available. Brand name drugs may be subject to the non-Preferred benefit if the generic becomes available. Brand name drugs listed in ALL CAPS. Select drugs on this list may be excluded under your specific plan design. Please refer to your coverage document to determine specific benefit levels. If you have questions, please call the Medica Customer Service number listed on the back of your ID card. This list is subject to change. © 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC. Last Updated: 10/24/14 Specialty Preferred Drug List Effective 1/1/2015 Drug Name Drug List Status Therapeutic Class Available Through SUTENT ‡ Tier 2 Antineoplastic Fairview Specialty Pharmacy SYLATRON Specialty Tier 1 Fairview Specialty Pharmacy SYNAREL Specialty Tier 1 Antineoplastic Hormones and Related Agents TAFINLAR * Tier 2 Antineoplastic Fairview Specialty Pharmacy TARCEVA ‡ Tier 2 Antineoplastic Fairview Specialty Pharmacy TARGRETIN CAPSULES ‡ Tier 2 Antineoplastic Fairview Specialty Pharmacy TARGRETIN TOPICAL GEL ‡ Tier 2 Antineoplastic Fairview Specialty Pharmacy TASIGNA ‡ Tier 2 Antineoplastic Fairview Specialty Pharmacy TECFIDERA QL Specialty Tier 1 Multiple Sclerosis Fairview Specialty Pharmacy temozolomide Tier 1 Antineoplastic Fairview Specialty Pharmacy TEV-TROPIN * Specialty Tier 2 Growth Hormones Fairview Specialty Pharmacy THALOMID Tier 2 Antineoplastic Fairview Specialty Pharmacy tobramycin (Tobi) Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy TOBI PODHALER Specialty Tier 1 Antiinfectives Fairview Specialty Pharmacy TRACLEER Specialty Tier 1 Pulmonary Hypertension Fairview Specialty Pharmacy TRELSTAR Specialty Tier 2 Hormone Antagonist Fairview Specialty Pharmacy TRELSTAR DEPOT Specialty Tier 2 Hormone Antagonist Fairview Specialty Pharmacy TRELSTAR LA Specialty Tier 2 Hormone Antagonist Fairview Specialty Pharmacy tretinoin oral Tier 1 Antineoplastic Fairview Specialty Pharmacy TYKERB Tier 2 Antineoplastic Fairview Specialty Pharmacy Specialty Tier 2 Antiinfective Fairview Specialty Pharmacy Tier 2 Antineoplastic Accredo Health VICTRELIS* Specialty Tier 2 Antiinfective Fairview Specialty Pharmacy VIRAZOLE Specialty Tier 2 Antiinfective Fairview Specialty Pharmacy VIVITROL, QL Specialty Tier 1 Chemical Dependency Fairview Specialty Pharmacy VOTRIENT QL ‡ Tier 2 Antineoplastic XALKORI QL * Tier 2 Antineoplastic Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) XELJANZ * Specialty Tier 2 Inflammatory Diseases Fairview Specialty Pharmacy XENAZINE Specialty Tier 1 Dopamine antagonist Accredo Health XGEVA* Specialty Tier 1 Immunological agent XOLAIR * Specialty Tier 1 Asthma XTANDI Tier 2 Antiandrogen Fairview Specialty Pharmacy Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) Fairview Specialty Pharmacy (UMP and Fairview Physicians) Walgreens Specialty Pharmacy (all other Physicians) XYREM Specialty Tier 1 Sedative / Hypnotic SDS Pharmacy ZAVESCA Specialty Tier 1 Enzyme Inhibitor Curascript or Accredo Health ZELBORAF * Tier 2 Antineoplastic Fairview Specialty Pharmacy ZOLINZA ‡ Tier 2 Antineoplastic Fairview Specialty Pharmacy ZORBTIVE * Specialty Tier 2 Growth Hormones Walgreens Specialty Pharmacy TYZEKA VALCHLOR Fairview Specialty Pharmacy * = PRIOR AUTHORIZATION REQUIRED, ST = Step Therapy, QL = Quantity Limits, = Not subject to specialty prescription drug copay; will collect the applicable outpatient prescription drug copay as outlined in member Certificate of Coverage. ‡ = Oral Oncology Split Fill Program. Prior authorization may be required to obtain coverage for select drugs on this list. Generic drugs will be dispensed when available. Brand name drugs may be subject to the non-Preferred benefit if the generic becomes available. Brand name drugs listed in ALL CAPS. Select drugs on this list may be excluded under your specific plan design. Please refer to your coverage document to determine specific benefit levels. If you have questions, please call the Medica Customer Service number listed on the back of your ID card. This list is subject to change. © 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC. Last Updated: 10/24/14 Specialty Preferred Drug List Effective 1/1/2015 Drug Name Drug List Status Therapeutic Class Available Through ZYDELIG Tier 2 Antineoplastic Fairview Specialty Pharmacy (UMP and Fairview Physicians) Onco360 Pharmacy ZYKADIA * Tier 2 Antineoplastic Fairview Specialty Pharmacy ZYTIGA Tier 2 Antiandrogen Fairview Specialty Pharmacy PHARMACY CONTACT INFORMATION ACRO PHARMACEUTICAL SERVICES (800) 906-7798 CURASCRIPT (888) 773-7376 ACCREDO (866) 898-0104 DIPLOMAT SPECIALTY PHARMACY (855) 253-3273 ADVANCED CARE SCRIPTS (855) 252-5715 FAIRVIEW SPECIALTY PHARMACY (612) 672-5288 or (877) 509-5114 BIOLOGICS, INC. (800) 850-4306 JUXTAPID REMS PROGRAM (855) 898-2743 CAREMARK (800) 237-2767 ONCO360 PHARMACY (877)-662-6633 CAYSTON ACCESS PROGRAM (877) 722-9786 SDS PHARMACY 1-866-997-3688 CHENODAL TOTAL CARE PROGRAM (866) 758-7068 WALGREENS SPECIALTY PHARMACY (866) 406-4209 ORAL ONCOLOGY BENEFIT INFORMATION Oral drugs for the treatment of cancer that are included on the Specialty Pharmacy benefit are restricted to the Specialty Pharmacy Network but are not subject to the specialty prescription drug copay. They will collect the applicable outpatient prescription drug copay as outlined in your benefit plan documents. Medications marked by ‡ are subject to the Oral Oncology Split Fill Program. If you are started on one of these medications, you will initially be able to receive up to a 15 day supply. The remainder of the prescription will be available after the initial fill. The partial fill of the medication will continue for the initial 3 months of treatment. Your copay for the full amount of * = PRIOR AUTHORIZATION REQUIRED, ST = Step Therapy, QL = Quantity Limits, = Not subject to specialty prescription drug copay; will collect the applicable outpatient prescription drug copay as outlined in member Certificate of Coverage. ‡ = Oral Oncology Split Fill Program. Prior authorization may be required to obtain coverage for select drugs on this list. Generic drugs will be dispensed when available. Brand name drugs may be subject to the non-Preferred benefit if the generic becomes available. Brand name drugs listed in ALL CAPS. Select drugs on this list may be excluded under your specific plan design. Please refer to your coverage document to determine specific benefit levels. If you have questions, please call the Medica Customer Service number listed on the back of your ID card. This list is subject to change. © 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC. Last Updated: 10/24/14 Specialty Preferred Drug List Effective 1/1/2015 medication will be divided evenly between the two split fills per month for the initial 3 months of treatment. * = PRIOR AUTHORIZATION REQUIRED, ST = Step Therapy, QL = Quantity Limits, = Not subject to specialty prescription drug copay; will collect the applicable outpatient prescription drug copay as outlined in member Certificate of Coverage. ‡ = Oral Oncology Split Fill Program. Prior authorization may be required to obtain coverage for select drugs on this list. Generic drugs will be dispensed when available. Brand name drugs may be subject to the non-Preferred benefit if the generic becomes available. Brand name drugs listed in ALL CAPS. Select drugs on this list may be excluded under your specific plan design. Please refer to your coverage document to determine specific benefit levels. If you have questions, please call the Medica Customer Service number listed on the back of your ID card. This list is subject to change. © 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC. Last Updated: 10/24/14
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