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