2015 Service Benefit Plan Specialty Drug List If you are a member or health care provider, please contact us toll-free at 1-888-346-3731 or visit the Pharmacy section on www.fepblue.org With over 30 years of specialty pharmacy experience, CVS Caremark Specialty Pharmacy provides proactive quality care and service. We have a network of pharmacies which includes those with Joint Commission and URAC accreditation. The Joint Commission and URAC are nationally-recognized symbols of quality which reflects an organization’s commitment to meet high standards of quality and safety. This is not an all-inclusive list and is subject to change. Changes may appear prior to their effective date. To determine the benefit tier of your medication, please contact the Specialty Pharmacy Program toll-free at 1-888-346-3731. A ABRAXANE 1 ACTEMRA 1 ACTHAR HP 1 ACTIMMUNE 1 ADCETRIS 1 ADCIRCA Adefovir Dipvoxil 1 ADEMPAS ADRIAMYCIN ADRUCIL ADVATE AFINITOR 1 ALDURAZYME 1 ALFERON N ALIMTA ALKERAN ALPHANATE ALPHANINE SD ALPROLIX AMEVIVE Amifostine 1 AMPYRA APOKYN ARALAST NP 1 ARANESP 1 ARCALYST ARRANON 1 ARZERRA 1 Prior Approval Required Last Revised: 1.13.15 1 AUBAGIO 1 AVASTIN AVEED AVONEX Azacitidine B BARACLUDE BCG VACCINE (TICE STRAIN) BEBULIN BENEFIX 1 BENLYSTA 1 BERINERT BETASERON BETHKIS BICNU 1 BIVIGAM Bleomycin 1 BOSULIF 1 BOTOX 1 BRAVELLE 1 BUPHENYL C CAMPTOSAR Capecitabine Carboplatin 1 CARIMUNE NF 1 CEPROTIN 1 CERDELGA CEREDASE 1 CEREZYME CERUBIDINE 1 CETROTIDE 1 CIMZIA 1 CINRYZE Cisplatin Cladribine CLOLAR COPAXONE 1 COPEGUS CORIFACT 1 CORTICOTROPIN COSMEGEN Cyclophosphamide 1 CYRAMZA CYSTAGON Cytarabine CYTOGAM CYTOVENE D Dacarbazine DACOGEN Dactinomycin Daunorubucin DAUNOXOME Deferoxamine DEPOCYT DESFERAL Desferal 1 DYSPORT E EGRIFTA 1 ELAPRASE 1 ELIGARD ELITEK ELLENCE ELOCTATE ELOXATIN ELSPAR 1 ENBREL Entecavir 1 ENTYVIO Epirubicin 1 EPOGEN ERBITUX 1 ERIVEDGE ESBRIET ETHYOL ETOPOPHOS Etoposide 1 EUFLEXXA 1 EXJADE EXTAVIA EYLEA F 1 FABRAZYME FASLODEX FEIBA 1 FIRAZYR FIRMAGON 1 FLEBOGAMMA Floxuridine FLUDARA Fludarabine Fluorouracil FOLLISTIM/ 1 ANTAGON FOLOTYN FORTEO FUDR FUSILEV G 1 GAMASTAN S/D 1 GAMMAGARD 1 GAMMAKED 1 GAMMAPLEX 1 GAMUNEX-C Ganciclovir 1 Ganirelix 1 GATTEX 1 GAZYVA 1 GEL-ONE Gemcitabine GEMZAR 1 GENOTROPIN 1 GILENYA Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. GLASSIA GLEEVEC 1 GONAL-F 1 GRANIX H HALAVEN 1 HARVONI HELIXATE HEMOFIL M HEPAGAM B HEPSERA 1 HERCEPTIN 1 HIZENTRA HUMATE-P 1 HUMATROPE 1 HUMIRA 1 HYALGAN HYCAMTIN HYPERHEP B S/D HYPERRHO S/D HyQvia I IDAMYCIN Idarubicin IFEX Ifosfamide Ifosfamide-Mesna 1 ILARIS IMPLANON 1 INCIVEK 1 INCRELEX INFERGEN 1 1 INLYTA 1 INTRON-A Irinotecan ISTODAX IXEMPRA J 1 JAKAFI 1 JEVTANA K 1 KADCYLA 1 KALBITOR 1 KALYDECO 1 KEPIVANCE 1 KINERET KOATE-DVI KOGENATE FS 1 Prior Approval Required Last Revised: 1.13.15 1 KRYSTEXXA 1 KUVAN 1 KYNAMRO 1 KYPROLIS L 1 LETAIRIS Leucovorin 1 LEUKINE 1 Leuprolide LEUSTATIN LIPODOX LUCENTIS 1 LUMIZYME LUPANETA 1 LUPRON DEPOT M MACUGEN MAKENA 1 MEKINIST Melphalan 1 MENOPUR MESNA MESNEX Methotrexate MICRHOGAM MIRENA Mitomycin Mitoxantrone MONOCLATE-P MONONINE 1 MONOVISC MOZOBIL MUSTARGEN 1 MYOBLOC 1 MYOZYME N Nabi-hb 1 NAGLAZYME NAVELBINE NEOSAR 1 NEULASTA NEUMEGA 1 NEUPOGEN NEXAVAR NEXPLANON NIPENT 1 NORDITROPIN NORHERA Novarel NOVOSEVEN NPLATE NULOJIX 1 NUTROPIN AQ O 1 OCTAGAM Octreotide 1 OLYSIO 1 OMNITROPE ONCASPAR ONTAK 1 OPDIVO 1 OPSUMIT 1 ORALAIR 1 ORENCIA 1 ORENITRAM 1 ORTHOVISC 1 OTEZLA OTREXUP 1 OVIDREL Oxaliplatin P Paclitaxel Pamidronate 1 PEGASYS 1 PEG-INTRON Pentostatin 1 PERJETA PHOTOFRIN PLEGRIDY 1 POMALYST Pregnyl 1 PRIVIGEN 1 PROCRIT PROFILNINE PROLEUKIN PROLIA 1 PROMACTA 1 PULMOZYME Q QUADRAMET R RASUVO 1 RAVICITI 1 REBETOL REBIF RECLAST RECOMBINATE 1 REMICADE 1 REMODULIN 1 REPRONEX 1 REVATIO 1 REVLIMID RHOGAM PLUS RHOPHYLAC RIASTAP Ribapak Ribasphere Ribatab Ribavirin 1 RITUXAN RIXUBIS RUCONEST S SABRIL 1 SAIZEN SAMSCA SANDOSTATIN SENSIPAR 1 SEROSTIM Sildenafil 1 SIMPONI SKYLA Sodium Phenylbutyrate SOLESTA 1 SOLIRIS SOMATULINE SOMAVERT 1 SOVALDI SPRYCEL 1 STELARA STIMATE 1 STIVARGA 1 SUPARTZ SUPPRELIN LA SUTENT 1 SYLATRON 1 SYNAGIS 1 SYNBRIO 1 SYNVISC T 1 TAFINLAR TARCEVA TARGRETIN TASIGNA TAXOTERE 1 TECFIDERA TEMODAR Temozolomide 1 TEV-TROPIN THALOMID THERACYS THIOTEPA THYROGEN TIKOSYN TOBI Tobramycin TOPOSAR Topotecan TORISEL TOTECT 1 TRACLEER 1 TREANDA TRELSTAR TRETTEN TRISENOX 1 TYKERB 1 TYSABRI 1 TYVASO TYZEKA U UVADEX V VALSTAR VANTAS 1 VARZIG VECTIBIX 1 VELCADE 1 VELETRI 1 VENTAVIS 1 VICTRELIS VIDAZA 1 VIEKIRA 1 VIMIZIM Vinblastine VINCASAR Vinocristine Vinorelbine VISUDYNE 1 VIVAGLOBIN VIVITROL VOTRIENT 1 VPRIV W WILATE Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. WINRHO SD/SDF X 1 XALKORI 1 XELJANZ XELODA 1 XENAZINE 1 XEOMIN XGEVA 1 XIAFLEX 1 XOLAIR 1 XTANDI XYNTHA Y 1 YERVOY Z ZALTRAP ZANOSAR 1 ZELBORAF ZEMAIRA ZINECARD ZOLADEX Zoledronic Acid 1 ZOLINZA ZOMETA 1 ZORBTIVE ZORTRESS 1 ZYKADIA 1 ZYTIGA 1 Prior Approval Required Last Revised: 1.13.15 Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. Limited Distribution Drug List Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through specific Preferred retail pharmacies, and are referred to as Limited Distribution Drugs. The following list of current Limited Distribution Specialty drugs may be obtained through a specific Preferred retail pharmacy with the Specialty Drug Pharmacy Program copayments under Standard Option and Basic Option. Please contact Caremark Specialty Pharmacy at 1-888-346-3731 for assistance with finding the appropriate pharmacy. Please read the Specialty Drug Pharmacy Program section of your Plan Benefit Brochure. JUXTAPID K KORLYM1 L LYNPARZA1 M PROLASTIN PROVENGE S SIGNIFOR SYNBRIO1 V C CAMPATH ELELYSO1 ERWINAZE F FERRIPROX FLOLAN1 FLOLAN STERILE DILUENT G GILOTRIF MATULANE MARQIBO VALCHLOR VORAXAZE CAYSTON CAPRELSA CARBAGLU COMETRIQ CYRAMZA CYSTADANE CYSTARAN E H HETLIOZ1 I IMBRUVICA ICLUSIG 1 IRESSA J JETREA MYALEPT1 O OFEV1 ORFADIN P PRIALT PROCYSBI1 PURIXAN Z ZAVESCA ZYDELIG A ADAGEN APLIGRAF B BELEODAQ1 BLINCYTO1 Limited Distribution Drugs (LDD) are medications the manufacturer chooses to limit the distribution of their medication to only a few pharmacies, or the Food and Drug Administration (FDA) may require this restriction during the drug approval process. This type of restricted distribution helps the manufacturer keep track of drug inventory, may have special dosing or lab monitoring requirements that need to be followed very closely and ensure that any risks that are associated with the LDD are minimized. Last Revised: 1.13.15