1. No category

Effective 1/01/2014
Revised 2/11/2015
Listed below are the medications covered under your Specialty Self Injectable Benefit. For plans with specialty
copays, these medications are divided into four levels of cost sharing for which you are responsible. These lists
may change without notice at any time. All of these medications require pre-certification. Limited to 30-day
supply. BCBSAZ has selected Briova Specialty Pharmacy please contact them at (866) 618-6741 to establish service.
Level A
Level B
Level C
Level D
Avonex*
Aranesp*
Acthar HP*
Gattex*
Copaxone*
Enbrel*
Cimzia*
Genotropin*
Fuzeon*
Epogen*
Kineret*
Humatrope*
Octreotide*
Extavia*
Neumega*
Increlex*
Forteo*
Relistor*
Norditropin*
Humira*
Sandostatin*
Omnitrope*
Infergen*
Signifor*
Orencia SQ*
Intron A*
Simponi*
Saizen*
Nutropin*
Synribo
Tev-Tropin*
Nutropin AQ*
Zorbitive*
Neulasta*
Neupogen*
Pegasys*
Pegasys Proclick*
Peg Intron Redipen or
vial*
Procrit*
Rebif*
Sandostatin LAR Depot*
Serostim*
Somatuline Depot*
Listed below are the medications covered under your Specialty Medication Benefit. For plans with specialty
copays, these medications are divided into four levels of cost sharing for which you are responsible. These lists
may change without notice at any time. The presence of a drug on this list is not a guarantee of coverage. Some of
these medications may require pre-certification. Limited to 30-day supply. BCBSAZ has selected Briova Specialty
Pharmacy - please contact them at (866) 618-6741 to establish service.
Level A
Level B
Level C
Level D
abacivir tabs
Alkeran
Adcirca tabs
Actemra infusion*
adefov dipiv
Aptivus Caps
Afinitor
Actemra prefill syringe *
*Precertification required.
Level A
Level B
Level C
Level D
Abacavir/lamivudine/
zidovudine
Avonex*
Aptivus Solution
Azilect tabs
Acthar HP*
Aransep*
Bethkis solution*
Actimmune
Copaxone*
Atripla tabs
Bosulif tabs
Adagen
cyclosporine modified
caps, solution (Generic
Neoral/Sandimmune) *
Baraclude solution
Caprelsa tab
Adempas*
Deferoxamine inj
Baraclude tabs
Cayston inhalation
Advate*
didanosine
Buphenyl tabs, powder
Cimzia*
Aldurazyme*
doxercalciferal caps
Capecitabine tabs
Cometriq caps
Alphanate VW*
epoprostenol
Complera tabs
Crinone*
Alphanine SD*
etoposide Cap
Crixivan caps
Cystadane oral solution
Ampyra tab*
ferric gluconate
complex
Cyclophosphamide tabs
Cystagon caps
Apokyn*
fluorouracil cream
Droxia caps
Cytogam
Aralast NP
Fuzeon*
Edurant tabs
Desferal
Arcalyst
Gengraf*
Emtriva caps, solution
Dificid tabs*
Astagraf XL caps
gengraf caps, solution*
Enbrel*
Elmiron caps
Aubagio
Hecoria
Epivir HBV solution
Esbriet*
Bebulin*
lamivudine tabs
Epogen*
Fareston tabs*
Bebulin VH*
lamivudine-zidovudine
tab
Extavia*
Ferriprox tabs
Benefix*
nevirapine tabs
Forteo*
Fluoroplex
Benlysta*
nevirapine ER/SR
400mg tab
Harvoni*
Fosrenol tabs
Berinert*
octreotide acetate*
Humira*
Gleevec
Bivigam 10% solution*
Phenylbutyra sodium
powder
Infergen
Hectoral caps
Botox 100 units*
ribasphere
Intelence tabs
Incivek tabs*
Carimune NF*
ribavirin
Intron A
Inlyta tabs
Cerdelga*
*Precertification required.
Level A
Level B
Level C
Level D
riluzole tabs
Invirase caps, tabs
Kineret*
Cerezyme*
sildenafil citrate 20mg
tabs
Isentress tabs
Korlym tabs
Cinryze
stavudine caps
Kaletra tabs, solution
Kuvan tabs*
Combivir tab
stavudine solution
Leukeran tabs
Lomustine
Copegus tabs
Tacrolimus
Lexiva tabs, suspension
Lysodren tabs
Corifact*
temozolomide caps
Mepron suspension
Matulane
Dysport
Tobramycin nebulizer
Multaq suspension
Mesnex tabs
Efudex
valganciclovir tabs
Nebupent aerosol
Mirapex ER tabs
Elaprase*
voriconazole
Nutropin AQ*
Neumega
Elelyso*
zidovudine caps
Nutropin AQ Nuspin*
Neupro
Eligard*
zidovudine syrup
Neulasta*
Nexavar
Elitek
zidovudine tabs
Neupogen*
paricalcitol
Emcyt caps
Procysbi DR caps
Emsam
Prograf caps
Epivir solution
Noxafil suspension
Prograf IV
Epivir tabs
Nuepogen
Promacta tabs
Epivir HBV tabs
Pegasys*
Samsca tabs
Epzicom tabs
Peg-Intron*
Sensipar tabs
Erivedge caps
Prezista tabs,
suspension
Signifor *
Exjade tab for suspension
Procrit*
Simponi*
Eylea
Prolastin C
Somavert*
Fabrazyme
Pulmozyme
Sovaldi*
Faslodex*
Rebif*
Synarel Nasal Spray*
Feiba NF*
Rebif Rebidose*
Synribo
Feiba VH*
Remicade*
Tarceva*
Ferrlecit
Rescriptor tabs*
Targretin caps
Firazyr*
Revlimid caps
Tasigna caps
Firmagon*
Nevirapine oral
suspension
Norvir tabs
*Precertification required.
Level A
Level B
Level C
Level D
Reyataz caps
Thalomid caps
Flebogamma 5% & 10% DIF*
Sabril tabs, solution
Tikosyn caps
Flolan
Sandimmune*
Tivicay tabs
GamaSTAN S/D
Sandostatin LAR Depot
Kit*
Tobi Podhaler
Gammagard S/D
Selzentry tabs
Tykerb tabs
Gammagard SD less IgA
Serostim*
Tyzeka tabs
Gammaked 10%
Somatuline Depot*
Valcyte oral solution
Gammaplex 5% liquid
Sustiva tabs, caps
Victrelis caps*
Gamunex-C 10%
Tracleer tabs
Viramune XR 100mg tabs
Gattex*
Truvada tabs
Vivitrol
Genotropin*
Videx solution
Votrient
Gilenya caps*
Viracept tabs
Xyrem oral solution*
Gilotrif tabs*
Viramune oral
suspension
Zolinza caps*
Glassia*
Viread tabs, powder
Zorbtive*
Helixate FS*
Xeloda tabs
Zortress tabs
Hemofil M*
Ziagen Solution
Zytiga*
Hepsera tabs
Hexalen
Hizentra
Humate-P*
Humatrope*
Hycamtin caps
Iclusig tabs
Ilaris*
Imbruvica
Increlex
Jakafi tabs
Juxtapid
Kalbitor*
Kalydeco tabs *
Kitabis Pak
Koate DVI
Kogenate FS*
Krystexxa*
Kynamro*
*Precertification required.
Level A
Level B
Level C
Level D
Letairis tabs
Leukine
Lucentis*
Lumizyme
Lupron Depot*
Lupron Depot-PED*
Macugen
Makena
Mekinist*
Mitoxantrone HCL
Moderiba
Monoclate P*
Mononine*
Mozobil
Myfortic
Myleran tabs
Myobloc*
Myozyme
Naglazyme
Neoral*
Norditropin*
Novoseven RT*
Nplate
Nuedexta caps*
Nulojix
Octagam 5%
Olysio*
Omnitrope*
Opsumit*
Orencia*
Orenitram*
Orfadin caps
Otezla tab*
Otezla Starter Kit*
Pamidronate Disodium
Pomalyst
*Precertification required.
Level A
Level B
Level C
Level D
Privigen 10%*
Profilnine SD*
Prolia
Protopic*
Ravicti
Rebetol
Reclast
Recombinate*
Remodulin
Retrovir caps
Retrovir syrup
Retrovir tabs
Revatio
Riastap*
Ribapak
Ribatab
Rilutek tabs
Rixubis*
Saizen*
Sandimmune caps*
Sandostatin*
Simponi Aria*
Soliris*
Sprycel
Stivarga tabs
Stribild tabs
Sucraid oral solution
Supprelin LA*
Sutent
Sylatron
Synagis*
Targretin 1% gel
Tafinlar*
Tecfidera
Temodar caps
Tev-Tropin*
*Precertification required.
Level A
Level B
Level C
Level D
Thyrogen Inj.
Tobi nebulizer
Trelstar*
Tretinoin caps (Vesanoid)
Trizivir tabs
Tysabri*
Tyvaso
Valchlor*
Valcyte tabs
Vantas
Veletri
Ventavis
Vfend
Videx EC
Viekira Pak*
Viramune tabs
Viramune XR 400mg tab
Visudyne
Vpriv
Wilate*
Winrho SDF
Xalkori caps
Xeljanz tabs*
Xenazine tabs
Xeomin*
Xgeva*
Xiaflex
Xifaxan tabs*
Xolair*
Xtandi caps
Xyntha*
Xyntha solofuse kit*
Zavesca*
Zelboraf*
Zemaira
Zemplar caps
*Precertification required.
Level A
Level B
Level C
Level D
Zerit Caps
Zerit Solution
Ziagen Tabs
Zoladex*
zoledronic
Zometa
Zykadia
*Precertification required.