High Cost Medical Drug List - Health Alliance

High Cost Medical Drugs List

High Cost Medical Drugs administered by Health Alliance providers within physician offices, infusion centers or

hospital outpatient settings must be acquired from preferred specialty vendors. Health Alliance will not

reimburse any drug listed as a ¡°High Cost Medical Drug,¡± whether obtained from the provider¡¯s own stock or

via ¡°buy-and-bill.¡±

This drug list does not apply to members with Medicare coverage. Information on how to acquire these

medications is located at the end of this document.

Recent Updates

Drug Therapy

Oncology ¨C Injectable

Oncology ¨C Injectable

Oncology ¨C Injectable

Oncology ¨C CAR-T

Ophthalmology

Disorders

Oncology ¨C CAR-T

Sickle Cell Disease

Rheumatoid Arthritis

Ophthalmology

Disorders

Oncology ¨C Injectable

Oncology ¨C Injectable

Neutropenia

Oncology ¨C Injectable

Oncology ¨C Injectable

Code

PA

Effective

Preferred

Vendor

Contact

Number

AVASTIN

LARTRUVO

VUMON

KYMRIAH

J9035

J9285

Q2017

Q2042

YES

YES

YES

YES

7/1/2020

7/1/2020

7/1/2020

8/1/2020

CVS/Caremark?

LDD

LDD

LDD

800-237-2767

Removed

Removed

Removed

Removed

TEPEZZA

J3590

YES

8/1/2020

Accredo?

866-759-1557

Added

YESCARTA

ADAKVEO

AVOSLA

Q2041

J0791

Q5121

YES 8/1/2020

YES 10/1/2020

YES 10/1/2020

LDD

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

Removed

Added

Added

DURYSTA

J3490

NO

10/1/2020

CVS/Caremark?

800-237-2767

Added

ENHERTU

HERZUMA

NYVEPRIA

ONTRUZANT

PADCEV

J9358

Q5113

TBD

Q5112

J9177

YES

YES

NO

YES

YES

10/1/2020

10/1/2020

10/1/2020

10/1/2020

10/1/2020

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

Added

Added

Added

Added

Added

Drug Name

Change

High Cost Medical Drug List

Drug Therapy

Acromegaly

Acromegaly

Additional Products

Additional Products

Additional Products

Additional Products

Additional Products

Additional Products

Drug Name

SANDOSTATIN

SOMATULINE

JETREA

PROLASTIN

QUTENZA

REVCOVI

RADICAVA

SIGNIFOR

Code

PA

Effective

Preferred

Vendor

Contact

Number

J2353

J1930

J7316

J0256

J7336

J3590

J1301

J2502

YES

YES

YES

YES

NO

YES

YES

YES

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

LDD

LDD

LDD

LDD

CVS/Caremark?

Accredo?

800-237-2767

800-237-2767

800-237-2767

866-759-1557

Drug Therapy

Drug Name

Code

PA

Effective

Preferred

Vendor

Contact

Number

Additional Products

Additional Products

Additional Products

Allergic Asthma

Allergic Asthma

Allergic Asthma

Allergic Asthma

Alpha-1 Antitrypsin

Deficiency

Alpha-1 Antitrypsin

Deficiency

Alpha-1 Antitrypsin

Deficiency

SPRAVATO

STRENSIQ

THIOTEPA

CINQAIR

FASENRA

NUCALA

XOLAIR

J3490

J3590

J9340

J2786

J0517

J2182

J2357

YES

YES

YES

YES

YES

YES

YES

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

LDD

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

ARALAST NP

J0256

YES

7/1/2020

CVS/Caremark?

800-237-2767

GLASSIA

J0257

YES

7/1/2020

CVS/Caremark?

800-237-2767

ZEMAIRA

J0256

YES

7/1/2020

CVS/Caremark?

800-237-2767

Anemia

ARANESP

NO

7/1/2020

CVS/Caremark?

800-237-2767

Anemia

EPOGEN

NO

7/1/2020

CVS/Caremark?

800-237-2767

Anemia

MIRCERA

NO

7/1/2020

LDD

NO

7/1/2020

CVS/Caremark?

800-237-2767

NO

7/1/2020

CVS/Caremark?

800-237-2767

Anemia

Anemia

Atypical Hemolytic

Uremic Syndrome

Botulinum Toxins

Botulinum Toxins

Botulinum Toxins

Botulinum Toxins

Dupuytren's

Contracture

Gout

Hematopoietics

Hemophilia

Hemophilia

Hemophilia

PROCRIT

RETACRIT

J0881

J0882

J0885

Q4081

J0887

J0888

J0885

Q4081

Q5105

Q5106

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

ULTOMIRIS

J1303

YES

7/1/2020

CVS/Caremark?

800-237-2767

BOTOX

DYSPORT

MYOBLOC

XEOMIN

J0585

J0586

J0587

J0588

YES

YES

YES

YES

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

CVS/Caremark ?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

800-237-2767

XIAFLEX

J0775

YES

7/1/2020

US Bioservices?

888-518-7246

KRYSTEXXA

MOZOBIL

ADVATE

ADYNOVATE

AFSTYLA

J2507

J2562

J7192

J7207

J7210

J7186

J7190

J7193

J7201

J7194

J7195

J7175

J7180

J7205

YES

YES

NO

NO

NO

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

NO

7/1/2020

CVS/Caremark?

800-237-2767

NO

NO

NO

NO

NO

NO

NO

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

Hemophilia

ALPHANATE

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

ALPHANINE SD

ALPROLIX

BEBULIN

BENEFIX

COAGADEX

CORIFACT

ELOCTATE

Page 2

PHRXGN20-highcostdrugMedList-0820

Updated Last 8/1/2020

Drug Name

Code

PA

Effective

Preferred

Vendor

Contact

Number

FEIBA

FIBRYGA

HELIXATE FS

HEMLIBRA

HEMOFIL M

HUMATE-P

IDELVION

IXINITY

JIVI

KOATE

KOGENATE

KOVALTRY

MONOCLATE-P

MONONINE

NOVOEIGHT

NOVOSEVEN RT

NUWIQ

OBIZUR

PROFILNINE SD

REBINYN

RECOMBINATE

RIASTAP

RIXUBIS

STIMATE

TRETTEN

VONVENDI

WILATE

XYNTHA

J7198

J7177

J7192

J7170

J7190

J7187

J7202

J7195

J7208

J7190

J7192

J7211

J7190

J7193

J7182

J7189

J7209

J7188

J7194

J7203

J7192

J7178

J7200

J3490

J7181

J7179

J7183

J7185

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

CINRYZE

J0598

YES

7/1/2020

CVS/Caremark?

800-237-2767

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

YES

7/1/2020

CVS/Caremark?

800-237-2767

YES

7/1/2020

CVS/Caremark?

800-237-2767

Hormonal Therapies

LUPRON DEPOT

YES

7/1/2020

CVS/Caremark?

800-237-2767

Hormonal Therapies

Hormonal Therapies

Hormonal Therapies

Hormonal Therapies

Hormonal Therapies

I.V.I.G.

I.V.I.G.

I.V.I.G.

SUPPRELIN

TRELSTAR

TRIPTODUR

VANTAS

ZOLADEX

ASCENIV

BIVIGAM

CARIMUNE

J9217

J9155

J1950

J9217

J3490

J1950

J9217

J9226

J3315

J3316

J9225

J9202

J1599

J1556

J1566

YES

YES

Hormonal Therapies

ELIGARD

FIRMAGON

LEUPROLIDE

ACETATE

LUPANETA PACK

YES

YES

YES

YES

YES

YES

YES

YES

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

LDD

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

Drug Therapy

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hemophilia

Hereditary

Angioedema

Hormonal Therapies

Hormonal Therapies

Hormonal Therapies

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

Page 3

PHRXGN20-highcostdrugMedList-0820

Updated Last 8/1/2020

Drug Therapy

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

I.V.I.G.

Infectious Disease

Infectious Disease

Inflammatory Bowel

Disease

Inflammatory Bowel

Disease

Inflammatory Bowel

Disease

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Drug Name

Code

PA

Effective

Preferred

Vendor

Contact

Number

CUTAQUIG

CYTOGAM

FLEBOGAMMA

GAMASTAN S/D

GAMMAGARD

GAMMAGARD S/D

GAMMAKED

GAMMAPLEX

GAMUNEX

GAMUNEX-C

HIZENTRA

HYPERRHO S/D

NABI-HB

OCTAGAM

PANZYGA

PRIVIGEN

RHOGAM

RHOPHYLAC

WINRHO

XEMBIFY

ALFERON N

TROGARZO

J3590

J0850

J1572

J1560

J1569

J1566

J1561

J1557

J1561

J1561

J1559

J2790

90371

J1568

J1599

J1459

J2790

J2791

J2792

J1558

J9215

J1746

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

NO

YES

YES

YES

YES

NO

NO

NO

YES

YES

NO

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

LDD

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

CIMZIA

J0717

YES

7/1/2020

CVS/Caremark?

800-237-2767

ENTYVIO

J3380

YES

7/1/2020

CVS/Caremark?

800-237-2767

RENFLEXIS

Q5104

YES

7/1/2020

CVS/Caremark?

800-237-2767

ALDURAZYME

J1931

YES

7/1/2020

CVS/Caremark?

800-237-2767

CEREZYME

J1786

YES

7/1/2020

CVS/Caremark?

800-237-2767

ELAPRASE

J1743

YES

7/1/2020

CVS/Caremark?

800-237-2767

ELELYSO

J3060

YES

7/1/2020

CVS/Caremark?

800-237-2767

FABRAZYME

J0180

YES

7/1/2020

CVS/Caremark?

800-237-2767

KANUMA

J2840

YES

7/1/2020

CVS/Caremark?

800-237-2767

LUMIZYME

J0221

YES

7/1/2020

CVS/Caremark?

800-237-2767

NAGLAZYME

J1458

YES

7/1/2020

CVS/Caremark?

800-237-2767

Page 4

PHRXGN20-highcostdrugMedList-0820

Updated Last 8/1/2020

Drug Therapy

Lysosomal Storage

Diseases

Lysosomal Storage

Diseases

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Neutropenia

Neutropenia

Neutropenia

Neutropenia

Neutropenia

Neutropenia

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Ophthalmology

Disorders

Oncology

Oncology

Oncology - Injectable

Oncology - Injectable

Oncology - Injectable

Oncology - Injectable

Oncology ¨C Injectable

Oncology ¨C Injectable

Code

PA

Effective

Preferred

Vendor

Contact

Number

VIMIZIM

J1322

YES

7/1/2020

CVS/Caremark?

800-237-2767

VPRIV

J3385

YES

7/1/2020

CVS/Caremark?

800-237-2767

LEMTRADA

OCREVUS

TYSABRI

FULPHILA

LEUKINE

NEULASTA

NYVEPRIA

UDENYCA

ZIEXTENZO

J0202

J2350

J2323

Q5108

J2820

J2505

TBD

Q5111

Q5120

YES

YES

YES

NO

NO

NO

NO

NO

NO

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

10/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

800-237-2767

BEOVU

J0179

NO

7/1/2020

CVS/Caremark?

800-237-2767

DURYSTA

J3490

NO

10/1/2020

CVS/Caremark?

800-237-2767

EYLEA

J0178

NO

7/1/2020

CVS/Caremark?

800-237-2767

ILUVIEN

J7313

NO

7/1/2020

CVS/Caremark?

800-237-2767

LUCENTIS

J2778

NO

7/1/2020

CVS/Caremark?

800-237-2767

LUXTURNA

J3398

YES

7/1/2020

Accredo?

866-759-1557

MACUGEN

J2503

NO

7/1/2020

CVS/Caremark?

800-237-2767

OZURDEX

J7312

NO

7/1/2020

CVS/Caremark?

800-237-2767

RETISERT

J7311

NO

7/1/2020

CVS/Caremark?

800-237-2767

TEPEZZA

J3590

YES

8/1/2020

Accredo?

866-759-1557

VISUDYNE

J3396

NO

7/1/2020

CVS/Caremark?

800-237-2767

YUTIQ

J7314

NO

7/1/2020

US Bioservices?

888-518-7246

ZOLEDRONIC ACID

TEMODAR

ADCETRIS

ALIQOPA

ASPARLAS

ARZERRA

AZACITIDINE

BAVENCIO

J3489

J9328

J9042

J9057

J9118

J9302

J9025

J9023

NO

YES

YES

YES

YES

YES

YES

YES

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

7/1/2020

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

LDD

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

CVS/Caremark?

800-237-2767

800-237-2767

800-237-2767

Drug Name

800-237-2767

800-237-2767

800-237-2767

800-237-2767

Page 5

PHRXGN20-highcostdrugMedList-0820

Updated Last 8/1/2020

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