Standard Formulary Specialty Drug List - Magellan Rx Management
Standard Formulary Specialty Drug List
Our Specialty Pharmacy provides patients with comprehensive support services and coordinated delivery related
to high-cost oral, inhaled or injectable specialty medications, used to treat complex conditions. We are your
single source for high-touch patient care management to control side effects, patient support and education to
ensure compliance or continued treatment, and specialized handling and distribution of medications directly to
the patient or care provider. Specialty medications may be covered under either the medical or pharmacy
benefit. Please consult your insurance documentation to determine which benefit covers these medications.
This list is updated with new information each quarter.
Characteristics of Specialty Medications
¡°Specialty¡± medications are defined as high-cost oral or injectable medications used to treat complex chronic
conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds
found within the body. High-touch patient care management is usually required to control side effects and
ensure compliance. Specialized handling and distribution are also necessary to ensure appropriate medication
administration. Medications must have at least one of the following characteristics in order to be classified as a
specialty medication by Magellan Rx Management.
High Cost
High-cost medications are typically priced at more than $670 per 30-day supply; including self-administered injectables,
professionally-administered injectables/infusions, and oral medications.
High Complexity
?
?
?
Biotechnology products
Orphan or Ultra-Orphan drugs
Medications that are included in a specialty therapeutic drug class strategy
High Touch
?
?
?
Medications that require temperature control or other special handling/shipping requirements (i.e., refrigerated or
frozen shipping)
Medications that require ongoing drug management by a pharmacist and/or physician specializing in treating the
member¡¯s condition
Medications that require focused, in-depth member education, compliance monitoring, side effect management and,
often, injection technique education
KEY:
Generics: Lower case italic. For example, tobramycin
Brands: All capital letters. For example, HUMIRA
QL: Quantity Limits apply under some benefits. Check your plan document for coverage details.
PA: Prior Authorization needed under some benefits. Check your plan document for coverage details.
PS: Preferred Specialty
PS1: Preferred Specialty first-line
PS2: Preferred Specialty second-line
DRUG NAME
QL
PA
PS
PS1
PS2
ANALGESICS
PRIALT
DRUG NAME
QL
PA
PS
NUCALA
X
X
X
X
X
XOLAIR
ANTIARTHRITICS
DUROLANE
ANTIBIOTICS
ARIKAYCE
X
ELITEK
X
X
BETHKIS
X
CAYSTON
X
X
EUFLEXXA
X
GEL-ONE
X
KITABIS PAK
GENVISC 850
X
THALOMID
HYALGAN
X
TOBI
X
HYMOVIS
X
TOBI PODHALER
X
X
X
X
KINERET
X
X
tobramycin
X
KRYSTEXXA
X
X
XENLETA
X
MONOVISC
ANTICOAGULANTS
X
OLUMIANT
X
X
ORENCIA
X
X
X
enoxaparin sodium
ORENCIA CLICKJECT
X
X
X
fondaparinux sodium
ORTHOVISC
PS1
ARIXTRA
FRAGMIN
X
OTEZLA
X
X
X
IPRIVASK
RINVOQ ER
X
X
X
LOVENOX
sodium hyaluronate
ANTIFUNGALS
SUPARTZ FX
X
TOLSURA
SYNVISC
X
X
SYNVISC-ONE
X
X
X
ANTIHYPERGLYCEMICS
KORLYM
TRILURON
X
ANTIINFECTIVES/MISCELLANEOUS
TRIVISC
IMPAVIDO
X
XELJANZ
X
X
X
XELJANZ XR
X
X
X
ANTIASTHMATICS
FASENRA
X
X
FASENRA PEN
X
X
2 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219
ANTIINFLAM.TUMOR NECROSIS FACTOR
INHIBITING AGENTS
CIMZIA
X
X
X
ENBREL
X
X
ENBREL MINI
X
X
ENBREL SURECLICK
X
X
PS2
DRUG NAME
QL
PA
HUMIRA
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
BELEODAQ
X
X
X
bendamustine hcl
X
X
X
X
X
X
bleomycin sulfate
X
X
X
BLINCYTO
REMICADE
X
X
RENFLEXIS
X
X
X
SIMPONI
X
X
X
SIMPONI ARIA
X
X
X
HUMIRA PEDIATRIC
CROHN'S
HUMIRA PEN
HUMIRA PEN
CROHN'S-UC-HS
HUMIRA PEN
PSOR-UVEITS-ADOL HS
HUMIRA(CF)
HUMIRA(CF) PEDIATRIC
CROHN'S
HUMIRA(CF) PEN
HUMIRA(CF) PEN
CROHN'S-UC-HS
HUMIRA(CF) PEN
PSOR-UV-ADOL HS
INFLECTRA
PS
PS1
PS2
ANTINEOPLASTICS
ABRAXANE
X
ACTIMMUNE
X
ADCETRIS
X
DRUG NAME
QL
PA
ALUNBRIG
X
X
ARRANON
arsenic trioxide
ARZERRA
X
AVASTIN
X
azacitidine
BALVERSA
bortezomib
BOSULIF
X
X
BRAFTOVI
X
X
busulfan
BUSULFEX
CABOMETYX
X
X
CALQUENCE
X
X
CAMPATH
capecitabine
CAPRELSA
AFINITOR
X
X
AFINITOR DISPERZ
X
X
ALECENSA
X
X
carmustine
X
cladribine
3 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219
X
BICNU
adrucil
ALKERAN
X
X
bexarotene
CAMPTOSAR
ALIMTA
X
BCG (TICE STRAIN)
ADRIAMYCIN
ALFERON N
PS
carboplatin
cisplatin
clofarabine
X
X
X
X
X
PS1
PS2
DRUG NAME
QL
PA
PS
PS1
PS2
CLOLAR
COMETRIQ
X
X
etoposide
X
EVOMELA
COSMEGEN
FARYDAK
X
FASLODEX
cyclophosphamide
X
FIRMAGON
CYRAMZA
X
floxuridine
X
cytarabine
fludarabine phosphate
dacarbazine
fluorouracil
DACOGEN
FOLOTYN
dactinomycin
fulvestrant
DARZALEX
X
daunorubicin hcl
DAURISMO
QL
PA
PS
ETOPOPHOS
COPIKTRA
COTELLIC
DRUG NAME
X
X
X
X
X
X
GAZYVA
X
X
gemcitabine hcl
X
X
GEMZAR
decitabine
GILOTRIF
X
X
DOCEFREZ
GLEEVEC
X
X
docetaxel
HALAVEN
X
DOXIL
HERCEPTIN
X
doxorubicin hcl
HERCEPTIN HYLECTA
X
doxorubicin hcl
liposome
ELIGARD
HEXALEN
X
HYCAMTIN
X
X
ELLENCE
ELZONRIS
X
EMCYT
IBRANCE
X
X
ICLUSIG
X
X
X
X
X
X
X
IDAMYCIN PFS
idarubicin hcl
epirubicin hcl
ERBITUX
X
ERIVEDGE
X
X
ERLEADA
X
X
erlotinib hcl
X
X
ERWINAZE
4 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219
IDHIFA
IFEX
ifosfamide
ifosfamide-mesna
imatinib mesylate
X
PS1
PS2
DRUG NAME
QL
PA
IMBRUVICA
X
X
INLYTA
X
X
INREBIC
X
X
mutamycin
X
MVASI
X
MYLERAN
INTRON A
IRESSA
X
PS
PS1
PS2
DRUG NAME
QL
mitoxantrone hcl
X
irinotecan hcl
PA
X
MUSTARGEN
X
X
NAVELBINE
IXEMPRA
X
NERLYNX
X
X
X
X
X
X
JAKAFI
X
X
NEXAVAR
JEVTANA
X
X
NILANDRON
KADCYLA
X
nilutamide
KANJINTI
X
KEYTRUDA
X
NIPENT
X
X
NUBEQA
X
X
X
X
ODOMZO
X
X
KISQALI FEMARA
CO-PACK
KYPROLIS
LENVIMA
X
X
X
leuprolide acetate
X
X
LONSURF
X
X
LORBRENA
X
X
LUMOXITI
X
LUPRON DEPOT
X
LYNPARZA
X
LYSODREN
MARQIBO
X
MATULANE
MEKINIST
MEKTOVI
X
MYLOTARG
ISTODAX
KISQALI
PS
X
X
X
melphalan hcl
mitomycin
5 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219
NINLARO
ONCASPAR
OPDIVO
X
oxaliplatin
paclitaxel
PERJETA
X
PHOTOFRIN
PIQRAY
X
X
POLIVY
X
X
POMALYST
X
X
PROLEUKIN
PROVENGE
X
X
PURIXAN
REVLIMID
X
X
X
X
RITUXAN
X
RITUXAN HYCELA
X
X
PS1
PS2
................
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