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

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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

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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

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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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