Standard Specialty Pharmacy Drug List - Magellan Rx …

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

PRIALT

ANALGESICS

DUROLANE ELITEK

ANTIARTHRITICS X

EUFLEXXA GEL-ONE GENVISC 850 HYALGAN HYMOVIS KINERET KRYSTEXXA MONOVISC OLUMIANT ORENCIA ORENCIA CLICKJECT ORTHOVISC OTEZLA RINVOQ ER sodium hyaluronate

X X

X

X

X

X

X X

X X

X

X X

X X

X

X X

X

X

X X

X

X X

X

SUPARTZ FX SYNVISC SYNVISC-ONE TRILURON TRIVISC XELJANZ XELJANZ XR

X X X X X

X

X X

X

X X

X

ANTIASTHMATICS

FASENRA

X X

FASENRA PEN

X X

DRUG NAME

NUCALA XOLAIR

QL PA PS PS1 PS2

X X X X X

ARIKAYCE BETHKIS CAYSTON KITABIS PAK THALOMID TOBI TOBI PODHALER tobramycin XENLETA

ANTIBIOTICS X X X X X X X X X X X

ARIXTRA

ANTICOAGULANTS

enoxaparin sodium

fondaparinux sodium

FRAGMIN

IPRIVASK

LOVENOX

TOLSURA

ANTIFUNGALS X

KORLYM

ANTIHYPERGLYCEMICS X

ANTIINFECTIVES/MISCELLANEOUS IMPAVIDO

ANTIINFLAM.TUMOR NECROSIS FACTOR

INHIBITING AGENTS

CIMZIA

X X

X

ENBREL

X X

ENBREL MINI

X X

ENBREL SURECLICK

X X

2 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219

DRUG NAME

QL PA PS PS1 PS2

HUMIRA

X X

X

HUMIRA PEDIATRIC CROHN'S

X X

X

HUMIRA PEN

X X

X

HUMIRA PEN CROHN'S-UC-HS

X X

X

HUMIRA PEN PSOR-UVEITS-ADOL HS

X

X

X

HUMIRA(CF)

X X

X

HUMIRA(CF) PEDIATRIC CROHN'S

X

X

X

HUMIRA(CF) PEN

X X

X

HUMIRA(CF) PEN CROHN'S-UC-HS

X X

X

HUMIRA(CF) PEN PSOR-UV-ADOL HS

X X

X

INFLECTRA

X X

X

REMICADE

X X

RENFLEXIS

X X

X

SIMPONI SIMPONI ARIA

X X

X

X X

X

ABRAXANE

ANTINEOPLASTICS X

ACTIMMUNE

X

ADCETRIS

X

ADRIAMYCIN

adrucil

AFINITOR

X X

AFINITOR DISPERZ ALECENSA

X X X X

ALFERON N

ALIMTA

X

ALKERAN

DRUG NAME

ALUNBRIG ARRANON arsenic trioxide ARZERRA AVASTIN azacitidine BALVERSA BCG (TICE STRAIN) BELEODAQ bendamustine hcl bexarotene BICNU bleomycin sulfate BLINCYTO bortezomib BOSULIF BRAFTOVI busulfan BUSULFEX CABOMETYX CALQUENCE CAMPATH CAMPTOSAR capecitabine CAPRELSA carboplatin carmustine cisplatin cladribine clofarabine

QL PA PS PS1 PS2

X X

X X X X X X

X X X X

X

X X X X

X X X X

3 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219

DRUG NAME

CLOLAR COMETRIQ COPIKTRA COSMEGEN COTELLIC cyclophosphamide CYRAMZA cytarabine dacarbazine DACOGEN dactinomycin DARZALEX daunorubicin hcl DAURISMO decitabine DOCEFREZ docetaxel DOXIL doxorubicin hcl doxorubicin hcl liposome ELIGARD ELLENCE ELZONRIS EMCYT epirubicin hcl ERBITUX ERIVEDGE ERLEADA erlotinib hcl ERWINAZE

QL PA PS PS1 PS2

X X X

X X X X

X X X

X X

X X X X X X X

DRUG NAME

ETOPOPHOS etoposide EVOMELA FARYDAK FASLODEX FIRMAGON floxuridine fludarabine phosphate fluorouracil FOLOTYN fulvestrant GAZYVA gemcitabine hcl GEMZAR GILOTRIF GLEEVEC HALAVEN HERCEPTIN HERCEPTIN HYLECTA HEXALEN HYCAMTIN IBRANCE ICLUSIG IDAMYCIN PFS idarubicin hcl IDHIFA IFEX ifosfamide ifosfamide-mesna imatinib mesylate

QL PA PS PS1 PS2

X X X

X

X X X

X

X X X X X

X X X X X X X X X

X X

X X X

4 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219

DRUG NAME

IMBRUVICA INLYTA INREBIC INTRON A IRESSA irinotecan hcl ISTODAX IXEMPRA JAKAFI JEVTANA KADCYLA KANJINTI KEYTRUDA KISQALI KISQALI FEMARA CO-PACK KYPROLIS LENVIMA leuprolide acetate LONSURF LORBRENA LUMOXITI LUPRON DEPOT LYNPARZA LYSODREN MARQIBO MATULANE MEKINIST MEKTOVI melphalan hcl mitomycin

QL PA PS PS1 PS2

X X X X X X X

X X X

X X X X X X X X X X X X X X X X X X X X X X X X X

X

X X X

DRUG NAME

mitoxantrone hcl MUSTARGEN mutamycin MVASI MYLERAN MYLOTARG NAVELBINE NERLYNX NEXAVAR NILANDRON nilutamide NINLARO NIPENT NUBEQA ODOMZO ONCASPAR OPDIVO oxaliplatin paclitaxel PERJETA PHOTOFRIN PIQRAY POLIVY POMALYST PROLEUKIN PROVENGE PURIXAN REVLIMID RITUXAN RITUXAN HYCELA

QL PA PS PS1 PS2

X

X X

X X X X

X X

X X X X X

X

X

X X X X X X

X X X

X X X

X X

5 | 2020 Magellan Rx Management, LLC. All rights reserved. MRX0367_1219

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