Specialty medications Oral and injectable specialty medications are covered on Tier 4. Injectable specialty medications are marked with an asterisk (*) and oral specialty medications are marked with a double asterisk (**) .
AIDS/HIV APRETUDE* + (PA) BIKTARVY** (QL) CABENUVA* ^ (PA) CIMDUO** (PA) DESCOVY 200-25 MG TABLET**+ (PA) DESCOVY 120-15M G TABLET* (PA) DOVATO** (QL) emtricitabine-tenofovir 100-150 mg, 133-200 mg, 167-250 mg** emtricitabine-tenofovir 200-300 mg**+ GENVOYA** (QL) JULUCA** (QL) nevirapine er** (PA) nevirapine** (PA) ODEFSEY** (PA, QL) PREZISTA 100 MG/ML SUSPEN- SION** PREZISTA 75 MG, 150 MG TABLET** SYMTUZA** (QL) tenofovir ** (PA) TRIUMEQ** (QL) TRIUMEQ PD** (QL) Anxiety/Depression/ Bipolar Disorder SPRAVATO** (PA) ZURZUVAE* (PA, QL) Asthma/COPD/Respiratory ADEMPAS** (PA) BRONCHITOL** (PA) FASENRA PEN* (PA) NUCALA AUTO-INJECTOR, SY- RINGE* (PA)
OFEV** (PA) OPSUMIT** (PA) ORENITRAM ER* (PA) ORENITRAM TITRATION KIT** (PA, QL) TEZSPIRE* (PA) TRACLEER 32 MG TABLET FOR SUSPENSION** (PA) TYVASO DPI* (PA) UPTRAVI TABLET, TITRATION PACK** (PA) XOLAIR 75 MG/0.5 ML, 150 MG/ ML SYRINGE, POWDER VIAL* (PA)
NUWIQ*^ (PA) NYVEPRIA* (PA) PROCRIT*^ (PA) PROMACTA** (PA) RECOMBINATE*^ (PA)
RETACRIT*^ (PA) STIMUFEND* (PA) TAVALISSE** (PA)
tranexamic acid 650 mg tablet** UDENYCA SYRINGE, AUTO-INJEC- TOR* (PA) UDENYCA ONBODY*^ (PA) XYNTHA*^ (PA) XYNTHA SOLOFUSE*^ (PA) ZARXIO*^ ZIEXTENZO* (PA) Blood Pressure/ Heart Conditions CORLANOR 5 MG/5 ML ORAL SOLUTION** (PA) ORLADEYO* * (PA, QL)
Blood Modifiers/ Bleeding Disorders ADVATE* ^ (PA) ADYNOVATE* ^ (PA)
AFSTYLA*^ (PA) ALTUVIIIO*^ (PA) ARANESP*^ (PA) DOPTELET** (PA) ELOCTATE* ^ (PA)
RELEUKO*^ (PA) TAKHZYRO* (PA) Blood Thinners/ Anti-Clotting FRAGMIN* (QL) Cancer AKEEGA** (PA, QL) ALECENSA** (PA, QL) BOSULIF** (PA, QL) BRAFTOVI** (PA) BRUKINSA** (PA, QL) CABOMETYX** (PA) CALQUENCE** (PA) COMETRIQ** (PA, QL)
EMPAVELI* (PA) EPOGEN* ^ (PA) ESPEROCT* ^ (PA) FABHALTA** (PA, QL)
FULPHILA* (PA) FYLNETRA* (PA) GRANIX*^ (PA) JIVI*^ (PA) KOGENATE FS*^ (PA) MIRCERA*^ (PA) NEULASTA ONPRO*^ (PA) NEULASTA* (PA) NEUPOGEN*^ (PA) NIVESTYM*^ NOVOEIGHT*^ (PA)
Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.
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