Specialty medications (Cont.) 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.
Cancer ( Cont.) COTELLIC** (PA) ERIVEDGE** (PA) ERLEADA** (PA) EXKIVITY** (PA)
XALKORI** (PA, QL) XTANDI** (PA)
SIGNIFOR LAR* (PA) SKYTROFA* (PA) SOMATULINE DEPOT*^ (PA) SOMAVERT* (PA, QL) Infections ARIKAYCE** (PA) BARACLUDE SOLUTION** DARAPRIM** (PA)
ZEJULA** (PA, QL) ZELBORAF** (PA) Contraceptive Products KYLEENA**+
GAVRETO** (PA, QL) IMBRUVICA** (PA, QL) INLYTA** (PA)
LILETTA**+ MIRENA**+ NEXPLANON*+ PARAGARD T 380-A**+
JAKAFI** (PA, QL) KISQALI** (PA, QL) KISQALI FEMARA CO-PACK** (PA, QL) LENVIMA** (PA)
EPCLUSA** (PA, QL) HARVONI** (PA, QL) KITABIS PAK* * (PA, QL) NUZYRA 150 MG TABLET* * (PA, QL) SOVALDI** (PA, QL) TOBI PODHALER* * (PA, QL) TOBRAMYCIN PAK 300 MG/5 ML** (PA, QL) VEMLIDY** VOSEVI** (PA, QL) ZEPATIER** (PA, QL) Infertility CHORIONIC GONADOTROPIN 10,000 UNIT VIAL*^ (PA) FOLLISTIM AQ* ^ (PA) GONAL-F RFF REDI-JECT * ^ (PA) GONAL-F RFF * ^ (PA) GONAL-F * ^ (PA) NOVAREL* ^ (PA) OVIDREL* ^ (PA) PREGNYL* ^ (PA) Miscellaneous AUSTEDO XR TITRATION KIT** (PA, QL) AUSTEDO XR** (PA, QL)
SKYLA**+ Diuretics
LORBRENA** (PA, QL) LUMAKRAS** (PA, QL) LYNPARZA** (PA, QL) MEKINIST** (PA, QL) MEKTOVI** (PA, QL) NINLARO** (PA, QL) NUBEQA** (PA) ODOMZO** (PA) ORGOVYX** (PA) PHESGO*^ (PA) PIQRAY** (PA) RETEVMO** (PA,QL) REVLIMID** (PA, QL) ROZLYTREK** (PA) RUBRACA** (PA, QL) SPRYCEL** (PA, QL) STIVARGA** (PA, QL) TAFINLAR** (PA, QL) TALZENNA** (PA, QL) TASIGNA** (PA, QL)
JYNARQUE** (PA) Eye Conditions XDEMVY** (PA, QL) Gastrointestinal/Heartburn ENTYVIO*^ (PA) OLPRUVA** (PA) PHEBURANE** (PA, QL) VOWST** (PA, QL) Hormonal Agents CETROTIDE* ^ (PA) desmopressin ampule, vial*
FENSOLVI* ^ (PA) fyremadel*^ (PA)
GENOTROPIN* (PA) LANREOTIDE*^ (PA) LUPRON DEPOT*^ (PA) LUPRON DEPOT-PED*^ (PA) OMNITROPE* (PA) SANDOSTATIN**^ (PA) SANDOSTATIN LAR DEPOT*^ (PA)
VERZENIO** (PA) VITRAKVI** (PA) VIZIMPRO** (PA)
Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.
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