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 (**) .
Miscellaneous ( Cont.) AUSTEDO** (PA) CARBAGLU** CERDELGA** (PA) CINRYZE*^ (PA) deferiprone** (PA) HAEGARDA* (PA) INGREZZA INITIATION PACK** (PA, QL) INGREZZA** (PA, QL) NITYR** (PA) ORFADIN** (PA) RADICAVA ORS** (PA) RUCONEST*^ (PA)
Pain Relief and Inflammatory Disease ACTEMRA ACTPEN, SYRINGE* (PA, QL) ADALIMUMAB-ADAZ(CF) PEN* (PA, QL) ADALIMUMAB-ADAZ(CF)* (PA, QL) ADALIMUMAB-ADBM(CF)* (PA, QL) ADALIMUMAB-ADBM(CF) PEN* (PA, QL) AVSOLA*^ (PA) BIMZELX AUTO-INJECTOR, SY- RINGE* (PA, QL) CIMZIA* (PA, QL) COSENTYX PEN INJECTOR, SY - RINGE* (PA, QL) CYLTEZO* (PA,QL) DUPIXENT PEN, SYRINGE* (PA) ENBREL, MINI, SURECLICK* (PA, QL) HUMIRA PEN* (PA, QL) HUMIRA(CF) PEN* (PA, QL) HUMIRA(CF)* (PA, QL) HUMIRA* (PA, QL) HYRIMOZ(CF) PEN* (PA, QL) HYRIMOZ(CF)* (PA, QL)
SIMPONI 100 MG/ML PEN INJEC- TOR, SYRINGE* (PA, QL) SIMPONI 50 MG/0.5 ML PEN IN- JECTOR, SYRINGE* (PA, QL) SIMPONI ARIA* (PA) SKYRIZI ON-BODY, PEN, SYRINGE* (PA, QL) SOTYKTU* *(PA, QL) STELARA 45 MG/0.5 ML SYRINGE, VIAL, 90 MG/ML SYRINGE* (PA, QL) TALTZ AUTO-INJECTOR, SYRINGE* (PA, QL)
TREMFYA* (PA, QL) XELJANZ** (PA, QL) XELJANZ XR** (PA, QL) ZEPOSIA** (PA) Parkinson's Disease APOKYN* (PA) INBRIJA* (PA) NOURIANZ** (PA, QL) Seizure Disorders
STRENSIQ* (PA) TEGLUTIK* (PA) TEGSEDI* (PA) TIGLUTIK** (PA)
VYLEESI*^ (PA, QL) Multiple Sclerosis AVONEX PEN* (PA) BAFIERTAM** (PA) BETASERON* (PA) FIRDAPSE** (PA, QL) glatopa* KESIMPTA PEN* (PA) MAVENCLAD** (PA) MAYZENT** (PA) PLEGRIDY PEN* (PA) PONVORY* (PA) REBIF* (PA) REBIF REBIDOSE* (PA) VUMERITY** (PA) Nutritional/Dietary betaine anhydrous** CYSTADANE**
ILUMYA* (PA, QL) INFLECTRA*^ (PA) INFLIXIMAB*^ (PA) KEVZARA* (PA, QL) KINERET* (PA, QL)
EPIDIOLEX** (PA) Skin Conditions ADBRY* (PA)
CIBINQO** (PA, QL) LITFULO** (PA, QL) Sleep Disorders/Sedatives LUMRYZ** (PA, QL) SODIUM OXYBATE** (PA, QL)
OLUMIANT** (PA, QL) OMVOH PEN* (PA, QL) ORENCIA CLICKJECT, SYRINGE* (PA, QL)
OTEZLA** (PA, QL) REMICADE*^ (PA) RINVOQ** (PA, QL) SILIQ* (PA, QL)
WAKIX** (PA, QL) XYWAV** (PA, QL)
Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters. Injectable specialty medications are marked with an asterisk (*) and oral specialty medications are marked with a double asterisk (**).
19
Made with FlippingBook - professional solution for displaying marketing and sales documents online