Injectable specialty medications The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
ACTEMRA SYRINGE (PA, QL) ACTEMRA ACTPEN (PA, QL)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
ACTIMMUNE (PA)
Cancer
ADALIMUMAB-ADAZ (CF) (PA, QL)
Pain Relief and Inflammatory Disease
ADBRY (PA)
Skin Conditions
ADVATE^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders
ADYNOVATE^ (PA) AFSTYLA^ (PA) ARACALYST (PA) ARANESP^ (PA)
AVONEX (PA)
Multiple Sclerosis Multiple Sclerosis
AVONEX PEN (PA) AVSOLA^ (PA) BENLYSTA* (PA) BETASERON (PA) BYNFEZIA (PA) CABENUVA^ (PA)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
Multiple Sclerosis Multiple Sclerosis
AIDS/HIV
CABLIVI^ (PA)
Blood Modifiers/Bleeding Disorders
CETROTIDE^ (PA)
Hormonal Agents
chorionic gonadotropin^ (PA)
Infertility
CIMZIA (PA, QL)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
COSENTYX (2 SYRINGES) (PA, QL)
COSENTYX SENSOREADY (2 PENS) (PA, QL) COSENTYX SENSOREADY PEN (PA, QL)
COSENTYX SYRINGE (PA, QL)
CYLTEZO (PA, QL) DUPIXENT (PA)
EGRIFTA (PA)
Hormonal Agents
ELOCTATE^ (PA) EMPAVELI (PA) ENBREL (PA, QL) ENTYVIO^ (PA) EPOGEN^ (PA) ESPEROCT^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease
Gastrointestinal/Heartburn
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
EXTAVIA (PA)
Multiple Sclerosis
FASENRA PEN (PA)
Asthma/COPD/Respiratory
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