Injectable specialty medications (Cont.) The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
FENSOLVI^ (PA)
Hormonal Agents
FOLLISTIM AQ^ (PA)
Infertility
FRAGMIN* (QL) FULPHILA (PA)
Blood Thinners/Anti-Clotting
Blood Modifiers/Bleeding Disorders
GANIRELIX^ GATTEX (PA)
Hormonal Agents
Gastrointestinal/Heartburn
GENOTROPIN (PA)
Hormonal Agents Multiple Sclerosis Multiple Sclerosis
glatiramer (PA)
glatopa (PA)
GRANIX^
Blood Modifiers/Bleeding Disorders Blood Presssure/Heart Medications Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
HAEGARDA (PA) HEMLIBRA (PA) HUMIRA (PA, QL) HYRIMOZ (PA, QL)
ILARIS^ (PA)
ILUMYA (PA, QL) INCRELEX (PA) INFLECTRA (PA) INFLIXIMAB^ (PA)
Hormonal Agents
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
JIVI^ (PA)
KALBITOR^ (PA) KESIMPTA PEN (PA) KEVZARA (PA, QL) KINERET (PA, QL) KOGENATE FS^ (PA)
Multiple Sclerosis
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
KOVALTRY^ (PA)
LANREOTIDE ACETATE^ (PA) LUPRON DEPOT-PED^ (PA)
Hormonal Agents Hormonal Agents
MIRCERA^ (PA) MYALEPT (PA) NATPARA (PA) NEULASTA (PA)
Blood Modifiers/Bleeding Disorders
Miscellaneous
Hormonal Agents
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
NEULASTA ONPRO^ (PA)
NEUPOGEN^ (PA) NIVESTYM^ (PA) NOVOEIGHT^ (PA)
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