Injectable specialty medications (Cont.) The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
NUCALA (PA) NUWIQ^ (PA)
Asthma/COPD/Respiratory
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
NYVEPRIA (PA) OMNITROPE (PA)
Hormonal Agents
ORENCIA SYRINGE (PA, QL)
Pain Relief and Inflammatory Disease
PALYNZIQ (PA) PEGASYS (PA) PHESGO^ (PA) PLEGRIDY (PA) PROCRIT^ (PA)
Miscellaneous
Infections
Cancer
Multiple Sclerosis
Blood Modifiers/Bleeding Disorders
REBIF (PA)
Multiple Sclerosis Multiple Sclerosis
REBIF REBIDOSE (PA) RECOMBINATE^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders Blood Presssure/Heart Medications Blood Presssure/Heart Medications
RELEUKO^ (PA) REMICADE^ (PA) RETACRIT^ (PA) RUCONEST^ (PA)
SAJAZIR (PA)
SANDOSTATIN^ (PA)
Hormonal Agents Hormonal Agents Hormonal Agents Hormonal Agents
SANDOSTATIN LAR^ (PA)
SEROSTIM (PA)
SIGNIFOR LAR^ (PA)
SILIQ (PA, QL)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
SIMPONI (PA, QL) SIMPONI ARIA (PA) SKYRIZI (PA, QL) SKYTROFA (PA, QL)
Hormonal Agents Hormonal Agents Hormonal Agents
SOMATULINE DEPOT^ (PA)
SOMAVERT (PA)
STELARA SYRINGE, 45MG/0.5ML VIAL (PA, QL)
Pain Relief and Inflammatory Disease
STRENSIQ (PA) TAKHZYRO (PA) TALTZ (PA, QL) TEGSEDI (PA) TEZSPIRE* (PA)
Miscellaneous
Blood Presssure/Heart Medications Pain Relief and Inflammatory Disease
Miscellaneous
Asthma/COPD/Respiratory
22
Made with FlippingBook - professional solution for displaying marketing and sales documents online