Injectable specialty medications (Cont.) The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
TREMFYA (PA, QL) UDENYCA^ (PA) VOXZOGO^ (PA) VYLEESI^ (PA, QL)
Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders
Miscellaneous Miscellaneous
XOLAIR (PA)
Asthma/COPD/Respiratory
XYNTHA^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
XYNTHA SOLOFUSE^ (PA)
ZARXIO^
ZIEXTENZO (PA) ZORBTIVE (PA)
Hormonal Agents
23
Made with FlippingBook - professional solution for displaying marketing and sales documents online