Texas Medicaid Specialty Drug List Effective December 15, 2017
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1 Texas Government Code (a)(23)(G), as added by Section.02(d), Senate Bill 7, 82nd Legislature, First Called Session, 20, requires Medicaid managed care organizations (MCOs) and subcontracted pharmacy benefit managers (PBMs) to adopt policies and procedures for reclassifying prescription drugs from retail to specialty drugs that are consistent with rules adopted by the Executive Commissioner. The only drugs that may be exclusively provided through the MCO s specialty pharmacy network are the drugs listed on this specialty drug list (SDL). The list was developed by HHSC and follows the criteria set forth in the specialty drug rule ( TAC ). Only drugs that may be exclusively provided through the MCO's specialty pharmacy network are listed on the specialty drug list. This list includes drugs that are on the Medicaid Formulary or provided as Medicaid medical benefit. The SDL is published quarterly (March, June, September, and December). ANTI-ALLERGENS ORAL allergen extracts of 5 grass pollens Oralair ANTIBIOTIC (INJ.) aztreonam Azactam tobramycin inhalation aztreonam Lysine ANTIBIOTICS (INHALED) Bethkis Kitabis Pak TOBI Podhaler Cayston protein c, human ANTICOAGULANT, PROTEIN C DEFICIENCY Ceprotin Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE OF 22
2 ANTIHEMOPHILIA AGENTS coagulation factor VIIa (recombinant) NovoSeven RT Monoclate-P coagulation factor VIII, human Koate-DVI Hemofil M Adynovate Eloctate Helixate FS coagulation factor VIII, recombinant Kovaltry Novoeight Nuwiq Recombinate Advate coagulation factor VIII, recombinant; plasma or albumin-free Xyntha coagulation Factor VIII, recombinant, single chain Afstyla coagulation factor (recombinant)porcine sequence Obizur Humate-P coagulation factor VIII / Von Willebrand factor complex, human Wilate Alphanate coagulation factor IX (albumin fusion protein recombinant) Idelvion Rixubis Alprolix coagulation factor IX (recombinant) Ixinity Benefix coagulation factor IX complex (human) Bebulin Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 2 OF 22
3 ANTIHEMOPHILIA AGENTS Profilnine coagulation factor IX (human, purified) Alphanine Mononine coagulation factor X, human Coagadex coagulation factor XIII, human Corifact Kit coagulation factor XIII, recombinant Tretten anti-inhibitor coagulant complex Feiba NF fibrinogen RiaSTAP ANTIHYPERLIPIDEMIC AGENTS lomitapide mesylate Juxtapid mipomersen Na Kynamro mifepristone Korlym ANTI-INFECTIVE AGENT bedaquiline fumarate Sirturo ANTIPARKINSON RELATED AGENTS (SUBCUTANEOUS) apomorphine HCl Apokyn carbidopa/levodopa Duopa Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 3 OF 22
4 ANTIPARKINSON RELATED AGENTS (SUBCUTANEOUS) pimavanserin Tartrate Nuplazid aripiprazole inj. aripiprazole lauroxil inj. olanzapine paliperidone palmitate risperidone ANTIPSYCHOTICS, LONG-ACTING INJECTABLE Abilify Maintena Aristada ER Zyprexa Relprevv Invega Sustenna Invega Trinza Risperdal Consta nevirapine ribavirin ANTIVIRAL Viamune Moderiba pamidronate disodium BISPHOSPHONATE, CALCIUM REGULATOR Pamidronate Disodium BLOOD MODIFIER AGENTS darbepoetin alfa Aranesp Vial /Syringe eculizumab Soliris Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 4 OF 22
5 BLOOD MODIFIER AGENTS eltrombopag olamine Promacta filgrastim-sndz Zarxio TBO-filgrastim Granix sargramostim Leukine romiplostim Nplate Aralast NP alpha- proteinase inhibitor human Prolastin C Zemaira Glassia (IV) oprelvekin Neumega Plerixafor Mozobil BONE DISORDER-OTHER asfotase alfa Strensiq denosumab Prolia BOTULINUM TOXIN abobotulinum toxin A Dysport incobotulinum toxin A Xeomin Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 5 OF 22
6 CANCER dalfampridine Ampyra ER abiraterone acetate Zytiga (Oral) ado-trastuzumab emtansine Kadcyla afatinib dimaleate Gilotrif aldesleukin Proleukin alectinib Alecensa altramine Hexalen amifostine Ethyol arsenic trioxide Trisenox asparaginase erwinia chrysanthemi Erwinaze atezolizumab Tecentriq avelumab Bavencio axitinib Inlyta azacitidine Vidaza (SQ) (IV) belinostat Beleodaq bendamustine hcl Treanda (brand name only) bevacizumab Avastin (IV) bexarotene Targretin (Brand only) blinatumomab Blincyto bortezomib Velcade bosutinib Bosulif brentuximab vedotin Adcetris brigatinib Alunbrig busulfan Busulfex cabazitaxel Jevtana cabozantinib Cometriq Daily Dose Pak, Cabometyx carfilzomib Kyprolis carmustine Bicnu Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 6 OF 22
7 CANCER ceritinib Zykadia cladribine cladribine clofarabine Clolar cobimetinib Cotellic crizotinib Xalkori (oral) cyclophosphamide inj. Cyclophosphamide inj. cytarabine Cytarabine cytarabine liposome Depocyt dabrafenib Tafinlar dacarbazine dacarbazine dactinomycin Cosmegen (IV) dalfampridine Ampyra ER daratumumab Darzalex daunorubicin daunorubicin decitabine Dacogen (IV) denosumab Xgeva dexrazoxane hcl Zinecard docetaxel Taxotere (IV) Docefrez doxorubicin peg-liposomal Doxil durvalumab Imfinzi elotuzumab Empliciti enzalutamide Xtandi eribulin mesylate Halaven etoposide phosphate Etopophos, Toposar everolimus Afinitor Disperz for oral suspension floxuridine floxuridine fulvestrant Faslodex (IV) gefitinib Iressa Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 7 OF 22
8 CANCER goserelin acetate Zoladex implant syringe histrelin acetate Vantas ibritumomab Zevalin (Y-90) ibrutinib Imbruvica idarubicin Idamycin idelalisib Zydelig ifosfamide/mesna ifosfamide/mesna ipilimumab Yervoy irinotecan liposome Onivyde ixabepilone Ixempra ixazomib Ninlaro lapatinib ditosylate Tykerb lenvatinib mesylate Lenvima levoleucovorin Ca Fusilev mercaptopurine Purixan mercaptopurine Mercaptopurine mitoxantrone HCl Mitoxantrone (IV) necitumumab Portrazza nelarabine Arranon niraparib Zejula nivolumab Opdivo obinutuzumab Gazyva ofatumumab Arzerra olaparib Lynparza olaratumab Lartruvo omacetaxine mepesuccinate Synribo osimertinib Tagrisso oxaliplatin Eloxatine Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 8 OF 22
9 CANCER palbociclib Ibrance palifermin Kepivance panitumumab Vectibix panobinostat Farydak pazopanib HCl Votrient pegaspargase Oncaspar (IM/IV) pentostatin Nipent pembrolizumab Keytruda pertuzumab Perjeta pomalidomide Pomalyst ponatinib HCl Iclusig pralatrexate Folotyn procarbazine HCl Matulane radium Ra 223 dichloride Xofigo ramucirumab Cyramza regorafenib Stivarga rituximab Rituxan romidepsin Istodax rucaparib Rubraca ruxolitinib Jakafi siltuximab Sylvant sipuleucel-t Provenge sonidegib Odomzo sorafenib Nexavar streptozocin Zanosar sunitinib malate Sutent talimogene laherparepvec Imlygic temozolomide Temodar Inj. Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 9 OF 22
10 CANCER temsirolimus Torisel teniposide Teniposide thalidomide Thalomid thiotepa Tepadina, thiotepa thyrotropin alfa Thyrogen topotecan HCl Hycamtin Inj. trabectedin Yondelis trametinib dimethyl sulfoxide Mekinist trastuzumab Herceptin trifluridine/tipiracil Lonsurf valrubicin Valstar vandetanib Caprelsa vedolizumab Entyvio vemurafenib Zelboraf venetoclax Venclexta vincristine sulfate Vincasar PFS vincristine sulfate liposome Marqibo vinorelbine tarterate Vinblastine, Navelbine vismodegib Erivedge ziv-aflibercept Zaltrap zoledronic acid Zometa (IV) CARBONIC ANHYDRASE INHIBITOR dichlorphenamide Keveyis Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 0 OF 22
11 CHRONIC KIDNEY FAILURE/DIALYSIS mechlorethamine HCl glycerol phenylbutyrate sodium phenylbutyrate Valchlor Ravicti Buphenyl deutetrabenazine sodium oxybate tasimelteon tetrabenazine CNS Austedo Xyrem Hetlioz Xenazine CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES rilonacept Arcalyst prothrombin complex concentrate (human) COAGULATION FACTOR REPLACEMENT PRODUCT Kcentra CYSTIC FIBROSIS ivacaftor Kalydeco Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE OF 22
12 lumacaftor/ivacaftor CYSTIC FIBROSIS Orkambi ENDOCRINE AND METABOLIC AGENT carglumic acid Carbaglu cystadane Cystadane repository corticotropin H.P. Acthar sapropterin dihydrochloride Kuvan leuprolide acetate Eligard Syr. Kit lipase/protease/amylase Pancrelipase 5000 mecasermin Increlex metreleptin Myalept miglustat Zavesca parathyroid hormone Natpara pasireotide diaspartate Signifor pegvisomant Somavert tesamorelin acetate Egrifta triptorelin pamoate Trelstar Depot Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 2 OF 22
13 ENZYME DISORDER agalsidase beta Fabrazyme pegademase bovine Adagen alglucosidase alfa Myozyme Lumizyme elosulfase alfa Vimizim galsulfase Naglazyme idursulfase Elaprase imiglucerase Cerezyme laronidase Aldurazyme cysteamine HCl Cystaran sebelipase alfa Kanuma taliglucerase alfa Elelyso cysteamine bitartrate Procysbi velaglucerase alfa Vpriv eliglustat tartrate Cerdelga vigabatrin EPILEPTIC SEIZURE Sabril EYE DISEASE aflibercept Eylea dexamethasone intravitreal implant Ozurdex Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 3 OF 22
14 EYE DISEASE flucinolone acetonide intravitreal implant Retisert, Iluvien ocriplasmin Jetrea pegaptanib octasodium Macugen verteporfin Visudyne chenodiol folic acid nitisinone obeticholic acid teduglutide GASTROINTESTINAL AGENT Chenodal Cholbam Orfadin Ocaliva Gattex GROWTH HORMONE somatropin - E-Coli or mammalian derived Genotropin; Genotropin Miniquick Humatrope Norditropin Flexpro Nutropin AQ Omnitrope Saizen Serostim Tev-Tropin Zorbtive Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 4 OF 22
15 GROWTH HORMONE Zomacton deferasirox deferiprone trientine HCl HEAVY METAL CHELATOR Exjade, Jadenu Ferriprox Syprine propranolol HCl INFANTILE HEMANGIOMA Hemangeol oral solution HEPATITIS B HepaGam B hepatitis B immune globulin Hyper Hep B S-D Nabi-HB elvitegravir enfuvirtide nevirapine pyrimethamine HIV INFECTION Vitekta Fuzeon nevirapine oral suspension (generic only) Daraprim Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 5 OF 22
16 ritonavir stavudine zidovudine syrup HIV INFECTION Norvir soft gel Zerit (Brand only) Retrovir Syrup HORMONES testosterone undecanoate Aveed histrelin acetate Supprelin LA chorionic gonadotropin, human Chorionic gonadotropin IMMUNE MODULATOR adalimumab Humira Ped. Crohn's Starter SQ Syringe Kit apremilast Otezla c esterase inhibitor, human Berinert (IV) Cinryze (IV) c esterase inhibitor, recombinant Ruconest canakinumab Ilaris ecallantide Kalbitor golimumab Simponi; Simponi ARIA icatibant acetate Firazyr infliximab Remicade ixekizumab Taltz lenalidomide Revlimid Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 6 OF 22
17 IMMUNE MODULATOR mepolizumab Nucala methotrexate Otrexup methotrexate SQ Rasuvo natalizumab Tysabri (IV) omalizumab Xolair reslizumab Cinqair Sarilumab Kevzara secukinumab Cosentyx siltuximab Sylvant teriflunomide Aubagio tocilizumab Actemra ustekinumab Stelara cytomegalovirus IG, human immune globulin human/recombinant immune globulin IMMUNE SERUM Cytogam (IV) HyQvia Bivigam Carimune NF Cuvitru Flebogamma, Flebogamma DIF GamaSTAN S-D Gammagard Gammagard S-D Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 7 OF 22
18 IMMUNE SERUM Gammaked Gammaplex Gamunex-C Hizentra MICRhoGAM Ultra-Filtered Octagam Privigen Rhophylac WinRho SDF varicella-zoster immune globulin Varizig INTERFERON interferon alfa-2b Intron-A interferon beta-b Extavia interferon gamma-b Actimmune pegylated interferon alfa-2b Pegintron peginterferon beta-a Plegridy levonorgestrel LONG ACTING REVERSIBLE CONTRACEPTIVE Kyleena Liletta Mirena Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 8 OF 22
19 LONG ACTING REVERSIBLE CONTRACEPTIVE Nexplanon Paragard T Skyla sumatriptan succinate MIGRAINE Zecuity droxidopa MISCELLANEOUS Northera MULTIPLE SCLEROSIS alemtuzumab Lemtrada daclizumab Zinbryta dimethyl fumarate Tecfidera ocrelizumab Ocrevus MUSCULAR DYSTROPHY deflazacort Emflaza eteplirsen Exondys 5 Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 9 OF 22
20 NEUROMUSCULAR nusinersen Spinraza OPHTHALMOLOGICAL AGENT (MONOCLONAL ANTIBODY FRAGMENT) ranibizumab Lucentis buprenorphine implant OPIOID DEPENDENCE TREATMENT Probuphine PAIN MANAGEMENT ziconotide Prialt ambrisentan bosentan epoprostenol Na (Arginine) epoprostenol Na (Glycine) iloprost tromethamine riociguat selexipag PULMONARY ARTERIAL HYPERTENSION AGENTS Letairis Tracleer Veletri Flolan Ventavis Adempas Uptravi Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 20 OF 22
21 PULMONARY ARTERIAL HYPERTENSION AGENTS treprostinil treprostinil diolamine Remodulin Tyvaso Orenitram nintedanib esylate pirfenidone PULMONARY FIBROSIS Ofev Esbriet palivizumab RSV INFECTION Synagis SYSTEMIC LUPUS ERYTHEMATOSUS belimumab Benlysta TRANSPLANT belatacept Nulojix tacrolimus Prograf amp. Envarsus XR Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 2 OF 22
22 UROLOGIC AGENT collagenase, clostridium histolyticum Xiaflex cysteamine bitartrate Cystagon tiopronin Thiola Rev. 0/208 drg-spltdl-257 TxVendorDrug.com PAGE 22 OF 22
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J9190 5-FU fluorouracil None. J0401 ABILIFY MAINTENA aripiprazole i.v. J9264 ABRAXANE paclitaxel protein bound J3262 ACTEMRA IV tocilizumab Yes, through Navitus. Restricted to (in at least consultation
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