1199SEIU Benefit Funds
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- Archibald Pitts
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1 1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective October 1, 2016 As of April 1, 2015, providers must use the web-based Expressth platform to obtain prior authorization of drug treatments. Register at If you have questions, please call (877) The symbol [] next to a drug name indicates that this medication is subject to the Prior Program. The symbol [C] next to a drug name indicates that this medication is subject to the Program. The symbol [evicore] next to a drug name indicates that this medication is subject to the evicore Comprehensive Oncology Management Program. Please contact (888) Brand Name Generic Description Disease State ACTEMRA TOCILIZUMAB INFLAMMATORY CONDITIONS YES J3262 ADAGEN PEGADEMASE BOVINE ENZYME DEFICIENCIES YES J2504 ADCIRCA ADCIRCA (TADALAFIL) PULMONARY HYPERTENSION YES J8499 ADEMS RIOCIGUAT CIRCULATION DISORDERS YES J8499 ADVATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 ADYNOVATE FACTOR VIII (ANTIHEMOPHL FCTR) RECOMB PEGYLATED HEMOPHILIA YES C9137, J7199 ALDURAZYME LARONIDASE ENZYME DEFICIENCIES C NO J1931 ALPHANATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7186 ALPHANINE SD FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7193 ALPROLIX FACTOR IX Fc FUSION HEMOPHILIA YES J7201 PROTEIN RECOMB AMPYRA DALFAMPRIDINE MULTIPLE SCLEROSIS YES J8499 APOKYN APOMORPHINE HCL MISCELLANEOUS CNS YES J0364 DISORDERS ARALAST NP ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY CONDITIONS YES J0256 ARCALYST RILONACEPT CRYOPYRIN-ASSOCIATED YES J2793 PERIODIC SYNDROMES ARIXTRA FONDARINUX SODIUM ANTICOAGULANT YES J1652 ATGAM LYMPHOCYTE IMMUNE GLOBULIN TRANSPLANT YES J7504 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
2 AUBAGIO TERIFLUNOMIDE MULTIPLE SCLEROSIS YES J8499 AVEED TESTOSTERONE UNDECANOATE ENDOCRINE DISORDERS YES J3145 AVONEX INTERFERON BETA-1A MULTIPLE SCLEROSIS YES J1826, Q3027 BEBULIN FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7194 BENEFIX FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7195 BENLYSTA BELIMUMAB INFLAMMATORY CONDITIONS YES J0490 BERINERT C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA YES J0597 BETASERON INTERFERON BETA-1B MULTIPLE SCLEROSIS YES J1830 BIVIGAM IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1556 BONIVA (IV) IBANDRONATE OSTEOPOROSIS YES J1740 BOTOX BOTULINUM TOXIN A NEUROMUSCULAR YES J0585 CONDITIONS/COSMETIC CARIMUNE NF IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1566 CELLCEPT MYCOPHENOLATE MOFETIL TRANSPLANT YES J7517, J7599 CEPROTIN PROTEIN C CONCENTRATE, HUMAN MISCELLANEOUS SPECIALTY YES J2724 CONDITIONS CERDELGA ELIGLUSTAT ENZYME DEFICIENCIES C YES J8499 CEREDASE ALGLUCERASE ENZYME DEFICIENCIES C NO J0205 CEREZYME IMIGLUCERASE ENZYME DEFICIENCIES C NO J1786 CHENODAL CHENODIOL MISCELLANEOUS SPECIALTY YES NO HCPC CONDITIONS CHORIONIC GONADOTROPIN, CHORIONIC INFERTILITY YES J0725 GONADOTROPIN CIMZIA CERTOLIZUMAB PEGOL INFLAMMATORY CONDITIONS YES J0717 CINQAIR RESLIZUMAB RESPIRATORY CONDITIONS YES J3490, C9481 CINRYZE C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA YES J0598 COXONE GLATIRAMER ACETATE MULTIPLE SCLEROSIS YES J1595 COPEGUS RIBAVIRIN HETITIS C YES J8499 CORIFACT FACTOR XIII HEMOPHILIA YES J7180 COSENTYX SECUKINUMAB INFLAMMATORY CONDITIONS YES C9399, J3590 CYCLOSPORINE CYCLOSPORINE TRANSPLANT YES J7502, J7515, J7516 CYCLOSPORINE CYCLOSPORINE TRANSPLANT YES J7502, J7515 MODIFIED CYTOGAM CYTOMEGALOVIRUS IMMUNE GLOB IMMUNE DEFICIENCY YES 90291, J0850 DAKLINZA DACLATASVIR HETITIS C YES J8499 DDAVP DESMOPRESSIN ACETATE ENDOCRINE DISORDERS YES J2597 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
3 DEFEROXAMINE DEFEROXAMINE IRON TOXICITY YES J0895 MESYLATE DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE ENDOCRINE DISORDERS YES J1071 DESFERAL DEFEROXAMINE IRON TOXICITY YES J0895 DESMOPRESSIN DESMOPRESSIN ACETATE ENDOCRINE DISORDERS YES J2597 ACETATE DYSPORT ABOBOTULINUMTOXINA NEUROMUSCULAR YES J0586 CONDITIONS/COSMETIC EGRIFTA TESAMORELIN ACETATE ENDOCRINE DISORDERS YES C9399, J3490 ELAPRASE IDURSULFASE ENZYME DEFICIENCIES C NO J1743 ELELYSO TALIGLUCERASE ALFA ENZYME DEFICIENCIES C NO J3060 ELOCTATE FACTOR IX Fc FUSION HEMOPHILIA YES J7205 PROTEIN RECOMB ENBREL ETANERCEPT INFLAMMATORY CONDITIONS YES J1438 ENOXARIN SODIUM ENOXARIN ANTICOAGULANT YES J1650 ENTYVIO VEDOLIZUMAB INFLAMMATORY CONDITIONS YES J3380 EPCLUSA SOFOSBUVIR/VELTASVIR HETITIS C YES J8499 EPOPROSTENOL EPOPROSTENOL NA PULMONARY HYPERTENSION YES J1325 SODIUM ESBRIET PIRFENIDONE IDIOTHIC PULMONARY YES J8499 FIBROSIS EUFLEXXA SODIUM HYALURONATE OSTEOARTHRITIS YES J7323 EXTAVIA INTERFERON BETA-1B MULTIPLE SCLEROSIS YES J1830 EYLEA AFLIBERCEPT OPHTHALMIC CONDITIONS YES J0178 FABRAZYME AGALSIDASE ENZYME DEFICIENCIES C NO J0180 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. HEMOPHILIA YES J7198 FIRAZYR ICATIBANT ACETATE HEREDITARY ANGIOEDEMA YES J1744 FLEBOGAMMA/ IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1572 FLEBOGAMMA DIF FLOLAN EPOPROSTENOL NA PULMONARY HYPERTENSION YES J1325 FOLLISTIM AQ FOLLITROPIN BETA, RECOMB INFERTILITY YES J3490, S0128 FONDARINUX FONDARINUX SODIUM ANTICOAGULANT YES J1652 SODIUM FORTEO TERIRATIDE OSTEOPOROSIS YES J3110 FRAGMIN DALTERIN (PORCINE) ANTICOAGULANT YES J1645 FUZEON ENFUVIRTIDE HIV YES J1324 GAMASTAN S-D IMMUNE GLOBULIN - IM IMMUNE DEFICIENCY YES 90281, J1460, J1560 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
4 GAMMAGARD LIQUID IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, 90284, J1569 GAMMAGARD S-D IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1566 GAMMAKED IMMUNE GLOBULIN - IV/SQ IMMUNE DEFICIENCY YES 90283, 90284, J1561 GAMMAPLEX IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1557 GAMUNEX-C IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, 90284, J1561 GEL-ONE HYALURONATE SODIUM OSTEOARTHRITIS YES J7326 GEL-SYN HYALURONATE SODIUM OSTEOARTHRITIS YES J7328 GENGRAF CYCLOSPORINE TRANSPLANT YES J7502, J7515 GENOTROPIN SOMATROPIN GROWTH DEFICIENCY YES J2941 GENVISC 850 HYALURONATE SODIUM OSTEOARTHRITIS YES Q9980 GILENYA FINGOLIMOD HYDROCHLORIDE MULTIPLE SCLEROSIS YES J8499 GLASSIA ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY CONDITIONS YES J0257 GLATO GLATIRAMER ACETATE MULTIPLE SCLEROSIS YES J1595 GRASTEK TIMOTHY GRASS POLLEN ASTHMA AND ALLERGY YES J3590, C9399 ALLERGEN EXTRACT H.P. ACTHAR GEL CORTICOTROPIN MISCELLANEOUS CNS YES J0800 DISORDERS HARVONI LEDISVIR/SOFOSBUVIR HETITIS C YES J8499 HELIXATE FS FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 HEMOFIL M FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7190 HEGAM B HEP.B IMMUNE GLOB/MALTOSE HETITIS B YES J1571, J1573 HETLIOZ TASIMELTEON MISC SPECIALTY CONDITIONS YES J8499 HIZENTRA IMMUNE GLOBULIN- SQ IMMUNE DEFICIENCY YES 90284, J1559 HUMATE-P FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7187 HUMATROPE SOMATROPIN GROWTH DEFICIENCY YES J2941 HUMIRA ADALIMUMAB INFLAMMATORY CONDITIONS YES J0135 HYALGAN SODIUM HYALURONATE OSTEOARTHRITIS YES J7321 HYMOVIS HYALURONIC ACID OSTEOARTHRITIS YES C9471, J3490 HYPERHEP B S-D HETITIS B IMMUNE GLOBULIN HETITIS B YES 90371, J3490 HYPERRAB S-D RABIES IMMUNE GLOBULIN IMMUNE DEFICIENCY YES HYPERRHO S-D RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, 90385, J2788, J2790 HYQVIA IMMUNE GLOBULIN - SQ IMMUNE DEFICIENCY YES J1575 IDELVION FACTOR IX ALBUMIN FUSION PROTEIN RECOMB HEMOPHILIA YES C9139, C9399, J7199 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
5 ILARIS CANAKINUMAB CRYOPYRIN-ASSOCIATED YES J0638 PERIODIC SYNDROMES IMOGAM RABIES-HT RABIES IMMUNE GLOBULIN IMMUNE DEFICIENCY YES IMPLANON ETONOGESTREL CONTRACEPTIVE YES J7307 INCIVEK TELAPREVIR HETITIS C YES J8499 INCRELEX MECASERMIN GROWTH DEFICIENCY YES J2170 INFERGEN INTERFERON ALFACON-1 HETITIS C YES J9212 INFLECTRA INFLIXIMAB - DYYB INFLAMMATORY CONDITIONS YES Q5102 IXINITY COAGULATION FACTOR IX RECOMB HEMOPHILIA YES J7195 KALBITOR ECALLANTIDE HEREDITARY ANGIOEDEMA YES J1290 KALYDECO IVACAFTOR RESPIRATORY CONDITIONS YES J8499 KANUMA SEBELISE ALFA ENZYME DEFICIENCIES C YES C9478, J3590, C9399 KCENTRA PROTHROMBIN COMPLEX HUMAN HEMOPHILIA YES C9132 KENALOG TRIAMCINOLONE ACETONIDE INFLAMMATORY CONDITIONS YES J3301 KINERET ANAKINRA INFLAMMATORY CONDITIONS YES J3590 KOATE-DVI FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7190 KOGENATE FS FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 KORLYM MIFEPRISTONE ENDOCRINE DISORDERS YES J8499, S0190 KOVALTRY FACTOR VIII (ANTIHEMOPHL HEMOPHILIA NO J7192 FCTR) RECOMB KRYSTEXXA PEGLOTICASE INFLAMMATORY CONDITIONS YES J2507 KUVAN SAPROPTERIN DIHYDROCHLORIDE ENDOCRINE DISORDERS YES J8499 LEMTRADA ALEMTUZUMAB MULTIPLE SCLEROSIS YES J0202 LETAIRIS AMBRISENTAN PULMONARY HYPERTENSION YES J8499 LILETTA LEVONORGESTREL CONTRACEPTIVE YES J7297 LOVENOX ENOXARIN ANTICOAGULANT YES J1650 LUCENTIS RANIBIZUMAB OPHTHALMIC CONDITIONS YES J2778 LUMIZYME ALGLUCOSIDASE ALFA ENZYME DEFICIENCIES C NO J0221 MACUGEN PEGAPTANIB SODIUM OPHTHALMIC CONDITIONS YES J2503 MAKENA HYDROXYPROGEST CAPROATE MISC SPECIALTY CONDITIONS YES J1725 MICRHOGAM PLUS RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90385, J2788 MIRENA LEVONORGESTREL CONTRACEPTIVE YES J7298 MODERIBA RIBAVIRIN HETITIS C YES J8499 MONOCLATE-P FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7190 MONONINE FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7193 MONOVISC SODIUM HYALURONATE OSTEOARTHRITIS YES C9399, J7327 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
6 MOZOBIL PLERIXAFOR BLOOD CELL DEFICIENCY YES J2562 MYALEPT METRELEPTIN LIPODYSTROPHY YES J3590, C9399 MYCOPHENOLATE MYCOPHENOLATE MOFETIL TRANSPLANT YES J7517 MOFETIL MYFORTIC MYCOPHENOLATE SODIUM TRANSPLANT YES J7518 MYOBLOC BOTULINUM TOXIN TYPE B NEUROMUSCULAR CONDITIONS/COSMETIC YES J0587 MYOZYME ALGLUCOSIDASE ALFA ENZYME DEFICIENCIES C NO J0220 NABI-HB HETITIS B IMMUNE GLOBULIN HETITIS B YES NAGLAZYME GALSULFASE ENZYME DEFICIENCIES C NO J1458 NATRA RATHYROID HORMONE ENDOCRINE DISORDERS YES C9399, J3590 NEORAL CYCLOSPORINE TRANSPLANT YES J7502, J7515 NEUMEGA OPRELVEKIN BLOOD CELL DEFICIENCY YES J2355 NEXPLANON ETONOGESTREL CONTRACEPTIVE YES J7307 NORDITROPIN SOMATROPIN GROWTH DEFICIENCY YES J2941 NOVAREL GONADOTROPIN, CHORIONIC INFERTILITY YES J0725 NOVOEIGHT FACTOR VIII (ANTIHEMOPHL HEMOPHILIA YES J7182 FCTR) RECOMB NOVOSEVEN RT FACTOR VIIA, RECOMB (BHK CELLS) HEMOPHILIA YES J7189 NPLATE ROMIPLOSTIM BLOOD CELL DEFICIENCY YES J2796 NUCALA MEPOLIZUMAB RESPIRATORY CONDITIONS YES J3590, C9399, C9473 NULOJIX BELATACEPT TRANSPLANT YES J0485 NUTROPIN SOMATROPIN GROWTH DEFICIENCY YES J2941 NUVARING ETONOGESTREL/ETHYINYL CONTRACEPTIVE YES J7303 ESTRADIOL NUWIQ FACTOR VIII (ANTIHEMOPHL HEMOPHILIA YES C9138, J7199 FCTR) RECOMB OBIZUR ANTIHEMOPHL FCTR (RECOMB) HEMOPHILIA YES J7194 PORCINE SEQUENCE OCTAGAM IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1568 OCTREOTIDE OCTREOTIDE ENDOCRINE DISORDERS YES J2354 ACETATE OFEV NINTEDANIB IDIOTHIC PULMONARY YES J8499 FIBROSIS OLYSIO SIMEPREVIR HETITIS C YES J8499 OMNITROPE SOMATROPIN GROWTH DEFICIENCY YES J2941 ONSOLIS FENTANYL CITRATE IN MANAGEMENT YES J8499 OPSUMIT MACITENTAN PULMONARY HYPERTENSION YES J8499 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
7 ORALAIR MIXED GRASS POLLENS ASTHMA AND ALLERGY YES J3590, C9399 ALLERGENS EXTRACT ORENCIA ABATACEPT/MALTOSE INFLAMMATORY CONDITIONS YES J0129 ORENITRAM TREPROSTINIL PULMONARY HYPERTENSION YES J8499 ORKAMBI LUMACAFTOR/IVACAFTOR CYSTIC FIBROSIS YES J8499 ORTHO EVRA NORELGESTROMIN/ETHINYL CONTRACEPTIVE YES J7304 ESTRADIOL ORTHOCLONE OKT-3 MURONAB-CD3 TRANSPLANT YES J7505 ORTHOVISC HYALURONATE SODIUM OSTEOARTHRITIS YES J7324 OTEZLA APREMILAST INFLAMMATORY CONDITIONS YES J8499 PLEGRIDY PEGINTERFERON BETA-1A MULTIPLE SCLEROSIS YES J3590, C9399 PRALUENT ALIROCUMAB HYPERCHOLESTEROLEMIA YES C9399, J3590 PREGNYL GONADOTROPIN,CHORIONIC INFERTILITY YES J0725 PRIALT ZICONOTIDE ACETATE IN MANAGEMENT YES J2278 PRIVIGEN IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1459 PROFILNINE/ FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7194 PROFILNINE SD PROGESTERONE PROGESTERONE INFERTILITY YES J2675, J3490, J8499 PROGRAF TACROLIMUS TRANSPLANT YES J7507, J7525 PROLASTIN/ ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY CONDITIONS YES J0256 PROLASTIN-C PROLIA DENOSUMAB OSTEOPOROSIS YES J0897 PROMACTA ELTROMBOG OLAMINE BLOOD CELL DEFICIENCY YES J8499 PULMOZYME DEOXYRIBONUCLEASE RESPIRATORY CONDITIONS YES J7639 QSYMIA PHENTERMINE; TOPIRAMATE MISC SPECIALTY CONDITIONS YES J8499 RAMUNE SIROLIMUS TRANSPLANT YES J7520 REBETOL RIBAVIRIN HETITIS C YES J8499 REBIF INTERFERON BETA-1A/ALBUMIN MULTIPLE SCLEROSIS YES C9399, J3590, Q3028 RECLAST ZOLEDRONIC ACID OSTEOPOROSIS YES J3489 RECOMBINATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 RECOMBINATE FACTOR VIII (ANTIHEMOPHL HEMOPHILIA YES J7192 FCTR) RECOMB REFLUDAN LEPIRUDIN,RECOMBINANT ANTICOAGULANT YES J1945 REMICADE INFLIXIMAB INFLAMMATORY CONDITIONS YES J1745 REMODULIN TREPROSTINIL SODIUM PULMONARY HYPERTENSION YES J3285 RETHA EVOLOCUMAB HYPERCHOLESTEROLEMIA YES C9399, J3590 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
8 RETROVIR ZIDOVUDINE HIV YES J3485, J8499, S0104 REVATIO SILDENAFIL CITRATE PULMONARY HYPERTENSION YES J3490, J8499 RHOGAM PLUS RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, J2790 RHOPHYLAC RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, 90386, J2791 RIBAK RIBAVIRIN HETITIS C YES J8499 RIBASPHERE RIBAVIRIN HETITIS C YES J8499 RIBATAB RIBAVIRIN HETITIS C YES J8499 RIBAVIRIN RIBAVIRIN HETITIS C YES J8499 RITUXAN RITUXIMAB INFLAMMATORY CONDITIONS/ CANCER / EviCore RUCONEST C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA YES J0596 SAIZEN SOMATROPIN GROWTH DEFICIENCY YES J2941 SANDIMMUNE CYCLOSPORINE TRANSPLANT YES J7502, J7515, J7516 SANDOSTATIN OCTREOTIDE ENDOCRINE DISORDERS YES J2354 SANDOSTATIN LAR OCTREOTIDE ENDOCRINE DISORDERS YES J2353 SEROSTIM SOMATROPIN GROWTH DEFICIENCY YES J2941 SIGNIFOR SIREOTIDE DIASRTATE ENDOCRINE DISORDERS YES C9399, J3490 SIGNIFOR LAR SIREOTIDE DIASRTATE INJ ENDOCRINE DISORDERS YES C9454, J2502 SILDENAFIL CITRATE SILDENAFIL CITRATE PULMONARY HYPERTENSION YES J3490, J8499 SIMPONI GOLIMUMAB INFLAMMATORY CONDITIONS YES C9399, J3590 SIMPONI ARIA GOLIMUMAB INFLAMMATORY CONDITIONS YES J1602 SIMULECT BASILIXIMAB TRANSPLANT YES J0480 SKYLA LEVONORGESTREL CONTRACEPTIVE YES J7301 SOLESTA DEXTRANOMER/HYALURONATE/ MISCELLANEOUS SPECIALTY YES L8605 SOD CONDITIONS SOLIRIS ECULIZUMAB MISCELLANEOUS SPECIALTY YES J1300 CONDITIONS SOMATULINE DEPOT LANREOTIDE ACETATE ENDOCRINE DISORDERS YES J1930 SOVALDI SOFOSBUVIR HETITIS C YES J8499 STELARA USTEKINUMAB INFLAMMATORY CONDITIONS YES J3357 SURTZ HYALURONATE SODIUM OSTEOARTHRITIS YES J7321 SUPPRELIN LA HISTRELIN AC ENDOCRINE DISORDERS YES J9226 SYNAGIS LIVIZUMAB RSV PREVENTION YES SYNVISC HYALURONATE SODIUM OSTEOARTHRITIS YES J7325 SYNVISC-ONE HYALURONATE SODIUM OSTEOARTHRITIS YES J7325 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior. YES J9310
9 TACROLIMUS TACROLIMUS TRANSPLANT YES J7507 TALTZ IXEKIZUMAB RESPIRATORY CONDITIONS YES J3490 TECFIDERA DIMETHYL FUMARATE MULTIPLE SCLEROSIS YES J8499 TECHNIVIE OMBITASVIR, RITAPREVIR, AND HETITIS C YES J8499 RITONAVIR TESTOPEL TESTOSTERONE PELLET ENDOCRINE DISORDERS YES J3490, S0189 TESTOSTERONE TESTOSTERONE ENANTHATE ENDOCRINE DISORDERS YES J3121 ENANTHATE THYMOGLOBULIN LYMPHOCYTE IMMUNE GLOBULIN TRANSPLANT YES J7511 TOBI TOBRAMYCIN/SODIUM CHLORIDE RESPIRATORY CONDITIONS YES J7682 TRACLEER BOSENTAN PULMONARY HYPERTENSION YES J8499 TYSABRI NATALIZUMAB MULTIPLE SCLEROSIS YES J2323 TYVASO TREPROSTINIL (TYVASO) PULMONARY HYPERTENSION YES J7686 UPTRAVI SELEXIG PULMONARY HYPERTENSION YES J8499 VELETRI EPOPROSTENOL NA PULMONARY HYPERTENSION YES J1325 VENTAVIS ILOPROST PULMONARY HYPERTENSION YES Q4074 VIEKIRA K OMBITASVIR, RITAPREVIR AND HETITIS C YES J8499 RITONAVIR; DASABUVIR VIEKIRA XR OMBITASVIR, RITAPREVIR AND RITONAVIR; DASABUVIR HETITIS C YES J8499 VIMIZIM ELOSULFASE ALFA ENZYME DEFICIENCIES C NO C9022, J1322 VISUDYNE VERTEPORFIN OPHTHALMIC CONDITIONS YES J3396 VIVAGLOBIN IMMUNE GLOBULIN- SQ IMMUNE DEFICIENCY YES 90284, J1562 VIVITROL NALTREXONE MICROSPHERES MISCELLANEOUS CNS DISORDERS YES J2315 VPRIV VELAGLUCERASE ALFA ENZYME DEFICIENCIES C NO J3385 WINRHO SDF RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, 90386, J2792 XELJANZ TOFACITINIB INFLAMMATORY CONDITIONS YES J8499 XENAZINE TETRABENAZINE MISCELLANEOUS CNS YES J8499 DISORDERS XEOMIN INCOBOTULINUMTOXINA NEUROMUSCULAR YES J0588 CONDITIONS/COSMETIC XIAFLEX COLLAGENASE CLOSTRIDIUM HIST. MISCELLANEOUS SPECIALTY YES J0775 CONDITIONS XOLAIR OMALIZUMAB RESPIRATORY CONDITIONS YES J2357 XULANE NORELGESTROMIN/ETHINYL ESTRADIOL CONTRACEPTIVE YES J7304 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
10 XYNTHA/XYNTHA FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7185 SOLOFUSE ZAVESCA MIGLUSTAT ENZYME DEFICIENCIES C YES J8499 ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY CONDITIONS YES J0256 ZETIER ELBASVIR/GRAZOPREVIR HETITIS C YES J8499 ZINBRYTA DACLIZUMA MULTIPLE SCLEROSIS YES C9399, J3590 ZOMACTON SOMATROPIN GROWTH DEFICIENCY YES J2941 ZORBTIVE SOMATROPIN GROWTH DEFICIENCY YES J2941 Indicates a change from previous Drug List (i.e., new drug added to list, new Prior requirement or new reimbursement code). s where there is a Prior requirement will have claims checked against the quantities and approvals obtained in the Prior.
RAHF PFM ALPHANINE SD COAGULATION FACTOR IX J7193 COAGULATION FACTOR IX (RFIXFC)
INFECTIOUS DISEASE ACTIMMUNE INTERFERON GAMMA 1B J9216 ADVATE RAHF PFM ONCOLOGY ORAL AFINITOR EVEROLIMUS J7527 INFECTIOUS DISEASE ALFERON N INTERFERON ALFA N3 J9215 ALPHANATE VWF J7186 ALPHANINE SD J7193
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