|
TIER STATUS
|
DRUG NAME
*shaded rows = Maintenance Medications |
INDICATIONS |
|
2
|
Aranesp |
Anemia |
|
2
|
Bravelle |
Infertility |
|
2
|
Celebrex** |
Arthritis Pain |
|
2
|
Enbrel** |
Rheumatoid Arthritis |
|
2
|
Enbrel** |
Psoriasis |
|
1
|
fentanyl lozenge** |
Breakthrough Cancer Pain |
|
2
|
Ganirelix |
Previously named Antagon, Infertility |
|
2
|
Gleevec** |
Cancer - CML/GIST |
|
2
|
Humira** |
Rheumatoid Arthritis/Crohn's Disease |
|
2
|
Increlex |
Growth Hormone Deficiency |
|
2
|
Kineret |
Rheumatoid Arthritis |
|
2
|
Leukine |
Stimulate granulocyte production |
|
1
|
meloxicam** |
Arthritis Pain |
|
2
|
Menopur |
Infertility |
|
2
|
Meridia |
Weight Loss |
|
2
|
Nexavar** |
Renal Cell Cancer |
|
2
|
Noxafil |
Fungal infections associated with Immunosupression |
|
2
|
Omnitrope |
Growth Hormone |
|
2
|
Procrit |
Anemia |
|
2
|
Provigil |
Narcolepsy, MS Fatigue |
|
2
|
Raptiva |
Psoriasis |
|
2
|
Revatio |
Pulmonary hypertension |
|
2
|
Revlimid** |
Cancer |
|
2
|
Singulair |
Will only be covered when prescribed to treat the diagnosis of asthma. It will not be covered when prescribed to treat allergies or any other conditions. |
|
|
|
|
|
|
2
|
Sprycel** |
Leukemia |
|
2
|
Sutent** |
Renal Cell Cancer & GIST |
|
2
|
Tazorac |
Acne (does not apply to ages 13-29) |
|
2
|
Tracleer |
Primary Pulmonary Hypertension |
|
1
|
Tretinoin |
Acne (does not apply to ages 13-29) |
|
2
|
Tykerb** |
Breast Cancer |
|
2
|
Ventavis |
Pulmonary hypertension |
|
2
|
Vfend (Antifungal) |
Infectious Disease |
|
2
|
Xenical |
Weight Loss |
|
2
|
Zolinza** |
cutaneous t-cell lymphoma |
|
2
|
Zyvox (Antibiotic) |
Infectious Disease |
|
MEDICAL DRUGS REQUIRING PRIOR APPROVAL
|
|
Amevive
|
Plaque psoriasis
|
|
Botox
|
Various
|
|
Cerezyme
|
Gaucher's Disease
|
|
Elaprase
|
Hunter's Syndrome
|
|
Fabrazyme
|
Fabry’s Disease
|
|
Flolan
|
Pulmonary Hypertension
|
|
myobloc
|
Various
|
|
Orencia
|
Rheumatoid Arthritis
|
|
Remicade
|
Rheumatoid Arthritis or Crohn’s
|
|
Remodulin
|
Pulmonary Hypertension
|
|
Rituxan
|
Rheumatoid Arthritis
|
|
Soliris
|
PNH
|
|
Tysabri
|
Multiple Sclerosis
|
|
Vivitrol
|
Alcohol Dependence
|
|
Xolair
|
Severe Asthma
|
Only FDA maintenance indicator drugs are allowed through mail order
** See quantity limitation list
Note: This list is subject to change.
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