Pharmacy Benefit Specialty Medication List
Pharmacy Benefit Specialty Medication ListThis list pertains to specialty medications that can be administered by oneself and are covered under thepharmacy benefit, such as capsules, tablets, topicals, and some nasal sprays and injectables. This list issubject to change at any time without notice.For specialty medications that are covered under the medical benefit, please see the PrecertificationCode Lookup tool here.How Do I Know If This List Applies to Me?This list applies to the following plans:This list applies to members with plans that include pharmacy benefits administered by Blue Cross BlueShield of Arizona (BCBSAZ).Certain employer-sponsored health plans with customized benefits and prior authorizationrequirements:Amkor Technology, Inc. (group 039176)OB Sports Golf Management, LLC (group 038043)City of Phoenix (groups 040000 and 040004)Snell & Wilmer (group 030313)Knight Transportation, Inc. (group 029653)State of Arizona (group 030855)Northwest Arizona Employee Benefit Trust (group 037461)Teamsters (groups 031843 and 031844)This list does not does not apply to the following plans: Federal Employee Program (FEP ) plans Medicare Advantage (MA) plans Employer-sponsored plans in our Corporate Health Services (CHS) program Plans offered or administered by other Blue Cross and/or Blue Shield plansFor benefits and eligibility, or to inquire about prior authorization requirements for specialtymedications not listed here or for one of the exempt plans listed above, you can call the pharmacybenefit manager (PBM) or administrator on the member ID card.Filling specialty medications covered under the pharmacy benefitOptum Specialty Pharmacy is our exclusive specialty pharmacy. You can call Optum Specialty Pharmacyat 1-877-850-7071 to order the prescription. Members should call Optum Specialty Pharmacy toestablish service.
Requesting Prior AuthorizationFor most members, BCBSAZ handles the prior authorization requests. You can do either of the following: Use the online request tool in the secure provider portal at azblue.com/providers PracticeManagement Precertification BCBSAZ Members-Requests for 2020. In the tool, be sure toselect "Pharmacy" for your request. Fax a prior authorization request to BCBSAZ Clinical Therapeutics Department at 602-864-3126.Important: Chart notes must be included with your request.Member Cost Share/Out-of-Pocket CostFor most BCBSAZ members, specialty copay tiers (A, B, C, or D) apply.TierDescriptionASpecialty Medications, Low Cost ShareBSpecialty Medications, Moderate Cost ShareCSpecialty Medications, Moderately High Cost ShareDSpecialty Medications, Highest Cost SharePlans may include specialty medications at varying cost share tiers.Questions?Log in to MyBlueSM to find participating retail pharmacies, review your specific benefit information, andcompare medication pricing and options. If you have questions, please call us.Member ServicesPhone NumberStandard Hours of OperationPharmacy Benefits1 (866) 325-179424/7/365BCBSAZCall the number on your ID card8:30 a.m. to 4:30 p.m.Monday - Friday
Specialty Medication ListTable of ants*. 4*Aminoglycosides*. 4*Analgesics - tic And Bronchodilator Agents*. 5*Anticonvulsants*. 5*Antidepressants*.6*Antidiabetics*. 6*Antidotes And Specific Antagonists*.6*Antihyperlipidemics*. 6*Antihypertensives*. 7*Anti-Infective Agents - Misc.*. 7*Antimyasthenic/Cholinergic Agents*. 7*Antimycobacterial Agents*. 7*Antineoplastics And Adjunctive Therapies*. 7*Antiparkinson And Related Therapy Agents*. 7*Antipsychotics/Antimanic Agents*. 7*Antivirals*. 8*Cardiovascular Agents - Misc.*.9*Corticosteroids*. 10*Dermatologicals*.10*Digestive Aids*.11*Diuretics*. 11*Endocrine And Metabolic Agents - Misc.*.11*Gastrointestinal Agents - Misc.*.13*Genitourinary Agents - Miscellaneous*.14*Hematological Agents - Misc.*. 14*Hematopoietic Agents*. 15*Hypnotics/Sedatives/Sleep Disorder Agents*. 16*Migraine Products*. 16*Miscellaneous Therapeutic Classes*. 16*Neuromuscular Agents* . 17*Ophthalmic Agents*. 17*Passive Immunizing And Treatment Agents*. 17*Progestins*. 18*Psychotherapeutic And Neurological Agents - Misc.*.18*Respiratory Agents - Misc.*. 20*Vaginal And Related Products*. 20*Vasopressors*. 203
DrugSpecialty norexiants**Histamine H3-Receptor Antagonist/Inverse Agonists***WAKIX ORAL TABLETDPA; SP; DS (30)DPA; WEIGHT (Tier Specialty D if WEIGHTapplies)ARIKAYCE INHALATION SUSPENSIONDPA; SP; DS (30)BETHKIS INHALATION NEBULIZATION SOLUTIONBPA; SP; DS (30)KITABIS PAK INHALATION NEBULIZATION SOLUTIONCPA; SP; DS (30)TOBI INHALATION NEBULIZATION SOLUTIONCPA; SP; DS (30)TOBI PODHALER INHALATION CAPSULECPA; SP; DS (30)tobramycin inhalation nebulization solutionCPA; SP; DS (30)OLUMIANT ORAL TABLETDPA; SP; DS (30)RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOURBPA; SP; DS (30)XELJANZ ORAL SOLUTIONBPA; SP; QL (10ml per day); DS (30); AL(Max 18 Years)XELJANZ ORAL TABLETBPA; SP; DS (30)XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOURBPA; SP; DS (30)HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUSPREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML &40MG/0.4MLBPA; SP; DS (30)HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40MG/0.4ML, 40 MG/0.8MLBPA; SP; DS (30)HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PENINJECTOR KITBPA; SP; DS (30)HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUSPEN-INJECTOR KIT 40 MG/0.8MLBPA; SP; DS (30)HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8MLBPA; SP; DS (30)SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTORBPA; SP; DS (30)SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGEBPA; SP; DS (30)DPA; SP; DS (30)DPA; SP; DS (30)CPA; SP; DS (30)*Melanocortin 4 (Mc4) Receptor Agonists***IMCIVREE SUBCUTANEOUS esics - Anti-Inflammatory**Antirheumatic - Janus Kinase (Jak) Inhibitors****Anti-Tnf-Alpha - Monoclonal Antibodies****Interleukin-1 Receptor Antagonist (Il-1Ra)***KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE*Interleukin-1Beta Blockers***ILARIS SUBCUTANEOUS SOLUTION*Interleukin-6 Receptor Inhibitors***ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTOINJECTORLast revision date:02/24/2022 To search for a drug use control f4
DrugSpecialty NotesCopayTierACTEMRA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGECPA; SP; DS (30)KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTORDPA; SP; DS (30)KEVZARA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGEDPA; SP; DS (30)OTEZLA ORAL TABLETBPA; SP; DS (30); AL (Min 18 Years)OTEZLA ORAL TABLET THERAPY PACKBPA; SP; DS (30); AL (Min 18 Years)ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTOINJECTORCPA; SP; DS (30)ORENCIA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGECPA; SP; DS (30)ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGEDPA; SP; DS (30)ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5MLDPA; SP; DS (30)ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGEDPA; SP; DS (30)ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTOINJECTORDPA; SP; DS (30)dofetilide oral capsule 125 mcg, 250 mcgASP; DS (30)dofetilide oral capsule 500 mcgASP; QL (2 capsules per day); DS (30)TIKOSYN ORAL CAPSULE 125 MCG, 250 MCGCSP; DS (30)TIKOSYN ORAL CAPSULE 500 MCGCSP; QL (2 capsules per day); DS (30)XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGEDPA; SP; DS (30)XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)FASENRA PEN SUBCUTANEOUS SOLUTION AUTOINJECTORDPA; SP; DS (30)FASENRA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGEDPA; SP; DS (30)NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTORDPA; SP; DS (30)NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGEDPA; SP; DS (30)NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)DIACOMIT ORAL CAPSULECPA; SP; DS (30)DIACOMIT ORAL PACKETCPA; SP; DS (30)FINTEPLA ORAL SOLUTIONLast revision date:02/24/2022 To search for a drug use control fCPA; SP; DS (30)*Phosphodiesterase 4 (Pde4) Inhibitors****Selective Costimulation Modulators****Soluble Tumor Necrosis Factor Receptor Agents****Antiarrhythmics**Antiarrhythmics Type Iii****Antiasthmatic And Bronchodilator Agents**Anti-Ige Monoclonal Antibodies****Interleukin-5 Antagonists (Igg1 Kappa)****Anticonvulsants**Anticonvulsants - Misc.***5
DrugSpecialty NotesCopayTier*Gaba Modulators***SABRIL ORAL PACKETBPA; SP; DS (30)SABRIL ORAL TABLETBPA; SP; DS (30)vigabatrin oral packetBPA; SP; DS (30)vigabatrin oral tabletBPA; SP; DS (30)VIGADRONE ORAL PACKETBPA; SP; DS (30)EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HRDSP; QL (1 patch per day); DS (30); AL (Min16 Years)EMSAM TRANSDERMAL PATCH 24 HOUR 6 MG/24HR, 9MG/24HRDSP; DS (30); AL (Min 16 Years)CPA; SP; DS (30)CHEMET ORAL CAPSULECPA; DS (30)deferasirox granules oral packetDPA; SP; DS (30)deferasirox oral tabletDPA; SP; DS (30)deferasirox oral tablet solubleDPA; SP; DS (30)deferiprone oral tabletDPA; SP; DS (30)EXJADE ORAL TABLET SOLUBLEDPA; SP; DS (30)FERRIPROX ORAL SOLUTIONDPA; SP; DS (30)FERRIPROX ORAL TABLETDPA; SP; DS (30)FERRIPROX TWICE-A-DAY ORAL TABLETDPA; SP; DS (30)JADENU ORAL TABLETDPA; SP; DS (30)JADENU SPRINKLE ORAL PACKETDPA; SP; DS (30)BSP; DS (30)DPA; SP; DS (30)PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTORBPA; SP; DS (30); AL (Min 18 Years)REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUSSOLUTION CARTRIDGEBPA; SP; QL (1 cartridge per 28 days); DS(30); AL (Min 13 Years)REPATHA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGEBPA; SP; QL (2 syringes per month); DS(30); AL (Min 13 Years)REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTOINJECTORBPA; SP; QL (2 pens per month); DS (30);AL (Min 13 Years)*Antidepressants**Monoamine Oxidase Inhibitors (Maois)****Antidiabetics**Progesterone Receptor Antagonists***KORLYM ORAL TABLET*Antidotes And Specific Antagonists**Antidotes - Chelating Agents****Opioid Antagonists***VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED*Antihyperlipidemics**Microsomal Triglyceride Transfer Protein Inhibitors***JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG*Pcsk9 Inhibitors***Last revision date:02/24/2022 To search for a drug use control f6
DrugSpecialty NotesCopayTier*Antihypertensives**Agents For Pheochromocytoma***DEMSER ORAL CAPSULEDST; DS (30 day limit applies)DIBENZYLINE ORAL CAPSULEDPA; SP; DS (30)metyrosine oral capsuleDST; SP; DS (30 day limit applies)phenoxybenzamine hcl oral capsuleDPA; SP; DS (30)NEBUPENT INHALATION SOLUTION RECONSTITUTEDBSP; DS (30)pentamidine isethionate inhalation solution reconstitutedBSP; DS (30)CPA; SP; DS (30)FIRDAPSE ORAL TABLETDPA; SP; DS (30)RUZURGI ORAL TABLETDPA; SP; DS (30)cycloserine oral capsuleCPA; DS (30)pretomanid oral tabletCPA; SP; DS (30)SIRTURO ORAL TABLETDPA; SP; DS (30)LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MGDPA; SP; QL (1 injection per month (FDAapproved only for Endometriosis andFibroids)); DS (30); FLUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MGDPA; SP; QL (1 injection per 90 days (FDAapproved only for Endometriosis andFibroids)); DS (84-90); FCSP; DS (30)AZILECT ORAL TABLETCSP; DS (30)rasagiline mesylate oral tabletASP; DS (30)KYNMOBI SUBLINGUAL FILMCPA; SP; DS (30)NEUPRO TRANSDERMAL PATCH 24 HOURCSP; DS (30)GEODON INTRAMUSCULAR SOLUTION RECONSTITUTEDBPA; SP; DS (30)ziprasidone mesylate intramuscular solution reconstitutedAPA; SP; DS (30)*Anti-Infective Agents - Misc.**Anti-Infective Agents - Misc.****Monobactams***CAYSTON INHALATION SOLUTION RECONSTITUTED*Antimyasthenic/Cholinergic Agents**Antimyasthenic/Cholinergic Agents****Antimycobacterial Agents**Antimycobacterial Agents****Antineoplastics And Adjunctive Therapies**Lhrh Analogs****Urinary Tract Protective Agents***MESNEX ORAL TABLET*Antiparkinson And Related Therapy Agents**Antiparkinson Monoamine Oxidase Inhibitors****Nonergoline Dopamine Receptor Agonists****Antipsychotics/Antimanic Agents**Antipsychotics - Misc.***Last revision date:02/24/2022 To search for a drug use control f7
DrugSpecialty NotesCopayTier*Benzisoxazoles***INVEGA HAFYERA INTRAMUSCULAR SUSPENSIONPREFILLED SYRINGECPA; DS (30)INVEGA SUSTENNA INTRAMUSCULAR SUSPENSIONPREFILLED SYRINGE 117 MG/0.75ML, 234 MG/1.5ML, 39MG/0.25ML, 78 MG/0.5MLBPA; DS (30)INVEGA SUSTENNA INTRAMUSCULAR SUSPENSIONPREFILLED SYRINGE 156 MG/MLBPAINVEGA TRINZA INTRAMUSCULAR SUSPENSIONPREFILLED SYRINGE 273 MG/0.88ML, 410 MG/1.32ML, 546MG/1.75ML, 819 MG/2.63MLBPA; QL (Specialty copay. May have retaildistribution.); DS (30)PERSERIS SUBCUTANEOUS PREFILLED SYRINGEBPA; DS (30)RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONRECONSTITUTED ERBPA; QL (Specialty copay. May have retaildistribution.); DS (30)ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGEBPA; QL (Specialty copay. May have retaildistribution.); DS (30)ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONRECONSTITUTED ERBPA; QL (Specialty copay. May have retaildistribution.); DS (30)ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGECPA; QL (Specialty copay. May have retaildistribution.); DS (30)ARISTADA INTRAMUSCULAR PREFILLED SYRINGECPA; QL (Specialty copay. May have retaildistribution.); DS (30)olanzapine intramuscular solution reconstitutedAPA; SP; DS (30)ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTEDBPA; SP; DS (30)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSIONRECONSTITUTEDBPA; SP; DS (30)APA; SP; DS (30)LIVTENCITY ORAL TABLETDPA; DS (30)PREVYMIS ORAL TABLETDPA; SP; DS (30)VALCYTE ORAL SOLUTION RECONSTITUTEDCSP; DS (30)VALCYTE ORAL TABLETDSP; DS (30)valganciclovir hcl oral solution reconstitutedASP; DS (30)valganciclovir hcl oral tabletASP; DS (30)adefovir dipivoxil oral tabletASP; DS (30)BARACLUDE ORAL SOLUTIONBSP; DS (30); AL (Min 16 Years)BARACLUDE ORAL TABLETDSP; DS (30); AL (Min 16 Years)entecavir oral tabletASP; DS (30); AL (Min 16 Years)EPIVIR HBV ORAL SOLUTIONBSP; DS (30)*Quinolinone *Antiretrovirals - Fusion Inhibitors***FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED*Cmv Agents****Hepatitis B Agents***Last revision date:02/24/2022 To search for a drug use control f8
DrugSpecialty NotesCopayTierEPIVIR HBV ORAL TABLETDSP; DS (30)HEPSERA ORAL TABLETDSP; DS (30)lamivudine oral tablet 100 mgASP; DS (30)VEMLIDY ORAL TABLETBSP; DS (30); AL (Min 18 Years)EPCLUSA ORAL PACKETDPA; SP; DS (30)EPCLUSA ORAL TABLET 200-50 MGBPA; SP; DS (30)EPCLUSA ORAL TABLET 400-100 MGBPA; SP; QL (1 tablet per day); DS (30)HARVONI ORAL PACKETCPA; SP; DS (30)HARVONI ORAL TABLET 45-200 MGCPA; SP; DS (30)HARVONI ORAL TABLET 90-400 MGBPA; SP; DS (30)ledipasvir-sofosbuvir oral tabletBPA; SP; DS (30)MAVYRET ORAL PACKETBPA; SP; DS (30)MAVYRET ORAL TABLETBPA; SP; DS (30)sofosbuvir-velpatasvir oral tabletBPA; SP; QL (1 tablet per day); DS (30); AL(Min 18 Years)VIEKIRA PAK ORAL TABLET THERAPY PACKDPA; SP; DS (30)VOSEVI ORAL TABLETDPA; SP; DS (30)ZEPATIER ORAL TABLETDPA; SP; DS (30)PEGASYS SUBCUTANEOUS SOLUTIONBSP; DS (30)ribavirin oral capsuleASP; DS (30)ribavirin oral tablet 200 mgASP; QL (2 tablets per day); DS (30)SOVALDI ORAL PACKETDPA; SP; DS (30)SOVALDI ORAL TABLETDPA; SP; DS (30)ORENITRAM ORAL TABLET EXTENDED RELEASEDPA; SP; DS (30)TYVASO INHALATION SOLUTIONDPA; SP; DS (30)TYVASO REFILL INHALATION SOLUTIONDPA; SP; DS (30)TYVASO STARTER INHALATION SOLUTIONDPA; SP; DS (30)VENTAVIS INHALATION SOLUTIONDPA; SP; DS (30)DPA; SP; DS (30); AL (Min 18 Years)ambrisentan oral tabletDPA; SP; DS (30); AL (Min 18 Years)bosentan oral tabletDPA; SP; DS (30)LETAIRIS ORAL TABLETDPA; SP; DS (30); AL (Min 18 Years)OPSUMIT ORAL TABLETDPA; SP; DS (30)*Hepatitis C Agent - Combinations****Hepatitis C Agents****Cardiovascular Agents - Misc.**Prostaglandin Vasodilators****Pulm Hyperten-Soluble Guanylate Cyclase Stimulator(Sgc)***ADEMPAS ORAL TABLET*Pulmonary Hypertension - Endothelin ReceptorAntagonists***Last revision date:02/24/2022 To search for a drug use control f9
DrugSpecialty NotesCopayTierTRACLEER ORAL TABLETDPA; SP; DS (30)TRACLEER ORAL TABLET SOLUBLEDPA; SP; DS (30)ADCIRCA ORAL TABLETDPA; SP; DS (30)ALYQ ORAL TABLETDPA; SP; DS (30)REVATIO ORAL SUSPENSION RECONSTITUTEDDPA; SP; DS (30)REVATIO ORAL TABLETDPA; SP; DS (30); AL (Min 18 Years)sildenafil citrate oral suspension reconstitutedDPA; SP; DS (30)sildenafil citrate oral tablet 20 mgAPA; SP; DS (30); AL (Min 18 Years)tadalafil (pah) oral tabletDPA; SP; DS (30)UPTRAVI ORAL TABLETDPA; SP; DS (30); AL (Min 18 Years)UPTRAVI ORAL TABLET THERAPY PACKDPA; SP; DS (30); AL (Min 18 Years)VYNDAMAX ORAL CAPSULEDPA; SP; DS (30)VYNDAQEL ORAL CAPSULEDPA; SP; DS (30)DPA; SP; DS (30)COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTIONPREFILLED SYRINGEDPA; SP; DS (30)COSENTYX SENSOREADY (300 MG) SUBCUTANEOUSSOLUTION AUTO-INJECTORDPA; SP; DS (30)COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTIONAUTO-INJECTOR 150 MG/MLDPA; SP; DS (30)COSENTYX SUBCUTANEOUS SOLUTION PREFILLEDSYRINGEDPA; SP; DS (30)methoxsalen rapid oral capsuleCQL (1 capsule per day); DS (30); AL (Min18 Years)SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGEDPA; SP; DS (30)SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLEDSYRINGE KITBPA; SP; DS (30)SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-INJECTORBPA; SP; DS (30)SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGEBPA; SP; DS (30)STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5MLBPA; SP; DS (30)STELARA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGEBPA; SP; DS (30)TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTORCPA; SP; DS (30)TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGECPA; SP; DS (30)TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTORBPA; SP; DS (30)*Pulmonary Hypertension - Phosphodiesterase Inhibitors****Pulmonary Hypertension - Prostacyclin Receptor Agonist****Transthyretin ds***TARPEYO ORAL CAPSULE DELAYED RELEASE*Dermatologicals**Antipsoriatics - Systemic***Last revision date:02/24/2022 To search for a drug use control f10
DrugTREMFYA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGESpecialty NotesCopayTierBPA; SP; DS (30)CIBINQO ORAL TABLETDPA; DS (30)OPZELURA EXTERNAL CREAMDPA; SP; DS (2)ADBRY SUBCUTANEOUS SOLUTION PREFILLED SYRINGEDPA; SP; DS (30)DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 200MG/1.14MLDPADUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300MG/2MLDPA; SP; DS (30)DUPIXENT SUBCUTANEOUS SOLUTION PREFILLEDSYRINGEDPA; SP; DS (30)DPA; SP; DS (30)DPA; SP; DS (30); AL (Min 18 Years)cinacalcet hcl oral tabletCSP; DS (30)SENSIPAR ORAL TABLETCSP; DS (30)CPA; SP; DS (30)ISTURISA ORAL TABLETCPA; SP; DS (30)RECORLEV ORAL TABLETDPA; SP; DS (30)DPA; SP; DS (30)CPA; SP; DS (30)DPA; SP; DS (30)GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTIONRECONSTITUTEDDPA; SP; DS (30)GENOTROPIN SUBCUTANEOUS SOLUTIONRECONSTITUTEDDPA; SP; DS (30)HUMATROPE INJECTION SOLUTION RECONSTITUTEDDPA; SP; DS (30)NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PENINJECTORDPA; DS (30)*Atopic Dermatitis - Janus Kinase (Jak) Inhibitors****Atopic Dermatitis - Monoclonal Antibodies****Digestive Aids**Digestive Enzymes***SUCRAID ORAL SOLUTION*Diuretics**Carbonic Anhydrase Inhibitors***KEVEYIS ORAL TABLET*Endocrine And Metabolic Agents - Misc.**Calcimimetic Agents****Corticotropin***ACTHAR INJECTION GEL*Cortisol Synthesis Inhibitors****Fabry Disease - Agents***GALAFOLD ORAL CAPSULE*Growth Hormone Receptor Antagonists***SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED*Growth Hormone Releasing Hormones (Ghrh)***EGRIFTA SV SUBCUTANEOUS SOLUTION RECONSTITUTED*Growth Hormones***Last revision date:02/24/2022 To search for a drug use control f11
DrugSpecialty NotesCopayTierNUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PENINJECTORBPA; SP; DS (30)NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PENINJECTORBPA; SP; DS (30)NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PENINJECTORBPA; SP; DS (30)OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGEDPA; DS (30)OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)SAIZEN INJECTION SOLUTION RECONSTITUTEDDPA; SP; DS (30)SAIZENPREP INJECTION SOLUTION RECONSTITUTEDDPA; SP; DS (30)SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4MG, 5 MG, 6 MGBPA; SP; DS (30)SKYTROFA SUBCUTANEOUS CARTRIDGEDPA; SP; DS (30 day limit applies)ZOMACTON (FOR ZOMA-JET 10) SUBCUTANEOUSSOLUTION RECONSTITUTEDDPA; SP; DS (30)ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTEDCPA; SP; DS (30)DPA; SP; DS (30)nitisinone oral capsuleDPA; SP; DS (30)NITYR ORAL TABLETDPA; DS (30)ORFADIN ORAL CAPSULEDPA; SP; DS (30)ORFADIN ORAL SUSPENSIONDPA; SP; DS (30)betaine oral powderCSP; DS (30)CYSTADANE ORAL POWDERCSP; DS (30)CARBAGLU ORAL TABLETDPA; SP; DS (30)carglumic acid oral tablet solubleDPA; SP; DS (30)CSP; DS (30)DPA; SP; DS (30)DPA; SP; DS (30)DPA; SP; DS (30)DPA; SP; QL (1 injection per month (FDAapproved only for Central PrecociousPuberty [CPP])); DS (30)*Hereditary Orotic Aciduria Treatment - Agents**XURIDEN ORAL PACKET*Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents****Homocystinuria Treatment - Agents****Hyperammonemia Treatment - Agents****Hyperparathyroid Treatment - Vitamin D Analogs***doxercalciferol oral capsule*Hypophosphatasia (Hpp) Agents***STRENSIQ SUBCUTANEOUS SOLUTION*Insulin-Like Growth Factors (Somatomedins)***INCRELEX SUBCUTANEOUS SOLUTION*Leptin Analogues***MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED*Lhrh/Gnrh Agonist Analog Pituitary Suppressants***LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KITLast revision date:02/24/2022 To search for a drug use control f12
DrugSpecialty NotesCopayTierLUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KITDPA; SP; QL (1 injection per 90 days (FDAapproved only for Central PrecociousPuberty [CPP])); DS (84-90)SYNAREL NASAL SOLUTIONCPA; SP; DS (30)FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620MCG/2.48MLBPA; SP; DS (30)NATPARA SUBCUTANEOUS CARTRIDGEDPA; SP; DS (30)teriparatide (recombinant) subcutaneous solution pen-injectorBPA; SP; DS (30)TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTORBPA; SP; DS (30)KUVAN ORAL PACKETDPA; SP; DS (30)PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLEDSYRINGECPA; SP; DS (30)sapropterin dihydrochloride oral packetDPA; SP; DS (30)DPA; SP; QL (1 prefilled syringe per 180days; x6 copay applies); DS (167-180); AL(Min 18 Years)JYNARQUE ORAL TABLETCPA; SP; DS (30)JYNARQUE ORAL TABLET THERAPY PACKCPA; SP; DS (30)SAMSCA ORAL TABLETCPA; SP; DS (30)tolvaptan oral tablet 15 mgCPA; DS (30)tolvaptan oral tablet 30 mgCPA; SP; DS (30)MYCAPSSA ORAL CAPSULE DELAYED RELEASEDPA; SP; DS (30)octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500mcg/mlAPA; SP; DS (30)octreotide acetate injection solution 1000 mcg/ml, 200 mcg/mlASP; DS (30)SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50MCG/ML, 500 MCG/MLDPA; SP; DS (30)SANDOSTATIN LAR DEPOT INTRAMUSCULAR KITDPA; SP; DS (30)BUPHENYL ORAL POWDER 3 GM/TSPBSP; DS (30)BUPHENYL ORAL TABLETBSP; DS (30)RAVICTI ORAL LIQUIDDPA; SP; DS (30)sodium phenylbutyrate oral powder 3 gm/tspASP; DS (30)sodium phenylbutyrate oral tabletBSP; DS (30)CPA; SP; DS (30)*Parathyroid Hormone And Derivatives****Phenylketonuria Treatment - Agents****Rank Ligand (Rankl) Inhibitors***PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE*Selective Vasopressin V2-Receptor Antagonists****Somatostatic Agents****Urea Cycle Disorder - Agents****Gastrointestinal Agents - Misc.**Bile Acid Synthesis Disorder Agents***CHOLBAM ORAL CAPSULELast revision date:02/24/2022 To search for a drug use control f13
DrugSpecialty NotesCopayTier*Farnesoid X Receptor (Fxr) Agonists***OCALIVA ORAL TABLETDPA; SP; DS (30)DPA; SP; DS (30)BYLVAY (PELLETS) ORAL CAPSULE SPRINKLEDPA; DS (30)BYLVAY ORAL CAPSULEDPA; DS (30)LIVMARLI ORAL SOLUTIONDPA; SP; DS (30)CPA; SP; DS (30)FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG,750 MGDSP; DS (30); AL (Min 16 Years)lanthanum carbonate oral tablet chewableBSP; DS (30); AL (Min 16 Years)DPA; SP; DS (30)CIMZIA PREFILLED SUBCUTANEOUS KITBPA; SP; DS (30)CIMZIA STARTER KIT SUBCUTANEOUS KITBPA; SP; DS (30)CIMZIA SUBCUTANEOUS KIT 2 X 200 MGBPA; SP; DS (30)CYSTAGON ORAL CAPSULECSP; DS (30)PROCYSBI ORAL CAPSULE DELAYED RELEASECPA; SP; DS (30)PROCYSBI ORAL PACKETAPA; SP; DS (30)DPA; SP; DS (30)FIRAZYR SUBCUTANEOUS SOLUTIONDPA; SP; DS (30)icatibant acetate subcutaneous solutionDPA; SP; DS (30)SAJAZIR SUBCUTANEOUS SOLUTIONDPA; SP; DS (30)BERINERT INTRAVENOUS KITDPA; SP; DS (30)CINRYZE INTRAVENOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)RUCONEST INTRAVENOUS SOLUTION RECONSTITUTEDDPA; SP; DS (30)EMPAVELI SUBCUTANEOUS SOLUTIONDPA; SP; DS (30)TAVNEOS ORAL CAPSULEDPA; DS (30)*Glucagon-Like Peptide-2 (Glp-2) Analogs***GATTEX SUBCUTANEOUS KIT*Ileal Bile Acid T
For most BCBSAZ members, specialty copay tiers (A, B, C, or D) apply. Tier Description A Specialty Medications, Low Cost Share B Specialty Medications, Moderate Cost Share C Specialty Medications, Moderately High Cost Share D Specialty Medications, Highest Cost Share Plans may include specialty medications at varying cost share tiers. Questions?
1. Review the items on the Medications list. 2. To add a medication to the list, click Add a Medication and follow the prompts on the screen. 3. Review the pharmacy list. 4. Click a pharmacy in the list for use during the visit. 5. To add a pharmacy to the list, click Add a Pharmacy and follow the prompts on the screen. 6. When all of the medication and pharmacy information is up -to .
pharmacy benefit manager’s website, and in either the contracted pharmacy’s contract with the pharmacy benefit manager or through a pharmacy provider manual distributed to contracted pharmacies, pharmacy service administ
Pharmacy Automation Supplies (PAS) Pharmacy Cure All, LLC (PCA) Pharmacy Development Services Pharmacy First Pharmacy Quality Solutions Pharmacy Technician Certification Board Pharmacy Times Pharmacy-Lite Packaging PharmPilot, Inc. PharmSaver LLC Pharmsource, LLC. Physician 360
Oct 14, 2009 · MM. CVS/pharmacy #9838 – Sun Valley NN. CVS/pharmacy #9840 – Reno OO. CVS/pharmacy #9841 – Reno PP. CVS/pharmacy #9842 – Carson City QQ. CVS/pharmacy #9843 – Fallon . Advanced Care Rx Pharmacy – Las Vegas CC. Prime Pharmacy – Henderson DD. Spring Valley Surgery Center
In re Pharmacy Benefit Managers Antitrust Litigation, 582 F.3d 432 (3d Cir. 2009). 26 In re Pharmacy Benefit Managers Antitrust Litigation, No. 03-cv-04731-JF, 2006 WL 3759712 (E.D. Pa. Dec. 18, 2006) . 26 In re Pharmacy Benefit Managers Antitrust Litigation, No. 07-1151 (3d Cir. Jan. 24, 2007). . 26 In re Pharmacy Benefits Managers .
Attachment F2 - Pharmacy Benefit Management Pricing Tables and Examples Page 1 Pharmacy Benefit Management Services Pricing Tables Claims Pricing Offer - Pass-Through Pricing at Retail; Guaranteed pricing at Mail Order/Aetna Specialty Pharmacy Aetna's offer is based on a total of both Act
143 Al-Hilal Multi-Specialty Medical Center -Riffa Polyclinic. 144 . 180 Rashid Hameed Physiotherapy Center Physiotherapy 181 Al-Haiki Physiotherapy & Rehabilitation Center Physiotherapy 182 Al Hilal Pharmacy (Branch of Nasser Pharmacy) Pharmacy 183 Al Jazeera Pharmacy (Branch of Nasser Pharmacy) Pharmacy .
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