2015 LDI Specialty Pharmacy Drug List

LDI integrated pharmacy services
SPECIALTY DRUG LIST
Last Updated: January 2015
ACROMEGALY
INJECTION
SOMATULANE DEPOT
SOMAVERT
AIDS/HIV
INHALATION
NEBUPENT
INJECTION
cidofovir
EGRIFTA
FUZEON
PENTAM 300
RETROVIR IV
SEROSTIM
VISTIDE
ORAL
abacavir
abacavir/lamivudine/
zidovudine
APTIVUS
ATRIPLA
COMBIVIR
COMPLERA
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR
EPZICOM
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine/zidovudine
LEXIVA
nevirapine
nevirapine er
NORVIR
PREZISTA
RESCRIPTOR
RETROVIR
REYATAZ
SELZENTRY
stavudine
STRIBILD
SUSTIVE
TIVICAY
TRIUMEQ
TRIZIVIR
TRUVADA
TYBOST
VIDEX
VIDEX EC
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIREAD
ZERIT
ZIAGEN
zidovudine
ANEMIA
INJECTION
ARANESP
EPOGEN
PROCRIT
ANTICOAGULANT
INJECTION
ARIXTRA
enoxaparin
fondaparinux
FRAGMIN
IPRIVASK
LOVENOX
ANTIREJECTION
ORAL
ASTAGRAF XL
ZORTRESS
ASTHMA
INJECTON
XOLAIR
CANCER
INJECTION
ACTIMMUNE
ELIGARD
INTRON-A
leuprolide acetate
LUPRON DEPOT
MOZOBIL
THYROGEN
TRELSTAR DEPOT
TRELSTAR LA
ORAL
AFINITOR
BOSULIF
capecitabine
CAPRELSA
COMETRIQ
EMCYT
ERIVEDGE
flutamide
GILOTRIF
GLEEVAC
HEXALEN
HYCAMTIN
ICLUSIG
IMBRUVICA
INLYTA
LYSODREN
MATULANE
MEKINIST
MYLERAN
NEXAVAR
POMALYST
REVLIMID
SPRYCEL
STIVARGA
SUTENT
TABLOID
TAFINLAR
TARCEVA
TARGRETIN
TASIGNA
THALOMID
tretinoin
TYKERB
VOTRIENT
XALKORI
XELODA
XYTANDI
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
ZYTIGA
TOPICAL
VALCHLOR
CANCER ADJUNCT
INJECTION
NEULASTA
NEUMEGA
NEUPOGEN
CENTRAL PRECOCIOUS
PUBERTY
INJECTION
SUPPRELIN LA
CERVICAL DYSTONIA
INJECTION
BOTOX
MYOBLOC
XEOMIN
CHEMICAL DEPENDENCE
INJECTION
VIVITROL
CONDUYLOMATA
ACUMINATA
INJECTION
ALFERON N
CROHN’S DISEASE
GROWTH HORMONE
INJECTION
GENOTROPIN
HUMATROPE
INCRELEX
NORDITROPIN
NUTROPIN
NUTROPIN AQ
OMNITROPE
SAIZEN
TEV-TROPIN
INJECTION
CIMZIA
CIMZIA PREFILL KIT
HUMIRA
HEMOPHILA
INJECTION
HEPATITIS B
CRYOPYRIN-ASSOCIATED
PERIODIC SYNDROMES
ARCALYST
ILARIS
CYSTIC FIBROSIS
INHALATION
BETHKIS
CAYSTON
PULMOZYME
TOBI
TOBI PODHALER
tobramycin neb
ORAL
KALYDECO
DUPUYTREN’S
CONTRACTURE
INJECTION
XIAFLEX
ENDOCRINE AND
METABOLIC DISORDERS
INJECTION
ACTHAR HP
ORAL
KUVAN
ENDOMETRIOSIS
OTHER
LUPANETA PACK
FAMILIAL
HYPERCHOLESTEROLEMIA
INJECTION
KYNAMRO
ORAL
JUXTAPID
GAUCHER’S DISEASE
ORAL
INJECTION
BEBULIN
ORAL
adefovir dipivoxil
BARACLUDE
entecavir
EPIVIR HBV
HEPSERA
HEPATITIS C
INJECTION
INTRON-A
PEGASYS
PEG-INTRON
SYLATRON
ORAL
COPEGUS
HARVONI
INCIVEK
MODERIBA
OLYSIO
REBETEL
RIBAPAK
ribasphere
RIBATAB
ribavirin
SOVALDI
VICTRELIS
HERIDITARY
ANGIOEDEMA
INJECTION
BERINERT
CINRYZE
FIRAZYR
KALBITOR
RUCONEST
CERDELGA
ZAVESCA
Medications listed in this formulary are subject to your plan coverage. If you have questions regarding what is covered by your plan, please contact LDI at (866)516‐3121.
BRANDS all UPPERCASE, generics all lowercase
Bold indicates drug is on Limited Distribution
Page 1 of 3
LDI integrated pharmacy services
SPECIALTY DRUG LIST
Last Updated: January 2015
HUNTER SYNDROME
INJECTION
ELAPRASE
HUNTINGTON’S
CHOREA
ORAL
XENAZINE
HYPONATREMIA
ORAL
SAMSCA
IMMUNODEFICIENCY
INJECTION
BIVIGAM
CARIMUNE NF
FLEBOGAMMA
GAMASTAN S/D
GAMMAGARD
GAMMAGARD S/D
GAMMAKED
GAMMAPLEX
GAMUNEX-C
HIZENTRA
HYQVIA
OCTAGAM
PRIVIGEN
INFECTION - BACTERIAL
INJECTION
colistimethate sodium
COLY-MYCIN M
INFECTION – VIRAL
LIPODYSTROPHY
INJECTION
MYALEPT
MULTIPLE SCHLEROSIS
INJECTION
AVONEX
BETASERON
COPAXONE
EXTAVIA
PLEGRIDY
REBIF
ORAL
AMPYRA
AUBAGIO
GILENYA
TECFIDERA
MYELOFIBROSIS
ORAL
JAKAFI
NAGS DEFICIENCY
ORAL
CARBAGLU
NARCOLEPSY
ORAL
XYREM
NEPHROPATHIC
CYSTINOSIS
ORAL
CYSTAGON
PROCYSBI
NEXAVIR
ORTHOSTATIC
HYPERTENSION
INJECTION
NORTHERA
INJECTION
INFERTILITY
BRAVELLE
CETROTIDE
chorionic gonadotropin
FOLLISTIM AQ
GANIRELIX ACETATE
GONAL-F
MENOPUR
NOVAREL
OVIDREL
PREGNYL
REPRONEX
IRON OVERLOAD
ORAL
EXJADE
FERRIPROX
ORAL
OSTEOARTHRITIS
INJECTION
EUFLEXXA
HYALGAN
MONOVISC
ORTHOVISC
SUPARTZ
SYNVISC
OSTEOPOROSIS
INJECTION
FORTEO
PROLIA
XGEVA
PARKINSON DISEASE
INJECTION
APOKYN
PAROXYSMAL
NOTURNAL
HEMOGLOBINURIA (PNH)
INJECTION
SOLARIS
PSORIASIS
INJECTION
ENBREL
HUMIRA
STELARA
ORAL
8-MOP
OXSORALEN ULTRA
PSORIATIC ARTHRITIS
CIMZIA
CIMZIA PREFILL KIT
ENBREL
HUMIRA
KINERET
ORENCIA
OTREXUP
RASUVO
SIMPONI
ORAL
XELJANZ
RSV PREVENTION
INJECTION
SYNAGIS
SIMPONI
SHORT BOWEL
SYNDROME
OTEZLA
OTEZLA STARTER PACK
GATTEX
ZORBTIVE
INJECTION
ORAL
PULMONARY ARTERIAL
HYPERTENSION (PAH)
INHALATION
INJECTION
SLEEP-WAKE DISORDER
ORAL
HETLIOZ
TYVASO
TYVASO REFILL
TYVASO STARTER
VENTAVIS
SUCRASE DEFICIENCY
epoprostenol
FLOLAN
REMODULIN
REVATIO
VELETRI
PROMACTA
INJECTION
ORAL
ADCIRCA
ADEMPAS
LETAIRIS
OPSUMIT
ORENITRAM
REVATIO
sildenafil
TRACLEER
ORAL
SUCRAID
THROMBOCYTOPENIA
ORAL
UREA CYCLE DISORDERS
ORAL
BUPHENYL
RAVICTI
sodium phenylbutyrate
RH HEMOLTYIC DISEASE
INJECTION
HYPERRHO S/D
MICRHOGAM PLUS
RHOGAM PLUS
RHOPHYLAC
WINRHO
RHEUMATOID ARTHRITIS
INJECTION
ACTEMRA
Medications listed in this formulary are subject to your plan coverage. If you have questions regarding what is covered by your plan, please contact LDI at (866)516‐3121.
BRANDS all UPPERCASE, generics all lowercase
Bold indicates drug is on Limited Distribution
Page 2 of 3
LDI integrated pharmacy services
SPECIALTY DRUG LIST
Last Updated: January 2015
Injectable formulations of the following drugs may be covered under most major medical benefits, however are also included in LDI’s specialty
program to monitor safety and cost. These drugs may be available through LDI upon request.
ABRAXANE
cisplatin
ELLENCE
HERCEPTIN
MUSTARGEN
VANTUS
ADCETRIS
cladribine
ELOCTATE
HUMATE P
MYOZYME
VECTIBIX
ADRIAMYCIN
CLOLAR
ELOXOXITIN
HYCAMTIN
NAGLAZYME
VELCADE
ADRUCIL
COSMOGEN
EMEND
ibandronate sodium
NAVELBINE
VIDAZA
ADVATE
cyclophosphamide
ENTYVIO
IDAMYCIN PFS
NIPENT
VIMIZIM
ALDURAZYME
CYRAMZA
epirubicin
idarubicin
NOVOSEVEN RT
vinblastine
ALIMTA
cytarabine
ERBITUX
IFEX
NPLATE
VINCASAR PFS
ALKERAN
CYTOGAM
ERWINAZE
ifosfamide
NULOJIX
vincristine
ALOXI
CYTOVEN
estradiol valerate
ifosfamide/mesna
octreotide acetate
vinorelbine
ALPHANATE
VWF/HUM
dacarbazine
ETHYOL
irinotecan
ONCASPAR
VPRIV
DACOGEN
ETOPOPHOS
ISTODAX
ondansetron
WILATE
ALPHANINE SD
daunorubicin
etoposide
IXEMPRA KIT
oxaliplatin
XOFIGO
ALPROLIX
DAUNOXOME
ELYEA
JETREA
paclitaxel
XYNTHA
amifostine
DDAVP
FABRAZYME
JEVTANA
XYNTHA SOLFUSE
ANZEMET
decitabine
FASLODEX
KADCYLA
pamidronate
sodium
PERJETA
ARALAST NP
DELESTROGEN
FEIBA NF
KEYTRUDA
PROFILNINE
ZALTRAP
ARRANON
FIRMAGON
KOGENATE FS
PROLASTINE-C
ZANOSAR
ARZERRA
desmopressin
acetate
dexrazoxane
floxuridine
KRYSTEXXA
PROLEUKIN
ZEMAIRA
AVASTIN
DOCEFERZ
FLUDARA
KYPROLIS
PROVENGE
ZEMPLAR
azacitidine
docetaxel
fludarabine
leucovorin calcium
RECLAST
ZEVALIN
BEBULIN VH
doxercalciferol
fluorouracil
LIPODOX
RECOMBINATE
ZINECARD
BELEODAQ
DOXIL
ganciclovir
LUCENTIS
REMICADE
ZOFRAN
BENEFIX
doxorubicin
GAZYVA
LUMIZYME
RITUXAN
ZOLADEX
BENLYSTA
gemcitabine
MACUGEN
RIXUBIS
zoledronic acid
BICNU
doxorubicin
liposomal
GEMZAR
MAKENA
SANDOSTATIN
ZOMETA
bleomycin
ELELYSO
GLASSIA
MARQIBO
SANDOSTATIN LAR
BONIVA
ELLENCE
granisetron
melphalan
STIMATE
BUULFEX
ELOCTATE
GRANIX
MESNEX
SYLVANT
CAMPTOSAR
ELOXOXITIN
HALAVEN
mitomycin
TREANDA
carboplatin
EMEND
HECTOROL
mitoxantrone
TRETTEN
CEREZYME
ENTYVIO
HELIZATE FS
MONOCLATE-P
TYSABRI
CERUBIDINE
ELELYSO
HEMOFIL M
MONONINE
TYZEKA
YERVOY
Medications listed in this formulary are subject to your plan coverage. If you have questions regarding what is covered by your plan, please contact LDI at (866)516‐3121.
BRANDS all UPPERCASE, generics all lowercase
Bold indicates drug is on Limited Distribution
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