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 Page 3 of 3
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