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Download Blood Cell Deficiency cladribine ifosfamide Aranesp
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Exclusive specialty drug list Blood Cell Deficiency Aranesp Epogen Granix Leukine Mozobil Neulasta Neumega Neupogen Nplate Procrit Promacta Zarxio Bone Conditions Forteo pamidronate disodium Prolia Reclast Xgeva zoledronic acid Zometa Cancer Abraxane Adcetris adriamycin adrucil Actimmune Afinitor Afinitor Disperz Alecensa Alferon N Alimta Alkeran amifostine Arranon Avastin azacitidine BCG (Tice Strain) Bendeka Bexarotene BICNU bleomycin sulfate Bosulif Busulfex Campath Camptosar capecitabine carboplatin cerubidine cisplatin 44150MUMENABS Rev. 6/1/2016 cladribine Clolar Cosmegen Cotellic cyclophosphamide cytarabine dacarbazine Dacogen dactinomycin Darzalex daunorubicin HCL Daunoxome decitabine Depocyt dexrazoxane Docefrez docetaxel Doxil doxorubicin HCL Eligard Elitek Ellence Eloxatin Elspar Empliciti epirubicin HCL Erbitux Erivedge Erwinaze Etopophos etoposide Evomela Farydak Faslodex Firmagon floxuridine Fludara fludarabine phosphate fluorouracil Folotyn Gazyva gemcitabine HCL Gemzar Gleevec Gilotrif Halaven Herceptin Hycamtin Ibrance Idamycin PFS idarubicin HCL Ifex ifosfamide ifosfamide-mesna imatinib Inlyta Intron A Iressa irinotecan Istodax Ixempra Jakafi Jevtana Kadcyla Lenvima Lipodox/50 Lonsurf Mekinist melphalan HCL mitomycin mitoxantrone HCL Mustargen Navelbine Nexavar Ninlaro Nipent Odomzo Oncaspar oxaliplatin paclitaxel pentostatin Perjeta Pomalyst Proleukin Revlimid Rituxan Sprycel Stivarga Sutent Sylatron Tagrisso Tafinlar Tarceva Targretin Tasigna Taxotere Temodar temozolomide teniposide Thalomid Theracys thiotepa Thyrogen Toposar topotecan HCL Torisel Totect Treanda Trelstar/LA/Depot Trisenox Tykerb Unituxin Valchlor Valstar Vantas Vectibix Velcade Vidaza vinblastine sulfate Vincasar PFS vincristine sulfate vinorelbine tartrate Votrient Vumon Xalkori Xeloda Xtandi Yervoy Zaltrap Zanosar Zelboraf Zinecard Zoladex Zolinza Zykadia Zytiga Contraceptive Implanon Liletta Nexplanon Cytomegalovirus cidofovir Cytogam Cytovene ganciclovir Valcyte valganciclovir Vistide Endocrine Disorders Egrifta Kuvan leuprolide acetate Lupaneta Lupron/Depot Lupron/Depot Ped Myalept Natpara octreotide acetate Sandostatin/LAR Signifor/LAR Somatuline Depot Somavert Enzyme Deficiency Aldurazyme Cerdelga Cerezyme Fabrazyme Lumizyme Myozyme Naglazyme Ravicti Sucraid VPRIV Vimizim Zavesca Eye Conditions Eylea Iluvien Lucentis Macugen Ozurdex Retisert Visudyne GI Disorders Gattex Growth Hormones Genotropin Humatrope Increlex Norditropin/Nordiflex Nutropin/AQ Omnitrope Saizen Serostim Tev-Tropin Zomacton Zorbtive Hemophilia Advate Adynovate Alphanate Alphanine SD Exclusive specialty drug list Alprolix Bebulin Bebulin VH Immuno Benefix Corifact Eloctate Feiba VH/NF Helixate FS Hemofil M Humate-P Idelvion Ixinity Koate-DVI Kogenate FS Kovaltry Monoclate-P Mononine Novoeight Novoseven RT Nuwiq Profilnine SD Recombinate Rixubis Tretten Wilate Xyntha Hepatitis adefovir dipivoxil Baraclude Copegus Daklinza entecavir Epivir HBV Harvoni Hepagam B Hepsera Hyperhep B S-D Incivek Infergen Nabi-HB moderibra Pegasys Pegintron Olysio Rebetol Ribapak ribasphere Ribatab ribavirin Sovaldi Technivie 44150MUMENABS Rev. 6/1/2016 Tyzeka Victrelis Viekira Zepatier Hereditary Angioedema Cinryze Firazyr Kalbitor Ruconest High Blood Cholesterol Kynamro Praluent Pen/Syringe Repatha Sureclick/ Syringe Immunodeficiency Bivigam Carimune NF Flebogamma Gamastan Gammagard Liquid Gammagard S-D Gammaked Gammaplex Gamunex Gamunex-C Hizentra Hyperrab S-D Hyperrho S-D Hyqvia Imogam Rabies-HT Micrhogam/Plus Octagam Privigen Rhogam/Plus Rhophylac Winrho SDF Immunosuppressants Astagraf XL Atgam Benlysta Cellcept cyclosporine Gengraf Hecoria mycophenolate mofetil mycophenolate sodium Myfortic Neoral Nulojix Prograf Rapamune Sandimmune Simulect sirolimus tacrolimus Thymoglobulin Zortress Infertility Bravelle Cetrotide chorionic gonadotropin Crinone Follistim/AQ Ganirelix Acetate Gonal-F/RFF Menopur Novarel Ovidrel Pregnyl Repronex Inflammatory Conditions Actemra Cimzia Cosentyx Enbrel Entyvio Humira Ilaris Krystexxa Orencia Otezla Otrexup Rasuvo Remicade Simponi Simponi Aria Stelara Taltz Xeljanz/XR Iron Toxicity deferoxamine mesylate Desferal Exjade Jadenu Miscellaneous Specialty Conditions 8-Mop Apokyn Arcalyst Arestin Botox Ceprotin Duopa Dysport Hetlioz Makena methoxsalen Myobloc Northera Nucala Onsolis Oxsoralen-Ultra Panretin Qutenza Rilutek riluzole Sabril Solesta Soliris Supprelin/LA Sylvant Synarel Syprine Tetrabenazine Vivitrol Xenazine Xeomin Xiaflex Xyrem Multiple Sclerosis Ampyra Aubagio Avonex Betaseron Copaxone Extavia Gilenya Glatopa H.P. Acthar Lemtrada Plegridy Rebif Tecfidera Tysabri Osteoarthritis Euflexxa Gel-One Genvisc Hyalgan Monovisc Orthovisc Supartz Synvisc/One Pulmonary Hypertension Adcirca Adempas epoprostenol sodium Flolan Letairis Opsumit Orenitram Remodulin Revatio sildenafil (Revatio) Tracleer Tyvaso Uptravi Veletri Ventavis Respiratory Conditions Aralast/NP Bethkis Esbriet Glassia Kalydeco Kitabis Ofev Orkambi Pulmozyme tobramycin (TOBI) TOBI/Podhaler Xolair Zemaira RSV Prevention Synagis Urinary Disorders Procysbi Envarsus XR Exclusive specialty drug list Generic drugs are lower case and brand name drugs are upper case. This list applies to drugs covered under the pharmacy benefit. This list may change without notice which may affect your benefit coverage. To be sure the specialty drug is covered, call the specialty pharmacy at 800-870-6419, Monday-Friday 8 a.m. to 11 p.m., Eastern time ans Saturday, 8 a.m. to 5 p.m., Eastern Time. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans 44150MUMENABS Rev. 6/1/2016
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