Specialty Drugs & Medication List - Mutual of Omaha
Specialty Drugs & Medication List - Mutual of Omaha
Specialty Drugs & Medication List - Mutual of Omaha
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<strong>Specialty</strong> <strong>Drugs</strong> & <strong>Medication</strong> <strong>List</strong><br />
<strong>Specialty</strong> Drug & Medicines are high-cost<br />
injectables, infused, oral or inhaled drugs for the<br />
ongoing treatment <strong>of</strong> a chronic condition. These<br />
drugs generally require close supervision and<br />
monitoring <strong>of</strong> the patient’s drug therapy.<br />
The drugs listed below are considered <strong>Specialty</strong><br />
<strong>Drugs</strong> & Medicines, as defined by <strong>Mutual</strong> <strong>of</strong> <strong>Omaha</strong>,<br />
and are covered under the <strong>Specialty</strong> Pharmacy <strong>Drugs</strong><br />
& Medicines <strong>of</strong> your Prescription Drug plan.<br />
NOTE: This list may not be all-inclusive and is<br />
subject to change. Certain drugs may require prior<br />
authorization and all drugs listed may not be<br />
covered under your specific plan. Please refer to<br />
your Benefits Document for details.<br />
To qualify for in-network benefits under your<br />
Prescription Drug plan, these medications must be<br />
obtained through one <strong>of</strong> the participating <strong>Specialty</strong><br />
Pharmacy providers, which are:<br />
CuraScript:<br />
866-297-0932 or www.curascript.com<br />
PharmaCare:<br />
888-900-3232 or www.pharmacare.com<br />
Caremark:<br />
800-237-2767 or www.caremark.com<br />
Unlike most retail pharmacies, the <strong>Specialty</strong><br />
Pharmacy providers maintain an adequate inventory<br />
<strong>of</strong> <strong>Specialty</strong> <strong>Drugs</strong> & Medicines in order to provide<br />
prompt home delivery <strong>of</strong> your medications.<br />
By utilizing a <strong>Specialty</strong> Pharmacy, you will also<br />
receive additional value added services while at the<br />
same time, maximizing pharmacy benefit dollars.<br />
These providers can help you at no extra cost with:<br />
n Education and wellness programs that provide<br />
information, materials and ongoing support to<br />
help you manage your health<br />
n Complete insurance billing, including<br />
coordination <strong>of</strong> benefits for lower out-<strong>of</strong>-pocket<br />
costs and virtually no paperwork<br />
n Timely, accurate and free courier delivery <strong>of</strong><br />
medications, many <strong>of</strong> the times with next<br />
day delivery<br />
n Supplies, including syringes, alcohol swabs and<br />
sharps kits, if required<br />
If you have any questions regarding the <strong>Specialty</strong><br />
Pharmacy <strong>Drugs</strong> & <strong>Medication</strong>s provision <strong>of</strong> your<br />
Prescription Drug plan, please contact Customer<br />
Service or your Plan Administrator.<br />
<strong>Specialty</strong> <strong>Drugs</strong> & <strong>Medication</strong>s<br />
ANTICOAGULANT THERAPY<br />
Arixtra<br />
Lovenox<br />
Fragmin<br />
ARTHRITIS THERAPY**<br />
Enbrel<br />
Orencia<br />
Humira<br />
Remicade<br />
Hyalgen<br />
Supartz<br />
Kineret<br />
Synvisc<br />
BLOOD FACTOR PRODUCTS<br />
Factor VIII (Recombinant)<br />
Advate<br />
Recombinate<br />
Helixate FS<br />
Refacto<br />
Kogenate FS<br />
Factor VIII (Monoclonal)<br />
Hem<strong>of</strong>il ® -M<br />
Monoclate ® P<br />
Monarc M ®<br />
Factor VIII (Other)<br />
Alphanate ® SDHT Koate DVI 1000 u/vial<br />
Humate ® -P (vWD)<br />
Factor IX (Recombinant)<br />
Benefix ® 250 u/vial<br />
Factor IX (Monoclonal/High Purity)<br />
Alphanine ® SDVF Mononine ®<br />
Factor IX (Other)<br />
Bebulin ® VH<br />
Konyne ® -80 1000 u/vial<br />
Pr<strong>of</strong>ilnine SD<br />
Proplex ® T<br />
Inhibitor Therapies<br />
Amicar<br />
Genarc<br />
Aminocaproic Acid Hyate-C<br />
Autoplex ® -T NovoSeven ®<br />
Feiba ® -VH<br />
Stimate<br />
GROWTH HORMONE***<br />
Genotropin ® 2 mg Nutropin ® Depot<br />
Humatrope ® Protropin ®<br />
Increlex Saizen ®<br />
Iplex<br />
Serostim<br />
Norditropin ®<br />
Zorbtive<br />
Nutropin<br />
MUGC8356_1106 <strong>Specialty</strong> Pharmacy <strong>Medication</strong> <strong>List</strong>
<strong>Specialty</strong> <strong>Drugs</strong> & <strong>Medication</strong>s (continued)<br />
HEMATOPOIETIC AGENTS<br />
Aranesp<br />
Epogen<br />
Leukine<br />
Neulasta<br />
Neumega<br />
Neupogen<br />
Procrit<br />
HEMOSTATIC AGENTS<br />
DDAVP Stimate ®<br />
HEPATITIS C THERAPY<br />
Copegus<br />
Infergen<br />
Intron A<br />
Peg Intron<br />
Pegasys<br />
HIV/AIDS MEDICATIONS<br />
Agenerase<br />
Combivir<br />
Crixivan<br />
Epivir<br />
Fortovase<br />
Fuzeon<br />
Hivid<br />
Invirase<br />
Kaletra<br />
Norvir<br />
INFERTILITY<br />
Antagon<br />
Bravelle<br />
Cetrotide<br />
Chorionic Gonadatropin<br />
Crinone<br />
Delestrogen<br />
Factrel<br />
Fertinex<br />
Follistim<br />
Gonal-F<br />
Gonal-F RFF<br />
IMMUNE DEFICIENCIES<br />
BayGam<br />
Carimune NF<br />
Flebogamma<br />
Gamimune N<br />
Gammagard S/D<br />
Gammar - PIV<br />
Rebetol (generic)<br />
Rebetron<br />
Ribavirin<br />
R<strong>of</strong>eron A<br />
Rescriptor<br />
Retrovir<br />
Sustiva<br />
Trizivir<br />
Videx<br />
Viracept<br />
Viramune<br />
Viread<br />
Zerit<br />
Ziagen<br />
Leuprolide Acetate<br />
Lupron<br />
Novarel<br />
Ovidrel<br />
Progesterone in Oil<br />
Pergonal<br />
Pregynl<br />
Pr<strong>of</strong>asi/HP<br />
Repronex<br />
Synarel<br />
Zoladex<br />
Gamunex<br />
Iveegam EN<br />
Octagam<br />
Panglobulin<br />
Polygam SD<br />
MS & NEUROLOGICAL DISORDERS<br />
Avonex ® Novantrone ®<br />
Betaseron<br />
Rebif<br />
Copaxone ®<br />
Tysabri<br />
OSTEOARTHRITIS<br />
Euflexxa<br />
Hyalgan<br />
Orthovisc<br />
OSTEOPOROSIS**<br />
Forteo<br />
Supartz<br />
Synvisc<br />
OTHER SPECIALTY THERAPIES<br />
Actimmune**<br />
Proleukin<br />
Actimmune NF<br />
Remicade**<br />
Aldurazyme<br />
Rituxan<br />
Alferon N<br />
Sandostatin<br />
Aludrazyme<br />
Sandostatin LAR<br />
Botox**<br />
Somavert**<br />
Ceredase<br />
Taxol<br />
Cerezyme<br />
Temodar<br />
Cytogam<br />
Thalomid<br />
Eligard, Fuzeon<br />
Thyrogen<br />
Fabrazyme<br />
Trelstar Depot<br />
Gleevec<br />
Trelstar LA<br />
Herceptin<br />
Viadur<br />
Iressa<br />
Visudyne<br />
Lupron<br />
Xeloda<br />
Mirena<br />
Xolair**<br />
Myobloc<br />
Zoladex<br />
Neumega<br />
Zometa<br />
Novantrone<br />
PSORIASIS**<br />
Amevive<br />
Enbrel<br />
Raptiva<br />
PULMONARY DISORDERS<br />
Aralast<br />
Respigam<br />
Flolan TOBI ®<br />
Pulmozyme ®<br />
Tracleer<br />
Remodulin<br />
RENAL DISEASE<br />
Sensipar<br />
RSV**<br />
Synagis<br />
TRANSPLANT AND IMMUNOSUPPRESSANTS<br />
Atgam<br />
Immune Globulin/ATG<br />
Azathioprine (Imuran) Muromonab-CD3<br />
Cellcept (Mycophenolate) Prograf<br />
Daclizumab (Zenapax) Simulect<br />
***<strong>Medication</strong>s requiring Prior Authorization<br />
***<strong>Medication</strong>s requiring Prior Authorization for members older than 18 years <strong>of</strong> age<br />
<strong>Specialty</strong> Pharmacy <strong>Medication</strong> <strong>List</strong>
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