Mandatory Specialty Drug List
Mandatory Specialty Drug List - LifeWise Health Plan of Oregon
Mandatory Specialty Drug List - LifeWise Health Plan of Oregon
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<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Abraxane<br />
Actemra<br />
Actimmune<br />
Adagen<br />
Adcetris<br />
Adcirca<br />
Adempas<br />
Advate<br />
Afinitor<br />
Aldurazyme<br />
Alphanate<br />
AlphaNine SD<br />
Alprolix<br />
Amevive<br />
Ampyra<br />
Apokyn<br />
Aralast NP<br />
Aranesp<br />
Arcalyst<br />
Arestin<br />
Arixtra<br />
Arranon<br />
Arzerra<br />
Atryn<br />
Aubagio<br />
Avastin<br />
Aveed<br />
Avonex<br />
Azacitidine<br />
Bebulin<br />
Beleodaq<br />
BeneFix<br />
Benlysta<br />
Berinert<br />
Betaseron<br />
Bethkis<br />
Bivigam<br />
Blincyto<br />
Bosulif<br />
Botox<br />
Bravelle<br />
Capecitabine<br />
Caprelsa<br />
Carbaglu<br />
Carimune<br />
Cayston<br />
Ceprotin<br />
Cerdelga<br />
Cerezyme<br />
Cetrotide<br />
Chenodal<br />
Generic Name<br />
Paclitaxel Protein-Bound<br />
Tocilizumab<br />
Interferon gamma-1b<br />
Pegademase bovine<br />
Brentuximab<br />
Tadalafil<br />
Riociguat<br />
Factor VIII<br />
everolimus<br />
Laronidase<br />
Factor VIII<br />
Factor IX Complex<br />
Factor IX Complex<br />
Alefacept<br />
Dalfampridine<br />
Apomorphine<br />
Alpha-1 proteinase inhibitor<br />
Darbepoetin alpha<br />
Rilonacept<br />
Minocycline Hcl<br />
Fondaparinux<br />
Nelarabine<br />
Ofatumumab<br />
Anti-thrombin<br />
Teriflunomide<br />
Bevacizumab<br />
Testosterone undecanoate<br />
Interferon beta-1a<br />
Azacitidine<br />
Factor IX Complex<br />
Belinostat<br />
Factor IX Complex<br />
Belimumab<br />
1 Esterase Inhibitor Human<br />
Interferon beta-1b<br />
Tobramycin<br />
Immune Globulin IV (IVIG)<br />
blinatumomab<br />
Bosutinib<br />
Onabotulinumtoxina<br />
Urofollitropin<br />
Capecitabine<br />
Vandetanib<br />
carbaglu acid<br />
Immune Globulin IV (IVIG)<br />
aztreonam<br />
Protein C Concentrate (Human)<br />
eliglustat<br />
Imiglucerase<br />
Cetrorelix Acetate<br />
Chenodiol<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Generic Name<br />
Cholbam<br />
Cholic Acid<br />
Chorionic Gonadotropin<br />
Chorionic Gonadotropin<br />
Cimzia<br />
Certolizumab Pegol<br />
Cinryze<br />
1 Esterase Inhibitor Human<br />
Cometriq<br />
cabozantinib<br />
Copaxone<br />
Glatiramer<br />
Copegus<br />
Ribavirin<br />
Corifact<br />
Factor XIII (human)<br />
Cosentyx<br />
secukinumab<br />
Cyramza<br />
ramucirumab<br />
Cystadane<br />
Betaine<br />
Cystagon<br />
Cysteamine Bitartrate<br />
Cystaran cysteamine ophthalmic solutions 0.44%<br />
CytoGam<br />
CMV Immune Globulin<br />
Cytovene<br />
Ganciclovir<br />
Dacogen<br />
Decitabine<br />
Daklinza<br />
daclatasvir<br />
Decitabine<br />
Decitabine<br />
Duopa<br />
carbidopa and Levodopa Enteral Suspension<br />
Dysport<br />
AbobotulinumtoxinA<br />
Egrifta<br />
Tesamorelin<br />
Elaprase<br />
Idursulfase<br />
Elelyso<br />
Taliglucerase Alfa<br />
Eligard<br />
Leuprolide Acetate<br />
Eloctate<br />
Antihemophilic Factor (Recombinant), Fc Fusion Protein<br />
Enbrel<br />
Etanercept<br />
Enoxaparin sodium<br />
Enoxaparin sodium<br />
Entyvio<br />
Vedolizumab<br />
Epogen<br />
Epoetin alpha<br />
Epoprostenol<br />
Epoprostenol (generic Flolan)<br />
Erbitux<br />
Cetuximab<br />
Erivedge<br />
Vismodegib<br />
Esbriet<br />
Pirfenidone<br />
Euflexxa<br />
Hyaluronic acid derivatives<br />
Evzio<br />
Naloxone<br />
Exjade<br />
Desferasirox<br />
Extavia<br />
Interferon beta-1b<br />
Eylea<br />
Aflibercept<br />
Fabrazyme<br />
Agalsidase beta<br />
Farydak<br />
panobinostat<br />
Feiba<br />
Anti-Inhibitor Coagulant Complex<br />
Ferriprox<br />
deferiprone<br />
Firazyr<br />
Icatibant<br />
Firmagon<br />
Degarelix<br />
Flebogamma<br />
Immune Globulin IV (IVIG)<br />
Flolan<br />
Epoprostenol<br />
Follistim AQ<br />
Follitropin beta<br />
Folotyn<br />
Pralatrexate<br />
Fondaparinux<br />
Fondaparinux<br />
Forteo<br />
Teriparatide<br />
Fragmin<br />
Dalteparin<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Fuzeon<br />
Gamastan<br />
Gammagard<br />
Gammagard Liquid<br />
Gammaked<br />
Gammaplex<br />
Gamunex<br />
Ganciclovir<br />
Ganirelix Acetate<br />
Gardasil<br />
Gattex<br />
Gazyva<br />
Gel One<br />
Genotropin<br />
Gilenya<br />
Gilotrif<br />
Glassia<br />
Glatopa<br />
Gleevec<br />
Gonal-F<br />
Granix<br />
Halaven<br />
Harvoni<br />
Helixate<br />
Hemofil M<br />
Herceptin<br />
Hetlioz<br />
Hizentra<br />
HP Acthar Gel<br />
Humate-P<br />
Humatrope<br />
Humira<br />
Hyalgan<br />
Hycamtin<br />
HyperRho<br />
HyQvia<br />
Ibrance<br />
Iclusig<br />
Ilaris<br />
Iluvien<br />
Imbruvica<br />
Implanon<br />
Incivek<br />
Increlex<br />
Infergen<br />
Inlyta<br />
Innohep<br />
Intron A<br />
Iprivask<br />
Iressa<br />
Istodax<br />
Generic Name<br />
Enfuvirtide<br />
Immune Globulin IM (IGIM)<br />
Immune Globulin IV (IVIG)<br />
Immune Globulin IV (IVIG)<br />
Immune Globulin IV/SQ<br />
Immune Globulin IV (IVIG)<br />
Immune Globulin IV (IVIG)<br />
Ganciclovir<br />
Ganirelix Acetate<br />
Human Papilomavirus Vaccine<br />
Teduglutide<br />
obinutuzumab<br />
Hyaluronic acid derivatives<br />
Somatropin<br />
Fingolimod<br />
Afatinib<br />
Alpha-1 proteinase inhibitor<br />
Glatiramer<br />
Imatinib mesylate<br />
Follitropin alfa<br />
tbo-fiograstim<br />
Eribulin<br />
Ledipasvir/Sofosbuvir<br />
Factor VIII<br />
Factor VIII<br />
Trastuzumab<br />
Tasimelteon<br />
Immune Globulin SQ<br />
Repository Coricotropin Gel<br />
Factor VIII/VWF<br />
Somatropin<br />
Adalimumab<br />
Hyaluronic acid derivatives<br />
Topotecan Hcl<br />
Rho(D) immune globulin<br />
Immune Globulin SQ<br />
palbociclib<br />
Ponatinib<br />
Canakinumab<br />
fluocinolone acetonide itravitreal implant<br />
ibrutinib<br />
Etonogestrel Implant<br />
telaprivir<br />
Mecasermin<br />
Interferon alfacon-1<br />
Axitinib<br />
Tinzaparin sodium<br />
Interferon alfa-2b<br />
Desirubin<br />
Gefitinib<br />
Romidepsin<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Ixempra<br />
Ixinity<br />
Jadenu<br />
Jakafi<br />
Jetrea<br />
Jevtana<br />
Juxtapid<br />
Kadcyla<br />
Kalbitor<br />
Kalydeco<br />
Keytruda<br />
Kineret<br />
Kitabis Pak<br />
Koate<br />
Kogenate<br />
Korlym<br />
Krystexxa<br />
Kuvan<br />
Kynamro<br />
Kyprolis<br />
Lenvima<br />
Letairis<br />
Leukine<br />
Leuprolide Acetate<br />
Liletta<br />
Lovenox<br />
Lucentis<br />
Lumizyme<br />
Lupaneta Pack<br />
Lupron Depot<br />
Luveris<br />
Lynparza<br />
Macugen<br />
Menopur<br />
MICRhoGAM(plus)<br />
Mircera<br />
Mirena<br />
Mitoxantrone<br />
Moderiba<br />
Monoclate-P<br />
Mononine<br />
Monovisc<br />
Mozobil<br />
Myalept<br />
Myobloc<br />
Myozyme<br />
Naglazyme<br />
Natpara<br />
Neulasta<br />
Neumega<br />
Neupogen<br />
Generic Name<br />
Ixabepilone<br />
Coagulation Factor IX (Recombinant)<br />
deferasirox<br />
Ruxolitinib<br />
Ocriplasmin<br />
Cabazitaxel<br />
lomitapide<br />
Ado-trastuzumab emtansine<br />
Ecallantide<br />
Ivacaftor<br />
Pembrolizumab<br />
Anakinra<br />
Tobramycin Inhalation Solution<br />
Factor VIII<br />
Factor VIII<br />
mifepristone<br />
Pegloticase<br />
Sapropterin dihydrochloide<br />
Mipromersen sodium<br />
carfilzomib<br />
lenvatinib<br />
Ambrisentan<br />
Sargramostim (GM-CSF)<br />
Leuprolide Acetate<br />
levonorgestrel-releasing intrauterine device<br />
Enoxaparin<br />
Ranibizumab<br />
Alglucosidase Alfa<br />
Leuprolide Acetate for depot susspension and norethindrone acetate tablets<br />
Leuprolide Acetate<br />
Lutropin alfa<br />
olaparib<br />
Pegaptanib<br />
Menotropins<br />
Rho(D) immune globulin<br />
methoxy polyethylene glycol-epoetin beta<br />
levonorgestrel-releasing intrauterine device<br />
Mitoxantrone<br />
Ribavirin<br />
Factor VIII<br />
Factor IX Complex<br />
High Molecular Weight Hyaluronan Injection<br />
Plerixafor<br />
Metreleptin<br />
rimabotulinumtoxinB<br />
Alglucosidase Alfa<br />
Galsulfase<br />
parathyroid hormone<br />
Pegfilgrastim<br />
Oprelvekin<br />
Filgrastim (G-CSF)<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Nexavar<br />
Nexplanon<br />
Norditropin<br />
Northera<br />
Novantrone<br />
Novarel<br />
NovoEight<br />
NovoSeven(RT)<br />
Nplate<br />
Nulojix<br />
Nutropin<br />
Obizur<br />
Octagam<br />
Octreotide Acetate<br />
Ofev<br />
Oforta<br />
Olysio<br />
Omnitrope<br />
Opdivo<br />
Opsumit<br />
Oralair<br />
Orencia<br />
Orenitram<br />
Orfadin<br />
Orkambi<br />
Orthovisc<br />
Otezla<br />
Ovidrel<br />
Ozurdex<br />
ParaGard<br />
Pegasys<br />
Peg-Intron<br />
Perjeta<br />
Plegridy<br />
Pomalyst<br />
Praluent<br />
Pregnyl<br />
Prialt<br />
Privigen<br />
Procrit<br />
Procysbi<br />
Profilnine<br />
Prolastin<br />
Proleukin<br />
Prolia<br />
Promacta<br />
Prothelial<br />
Pulmozyme<br />
Purixan<br />
Qutenza<br />
Ravicti<br />
Generic Name<br />
Sorafenib<br />
etonogestrel Implant<br />
Somatropin<br />
Droxidopa<br />
Mitoxantrone<br />
Chorionic Gonadotropin<br />
antihemophilic Factor (Recombinant)<br />
Factor VIIa<br />
Romiplostim<br />
Belatacept<br />
Somatropin<br />
antihemophilic Factor (Recombinant)<br />
Immune Globulin IV (IVIG)<br />
Octreotide Acetate<br />
nitedanib<br />
Fludarabine<br />
simeprevir<br />
Somatropin<br />
nivolumab<br />
macitentan<br />
Grass Pollen Extract<br />
Abatacept<br />
Treprostinil<br />
Nitisinone<br />
lumacaftor/ivacaftor<br />
Hyaluronic acid derivatives<br />
Apremilast<br />
Choriogonadotropin alpha<br />
dexamethasone intravitreal implant<br />
IUD Copper Contraceptive<br />
Peginterferon alfa-2a<br />
Peginterferon alfa-2b<br />
Pertuzumab<br />
Peginterferon Beta-1a<br />
Pomalidomide<br />
alirocumab<br />
Chorionic Gonadotropin<br />
Ziconotide<br />
Immune Globulin IV (IVIG)<br />
Epoetin alpha<br />
Cysteamine Bitartrate<br />
Factor IX Complex<br />
Alpha-1 proteinase inhibitor<br />
Aldesleukin<br />
Denosumab<br />
Eltrombapag<br />
Sucralfate Malate, Polymerized<br />
Dornase alfa<br />
mercaptopurine<br />
Capsaicin<br />
Glycerol phenylbutyrate<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Rebetol<br />
Rebif<br />
Recombinate<br />
Refacto<br />
Remicade<br />
Remodulin<br />
Repatha<br />
Repronex<br />
Retisert<br />
Revatio<br />
Revlimid<br />
Rhogam(Plus)<br />
Rhophylac<br />
Riastap<br />
Ribapak<br />
Ribasphere<br />
Ribatab<br />
Ribavirin<br />
Rituxan<br />
Rixubis<br />
Ruconest<br />
Sabril<br />
Saizen<br />
Samsca<br />
Sandostatin<br />
Sensipar<br />
Serostim<br />
Signifor<br />
Sildenafil<br />
Simponi<br />
Skyla<br />
Solesta<br />
Soliris<br />
Somatuline Depot<br />
Somavert<br />
Sovaldi<br />
Sprix<br />
Sprycel<br />
Stelara<br />
Stimate<br />
Stivarga<br />
Sucraid<br />
Supartz<br />
Supprelin LA<br />
Sutent<br />
Sylatron<br />
Sylvant<br />
Synagis<br />
Synribo<br />
Synvisc<br />
Tafinlar<br />
Generic Name<br />
Ribavirin<br />
Interferon beta-1a<br />
Factor VIII<br />
antihemophilic Factor (Recombinant)<br />
Infliximab<br />
Treprostinil sodium<br />
evolocumab<br />
Menotropins<br />
Fluocinolone Acetonide Intravitreal Implant<br />
Sildenafil<br />
Lenalidomide<br />
Rho(D) immune globulin<br />
Rho(D) immune globulin<br />
Fibrinogen Concetrate<br />
Ribavirin<br />
Ribavirin<br />
Ribavirin<br />
Ribavirin<br />
Rituximab<br />
Coagulation Factor IX (Recombinant)<br />
C1 esterase inhibitor (recombinant)<br />
Vigabatrin<br />
Somatropin<br />
Tolvaptan<br />
Octreotide Acetate<br />
Cinacalcet<br />
Somatropin<br />
Pasireotide<br />
Sildenafil<br />
Golimumab<br />
levonorgestrel-releasing intrauterine device<br />
dextranomer microsphere<br />
Eculizumab<br />
Lanreotide<br />
Pegvisomant<br />
Sofosbuvir<br />
Ketorolac tromethamine<br />
Dasatinib<br />
Ustekinumab<br />
Desmopressin nasal<br />
Regorafenib<br />
sacrosidase<br />
Hyaluronic acid derivatives<br />
Histrelin Acetate<br />
Sunitinib<br />
Peginterferon alfa-2b<br />
Situximab<br />
Palivizumab<br />
Omacetaxine mepesuccinate<br />
Hyaluronic acid derivatives<br />
Dabrafenib<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Tarceva<br />
Tasigna<br />
Tecfidera<br />
Technivie<br />
Temozolomide<br />
Tetrabenazine<br />
Tev-Tropin<br />
Thalomid<br />
TOBI<br />
TOBI Podhaler<br />
Tobramycin<br />
Torisel<br />
Tracleer<br />
Treanda<br />
Tretten<br />
Tykerb<br />
Tysabri<br />
Tyvaso<br />
Vantas<br />
Varithena<br />
Vectibix<br />
Velcade<br />
Veletri<br />
Ventavis<br />
Victrelis<br />
Vidaza<br />
Viekira Pak<br />
Vimizim<br />
Visudyne<br />
Vivaglobin<br />
Vivitrol<br />
Votrient<br />
Vpriv<br />
Wilate<br />
WinRho<br />
Xalkori<br />
Xeljanz<br />
Xeloda<br />
Xenazine<br />
Xeomin<br />
Xgeva<br />
Xiaflex<br />
Xofigo<br />
Xolair<br />
Xtandi<br />
Xyntha<br />
Yervoy<br />
Zaltrap<br />
Zarxio<br />
Zavesca<br />
Zelboraf<br />
Generic Name<br />
Erlotinib<br />
Nilotinib<br />
Dimethyl fumarate<br />
ombitasvir, paritaprevir and ritonavir<br />
Temozolomide<br />
Tetrabenazine<br />
Somatropin<br />
Thalidomide<br />
Tobramycin Inhalation Solution<br />
Tobramycin Inhalation Powder<br />
Tobramycin Inhalation Solution<br />
Temsirolimus<br />
Bosentan<br />
Bendamustine HCL<br />
Coagulation Factor XIII A-Subunit (Recombinant)<br />
Lapatinib ditosylate<br />
Natalizumab<br />
Treprostinil<br />
Histrelin<br />
polidocanol injectable foam<br />
Panitumumab<br />
Bortezomib<br />
Epoprostenol Sodium<br />
Iloprost<br />
Boceprevir<br />
Azacitidine<br />
ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir<br />
Elosulase alfa<br />
Verteporfin<br />
Immune Globulin SQ<br />
Naltrexone Injectable<br />
Pazopanib<br />
Velagulcerase alfa<br />
Factor VIII<br />
Rho(D) immune globulin<br />
Crizotinib<br />
Tofacitinib<br />
Capecitabine<br />
Tetrabenazine<br />
IncobotulinumtoxinA<br />
Denosumab<br />
Collagenase clostridium histolyticum<br />
radium Ra 223 dichloride<br />
Omalizumab<br />
Enzalutamide<br />
Factor VIII<br />
Ipilimumab<br />
Ziv-aflibercept<br />
Filgrastim (SNDZ)<br />
Miglustat<br />
Vemurafenib<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><br />
<strong>Drug</strong> Name<br />
Zemaira<br />
Zoladex<br />
Zolinza<br />
Zomacton<br />
Zorbtive<br />
Zydelig<br />
Zykadia<br />
Zytiga<br />
Generic Name<br />
Alpha-1 proteinase inhibitor<br />
Goserelin acetate<br />
Vorinostat<br />
Somatropin<br />
Somatropin<br />
idelalisib<br />
Ceritinib<br />
Abiraterone acetate<br />
Provided by LifeWise Health Plan of Oregon, LifeWise Health Plan of Washington<br />
and LifeWise Assurance Company 017541 (10-2015)
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