View the Mandatory Specialty Drug List - Premera Blue Cross
View the Mandatory Specialty Drug List - Premera Blue Cross
View the Mandatory Specialty Drug List - Premera Blue Cross
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<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><strong>Drug</strong> NameLucentisLumizymeLupaneta PackLupron DepotLuverisLynparzaMacugenMakenaMatulaneMekinistMenopurMICRhoGAM(plus)MirceraMirenaMitoxantroneMonoclate-PMononineMonoviscMozobilMyaleptMyozymeNaglazymeNeulastaNeumegaNeupogenNexavarNorditropinNor<strong>the</strong>raNovantroneNovarelNovoSeven(RT)NplateNulojixNutropinObizurOctagamOctreotide AcetateOfevOfortaOlysioOmnitropeOpdivoOpsumitOralairOrenciaOrenitramOrfadinOrthoviscOtezlaOvidrelOzurdexGeneric NameRanibizumabAlglucosidase AlfaLeuprolide Acetate for depot susspension and norethindrone acetate tabLeuprolide AcetateLutropin alfaolaparibPegaptanibHydroxyprogesterone caproateProcarbazine HCLTrametinibMenotropinsRho(D) immune globulinmethoxy polyethylene glycol-epoetin betalevonorgestrel-releasing intrauterine deviceMitoxantroneFactor VIIIFactor IX ComplexHigh Molecular Weight Hyaluronan InjectionPlerixaforMetreleptinAlglucosidase AlfaGalsulfasePegfilgrastimOprelvekinFilgrastim (G-CSF)SorafenibSomatropinDroxidopaMitoxantroneChorionic GonadotropinFactor VIIaRomiplostimBelataceptSomatropinAntihemophilic Factor (Recombinant)Immune Globulin IV (IVIG)Octreotide AcetatenitedanibFludarabinesimeprevirSomatropinnivolumabmacitentanGrass Pollen ExtractAbataceptTreprostinilNitisinoneHyaluronic acid derivativesApremilastChoriogonadotropin alphadexamethasone intravitreal implantProvided by <strong>Premera</strong> <strong>Blue</strong> <strong>Cross</strong> and <strong>Premera</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> Shield of AlaskaAn Independent Licensee of <strong>the</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> Shield Association 017542 (01-2015)
<strong>Mandatory</strong> <strong>Specialty</strong> <strong>Drug</strong> <strong>List</strong><strong>Drug</strong> NameXiaflexXolairXtandiXynthaYervoyZaltrapZavescaZelborafZemairaZoladexZolinzaZorbtiveZydeligZykadiaZytigaGeneric NameCollagenase clostridium histolyticumOmalizumabEnzalutamideFactor VIIIIpilimumabZiv-afliberceptMiglustatVemurafenibAlpha-1 proteinase inhibitorGoserelin acetateVorinostatSomatropinidelalisibCeritinibAbiraterone acetateProvided by <strong>Premera</strong> <strong>Blue</strong> <strong>Cross</strong> and <strong>Premera</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> Shield of AlaskaAn Independent Licensee of <strong>the</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> Shield Association 017542 (01-2015)
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