Self-injectable, infused and oral specialty drugs

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Specialty Pharmacy and the University of Virginia Health Plan Specialty Pharmacy Basic Health Drug List Self-injectable, infused and oral specialty drugs XX.XX.XXX.X (X/16)

2 You may only purchase specialty drugs through UVA Specialty Pharmacy or Aetna Specialty Pharmacy. Drugs purchased at any other pharmacy will not be covered. Please review your plan documents for more about the requirements and limitations of your pharmacy benefits and insurance plan. What is a specialty drug? Specialty drugs treat complex, chronic conditions that often require support by a nurse or pharmacist during treatment.because of the complex therapy needed, a pharmacist or nurse should check in with you often during your treatment. These drugs may be injected, infused or taken by mouth. They may need to be refrigerated. To get started with Aetna Specialty Pharmacy, call ASRX ( ) or TDD: ASRX ( ). Or visit Or call the University of Virginia Health Plan Specialty Pharmacy Key NPL National precertification * Drug may not be available through Aetna Specialty Pharmacy. Precertification Bold New QL ST NPS Quantity limit applies Step therapy applies Non-preferred specialty drug Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health of California Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

3 Antineoplastic agents Antineoplastics (oral) bexarotene capecitabine temozolomide tretinoin QL QL QL AFINITOR ST AFINITOR DIS BOSULIF ST CAELSA * COMETRIQ ERIVEDGE FARYDAK GILOTRIF * GLEEVEC HYCAMTIN IBRANCE ICLUSIG ST IMBRUVICA INLYTA ST IRESSA JAKAFI * LENVIMA * LYNPARZA MEKINIST NEXAVAR ST POMALYST PURIXAN ST REVLIMID SYCEL ST STIVARGA SUTENT TAFINLAR TARCEVA TARGRETIN TASIGNA ST TEMODAR THALOMID TYKERB VOTRIENT ST XELODA QL XALKORI * ZELBORAF ST ZOLINZA ZYDELIG ZYKADIA QL Antineoplastics hormonal agents leuprolide ELIGARD FASLODEX FIRMAGON LUPANETA LUON LUON DEPOT TRELSTAR LA Antineoplastics miscellaneous ACTIMMUNE ALFERON N INTRON A IRESSA TRELSTAR DEPOT TRELSTAR MIX VANTAS XTANDI * ST ZOLADEX ZYTIGA LU DEP-PED SYLATRON TARGRETIN Gel VALCHLOR NPS Blood products modifiers volume expanders Anti-inhibitor coagulant complex FEIBA NF FEIBA VH Blood-clotting factor VIIa (recombinant) NOVOSEVEN NOVOSEVEN RT Blood-clotting factor VIII (human) ALPHANATE CORIFACT HEMOFIL M HUMATE-P KOATE-DVI MONOCLATE-P WILATE Blood-clotting factor VIII (recombinant) ADVATE ELOCTATE HELIXATE FS IXINITY KOGENATE FS NOVOEIGHT RECOMBINATE XYNTHA Blood-clotting factor IX (nonrecombinant) ALPHANINE SD MONONINE OFILNINE Blood-clotting factor IX (recombinant) ALOLIX BEBULIN VH BENEFIX IXINITY

4 Blood-clotting factor XIII (recombinant) TRETTEN Blood-clotting complex KCENTRA Fibrinogen concentrate (human) RIASTAP NPL RIXUBIS Hematopoietic growth factors ARANESP EPOGEN GRANIX LEUKINE MIRCERA NEULASTA Hereditary angioedema BERINERT CINRYZE * FIRAZYR NEUMEGA NEUPOGEN NPLATE OCRIT OMACTA ZARXIO KALBITOR * RUCONEST * Paroxysmal nocturnal hemoglobinuria Cardiovascular system SOLIRIS Hypertension VECAMYL ST Inherited homozygous familial hypercholesterolemia Inherited heterozygous familial hypercholesterolemia JUXTAPID* ST KYNAMRO ST REPATHA QL ST ALUENT QL ST REPATHA QL ST Orthostatic hypotension NORTHERA ST Pulmonary hypertension agents epoprostenol * ADCIRCA sildenafil QL QL ST QL ST ADEMPAS FLOLAN * LETAIRIS OPSUMIT ORENITRAM QL ST REMODULIN * QL REVATIO QL ST TRACLEER TYVASO * VELETRI * VENTAVIS * Central nervous system Analgesics nonnarcotic IALT Anticonvulsants GABA modulators SABRIL * Huntington s disease chorea tetrabenazine XENAZINE *

5 Multiple sclerosis agents glatopa AMPYRA AUBAGIO AVONEX ST BETASERON COPAXONE 20 mg ST COPAXONE 40 mg QL ST ST EXTAVIA ST QL ST GILENYA LEMTRADA PLEGRIDY REBIF TECFIDERA TYSABRI QL ST QL ST QL ST ST Dermatological agents Antineoplastic-alkylating agents VALCHLOR Gel * ST Antipsoriatics COSENTYX ST ENBREL HUMIRA KINERET ST OTEZLA QL OTREXUP ST RASUVO ST REMICADE SIMPONI STELARA ST Endocrine system Acromegaly octreotide SANDOSTATIN SANDOSTATIN LAR SIGNIFOR LAR * SOMATULINE SOMAVERT Congenital sucrase-isomaltase deficiency SUCRAID * Corticotropin ACTHAR HP Cushing s disease SIGNIFOR KORLYM Diagnostic drugs THYROGEN Fabry disease FABRAZYME Gaucher disease CERDELGA CEREZYME ELELYSO * ST VIV ST ZAVESCA * Growth factors, insulin-like INCRELEX Growth hormone agents GENOTROPIN ST HUMATROPE ST NORDITROPIN ST NUTROPIN ST NUTROPIN AQ ST NUTROPIN AQ NUSPIN OMNITROPE SAIZEN ST SEROSTIM ST ZOMACTON ST ZORBTIVE Hereditary tyrosinemia ORFADIN * Homocystinuria CYSTADANE ST

6 Hormone replacement progestins MAKENA Hunter syndrome ELAASE * Hyperammonemia phenylbutyrate AMMONUL BUPHENYL Hyperparathyroidism doxercalciferol paricalcitol HECTOROL SENSIPAR ZEMPLAR Hypoparathyroidism NATPARA * QL Leptin deficiency MYALEPT QL LHRH/GnRH agonist analog pituitary suppressants SUPELIN LA SYNAREL Morquio A syndrome VIMIZIM Mucopolysaccharidosis I ALDURAZYME Mucopolysaccharidosis VI NAGLAZYME Phenylketonuria KUVAN * Pompe disease LUMIZYME MYOZYME Vasopressin receptor antagonists SAMSCA * Gastrointestinal system Bile acid synthesis disorders CHOLBAM * Crohn s disease CIMZIA ST ENTYVIO ST HUMIRA REMICADE Short bowel syndrome GATTEX * QL Infections and infestations Antiretrovirals fusion inhibitors FUZEON Antivirals cytomegalovirus (CMV) agents cidofovir foscarnet ganciclovir valganciclovir CYTOGAM CYTOVENE FOSCAVIR VALCYTE VALCYTE SOL VISTIDE

7 Antivirals hepatitis agents adefovir entecavir lamivudine ribapak ribasphere ribavirin BARACLUDE COPEGUS DAKLINZA EPIVIR HBV HARVONI HEPSERA I NFERGEN OLYSIO QL ST ST QL ST PEGASYS PEGINTRON REBETOL SOVALDI TECHNIVIE TYZEKA VIEKIRA ST ZEPATIER QL ST QL ST NPS Musculoskeletal system Bone-modifying agents ibandronate (inj only) pamidronate zoledronic acid FORTEO GANITE NPL OLIA RECLAST XGEVA ZOMETA Enzymes XIAFLEX Gout KRYSTEXXA Interleukin-1beta blockers ILARIS * Interleukin-1 blockers ARCALYST * Neuromuscular blocking agent neurotoxins BOTOX DYSPORT XEOMIN Osteoarthritis EUFLEXXA GEL-ONE INJ HYALGAN MONOVISC ST ST Rheumatoid arthritis ACTEMRA ST ACTEMRA SC CIMZIA ST ENBREL HUMIRA KINERET ST ORENCIA ST ST ORTHOVISC SUPARTZ ST SYNVISC ST SYNVISC ONE OTREXUP ST RASUVO ST REMICADE SIMPONI SIMPONI ARIA XELJANZ ST ST QL ST Ophthalmic agents Macular degeneration EYLEA LUCENTIS NPS NPL NPS NPL MACUGEN NPL VISUDYNE Macular edema OZURDEX Vitreomacular adhesion JETREA Respiratory tract agents Alpha-proteinase inhibitors ARALAST ARALAST NP GLASSIA * OLASTIN * OLASTIN-C * ZEMAIRA *

8 Antiasthmatic monoclonal antibodies XOLAIR Cystic fibrosis colistimethate sodium tobramycin neb sol BETHKIS NEB CAYSTON * COLY-MYCIN M KALYDECO * ORKAMBI * PULMOZYME TOBI TOBI podhaler Idiopathic pulmonary fibrosis ESBRIET OFEV Respiratory syncytial virus monoclonal antibodies SYNAGIS QL Tuberculosis SIRTURO ST Therapeutic nutrients vitamins minerals electrolytes Mineral supplements ferric gluconate FERRIOX FERRLECIT VENOFER Toxicologic agents Alcohol dependence VIVITROL Antidotes deferoxamine mesylate DESFERAL EXJADE JADENU Vaccines, toxoids and biologics Immune globulin CMV CYTOGAM Immune globulin immune disorders ADAGEN BIVIGAM CARIMUNE NANOFILTERED FLEBOGAMMA GAMASTAN S/D GAMMAGARD GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX GAMUNEX-C HIZENTRA HYQVIA OCTAGAM IVIGEN VIVAGLOBIN Immune globulin hepatitis B HEPAGAM B HYPERHEP B NABI-HB Immune globulin rabies HYPERRAB S/D IMOGAM RABIES

9 Immune globulin Rh isoimmunization HYPERRHO S/D MICRHOGAM ULTRA-FILTERED RHOGAM ULTRA-FILTERED PLUS RHOPHYLAC WINRHO SDF Immune globulin tetanus HYPERTET S/D Miscellaneous Cystinosis CYSTARAN * OCYSBI ST Immunosuppressive agents azathioprine (inj only) cyclosporine gengraf mycophenolic acid mycophenolate mofetil sirolimus tacrolimus ASTAGRAF ATGAM CELLCEPT MYFORTIC NEORAL NULOJIX OGRAF RAPAMUNE SANDIMMUNE SIMULECT THYMOGLOBULIN ZORTRESS Narcolepsy XYREM * Primary periodic paralysis KEVEYIS * Systemic lupus erythematosus agents BENLYSTA Urea cycle disorder RAVICTI * Anxiolytics, sedatives, hypnotics miscellaneous HETLIOZ Parkinson's disease DUOPA * ST Wilson's disease Alpha-1 blockers phenoxybenzamine CUIMINE SYINE THIOLA DIBENZYLINE

10 Commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who have coverage for medications that are added to or removed from the Aetna Specialty CareRx SM list, national precertification list, precertification safety edit list, precertification list, step-therapy list or quantity limit list, or have quantity limits modified, during the plan year will continue to have those medications covered at the same benefits level under their plan prior to the addition, removal or change, until their plan s renewal date. The term precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company s clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. In accordance with state law, fully insured commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the precertification or step-therapy lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee s medical condition. In accordance with state law, fully insured commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the precertification or step-therapy lists will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a licensed pharmacy subsidiary of Aetna Inc. that operates through specialty pharmacy prescription fulfillment. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Policy forms issued in OK include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23 and/or GR-29/GR-29N Aetna Inc. XX.XX.XXX.X (X/16)