Office-administered Specialty Drug Network

docs.jpgAvailability

Office–administered specialty pharmacy products ordered by a provider and administered in an office or outpatient setting and are GENERALLY covered under medical benefits. The following office–administered specialty drugs may have medical policies or require prior plan approval. For each drug class, each ingredient name is listed with its brand name equivalents in parentheses.

Please note: Self–administered specialty medications covered under the prescription drug benefit must be filled by a pharmacy in the Retail Specialty Network. Certain self–administered medications have been excluded from BCBSNC's medical benefits but are still covered under the prescription drug benefit. For more information, see self–administered injectable medications.

Please note: Some of these medications listed below may require prior review.

Current Specialty Pharmacy Drugs (as of December 1, 2011)

*Note: New Class Names, New Ingredient Names and/or New Brand Names are highlighted in red.

Class: Antifungal

  • Voriconazole (Vfend®)

Class: Anemia/Renal disorders

  • Darbepoetin alfa (Aranesp®, Aranesp SureClick®)
  • Epoetin alfa (Epogen®, Procrit®)

Class: Antiemetics

  • Dolasetron mesylate (Anzemet®)
  • Fosaprepitant dimeglumine (Emend®)
  • Granisetron hydrochloride (Kytril®–IV)
  • Ondansetron hydrochloride (Zofran®)
  • Palonosetron hydrochloride (Aloxi®)

Class: Antihemophilic agent

  • Anti–inhibitor Coagulant Complex (Feiba VH Immuno®)
  • Factor IX Complex (Profilnine SD®, Bebulin VH®, Proplex T®)
  • Factor IX Human (AlphaNine SD®, Mononine®)
  • Factor IX Recombinant (BeneFIX®)
  • Factor VIII Human (Alphanate®, Alphanate/VWF Complex®, Hemofil M®, Koate DVI®, Koate–HP®, Monoclate–P®)
  • Factor VIIa (e.g. NovoSeven®, NovoSeven RT®)
  • Factor VIII Recombinant (Advate®, Recombinate®, Kogenate FS®, Kogenate FS Bio–Set®, Helixate FS®, ReFacto®, Xyntha®, Advate H®, Advate L®, Advate M®, Advate SH®, Advate UH®)
  • VonWillebrand Factor Complex (Humate–P®)
  • VonWillebrand Factor / Coagulation Factor VIII Complex (Wilate®)

Class: Antipsychotics

  • Paliperidone (Invega Sustenna®)
  • Risperidone long–acting (Risperdal ConstaTM)

Class: Antiviral

  • Cidofovir (Vistide®)
  • Foscarnet sodium (Foscavir®)
  • Ganciclovir (Cytovene®–IV)
  • Ribavirin (Virazole®)

Class: Bisphosphonate

  • Denosumab (Prolia®)
  • Ibandronate (Boniva®)
  • Pamidronate disodium (Aredia®)
  • Zoledronic acid (Reclast®, Zometa®)

Class: Blood modifier

  • Filgrastim (Neupogen®)
  • Iron dextran (Dexferrum®, Infed®)
  • Iron sucrose (Venofer®)
  • Lepirudin (Refludan®)
  • Pegfilgrastim (Neulasta®)
  • Plerixafor (Mozobil®)
  • Protein C Concentrate (Ceptorin®)
  • Sargramostim (Leukine®)
  • Urokinase (Kinlytic®)
  • Velaglucerase alfa (VPRIV®)

Class: Botulinum toxin

  • AbobutulinumtoxinA (Dysport ®), PPA may be required
  • Incobotulinum ToxinA (Xeomin®)
  • OnabotilinumtoxinA (Botox®)
  • RimabotilinumtoxinB (MyoblocTM)

Class: Cardiovascular

  • Epoprostenol Sodium (Flolan®)
  • Iloprost (Ventavis®)
  • Nesiritide (Natrecor®)
  • Treprosinil inhalation (Tyvaso®)
  • Treprostinil injection (Remodulin®)

Class: Contraception

  • Etonogestrel (Implanon®)
  • Levonorgestrel – releasing intrauterine contraceptive system (Mirena®)
  • Medroxyprogesterone acetate (Depo–ProveraTM)

Class: Endocrine / Metabolic

  • Corticotropin (Acthar®)
  • Hydroxyprogesterone Caproate (Makena TM)
  • Methylnaltrexone bromide (Relistor®)
  • Pegloticase (Krystexxa TM)

Class: Enzyme replacement

  • Agalsidase beta (Fabrazyme®)
  • Alglucerase (Ceredase®)
  • Alglucosidase Alfa (Lumizyme®, Myozyme®)
  • Alpha – 1 proteinase inhibitor (Aralast®)
  • Alpha – 1 proteinase inhibitor (Prolastin®)
  • Alpha – 1 proteinase inhibitor (Zemaira®)
  • Galsulfase (Naglazyme®)
  • Idursulfase (Elaprase®)
  • Imiglucerase (Cerezyme®)
  • Laronidase (Aldurazyme®)
  • Pegademase bovine (Adagen®)

Class: Hormone

  • Histrelin acetate (Supprelin LA®)
  • Testosterone (Testopel®)
  • Thyrotropin alfa (Thyrogen®)

Class: Immune globulinsupplies.jpg

  • CMV–IVIG (human) (CytoGam®)
  • Immune Globulin Intravenous ( CarimuneNF®, Flebogamma®, Gammagard S/D®, Gammagard®, Gammaplex®, Gamunex®, Octagam®, Privigen®) – PPA may be required
  • Palivizumab (Synagis®)
  • Rho(D) Immune Globulin Human (HyperRho S/D®, MICRhoGAM®, MiCRhoGAM Plus®, RhoPhylac®, Rhogam Ultra Filtered Plus®, WinRho SDF®)
  • Immune Globulin Subcutaneous (Hizentra®, Vivaglobin®) – PPA may be required

Class: Immunomodulator

  • Abatecept (Orencia®)
  • Alefacept (Amevive®)
  • Belimumab (Benlysta®)
  • Golimimab (Simponi®), PPA may be required
  • Infliximab (Remicade®), PPA may be required
  • Interferon alfa–2b recombinant (Intron A®)
  • Interferon alfa–n3 (Alferon–N®)
  • Natalizumab (Tysabri®)
  • Peginterferon alfa–2b (Sylatron TM)
  • Rituximab (Rituxan®), PPA may be required
  • Tocilizumab (Actemra®), PPA may be required
  • Ustekinumab (Stelara®)

Class: Immunosuppresive

  • Belatacept (Nulojix®)
  • Cyclosporine injection (Sandimmune®)

Class: Migraine

  • Dihydroergotamine mesylate (D.H.E. 45®)

Class: Miscellaneous

  • Antithymocyte globulin (Atgam®)
  • Basililiximab (Simulect®)
  • Betaine (Cystadane®)
  • Calcitriol (Calcijex®)
  • C1 esterase inhibitor (Berinert® , Cinryze®)
  • Canakinumab (Ilaris®)
  • Capsaicin (Qutenza®)
  • Collagenase Colistridium Histolyticum (Xiaflex®)
  • DMSO, dimethyl sulfoxide (Rimso–50®)
  • Daclizumab (Zenapax®)
  • Deferoxamine mesylate (Desferal®)
  • Ecallantide (Kalbitor®)
  • Eculizumab (Soliris®)
  • Gold sodium thiomalate (Myochrysine®)
  • Hyaluronidase ovine (Vitrase®)
  • Lymphocyte immune globulin (Thymoglobulin®)
  • Naltrexone hydrochloride (Vivitrol®)
  • Octreotide depot (Sandostatin® LAR)
  • Octreotide non depot (Sandostatin®)
  • Recombinant Hyaluronidase Human (Hylenex®)
  • Romiplostim (Nplate®)
  • Secretin, synthetic, human (ChiRhoStim®)
  • Tranexamic Acid injection (Cyklokapron®)
  • Ziconotide (Prialt®)
  • Unclassified Biologic: When filing a Drug with an unclassified HCPC code, the appropriate NDC # must be included on the claim.

Class: Oncology

  • Adrucil (Fluorouracil®)
  • Aldesleukin (Proleukin®)
  • Alemtuzumab (Campath®)
  • Amifostine crystalline (Ethyol®)
  • Arsenic trioxide (Trisenox®)
  • Asparaginase (Elspar®)
  • Azacitidine (Vidaza®)
  • BCG Live intravesical (TheraCys®, Tice BCG®)
  • Bendamustine HCL (Treanda®)
  • Bevacizumab (Avastin®)
  • Bleomycin sulfate (Blenoxane®)
  • Bortezomib (Velcade®)
  • Brentuximab (Adcetris®)
  • Busulfan (Busulfex®)
  • Cabazitaxel (Jevtana®)
  • Carboplatin aqueous solution (Paraplatin®)
  • Carmustine (Bicnu®)
  • Cetuximab (Erbitux®)
  • Cisplatin (Platinol® AQ)
  • Cladribine (Leustatin®)
  • Clofarabine (Clolar®)
  • Cyclophosphamide (Cytoxan®)
  • Cytarabine liposome (DepoCyt®)
  • Dacarbazine (DTIC–DOME®)
  • Dactinomycin (Cosmegen®)
  • Daunorubicin citrate (Daunoxome®)
  • Decitabine (Dacogen®)
  • Degarelix (Firmagon®)
  • Denileukin Diftitox (Ontak®)
  • Denosumab (Xgeva TM)
  • Dexrazoxane hydrochloride (Totect®, Zinecard®)
  • Docetaxel (Taxotere®)
  • Doxorubicin hydrochloride (Adriamycin®)
  • Doxorubicin hydrochloride liposome (Doxil®)
  • Epirubicin HCL (Ellence®)
  • Eribulin Mesylate (Halaven TM)
  • Etoposide (Toposar®)
  • Etoposide phosphate (Etopophos®)
  • Floxuridine (Fudr®)
  • Fludarabine phosphate (Fludara®)
  • Fluorouracil (Adrucil®, Fluorouracil®)
  • Fulvestrant (Faslodex®)
  • Gemcitabine hydrochloride (Gemzar®)
  • Gemtuzumab ozogamicin (Mylotarg®)
  • Goserelin acetate (Zoladex®)
  • Gytarabine (Cytarabine®)
  • Histrelin acetate (Vantas®)
  • Idarubicin hydrochloride (Idamycin PFS®)
  • Ifosfamide (Ifex®)
  • Irinotecan hydrochloride (Camptosar®)
  • Ixabepilone (Ixempra®)
  • Lanreotide acetate (Somatuline Depot®)
  • Leucovorin calcium injection
  • Levoleucovorin calcium (Fusilev®)
  • Leuprolide acetate depot (Leupron Depot®, Lupron Depot® – Pediatric, Eligard®)
  • Mechlorethamine hydrochloride (Mustargen®)
  • Melphalan hydrochloride (Alkeran®)
  • Mesna (Mesnex®)
  • Mitomycin (Mitomycin®)
  • Mitoxantrone hydrochloride (Novantrone®)
  • Nelarabine(Arranon®)
  • Ofatumumab (Arzerra®)
  • Oxaliplatin (Eloxatin®)
  • Paclitaxel protein bound (Abraxane®)
  • Paclitaxel (Taxol®, OnxolTM)
  • Palifermin (Kepivance®)
  • Panitumumab (Vectibix®)
  • Pegaspargase (Oncaspar®)
  • Pemetrexed disodium (Alimta®)
  • Pentostatin (Nipent®)
  • Porfimer sodium (Photofrin®)
  • Pralatrexate (Folotyn®)
  • Rasburicase (Elitek®)
  • Rituximab (Rituxan®)
  • Streptozocin (Zanosar®)
  • Temsirolimus (Torisel®)
  • Temozolomide (Temodar®)
  • Teniposide (Vumon®)
  • Thiotepa (Thiotepa®)
  • Topotecan hydrochloride (Hycamtin®)
  • Trastuzumab (Herceptin®)
  • Triptorelin pamoate ( Trelstar Depot®, Trelstar LA®)
  • Valrubicin (Valstar®)
  • Vinblastine sulfate (Velban®)
  • Vincristine sulfate (Vincasar®)
  • Vinorelbine tartrate (Navelbine®)

Class: Ophthalmology

  • Fluocinolone acetonide (Retisert®)
  • Ganciclovir (Vitrasert®)
  • Pegaptanib sodium(Macugen®)
  • Verteporfin (Visudyne®)
  • Ranibizumab (Lucentis®)

Class: Osteoarthritis

  • Hyaluronan (Orthovisc®)
  • Hylan Polymers (Synvisc®, Synvisc One®)
  • Sodium hyaluronate (Hyalgan®, SupartzTM, Euflexxa®)

 

Class: Respiratory

  • Alpha–1 proteinase inhibitor, Human (Glassia®)
  • Aztreonam (Cayston®)
  • Omalizumab (Xolair®), PPA may be required