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Office-administered Specialty Drug Network

Availability

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. The generic drug name is listed with examples of 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.

Changes or Deletions (effective July 1, 2009)

Changes to Specialty Pharmacy Drugs

  • Factor VIIa is hereby adding NovoSeven RT® brand name in the Antihemophilic agent class of drugs
  • Factor VIII Recombinant is hereby adding Xyntha® and Genarc® brand names in the Antihemophilic agent class of drugs

Deleted Specialty Pharmacy Drugs

  • Fomivirsen sodium (e.g.Vitravene® ) in the Ophthalmology class of drugs
  • Sermorelin acetate (e.g. Geref®) in the Hormone class of drugs

Current Specialty Pharmacy Drugs (as of January 1, 2009)

Class: Anemia/Renal disorders

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

Class: Antihemophilic agent

  • Anti-inhibitor Coagulant Complex (AutoPlex-T®, Feiba VH Immuno®)
  • Factor IX Recombinant (BeneFix®)
  • Factor IX Complex (Profilnine SD®, Bebulin VH®, Proplex T®)
  • Factor IX Human (AlphaNine SD®, Mononine®)
  • Factor VIII Human (Alphanate®, Hemofil M®, Koate DVI®, Koate–HP®, Monarc–M®, Monoclate–P®)
  • Factor VIII Porcine (Hyate–C®)
  • Factor VIII Recombinant (Advate®, RecombinateTM, Kogenate®, Helixate®, ReFacto®)
  • VonWillebrand Factor Complex (Humate–P®)

Class: Antiemetics

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

Class: Antiviral

  • Cidofovir (Vistide®)
  • Ganciclovir (Cytovene®–IV)

Class: Bisphosphonate

  • Pamidronate disodium (Aredia®)
  • Zoledronic acid (Zometa®)
  • Zoledronic acid (Reclast®) 

Class: Blood modifier

  • Filgrastim (Neupogen®)
  • Pegfilgrastim (Neulasta®)
  • Sargramostim (Leukine®)

Class: Botulinum toxin

  • Botulinum Toxin Type-A (Botox®), PPA may be required
  • Botulinum Toxin Type-B (MyoblocTM), PPA may be required

Class: Contraception

  • Medroxyprogesterone acetate 150 mg (Depo-ProveraTM)
  • Etonogestrel (Implanon®)

Class: Enzyme replacement

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

Class: Hormone

  • Histrelin acetate (Supprelin LA®)
  • Thyrotropin alpha (Thyrogen®)
  • Gonadorelin (Factrel®)

Class: Immune globulin

  • Cytomegalovirus immune globulin intravenous (human) CMV–IVIG (CytoGam®)
  • Immune Globulin Intravenous (Carimune®, Carimune®NF, Flebogamma®, Gammagard S/D®, Gammar–P®, Gamimune N®, Gamunex®, Iveegam®, Octagam®, Panglobulin®, Polygam S/D®, Sandoglobulin®, Venoglobulin–S®)
  • Palivizumab (Synagis®)
  • Respiratory Syncytial Virus Immune Globulin (RSV-IGIV) (RespigamTM)
  • Rabies Immune Globulin RIG (BayRab®)
  • Rabies Immune Globulin RIG-HT (Imogam-Rabies HT®)
  • RhoPhylac (Rho(D) Immune Globulin®)
  • Rho(D) Immune Globulin (BayRho-D®)
  • Rho(D) Immune Globulin (Rhogam®)
  • Rho(D) Immune Globulin (WinRho SDF®)
  • Immune Globulin (Vivaglobin®)

Class: Interferons

  • Interferon –alfa–n3 (Alferon N®)
  • Interferon alfa–2a recombinant (Roferon®)
  • Interferon alfa–2b recombinant (Intron A®)

Class: Migraine

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

Class: Miscellaneous

  • Eculizumab (Soliris®)
  • Ibandronate (Boniva®)
  • Protein C Concentrate (Ceprotin®)
  • Ziconotide (Prialt®)
  • Octreotide (Sandostatin®, Sandostatin® LAR)
  • Recombinant Hyaluronidase Human Inj.(Hylenex®)
  • Naltrexone (Vivitrol®)

Class: Multiple Sclerosis

  • Natalizumab (Tysabri®)

Class: Oncology

  • Paclitaxel (Abraxane®)
  • Pemetrexed (Alimta®)
  • Cetuximab (Erbitux®)
  • Fulvestrant (Faslodex®)
  • Histrelin Acetate (Vantas®)
  • Bortezomib (Velcade®)
  • Aldesleukin (Proleukin®)
  • Fludarabine phosphate (Fludara®)
  • Gemcitabine HCL (Gemzar®)
  • Doxorubicin (Adriamycin®)
  • Bleomycin (Blenoxane®)
  • Alemtuzumab (Campath®)
  • Irinotecan (Camptosar®)
  • Doxorubicin HCl liposome (Doxil®)
  • Amifostine (Ethyol®)
  • Temsirolimus (Torisel®)
  • Topotecan HCl (Hycamtin® injection)
  • Leucovorin calcium injection
  • Leuprolide acetate depot (Leupron Depot®, Eligard®)
  • Leuprolide acetate implant (Viadur®)
  • Vinorelbine tartrate (Navelbine®)
  • Carboplatin aqueous solution (Paraplatin®)
  • Cisplatin (Platinol® AQ)
  • Paclitaxel (Taxol®, OnxolTM)
  • Docetaxel (Taxotere®)
  • Triptorelin pamoate (Trelstar®)
  • Bevacizumab (Avastin®)
  • Goserelin (Zoladex®)
  • Mitoxantrone (Novantrone®)
  • Gemtuzumab (Mylotarg®)
  • Rituximab (Rituxan®)
  • Trastuzumab (Herceptin®)
  • Azacitidine (Vidaza®)
  • Decitabine (Dacogen®)
  • Nelarabine(Arranon®)
  • Panitumumab (Vectibix®)

Class: Ophthalmology

  • Pegaptanib (Macugen®)
  • Verteporfin (Visudyne®)
  • Ranibizumab (Lucentis®)
  • Fomivirsen sodium (e.g. Vitravene®

Class: Osteoarthritis

  • Sodium hyaluronate (Hyalgan®, SupartzTM, Orthovisc®, Euflexxa®)
  • Hylan G-F 20 (Synvisc®)

Class: Psoriasis

  • Alefacept (Amevive®)

Class: Pulmonary

  • Omalizumab (Xolair®), PPA may be required
  • Epoprostenol Sodium (Flolan®)
  • Treprostinil (Remodulin®)
  • Iloprost (Ventavis®)

Class: Rheumatoid Arthritis

  • Abatecept (Orencia®), PPA may be required
  • Infliximab (Remicade®), PPA may be required

Class: Schizophrenia

  • Risperidone long-acting (Risperdal ConstaTM)

Class: Vaccine

  • Gardasil® (Human Papilloma Virus (HPV)) Vaccine
  • Zostavax® (Herpes Zoster) Vaccine
  • Adacel (Tetanus, diphteria toxoids and acellular pertussis) Vaccine
  • Rabies Vaccine ID (Imovax®ID)
  • Rabies Vaccine IM (Imovax®)
  • Meningococcal Conjugate Vaccine (Menactra TM)
  • Meningococcal Polysaccharide Vaccine (Menomune®)