Specialty medication list

An evidence-based pharmacy

program that works for you

All specialty medications, including those listed below, require prior authorization before

they can be dispensed.

Prior authorization (PA) is the process a member follows to obtain approval from Moda

Health before we can process payment for a specific medication. To request PA for your

specialty medication, please contact our Pharmacy Customer Service and we’ll work directly

with your healthcare provider to complete this process. If you do not have the required

authorization, we may deny payment for your medication.

For a complete list of drugs that require authorization log in to your myModa account at

modahealth.com (after your effective date of coverage). Or, call us toll free at 800-913-4311.

Please note that we update this list as new medications enter the market and it is subject to

change. You must access specialty medications through the exclusive specialty pharmacy. To

enroll with Ardon Health Specialty Pharmacy, call toll free at 855-425-4085.

2018.2 (4/2/2018).

For prior effective dates, please contact Moda Health. 2 modahealth.com

Brand Name Dosage

Abilify Maintena Suser Vial

Abilify Maintena Suser Syr

Actemra Vial

Actemra Syringe

Actimmune Vial

Adefovir Dipivoxil Tablet

Adempas Tablet

Advate Vial

Adynovate Vial

Afinitor Tablet

Afinitor Disperz Tab Susp

Afstyla Vial

Alecensa Capsule

Alferon N Vial

Alimta Vial

Alkeran Tablet

Alphanate Vial

Alphanine SD Vial

Alprolix Vial

Alunbrig Tab Ds Pk

Alunbrig Tablet

Amicar Solution

Amicar (1000 mg) Tablet

Aminocaproic Acid Vial

Ampyra Tab ER 12h

Amvisc Syringe

Amvisc Plus Syringe

Anzemet Tablet

Anzemet Vial

Apokyn Cartridge

Aralast NP Vial

Aranesp Vial

Aranesp Syringe

Arcalyst Vial

Aristada Suser Syr

Atryn Vial

Aubagio Tablet

Austedo Tablet

Aveed Vial

Avelox IV Piggyback

Avonex Kit

Avonex Syringekit

Avonex Syringe

Brand Name Dosage

Avonex Pen Pen Injctr

Avonex Pen Pen Ij Kit

Azactam Vial

Aztreonam Vial

Baraclude Tablet

Baraclude Solution

Bebulin Vial

Benefix Kit

Benlysta Auto Injct

Benlysta Syringe

Benlysta Vial

Berinert Kit

Berinert Vial

Betaseron Vial

Betaseron Kit

Bethkis Ampul-Neb

Bexarotene Capsule

Bosulif Tablet

Botox Vial

Brevibloc IV Soln

Brevibloc Vial

Buphenyl Powder

Buphenyl Tablet

Bupivacaine HCl Els Pmp Fr

Cabometyx Tablet

Calcium Gluconate-0.9% Nacl Plast. Bag

Calquence Capsule

Camptosar Vial

Capecitabine Tablet

Caprelsa Tablet

Carbaglu Tab Disper

Carboplatin Vial

Carimune Nf Nanofiltered Vial

Caverject Vial

Caverject Kit

Cayston Vial-Neb

Cefazolin Sodium-Dextrose Piggyback

Cefazolin Sodium-Dextrose Froz.Piggy

Ceftazidime Piggyback

Ceprotin Vial

Cerdelga Capsule

Cerezyme Vial

Chenodal Tablet

2018.2 (4/2/2018).

For prior effective dates, please contact Moda Health. 3 modahealth.com

Brand Name Dosage

Cholbam Capsule

Chorionic Gonadotropin Vial

Cimzia Kit

Cimzia Syringekit

Cinryze Vial

Coagadex Vial

Cometriq (100 mg/day And 140 mg/day) Capsule

Copaxone Syringe

Copegus Tablet

Corifact Kit

Cosentyx (2 Syringes) Syringe

Cosentyx Pen Pen Injctr

Cosentyx Pen (2 Pens) Pen Injctr

Cosentyx Syringe Syringe

Cotellic Tablet

Cuvitru Vial

Cyclophosphamide Vial

Cyklokapron Vial

Cystadane Powder

Cystagon Capsule

Cystaran Drops

Cytarabine Vial

Daklinza Tablet

Ddavp Ampul

Ddavp Vial

Desmopressin Acetate Ampul

Desmopressin Acetate Vial

Dexamethasone-0.9% Nacl Piggyback

Dexrazoxane Vial

Dilaudid-Hp Vial

Diphenhydramine-0.9% Nacl Piggyback

Docefrez Vial

Docetaxel Vial

Dupixent Syringe

Dysport Vial

Edex Kit

Eligard Syringe

Elitek Vial

Ellence Vial

Eloctate Vial

Emcyt Capsule

Emend Vial

Emflaza Tablet

Brand Name Dosage

Enbrel Cartridge

Enbrel Vial

Enbrel Syringe

Enbrel Pen Injctr

Entecavir Tablet

Epclusa Tablet

Epinephrine-D5w Plast. Bag

Epirubicin HCl Vial

Epivir HBV Tablet

Epivir HBV Solution

Epogen Vial

Erivedge Capsule

Esbriet Capsule

Esbriet Tablet

Esmolol HCl Vial

Etoposide Capsule

Exjade Tab Disper

Extavia Vial

Extavia Kit

Fabrazyme Vial

Fareston Tablet

Farydak Capsule

Feiba Nf Vial

Fentanyl Citrate Vial

Fentanyl Citrate Plast. Bag

Fentanyl Citrate Pca Syring

Fentanyl Citrate Syringe

Fentanyl Citrate Ampul

Fentanyl Citrate-0.9% Nacl Plast. Bag

Fentanyl Citrate-0.9% Nacl Syringe

Fentanyl Citrate-0.9% Nacl Vial

Fentanyl Citrate-0.9% Nacl Pca Syring

Fentanyl Citrate-0.9% Nacl Pump Resvr

Fentanyl Citrate-D5w Pca Syring

Fentanyl Citrate-D5w Plast. Bag

Fentanyl-Bupivacaine-0.9% Nacl Plast. Bag

Fentanyl-Bupivacaine-0.9% Nacl Pump Resvr

Fentanyl-Ropivacaine-0.9% Nacl Plast. Bag

Fentanyl-Ropivacaine-0.9% Nacl Pump Resvr

Ferriprox Tablet

Ferriprox Solution

Firazyr Syringe

Firmagon Vial

2018.2 (4/2/2018).

For prior effective dates, please contact Moda Health. 4 modahealth.com

Brand Name Dosage

Fludarabine Phosphate Vial

Folotyn Vial

Forteo Pen Injctr

Fuzeon Vial

Gablofen Vial

Gamastan S-D Vial

Gammagard S-D Vial

Gammaked Vial

Gamunex-C Vial

Gattex Kit

Gemcitabine HCl Vial

Gemzar Vial

Genotropin Cartridge

Genotropin Syringe

Geodon Vial

Gilenya Capsule

Gilotrif Tablet

Glassia Vial

Glatiramer Acetate Syringe

Glatopa Syringe

Gleevec Tablet

Gleostine Capsule

Glycopyrrolate Syringe

Granisetron HCl Tablet

Granisetron HCl Vial

Granix Syringe

H.P. Acthar Vial

Haegarda Vial

Haldol Decanoate 100 Ampul

Haldol Decanoate 50 Ampul

Haloperidol Decanoate Vial

Haloperidol Decanoate Ampul

Haloperidol Decanoate 100 Ampul

Haloperidol Lactate Vial

Harvoni Tablet

Healon5 Syringe

Helixate FS Vial

Hemlibra Vial

Hemofil M Vial

Heparin Flush Kit

Heparin Sodium-0.9% Nacl IV Soln

Hepsera Tablet

Hetlioz Capsule

Brand Name Dosage

Hexalen Capsule

Hizentra Vial

Humate-P Vial

Humatrope Vial

Humatrope Cartridge

Humira Syringekit

Humira Pediatric Crohn's Syringekit

Humira Pen Pen Ij Kit

Humira Pen Crohn-UC-HS Starter Pen Ij Kit

Humira Pen Psoriasis-Uveitis Pen Ij Kit

Hycamtin Vial

Hycamtin Capsule

Hydromorph-Bupivac-0.9% Nacl Pump Resvr

Hydromorphone HCl Vial

Hydromorphone HCl-0.9% Nacl Pca Syring

Hydromorphone HCl-0.9% Nacl Pca Vial

Hydromorphone HCl-0.9% Nacl Plast. Bag

Hydromorphone HCl-D5w Pca Syring

Hydroxyprogesterone Caproate Vial

Hyqvia Vial

Hyqvia Hy Component Vial

Hyqvia Ig Component Vial

Ibrance Capsule

Iclusig Tablet

Idelvion Vial

Idhifa Tablet

Ifex Vial

Ifosfamide Vial

Imatinib Mesylate Tablet

Imbruvica Capsule

Imbruvica Tablet

Imipenem-Cilastatin Sodium Vial

Impavido Capsule

Increlex Vial

Ingrezza Capsule

Inlyta Tablet

Intron A Vial

Invega Sustenna Syringe

Iressa Tablet

Irinotecan HCl Vial

Ixempra Vial

Ixinity Vial

Jadenu Tablet

2018.2 (4/2/2018).

For prior effective dates, please contact Moda Health. 5 modahealth.com

Brand Name Dosage

Jadenu Sprinkle Gran Pack

Jakafi Tablet

Juxtapid Capsule

Kalydeco Tablet

Kalydeco Gran Pack

Keveyis Tablet

Kevzara Syringe

Kineret Syringe

Kisqali Tablet

Koate Vial

Koate-Dvi Vial

Kogenate FS Vial

Korlym Tablet

Kovaltry Vial

Kuvan Tablet Sol

Kuvan Powd Pack

Kynamro Syringe

Lamivudine (100mg) Tablet

Lamivudine HBV Tablet

Lenvima Capsule

Letairis Tablet

Leukeran Tablet

Leukine Vial

Leuprolide Acetate Vial

Leuprolide Acetate Kit

Levaquin Piggyback

Levetiracetam-Nacl Piggyback

Levofloxacin-D5w Piggyback

Levophed Bitartrate Vial

Levothyroxine Sodium Vial

Lidocaine HCl Syringe

Lidocaine HCl Vial

Lidocaine HCl Ampul

Lioresal Intrathecal Ampul

Lomustine Capsule

Lonsurf Tablet

Lucentis Vial

Lupaneta Pack Kt Syr Tab

Lupron Depot Syringekit

Lupron Depot (Lupaneta) Syringekit

Lupron Depot-Ped Kit

Lupron Depot-Ped Syringekit

Lynparza Capsule

Brand Name Dosage

Magnesium Sulfate-0.9% Nacl Piggyback

Makena Auto Injt

Makena Vial

Matulane Capsule

Mavyret Tablet

Mekinist Tablet

Melphalan Tablet

Meperidine HCl-0.9% Nacl Pca Syring

Meropenem Vial

Merrem Vial

Mesna Vial

Mesnex Vial

Mesnex Tablet

Methadone HCl Vial

Methoxsalen (NDC 68682-0065-10) Cap Lq Rap

Mircera Syringe

Mitomycin Vial

Moderiba Tablet

Moderiba Tab Ds Pk

Monoclate-P Vial

Mononine Vial

Morphine Sulfate Cartridge

Morphine Sulfate-0.9% Nacl Pca Syring

Morphine Sulfate-0.9% Nacl Plast. Bag

Morphine Sulfate-0.9% Nacl Syringe

Morphine Sulfate-0.9% Nacl Pump Resvr

Morphine Sulfate-0.9% Nacl Pca Vial

Myalept Vial

Myleran Tablet

Myobloc Vial

Natpara Cartridge

Neostigmine Methylsulfate Vial

Nerlynx Tablet

Neulasta Syringe

Neulasta Syr W/ Inj

Neumega Vial

Neupogen Syringe

Neupogen Vial

Nexavar Tablet

Nexplanon Implant

Nexterone Plast. Bag

Nilandron Tablet

Nilutamide Tablet

2018.2 (4/2/2018).

For prior effective dates, please contact Moda Health. 6 modahealth.com

Brand Name Dosage

Ninlaro Capsule

Nityr Tablet

Norditropin Flexpro Pen Injctr

Norditropin Nordiflex Pen Injctr

Norepinephrine Bitar-0.9% Nacl Plast. Bag

Norepinephrine Bitartrate Vial

Northera Capsule

Novarel Vial

Novoeight Vial

Novoseven Rt Vial

Nplate Vial

Nuplazid Tablet

Nutropin AQ Cartridge

Nutropin AQ Nuspin Pen Injctr

Nuwiq Vial

Obizur Vial

Ocaliva Tablet

Octagam Vial

Octreotide Acetate Vial

Octreotide Acetate Ampul

Octreotide Acetate Syringe

Odomzo Capsule

Ofev Capsule

Olanzapine Vial

Olysio Capsule

Omnitrope Cartridge

Omnitrope Vial

Ondansetron HCl Vial

Ondansetron HCl Syringe

Opsumit Tablet

Orencia Syringe

Orencia Clickject Auto Injct

Orenitram ER Tablet ER

Orfadin Oral Susp

Orfadin (2 mg, 5 mg And 10 mg) Capsule

Orkambi Tablet

Otezla Tab Ds Pk

Otezla Tablet

Oxaliplatin Vial

Pamidronate Disodium Vial

Pegasys Vial

Pegasys Syringe

Pegasys Proclick Pen Injctr

Brand Name Dosage

Pegintron Kit

Pegintron Redipen Pen Ij Kit

Phenylephrine HCl-0.9% Nacl Plast. Bag

Piperacillin-Tazobactam Vial Port

Piperacillin-Tazobactam Vial

Plegridy Syringe

Plegridy Pen Pen Injctr

Pomalyst Capsule

Potassium Phosphate-0.9% Nacl Plast. Bag

Praluent Pen Pen Injctr

Praluent Syringe Syringe

Pregnyl Vial

Prevymis

Prialt Vial

Primaxin Vial

Primaxin Vial Port

Procrit Vial

Procysbi Cap Dr Spr

Profilnine Vial

Prolastin C Vial

Prolia Syringe

Promacta Tablet

Pulmozyme Solution

Ravicti Liquid

Rebetol Capsule

Rebetol Solution

Rebif Syringe

Rebif Rebidose Pen Injctr

Rebinyn Vial

Recombinate Vial

Relistor Tablet

Relistor Vial

Relistor Syringe

Remodulin Vial

Repatha Pushtronex Wear Injct

Repatha Sureclick Pen Injctr

Repatha Syringe Syringe

Revlimid Capsule

Ribasphere Capsule

Ribasphere Tablet

Ribasphere Ribapak Tab Ds Pk

Ribatab Tab Ds Pk

Ribavirin Tablet

2018.2 (4/2/2018).

For prior effective dates, please contact Moda Health. 7 modahealth.com

Brand Name Dosage

Ribavirin Capsule

Rilutek Tablet

Riluzole Tablet

Risperdal Consta Syringe

Rixubis Vial

Ropivacaine HCl Els Pmp Hr

Ropivacaine HCl Els Pmp Lr

Ropivacaine HCl Syringe

Ropivacaine HCl-0.9% Nacl Pump Resvr

Ropivacaine HCl-0.9% Nacl Els Pmp Hr

Ropivacaine HCl-0.9% Nacl Plast. Bag

Rubraca Tablet

Ruconest Vial

Rydapt Capsule

Sabril Tablet

Sabril Powd Pack

Saizen Vial

Saizen Cartridge

Saizen-Saizenprep Cartridge

Sancuso Patch Tdwk

Sandostatin Ampul

Sandostatin Vial

Sandostatin Lar Kit

Sandostatin Lar Depot Vial

Serostim Vial

Signifor Ampul

Siliq Syringe

Simponi Syringe

Simponi Pen Injctr

Simulect Vial

Sirturo Tablet

Sodium Phenylbutyrate Powder

Sodium Phenylbutyrate Tablet

Soltamox Solution

Somatuline Depot Syringe

Somavert Vial

Sovaldi Tablet

Sprycel Tablet

Stelara Vial

Stelara Syringe

Stivarga Tablet

Strensiq Vial

Sutent Capsule

Brand Name Dosage

Sylatron Kit

Synagis Vial

Synarel Spray

Synribo Vial

Tabloid Tablet

Tafinlar Capsule

Tagrisso Tablet

Taltz Autoinjector Auto Injct

Taltz Autoinjector (2 Pack) Auto Injct

Taltz Autoinjector (3 Pack) Auto Injct

Taltz Syringe Syringe

Taltz Syringe (2 Pack) Syringe

Taltz Syringe (3 Pack) Syringe

Tarceva Tablet

Targretin Gel (Gram)

Targretin Capsule

Tasigna Capsule

Taxotere Vial

Tecfidera Capsule Dr

Technivie Tablet

Temodar Capsule

Temozolomide Capsule

Tetrabenazine Tablet

Thalomid Capsule

Thrombate Iii Vial

Tobi Podhaler Capsule

Tobi Podhaler Cap W/Dev

Topotecan HCl Vial

Tracleer Tablet

Tracleer Tab Susp

Tranexamic Acid Vial

Treanda Vial

Trelstar Syringe

Trelstar Vial

Tremfya Syringe

Tretten Vial

Tykerb Tablet

Tymlos Pen Injctr

Tyvaso Ampul-Neb

Tyvaso Institutional Start Kit Ampul-Neb

Tyvaso Refill Kit Ampul-Neb

Tyvaso Starter Kit Ampul-Neb

Uptravi Tablet

2018.2 (4/2/2018).

For prior effective dates, please contact Moda Health. 8 modahealth.com

Brand Name Dosage

Uptravi Tab Ds Pk

Valchlor Gel (Gram)

Vecamyl (NDC 45043-0558-40) Tablet

Vemlidy Tablet

Venclexta Tablet

Venclexta Starting Pack Tab Ds Pk

Ventavis Ampul-Neb

Verzenio Tablet

Vibativ Vial

Viekira Pak Tab Ds Pk

Viekira XR Tab Bp 24h

Vinblastine Sulfate Vial

Vinorelbine Tartrate Vial

Vistogard Gran Pack

Vivitrol Sus ER Rec

Vonvendi Vial

Vosevi Tablet

Votrient Tablet

Wilate Vial

Xalkori Capsule

Xeljanz Tablet

Xeljanz XR Tab ER 24h

Xeloda Tablet

Xenazine Tablet

Xermelo Tablet

Xgeva Vial

Xolair Vial

Xtandi Capsule

Xuriden Gran Pack

Brand Name Dosage

Xylocaine Vial

Xylocaine IV Ampul

Xylocaine-Mpf Vial

Xyntha Vial

Xyntha Solofuse Syringe

Xyrem Solution

Yervoy Vial

Zaltrap Vial

Zarxio Syringe

Zavesca Capsule

Zejula Capsule

Zelboraf Tablet

Zemaira Vial

Zepatier Tablet

Zinbryta Syringe

Zinecard Vial

Zoladex Implant

Zolinza Capsule

Zolpimist Spray/Pump

Zomacton Vial

Zometa Pggybk Btl

Zorbtive Vial

Zortress Tablet

Zosyn Vial

Zydelig Tablet

Zykadia Capsule

Zyprexa Vial

Zyprexa Relprevv Vial

Zytiga Tablet

This document is provided for informational purposes only, and is intended as a quick reference. For cost and further

details of the coverage, including exclusions, any reduction or limitations and the terms under which the policy may be

continued in force, contact your producer or Moda Health.

Copyright © 2014 Moda, Inc. All Rights Reserved. Health plans in Oregon, Alaska and Washington provided by Moda Health Plan, Inc. Health plans in California provided by Moda Health Plan, Inc. dba Moda

Health Insurance.

Effective 1/2/2013. For prior effective dates, please contact Moda Health.

Effective 1/2/2013. For prior effective dates, please contact Moda Health.