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OptumRx | optumrx.com

BriovaRx®, the OptumRx® specialty pharmacy, provides comprehensive support services, including access to pharmacists around the clock, for high-cost oral and injectable medications used to treat rare and complex conditions. In addition, your medications will be shipped to you at no extra cost.

Specialty pharmacy drug list

Effective January 1, 2017

Characteristics of specialty medications

“Specialty” medications are defined as high-cost oral or injectable medications used to treat rare and complex conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds found within the body. Medications must have at least one of the following characteristics in order to be classified as a specialty medication by BriovaRx:

High cost• Typically priced at more than $1,000 per 30-day supply.

High complexity• Biotechnology products†

• Medications that treat ultra rare conditions

• Medications that are included in a specialty therapeutic drug class strategy

High-touch medications that require:• Temperature control or other special handling and shipping requirements

(e.g., refrigerated or frozen shipping)

• Ongoing management by a pharmacist and/or physician specializing in treating the condition

• Focused, in-depth education including how to administer injections, adhere to the treatment protocol, and manage side effects

† Protein or protein-based molecular entities



Alpha-1

Glassia PA

Ammonia detoxicants

Ravicti PA

Antilipemic agents

Juxtapid PA

Kynamro PA

Repatha PA, ST

Antiviral

ActimmuneAdefov DipivAlferon NBaracludeCopegus PA

Daklinza PA, ST

Epclusa PA, ST

HepseraInfergen PA

Intron-A PA

Olysio PA, ST * Pegasys PA *

Peg-Intron PA Rebetol PA Ribapak PA Ribasphere PA Ribatab PA Ribavirin PA * Sovaldi PA, ST * Synagis PA

Tyzeka Victrelis PA, ST

Viekira XR PA

Zepatier PA

Asthma

Xolair PA

Birth control

Implanon Mirena Nexplanon

Cancer

Abraxane

Adcetris PA Adriamyc Adriamycin Adrucil Afinitor PA Afinitor Dis PA Alecensa PA Alimta Alkeran Amifostine Arranon Arzerra PA

Avastin Azacitidine Bendeka Bicnu

Bleomycin Bosulif ST Busulfex Cabometyx PA

Camptosar

Capecitabine Caprelsa PA Carboplatin Cerubidine Cisplatin Cladribine Clolar Cometriq PA Cosmegen Cyclophosph Cyclophospha Cytarabine Dacarbazine Dacogen PA Dactinomycin Daunorubicin Daunoxome Decitabine PA Dexrazoxane Docefrez Docetaxel Doxil Doxorubicin Eligard PA, ST Ellence Eloxatin Elspar Epirubicin Erbitux PA

Erivedge PA

ErwinazeEthyolEtopophosEtoposideEvomela FaslodexFirmagon PA

FloxuridineFludara

FludarabineFluorouracilFolotyn PA

FusilevGablofenGemcitabineGemzarGilotrif PA

Gleevec PA *

Halaven PA

Herceptin PA

HycamtinIclusig PA, ST

Idamycin PFSIdarubicinIfexIfosfamideInlyta PA

IrinotecanIstodax PA

Ixempra KitJakafi PA

Jevtana PA

Kadcyla PA

KepivanceKyprolis PA

Lenvima PA

Leuprolide PA

LipodoxLipodox 50Lupaneta Kit PA

Lupr Dep-Ped PA *

Lupron Depot PA *

MarqiboMekinist PA

MelphalanMercaptopuriMesnaMesnex

3PA – Prior authorization required • ST – Step therapy • * – Preferred

Harvoni PA

Aniparasite

Daraprim

Bleo 15K

4 OptumRx | optumrx.com



MitomycinMitomycin CMitoxantron PA

MustargenNavelbineNexavar PA

NipentOncasparOxaliplatinPaclitaxelPamidronatePentostatinPerjeta PA

PhotofrinPomalyst PA

Portrazza PA

ProleukinprovengeRevlimid PA

Rituxan PA, ST

Sprycel PA, ST

Stivarga PA

Supprelin LASutent PA

Sylatron PA

Synribo PA

Tafinlar PA

Tarceva PA

Targretin PA

Tasigna PA, ST *

TaxotereTecentriq PA

Temodar PA

Temozolomide PA

TeniposideThalomid PA

TheracysThiotepaTice BcgToposarTopotecanToriselTotectTreanda PA

Trelstar LA ST

Trelstar Mix ST

TretinoinTrisenoxTykerb PA

Vantas ST

VectibixVelcade PA

Venclexta PA

VidazaVinblastineVincasar PFSVincristineVinorelbineVotrient PA

Xalkori PA

XelodaXgeva PA

Xtandi PA, ST

Yervoy PA

Zaltrap PA

ZanosarZelboraf PA

ZevalinZinecardZoladex *

Zolinza PA

Zytiga PA

Chemotherapy Protectant

Xuriden PA

Enzyme replacement/modifiersCarbaglu Kanuma PA

Orfadin

Enzyme therapy

AdagenAldurazyme PA

Aralast NP PA

Cerezyme PA

Elaprase PA

Elelyso PA

Fabrazyme PA

KuvanKuvan PowderLumizyme PA

Myozyme PA

Naglazyme PA

ProcysbiProlastin-C PA

Vimizim InjVpriv PA

Zavesca PA

Zemaira PA

Gastrointestinal agents

Gattex PA

Ocaliva PA SolestaSucraid

Gout

Krystexxa PA

Growth hormone

Genotropin PA, ST

Humatrope PA, ST

Increlex PA

Norditropin PA, ST

Nutropin PA, ST *

Nutropin AQ PA, ST *

Omnitrope PA, ST

Saizen PA, ST *

Serostim PA

Tev-Tropin PA, ST *

Zorbtive PA

Hematological agents

AdvateAlphanateAlphanine SDAranesp PA *

AfstylaBebulinBebulin VHBenefixBerinert PA

Cinryze PA

CorifactEpogen PA

Feiba NFFeiba VHFirazyr PA

IdelvionHelixate FSHemofil M

5

Humate-PKalbitor PA

Koate-DVIKogenate FSLeukine PA

Monoclate-PMononineMozobil PA

Neulasta PA

Neumega PA

Neupogen PA

Novoseven RTNplate PA

Omontys PA

Procrit PA *

ProfilninePromacta PA

RecombinateRixubisTretten InjWilateXynthaXyntha Solof

Hemophilia

Afstyla Vonvendi

HIV

Abacavir *

Aptivus *

Atripla *

Combivir

Complera *

Crixivan *

Didanosine *

Descovy Edurant *

Egrifta PA

Emtriva *

EpivirEpivir HBV *

Epzicom *

FuzeonIntelence *

Invirase *

Isentress *

Kaletra *

Lamivud/Zido *

Lamivudine *

Lexiva *

Nevirapine *

Norvir *

OdefseyPrezista *

Rescriptor *

RetrovirReyataz *

Selzentry PA *

Stavudine *

Stribild *

Sustiva *

Tivicay *

TrizivirTruvada *

Videx *

Videx EC

Viracept *

ViramuneViramune XRViread *

ZeritZiagenZidovudine *

Hormones and hormone modifiers

Acthar HP PA

ActhrelOctreotide PA

SamscaSandostatin PA

SensiparSignifor PA

Somatuline PA

Somavert PA

Thyrogen

Huntington’s disease

Xenazine PA

Immune globulin

AtgamBivigam PA

Carimune NF PA

CytogamFlebogamma PA

Gamastan S/D PA

Gammagard PA

Gammagard SD PA

Gammaked PA

Gammaplex PA

Gamunex-C PA

Hizentra PA

Hyperrab S/DHyperrho S/DImogam RabieMicrhogam PLOctagam PA

Privigen PA

Rhogam PlusRhophylacSolirisWinrho SDF

Immunomodulator

Benlysta PA

Infertility

Bravelle PA, ST

CetrotideChor Gonadot PA

Delalutin PA

Follistim AQ PA , ST *

Ganirelix ACGonal-f PA, ST *

Gonal-f RFF PA, ST *

Makena PA *

Menopur PA

Novarel PA

OvidrelPregnyl PA *

Repronex PA

PA – Prior authorization required • ST – Step therapy • * – Preferred

Inflammatory conditions

Actemra PA, ST

Arcalyst PA

Cimzia PA, ST *

Cimzia Prefl PA, ST *

Enbrel PA, ST

Enbrel Srclk PA, ST

Humira PA, ST *

Humira Pen PA, ST *

Ilaris PA

Kineret PA, ST

Orencia PA, ST

Otrexup Injection PA Remicade PA

Simponi PA, ST *

Stelara PA, ST *

Taltz PA, ST

Xeljanz PA, ST

Xeljanz XR PA, ST

Iron overload

ExjadeFerriprox PA

Multiple sclerosis

Ampyra PA *

Aubagio PA, ST

Avonex PA, ST *

Avonex Pen PA, ST *

Avonex Prefl PA, ST *

Betaseron PA, ST *

Copaxone PA, ST *

Extavia PA, ST

Gilenya PA, ST

Rebif PA, ST

Rebif Rebido PA

Rebif Titrtn PA

Tecfidera PA, ST *

Tysabri PA

Zinbryta PA, ST

Musculoskeletal agents

Botox PA

Dysport PA

Myobloc PA

Xeomin PA

XiaflexZoledronicZometa

Narcolepsy

Xyrem PA

Ophthalmic agents

Cystaran PA

EyleaJetreaLucentisMacugenVisudyne

Osteoarthritis

Euflexxa PA

Gelsyn-3 PA

Gel-One PA, ST

Hyalgan PA, ST

Hymovis PA

Orthovisc PA

Supartz PA, ST

Synvisc PA *

Synvisc One PA *

Osteoporosis

Forteo PA *

Prolia PA

Reclast

Pain management

PrialtQutenza

6 OptumRx | optumrx.com



Parkinson’s disease

Apokyn PA

Pregnancy

Makena

Pulmonary hypertension

Adcirca PA

Epoprostenol PA

Flolan PA

Letairis PA *

Opsumit PA Remodulin PA

Revatio PA

Sildenafil PA

Tracleer PA *

Tyvaso PA

Tyvaso Refil PA

Tyvaso Start PA

Uptravi PA

Veletri PA

Ventavis PA

Recombinant Human Leptin Analog

Alprolix

Respiratory agents

Bethkis Neb ST Cayston PA

Cinqair PA Kalydeco PA

PulmozymeTobi ST

Tobi Podhalr ST Tobramycin Neb ST

Substance abuse treatment agents

Vivitrol PA

Transplant

Astagraf XLCellceptCellcept IVCyclosporine *

GengrafHecoriaMycophenolate *

MyforticNeoralNulojix PA

PrografRapamuneSandimmuneSirolimus Tabs TacrolimusZortress PA

7PA – Prior authorization required • ST – Step therapy • * – Preferred

About OptumRx

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. BriovaRx is our specialty pharmacy. Our high-quality, integrated services deliver optimal member outcomes, superior savings and outstanding customer service. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.

To fill a prescription for a specialty medication on this list, please call 1-866-218-7398 or visit optumrx.com.

This specialty pharmacy drug list may not be a complete representation of all available specialty medications; this list is subject to change at any time without prior notice.

Non-specialty alternatives may be a recommended first-line therapy to treat your condition. Please consult your physician.

[email protected] | optumrx.com

2300 Main Street, Irvine, CA 92614

All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

M56312-B ©2017 OptumRx, Inc. ORX2700_170101

Specialty Pharmacy Drug List

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