2nd Quarter 2020 Elevate Specialty Pharmacy Drug List · 2020-05-13 · Elevate Specialty Pharmacy...

Drug Name Drug Form Preferred or Non-

PreferredGEHA Coverage

Preauth

Required

Preauth

Reviewer

Limited

Distribution

Exclusive to

CVS Specialty

abacavir Oral Preferred Covered X

abiraterone acetate Oral Preferred Covered X Optum X

Actemra IV/SQ Non-Preferred No Coverage X CVS X

Actimmune SQ Non-Preferred No Coverage X CVS/Optum X

Adagen Injection Preferred Covered X CVS X

Adakveo Injection Non-Preferred No Coverage X CVS X

Adcetris IV Non-Preferred No Coverage X Optum X

Adcirca Oral Non-Preferred No Coverage X CVS X

adefovir Oral Preferred Covered X

Adempas Oral Preferred Covered X CVS X

Advate IV Non-Preferred No Coverage X CVS X

Adynovate IV Preferred Covered X CVS X

Afinitor Oral Preferred Covered X Optum X

Afstyla IV Non-Preferred No Coverage X CVS X

Aldurazyme IV Non-Preferred No Coverage X CVS X

Alferon N Injection Non-Preferred No Coverage X CVS/Optum X

Aliqopa Injection Preferred Covered X Optum X

Alphanate IV Non-Preferred No Coverage X CVS X

AlphaNine SD IV Non-Preferred No Coverage X CVS X

Alprolix IV Non-Preferred No Coverage X CVS X

Alunbrig Oral Non-Preferred No Coverage X Optum X

Alyq Oral Preferred Covered X CVS X

ambrisentan Oral Preferred Covered X CVS X

Ampyra Oral Non-Preferred No Coverage X CVS X

Apligraf Topical Non Covered Benefit X

Apokyn Injection Non-Preferred No Coverage X CVS X

Aptivus Oral Non-Preferred No Coverage X CVS X

Aralast NP IV Non-Preferred No Coverage X CVS X

Aranesp IV/Injection Non-Preferred No Coverage X CVS/Optum X

Arcalyst Injection Non-Preferred No Coverage X CVS X

Arzerra IV Non-Preferred No Coverage X Optum X

Asparlas IV Non-Preferred No Coverage X Optum

Astagraf XL Oral Non-Preferred No Coverage X CVS X

atazanavir sulfate Oral Powder Preferred Covered X

Atripla Oral Preferred Covered X

Aubagio Oral Preferred Covered X CVS X

Austedo Oral Non-Preferred No Coverage X CVS X

Avastin IV Non-Preferred No Coverage X CVS/Optum X

Aveed Injection Non-Preferred No Coverage X CVS X

Avonex Injection Non-Preferred No Coverage X CVS X

azacitidine IV/Injection Preferred Covered X Optum X

Balversa Oral Preferred Covered X Optum X

Baraclude Oral Non-Preferred No Coverage X CVS X

Baraclude Solution Preferred Covered X CVS X

Bavencio Injection Non-Preferred No Coverage X Optum X

Bebulin IV Non-Preferred No Coverage X CVS X

Beleodaq IV Non-Preferred No Coverage X Optum X

Belrapzo IV Non-Preferred No Coverage X Optum X

Bendeka IV Non-Preferred No Coverage X Optum X

BeneFIX IV Non-Preferred No Coverage X CVS X

Benlysta IV Non-Preferred No Coverage X CVS X

Beovu Injection Non-Preferred No Coverage X CVS X

Berinert IV Non-Preferred No Coverage X CVS X

Besponsa IV Preferred Covered X Optum X

Betaseron Injection Preferred Covered X CVS X

Bethkis Inhalent Preferred Covered X CVS X

bexarotene Oral Preferred Covered X Optum X

2nd Quarter 2020

Elevate Specialty Pharmacy Drug List

If you are a plan member or health care provider, please contact Specialty Customer Care at (800) 237-2767 or visit CVSSpecialty.com.

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Biktarvy Oral Preferred Covered X

Bivigam Injection Non-Preferred No Coverage X CVS X

Blincyto IV Non-Preferred No Coverage X Optum X

bortezomib IV Non-Preferred No Coverage X Optum X

bosentan Oral Preferred Covered X CVS X

Bosulif Oral Preferred Covered X Optum X

Braftovi Oral Preferred Covered X Optum X

Buphenyl Oral Non-Preferred No Coverage X CVS X

Cablivi IV/SQ Non-Preferred No Coverage X CVS X

Cabometyx Oral Preferred Covered X CVS X

Calquence Oral Preferred Covered X Optum X

capecitabine Oral Preferred Covered X Optum X

Caprelsa Oral Preferred Covered X Optum X

Carbaglu Oral Preferred Covered X CVS X

Carimune NF IV Non-Preferred No Coverage X CVS X

Cayston Inhalant Preferred Covered X CVS X

CellCept Oral, IV Non-Preferred No Coverage X CVS X

Ceprotin IV Non-Preferred No Coverage X CVS X

Cerdelga Oral Preferred Covered X CVS X

Cerezyme IV Preferred Covered X CVS X

Cholbam Oral Non-Preferred No Coverage X CVS X

Cimduo Oral Non-Preferred No Coverage X CVS X

Cimzia Injection Non-Preferred No Coverage X CVS X

Cinqair IV Non-Preferred No Coverage X CVS X

Cinryze IV Non-Preferred No Coverage X CVS X

Coagadex Injection Preferred Covered X CVS X

Combivir Oral Non-Preferred No Coverage X CVS X

Cometriq Oral Preferred Covered X Optum X

Complera Oral Non-Preferred No Coverage X CVS X

Copaxone Injection Non-Preferred No Coverage X CVS X

Copegus Oral Non-Preferred No Coverage X CVS X

Copiktra Oral Preferred Covered X Optum X

Corifact IV Preferred Covered X CVS X

Cosentyx Injection Preferred Covered X CVS X

Cotellic Oral Non-Preferred No Coverage X Optum X

Crixivan Oral Non-Preferred No Coverage X CVS X

Crysvita Injection Non-Preferred No Coverage X CVS X

Cuvitru Injection Non-Preferred No Coverage X CVS X

cyclosporine Oral Preferred Covered X

Cyramza Injection Preferred Covered X Optum X

Cystadane Oral Preferred Covered X

Cystagon Oral Non-Preferred No Coverage X CVS X

Cystaran Opthalmic Preferred Covered X CVS X

Cytogam IV Non-Preferred No Coverage X CVS X

Dacogen IV Non-Preferred No Coverage X Optum X

Daklinza Oral Non-Preferred No Coverage X CVS X

Darzalex IV Non-Preferred No Coverage X Optum X

Daurismo Oral Non-Preferred No Coverage X Optum X

decitabine IV Preferred Covered X Optum X

deferasirox Oral Preferred Covered X CVS X

deferoxamine IV Preferred Covered X CVS X

Delstrigo Oral Non-Preferred No Coverage X CVS X

Descovy Oral Preferred Covered X

Desferal Injection Non-Preferred No Coverage X CVS X

didanosine Oral Preferred Covered X

dofetilide Oral Preferred Covered X CVS X

Doptelet Oral Non-Preferred No Coverage X CVS X

Dovato Oral Non-Preferred No Coverage X CVS X

Duopa Oral Preferred Covered X

Dupixent IV Preferred Covered X CVS X

Edurant Oral Preferred Covered X

efavirenz Oral Preferred Covered X

Egrifta Injection Non-Preferred No Coverage X CVS X

Elaprase IV Non-Preferred No Coverage X CVS X

Elelyso Injection Non-Preferred No Coverage X CVS X

Eligard Injection Preferred Covered X CVS/Optum X


Eloctate IV Non-Preferred No Coverage X CVS X

Emflaza Oral Non-Preferred No Coverage X CVS X

Empliciti IV Non-Preferred No Coverage X Optum X

Emtriva Oral Preferred Covered X

Enbrel Injection Preferred Covered X CVS X

Endari Oral Preferred No Coverage X CVS X

entecavir Oral Preferred Covered X

Entyvio IV Non-Preferred No Coverage X CVS X

Envarsus XR Oral, Injection Non-Preferred No Coverage X CVS X

Epclusa Oral Preferred Covered X CVS X

Epidiolex Oral Non-Preferred No Coverage X CVS X

Epivir Oral, Solution Non-Preferred No Coverage X CVS X

Epivir HBV Oral, Solution Non-Preferred No Coverage X CVS X

Epogen IV Non-Preferred No Coverage X CVS/Optum X

epoprostenol sodium IV Preferred Covered X CVS X

Epzicom Oral Non-Preferred No Coverage X CVS X

Erbitux IV Non-Preferred No Coverage X Optum X

Erivedge Oral Non-Preferred No Coverage X Optum X

Erleada Oral Preferred Covered X Optum X

erlotinib hydrochloride Oral Preferred Covered X Optum

Erwinaze Injection Preferred Covered X Optum X

Esbriet Oral Preferred Covered X CVS X

Evenity Injection Non-Preferred No Coverage X CVS X

Evomela IV Non-Preferred No Coverage X CVS X

Evotaz Oral Preferred Covered X

Exjade Oral Non-Preferred No Coverage X CVS X

Exondys 51 Injection Preferred Covered X CVS X

Extavia Injection Non-Preferred No Coverage X CVS X

Eylea Injection Non-Preferred No Coverage X CVS X

Fabrazyme IV Non-Preferred No Coverage X CVS X

Farydak Oral Non-Preferred No Coverage X Optum X

Fasenra Injection Preferred Covered X CVS X

Feiba NF Injection Non-Preferred No Coverage X CVS X

Ferriprox Oral Preferred Covered X CVS X

Fibryga IV Non-Preferred No Coverage X CVS X

Firazyr Injection Preferred Covered X CVS X

Firmagon Injection Non-Preferred No Coverage X Optum X

Flebogamma IV Non-Preferred No Coverage X CVS X

Flebogamma DIF IV Non-Preferred No Coverage X CVS X

Flolan Injection Non-Preferred No Coverage X CVS X

Folotyn IV Non-Preferred No Coverage X Optum X

Forteo Injection Preferred Covered X CVS X

fosamprenavir Oral Preferred Covered X

Fulphila Injection/IV Non-Preferred No Coverage X CVS/Optum X

Fusilev IV Non-Preferred No Coverage X Optum X

Fuzeon Injection Preferred Covered X CVS X

GamaSTAN Injection Non-Preferred No Coverage X CVS X

GamaSTAN S/D Injection Non-Preferred No Coverage X CVS X

Gammagard Liquid Injection Non-Preferred No Coverage X CVS X

Gammagard S/D Injection Non-Preferred No Coverage X CVS X

Gammaked Injection Non-Preferred No Coverage X CVS X

Gammaplex Injection Non-Preferred No Coverage X CVS X

Gamunex C Injection Non-Preferred No Coverage X CVS X

Gattex Injection Non-Preferred No Coverage X CVS X

Gazyva IV Non-Preferred No Coverage X Optum X

Gengraf Oral Preferred Covered X

Genotropin Injection Non-Preferred No Coverage X CVS X

Genvoya Oral Preferred Covered X

Gilenya Oral Preferred Covered X CVS X

Gilotrif Oral Non-Preferred No Coverage X Optum X

Glassia IV Non-Preferred No Coverage X CVS X

glatiramer acetate Injection Preferred Covered X CVS X

GLATOPA Injection Preferred Covered X CVS X

Gleevec Oral Non-Preferred No Coverage X Optum X

Granix Injection Non-Preferred No Coverage X CVS/Optum X


H.P. Acthar Gel Injection Non-Preferred No Coverage X CVS X

Haegarda Injection Non-Preferred No Coverage X CVS X

Halaven Injection Non-Preferred No Coverage X Optum X

Harvoni Oral Preferred Covered X CVS X

Helixate FS IV Non-Preferred No Coverage X CVS X

Hemlibra Injection Non-Preferred No Coverage X CVS X

Hemofil M IV Non-Preferred No Coverage X CVS X

HepaGam B Injection Non-Preferred No Coverage X CVS X

Hepsera Oral Non-Preferred No Coverage X CVS X

Herceptin Injection Non-Preferred No Coverage X Optum

Herceptin Hylecta Injection Non-Preferred No Coverage X Optum X

Hetlioz Oral Preferred Covered X CVS X

Hizentra Injection Non-Preferred No Coverage X CVS X

Humate-P Injection Non-Preferred No Coverage X CVS X

Humatrope Injection Preferred Covered X CVS X

Humira Injection Preferred Covered X CVS X

Hycamtin Oral/Injection Non-Preferred No Coverage X CVS/Optum X

hydroxyprogesterone caproate Injection Preferred Covered X CVS X

HyperHEP B Injection Non-Preferred No Coverage X CVS X

HyperRHO S/D Injection Non-Preferred No Coverage X CVS X

HyQvia Injection Non-Preferred No Coverage X CVS X

Ibrance Oral Preferred Covered X Optum X

icatibant acetate Injection Preferred Covered X CVS X

Iclusig Oral Preferred Covered X Optum X

Idelvion IV Non-Preferred No Coverage X CVS X

Idhifa Oral Non-Preferred No Coverage X CVS X

Ilaris Injection Non-Preferred No Coverage X CVS X

Ilumya Injection Non-Preferred No Coverage X CVS X

Iluvien Injection Non-Preferred No Coverage X CVS X

imatinib mesylate Oral Preferred Covered X Optum X

Imbruvica Oral Preferred Covered X Optum X

Imfinzi IV Non-Preferred No Coverage X Optum X

Imlygic Injection Non-Preferred No Coverage X Optum X

Inbrija Inhalant Non-Preferred No Coverage X CVS X

Increlex Injection Non-Preferred No Coverage X CVS X

Inflectra IV Non-Preferred No Coverage X CVS X

Infugem Injection Preferred Covered X Optum

Inlyta Oral Non-Preferred No Coverage X Optum X

Inrebic Oral Non-Preferred No Coverage X Optum X

Intelence Oral Preferred Covered X

Intron A Injection Non-Preferred No Coverage X CVS/Optum X

Invirase Oral Non-Preferred No Coverage X CVS X

Iressa Oral Preferred Covered X Optum X

Isentress Oral Preferred Covered X

Istodax Injection Non-Preferred No Coverage X Optum X

Ixempra Injection Non-Preferred No Coverage X Optum X

Ixinity Inection Non-Preferred No Coverage X CVS X

Jadenu Oral Non-Preferred No Coverage X CVS X

Jakafi Oral Non-Preferred No Coverage X Optum X

Jetrea Injection Preferred Covered X

Jevtana Injection Non-Preferred No Coverage X Optum X

Jivi Injection Preferred Covered X CVS X

Juluca Oral Non-Preferred No Coverage X CVS X

Juxtapid Oral Non-Preferred No Coverage X CVS X

Jynarque Oral Preferred Covered X CVS X

Kadcyla Injection Non-Preferred No Coverage X Optum X

Kalbitor Injection Non-Preferred No Coverage X CVS X

Kaletra solution Oral Non-Preferred No Coverage X CVS X

Kaletra tablets Oral Preferred Covered X

Kalydeco Oral Non-Preferred No Coverage X CVS X

Kanjinti Injection Non-Preferred No Coverage X Optum X

Kanuma Injection Non-Preferred No Coverage X CVS X

Keveyis Oral Preferred Covered X CVS X

Kevzara Injection Preferred Covered X CVS X

Keytruda Injection Non-Preferred No Coverage X Optum X


Khapzory IV Non-Preferred No Coverage X Optum

Kineret Injection Non-Preferred No Coverage X CVS X

Kisqali ORAL Preferred Covered X Optum X

Kisqali Femara ORAL Preferred Covered X Optum X

Kitabis Pak Inhalant Non-Preferred No Coverage X CVS X

Koate-DVI IV Non-Preferred No Coverage X CVS X

Kogenate FS IV Preferred Covered X CVS X

Korlym Oral Preferred Covered X CVS X

Kovaltry IV Non-Preferred No Coverage X CVS X

Krystexxa Injection Non-Preferred No Coverage X CVS X

Kuvan Oral Non-Preferred No Coverage X CVS X

Kynamro Injection Non-Preferred No Coverage X CVS X

Kyprolis Injection Non-Preferred No Coverage X Optum X

lamivudine Oral, Solution Preferred Covered X

lamivudine HBV Oral Preferred Covered X

lamivudine-zidovudine Oral Preferred Covered X

Lartruvo Injection Preferred Covered X CVS X

ledipasvir/sofosbuvir Oral Preferred Covered X CVS X

Lemtrada IV Non-Preferred No Coverage X CVS X

Lenvima Oral Preferred Covered X Optum X

Letairis Oral Non-Preferred No Coverage X CVS X

Leukine Injection Non-Preferred No Coverage X CVS/Optum X

leuprolide acetate vial Injection Non Covered Benefit X

levoleucovorin calcium Injection Preferred Covered X Optum X

Lexiva Oral Non-Preferred No Coverage X CVS X

Libtayo IV Preferred Covered X Optum X

Lonsurf Oral Non-Preferred No Coverage X Optum X

lopinavir ritonavir solution Oral Preferred Covered X

Lorbrena Oral Non-Preferred No Coverage X Optum X

Lucentis Injection Non-Preferred No Coverage X CVS X

Lumizyme IV Non-Preferred No Coverage X CVS X

Lumoxiti Injection Non-Preferred No Coverage X Optum X

Lupaneta Pack Injectable Non-Preferred No Coverage X CVS X

Lupron Injection Preferred Covered X CVS/Optum X

Lupron Depot 11.25mg Injection Non-Preferred No Coverage X CVS/Optum X



Lupron Depot 30mg Injection Non-Preferred No Coverage X CVS/Optum X

Lupron Depot 45mg Injection Non-Preferred No Coverage X CVS/Optum X


Lynparza Oral Preferred Covered X Optum X

Macugen IV Non-Preferred No Coverage X CVS X

Makena Injection Non-Preferred No Coverage X CVS X

Marqibo Injection Preferred Covered X

Mavenclad Oral Non-Preferred No Coverage X CVS X

Mavyret Oral Non-Preferred No Coverage X CVS X

Mayzent Oral Preferred Covered X CVS X

Mekinist Oral Non-Preferred No Coverage X Optum X

Mektovi Oral Preferred Covered X Optum X

Mepsevii IV/Injection Preferred Covered X CVS X

MICRhoGAM IV Non-Preferred No Coverage X CVS X

Mircera Injection Non-Preferred No Coverage X CVS X

mitoxantrone IV Preferred Covered X Optum X

Moderiba Oral Non-Preferred No Coverage X CVS X

Monoclate-P IV Non-Preferred No Coverage X CVS X

Mononine IV Non-Preferred No Coverage X CVS X

Mozobil Injection Non-Preferred No Coverage X Optum X

Mugard Oral Non-Preferred No Coverage X CVS X

Mulpleta Oral Non-Preferred No Coverage X CVS X

Mvasi IV Non-Preferred No Coverage X CVS/Optum X

Myalept Injection Preferred Covered X CVS X

mycophenolate mofetil Oral Preferred Covered X

mycophenolate sodium DR Oral Preferred Covered X

Myfortic Oral Non-Preferred No Coverage X CVS X

Mylotarg Injection Preferred Covered X Optum X

Myozyme Injection Non-Preferred No Coverage X CVS X


Nabi-HB Injection Non-Preferred No Coverage X CVS X

Naglazyme Injection Non-Preferred No Coverage X CVS X

Natpara Injection Non-Preferred No Coverage X CVS X

Neoral Oral Non-Preferred No Coverage X CVS X

Nerlynx Oral Non-Preferred No Coverage X CVS X

Neulasta Injection Non-Preferred No Coverage X CVS/Optum X

Neumega Injection Non-Preferred No Coverage X CVS/Optum X

Neupogen Injection Non-Preferred No Coverage X CVS/Optum X

nevirapine Oral Preferred Covered X

Nexavar Oral Non-Preferred No Coverage X Optum X

Ninlaro Oral Non-Preferred No Coverage X Optum X

Nivestym Injection Non-Preferred No Coverage X CVS/Optum X

Norditropin Injection Non-Preferred No Coverage X CVS X

Northera Oral Non-Preferred No Coverage X CVS X

Norvir 100MG Powder Non-Preferred No Coverage X CVS X

Norvir 80MG & 100MG Oral/Solution Preferred Covered X

NovoEight Injection Non-Preferred No Coverage X CVS X

NovoSeven RT Injection Non-Preferred No Coverage X CVS X

Nplate Injection Non-Preferred No Coverage X CVS X

Nubeqa Oral Preferred Covered X Optum X

Nucala Injection Preferred Covered X CVS X

Nulojix Injection Non-Preferred No Coverage X CVS X

Nuplazid Oral Non-Preferred No Coverage X CVS X

Nutropin Injection Non-Preferred No Coverage X CVS X

Nuwiq Injection Non-Preferred No Coverage X CVS X

Obizur Injection Non-Preferred No Coverage X CVS X

Ocaliva Oral Non-Preferred No Coverage X CVS X

Ocrevus IV Non-Preferred No Coverage X CVS X

Octagam Injection Non-Preferred No Coverage X CVS X

octreotide Acetate Injection Preferred Covered X CVS/Optum X

Odefsey Oral Preferred Covered X

Odomzo Oral Non-Preferred No Coverage X Optum X

Ofev Oral Preferred Covered X CVS X

Olumiant Oral Non-Preferred No Coverage X CVS X

Omnitrope Injection Non-Preferred No Coverage X CVS X

Omontys Injection Non-Preferred No Coverage X CVS X

Oncaspar Injection Non-Preferred No Coverage X Optum X

Onivyde Injection Preferred Covered X Optum X

Onpattro IV Preferred Covered X CVS X

Opdivo Injection Non-Preferred No Coverage X Optum X

Opsumit Oral Preferred Covered X CVS X

Orencia 125mg, 87.5mg &

50mgInjection Preferred Covered X CVS X

Orencia 250mg IV Non-Preferred No Coverage X CVS X

Orencia Clickject 125mg Injection Preferred Covered X CVS X

Orenitram Oral Non-Preferred No Coverage X CVS X

Orfadin Oral Preferred Covered X CVS X

Orkambi Oral Non-Preferred No Coverage X CVS X

Otezla Oral Preferred Covered X CVS X

Otrexup Injection Non-Preferred No Coverage X CVS X

Oxbryta Oral Non-Preferred No Coverage X CVS X

Ozurdex Injection Non-Preferred No Coverage X CVS X

Palynziq Injection Non-Preferred No Coverage X CVS X

Panzyga Injection Non-Preferred No Coverage X CVS X

Parsabiv Injection Non-Preferred No Coverage X CVS X

Pegasys Injection Non-Preferred No Coverage X CVS X

PegIntron Injection Non-Preferred No Coverage X CVS X

Perjeta Injection Non-Preferred No Coverage X Optum X

phenylbutyrate sodium Oral Preferred Covered X CVS X

Pifeltro Oral Non-Preferred No Coverage X CVS X

Piqray Oral Non-Preferred No Coverage X Optum X

Plegridy Injection Non-Preferred No Coverage X CVS X

Polivy IV Non-Preferred No Coverage X Optum X

Pomalyst Oral Non-Preferred No Coverage X Optum X

Portrazza Injection Preferred Covered X CVS X

Poteligeo Injection Non-Preferred No Coverage X Optum X


Prezcobix Oral Preferred Covered X

Prezista Oral Preferred Covered X

Prialt Injection Preferred Covered X CVS X

Privigen Injection Non-Preferred No Coverage X CVS X

Procrit Injection Non-Preferred No Coverage X CVS/Optum X

Procysbi Oral Non-Preferred No Coverage X CVS X

Profilnine SD Injection Non-Preferred No Coverage X CVS X

Prograf Oral Non-Preferred No Coverage X CVS X

Prolastin Injection Preferred Covered X CVS X

Prolastin-C Injection Preferred Covered X CVS X

Proleukin Injection Non-Preferred No Coverage X Optum X

Prolia Injection Preferred Covered X CVS X

Promacta Oral Non-Preferred No Coverage X CVS X

Pulmozyme Inhalant Non-Preferred No Coverage X CVS X

Purixan Oral Non-Preferred No Coverage X Optum X

Qutenza Topical Preferred Covered X

Radicava IV Non-Preferred No Coverage X CVS X

Rapamune Oral Non-Preferred No Coverage X CVS X

Rapamune Solution Solution Non-Preferred No Coverage X CVS X

Rasuvo Injection Preferred Covered X CVS X

Ravicti Oral Non-Preferred No Coverage X CVS X

Rebetol Oral Non-Preferred No Coverage X CVS X

Rebif Injection Preferred Covered X CVS X

Rebinyn IV Preferred Covered X CVS X

Reblozyl Injection Non-Preferred No Coverage CVS X

Reclast Injection Non-Preferred No Coverage X CVS X

Recombinate Injection Non-Preferred No Coverage X CVS X

Remicade Injection Preferred Covered X CVS X

Remodulin Injection Non-Preferred No Coverage X CVS X

Renflexis IV Non-Preferred No Coverage X CVS X

Rescriptor Oral Non-Preferred No Coverage X CVS X

Retacrit Injection Preferred Covered X CVS/Optum X

Retisert Opthalmic Non-Preferred No Coverage X CVS X

Retrovir Injection, Oral Non-Preferred No Coverage X CVS X

Revatio Oral Non-Preferred No Coverage X CVS X

Revlimid Oral Preferred Covered X Optum X

Reyataz Oral Non-Preferred No Coverage X CVS X

RhoGAM Injection Non-Preferred No Coverage X CVS X

Rhophylac Injection Non-Preferred No Coverage X CVS X

RiaSTAP Injection Non-Preferred No Coverage X CVS X

RibaPak Oral Non-Preferred No Coverage X CVS X

Ribasphere Oral Non-Preferred No Coverage X CVS X

Ribatab Oral Non-Preferred No Coverage X CVS X

ribavirin Oral Non-Preferred No Coverage X CVS X

Rinvoq Oral Preferred Covered X CVS X

ritonavir Oral Preferred Covered X

Rituxan IV Non-Preferred No Coverage X CVS/Optum X

Rituxan Hycela IV Non-Preferred No Coverage X CVS/Optum X

Rixubis Injection Non-Preferred No Coverage X CVS X

romidepsin Injectable Non-Preferred No Coverage X Optum X

Rozlytrek Oral Non-Preferred No Coverage X Optum X

Rubraca Oral Preferred Covered X Optum X

Ruconest Injection Preferred Covered X CVS X

Rydapt Oral Preferred Covered X Optum X

Sabril Oral Non-Preferred No Coverage X CVS X

Sabril pwd Oral Non-Preferred No Coverage X CVS X

Saizen Injection Non-Preferred No Coverage X CVS X

Samsca Oral Non-Preferred No Coverage X CVS X

Sandimmune Oral Non-Preferred No Coverage X CVS X

Sandostatin Injection Non-Preferred No Coverage X CVS/Optum X

Sandostatin LAR Injection Non-Preferred No Coverage X CVS/Optum X

Selzentry 20mg/ml, 150mg, &

300mgOral, Powder Preferred Covered X

Selzentry 25mg & 75 mg Oral Non-Preferred No Coverage X CVS X

Sensipar Oral Non-Preferred No Coverage X CVS X

Serostim Injection Non-Preferred No Coverage X CVS X


Signifor Injection Preferred Covered X CVS X

Signifor LAR Injection Non-Preferred No Coverage X CVS X

sildenafil citrate Oral, Injection Preferred Covered X CVS X

Siliq Solution Non-Preferred No Coverage X CVS X

Simponi Injection Non-Preferred No Coverage X CVS X

Simponi ARIA Injection Preferred Covered X CVS X

sirolimus tab Oral Preferred Covered X

Skyrizi Injection Preferred Covered X CVS X

sofosbuvir/velpatasvir Oral Preferred Covered X CVS X

Solesta Injection Non-Preferred No Coverage X CVS X

Soliris Injection Non-Preferred No Coverage X CVS X

Somatuline Depot Injection Preferred Covered X CVS/Optum X

Somavert Injection Preferred Covered X CVS X

Sovaldi Oral Non-Preferred No Coverage X CVS X

Spravato Inhalant Non-Preferred No Coverage X CVS X

Sprycel Oral Preferred Covered X Optum X

stavudine Oral Preferred Covered X CVS X

Stelara IV IV Non-Preferred No Coverage X CVS X

Stelara subcutaneous Injection Preferred Covered X CVS X

Stimate Injection Non-Preferred No Coverage X CVS X

Stivarga Oral Non-Preferred No Coverage X Optum X

Strensiq Injection Preferred Covered X CVS X

Stribild Oral Non-Preferred No Coverage X CVS X

Supprelin LA Injection Non-Preferred No Coverage X CVS X

Sustiva Oral Non-Preferred No Coverage X CVS X

Sutent Oral Preferred Covered X Optum X

Sylatron Injection Non-Preferred No Coverage X Optum X

Sylvant Injection Preferred Covered X Optum X

Symfi Lo Oral Non-Preferred No Coverage X CVS X

Synagis Injection Non-Preferred No Coverage X CVS X

Synribo Injection Preferred Covered X Optum X

Syntuza Oral Non-Preferred No Coverage X CVS X

tacrolimus IV, Oral Preferred Covered X

Tafinlar Oral Non-Preferred No Coverage X Optum X

Tagrisso Oral Non-Preferred No Coverage X Optum X

Takhzyro Injection Non-Preferred No Coverage X CVS X

Taltz Injection Preferred Covered X CVS X

Talzenna Oral Non-Preferred No Coverage X Optum X

Tarceva Oral Non-Preferred No Coverage X Optum X

Targretin Oral Non-Preferred No Coverage X Optum X

Tasigna Oral Non-Preferred No Coverage X Optum X

Tavalisse Oral Non-Preferred No Coverage X CVS X

Tecentriq Injection Non-Preferred No Coverage X Optum X

Tecfidera Oral Preferred Covered X CVS X

Tegsedi Injection Preferred Covered X CVS X

Temodar Oral Non-Preferred No Coverage X Optum X

temozolomide Injection Preferred Covered X Optum

temsirolimus Injection Preferred Covered X CVS/Optum X

tenofovir disoproxil fumate ORAL Preferred Covered X

Tepadina IV Non-Preferred No Coverage X Optum X

tetrabenazine Oral Preferred Covered X CVS X

Tev-Tropin Injection Non-Preferred No Coverage X CVS X

Thalomid Oral Preferred Covered X Optum X

Thyrogen Injection Non-Preferred No Coverage X Optum X

Tibsovo Oral Preferred Covered X Optum X

Tikosyn Oral Non-Preferred No Coverage X CVS X

Tivicay Oral Preferred Covered X

TOBI Inhalant Non-Preferred No Coverage X CVS X

TOBI Podhaler Inhalant Non-Preferred No Coverage X CVS X

tobramycin nebulizer Inhalant Preferred Covered X CVS X

Torisel Injection Non-Preferred No Coverage X Optum

Tracleer Oral Non-Preferred No Coverage X CVS X

Treanda Injection Non-Preferred No Coverage X CVS X

Trelstar Injection Non-Preferred No Coverage X CVS/Optum X

Tremfya Injection Preferred Covered X CVS X


treprostinil sodium Injection Preferred Covered X CVS X

Tretten Injection Non-Preferred No Coverage X CVS X

Trikafta Oral Preferred Covered X CVS X

Triptodur Injection Non-Preferred No Coverage X CVS X

Triumeq Oral Preferred Covered X

Trizivir Oral Non-Preferred No Coverage X CVS X

Trogarzo IV Non-Preferred No Coverage X CVS X

Truvada Oral Preferred Covered X

Tybost Oral Non-Preferred No Coverage X CVS X

Tykerb Oral Preferred Covered X Optum X

Tymlos Injection Preferred Covered X CVS X

Tysabri Injection Preferred Covered X CVS X

Tyvaso Inhalant Non-Preferred No Coverage X CVS X

Udenyca Injection Non-Preferred No Coverage X CVS/Optum X

Ultomiris IV Non-Preferred No Coverage X CVS X

Unituxin IV Preferred Covered X Optum X

Valchlor Topical Preferred Covered X Optum X

valrubicin Solution Preferred Covered X Optum

Valstar Injection Non-Preferred No Coverage X Optum X

Vantas Injection Non-Preferred No Coverage X Optum X

Varithena IV Preferred Covered X

Varizig Injection Non-Preferred No Coverage X CVS X

Vectibix Injection Non-Preferred No Coverage X Optum X

Velcade Injection Non-Preferred No Coverage X Optum X

Veletri Injection Non-Preferred No Coverage X CVS X

Vemlidy Oral Preferred Covered X CVS X

Venclexta Oral Preferred Covered X Optum X

Ventavis Inhalation Non-Preferred No Coverage X CVS X

Verzenio Oral Non-Preferred No Coverage X Optum X

Vidaza Injection Non-Preferred No Coverage X Optum X

Videx Oral Non-Preferred No Coverage X CVS X

Videx EC Oral Non-Preferred No Coverage X CVS X

Viekira Pak Oral Non-Preferred No Coverage X CVS X

vigabatrin powder Powder Preferred Covered X CVS X

vigabatrin tablet Oral Preferred Covered X CVS X

Vigadrone Oral Preferred Covered X CVS X

Vimizim Injection Non-Preferred No Coverage X CVS X

Viracept Oral Non-Preferred No Coverage X CVS X

Viramune Oral Non-Preferred No Coverage X CVS X

Viramune XR Oral Non-Preferred No Coverage X CVS X

Viread Oral Non-Preferred No Coverage X CVS X

Vistogard Oral Non-Preferred No Coverage X CVS X

Visudyne Injection Non-Preferred No Coverage X CVS X

Vitrakvi Oral Non-Preferred No Coverage X Optum X

Vivitrol Injection Non-Preferred No Coverage X CVS X

Vizimpro Oral Non-Preferred No Coverage X Optum X

Vonvendi Injection Non-Preferred No Coverage X CVS X

Vosevi Oral Preferred Covered X CVS X

Votrient Oral Preferred Covered X Optum X

VPRIV Injection Non-preferred No Coverage X CVS X

Vyndamax Oral Non-Preferred No Coverage X CVS X

Vyndaqel Oral Non-Preferred No Coverage X CVS X

Vyxeos Injection Preferred Covered X Optum X

Wilate Injection Non-preferred No Coverage X CVS X

WinRho SDF Injection Non-preferred No Coverage X CVS X

Xalkori Oral Non-preferred No Coverage X Optum X

Xeljanz Oral Preferred Covered X CVS X

Xeljanz XR Oral Preferred Covered X CVS X

Xeloda Oral Non-preferred No Coverage X Optum X

Xenazine Oral Non-Preferred No Coverage X CVS X

Xermelo Oral Preferred Covered X CVS/Optum X

Xgeva Injection Non-preferred No Coverage X Optum X

Xiaflex Injection Preferred Covered X CVS X

Xolair Injection Preferred Covered X CVS X

Xospata Oral Preferred Covered X Optum X

Xtandi Oral Preferred Covered X Optum X


Xuriden Oral Preferred Covered X

Xyntha IV Non-preferred No Coverage X CVS X

Xyrem Oral Preferred Covered X CVS X

Yervoy Injection Non-preferred No Coverage X Optum X

Yondelis Injection Non-preferred No Coverage X Optum X

Yonsa Oral Preferred Covered X Optum X

Zaltrap Injection Non-Preferred No Coverage X Optum X

Zarxio Injection Non-Preferred No Coverage X CVS/Optum X

Zavesca Oral Preferred Covered X CVS X

Zejula Oral Preferred Covered X Optum X

Zelboraf Oral Non-preferred No Coverage X Optum X

Zemaira Injection Non-Preferred No Coverage X CVS X

Zepatier Oral Non-Preferred No Coverage X CVS X

Zerit Oral Non-preferred No Coverage X CVS X

Ziagen Oral Non-preferred No Coverage X CVS X

zidovudine Oral, Injection Preferred Covered X

Zoladex Injection Non-Preferred No Coverage X CVS/Optum X

zoledronic acid Injection Preferred Covered X CVS/Optum X

Zolinza Oral Non-preferred No Coverage X Optum X

Zomacton Injection Non-Preferred No Coverage X CVS X

Zometa Injection Non-preferred No Coverage X CVS/Optum X

Zorbtive Injection Non-preferred No Coverage X CVS X

Zortress Oral Non-preferred No Coverage X CVS X

Zulresso Injection Non-Preferred No Coverage X CVS X

Zydelig Oral Non-Preferred No Coverage X Optum X

Zykadia Oral Non-preferred No Coverage X Optum X

©2020 CVS Specialty. All rights reserved. 75-50648B 050520

This document contains confidential and proprietary information of CVS Specialty and may not be reproduced, distributed or printed

without written permission from CVS Specialty. This document contains references to brand-name prescription drugs that are

trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty.

Limited Distribution – CVS Specialty® does not have access to dispense the medication.

No Coverage – Non-preferred medication that member pays 100% of all charges. These medications can be covered with a medical

necessity review.

Non-Preferred – Medication is on the CVS Caremark formulary.

Preferred – Medication is on the CVS Caremark formulary.

TBD – To be determined. Formulary status has not been determine. Medication can be covered with a medical necessity review.

This is a listing of specialty medications for GEHA. It does not guarantee coverage. Due to the large number of available medicines, this

list may not be all inclusive and may change without notice. With the Elevate Option for Non-Preferred, you pay 100% of all charges.

Recurring oral medications are to be processed through the pharmacy benefit. Listed products are for informational purposes only and

are not intended to replace the clinical judgment of the prescriber. Please reference the GEHA Benefit Plan Brochure, Section 5(f)

Prescription Drug Benefits, for benefit information.

Non Covered Benefit – A non-covered product under the pharmacy benefit.


2nd Quarter 2020 Elevate Specialty Pharmacy Drug List · 2020-05-13 · Elevate Specialty Pharmacy...

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Transcript of 2nd Quarter 2020 Elevate Specialty Pharmacy Drug List · 2020-05-13 · Elevate Specialty Pharmacy...