Specialty Medication List

State Health Benefits Program Specialty Medication List

GROWTH HORMONE
Genotropin® ¹	Humatrope® ¹	Norditropin® ¹
Nutropin® ¹	Nutropin AQ® ¹	Nutropin Depot® ¹
Saizen® ¹	Tev-Tropin® ¹	Zorbtive™ ^{1, 2}

GONADOTROPIN- RELEASING HORMONE
Eligard® ²	Lupron® / Lupron Depot® ²	Trelstar® Depot ²
Trelstar®LA ²	Viadur® ²	Zoladex® ²

GROWTH HORMONE/HIV
Fuzeon® ^{1, 2}	Serostim® ^{1, 2}

HEMATOPOIETICS
Aranesp® ^{1, 2}	Neupogen® ^{1, 2}	Epogen® ^{1, 2}
Leukine® ^{1, 2}	Neumega® ^{1, 2}	Neulasta® ^{1, 2}
Procrit® ^{1, 2}

HEPATITIS C
Copegus® ^{1, 2}	Infergen® ^{1, 2}	Intron®-A ¹
Pegasys® ^{1, 2}	Peg-Intron® ^{1, 2}	Rebetol® ^{1, 2}
Rebetron® ^{1, 2}	Ribavirin (generic) ^{1, 2}	Roferon®-A ¹

INFERTILITY
Bravelle® ²	Cetrotide® ²	Chorex®-10 ²
Chorionic Gonadotropin ²	Delestrogen	Follistim® AQ ²
Ganirelix Acetate ²	Gonal-F® ²	Gonal-F® RFF ²
Leuprolide Acetate	Luveris® ²	Menopur® ²
Novarel® ²	Ovidrel® ²	Pregnyl® ²
Progesterone in Oil	Repronex® ²	Valergen-20

MULTIPLE SCLEROSIS
Avonex® ^{1, 2}	Betaseron® ^{1, 2}	Copaxone® ^{1, 2}
Rebif® ^{1, 2}

ORAL ONCOLOGY
Gleevec®	Nexavar® ^1,	Revlimid® ^1,
Sutent® ^1,	Tarceva®	Temodar® ²
Thalomid® ^1,	Xeloda® ²

RHEUMATOID ARTHRITIS, OSTEOARTHRITIS & OSTEOPOROSIS
Enbrel® ^{1, 2}	Forteo® ²	Humira® ^{1, 2}
Kineret® (anakinra)

RESPIRATORY
Pulmozyme® ^{1, 2}	RevatioT ^{1, 2}	Tobi® ²
Tracleer® ²

PSORIASIS
Enbrel® ^{1, 2}	Raptiva® ^{1, 2}

RENAL
Sensipar®

MISCELLANEOUS / OTHER
Actimmune® ^{1, 2}	Increlex ® ¹	Octreotide Acetate
Proleukin®	Sandostatin®	Sandostatin® LAR®
Stimate® ¹	Somavert® ^{1, 2}

1. Prior Authorization Required - Select drugs or drug categories require authorization before prescriptions can be filled. These drugs are commonly used for purposes other than those specifically approved by the Food and Drug Administration; that is off-label uses. This medication requires prior authorization to be eligible for coverage. It is important that you or your physician initiate a review before your prescription is filled to eliminate a delay in receiving your medication. To start your review, please have your physician call 1-866-776-5684.

2. Dispensing Limits Apply - Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) monitors claims for certain drugs to ensure they are prescribed and dispensed within the proper safety standards for dosage and/or the length of time you use the drug. These standards are established from a number of sources such as Food and Drug Administration product labeling, medical literature, dispensing patterns and generally accepted standards of medical practice. Prescription quantities within the dispensing limits will be covered under your prescription drug plan. If your specialty medication prescription requires you to exceed the dispensing limit, you will be notified. You or your doctor can request an exception. Call 877-542-0091 to request an exception request form for your doctor to complete and fax to Horizon BCBSNJ for review.

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