Limited distribution specialty drug list

Effective July 1, 2023

This drug list includes drugs on our Commercial Formulary. Limited Distribution (LD) meaning there is a restriction on which pharmacies can dispense them. This limits where the member may obtainz the prescription. Members may be required to use another pharmacy for limited distribution prescription drugs.

Drug name Pharmacy name

ALUNBRIG PAK

ONCO360

ALUNBRIG PAK

BIOLOGICS

ALUNBRIG TAB 30MG

BIOLOGICS

ALUNBRIG TAB 30MG

ONCO360

ALUNBRIG TAB 90MG

BIOLOGICS

ALUNBRIG TAB 90MG

ONCO360

ALUNBRIG TAB 30MG

BIOLOGICS

ALUNBRIG TAB 180MG

BIOLOGICS

ALUNBRIG TAB 180MG

ONCO360

ALYQ TAB 20MG

ALLIANCERX

APOMORPHINE INJ 30MG/3ML

ALLIANCERX

ARIKAYCE SUS

PHARMACEUTICAL SPECIAL

ARIKAYCE SUS

PANTHERX

ARIKAYCE SUS

MAXOR PHARMACY

ARIKAYCE SUS

ORSINI

AYVAKIT TAB 25MG

BIOLOGICS

AYVAKIT TAB 25MG

PANTHERX

AYVAKIT TAB 50MG

PANTHERX

AYVAKIT TAB 50MG

BIOLOGICS

AYVAKIT TAB 100MG

PANTHERX

AYVAKIT TAB 100MG

BIOLOGICS

AYVAKIT TAB 200MG

BIOLOGICS

AYVAKIT TAB 200MG

PANTHERX

AYVAKIT TAB 300MG

PANTHERX

AYVAKIT TAB 300MG

BIOLOGICS

BALVERSA TAB 3MG

CAREMARK SPECIALTY PH

BALVERSA TAB 4MG

CAREMARK SPECIALTY PH

BALVERSA TAB 5MG

CAREMARK SPECIALTY PH

BESREMI SOL 500MCG

ONCO360

BRUKINSA CAP 80MG

BIOLOGICS

BRUKINSA CAP 80MG

ONCO360

BRUKINSA CAP 80MG

OPTUM PHARMACY

BUPHENYL POW

ALLIANCERX

BUPHENYL TAB 500MG

ALLIANCERX

CABLIVI KIT 11MG

BIOLOGICS

CALQUENCE CAP 100MG

ONCO360

CALQUENCE CAP 100MG

AVELLA

CALQUENCE CAP 100MG

BIOLOGICS

CALQUENCE CAP 100MG

OPTUM PHARMACY

CALQUENCE TAB 100MG

ONCO360

CALQUENCE TAB 100MG

OPTUM PHARMACY

CALQUENCE TAB 100MG

BIOLOGICS

CALQUENCE TAB 100MG

AVELLA

CAMZYOS CAP 2.5MG

CAREMARK SPECIALTY PH

CAMZYOS CAP 5MG

CAREMARK SPECIALTY PH

CAMZYOS CAP 10MG

CAREMARK SPECIALTY PH

CAMZYOS CAP 15MG

CAREMARK SPECIALTY PH

CAPRELSA TAB 100MG

BIOLOGICS

CAPRELSA TAB 300MG

BIOLOGICS

CARGLUMIC TAB 200MG

ANOVORX

CHENODAL TAB 250MG

EVERSANA LIFE SCIENCE

CHOLBAM CAP 50MG

EVERSANA LIFE SCIENCE

CHOLBAM CAP 250MG

EVERSANA LIFE SCIENCE

COAGADEX INJ 250UNIT

OPTUM PHARMACY

COAGADEX INJ 250UNIT

OPTION CARE

COAGADEX INJ 500UNIT

OPTION CARE

COAGADEX INJ 500UNIT

OPTUM PHARMACY

COPIKTRA CAP 15MG

ONCO360

COPIKTRA CAP 15MG

OPTUM PHARMACY

COPIKTRA CAP 15MG

CAREMARK SPECIALTY PH

COPIKTRA CAP 15MG

BIOLOGICS

COPIKTRA CAP 15MG

AVELLA

COPIKTRA CAP 25MG

BIOLOGICS

COPIKTRA CAP 25MG

ONCO360

COPIKTRA CAP 25MG

AVELLA

COPIKTRA CAP 25MG

CAREMARK SPECIALTY PH

COPIKTRA CAP 25MG

OPTUM PHARMACY

CYSTADANE POW

ANOVORX

CYSTADROPS SOL 0.37%

ANOVORX

CYSTAGON CAP 50MG

CAREMARK SPECIALTY PH

CYSTAGON CAP 150MG

CAREMARK SPECIALTY PH

CYSTARAN SOL 0.44%

ALLIANCERX

CYSTARAN SOL 0.44%

WALGREENS SPECIALTY PH

DEFERIPRONE TAB 500MG

ALLIANCERX

DEFERIPRONE TAB 1000MG

ALLIANCERX

DIACOMIT CAP 250MG

PANTHERX

DIACOMIT CAP 500MG

PANTHERX

DIACOMIT PAK 250MG

PANTHERX

DIACOMIT PAK 500MG

PANTHERX

EMPAVELI INJ 1080MG

PANTHERX

ENDARI POW 5GM

CAREMARK SPECIALTY PH

EXKIVITY CAP 40MG

BIOLOGICS

EXKIVITY CAP 40MG

ONCO360

FENSOLVI INJ 45MG

PHARMACEUTICAL SPECIAL

FENSOLVI INJ 45MG

MAXOR PHARMACY

FERPRX 2-DAY TAB 1000MG

EVERSANA LIFE SCIENCE

FERRIPROX SOL 100MG/ML

EVERSANA LIFE SCIENCE

FERRIPROX TAB 1000MG

EVERSANA LIFE SCIENCE

FERRIPROX TAB 500MG

EVERSANA LIFE SCIENCE

FINTEPLA SOL 2.2MG/ML

ANOVORX

FIRDAPSE TAB 10MG

ANOVORX

FOTIVDA CAP 0.89MG

BIOLOGICS

FOTIVDA CAP 0.89MG

ONCO360

FOTIVDA CAP 1.34MG

BIOLOGICS

FOTIVDA CAP 1.34MG

ONCO360

FUROSCIX KIT 80/10ML

BIOMATRIX

FYLNETRA INJ 6MG/0.6

ALLIANCERX

GOCOVRI CAP 137MG

ALLIANCERX

GOCOVRI CAP 68.5MG

ALLIANCERX

HYFTOR GEL 0.2%

ALLIANCERX

ICLUSIG TAB 10MG

ACARIAHEALTH

ICLUSIG TAB 15MG

ACARIAHEALTH

ICLUSIG TAB 30MG

ACARIAHEALTH

ICLUSIG TAB 45MG

ACARIAHEALTH

IMBRUVICA CAP 70MG

AVELLA

IMBRUVICA CAP 70MG

OPTUM PHARMACY

IMBRUVICA CAP 70MG

ONCO360

IMBRUVICA CAP 70MG

BIOLOGICS

IMBRUVICA CAP 140MG

BIOLOGICS

IMBRUVICA CAP 140MG

OPTUM PHARMACY

IMBRUVICA CAP 140MG

AVELLA

IMBRUVICA CAP 140MG

ONCO360

IMBRUVICA SUS 70MG/ML

AVELLA

IMBRUVICA SUS 70MG/ML

BIOLOGICS

IMBRUVICA SUS 70MG/ML

ONCO360

IMBRUVICA SUS 70MG/ML

OPTUM PHARMACY

IMBRUVICA TAB 140MG

ONCO360

IMBRUVICA TAB 140MG

OPTUM PHARMACY

IMBRUVICA TAB 140MG

BIOLOGICS

IMBRUVICA TAB 140MG

AVELLA

IMBRUVICA TAB 280MG

BIOLOGICS

IMBRUVICA TAB 280MG

ONCO360

IMBRUVICA TAB 280MG

OPTUM PHARMACY

IMBRUVICA TAB 280MG

AVELLA

IMBRUVICA TAB 420MG

BIOLOGICS

IMBRUVICA TAB 420MG

AVELLA

IMBRUVICA TAB 420MG

OPTUM PHARMACY

IMBRUVICA TAB 420MG

ONCO360

IMBRUVICA TAB 560MG

ONCO360

IMBRUVICA TAB 560MG

OPTUM PHARMACY

IMBRUVICA TAB 560MG

BIOLOGICS

IMBRUVICA TAB 560MG

AVELLA

IMCIVREE INJ 10MG/ML

PANTHERX

INBRIJA CAP 42MG

ALLIANCERX

INGREZZA CAP 40-80MG

ORSINI

INGREZZA CAP 40-80MG

PANTHERX

INGREZZA CAP 40MG

PANTHERX

INGREZZA CAP 40MG

ORSINI

INGREZZA CAP 60MG

PANTHERX

INGREZZA CAP 60MG

ORSINI

INGREZZA CAP 80MG

ORSINI

INGREZZA CAP 80MG

PANTHERX

ISTURISA TAB 1MG

ANOVORX

ISTURISA TAB 5MG

ANOVORX

ISTURISA TAB 10MG

ANOVORX

JAVYGTOR PAK 100MG

OPTUM FRONTIER THERAPI

JAVYGTOR POW 500MG

OPTUM FRONTIER THERAPI

JAVYGTOR TAB 100MG

OPTUM FRONTIER THERAPI

JYNARQUE PAK 15MG

ALLIANCERX

JYNARQUE PAK 30-15MG

ALLIANCERX

JYNARQUE PAK 45-15MG

ALLIANCERX

JYNARQUE PAK 60-30MG

ALLIANCERX

JYNARQUE PAK 90-30MG

ALLIANCERX

JYNARQUE TAB 15MG

ALLIANCERX

JYNARQUE TAB 30MG

ALLIANCERX

KEVEYIS TAB 50MG

PANTHERX

KEVEYIS TAB 50MG

OPTUM PHARMACY

KINERET INJ

BIOLOGICS

KINERET INJ

RXCROSSROADS

KORLYM TAB 300MG

OPTIME CARE

KOSELUGO CAP 10MG

ONCO360

KOSELUGO CAP 25MG

ONCO360

KRAZATI TAB 200MG

ONCO360

LENALIDOMIDE CAP 2.5MG

ALLIANCERX

LENALIDOMIDE CAP 2.5MG

ONCO360

LENALIDOMIDE CAP 5MG

ONCO360

LENALIDOMIDE CAP 5MG

ALLIANCERX

LENALIDOMIDE CAP 10MG

ALLIANCERX

LENALIDOMIDE CAP 10MG

ONCO360

LENALIDOMIDE CAP 15MG

ALLIANCERX

LENALIDOMIDE CAP 15MG

ONCO360

LENALIDOMIDE CAP 20MG

ALLIANCERX

LENALIDOMIDE CAP 20MG

ONCO360

LENALIDOMIDE CAP 25MG

ALLIANCERX

LENALIDOMIDE CAP 25MG

ONCO360

LIVMARLI SOL 9.5MG/ML

EVERSANA LIFE SCIENCE

LIVTENCITY TAB 200MG

BIOLOGICS

LUPKYNIS CAP 7.9MG

PANTHERX

LUPKYNIS CAP 7.9MG

BIOLOGICS

LYTGOBI TAB 4MG

ONCO360

MATULANE CAP 50MG

ALLIANCERX

MATULANE CAP 50MG

WALGREENS SPECIALTY PH

MIRCERA INJ 30MCG

ALLIANCERX

MIRCERA INJ 50MCG

ALLIANCERX

MIRCERA INJ 100MCG

ALLIANCERX

MIRCERA INJ 120MCG

ALLIANCERX

MIRCERA INJ 150MCG

ALLIANCERX

MIRCERA INJ 200MCG

ALLIANCERX

MIRCERA INJ 75MCG

ALLIANCERX

MYCAPSSA CAP 20MG

ACARIAHEALTH

NULIBRY INJ 9.5MG

BIOLOGICS

OBIZUR INJ 500 UNIT

ALLIANCERX

OCTREOTIDE INJ 500MCG

ACARIAHEALTH

ORFADIN CAP 2MG

EVERSANA LIFE SCIENCE

ORFADIN CAP 5MG

EVERSANA LIFE SCIENCE

ORFADIN CAP 10MG

EVERSANA LIFE SCIENCE

ORFADIN CAP 20MG

EVERSANA LIFE SCIENCE

ORFADIN SUS 4MG/ML

EVERSANA LIFE SCIENCE

ORGOVYX TAB 120MG

ONCO360

ORGOVYX TAB 120MG

BIOLOGICS

ORLADEYO CAP 110MG

OPTIME CARE

ORLADEYO CAP 150MG

OPTIME CARE

PEMAZYRE TAB 4.5MG

BIOLOGICS

PEMAZYRE TAB 9MG

BIOLOGICS

PEMAZYRE TAB 13.5MG

BIOLOGICS

PHENYLBUTYRA POW SODIUM

ALLIANCERX

PHOSPHOLINE SOL 0.125%OP

ALLIANCERX

PYRUKYND TAB 5MG

BIOLOGICS

PYRUKYND TAB 20MG

BIOLOGICS

PYRUKYND TAB 50MG

BIOLOGICS

PYRUKYND TAB 5MG TP

BIOLOGICS

PYRUKYND TAB 20MGX5MG

BIOLOGICS

PYRUKYND TAB 50MGX20M

BIOLOGICS

QINLOCK TAB 50MG

PANTHERX

RECORLEV TAB 150MG

PANTHERX

REVCOVI INJ 1.6MG/ML

EVERSANA LIFE SCIENCE

REVCOVI INJ 1.6MG/ML

ALLIANCERX

REZLIDHIA CAP 150MG

BIOLOGICS

REZLIDHIA CAP 150MG

OPTIME CARE

REZUROCK TAB 200MG

ONCO360

REZUROCK TAB 200MG

BIOLOGICS

RUZURGI TAB 10MG

PANTHERX

SAJAZIR INJ 30MG/3ML

OPTUM FRONTIER THERAPI

SIGNIFOR INJ 0.3MG/ML

ANOVORX

SIGNIFOR INJ 0.6MG/ML

ANOVORX

SIGNIFOR INJ 0.9MG/ML

ANOVORX

SIGNIFOR LAR INJ 10MG

ANOVORX

SIGNIFOR LAR INJ 20MG

ANOVORX

SIGNIFOR LAR INJ 30MG

ANOVORX

SIGNIFOR LAR INJ 40MG

ANOVORX

SIGNIFOR LAR INJ 60MG

ANOVORX

SKYTROFA INJ 3MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 3MG

ALLIANCERX

SKYTROFA INJ 3.6MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 3.6MG

ALLIANCERX

SKYTROFA INJ 4.3MG

ALLIANCERX

SKYTROFA INJ 4.3MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 5.2MG

ALLIANCERX

SKYTROFA INJ 5.2MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 6.3MG

ALLIANCERX

SKYTROFA INJ 6.3MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 7.6MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 7.6MG

ALLIANCERX

SKYTROFA INJ 9.1MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 9.1MG

ALLIANCERX

SKYTROFA INJ 11MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 11MG

ALLIANCERX

SKYTROFA INJ 13.3MG

CAREMARK SPECIALTY PH

SKYTROFA INJ 13.3MG

ALLIANCERX

SODIUM PHENY TAB 500MG

ALLIANCERX

SPRAVATO SOL 56MG DOS

ALLIANCERX

SPRAVATO SOL 84MG DOS

ALLIANCERX

STRENSIQ INJ 18/0.45

PANTHERX

STRENSIQ INJ 28/0.7ML

PANTHERX

STRENSIQ INJ 40MG/ML

PANTHERX

STRENSIQ INJ 80/0.8ML

PANTHERX

SYNRIBO INJ 3.5MG

CORAM

SYNRIBO INJ 3.5MG

OPTUM PHARMACY

TAVALISSE TAB 100MG

BIOLOGICS

TAVALISSE TAB 100MG

OPTUM PHARMACY

TAVALISSE TAB 150MG

BIOLOGICS

TAVALISSE TAB 150MG

OPTUM PHARMACY

TAZVERIK TAB 200MG

ONCO360

TEPMETKO TAB 225MG

BIOLOGICS

THIOLA TAB 100MG

EVERSANA LIFE SCIENCE

THIOLA EC TAB 100MG

EVERSANA LIFE SCIENCE

THIOLA EC TAB 300MG

EVERSANA LIFE SCIENCE

TIBSOVO TAB 250MG

ONCO360

TIBSOVO TAB 250MG

BIOLOGICS

TIBSOVO TAB 250MG

OPTUM PHARMACY

TRIPTODUR SUS 22.5MG

PANTHERX

TRUSELTIQ CAP 50MG

BIOLOGICS

TRUSELTIQ CAP 75MG

BIOLOGICS

TRUSELTIQ CAP 100MG

BIOLOGICS

TRUSELTIQ CAP 125MG

BIOLOGICS

TUKYSA TAB 50MG

ONCO360

TUKYSA TAB 50MG

BIOLOGICS

TUKYSA TAB 150MG

BIOLOGICS

TUKYSA TAB 150MG

ONCO360

TURALIO CAP 125MG

BIOLOGICS

TURALIO CAP 200MG

BIOLOGICS

UKONIQ TAB 200MG

ONCO360

VENCLEXTA TAB 10MG

ONCO360

VENCLEXTA TAB 10MG

OPTUM PHARMACY

VENCLEXTA TAB 10MG

AVELLA

VENCLEXTA TAB 50MG

ONCO360

VENCLEXTA TAB 50MG

AVELLA

VENCLEXTA TAB 50MG

OPTUM PHARMACY

VENCLEXTA TAB 100MG

ONCO360

VENCLEXTA TAB 100MG

OPTUM PHARMACY

VENCLEXTA TAB 100MG

AVELLA

VENCLEXTA TAB START PK

ONCO360

VIGADRONE POW 500MG

PANTHERX

VIRAZOLE INH 6GM

ALLIANCERX

VISTOGARD PAK 10GM

BIOMATRIX

VISTOGARD PAK 10GM

BIOLOGICS

VONJO CAP 100MG

ONCO360

VONJO CAP 100MG

BIOLOGICS

VYLEESI INJ 1.75/0.3

AVELLA

VYLEESI INJ 1.75/0.3

BIOPLUS

WELIREG TAB 40MG

BIOLOGICS

WELIREG TAB 40MG

ONCO360

XENLETA INJ 150/15ML

CRITICAL CARE SYSTEMS

XENLETA INJ 150/15ML

ACARIAHEALTH

XENLETA INJ 150/15ML

CRESCENT HEALTHCARE

XENLETA INJ 150/15ML

OPTION CARE

XENLETA TAB 600MG

CRESCENT HEALTHCARE

XENLETA TAB 600MG

CRITICAL CARE SYSTEMS

XENLETA TAB 600MG

OPTION CARE

XENLETA TAB 600MG

ACARIAHEALTH

XERMELO TAB 250MG

BIOLOGICS

XERMELO TAB 250MG

OPTUM PHARMACY

XOSPATA TAB 40MG

ONCO360

XOSPATA TAB 40MG

BIOLOGICS

XOSPATA TAB 40MG

CAREMARK SPECIALTY PH

XPOVIO PAK 40MG

ONCO360

XPOVIO PAK 50MG

ONCO360

XPOVIO PAK 60MG

ONCO360

XPOVIO PAK 80MG

ONCO360

XPOVIO PAK 100MG

ONCO360

XURIDEN POW 2GM

BIOMATRIX

ZEPATIER TAB 50-100MG

ALLIANCERX

ZOKINVY CAP 50MG

CAREMARK SPECIALTY PH

ZOKINVY CAP 75MG

CAREMARK SPECIALTY PH

ZTALMY SUS 50MG/ML

ORSINI