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 |