Pharmacy Customer Service: Phone: (800) option 2 Phone: (855) Fax: (570) Fax: (570)

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Aleksandra Matusiak
6 lat temu
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1 GHP Family Specialty Drug List/Procedure prescribers can fax or e-prescribe a prescription directly to the contracted pharmacy or can call (888) for assistance. Requests for prior authorization should be faxed to the respective number noted below. Medical Management: Pharmacy Customer Service: Phone: (800) option 2 Phone: (855) Fax: (570) Fax: (570) Drugs included in Geisinger Health Plan Specialty Pharmacy Drug Program Prior Authorization required if marked. Pharmacy ABILIFY MAINTENA X CS, ABRAXANE X ACITRETIN X CS, ACTEMRA X CS, ACTIMMUNE X CV ADAGEN WG ADCETRIS X ADCIRCA X CS, ADEFOVIR DIPIVOXIL X CS, ADEMPAS X AC, CV* ADVATE X ADYNOVATE X AFINITOR X CS, AFINITOR DISPERZ X CS, AFSTYLA X AGRYLIN X CS, ALDURAZYME X K, ALECENSA X CS, U ALFERON N WG ALIMTA ALKERAN

2 ALPHANATE X ALPHANINE SD X ALPROLIX X ALUNBRIG X CS, K, AMPYRA X CS, U APOKYN X AC, CV* ARALAST NP X AC, CV* ARANESP X CS, ARCALYST X AC, CV* ARESTIN X AC ARISTADA X CS, ARRANON X ARZERRA X U ATRYN K AUBAGIO X (7 MG ONLY) CS, AUSTEDO X CS, AVASTIN CS, AVONEX CS, AVONEX PEN CS, AZACITIDINE BARACLUDE CS, BAVENCIO X B BEBULIN X K, BELEODAQ X BENDEKA BENEFIX X BENLYSTA X CS, BERINERT X CV BESPONSA X B BETASERON CS, BETHKIS X CS, BEXAROTENE X BICNU BIVIGAM X BLEO 15K BLEOMYCIN SULFATE BLINCYTO X K, BORTEZOMIB X

3 BOSULIF X CS, BOTOX X BRAFTOVI U BRAVELLE K, BRINEURA X U BUPHENYL X CV BUSULFAN U BUSULFEX CABOMETYX X CS, U CALQUENCE X CS, CAMPTOSAR CAPECITABINE CS, CAPRELSA X B CARBAGLU X AC CARBOPLATIN CARIMUNE NF NANOFILTERED X CARMUSTINE CAYSTON X K, CEPROTIN AC, CV* CERDELGA X CS, CEREZYME X K CETROTIDE X CHENODAL X DO CHOLBAM X DO CIMZIA X CS, CINQAIR X CINRYZE X AC, CV* CISPLATIN CLADRIBINE CLOFARABINE X CLOLAR X COAGADEX OC COMETRIQ X DI COPAXONE CS, CORIFACT COSENTYX (2 SYRINGES) X CS, COSENTYX PEN X CS, COSENTYX PEN (2 PENS) X CS,

4 COSENTYX SYRINGE X CS, COSMEGEN COTELLIC X CS, U CRYSVITA X AC, CV* CUPRIMINE X CS, CUVITRU X AC, CV* CYCLOPHOSPHAMIDE CS, CYRAMZA X U CYSTADANE X AN CYSTAGON CV CYSTARAN X WG CYTARABINE CYTOGAM X DACOGEN X DACTINOMYCIN DAKLINZA X CS, DALFAMPRIDINE ER X DARAPRIM X DARZALEX X DAUNORUBICIN HCL DECITABINE DEPEN X DEPOCYT K, DIBENZYLINE X U DOCETAXEL DOPTELET K, DOXIL DOXORUBICIN HCL LIPOSOME DUPIXENT X CS, DYSPORT X U EGRIFTA X K, ELAPRASE X ELELYSO X K, ELIGARD X ELLENCE ELOCTATE X EMCYT EMFLAZA X U

5 EMPLICITI X ENBREL X CS, ENBREL MINI X CS, ENBREL SURECLICK X CS, ENDARI X U ENTECAVIR CS, ENTYVIO X CS, EPCLUSA X CS, EPIRUBICIN HCL EPOGEN X CS, EPOPROSTENOL SODIUM AC, CV* ERBITUX ERIVEDGE X CS, ERLEADA X CS, ERWINAZE X B ESBRIET X CS, K, EVOMELA EXJADE X CS, U EXONDYS 51 X K, EXTAVIA CS, EYLEA U FABRAZYME X K, FARESTON X FARYDAK X CS, FASENRA X CS, FASLODEX CS, FEIBA NF X FERRIPROX X DO FIRAZYR X CS, FIRMAGON FLEBOGAMMA DIF X FLOLAN X AC FLOXURIDINE K, FLUDARABINE PHOSPHATE FOLLISTIM AQ X CS, FOLOTYN FORTEO X CS, FULPHILA

6 FUSILEV GALAFOLD AC GAMASTAN GAMASTAN S-D X GAMMAGARD LIQUID X GAMMAGARD S-D X GAMMAKED X GAMMAPLEX X GAMUNEX-C X GANIRELIX ACETATE X CS, GATTEX X AC, CV* GAZYVA X GEMCITABINE HCL GEMZAR GENOTROPIN X CS, GILENYA CS, GILOTRIF X AC GLASSIA X CV GLATIRAMER ACETATE CS, GLATOPA X CS, GLEEVEC X CS, GLEOSTINE CS, GLIADEL GOCOVRI X WG GONAL-F X GONAL-F RFF X GONAL-F RFF REDI-JECT X GRANIX X CS, H.P. ACTHAR X AC, CV* HAEGARDA X AC, CV* HALAVEN X HARVONI X CS, HELIXATE FS X HEMLIBRA X U HEMOFIL M X HEPSERA X CS, HERCEPTIN HETLIOZ X AC

7 HEXALEN HIZENTRA X HUMATE-P X HUMATROPE X CS, HUMIRA X CS, HUMIRA PEDIATRIC CROHN'S X CS, HUMIRA PEN X CS, HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS- UVEITIS HYCAMTIN X X CS, CS, CS, HYDROXYPROGESTERONE CAPROATE X HYQVIA X HYQVIA IG COMPONENT X IBRANCE X CS, ICLUSIG X B IDAMYCIN PFS IDARUBICIN HCL IDELVION X IDHIFA X CV IFEX IFOSFAMIDE IFOSFAMIDE-MESNA K, ILARIS X ILUMYA IMATINIB MESYLATE X CS, IMBRUVICA X CS, IMFINZI X U INCRELEX INFLECTRA X CS, INGREZZA X PRX INJECTAFER U INLYTA X CS, INTRON A CS, INVEGA SUSTENNA X CS, INVEGA TRINZA X CS, IRESSA X CS, U IRINOTECAN HCL

8 ISTODAX X IXEMPRA X IXINITY X K JADENU X CS, JADENU SPRINKLE X CS, JAKAFI X U JEVTANA X JIVI JUXTAPID X DO JYNARQUE X PRX* KADCYLA X KALBITOR X U KALYDECO X CS, K, KANUMA X U KCENTRA KEPIVANCE KEVEYIS X PRX KEVZARA X CS, KEYTRUDA X KINERET X RXC* KISQALI X CS, KISQALI FEMARA CO-PACK X CS, KITABIS PAK X CS, KOATE X KOATE-DVI X KOGENATE FS X KORLYM X OC KOVALTRY KRYSTEXXA KUVAN X AC, CV* KYNAMRO X AC, CV* KYPROLIS X LARTRUVO X U LEMTRADA X CV LENVIMA X B LETAIRIS X AC, CV* LEUKERAN CS, LEUKINE X

9 LEUPROLIDE ACETATE X CS, LEVOLEUCOVORIN CALCIUM LOMUSTINE K LONSURF X CS, LUCENTIS K, LUMIZYME X K, LUPANETA PACK LUPRON DEPOT CS, LUPRON DEPOT (LUPANETA) CS, LUPRON DEPOT-PED CS, LUXTURNA X AC LYNPARZA X CS, LYSODREN CS, MACRILEN MACUGEN K, MAKENA X CS, MATULANE B MAVYRET X CS, MEKINIST X CS, MEKTOVI U MELPHALAN HCL MENOPUR X CS, MEPSEVII X AC MIGLUSTAT X MITOMYCIN MITOMYCIN-STERILE WATER MITOXANTRONE HCL MONOCLATE-P X MONONINE X MOZOBIL X K, MULPLETA K, MUSTARGEN MUTAMYCIN MYALEPT X AC MYLERAN MYLOTARG X B MYOBLOC X MYOZYME X K,

10 NAGLAZYME X CV NATPARA X AC, CV* NAVELBINE NERLYNX X AC, B* NEULASTA X CS, NEUPOGEN X CS, NEXAVAR X CS, U NILANDRON NILUTAMIDE NINLARO X CS, NIPENT NITYR X DI NIVESTYM U NORDITROPIN FLEXPRO X CS, NORDITROPIN NORDIFLEX X CS, K, NORTHERA X AC, CV* NOVOEIGHT X NOVOSEVEN RT X NPLATE X NUCALA X CS, NUPLAZID X AC, CV* NUTROPIN AQ X CS, NUTROPIN AQ NUSPIN X CS, NUWIQ NYMALIZE X OCALIVA X AC, CV* OCREVUS X CS, OCTAGAM X OCTREOTIDE ACETATE CS, ODOMZO X OFEV X AC, CV* OLUMIANT OLYSIO X CS, OMNITROPE X CS, ONCASPAR ONIVYDE X U ONPATTRO OPDIVO X CS,

11 OPSUMIT X AC, CV* ORENCIA X CS, ORENCIA CLICKJECT X CS, ORENITRAM ER X AC, CV* ORFADIN X DO ORKAMBI X CS, K, OTEZLA X CS, OTREXUP X OXALIPLATIN X PACLITAXEL PALYNZIQ AC PANHEMATIN PANRETIN X PEGASYS CS, PEGASYS PROCLICK CS, PEGINTRON CS, PEGINTRON REDIPEN CS, K, PERJETA CS, PHENOXYBENZAMINE HCL X PHOTOFRIN WG PLEGRIDY CS, PLEGRIDY PEN CS, POMALYST X PORTRAZZA X U PRALUENT PEN X CS, PRALUENT SYRINGE X CS, K, PREVYMIS X CS, PRIALT X PRIVIGEN PROCRIT X CS, PROCYSBI X AC PROFILNINE X PROLASTIN C DO PROLEUKIN PROLIA X CS, PROMACTA X CS, PULMOZYME X CS, PURIXAN X CV

12 RADICAVA X U RASUVO X CS, RAVICTI X AC, CV* REBIF CS, REBIF REBIDOSE CS, REBINYN X U RECLAST CS, RECOMBINATE X REMICADE X CS, REMODULIN X AC, CV* RENFLEXIS X CS, REPATHA PUSHTRONEX X CS, REPATHA SURECLICK X CS, REPATHA SYRINGE X CS, RETACRIT REVATIO CS, REVLIMID X RIDAURA RISPERDAL CONSTA X CS, RITUXAN X CS, RITUXAN HYCELA X CS, RIXUBIS X ROMIDEPSIN X RUBRACA X U RUCONEST X AC, CV* RYDAPT X CS, SABRIL X AC, CV* SAIZEN X CS, SAIZEN-SAIZENPREP X CS, SAMSCA X AC, CV* SANDOSTATIN CS, SANDOSTATIN LAR CS, SANDOSTATIN LAR DEPOT CS, SENSIPAR X CS, SEROSTIM X CV SIGNIFOR X SIGNIFOR LAR X SILIQ X CS,

13 SIMPONI X CS, SIMPONI ARIA X CS, SIRTURO X MMS SODIUM PHENYLBUTYRATE X SOLESTA CV SOLIRIS X U SOMATULINE DEPOT SOMAVERT X U SORIATANE X CS, SOVALDI X CS, SPINRAZA X AC SPRYCEL X CS, STELARA X CS, STIVARGA X CS, U STRENSIQ X PRX SUBLOCADE X AC SUCRAID X U SUPPRELIN LA X SUTENT X CS, SYLATRON X CS, SYLATRON 4-PACK X CS, SYLVANT X SYMDEKO X K, SYNAGIS X U SYNAREL X SYNRIBO X U SYPRINE X TABLOID X TADALAFIL X TAFINLAR X CS, TAGRISSO X CS, U TAKHZYRO X AC, CV* TALTZ AUTOINJECTOR X CS, TALTZ AUTOINJECTOR (2 PACK) X CS, TALTZ AUTOINJECTOR (3 PACK) X CS, TALTZ SYRINGE X CS, TALTZ SYRINGE (2 PACK) X CS, K, TALTZ SYRINGE (3 PACK) X CS, K,

14 TARCEVA X CS, TARGRETIN X CS, TASIGNA X CS, TAVALISSE X U TAXOTERE TECENTRIQ X TECFIDERA CS, TECHNIVIE X CS, TEMODAR TEMOZOLOMIDE CS, CS, TEMSIROLIMUS X TENIPOSIDE TEPADINA X TETRABENAZINE X CS, THALOMID X THIOLA X DO THIOTEPA THYROGEN K, TIBSOVO TOBI X CS, TOBI PODHALER X CS, TOBRAMYCIN X CS, TOPOTECAN HCL B CS, TORISEL X TRACLEER X AC, CV* TREANDA TRELSTAR TREMFYA X CS, TRETINOIN TRETTEN K, CS, TRIENTINE HCL X TRIPTODUR TRISENOX PRX TYKERB X CS, TYMLOS X CS, TYSABRI X AC, CV* TYVASO X AC, CV* TYVASO INSTITUTIONAL START KIT X AC, CV*

15 TYVASO REFILL KIT X AC, CV* TYVASO STARTER KIT X AC, CV* UPTRAVI X AC, CV* VALCHLOR X AC VALSTAR VANTAS X VECTIBIX X VELCADE X VELETRI X AC, CV* VEMLIDY CS, VENCLEXTA X CS, VENCLEXTA STARTING PACK X CS, VENTAVIS X AC, CV* VERZENIO X CS, U VIDAZA VIEKIRA PAK X CS, VIEKIRA XR X CS, VIGABATRIN X AC, CV* VIGADRONE X PRX VIMIZIM X VINBLASTINE SULFATE VINORELBINE TARTRATE VISTOGARD X B VISUDYNE CV VIVITROL CS, VONVENDI U VORAXAZE X U VOSEVI X CS, VOTRIENT X CS, VPRIV X VYXEOS X B WILATE X WINRHO SDF XALKORI X CS, XATMEP X XELJANZ X CS, XELJANZ XR X CS, XELODA CS,

16 XENAZINE X CS, XEOMIN X XERMELO X B XGEVA X CS, XOLAIR X CS, XTANDI X XURIDEN X CH XYNTHA X XYNTHA SOLOFUSE X XYREM X ES YERVOY X CS, YONDELIS X YONSA X ZALTRAP X U ZANOSAR ZARXIO X CS, ZAVESCA X AC ZEJULA X CS, U ZELBORAF X CS, U ZEMAIRA X AC, CV* ZEPATIER X CS, ZINBRYTA X CV ZOLADEX ZOLEDRONIC ACID CS, ZOLINZA X CS, ZOMACTON ZOMETA CS, CS, ZORBTIVE X ZYDELIG X CS, ZYKADIA X CS, U ZYPREXA RELPREVV X CS, ZYTIGA X CS, *Use of the Specialty Pharmacy Drug Program is mandatory only when medication will be selfadministered by the member at home. Use of the Specialty Pharmacy Drug Program is not mandatory if the physician elects to buy and bill the medication. Last Updated 10/29/2018

17 KEY: Phone # Fax # AC = Accredo AN = AnovoRx B = Biologics CH = Cardinal Health CS = Caresite Specialty CV = CVS Specialty DI = Diplomat DO = Dohmen Life Sciences ES = Express Scripts Distribution Services K = Kroger Specialty MSS = MMS RXC = RxCrossroads OC = OptimeCare PRX = PantheRx U = US Bioservices WG = Walgreens MedImpact Direct Specialty

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