Limited distribution specialty drugs

Effective January 1, 2022

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 obtain the prescription. Members may be required to use another pharmacy for limited distribution prescription drugs.

Drug name

Pharmacy name

ALUNBRIG PAK

Capital Blue Cross - WLO - BIOLOGICS

ALUNBRIG TAB 30MG

Capital Blue Cross - WLO - BIOLOGICS

ALUNBRIG TAB 90MG

Capital Blue Cross - WLO - BIOLOGICS

ALUNBRIG TAB 180MG

Capital Blue Cross - WLO - BIOLOGICS

alyq tab 20mg

Capital Blue Cross - WLO - ALLIANCERX

ARIKAYCE SUS

Capital Blue Cross - WLO - PANTHERX

Capital Blue Cross - WLO - PHARMACEUTICAL SPECIAL

Capital Blue Cross - WLO - MAXOR PHARMACY

Capital Blue Cross - WLO - ORSINI

AYVAKIT TAB 25MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - PANTHERX

AYVAKIT TAB 50MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - PANTHERX

AYVAKIT TAB 100MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - PANTHERX

AYVAKIT TAB 200MG

Capital Blue Cross - WLO - PANTHERX

Capital Blue Cross - WLO - BIOLOGICS

AYVAKIT TAB 300MG

Capital Blue Cross - WLO - BIOLOGICS

AYVAKIT TAB 300MG

Capital Blue Cross - WLO - PANTHERX

BALVERSA TAB 3MG

Capital Blue Cross - WLO - US BIOSERVICES

BALVERSA TAB 4MG

Capital Blue Cross - WLO - US BIOSERVICES

BALVERSA TAB 5MG

Capital Blue Cross - WLO - US BIOSERVICES

BRUKINSA CAP 80MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

BUPHENYL POW

Capital Blue Cross - WLO - ALLIANCERX

BUPHENYL TAB 500MG

Capital Blue Cross - WLO - ALLIANCERX

CABLIVI KIT 11MG

Capital Blue Cross - WLO - BIOLOGICS

CALQUENCE CAP 100MG

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - BIOLOGICS

CAPRELSA TAB 100MG

Capital Blue Cross - WLO - BIOLOGICS

CAPRELSA TAB 300MG

Capital Blue Cross - WLO - BIOLOGICS

CARGLUMIC TAB 200MG

Capital Blue Cross - WLO - ANOVORX

CHENODAL TAB 250MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

CHOLBAM CAP 50MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

CHOLBAM CAP 250MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

COAGADEX INJ 250UNIT

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - OPTION CARE

COAGADEX INJ 500UNIT

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - OPTION CARE

COPIKTRA CAP 15MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - US BIOSERVICES

Capital Blue Cross - WLO - BIOLOGICS

COPIKTRA CAP 25MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - US BIOSERVICES

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - BIOLOGICS

CYSTADANE POW

Capital Blue Cross - WLO - ANOVORX

CYSTAGON CAP 50MG

Capital Blue Cross - WLO - CAREMARK SPECIALTY PH

CYSTAGON CAP 150MG

Capital Blue Cross - WLO - CAREMARK SPECIALTY PH

CYSTARAN SOL 0.44%

Capital Blue Cross - WLO - WALGREENS SPECIALTY PH

Capital Blue Cross - WLO - ALLIANCERX

deferiprone tab 500mg

Capital Blue Cross - WLO - ALLIANCERX

DIACOMIT CAP 250MG

Capital Blue Cross - WLO - US BIOSERVICES

DIACOMIT CAP 500MG

Capital Blue Cross - WLO - US BIOSERVICES

DIACOMIT PAK 250MG

Capital Blue Cross - WLO - US BIOSERVICES

DIACOMIT PAK 500MG

Capital Blue Cross - WLO - US BIOSERVICES

EMPAVELI INJ 1080MG

Capital Blue Cross - WLO - PANTHERX

ENDARI POW 5GM

Capital Blue Cross - WLO - US BIOSERVICES

FENSOLVI INJ 45MG

Capital Blue Cross - WLO - PHARMACEUTICAL SPECIAL

Capital Blue Cross - WLO - MAXOR PHARMACY

FERRIPROX SOL 100MG/ML

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

FERRIPROX TAB 1000MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

FERRIPROX TAB 500MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

FINTEPLA SOL 2.2MG/ML

Capital Blue Cross - WLO - ANOVORX

FIRDAPSE TAB 10MG

Capital Blue Cross - WLO - ANOVORX

FOTIVDA CAP 0.89MG

Capital Blue Cross - WLO - BIOLOGICS

FOTIVDA CAP 1.34MG

Capital Blue Cross - WLO - BIOLOGICS

GOCOVRI CAP 68.5MG

Capital Blue Cross - WLO - ALLIANCERX

GOCOVRI CAP 137MG

Capital Blue Cross - WLO - ALLIANCERX

ICLUSIG TAB 10MG

Capital Blue Cross - WLO - ACARIAHEALTH

ICLUSIG TAB 15MG

Capital Blue Cross - WLO - ACARIAHEALTH

ICLUSIG TAB 30MG

Capital Blue Cross - WLO - ACARIAHEALTH

ICLUSIG TAB 45MG

Capital Blue Cross - WLO - ACARIAHEALTH

IMBRUVICA CAP 140MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

IMBRUVICA CAP 70MG

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

IMBRUVICA TAB 140MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - AVELLA

IMBRUVICA TAB 280MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - BIOLOGICS

IMBRUVICA TAB 420MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - AVELLA

IMBRUVICA TAB 560MG

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

IMCIVREE INJ 10MG/ML

Capital Blue Cross - WLO - PANTHERX

INBRIJA CAP 42MG

Capital Blue Cross - WLO - ALLIANCERX

INGREZZA CAP 40-80MG

Capital Blue Cross - WLO - PANTHERX

Capital Blue Cross - WLO - ORSINI

INGREZZA CAP 40MG

Capital Blue Cross - WLO - PANTHERX

Capital Blue Cross - WLO - ORSINI

INGREZZA CAP 60MG

Capital Blue Cross - WLO - ORSINI

Capital Blue Cross - WLO - PANTHERX

INGREZZA CAP 80MG

Capital Blue Cross - WLO - ORSINI

Capital Blue Cross - WLO - PANTHERX

ISTURISA TAB 1MG

Capital Blue Cross - WLO - ANOVORX

ISTURISA TAB 5MG

Capital Blue Cross - WLO - ANOVORX

ISTURISA TAB 10MG

Capital Blue Cross - WLO - ANOVORX

JYNARQUE PAK 30-15MG

Capital Blue Cross - WLO - ALLIANCERX

JYNARQUE PAK 45-15MG

Capital Blue Cross - WLO - ALLIANCERX

JYNARQUE PAK 60-30MG

Capital Blue Cross - WLO - ALLIANCERX

JYNARQUE PAK 90-30MG

Capital Blue Cross - WLO - ALLIANCERX

JYNARQUE TAB 15MG

Capital Blue Cross - WLO - ALLIANCERX

JYNARQUE TAB 30MG

Capital Blue Cross - WLO - ALLIANCERX

KEVEYIS TAB 50MG

Capital Blue Cross - WLO - PANTHERX

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

KINERET INJ

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - RXCROSSROADS

KORLYM TAB 300MG

Capital Blue Cross - WLO - OPTIME CARE

LUPKYNIS CAP 7.9MG

Capital Blue Cross - WLO - PANTHERX

Capital Blue Cross - WLO - BIOLOGICS

MATULANE CAP 50MG

Capital Blue Cross - WLO - WALGREENS SPECIALTY PH

Capital Blue Cross - WLO - ALLIANCERX

MIRCERA INJ 30MCG

Capital Blue Cross - WLO - ALLIANCERX

MIRCERA INJ 50MCG

Capital Blue Cross - WLO - ALLIANCERX

MIRCERA INJ 75MCG

Capital Blue Cross - WLO - ALLIANCERX

MIRCERA INJ 100MCG

Capital Blue Cross - WLO - ALLIANCERX

MIRCERA INJ 150MCG

Capital Blue Cross - WLO - ALLIANCERX

MIRCERA INJ 200MCG

Capital Blue Cross - WLO - ALLIANCERX

NULIBRY INJ 9.5MG

Capital Blue Cross - WLO - BIOLOGICS

OBIZUR INJ 500 UNIT

Capital Blue Cross - WLO - ALLIANCERX

ORFADIN CAP 2MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

ORFADIN CAP 2MG

Capital Blue Cross - WLO - CURASCRIPT

ORFADIN CAP 5MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

ORFADIN CAP 5MG

Capital Blue Cross - WLO - CURASCRIPT

Capital Blue Cross - WLO - CURASCRIPT

ORFADIN CAP 20MG

Capital Blue Cross - WLO - CURASCRIPT

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

ORFADIN SUS 4MG/ML

Capital Blue Cross - WLO - CURASCRIPT

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

ORGOVYX TAB 120MG

Capital Blue Cross - WLO - US BIOSERVICES

ORLADEYO CAP 110MG

Capital Blue Cross - WLO - OPTIME CARE

ORLADEYO CAP 150MG

Capital Blue Cross - WLO - OPTIME CARE

PEMAZYRE TAB 4.5MG

Capital Blue Cross - WLO - BIOLOGICS

PEMAZYRE TAB 9MG

Capital Blue Cross - WLO - BIOLOGICS

PEMAZYRE TAB 13.5MG

Capital Blue Cross - WLO - BIOLOGICS

phenylbutyrate pow sodium

Capital Blue Cross - WLO - ALLIANCERX

QINLOCK TAB 50MG

Capital Blue Cross - WLO - PANTHERX

Capital Blue Cross - WLO - US BIOSERVICES

REVCOVI INJ 1.6MG/ML

Capital Blue Cross - WLO - ALLIANCERX

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

RUZURGI TAB 10MG

Capital Blue Cross - WLO - PANTHERX

SIGNIFOR INJ 0.3MG/ML

Capital Blue Cross - WLO - ANOVORX

SIGNIFOR INJ 0.6MG/ML

Capital Blue Cross - WLO - ANOVORX

SIGNIFOR INJ 0.9MG/ML

Capital Blue Cross - WLO - ANOVORX

SIGNIFOR LAR INJ 10MG

Capital Blue Cross - WLO - ANOVORX

SIGNIFOR LAR INJ 20MG

Capital Blue Cross - WLO - ANOVORX

SIGNIFOR LAR INJ 30MG

Capital Blue Cross - WLO - ANOVORX

SIGNIFOR LAR INJ 40MG

Capital Blue Cross - WLO - ANOVORX

SIGNIFOR LAR INJ 60MG

Capital Blue Cross - WLO - ANOVORX

sodium phenylbutyrate tab 500mg

Capital Blue Cross - WLO - ALLIANCERX

SPRAVATO SOL 56MG DOS

Capital Blue Cross - WLO - ALLIANCERX

SPRAVATO SOL 84MG DOS

Capital Blue Cross - WLO - ALLIANCERX

STRENSIQ INJ 18/0.45

Capital Blue Cross - WLO - PANTHERX

STRENSIQ INJ 28/0.7ML

Capital Blue Cross - WLO - PANTHERX

STRENSIQ INJ 80/0.8ML

Capital Blue Cross - WLO - PANTHERX

STRENSIQ INJ 40MG/ML

Capital Blue Cross - WLO - PANTHERX

SYNRIBO INJ 3.5MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

TAVALISSE TAB 100MG

Capital Blue Cross - WLO - US BIOSERVICES

TAVALISSE TAB 150MG

Capital Blue Cross - WLO - US BIOSERVICES

TEPMETKO TAB 225MG

Capital Blue Cross - WLO - BIOLOGICS

THIOLA TAB 100MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

THIOLA EC TAB 100MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

THIOLA EC TAB 300MG

Capital Blue Cross - WLO - EVERSANA LIFE SCIENCE

TIBSOVO TAB 250MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - BIOLOGICS

TRIPTODUR SUS 22.5MG

Capital Blue Cross - WLO - PANTHERX

TRUSELTIQ CAP 50MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

TRUSELTIQ CAP 75MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

TRUSELTIQ CAP 100MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

TRUSELTIQ CAP 125MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

TUKYSA TAB 150MG

Capital Blue Cross - WLO - BIOLOGICS

TUKYSA TAB 50MG

Capital Blue Cross - WLO - BIOLOGICS

TURALIO CAP 200MG

Capital Blue Cross - WLO - BIOLOGICS

VENCLEXTA TAB 10MG

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

VENCLEXTA TAB 50MG

Capital Blue Cross - WLO - AVELLA

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

VENCLEXTA TAB 100MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - AVELLA

vigadrone pow 500mg

Capital Blue Cross - WLO - PANTHERX

VIRAZOLE INH 6GM

Capital Blue Cross - WLO - ALLIANCERX

VISTOGARD PAK 10GM

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - CARDINAL HEALTH

XERMELO TAB 250MG

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - BIOLOGICS

XOSPATA TAB 40MG

Capital Blue Cross - WLO - BIOLOGICS

XPOVIO PAK 40MG

Capital Blue Cross - WLO - US BIOSERVICES

Capital Blue Cross - WLO - BIOLOGICS

XPOVIO PAK 50MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

XPOVIO PAK 60MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

XPOVIO PAK 80MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

XPOVIO PAK 100MG

Capital Blue Cross - WLO - BIOLOGICS

Capital Blue Cross - WLO - US BIOSERVICES

XURIDEN POW 2GM

Capital Blue Cross - WLO - CARDINAL HEALTH

ZEJULA CAP 100MG

Capital Blue Cross - WLO - US BIOSERVICES

Capital Blue Cross - WLO - DIPLOMAT SPECIALTY PH

Capital Blue Cross - WLO - BIOLOGICS

ZEPATIER TAB 50-100MG

Capital Blue Cross - WLO - ALLIANCERX

ZOKINVY CAP 50MG

Capital Blue Cross - WLO - US BIOSERVICES

ZOKINVY CAP 75MG

Capital Blue Cross - WLO - US BIOSERVICES