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 |