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General PRUDENTES Specialty Drug List October 2020Medications listed below are covered under the PrudentRx ProgramBrand-name drugs are capitalized (e.g., SANDOSTATIN) and generic drugs are listed in lower case (e.g., octreotide acetate).Please note: If you are a plan member, please call 1-800-578-4403 and a customer service advocate will be available to answerany questions and enroll you in the program. Representatives are available Monday through Friday from 8 a.m. to 8 p.m. ETACROMEGALYBYNFEZIA PEN1CRYOPYRIN-ASSOCIATEDPERIODIC ARCALYSTILARIS1ZORBTIVE1SOMAVERT1CYSTIC FIBROSISBETHKIS1ALPHA-1 ANTITRYPSINDEFICIENCYCAYSTON1KITABIS PAK1HEMOPHILIAADVATE1ARALAST NP1PULMOZYME1ADYNOVATE1TOBI1AFSTYLA1TOBI PODHALER1ALPHANATE1tobramycinALPHANINE SDALPROLIX1ELECTROLYTE A1HEMOFIL M1HUMATE-P1IDELVION1IXINITY1NUCALA1GROWTH HORMONE ANDRELATED TROPE1KOVALTRY1INCRELEX1MONONINENOVOEIGHTNOVOSEVEN RT1FASENRA1ATOPIC N ILNINE SDMedications on the PrudentRx specialty drug list may change at any time, with or without notice. Your plan may not cover certain medications even though they appear on the PrudentRxdrug list. Copayments for the medications on this list, whether made by your plan or a manufacturer’s copay assistance program, will not count toward your plan deductible.1- Member cost share payments for these medications, whether made by you, your plan or a manufacturer copay assistance program, do not count towards the plan’s out-of-pocketmaximum.
EX1ENTYVIO1STIMATETRETTEN1HUMANIMMUNODEFICIENCY NATE1XYNTHAHEPATITIS ALDIVIEKIRA PAK1HUMIRA1IMMUNE DEFICIENCIESAND RELATED A1GAMASTAN S/D1GAMMAGARD EX1HEREDITARY ANGIOEDEMABERINERT1HEPAGAM BHIZENTRA1CINRYZE1HYPERHEP BHYPERRHO S/DHYQVIA1HAEGARDA1icatibant acetate1KALBITOR1RUCONESTTAKHZYRO1HORMONAL THERAPIESAVEED1ELIGARDFIRMAGONleuprolide acetateLUPANETA PACK1LUPRON STELARA1IRON Y1LYSOSOMAL statNAGLAZYMEVIMIZIMVPRIV1MENTAL HEALTHCONDITIONSZULRESSO1MOVEMENT DISORDERSAPOKYN1AUSTEDO1INBRIJA1INFECTIOUS DISEASE RY BOWELDISEASERADICAVA1Medications on the PrudentRx specialty drug list may change at any time, with or without notice. Your plan may not cover certain medications even though they appear on thePrudentRx drug list. Copayments for the medications on this list, whether made by your plan or a manufacturer’s copay assistance program, will not count toward your plan deductible.1- Member cost share payments for these medications, whether made by you, your plan or a manufacturer copay assistance program, do not count towards the plan’s out-of-pocketmaximum.
tetrabenazineXENAZINEMULTIPLE SCLEROSISAMPYRA1AUBAGIOAVONEXILUVIEN1imatinib BIC1VISUDYNE1IRESSA11JAKAFI11COPAXONE 201ONCOLOGYabiraterone acetateAFINITOR1COPAXONE 401ALECENSA1dalfampridinedimethyl Q1glatiramer acetate 201BELRAPZO1glatiramer acetate ne capBLINCYTO1BETASERON1glatopa 201glatopa ALEX LASTA1ERLEADA1POTELIGEO1NEUPOGEN1erlotinib STYMUDENYCAZARXIO1FARYDAK1REVLIMIDRITUXAN HYCELA1ZIEXTENZO1GLEEVEC1ROZLYTREK1RUBRACA1OCULAR RUXIENCE1RYDAPT1SARCLISAMedications on the PrudentRx specialty drug list may change at any time, with or without notice. Your plan may not cover certain medications even though they appear on thePrudentRx drug list. Copayments for the medications on this list, whether made by your plan or a manufacturer’s copay assistance program, will not count toward your plan deductible.1- Member cost share payments for these medications, whether made by you, your plan or a manufacturer copay assistance program, do not count towards the plan’s out-of-pocketmaximum.
SPRYCEL1STIVARGATERIPARATIDETYMLOS11zoledronic acid ostSUTENT1SYLVANTTABRECTA1PAROXYSMAL ONURIAKUVAN1PALYNZIQ1TECENTRIQ1TEMODAR (ORAL)temozolomideTEPADINA1PRE-TERM BIRTHhydroxyprogesterone caproMAKENATRACLEERtreprostinil sodiumTYVASOUPTRAVI1VELETRIVENTAVIS1PULMONARY DISORDERS OTHERESBRIETOFEV1RARE DISORDERS - OTHERCRYSVITA1GAMIFANT1PSORIASISCOSENTYX1RENAL DISEASEcinacalcet RIENT1STELARA1XALKORI1TALTZ1RHEUMATOID 1PULMONARY PIRATORY F11ADCIRCAADEMPAS1alyqzoledronic acid A11KEVZARA1ORENITRAM1REMODULIN1REVATIO1sildenafil ANZ1SEIZURE DISORDERSHP ACTHAR GELEPIDIOLEX1SABRIL1vigabatrin1SICKLE CELL DISEASEMedications on the PrudentRx specialty drug list may change at any time, with or without notice. Your plan may not cover certain medications even though they appear on thePrudentRx drug list. Copayments for the medications on this list, whether made by your plan or a manufacturer’s copay assistance program, will not count toward your plan deductible.1- Member cost share payments for these medications, whether made by you, your plan or a manufacturer copay assistance program, do not count towards the plan’s out-of-pocketmaximum.
ADAKVEO1OXBRYTA1SLEEP DISORDERWAKIX1SYSTEMIC T1MULPLETA1NPLATE1PROMACTA1UREA CYCLE DISORDERSBUPHENYL1RAVICTI1sodium phenylbutyrate1Medications on the PrudentRx specialty drug list may change at any time, with or without notice. Your plan may not cover certain medications even though they appear on thePrudentRx drug list. Copayments for the medications on this list, whether made by your plan or a manufacturer’s copay assistance program, will not count toward your plan deductible.1- Member cost share payments for these medications, whether made by you, your plan or a manufacturer copay assistance program, do not count towards the plan’s out-of-pocketmaximum.
Copayments for the medications on this list, whether made by your plan or a manufacturer’s copay assistance program, will not count toward your plan deductible. 1- Member cost share payments for these medications, whether made by you, your plan or a manufacturer copay assistance progra
