List of Designated High-Cost Drugs

For details on the High-Cost Drug policy, see Section 5.8 of the PharmaCare Policy Manual.

Page last updated: August 20, 2020

An asterisk (*) indicates the most recent addition(s) to the current list.

Current List

Deletions are listed at the end of this document.

Current list of high-cost drugs

DIN/PIN

Chemical Description

Product Name

Allowable Markup

Effective Date

02402475

abatacept subcutaneous 125 mg/mL pre-filled syringe

Orencia®

5%

Apr 1, 2014

02282097

abatacept 250 mg vial

Orencia®

5%

Apr 1, 2011

02258595

adalimumab 40 mg/0.8 mL kit

Humira®

5%

Apr 1, 2011

02418320

alemtuzumab 10 mg/mL (1.2 mL) concentrated solution for IV infusion

Lemtrada®

5%

Apr 12, 2018

02204606

alpha 1-proteinase inhibitor 1000 mg vial

Prolastin-C®

5%

Apr 1, 2011

02307065

ambrisentan 5 mg tablet

Volibris®

5%

Apr 2, 2012

02307073

ambrisentan 10 mg tablet

Volibris®

5%

Apr 2, 2012

02245913

anakinra 100 mg/0.67 mL syringe

Kineret®

5%

Apr 1, 2011

02452294

asunapravir

Sunpreva™

2%

Mar 21, 2017

02329840

aztreonam 75 mg/vial powder for solution

Cayston™

5%

Sep 13, 2012

02131064

baclofen 2 mg/mL ampule

Lioresal®

5%

Apr 1, 2011

02473232

benralizumab 30 mg/mL in 1 mL syringe

Fasenra®

5%

Apr 1, 2020

02244981

bosentan 62.5 mg tablet

Tracleer®

5%

Apr 1, 2011

02244982

bosentan 125 mg tablet

Tracleer®

5%

Apr 1, 2011

01981501

botulinum toxin 50/100/200 unit vial

Botox®

5%

Apr 1, 2011

02324032

botulinum toxin 100 unit vial

Xeomin®

5%

Apr 1, 2011

02266121

cannabidiol/tetrahydrocannabinol 2.5 mg/2.7 mg per mL spray

Sativex®

5%

Apr 2, 2012

02465574

certolizumab pegol 200 mg/mL auto-injector pre-filled pen

Cimzia®

5%

Feb 1, 2018

02331675

certolizumab pegol 400 mg/2 mL syringe kit

Cimzia®

5%

Apr 1, 2011

02244849

colistimethate sodium 150 mg vial

Colistimethate®

5%

Apr 1, 2011

00476420

colistimethate sodium 150 mg vial

Coly-Mycin®

5%

Apr 1, 2015

02452219

deferasirox 90 mg tablet

Jadenu®

5%

Oct 26, 2017

02452227

deferasirox 180 mg tablet

Jadenu®

5%

Oct 26, 2017

02452235

deferasirox 360 mg tablet

Jadenu®

5%

Oct 26, 2017

02287447

deferasirox 500 mg tablet for suspension

Exjade®

5%

Apr 1, 2011

02436558

deferiprone 1000 mg tablet

Ferriprox®

5%

Jan 18, 2017

02436523

deferiprone 100 mg/mL oral solution

Ferriprox®

5%

Jan 18, 2017

02404508

dimethyl fumarate 120 mg capsule

Tecfidera®

5%

Dec 15, 2014

02420201

dimethyl fumarate 240 mg capsule

Tecfidera®

5%

Dec 15, 2014

02475472

edaravone 30 mg/100 mL solution for intravenous use

Radicava™

0%

Aug 19, 2020

02451131

elbasvir-grazoprevir

Zepatier™

2%

Mar 21, 2017

02397447

epoprostenol sodium (arginine) 0.5 mg vial

Caripul

5%

Dec 22, 2014

02397455

epoprostenol sodium (arginine) 1.5 mg vial

Caripul

5%

Dec 22, 2014

02230848

epoprostenol sodium 1.5 mg vial

Flolan®

5%

Apr 1, 2011

02242903

etanercept 25 mg kit

Enbrel®

5%

Apr 1, 2011

02274728

etanercept 50 mg/mL syringe

Enbrel®

5%

Apr 1, 2011

01968017

filgrastim 300 mcg/mL vial

Neupogen®

5%

Apr 1, 2011

02365480

fingolimod 0.5 mg capsule

Gilenya®

5%

Jun 13, 2013

02245619

glatiramer acetate 20 mg kit

Copaxone®

5%

Apr 1, 2011

02467550

glecaprevir-pibrentasvir 100mg-40 mg tablet

Maviret™

2%

Mar 21, 2019

02453304

glycerol phenylbutyrate 1.1 g/mL oral liquid

Ravicti™

5%

Apr 12, 2018

02324776

golimumab 50 mg/0.5 mL pre-filled syringe

Simponi®

5%

Apr 1, 2011

02324784

golimumab 50 mg/0.5 mL auto-injector

Simponi®

5%

Apr 1, 2011

02146118

hydromorphone 20 mg/mL vial

Dilaudid-HP-Plus®

5%

Apr 1, 2011

02145936

hydromorphone 20 mg/mL vial

Hydromorphone HP 20®

5%

Apr 2, 2012

02145863

hydromorphone 50 mg/mL vial

Dilaudid-XP®

5%

Apr 2, 2012

02146126

hydromorphone 50 mg/mL vial

Hydromorphone HP 50®

5%

Apr 1, 2011

02241751

imiglucerase 400 unit vial

Cerezyme®

5%

Apr 1, 2011

02371081

incobotulinumtoxinA (also known as
clostridium botulinum toxin Type A) 50 unit vial

Xeomin®

5%

Apr 1, 2014

02419475

infliximab 100 mg vial

Inflectra™

5%

Apr 1, 2016

02470373

infliximab 100 mg vial

Renflexis™

5%

Nov 3, 2018

02244016

infliximab 100 mg vial

Remicade®

5%

Apr 1, 2011

02237770

interferon beta-1a  30 mcg /mL kit

Avonex®

5%

Apr 2, 2012

02269201

interferon beta-1a  30 mcg /0.5 mL kit

Avonex® PS

5%

Apr 1, 2011

02281708

interferon beta-1a 8.8 mcg/0.2 mL - 22 mcg/0.5 mL syringe initiation pack

Rebif®

5%

Apr 2, 2012

02237319

interferon beta-1a 22 mcg/0.5 mL syringe

Rebif®

5%

Apr 1, 2011

02237320

interferon beta-1a 44 mcg/0.5 mL syringe

Rebif®

5%

Apr 1, 2011

02318253

interferon beta-1a 66 mcg/1.5 mL cartridge

Rebif®

5%

Apr 1, 2011

02318261

interferon beta-1a 132 mcg/1.5 mL cartridge

Rebif®

5%

Apr 1, 2011

02169649

interferon beta-1b 0.3 mg vial

Betaseron®

5%

Apr 1, 2011

02337819

interferon beta-1b 0.3 mg vial

Extavia®

5%

Apr 1, 2011

02455102

ixekizumab 80 mg/mL autoinjector

Taltz™

5%

Mar 6, 2018

02455110

ixekizumab 80 mg/mL pre-filled syringe

Taltz™

5%

Mar 6, 2018

02432226

ledipasvir/sofosbuvir 90 mg-400 mg tablet

Harvoni®

2%

Mar 1, 2017

02292165

levodopa/carbidopa intestinal gel 20 mg/mL – 5 mg/mL

Duodopa®

5%

Aug 24, 2017

02449781

mepolizumab 100 mg/mL vial of lyophilized powder for subcutaneous injection

Nucala

5%

Nov 13, 2018

02492989

mepolizumab 100 mg/mL pre-filled autoinjector

Nucala

5%

May 26, 2020

02492997

mepolizumab 100 mg/mL pre-filled safety syringe

Nucala

5%

May 26, 2020

02286386

natalizumab 300 mg/15 mL vial

Tysabri®

5%

Apr 2, 2012

02325926

nimodipine 30 mg tablet

Nimotop®

5%

Apr 2, 2012

02443066

nintedanib 100 mg tablet

Ofev™

5%

Apr 12, 2018

02443074

nintedanib 150 mg tablet

Ofev™

5%

Apr 12, 2018

02463121

obeticholic acid 5 mg tablet

Ocaliva

5%

Oct 30, 2018

02463148

obeticholic acid 10 mg tablet

Ocaliva

5%

Oct 30, 2018

02467224

ocrelizumab 30 mg/mL solution for intravenous use (10 mL vial)

Ocrevus®

5%

Aug 10, 2020

00839205

octreotide acetate 100 mcg/mL ampule

Sandostatin®

5%

Apr 1, 2011

02260565

omalizumab 150 mg vial

Xolair®

5%

Apr 1, 2011

02393751

pirfenidone 267 mg capsule

Esbriet®

5%

Apr 12, 2018

02464500

pirfenidone 801 mg tablet

Esbriet®

5%

Apr 12, 2018

02464489

pirfenidone 267 mg tablet

Esbriet®

5%

Apr 12, 2018

02487454

risankizumab 75 mg/0.83 mL pre-filled syringe

Skyrizi®

5%

May 5, 2020

02241927

rituximab 10 mg/mL vial

Rituxan®

5%

Apr 1, 2011

02322854

romiplostim 250 mcg/0.5 mL powder

Nplate®

5%

Apr 2, 2012

02322862

romiplostim 500 mcg/mL powder

Nplate®

5%

Apr 2, 2012

02350580

sapropterin

For tetrahydrobiopterin (BH4) deficiency only.

Kuvan®

5%

Oct 16, 2012

02460521*

sarilumab 150 mg/1.14 mL pre-filled syringe

Kevzara®

5%

June 30, 2020

02472961*

sarilumab 150 mg/1.14 mL pre-filled pen

Kevzara®

5%

June 30, 2020

02460548*

sarilumab 200 mg/1.14 mL pre-filled syringe

Kevzara®

5%

June 30, 2020

02472988*

sarilumab 200 mg/1.14 mL pre-filled pen

Kevzara®

5%

June 30, 2020

02438070

secukinumab 150 mg/mL solution for injection

Cosentyx®

5%

Nov 10, 2016

02451158

selexipag 200 mcg tablet

Uptravi®

5%

Oct 30, 2018

02451166

selexipag 400 mcg tablet

Uptravi®

5%

Oct 30, 2018

02451174

selexipag 600 mcg tablet

Uptravi®

5%

Oct 30, 2018

02451182

selexipag 800 mcg tablet

Uptravi®

5%

Oct 30, 2018

02451190

selexipag 1000 mcg tablet

Uptravi®

5%

Oct 30, 2018

02451204

selexipag 1200 mcg tablet

Uptravi®

5%

Oct 30, 2018

02451212

selexipag 1400 mcg tablet

Uptravi®

5%

Oct 30, 2018

02451220

selexipag 1600 mcg tablet

Uptravi®

5%

Oct 30, 2018

02416441

simeprevir sodium 150 mg capsule

Galexos™

2%

Mar 1, 2017

02436663

sodium phenylbutyrate 483 mg/g oral granules

Pheburane®

5%

Apr 12, 2018

02418355

sofosbuvir 400 mg tablet

Sovaldi®

2%

Mar 1, 2017

02456370

sofosbuvir-velpatasvir

Epclusa™

2%

Mar 21, 2017

02467542

sofosbuvir-velpatasvir-voxilaprevir

400-100-100 mg tablet

Vosevi™

2%

May 25, 2018

02399091

somatropin 5 mg/2 mL cartridge

Nutropin AQ Nuspin 5

5%

Dec 22, 2014

02243078

somatropin 12 mg cartridge

Humatrope®

5%

Apr 1, 2011

02243079

somatropin 24 mg cartridge

Humatrope®

5%

Apr 1, 2011

02334852

somatropin  5 mg/1.5mL pen

Norditropin Nordiflex®

5%

Nov 10, 2016

02334860

somatropin 10 mg/1.5mL pen

Norditropin Nordiflex®

5%

Nov 10, 2016

02334879

somatropin 15 mg/1.5mL pen

Norditropin Nordiflex®

5%

Nov 10, 2016

02376393

somatropin 10 mg/2 mL cartridge

Nutropin® AQ NuSpin

5%

Dec 18, 2012

02350149

somatropin 20 mg/2 mL cartridge

Saizen®

5%

Apr 2, 2012

02399083

somatropin 20 mg/2 mL cartridge

Nutropin® AQ Nuspin 20

5%

Dec 22, 2014

02237971

somatropin 5 mg vial

Saizen®

5%

Apr 1, 2011

02416328

teriflunomide 14 mg tablet

Aubagio®

5%

Mar 2, 2015

02365154

tobramycin 28 mg capsule

Tobi® Podhaler®

5%

Sep 13, 2012

02239630

tobramycin sulphate 300 mg/5 mL solution for inhalation

Tobi®

5%

Sep 13, 2012

02424770

tocilizumab 162mg/0.9 mL pre-filled syringe

Actemra®

5%

July 1, 2016

02350092

tocilizumab 80 mg/4 mL vial

Actemra®

5%

Aug 9, 2011

02350106

tocilizumab 200 mg/10 mL vial

Actemra®

5%

Aug 9, 2011

02350114

tocilizumab 400 mg/20 mL vial

Actemra®

5%

Aug 9, 2011

02423898

tofacitinib 5 mg tablet

Xeljanz®

5%

Apr 2, 2017

02246552

treprostinil sodium 1 mg/mL vial

Remodulin®

5%

Apr 1, 2011

02246553

treprostinil sodium 2.5 mg/mL vial

Remodulin®

5%

Apr 2, 2012

02246554

treprostinil sodium 5 mg/mL vial

Remodulin®

5%

Apr 1, 2011

02246555

treprostinil sodium 10 mg/mL vial

Remodulin®

5%

Apr 1, 2011

02320673

ustekinumab 45 mg/0.5 mL vial

Stelara®

5%

Apr 1, 2011

02320681

ustekinumab 90 mg/1 mL vial

Stelara®

5%

Jun 20, 2013

02436841

vedolizumab 300 mg vial

Entyvio®

5%

Aug 24, 2017

66123781

sodium phenyl butyrate powder

Note: unclassed therapeutic non-benefits (SAP)

Buphenyl®

5%

Apr 1, 2011

Deletions

List of deletions

DIN/PIN

Chemical Description

Product Name

Effective Date of Deletion

02370816

boceprevir 200 mg capsule

Victrelis™

Apr 6, 2016

02371448

boceprevir/ribavirin/Peg-IFN-alfa-2b

200 mg/200 mg/80 mcg pen injection kit

Victrelis Triple™

Apr 6, 2016

02371456

boceprevir/ribavirin/Peg-IFN-alfa-2b

200 mg/200 mg/100 mcg pen injection kit

Victrelis Triple™

Apr 6, 2016

02371464

boceprevir/ribavirin/Peg-IFN-alfa-2b

200 mg/200 mg/120 mcg pen injection kit

Victrelis Triple™

Apr 6, 2016

02371472

boceprevir/ribavirin/Peg-IFN-alfa-2b

200 mg/200 mg/150 mcg pen injection kit

Victrelis Triple™

Apr 6, 2016

02386194

bosentan 62.5 mg tablet

Co Bosentan

Apr 1, 2015

02444747

daclatasvir 30 mg tablet

Daklinza™

July 29, 2020

02444755

daclatasvir 60 mg tablet

Daklinza™

July 29, 2020

02455323

etanercept 50 mg/mL syringe

Brenzys®

May 1, 2018

02455331

etanercept 50 mg/mL pen injector

Brenzys®

May 1, 2018

02436027

ombitasvir-paritaprevir-ritonavir and dasabuvir 12.5 mg/75 mg/50 mg and 250 mg tablet

HOLKIRA™ PAK

Mar 21, 2017

02216191

somatropin, kit: 10 mg vial (powder) + 10 mL vial (liquid)

Nutropin®

June 30, 2020

02229722

somatropin 10 mg/2 mL vial

Nutropin® AQ

June 30, 2020

02230694

imiglucerase 200 unit vial

Cerezyme®

June 30, 2020

02240694

interferon alfa-2b 30 million IU recombinant pen injection kit

Intron A®

June 30, 2020

02240695

interferon alfa-2b 60 million IU recombinant pen injection kit

Intron A®

June 30, 2020

02246026

ribavirin/PegIFN-alpha-2b, 200 mg cap/50 mcg/0.5 mL combination pkg

Pegetron®

June 30, 2020

02246027

ribavirin/PegIFN-alpha-2b, 200 mg cap/80 mcg/0.5 mL combination pkg

Pegetron®

June 30, 2020

02246028

ribavirin/PegIFN-alpha-2b, 200 mg cap/100 mcg/0.5 mL combination pkg

Pegetron®

June 30, 2020

02246029

ribavirin/PegIFN-alpha-2b, 200 mg cap/120 mcg/0.5 mL combination pkg

Pegetron®

June 30, 2020

02246030

ribavirin/PegIFN-alpha-2b, 200 mg cap/150 mcg/0.5 mL combination pkg

Pegetron®

June 30, 2020

02249002

somatropin 10 mg/2 mL cartridge

Nutropin®

June 30, 2020

02253410

ribavirin/PegIFN-alpha-2a, 200 mg tablet and 180 mcg/mL combination pkg

Pegasys® RBV

June 30, 2020

02253429

ribavirin/PegIFN-alpha-2a, 200 mg tablet/180 mcg/0.5 mL combination pkg

Pegasys® RBV

June 30, 2020

02254581

ribavirin/PegIFN-alpha-2b, 200 mg cap/80 mcg/0.5 mL pen injection kit

Pegetron®

June 30, 2020

02254603

ribavirin/PegIFN-alpha-2b, 200 mg cap/100 mcg/0.5 mL pen injection kit

Pegetron®

June 30, 2020

02254638

ribavirin/PegIFN-alpha-2b, 200 mg cap/120 mcg/0.5 mL pen injection kit

Pegetron®

June 30, 2020

02254646

ribavirin/PegIFN-alpha-2b, 200 mg cap/150 mcg /0.5 mL pen injection kit

Pegetron®

June 30, 2020

02272083

somatropin 8.8 mg vial

Saizen®

June 30, 2020