Site of Care List (Commercial) – Effective 10/1/17 1

Site of Care October 2017

The Site of Care drug program identifies members who are receiving certain specialty drugs at a higher cost site of service (i.e., hospital outpatient setting) and requires them to move to an equally appropriate, alternative site of service (infusion center or home). The drugs on this list are the only drugs that are part of the program and only certain members are identified for the program based on where they are currently receiving their specialty drug. This list may change or expand from time to time without prior notice.

Actemra Aldurazyme Aralast NP Benlysta Bivigam Carimune NF Cerezyme Cytogam

Elaprase Elelyso Entyvio Fabrazyme Flebogamma Gammagard Liquid Gammagard S/D Gammaked

Gammaplex Gamunex C Glassia Inflectra Krystexxa Lumizyme Naglazyme Ocrevus

Octagam Orencia (IV only) Privigen Prolastin-C Remicade Simponi Aria Soliris Stelara

Tysabri Vimizim VPRIV Zemaira

3/[Type  here]   [Type  here]   [Type  here]  

 

Rvs  3/13/2017             1           19199-­‐3-­‐2017    

3/[Type  here]   [Type  here]   [Type  here]  

 

Rvs  3/13/2017             2           19199-­‐3-­‐2017