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Medications Excluded from Emergency Fill

Abraxane
Actemra
Actimmune
Adagen
Adcetris
Adcirca
Adefovir Dipivoxil
Adriamycin
Adrucil
Afinitor
Aldurazyme
Alimta
Amevive
Ampyra
Apokyn
Aralast
Aralast NP
Aranesp (Albumin Free)
Arcalyst
Aredia
Arixtra
Aromasin
Arranon
Arzerra
Atgam
Avastin
Avonex
Avonex Pen
Avonex Prefilled
AzaCITIDine

Baraclude
Betaseron
Bexarotene
Bexxar
Bicalutamide
BiCNU
Bleomycin Sulfate
Boniva
Bosulif
Busulfex

Campath
Camptosar
Capecitabine
Caprelsa
Carbaglu
CARBOplatin
Carimune NF
Casodex
Cayston
CeeNU
Cerezyme
Cerubidine
Chloramphenicol Sod Succinate
Cholbam
Chorionic Gonadotropin
Cimzia
Cimzia Prefilled
Cimzia Starter Kit
CISplatin
Clolar
Cometriq (100 mg Daily Dose)
Cometriq (140 mg Daily Dose)
Cometriq (60 mg Daily Dose)
Copaxone
Cosmegen
Cyclophosphamide
Cystadane
Cytarabine
Cytarabine (PF)

Dacarbazine
Dacogen
DACTINomycin
DAUNOrubicin HCl
DaunoXome
Decitabine
DepoCyt
Docefrez
DOCEtaxel
Doxil
DOXOrubicin HCl
DOXOrubicin HCl Liposomal

Elaprase
Elelyso
Eligard
Ellence
Eloxatin
Elspar
Enbrel
Enbrel SureClick
Entecavir
Epirubicin HCl
Epogen
Erbitux
Erivedge
Erwinaze
Etopophos
Etoposide
Exjade
Extavia

Fabrazyme
Faslodex
Firmagon
Floxuridine
Fludara
Fludarabine Phosphate
Fluorouracil
Flutamide
Folotyn
Fondaparinux Sodium
Forteo
Fragmin
Fuzeon

Gammagard
Gammagard S/D
Gammagard S/D Less IgA
Gammaked
Gamunex-C
Gemcitabine HCl
Gemzar
Genotropin
Genotropin MiniQuick
Gilenya
Glatopa
Gleevec
Gleostine

Halaven
Harvoni
Hepsera
Herceptin
Hexalen
Hizentra
Hizentra 20%
Humatrope
Humira
Humira Pediatric Crohns Start
Humira Pen
Humira Pen-Crohns Starter
Humira Pen-Psoriasis Starter
Hycamtin

Ibandronate Sodium
Idamycin PFS
IDArubicin HCl
Ifex
Ifosfamide
Ifosfamide-Mesna
Imatinib Mesylate
Increlex
Infergen
Inlyta
Intron A
Irinotecan HCl
Istodax
Ixempra Kit

Jadenu
Jakafi
Jevtana

Kalydeco
Kepivance
Kineret
Kitabis Pak
Kuvan
Kyprolis

Letairis
Leukeran
Leukine
Leuprolide Acetate
Leustatin
Lipodox
Lipodox 50
Lomustine
Lumizyme
Lupron Depot
Lupron Depot-Ped
Lysodren

Matulane
Mitomycin
Mitoxantrone HCl
Mozobil
Mustargen
Myleran
Myozyme

Naglazyme
Navelbine
Neulasta
Neulasta Onpro
Neupogen
NexAVAR
Ninlaro
Nipent
Norditropin
Norditropin FlexPro
Norditropin NordiFlex Pen
Novarel
Nplate
Nulojix
Nutropin
Nutropin AQ
Nutropin AQ NuSpin 10
Nutropin AQ Pen

Octreotide Acetate
Oforta
Omnitrope
Oncaspar
Ontak
Orencia
Orfadin
Oxaliplatin

PACLitaxel
Pamidronate Disodium
Pegasys
Pegasys ProClick
PegIntron
Peg-Intron
Peg-Intron Redipen
Peg-Intron Redipen Pak 4
Pentostatin
Perjeta
Photofrin
Pregnyl
Procrit
Prolastin
Prolastin-C
Proleukin
Prolia
Promacta
Pulmozyme

Rebetol
Rebif
Rebif Rebidose
Rebif Rebidose Titration Pack
Rebif Titration Pack
Reclast
Remicade
Remodulin
Revlimid
Rheumatrex
Rituxan

Sabril
Saizen
Saizen Click.Easy
Samsca
SandoSTATIN
Sensipar
Serostim
Sildenafil Citrate
Simponi
Somatuline Depot
Somavert
Sovaldi
Sprycel
Stelara
Stimate
Stivarga
Sutent
Sylatron
Synarel
Synribo
Syprine

Tabloid
Tarceva
Targretin
Tasigna
Taxotere
Temodar
Temozolomide
Teniposide
Tetrabenazine
Tev-Tropin
Thalomid
Thiotepa
Thymoglobulin
Tobi
Tobramycin
Tobramycin Pak
Toposar
Topotecan HCl
Torisel
Treanda
Trelstar
Trelstar Depot Mixject
Trelstar LA Mixject
Trelstar Mixject
Trexall
Trisenox
Tykerb
Tysabri
Tyzeka

Uvadex

Valstar
Vandetanib
Vectibix
Velcade
Ventavis
Victrelis
Vidaza
VinBLAStine Sulfate
Vincasar PFS
VinCRIStine Sulfate
Vinorelbine Tartrate
Voraxaze
Votrient
Vpriv
Vumon

Xalkori
Xeljanz
Xeloda
Xenazine
Xgeva
Xolair
Xtandi
Xyrem

Yervoy

Zaltrap
Zanosar
Zavesca
Zelboraf
Zemaira
Zoladex
Zoledronic Acid
Zolinza
Zomacton
Zometa
Zorbtive
Zortress
Zytiga

Pursuant to section WAC 284-170-470:

a) The authorized amount of the emergency fill will be no more than the prescribed amount up to a seven day supply or the minimum packaging size available at the time the emergency fill is dispensed

b) An emergency fill medication does not necessarily constitute a covered health service. Determination as to whether this is a covered health service under the patient benefit will be made as part of the prior authorization processsing.