UHA Medical Drug List

Transcription

1 for pricing information The following is a list of drugs that are covered under the medical benefit. The cost share may be dependent on the diagnosis and/or the dose prescribed by your physician. Customer Service at (Oahu) or (neighbor islands) for more information. Drug Name Cost indicator Requirements 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) PA 5% DEXTROSE/WATER (500 ML = 1 UNIT) Abraxane PA Actemra IV PA Actemra SC PA Actimmune PA Adcetris PA Adcirca PA Adempas PA Adrucil PA Alimta PA Alkeran PA Amifostine PA AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SIN Ampyra PA ANTI INHIBITOR, PER I.U. ANTITHROMBIN III (HUMAN), PER I.U. PA Aralast NP PA Aranesp PA Arcalyst PA Arranon PA Arzerra PA Aubagio PA Avastin PA Avonex PA Azacitidine PA AZATHIOPRINE, PARENTERAL, 100 MG PA BACILLUS CALMETTE GUERIN VACCINE (BCG) FOR TUBERCULOSIS, LIV $0 PA BCG (INTRAVESICAL) PER INSTILLATION PA Beleodaq PA Bendeka PA Berinert PA 1

2 for pricing information Betaseron PA Bicnu PA Bivigam PA Bleomycin Sulfate PA Blincyto PA Boniva PA Botox PA BOTULINUM ANTITOXIN, EQUINE, ANY ROUTE BOTULISM IMMUNE GLOBULIN, HUMAN, FOR INTRAVENOUS USE Busulfex PA Calcium Folinate PA Camptosar PA Capecitabine PA Carboplatin PA Carimune NF PA Cimzia PA Cinryze PA Cisplatin PA Cladribine PA Clolar PA CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACH Copaxone PA Copegus PA Cosentyx PA Cosmegen PA Cyclophosphamide PA CYCLOPHOSPHAMIDE, 100 MG CYCLOSPORIN, PARENTERAL, 250 MG Cyramza PA Cytarabine PA CYTOMEGALOVIRUS IMMUNE GLOBULIN (CMV IGIV), HUMAN, FOR INTRA Dacarbazine PA DACARBAZINE, 100 MG DACLIZUMAB, PARENTERAL, 25 MG Dacogen PA Daklinza PA Darzalex PA 2

3 for pricing information Daunorubicin HCl PA Daunoxome PA Decitabine PA Delatestryl PA Depo Testosterone PA Depocyst PA Dexrazoxane PA DIPHTHERIA AND TETANUS TOXOIDS ADSORBED (DT) WHEN ADMINISTER $0 DIPHTHERIA ANTITOXIN, EQUINE, ANY ROUTE DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND $0 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HA $0 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HE $0 DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE $0 Docefrez PA Docetaxel PA Doxil PA Doxorubicin HCl PA DRUG ADMINISTERED THROUGH A METERED DOSE INHALER Dysport PA EDETATE DISODIUM, PER 150 MG Egrifta PA Eligard PA Elitek PA Ellence PA Empliciti PA Enbrel PA Entyvio PA Epirubicin HCl PA Epogen PA Epoprostenol Sodium PA Erbitux PA Erbitux PA Erwinaze PA Esbriet PA 3

4 for pricing information ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLA Etopophos PA Etoposide PA Euflexxa PA Extavia PA Eylea PA FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON RECOMBINANT) $$$$$ FACTOR IX, COMPLEX, PER I.U. FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICR 4 FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U. PA FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. PA FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., N $$$$$ Faslodex PA Firazyr PA Firmagon PA Flebogamma DIF PA Flolan PA Floxuridine PA Fludarabine Phosphate PA FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT Fluorouracil PA Folotyn PA Forteo PA Fusilev PA Gammagard Liquid PA Gammagard S/D PA Gammaked PA Gammaplex PA Gamunex C PA GANCICLOVIR, 4.5 MG, LONG ACTING IMPLANT PA Gazyva PA Gel One PA Gemcitabine HCl PA Gemzar PA Genotropin PA GenVisc PA

5 for pricing information Gilenya PA Glassia PA Glatopa PA GOSERELIN ACETATE IMPLANT, PER 3.6 MG PA Granix PA Grastek PA HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP OMP CONJUGA $0 PA HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP T CONJUGATE $0 PA Halaven PA Harvoni PA HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED PA HEPATITIS A AND HEPATITIS B VACCINE (HEPA HEPB), ADULT DOSAG $0 PA HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR PA HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE 2 DO $0 PA HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE 3 DO $0 PA HEPATITIS B AND HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB H $0 PA HEPATITIS B IMMUNE GLOBULIN (HBIG), HUMAN, FOR INTRAMUSCULAR PA HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR $0 PA HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, F $0 PA HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPPRESSED PAT $0 PA HEPATITIS B VACCINE (HEPB), DIALYSIS OR IMMUNOSUPPRESSED PAT $0 PA HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 D $0 PA Herceptin PA Hetlioz PA Hizentra PA HP Acthar PA Humatrope PA Humira PA Hyalgan PA HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA ARTICULAR INJE HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA ARTI 5

6 for pricing information HYALURONAN OR DERIVATIVE, MONOVISC, FOR INTRA ARTICULAR INJE HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA ARTICULAR INJ PA HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC ONE, FOR INTRA PA Hycamtin PA HyQvia PA Idamycin PFS PA Idarubicin HCl PA Ifex PA Ifosfamide PA Ilaris PA Imlygic PA IMMUNE GLOBULIN (IG), HUMAN, FOR INTRAMUSCULAR USE PA IMMUNE GLOBULIN (IGIV), HUMAN, FOR INTRAVENOUS USE IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED 6 Increlex PA INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTED, F $0 INFLUENZA VIRUS VACCINE (IIV), PANDEMIC FORMULATION, SPLIT V $0 INFLUENZA VIRUS VACCINE (IIV), PANDEMIC FORMULATION, SPLIT V $0 INFLUENZA VIRUS VACCINE (IIV), PANDEMIC FORMULATION, SPLIT V $0 INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FRE $0 PA INFLUENZA VIRUS VACCINE, LIVE (LAIV), PANDEMIC FORMULATION, $0 PA INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0 $0 PA INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0 $0 PA INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, P $0 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, P $0 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, P $0 INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LAIV4), FOR INT $0 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO I $0 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO I $0 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO I $0 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO I $0 INFLUENZA VIRUS VACCINE, TRIVALENT (CCIIV3), DERIVED FROM CE INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 $0 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 $0 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRES $0 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRES $0

7 for pricing information INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRES $0 INFLUENZA VIRUS VACCINE, TRIVALENT (RIV3), DERIVED FROM RECO $0 INFLUENZA VIRUS VACCINE, TRIVALENT, LIVE (LAIV3), FOR INTRAN $0 INFUSION, D5W, 1000 CC INFUSION, DEXTRAN 40, 500 ML INFUSION, DEXTRAN 75, 500 ML PA INFUSION, NORMAL SALINE SOLUTION, 1000 CC INFUSION, NORMAL SALINE SOLUTION, 250 CC INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT) INJECTION ABCIXIMAB, 10 MG INJECTION FLUCONAZOLE, 200 MG INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING $0 PA INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING PA INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING PA INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING INJECTION, ABATACEPT, 10 MG (CODE MAY BE USED FOR MEDICARE W PA INJECTION, ABOBOTULINUMTOXINA, 5 UNITS PA INJECTION, ACETAMINOPHEN, 10 MG PA INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG PA INJECTION, ACYCLOVIR, 5 MG INJECTION, ADALIMUMAB, 20 MG INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADE PA INJECTION, ADO TRASTUZUMAB EMTANSINE, 1 MG $$$$$ INJECTION, ADRENALIN, EPINEPHRINE, 0.1 MG PA INJECTION, AFLIBERCEPT, 1 MG PA INJECTION, AGALSIDASE BETA, 1 MG PA INJECTION, ALATROFLOXACIN MESYLATE, 100 MG INJECTION, ALEFACEPT, 0.5 MG INJECTION, ALEMTUZUMAB, 1 MG INJECTION, ALGLUCERASE, PER 10 UNITS INJECTION, ALGLUCOSIDASE ALFA, (LUMIZYME), 10 MG INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), PA 7

8 for pricing information INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), NOT OTHERWI PA INJECTION, ALTEPLASE RECOMBINANT, 1 MG PA INJECTION, AMIFOSTINE, 500 MG PA INJECTION, AMINOPHYLLIN, UP TO 250 MG PA INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG PA INJECTION, AMOBARBITAL, UP TO 125 MG INJECTION, AMPHOTERICIN B, 50 MG INJECTION, AMPICILLIN SODIUM, 500 MG INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM 8 INJECTION, ANISTREPLASE, PER 30 UNITS PA INJECTION, ARBUTAMINE HCL, 1 MG INJECTION, ARIPIPRAZOLE, EXTENDED RELEASE, 1 MG INJECTION, ATROPINE SULFATE, 0.01 MG INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG INJECTION, AZACITIDINE, 1 MG INJECTION, AZITHROMYCIN, 500 MG PA INJECTION, BACLOFEN, 10 MG PA INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL INJECTION, BELATACEPT, 1 MG INJECTION, BELIMUMAB, 10 MG INJECTION, BENDAMUSTINE HCL (TREANDA), 1 MG INJECTION, BENZTROPINE MESYLATE, PER 1 MG INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODI INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, INJECTION, BEVACIZUMAB, 10 MG INJECTION, BIPERIDEN LACTATE, PER 5 MG PA INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BORTEZOMIB, 0.1 MG INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG INJECTION, BUPIVICAINE HYDROCHLORIDE, 30 ML PA INJECTION, BUTORPHANOL TARTRATE, 1 MG PA INJECTION, C 1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNIT PA INJECTION, C 1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS PA INJECTION, C1 ESTERASE INHIBITOR (RECOMBINANT), RUCONEST, 10 PA INJECTION, CALCITONIN SALMON, UP TO 400 UNITS PA INJECTION, CALCIUM GLUCONATE, PER 10 ML PA

9 for pricing information INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER INJECTION, CANAKINUMAB, 1 MG INJECTION, CARBOPLATIN, 50 MG 9 INJECTION, CARFILZOMIB, 1 MG PA INJECTION, CEFAZOLIN SODIUM, 500 MG PA INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG INJECTION, CEFOTAXIME SODIUM, PER GM $0 PA INJECTION, CEFOXITIN SODIUM, 1 GM PA INJECTION, CEFTAROLINE FOSAMIL, 10 MG PA INJECTION, CEFTAZIDIME, PER 500 MG INJECTION, CEFTIZOXIME SODIUM, PER 500 MG INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, CEPHALOTHIN SODIUM, UP TO 1 GRAM INJECTION, CEPHAPIRIN SODIUM, UP TO 1 GM INJECTION, CERTOLIZUMAB PEGOL, 1 MG (CODE MAY BE USED FOR ME INJECTION, CETUXIMAB, 10 MG PA INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM PA INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML INJECTION, CHLOROQUINE HYDROCHLORIDE, UP TO 250 MG INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS INJECTION, CIDOFOVIR, 375 MG INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG $0 INJECTION, CIMETIDINE HYDROCHLORIDE, 300 MG INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG PA INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG PA INJECTION, CLADRIBINE, PER 1 MG $0 PA INJECTION, CLINDAMYCIN PHOSPHATE, 300 MG INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG $$$$$ INJECTION, CORTICOTROPIN, UP TO 40 UNITS $$$$$ INJECTION, COSYNTROPIN (CORTROSYN), 0.25 MG INJECTION, CYTARABINE LIPOSOME, 10 MG

10 for pricing information INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMA PA INJECTION, DALBAVANCIN, 5 MG INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, DAPTOMYCIN, 1 MG INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYS 10 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON ESRD USE) PA INJECTION, DECITABINE, 1 MG PA INJECTION, DEFEROXAMINE MESYLATE, 500 MG PA INJECTION, DEGARELIX, 1 MG $0 INJECTION, DENOSUMAB, 1 MG INJECTION, DEPO ESTRADIOL CYPIONATE, UP TO 5 MG INJECTION, DEXAMETHASONE ACETATE, 1 MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MG INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG INJECTION, DIAZEPAM, UP TO 5 MG PA INJECTION, DIAZOXIDE, UP TO 300 MG PA INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, DIGOXIN, UP TO 0.5 MG PA INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG PA INJECTION, DIMENHYDRINATE, UP TO 50 MG INJECTION, DIMERCAPROL, PER 100 MG PA INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG PA INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG INJECTION, DOCETAXEL, 1 MG INJECTION, DOLASETRON MESYLATE, 10 MG PA INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG PA INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWI INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML AMPUL PA INJECTION, DROPERIDOL, UP TO 5 MG PA INJECTION, DYPHYLLINE, UP TO 500 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG PA INJECTION, ELOSULFASE ALFA, 1 MG

11 for pricing information INJECTION, ENFUVIRTIDE, 1 MG PA INJECTION, ENOXAPARIN SODIUM, 10 MG PA INJECTION, EPOETIN ALFA, (FOR NON ESRD USE), 1000 UNITS PA INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR ESRD ON DIALYSIS) 11 INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR NON ESRD USE) PA INJECTION, EPOPROSTENOL, 0.5 MG PA INJECTION, EPTIFIBATIDE, 5 MG PA INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, ERTAPENEM SODIUM, 500 MG PA INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG $0 PA INJECTION, ESTRADIOL VALERATE, UP TO 10 MG PA INJECTION, ESTROGEN CONJUGATED, PER 25 MG INJECTION, ESTRONE, PER 1 MG INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE PA INJECTION, ETIDRONATE DISODIUM, PER 300 MG PA INJECTION, ETOPOSIDE, 10 MG PA INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PE PA INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PA INJECTION, FAMOTIDINE, 20 MG INJECTION, FENTANYL CITRATE, 0.1 MG PA INJECTION, FERRIC CARBOXYMALTOSE, 1 MG PA INJECTION, FERRIC PYROPHOSPHATE CITRATE SOLUTION, 0.1 MG OF INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANE INJECTION, FILGRASTIM (G CSF), BIOSIMILAR, 1 MICROGRAM INJECTION, FILGRASTIM (G CSF), EXCLUDES BIOSIMILARS, 1 MICRO INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT, 0.0 INJECTION, FLUOROURACIL, 500 MG INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG INJECTION, FONDAPARINUX SODIUM, 0.5 MG INJECTION, FOSAPREPITANT, 1 MG INJECTION, FOSCARNET SODIUM, PER 1000 MG INJECTION, FULVESTRANT, 25 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, GADOLINIUM BASED MAGNETIC RESONANCE CONTRAST AGEN INJECTION, GALSULFASE, 1 MG

12 for pricing information INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC PA INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC PA INJECTION, GANCICLOVIR SODIUM, 500 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG 12 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG PA INJECTION, GLATIRAMER ACETATE, 20 MG INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG PA INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE PA INJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCG PA INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNIT INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, HYALURONIDASE, UP TO 150 UNITS INJECTION, HYDRALAZINE HCL, UP TO 20 MG INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG PA INJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG PA INJECTION, HYDROMORPHONE, UP TO 4 MG PA INJECTION, HYDROXYPROGESTERONE CAPROATE, 1 MG INJECTION, HYDROXYZINE HCL, UP TO 25 MG INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG INJECTION, IBANDRONATE SODIUM, 1 MG INJECTION, IBUTILIDE FUMARATE, 1 MG INJECTION, IDURSULFASE, 1 MG INJECTION, IMIGLUCERASE, 10 UNITS PA INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG PA INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON LYOP PA INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG PA INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INT INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON LYOPHILI INJECTION, IMMUNE GLOBULIN, (GAMUNEX C/GAMMAKED), NON LYOPHI INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON LYOP

13 for pricing information INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G., INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG INJECTION, INSULIN, PER 5 UNITS INJECTION, INTERFERON ALFACON 1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON BETA 1A, 1 MCG FOR INTRAMUSCULAR USE $$$$$ INJECTION, INTERFERON BETA 1A, 1 MCG FOR SUBCUTANEOUS USE $0 PA INJECTION, INTERFERON BETA 1A, 30 MCG $$$$$ INJECTION, INTERFERON BETA 1B, 0.25 MG (CODE MAY BE USED FOR INJECTION, INTERFERON, ALFA 2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA 2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA N3, (HUMAN LEUKOCYTE DERIVED), 2 PA INJECTION, IPILIMUMAB, 1 MG $0 INJECTION, IRINOTECAN, 20 MG INJECTION, IRON DEXTRAN, 50 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, ITRACONAZOLE, 50 MG PA INJECTION, IV, UROKINASE, 250,000 I.U. VIAL INJECTION, IXABEPILONE, 1 MG $0 PA INJECTION, KANAMYCIN SULFATE, UP TO 500 MG PA INJECTION, KANAMYCIN SULFATE, UP TO 75 MG INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG PA INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3. PA INJECTION, LEVOCARNITINE, PER 1 GM INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG INJECTION, LINCOMYCIN HCL, UP TO 300 MG INJECTION, LORAZEPAM, 2 MG PA INJECTION, MAGNESIUM SULFATE, PER 500 MG INJECTION, MANNITOL, 25% IN 50 ML INJECTION, MECASERMIN, 1 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 1 MG PA INJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG PA INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML PA 13

14 for pricing information INJECTION, MEROPENEM, 100 MG PA INJECTION, METARAMINOL BITARTRATE, PER 10 MG PA INJECTION, METHADONE HCL, UP TO 10 MG INJECTION, METHOCARBAMOL, UP TO 10 ML INJECTION, METHYLDOPATE HCL, UP TO 250 MG INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, METHYLNALTREXONE, 0.1 MG INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG 14 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG PA INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MILRINONE LACTATE, 5 MG INJECTION, MORPHINE SULFATE, UP TO 10 MG INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG $0 INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG INJECTION, NALTREXONE, DEPOT FORM, 1 MG INJECTION, NANDROLONE DECANOATE, UP TO 50 MG INJECTION, NATALIZUMAB, 1 MG INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, NIVOLUMAB, 1 MG $$$$$ INJECTION, OCRIPLASMIN, MG PA INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTIO PA INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG INJECTION, OMALIZUMAB, 5 MG PA INJECTION, ONABOTULINUMTOXINA, 1 UNIT INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, OPRELVEKIN, 5 MG INJECTION, ORPHENADRINE CITRATE, UP TO 60 MG INJECTION, OXACILLIN SODIUM, UP TO 250 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, OXYMORPHONE HCL, UP TO 1 MG PA INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG PA INJECTION, OXYTOCIN, UP TO 10 UNITS

15 for pricing information INJECTION, PACLITAXEL PROTEIN BOUND PARTICLES, 1 MG INJECTION, PACLITAXEL, 1 MG INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, 1 MG INJECTION, PALONOSETRON HCL, 25 MCG 15 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG $0 PA INJECTION, PANITUMUMAB, 10 MG $$$$$ INJECTION, PANTOPRAZOLE SODIUM, 40 MG INJECTION, PAPAVERINE HCL, UP TO 60 MG $0 INJECTION, PEGAPTANIB SODIUM, 0.3 MG INJECTION, PEGFILGRASTIM, 6 MG PA INJECTION, PEGYLATED INTERFERON ALFA 2A, 180 MCG PER ML $0 PA INJECTION, PEMETREXED, 10 MG PA INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE PA INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS PA INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS PA INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNI PA INJECTION, PENTAZOCINE, 30 MG PA INJECTION, PENTOBARBITAL SODIUM, PER 50 MG PA INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML PA INJECTION, PERPHENAZINE, UP TO 5 MG INJECTION, PERTUZUMAB, 1 MG $$$$$ INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG $0 INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PHENYTOIN SODIUM, PER 50 MG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG $0 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.1 INJECTION, PLERIXAFOR, 1 MG INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ PA INJECTION, PRALATREXATE, 1 MG $$$$$ PA INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, PROCAINAMIDE HCL, UP TO 1 GM INJECTION, PROCHLORPERAZINE, UP TO 10 MG INJECTION, PROGESTERONE, PER 50 MG INJECTION, PROMAZINE HCL, UP TO 25 MG PA INJECTION, PROMETHAZINE HCL, UP TO 50 MG PA

16 for pricing information INJECTION, PROPOFOL, 10 MG PA INJECTION, PROPRANOLOL HCL, UP TO 1 MG INJECTION, PROTAMINE SULFATE, PER 10 MG 16 INJECTION, PROTIRELIN, PER 250 MCG PA INJECTION, PYRIDOXINE HCL, 100 MG INJECTION, RANIBIZUMAB, 0.1 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, REGADENOSON, 0.1 MG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICR INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROG INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVEN PA INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTR PA INJECTION, RILONACEPT, 1 MG INJECTION, RIMABOTULINUMTOXINB, 100 UNITS INJECTION, RITUXIMAB, 100 MG INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG PA INJECTION, SARGRAMOSTIM (GM CSF), 50 MCG INJECTION, SERMORELIN ACETATE, 1 MICROGRAM INJECTION, SINCALIDE, 5 MICROGRAMS INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECT INJECTION, SOMATROPIN, 1 MG PA INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG $0 INJECTION, STREPTOKINASE, PER 250,000 IU INJECTION, STREPTOMYCIN, UP TO 1 GM INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR INJECTION, TALIGLUCERACE ALFA, 10 UNITS INJECTION, TBO FILGRASTIM, 1 MICROGRAM INJECTION, TEMOZOLOMIDE, 1 MG INJECTION, TEMSIROLIMUS, 1 MG INJECTION, TERBUTALINE SULFATE, UP TO 1 MG PA INJECTION, TERIPARATIDE, 10 MCG PA INJECTION, TESTOSTERONE CYPIONATE, 1 MG PA

17 for pricing information INJECTION, TESTOSTERONE ENANTHATE, 1 MG PA INJECTION, TESTOSTERONE UNDECANOATE, 1 MG PA INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS PA INJECTION, TETRACYCLINE, UP TO 250 MG PA INJECTION, THEOPHYLLINE, PER 40 MG INJECTION, THIAMINE HCL, 100 MG INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG PA INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIA PA INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG PA INJECTION, TOCILIZUMAB, 1 MG PA INJECTION, TOLAZOLINE HCL, UP TO 25 MG PA INJECTION, TOPOTECAN, 0.1 MG $0 PA INJECTION, TORSEMIDE, 10 MG/ML PA INJECTION, TRASTUZUMAB, 10 MG INJECTION, TREPROSTINIL, 1 MG $$$$$ INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, INJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE FREE, 1 MG INJECTION, TRIAMCINOLONE DIACETATE, PER 5 MG INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5 MG INJECTION, TRIFLUPROMAZINE HCL, UP TO 20 MG INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG $0 INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, UREA, UP TO 40 GM INJECTION, UROFOLLITROPIN, 75 IU PA INJECTION, UROKINASE, 5000 IU VIAL INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, VELAGLUCERASE ALFA, 100 UNITS INJECTION, VERTEPORFIN, 0.1 MG PA INJECTION, VINBLASTINE SULFATE, 1 MG INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG INJECTION, VINORELBINE TARTRATE, 10 MG $0 INJECTION, VITAMIN B 12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, ZIV AFLIBERCEPT, 1 MG $$$$$ INJECTION, ZOLEDRONIC ACID, 1 MG INTRAUTERINE COPPER CONTRACEPTIVE 17

18 for pricing information INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS PA INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HO Intron A PA Irinotecan HCl PA Istodax PA Ixempra PA JAPANESE ENCEPHALITIS VIRUS VACCINE, INACTIVATED, FOR INTRAM $0 PA Jevtana PA Kadcyla PA Kalbitor PA Kalydeco PA Kepivance PA Keytruda PA Kineret PA Korlym PA Krystexxa PA Kuvan PA Kyprolis PA Lemtrada PA Letairis PA Leucovorin Calcium PA Leuprolide Acetate PA LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE IMPLANT, 65 MG LEUPROLIDE ACETATE, PER 1 MG Levoleucovorin Calcium PA LEVONORGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMP LEVONORGESTREL RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM ( 18

19 for pricing information LEVONORGESTREL RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM ( PA LEVONORGESTREL RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM ( PA Lipodox PA Lucentis PA Lupaneta Pack PA Lupron Depot PA Lupron Depot Ped PA LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PA Macugen PA Makena PA Marqibo PA MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SU $0 PA MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, $0 PA Melphalan HCl PA MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W $0 PA MENINGOCOCCAL RECOMBINANT LIPOPROTEIN VACCINE, SEROGROUP B ( $0 PA MENINGOCOCCAL RECOMBINANT PROTEIN AND OUTER MEMBRANE VESICLE $0 PA Mesna PA Mesnex PA Methotrexate PA METHOTREXATE SODIUM, 5 MG PA METHOTREXATE SODIUM, 50 MG 19 Mitomycin PA MITOMYCIN, OPHTHALMIC, 0.2 MG $0 PA Mitoxantrone HCl PA Moderiba PA Monovisc PA MUROMONAB CD3, PARENTERAL, 5 MG PA Mustargen PA Myalept PA Myleran PA Myobloc PA NASAL VACCINE INHALATION $0 PA

20 for pricing information Natpara PA Navelbine PA Neulasta PA Neupogen PA Nipent PA NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME PA NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH PA Norditropin PA Nucala PA Nutropin PA Nutropin AQ PA Octagam PA Ofev PA Olysio PA Oncaspar PA Onivyde PA Opdivo PA Opsumit PA Oralair PA Orencia PA Orenitram PA Orkambi PA Orthovisc PA Otezla tablets PA Oxaliplatin PA Paclitaxel PA Pegasys PA PEG Intron PA PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA APPROVED F PA Perjeta PA PHARMACOLOGIC AGENT ADMINISTRATION (EG, INHALED NITRIC OXIDE PA Photofrin PA Plegridy PA PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRA $0 PA PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23 VALENT (PPSV23), ADU $0 PA 20

21 for pricing information POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR I $0 PA Pomalyst PA Portrazza PA Praluent PA Privigen PA Procrit PA Prolastin C PA Proleukin PA Prolia PA Promacta PA Provenge PA Purixan PA RABIES IMMUNE GLOBULIN (RIG), HUMAN, FOR INTRAMUSCULAR AND/O PA RABIES IMMUNE GLOBULIN, HEAT TREATED (RIG HT), HUMAN, FOR IN PA RABIES VACCINE, FOR INTRAMUSCULAR USE $0 PA Rebetol PA Rebetol oral solution PA Rebif PA Reclast PA Remicade PA Remodulin PA Repatha PA RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINAN Revatio PA RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, FULL DOSE, FOR INTRAMU RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, MINI DOSE, FOR INTRAMU PA RHO(D) IMMUNE GLOBULIN (RHIGIV), HUMAN, FOR INTRAVENOUS USE Ribasphere PA RINGERS LACTATE INFUSION, UP TO 1000 CC PA Rituxan PA ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, $0 PA ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, $0 Ruconest PA Saizen PA 21

22 for pricing information Serostim PA Signifor PA Signifor LAR PA SILDENAFIL CITRATE, 25 MG PA Simponi Aria PA Simponi SC PA SIPULEUCEL T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS A PA Sovaldi PA Stelara PA STERILE DILUTANT FOR EPOPROSTENOL, 50 ML PA SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SU PA Supartz FX PA Sylatron PA Sylvant PA Synagis PA Synribo PA Synvisc, Synvisc One PA Taxotere PA Tecfidera PA Teniposide PA Testopel PA TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE F $0 PA TETANUS IMMUNE GLOBULIN (TIG), HUMAN, FOR INTRAMUSCULAR USE PA TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE $0 PA Theracys PA THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY $0 PA THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY PA THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY PA THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY PA THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY PA Thiotepa PA Toposar PA Topotecan HCl PA Torisel PA Totect PA 22

23 for pricing information Tracleer PA Treanda PA Trelstar PA Trexall PA Trisenox PA TYPHOID VACCINE, LIVE, ORAL $0 PA TYPHOID VACCINE, VI CAPSULAR POLYSACCHARIDE (VICPS), FOR INT $0 PA Tysabri PA Tyvaso PA UNCLASSIFIED BIOLOGICS PA Unituxin PA UNLISTED THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INTRAVENOU PA UNLISTED VACCINE/TOXOID $0 PA Uptravi PA USTEKINUMAB, FOR SUBCUTANEOUS INJECTION, 1 MG $$$$$ PA VACCINIA IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE PA Valchlor PA Valstar PA Vantas PA VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE $0 PA VARICELLA ZOSTER IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR U PA Vectibix PA Velcade PA Veletri PA Ventavis PA Vidaza PA Viekira Pak PA Vinblastine Sulfate PA Vincasar PFS PA Vincristine Sulfate PA VINCRISTINE SULFATE, 1 MG Vinorelbine Tartrate PA Xeljanz, Xeljanz XR PA Xeloda PA Xenazine PA Xeomin PA Xgeva PA 23

24 for pricing information Xofigo PA Xolair PA YELLOW FEVER VACCINE, LIVE, FOR SUBCUTANEOUS USE $0 PA Yervoy PA Yondelis PA Zaltrap PA Zanosar PA Zarxio PA Zemaira PA Zepatier PA Zevalin PA Zinecard PA Zoladex PA Zoledronic Acid PA Zolinza PA Zomacton PA Zometa PA Zorbtive PA HCR