LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT

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Transcription:

LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT The following medications may be covered under your medical benefit if they are provided to you in your doctor s office or outpatient infusion center. Your cost-share for those drugs will depend on the plan in which you have enrolled. Please consult your individual Summary of Benefits and Coverage for further information. As a guide we have provided general information below. Plan Medical Co-insurance after deductible Secure Care 1 20% Balanced Care 1 20% Balanced Care 2 0% Balanced Care 3 30% Balanced Care 4 0% Balanced Care 10 20% Balanced Care 12 20% Essential Care 1 0% BRAND NAME GENERIC DESCRIPTION Abilify Maintena RECON SUSP 300 MG Aripiprazole IM For Extended Release Susp 300 MG Abilify Maintena RECON SUSP 400 MG Aripiprazole IM For Extended Release Susp 400 MG Abilify SOLUTION 9.75 MG/1.3ML Aripiprazole IM Inj 9.75 MG/1.3ML (7.5 Adrenaclick SOLN A-INJ 0.15 MG/0.15ML Epinephrine Solution Auto-injector 0.15 MG/0.15ML (1:1000) Adrenalin SOLUTION 1 MG/ML Epinephrine Inj 1 MG/ML (1:1000) Adrenalin SOLUTION 30 MG/30ML Epinephrine Inj 30 MG/30ML (1 (1:1000) Adriamycin RECON SOLN 20 MG Doxorubicin HCl For Inj 20 MG Alsuma SOLN A-INJ 6 Sumatriptan Succinate Solution Auto-injector 6 Amevive RECON SOLN 15 MG Alefacept For IM Inj 15 MG Aralast NP RECON SOLN 500 MG Alpha1-Proteinase Inhibitor (Human) For IV Soln 500 MG Aranesp (Albumin Free) SOLN PRSYR 100 MCG/0.5ML Darbepoetin Alfa Soln Prefilled Syringe 100 MCG/0.5ML

Aranesp (Albumin Free) SOLN PRSYR 25 MCG/0.42ML Darbepoetin Alfa Soln Prefilled Syringe 25 MCG/0.42ML Aranesp (Albumin Free) SOLN PRSYR 40 Darbepoetin Alfa Soln Prefilled Syringe 40 Aranesp (Albumin Free) SOLN PRSYR 60 MCG/0.3ML Darbepoetin Alfa Soln Prefilled Syringe 60 MCG/0.3ML Aranesp (Albumin Free) SOLUTION 10 Darbepoetin Alfa Soln Prefilled Syringe 10 Aranesp (Albumin Free) SOLUTION 150 Darbepoetin Alfa Soln Inj 150 MCG/0.75ML MCG/0.75ML Aranesp (Albumin Free) SOLUTION 200 MCG/ML Darbepoetin Alfa Soln Inj 200 MCG/ML Aranesp (Albumin Free) SOLUTION 300 MCG/ML Darbepoetin Alfa Soln Inj 300 MCG/ML Arixtra SOLUTION 10 MG/0.8ML Fondaparinux Sodium Inj 10 MG/0.8ML Arixtra SOLUTION 10 MG/0.8ML Fondaparinux Sodium Subcutaneous Inj 10 MG/0.8ML Arixtra SOLUTION 2.5 Fondaparinux Sodium Subcutaneous Inj 2.5 Arixtra SOLUTION 5 MG/0.4ML Fondaparinux Sodium Subcutaneous Inj 5 MG/0.4ML Arixtra SOLUTION 7.5 MG/0.6ML Fondaparinux Sodium Subcutaneous Inj 7.5 MG/0.6ML Bendeka SOLUTION 100 MG/4ML Bendamustine HCl IV Soln 100 MG/4ML (25 Bivigam SOLUTION 10 GM/100ML Immune Globulin (Human) IV Soln 10 GM/100ML Bivigam SOLUTION 5 GM/50ML Bleo 15K RECON SOLN 15 (15000 IU) UNIT Bleomycin Sulf For Inj 15 USP Unit(15000 International Unit) Bleomycin Sulfate RECON SOLN 30 UNIT Bleomycin Sulfate For Inj 30 Unit Camptosar SOLUTION 300 MG/15ML Irinotecan HCl Inj 300 MG/15ML (20 Carimune NF RECON SOLN 12 GM Immune Globulin (Human) IV For Soln 12 GM Carimune NF RECON SOLN 6 GM Immune Globulin (Human) IV For Soln 6 GM Cuvitru SOLUTION 8 GM/40ML Immune Globulin (Human) Subcutaneous Inj 8 GM/40ML Cytarabine RECON SOLN 1 GM Cytarabine For Inj 1 GM Cytarabine SOLUTION 20 MG/ML Cytarabine Inj 20 MG/ML DDAVP SOLUTION 4 MCG/ML Desmopressin Acetate Inj 4 MCG/ML DOCEtaxel (Non-Alcohol) SOLUTION 160 MG/8ML Docetaxel (Non-Alcohol Formula) IV Soln 160 MG/8ML DOCEtaxel (Non-Alcohol) SOLUTION 20 MG/ML Docetaxel (Non-Alcohol Formula) IV Soln 20 MG/ML DOCEtaxel (Non-Alcohol) SOLUTION 80 MG/4ML Docetaxel (Non-Alcohol Formula) IV Soln 80 MG/4ML DOCEtaxel CONC 140 MG/7ML Docetaxel For Inj Conc 140 MG/7ML (20 DOCEtaxel CONC 160 MG/8ML Docetaxel For Inj Conc 160 MG/8ML (20 DOCEtaxel CONC 80 MG/2ML Docetaxel For Inj Conc 80 MG/2ML (40

DOCEtaxel CONC 80 MG/4ML Docetaxel For Inj Conc 80 MG/4ML (20 DOCEtaxel SOLUTION 160 MG/16ML Docetaxel Soln for IV Infusion 160 MG/16ML DOCEtaxel SOLUTION 200 MG/20ML Docetaxel Soln for IV Infusion 200 MG/20ML DOCEtaxel SOLUTION 80 MG/8ML Docetaxel Soln for IV Infusion 80 MG/8ML Ellence SOLUTION 200 MG/100ML Epirubicin HCl IV Soln 200 MG/100ML (2 Eloxatin SOLUTION 200 MG/40ML Oxaliplatin IV Soln 200 MG/40ML EPINEPHrine SOLN A-INJ 0.15 MG/0.15ML Epinephrine Solution Auto-injector 0.15 MG/0.15ML (1:1000) EpiRUBicin HCl RECON SOLN 50 MG Epirubicin HCl For IV Inj 50 MG EpiRUBicin HCl SOLUTION 200 MG/100ML Epirubicin HCl IV Soln 200 MG/100ML (2 EPIsnap KIT 1 MG/ML Epinephrine Inj Kit 1 MG/ML (1:1000) EPY II KIT 1 MG/ML Epinephrine Inj Kit 1 MG/ML (1:1000) EPY KIT 1 MG/ML Epinephrine Inj Kit 1 MG/ML (1:1000) Flebogamma DIF SOLUTION 0.5 GM/10ML Immune Globulin (Human) IV Soln 0.5 GM/10ML Flebogamma DIF SOLUTION 10 GM/100ML Immune Globulin (Human) IV Soln 10 GM/100ML Flebogamma DIF SOLUTION 10 GM/200ML Immune Globulin (Human) IV Soln 10 GM/200ML Flebogamma DIF SOLUTION 2.5 GM/50ML Immune Globulin (Human) IV Soln 2.5 GM/50ML Flebogamma DIF SOLUTION 20 GM/200ML Immune Globulin (Human) IV Soln 20 GM/200ML Flebogamma DIF SOLUTION 20 GM/400ML Immune Globulin (Human) IV Soln 20 GM/400ML Flebogamma DIF SOLUTION 5 GM/100ML Immune Globulin (Human) IV Soln 5 GM/100ML Flebogamma DIF SOLUTION 5 GM/50ML Flebogamma SOLUTION 0.5 GM/10ML Immune Globulin (Human) IV Soln 0.5 GM/10ML Folic Acid SOLUTION 5 MG/ML Folic Acid Inj 5 MG/ML Fragmin SOLUTION 95000 UNIT/3.8ML Dalteparin Sodium Inj 95000 Unit/3.8ML Gammaplex SOLUTION 10 GM/200ML Immune Globulin (Human) IV Soln 10 GM/200ML Gammaplex SOLUTION 2.5 GM/50ML Immune Globulin (Human) IV Soln 2.5 GM/50ML Gammaplex SOLUTION 20 GM/400ML Immune Globulin (Human) IV Soln 20 GM/400ML Gammaplex SOLUTION 5 GM/100ML Immune Globulin (Human) IV Soln 5 GM/100ML Genotropin MiniQuick RECON SOLN 0.4 MG Somatropin For Inj 0.4 MG Genotropin MiniQuick RECON SOLN 0.6 MG Somatropin For Inj 0.6 MG Genotropin MiniQuick RECON SOLN 0.8 MG Somatropin For Inj 0.8 MG Genotropin MiniQuick RECON SOLN 1 MG Somatropin For Inj 1 MG Genotropin MiniQuick RECON SOLN 1.2 MG Somatropin For Inj 1.2 MG Genotropin MiniQuick RECON SOLN 1.4 MG Somatropin For Inj 1.4 MG Genotropin MiniQuick RECON SOLN 1.6 MG Somatropin For Inj 1.6 MG Genotropin MiniQuick RECON SOLN 1.8 MG Somatropin For Inj 1.8 MG Genotropin MiniQuick RECON SOLN 2 MG Somatropin For Inj 2 MG Genotropin RECON SOLN 12 MG Somatropin For Inj 12 MG (13.8 MG Overfill) Glassia SOLUTION 1000 MG/50ML Alpha1-Proteinase Inhibitor (Human) Inj 1000 MG/50ML Haldol Decanoate SOLUTION 100 MG/ML Haloperidol Decanoate IM Soln 100 MG/ML Haldol Decanoate SOLUTION 50 MG/ML Haloperidol Decanoate IM Soln 50 MG/ML

Humira PREF SY KT 10 MG/0.2ML Adalimumab Prefilled Syringe Kit 10 MG/0.2ML Idamycin PFS SOLUTION 20 MG/20ML Idarubicin HCl IV Inj 20 MG/20ML (1 IDArubicin HCl SOLUTION 20 MG/20ML Idarubicin HCl IV Inj 20 MG/20ML (1 Imitrex SOLUTION 6 Sumatriptan Succinate Inj 6 Imitrex STATdose Refill SOLN CART 4 Sumatriptan Succinate Solution Cartridge 4 Imitrex STATdose Refill SOLN CART 6 Sumatriptan Succinate Solution Cartridge 6 Imitrex STATdose System SOLN A-INJ 4 Sumatriptan Succinate Solution Auto-injector 4 Imitrex STATdose System SOLN A-INJ 6 Sumatriptan Succinate Solution Auto-injector 6 Irinotecan HCl SOLUTION 500 MG/25ML Irinotecan HCl Inj 500 MG/25ML (20 Keppra SOLUTION 500 MG/5ML Levetiracetam Inj 500 MG/5ML (100 Leustatin SOLUTION 1 MG/ML Cladribine Inj 1 MG/ML Lovenox SOLUTION 100 MG/ML Enoxaparin Sodium Inj 100 MG/ML Lovenox SOLUTION 120 MG/0.8ML Enoxaparin Sodium Inj 120 MG/0.8ML Lovenox SOLUTION 150 MG/ML Enoxaparin Sodium Inj 150 MG/ML Lovenox SOLUTION 30 MG/0.3ML Enoxaparin Sodium Inj 30 MG/0.3ML Lovenox SOLUTION 300 MG/3ML Enoxaparin Sodium Inj 300 MG/3ML Lovenox SOLUTION 40 MG/0.4ML Enoxaparin Sodium Inj 40 MG/0.4ML Lovenox SOLUTION 60 MG/0.6ML Enoxaparin Sodium Inj 60 MG/0.6ML Lovenox SOLUTION 80 MG/0.8ML Enoxaparin Sodium Inj 80 MG/0.8ML Methotrexate Sodium (PF) SOLUTION 1 GM/40ML Methotrexate Sodium Inj PF 1000 MG/40ML (25 Methotrexate Sodium (PF) SOLUTION 100 MG/4ML Methotrexate Sodium Inj PF 100 MG/4ML (25 Methotrexate Sodium (PF) SOLUTION 200 MG/8ML Methotrexate Sodium Inj PF 200 MG/8ML (25 Methotrexate Sodium (PF) SOLUTION 250 MG/10ML Methotrexate Sodium Inj PF 250 MG/10ML (25 Methotrexate Sodium (PF) SOLUTION 50 MG/2ML Methotrexate Sodium Inj PF 50 MG/2ML (25 MitoMYcin RECON SOLN 40 MG Mitomycin For IV Soln 40 MG MitoMYcin RECON SOLN 5 MG Mitomycin For IV Soln 5 MG MitoXANTRONE HCl CONC 20 MG/10ML Mitoxantrone HCl Inj Conc 20 MG/10ML (2 MitoXANTRONE HCl CONC 30 MG/15ML Mitoxantrone HCl Inj Conc 30 MG/15ML (2 Norditropin FlexPro SOLUTION 30 MG/3ML Somatropin Inj 30 MG/3ML Norditropin NordiFlex Pen SOLUTION 30 MG/3ML Somatropin Inj 30 MG/3ML Novantrone CONC 20 MG/10ML Mitoxantrone HCl Inj Conc 20 MG/10ML (2 Nutropin AQ NuSpin 20 SOLUTION 20 MG/2ML Somatropin Inj 20 MG/2ML

Nutropin AQ NuSpin 5 SOLUTION 5 MG/2ML Nutropin AQ Pen SOLUTION 20 MG/2ML Octagam SOLUTION 1 GM/20ML Octagam SOLUTION 10 GM/100ML Octagam SOLUTION 10 GM/200ML Octagam SOLUTION 2 GM/20ML Octagam SOLUTION 2.5 GM/50ML Octagam SOLUTION 20 GM/200ML Octagam SOLUTION 25 GM/500ML Octagam SOLUTION 5 GM/100ML Octagam SOLUTION 5 GM/50ML Omnitrope RECON SOLN 5.8 MG Onxol 30 MG/5ML Oxaliplatin RECON SOLN 100 MG Oxaliplatin RECON SOLN 50 MG PACLitaxel CONC 30 MG/5ML PACLitaxel CONC 300 MG/50ML Privigen SOLUTION 10 GM/100ML Privigen SOLUTION 20 GM/200ML Privigen SOLUTION 40 GM/400ML Privigen SOLUTION 5 GM/50ML Prolastin RECON SOLN 500 MG SandoSTATIN LAR Depot KIT 10 MG SandoSTATIN LAR Depot KIT 20 MG SandoSTATIN LAR Depot KIT 30 MG Simponi Aria SOLUTION 50 MG/4ML Somavert RECON SOLN 25 MG Somavert RECON SOLN 30 MG SUMAtriptan Succinate SOLN PRSYR 6 Somatropin Inj 5 MG/2ML Somatropin Inj 20 MG/2ML Immune Globulin (Human) IV Soln 1 GM/20ML Immune Globulin (Human) IV Soln 10 GM/100ML Immune Globulin (Human) IV Soln 10 GM/200ML Immune Globulin (Human) IV Soln 2 GM/20ML Immune Globulin (Human) IV Soln 2.5 GM/50ML Immune Globulin (Human) IV Soln 20 GM/200ML Immune Globulin (Human) IV Soln 25 GM/500ML Immune Globulin (Human) IV Soln 5 GM/100ML Somatropin For Inj 5.8 MG Paclitaxel IV Conc 30 MG/5ML (6 Oxaliplatin For IV Inj 100 MG Oxaliplatin For IV Inj 50 MG Paclitaxel IV Conc 30 MG/5ML (6 Paclitaxel IV Conc 300 MG/50ML (6 Immune Globulin (Human) IV Soln 10 GM/100ML Immune Globulin (Human) IV Soln 20 GM/200ML Immune Globulin (Human) IV Soln 40 GM/400ML Alpha1-Proteinase Inhibitor (Human) For IV Soln 500 MG Octreotide Acetate For IM Inj Kit 10 MG Octreotide Acetate For IM Inj Kit 20 MG Octreotide Acetate For IM Inj Kit 30 MG Golimumab IV Soln 50 MG/4ML Pegvisomant For Inj 25 MG (As Protein) Pegvisomant For Inj 30 MG (As Protein) Sumatriptan Succinate Solution Prefilled Syringe 6 Sumavel DosePro SOLN J-INJ 4 Sumatriptan Succinate Solution Jet-injector 4 Sumavel DosePro SOLN J-INJ 6 Sumatriptan Succinate Solution Jet-injector 6 Taxotere CONC 80 MG/4ML Topotecan HCl SOLUTION 4 MG/4ML Docetaxel For Inj Conc 80 MG/4ML (20 Topotecan HCl Inj 4 MG/4ML (Base Equiv) (For Infusion) Treanda SOLUTION 180 MG/2ML Bendamustine HCl IV Soln 180 MG/2ML (90 Treanda SOLUTION 45 Bendamustine HCl IV Soln 45 (90

Zembrace SymTouch SOLN A-INJ 3 Sumatriptan Succinate Solution Auto-injector 3 ZyPREXA RECON SOLN 10 MG Olanzapine For IM Inj 10 MG

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