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MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

ABACAVIR ABACAVIR SULFATE SPECIALTY - HIV ABACAVIR- ABACAVIR SULFATE/LAMIVUDINE SPECIALTY - HIV ABACAVIR-LAMIVUDINE-ZIDOVUDINE ABACAVIR/LAMIVUDINE/ZIDOVUDINE SPECIALTY - HIV ABILIFY MAINTENA SPECIALTY - BEHAVIORAL HEALTH ABILIFY MYCITE ARIPIPRAZOLE SPECIALTY - BEHAVIORAL HEALTH ABIRATERONE ACETATE ABIRATERONE ACETATE SPECIALTY - ONCOLOGY ABRAXANE PROTEIN-BOUND SPECIALTY - ONCOLOGY ACITRETIN ACITRETIN SPECIALTY - CORE ACTEMRA TOCILIZUMAB SPECIALTY - CORE ACTEMRA ACTPEN TOCILIZUMAB SPECIALTY - CORE ACTIMMUNE GAMMA-1B,RECOMB. SPECIALTY - CORE ADAGEN PEGADEMASE BOVINE SPECIALTY - CORE ADASUVE SPECIALTY - BEHAVIORAL HEALTH ADCETRIS SPECIALTY - ONCOLOGY ADCIRCA SPECIALTY - CORE DIPIVOXIL ADEFOVIR DIPIVOXIL SPECIALTY - CORE ADEMPAS SPECIALTY - CORE ADVATE ANTIHEMOPH.FVIII,FULL LENGTH SPECIALTY - CORE ADVATE ANTIHEMOPH.FVIII PLAS/ALB FREE SPECIALTY - CORE ADYNOVATE ANTIHEMO.FVIII,FULL LENGTH PEG SPECIALTY - CORE AFINITOR SPECIALTY - ONCOLOGY AFINITOR DISPERZ EVEROLIMUS SPECIALTY - ONCOLOGY AFSTYLA ANTIHEM.FVIII,SIN-CHN,B-DM TRU SPECIALTY - CORE AGGRASTAT HCL M-HYDRATE SPECIALTY - ANTICOAG AGGRASTAT TIROFIBAN HCL M-HYDRATE/NS SPECIALTY - ANTICOAG AGRYLIN HCL SPECIALTY - CORE ALDURAZYME LARONIDASE SPECIALTY - CORE ALECENSA HYDROCHLORIDE SPECIALTY - ONCOLOGY ALFERON N -N3 SPECIALTY - CORE ALIMTA DISODIUM SPECIALTY - ONCOLOGY ALIQOPA DI-HCL SPECIALTY - ONCOLOGY ALKERAN HCL SPECIALTY - ONCOLOGY ALPHANATE AHF,HUMAN/VWF,HUMAN SPECIALTY - CORE ALPHANINE SD FACTOR IX SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

ALPROLIX FACTOR IX REC, FC FUSION PROTN SPECIALTY - CORE ALUNBRIG SPECIALTY - ONCOLOGY ALYQ TADALAFIL SPECIALTY - CORE AMPYRA FAMPRIDINE (4-AMINOPYRIDINE) SPECIALTY - CORE ANDEXXA FACTOR XA,INACTIVATED-ZHZO SPECIALTY - CORE ANGIOMAX SPECIALTY - ANTICOAG APOKYN HCL SPECIALTY - CORE APTIVUS TIPRANAVIR/VITAMIN E TPGS SPECIALTY - HIV APTIVUS TIPRANAVIR SPECIALTY - HIV ARALAST NP ALPHA-1-PROTEINASE INHIBITOR SPECIALTY - CORE ARANESP IN POLYSORBAT SPECIALTY - CORE ARCALYST RILONACEPT SPECIALTY - CORE ARESTIN MINOCYCLINE HCL MICROSPHERES SPECIALTY - CORE ARGATROBAN SPECIALTY - ANTICOAG ARGATROBAN-0.9% NACL ARGATROBAN IN 0.9 % SOD CHLOR SPECIALTY - ANTICOAG ARGATROBAN-SODIUM CHLORIDE ARGATROBAN IN , ISO-OSMO SPECIALTY - ANTICOAG ARIKAYCE AMIKACIN LIPOSOMAL/NEB.ACCESSR SPECIALTY - CORE ARISTADA SPECIALTY - BEHAVIORAL HEALTH ARIXTRA SODIUM SPECIALTY - ANTICOAG ARRANON SPECIALTY - ONCOLOGY ARSENIC TRIOXIDE SPECIALTY - ONCOLOGY ARZERRA SPECIALTY - ONCOLOGY ASTAGRAF XL TACROLIMUS SPECIALTY - TRANSPLANT ATAZANAVIR SULFATE ATAZANAVIR SULFATE SPECIALTY - HIV ATGAM LYMPHOCYTE IMMUNE GLOBULIN SPECIALTY - TRANSPLANT ATRIPLA /EMTRICITAB/TENOFOVIR SPECIALTY - HIV ATRYN ALFA (HUM RECOM) SPECIALTY - CORE AUBAGIO TERIFLUNOMIDE SPECIALTY - CORE AUSTEDO DEUTETRABENAZINE SPECIALTY - CORE AVASTIN SPECIALTY - ONCOLOGY AVONEX INTERFERON BETA-1A/ALBUMIN SPECIALTY - CORE AVONEX INTERFERON BETA-1A SPECIALTY - CORE AVONEX PEN INTERFERON BETA-1A SPECIALTY - CORE AZACITIDINE SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

AZEDRA DOSIMETRIC IOBENGUANE IODINE-131 SPECIALTY - ONCOLOGY AZEDRA THERAPEUTIC IOBENGUANE IODINE-131 SPECIALTY - ONCOLOGY BARACLUDE SPECIALTY - CORE BARACLUDE ENTECAVIR SPECIALTY - CORE BAVENCIO AVELUMAB SPECIALTY - ONCOLOGY BEBULIN FACTOR IX COMPLEX HUMAN SPECIALTY - CORE BELEODAQ SPECIALTY - ONCOLOGY BENDEKA HCL SPECIALTY - ONCOLOGY BENEFIX FACTOR IX HUMAN RECOMBINANT SPECIALTY - CORE BENLYSTA SPECIALTY - CORE BERINERT COMPLEMENT C1 ESTERASE INHIB SPECIALTY - CORE BESPONSA INOTUZUMAB OZOGAMICIN SPECIALTY - ONCOLOGY BETASERON INTERFERON BETA-1B SPECIALTY - CORE BETHKIS TOBRAMYCIN SPECIALTY - CORE BEVACIZUMAB BEVACIZUMAB SPECIALTY - CORE BEXAROTENE SPECIALTY - ONCOLOGY BICNU SPECIALTY - ONCOLOGY BIKTARVY BICTEGRAV/EMTRICIT/TENOFOV ALA SPECIALTY - HIV BIVALIRUDIN BIVALIRUDIN SPECIALTY - ANTICOAG BIVALIRUDIN-0.9% NACL BIVALIRUDIN/0.9 % SODIUM CHLOR SPECIALTY - ANTICOAG BIVIGAM IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE BLEO 15K SULFATE SPECIALTY - ONCOLOGY BLEOMYCIN SULFATE BLEOMYCIN SULFATE SPECIALTY - ONCOLOGY BLINCYTO BLINATUMOMAB SPECIALTY - ONCOLOGY BORTEZOMIB SPECIALTY - ONCOLOGY BOSULIF SPECIALTY - ONCOLOGY BOTOX BOTULINUM TOXIN TYPE A SPECIALTY - CORE BRAFTOVI SPECIALTY - ONCOLOGY BRAVELLE UROFOLLITROPIN (FSH) SPECIALTY - FERTILITY BRINEURA CERLIPONASE ALFA SPECIALTY - CORE BUPHENYL SPECIALTY - CORE BUSULFAN SPECIALTY - ONCOLOGY BUSULFEX BUSULFAN SPECIALTY - ONCOLOGY CABLIVI CAPLACIZUMAB-YHDP SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

CABOMETYX S-MALATE SPECIALTY - ONCOLOGY CALQUENCE SPECIALTY - ONCOLOGY CAMPTOSAR HCL SPECIALTY - ONCOLOGY CAMPTOSAR IRINOTECAN HCL SPECIALTY - ONCOLOGY CAPECITABINE SPECIALTY - ONCOLOGY CAPRELSA SPECIALTY - ONCOLOGY CARBAGLU SPECIALTY - CORE CARBOPLATIN SPECIALTY - ONCOLOGY CARIMUNE NF NANOFILTERED IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE CARMUSTINE CARMUSTINE SPECIALTY - ONCOLOGY CAYSTON AZTREONAM SPECIALTY - CORE CELLCEPT MYCOPHENOLATE MOFETIL HCL SPECIALTY - TRANSPLANT CEPROTIN CONCENTRATE, HUMAN SPECIALTY - CORE CERDELGA TARTRATE SPECIALTY - CORE CEREZYME SPECIALTY - CORE CETROTIDE CETRORELIX ACETATE SPECIALTY - FERTILITY CHENODAL CHENODIOL SPECIALTY - CORE CHOLBAM CHOLIC ACID SPECIALTY - CORE CIMDUO LAMIVUDINE/TENOFOVIR DISOP FUM SPECIALTY - HIV CIMZIA CERTOLIZUMAB PEGOL SPECIALTY - CORE CINACALCET HCL CINACALCET HCL SPECIALTY - CORE CINQAIR RESLIZUMAB SPECIALTY - CORE CINRYZE COMPLEMENT C1 ESTERASE INHIB SPECIALTY - CORE CISPLATIN SPECIALTY - ONCOLOGY CLADRIBINE SPECIALTY - ONCOLOGY CLOFARABINE SPECIALTY - ONCOLOGY CLOLAR CLOFARABINE SPECIALTY - ONCOLOGY COAGADEX COAGULATION SPECIALTY - CORE COMBIVIR LAMIVUDINE/ZIDOVUDINE SPECIALTY - HIV COMETRIQ CABOZANTINIB S-MALATE SPECIALTY - ONCOLOGY COMPLERA EMTRICITAB/RILPIVIRINE/TENOFOV SPECIALTY - HIV COPAXONE SPECIALTY - CORE COPIKTRA UNKNOWN SPECIALTY - ONCOLOGY CORIFACT FACTOR XIII SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

COSENTYX (2 SYRINGES) SECUKINUMAB SPECIALTY - CORE COSENTYX PEN SECUKINUMAB SPECIALTY - CORE COSENTYX PEN (2 PENS) SECUKINUMAB SPECIALTY - CORE COSENTYX SYRINGE SECUKINUMAB SPECIALTY - CORE COSMEGEN SPECIALTY - ONCOLOGY COTELLIC FUMARATE SPECIALTY - ONCOLOGY CRYSVITA BUROSUMAB-TWZA SPECIALTY - CORE CUPRIMINE PENICILLAMINE SPECIALTY - CORE CUVITRU IMMUN GLOB G (IGG)/GLY/IGA 50+ SPECIALTY - CORE CYCLOPHOSPHAMIDE SPECIALTY - ONCOLOGY CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE SPECIALTY - ONCOLOGY CYCLOSPORINE CYCLOSPORINE SPECIALTY - TRANSPLANT CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED SPECIALTY - TRANSPLANT CYRAMZA RAMUCIRUMAB SPECIALTY - ONCOLOGY CYSTADANE BETAINE SPECIALTY - CORE CYSTAGON SPECIALTY - CORE CYSTARAN CYSTEAMINE HYDROCHLORIDE SPECIALTY - CORE CYTARABINE SPECIALTY - ONCOLOGY CYTARABINE CYTARABINE/PF SPECIALTY - ONCOLOGY CYTOGAM IMMUNE GLOB SPECIALTY - CORE D-PENAMINE PENICILLAMINE SPECIALTY - CORE DACOGEN SPECIALTY - ONCOLOGY DACTINOMYCIN DACTINOMYCIN SPECIALTY - ONCOLOGY DAKLINZA DACLATASVIR DIHYDROCHLORIDE SPECIALTY - CORE DALFAMPRIDINE ER FAMPRIDINE (4-AMINOPYRIDINE) SPECIALTY - CORE DARAPRIM PYRIMETHAMINE SPECIALTY - CORE DARZALEX DARATUMUMAB SPECIALTY - ONCOLOGY HCL DAUNORUBICIN HCL SPECIALTY - ONCOLOGY DAUNOXOME DAUNORUBICIN CITRATE LIPOSOMAL SPECIALTY - ONCOLOGY DAURISMO GLASDEGIB MALEATE SPECIALTY - ONCOLOGY DECITABINE DECITABINE SPECIALTY - ONCOLOGY DEFERASIROX DEFERASIROX SPECIALTY - CORE DELSTRIGO DORAVIRINE/LAMIVU/TENOFOV DISO SPECIALTY - HIV DEPEN PENICILLAMINE SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

DEPOCYT CYTARABINE LIPOSOME SPECIALTY - ONCOLOGY DESCOVY EMTRICITABINE/TENOFOV ALAFENAM SPECIALTY - HIV DIBENZYLINE PHENOXYBENZAMINE HCL SPECIALTY - CORE DOCEFREZ SPECIALTY - ONCOLOGY DOCETAXEL DOCETAXEL SPECIALTY - ONCOLOGY DOCETAXEL DOCETAXEL SPECIALTY - ONCOLOGY DOPTELET AVATROMBOPAG MALEATE SPECIALTY - CORE DOXIL HCL LIPOSOMAL SPECIALTY - ONCOLOGY DOXORUBICIN HCL LIPOSOME DOXORUBICIN HCL LIPOSOMAL SPECIALTY - ONCOLOGY DUOPA CARBIDOPA/LEVODOPA SPECIALTY - CORE DUPIXENT DUPILUMAB SPECIALTY - CORE DUPIXENT DUPILUMAB SPECIALTY - CORE DYSPORT ABOBOTULINUMTOXINA SPECIALTY - CORE EDURANT RILPIVIRINE HYDROCHLORIDE SPECIALTY - HIV EFAVIRENZ EFAVIRENZ SPECIALTY - HIV EGRIFTA TESAMORELIN ACETATE SPECIALTY - CORE ELAPRASE SPECIALTY - CORE ELELYSO SPECIALTY - CORE ELIGARD LEUPROLIDE ACETATE SPECIALTY - ONCOLOGY ELLENCE HCL SPECIALTY - ONCOLOGY ELOCTATE FACTOR VIII REC,FC FUSION PROT SPECIALTY - CORE ELOXATIN SPECIALTY - ONCOLOGY ELZONRIS TAGRAXOFUSP-ERZS SPECIALTY - ONCOLOGY EMCYT ESTRAMUSTINE SODIUM SPECIALTY - ONCOLOGY EMFLAZA DEFLAZACORT SPECIALTY - CORE EMPLICITI ELOTUZUMAB SPECIALTY - ONCOLOGY ENBREL SPECIALTY - CORE ENBREL MINI ETANERCEPT SPECIALTY - CORE ENBREL SURECLICK ETANERCEPT SPECIALTY - CORE ENDARI SPECIALTY - CORE ENOXAPARIN SODIUM SPECIALTY - ANTICOAG ENTECAVIR ENTECAVIR SPECIALTY - CORE ENTYVIO VEDOLIZUMAB SPECIALTY - CORE ENVARSUS XR TACROLIMUS SPECIALTY - TRANSPLANT MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

EPCLUSA SOFOSBUVIR/VELPATASVIR SPECIALTY - CORE EPIDIOLEX (CBD) EXTRACT SPECIALTY - CORE EPIRUBICIN HCL EPIRUBICIN HCL SPECIALTY - ONCOLOGY EPOGEN SPECIALTY - CORE EPOPROSTENOL SODIUM EPOPROSTENOL NA SPECIALTY - CORE EPTIFIBATIDE SPECIALTY - ANTICOAG EPZICOM ABACAVIR SULFATE/LAMIVUDINE SPECIALTY - HIV ERBITUX SPECIALTY - ONCOLOGY ERIVEDGE SPECIALTY - ONCOLOGY ERLEADA APALUTAMIDE SPECIALTY - ONCOLOGY ERWINAZE ERWINIA SPECIALTY - ONCOLOGY ESBRIET PIRFENIDONE SPECIALTY - CORE EVOMELA MELPHALAN HCL/BETADEX SBES SPECIALTY - ONCOLOGY EVOTAZ ATAZANAVIR SULFATE/COBICISTAT SPECIALTY - HIV EXJADE DEFERASIROX SPECIALTY - CORE EXONDYS 51 ETEPLIRSEN SPECIALTY - CORE EXTAVIA INTERFERON BETA-1B SPECIALTY - CORE EYLEA SPECIALTY - CORE FABRAZYME AGALSIDASE BETA SPECIALTY - CORE FARESTON TOREMIFENE CITRATE SPECIALTY - ONCOLOGY FARYDAK LACTATE SPECIALTY - ONCOLOGY FASENRA BENRALIZUMAB SPECIALTY - CORE FASLODEX FULVESTRANT SPECIALTY - ONCOLOGY FEIBA NF ANTI-INHIBITOR COAGULANT COMP. SPECIALTY - CORE FERRIPROX DEFERIPRONE SPECIALTY - CORE FIRAZYR ICATIBANT ACETATE SPECIALTY - CORE FIRDAPSE AMIFAMPRIDINE PHOSPHATE SPECIALTY - CORE FIRMAGON DEGARELIX ACETATE SPECIALTY - ONCOLOGY FLEBOGAMMA DIF IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE FLOLAN EPOPROSTENOL NA SPECIALTY - CORE FLOXURIDINE SPECIALTY - ONCOLOGY PHOSPHATE FLUDARABINE PHOSPHATE SPECIALTY - ONCOLOGY FOLLISTIM AQ FOLLITROPIN BETA,RECOMB SPECIALTY - FERTILITY FOLOTYN SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

FONDAPARINUX SODIUM FONDAPARINUX SODIUM SPECIALTY - ANTICOAG FORTEO TERIPARATIDE SPECIALTY - CORE FOSAMPRENAVIR CALCIUM FOSAMPRENAVIR CALCIUM SPECIALTY - HIV FRAGMIN ,PORCINE SPECIALTY - ANTICOAG FULPHILA -JMDB SPECIALTY - CORE FUSILEV LEVOLEUCOVORIN CALCIUM SPECIALTY - CORE FUZEON ENFUVIRTIDE SPECIALTY - HIV GALAFOLD MIGALASTAT HCL SPECIALTY - CORE GAMASTAN IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE GAMASTAN S-D IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE GAMIFANT -LZSG SPECIALTY - CORE GAMMAGARD LIQUID IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE GAMMAGARD S-D IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE GAMMAKED IMMUNE GLOB,GAM CAPRYLATE(IGG) SPECIALTY - CORE GAMMAPLEX IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE GAMMAPLEX IMMUN GLOB G(IGG)/GLY/IGA 0-50 SPECIALTY - CORE GAMUNEX-C IMMUNE GLOB,GAM CAPRYLATE(IGG) SPECIALTY - CORE GANIRELIX ACETATE GANIRELIX ACETATE SPECIALTY - FERTILITY GATTEX SPECIALTY - CORE GAZYVA OBINUTUZUMAB SPECIALTY - ONCOLOGY HCL GEMCITABINE HCL SPECIALTY - ONCOLOGY GEMZAR GEMCITABINE HCL SPECIALTY - ONCOLOGY GENGRAF CYCLOSPORINE, MODIFIED SPECIALTY - TRANSPLANT GENOTROPIN SOMATROPIN SPECIALTY - CORE GENVOYA ELVITEG/COBI/EMTRIC/TENOFO ALA SPECIALTY - HIV GILENYA FINGOLIMOD HYDROCHLORIDE SPECIALTY - CORE GILOTRIF DIMALEATE SPECIALTY - ONCOLOGY GLASSIA ALPHA-1-PROTEINASE INHIBITOR SPECIALTY - CORE GLATIRAMER ACETATE GLATIRAMER ACETATE SPECIALTY - CORE GLATOPA GLATIRAMER ACETATE SPECIALTY - CORE GLEEVEC MESYLATE SPECIALTY - ONCOLOGY GLEOSTINE SPECIALTY - ONCOLOGY GLIADEL CARMUSTINE/POLIFEPROSAN 20 SPECIALTY - ONCOLOGY GOCOVRI AMANTADINE HCL SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

GONAL-F FOLLITROPIN ALPHA,RECOMB SPECIALTY - FERTILITY GONAL-F RFF FOLLITROPIN ALPHA,RECOMB SPECIALTY - FERTILITY GONAL-F RFF REDI-JECT FOLLITROPIN ALPHA,RECOMB SPECIALTY - FERTILITY GRANIX TBO- SPECIALTY - CORE H.P. ACTHAR CORTICOTROPIN SPECIALTY - CORE HAEGARDA COMPLEMENT C1 ESTERASE INHIB SPECIALTY - CORE HALAVEN MESYLATE SPECIALTY - ONCOLOGY HARVONI LEDIPASVIR/SOFOSBUVIR SPECIALTY - CORE HELIXATE FS ANTIHEMOPH.FVIII,FULL LENGTH SPECIALTY - CORE HELIXATE FS ANTIHEMOPHILIC FACTOR, HUM REC SPECIALTY - CORE HEMLIBRA EMICIZUMAB-KXWH SPECIALTY - CORE HEMOFIL M ANTIHEMOPHILIC FACTOR,HUMAN SPECIALTY - CORE HEPSERA ADEFOVIR DIPIVOXIL SPECIALTY - CORE HERCEPTIN SPECIALTY - ONCOLOGY HETLIOZ TASIMELTEON SPECIALTY - CORE HEXALEN SPECIALTY - ONCOLOGY HIZENTRA IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE HUMATE-P AHF,HUMAN/VWF,HUMAN SPECIALTY - CORE HUMATROPE SOMATROPIN SPECIALTY - CORE HUMIRA ADALIMUMAB SPECIALTY - CORE HUMIRA PEDIATRIC CROHN'S ADALIMUMAB SPECIALTY - CORE HUMIRA PEN ADALIMUMAB SPECIALTY - CORE HUMIRA PEN CROHN'S-UC-HS ADALIMUMAB SPECIALTY - CORE HUMIRA PEN PSOR-UVEITS-ADOL HS ADALIMUMAB SPECIALTY - CORE HUMIRA(CF) ADALIMUMAB SPECIALTY - CORE HUMIRA(CF) PEDIATRIC CROHN'S ADALIMUMAB SPECIALTY - CORE HUMIRA(CF) PEN ADALIMUMAB SPECIALTY - CORE HUMIRA(CF) PEN CROHN'S-UC-HS ADALIMUMAB SPECIALTY - CORE HUMIRA(CF) PEN PSOR-UV-ADOL HS ADALIMUMAB SPECIALTY - CORE HYCAMTIN HCL SPECIALTY - ONCOLOGY HYCAMTIN TOPOTECAN HCL SPECIALTY - ONCOLOGY HYDROXYPROGESTERONE CAPROATE HYDROXYPROGESTERONE CAPROAT/PF SPECIALTY - CORE HYDROXYPROGESTERONE CAPROATE HYDROXYPROGESTERONE CAPROATE SPECIALTY - CORE HYQVIA IGG/HYALURONIDASE,RECOMBINANT SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

HYQVIA IG COMPONENT IMMUN GLOB G(IGG)/GLY/IGA 0-50 SPECIALTY - CORE IBRANCE SPECIALTY - ONCOLOGY ICLUSIG HCL SPECIALTY - ONCOLOGY IDAMYCIN PFS HCL SPECIALTY - ONCOLOGY IDARUBICIN HCL IDARUBICIN HCL SPECIALTY - ONCOLOGY IDELVION FACTOR IX RECOM,ALBUMIN FUSION SPECIALTY - CORE IDHIFA MESYLATE SPECIALTY - ONCOLOGY IFEX SPECIALTY - ONCOLOGY IFOSFAMIDE IFOSFAMIDE SPECIALTY - ONCOLOGY IFOSFAMIDE-MESNA IFOSFAMIDE/MESNA SPECIALTY - ONCOLOGY ILARIS CANAKINUMAB/PF SPECIALTY - CORE ILUMYA TILDRAKIZUMAB-ASMN SPECIALTY - CORE IMATINIB MESYLATE IMATINIB MESYLATE SPECIALTY - ONCOLOGY IMBRUVICA SPECIALTY - ONCOLOGY IMFINZI DURVALUMAB SPECIALTY - ONCOLOGY IMLYGIC TALIMOGENE LAHERPAREPVEC SPECIALTY - ONCOLOGY INBRIJA LEVODOPA SPECIALTY - CORE INCRELEX MECASERMIN SPECIALTY - CORE INFLECTRA INFLIXIMAB-DYYB SPECIALTY - CORE INFUGEM GEMCITABINE HCL IN 0.9 % NACL SPECIALTY - ONCOLOGY INGREZZA VALBENAZINE TOSYLATE SPECIALTY - CORE INJECTAFER FERRIC CARBOXYMALTOSE SPECIALTY - CORE INLYTA SPECIALTY - ONCOLOGY INTEGRILIN EPTIFIBATIDE SPECIALTY - ANTICOAG INTELENCE ETRAVIRINE SPECIALTY - HIV INTRON A INTERFERON ALFA-2B,RECOMB. SPECIALTY - CORE INVEGA SUSTENNA PALMITATE SPECIALTY - BEHAVIORAL HEALTH INVEGA TRINZA PALIPERIDONE PALMITATE SPECIALTY - BEHAVIORAL HEALTH INVIRASE SAQUINAVIR MESYLATE SPECIALTY - HIV IPRIVASK DESIRUDIN SPECIALTY - ANTICOAG IRESSA SPECIALTY - ONCOLOGY IRINOTECAN HCL IRINOTECAN HCL SPECIALTY - ONCOLOGY ISENTRESS RALTEGRAVIR POTASSIUM SPECIALTY - HIV ISENTRESS HD RALTEGRAVIR POTASSIUM SPECIALTY - HIV MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

ISTODAX SPECIALTY - ONCOLOGY ISTODAX ROMIDEPSIN SPECIALTY - ONCOLOGY IXEMPRA SPECIALTY - ONCOLOGY IXINITY FACTOR IX HUMAN RECOMB,THR 148 SPECIALTY - CORE JADENU DEFERASIROX SPECIALTY - CORE JADENU SPRINKLE DEFERASIROX SPECIALTY - CORE JAKAFI PHOSPHATE SPECIALTY - ONCOLOGY JEVTANA SPECIALTY - ONCOLOGY JIVI FVIII REC,B-DOM DELET PEG-AUCL SPECIALTY - CORE JULUCA DOLUTEGRAVIR/RILPIVIRINE SPECIALTY - HIV JUXTAPID LOMITAPIDE MESYLATE SPECIALTY - CORE JYNARQUE TOLVAPTAN SPECIALTY - CORE KADCYLA SPECIALTY - ONCOLOGY KALBITOR ECALLANTIDE SPECIALTY - CORE KALETRA LOPINAVIR/RITONAVIR SPECIALTY - HIV KALETRA LOPINAVIR/RITONAVIR SPECIALTY - HIV KALYDECO IVACAFTOR SPECIALTY - CORE KANUMA SPECIALTY - CORE KCENTRA HUMAN PROTHROMIN COMPLEX (PCC) SPECIALTY - CORE KEPIVANCE PALIFERMIN SPECIALTY - CORE KEVEYIS DICHLORPHENAMIDE SPECIALTY - CORE KEVZARA SARILUMAB SPECIALTY - CORE KEYTRUDA PEMBROLIZUMAB SPECIALTY - ONCOLOGY KHAPZORY LEVOLEUCOVORIN SPECIALTY - CORE KINERET ANAKINRA SPECIALTY - CORE KISQALI SUCCINATE SPECIALTY - ONCOLOGY KISQALI FEMARA CO-PACK RIBOCICLIB SUCCINATE/LETROZOLE SPECIALTY - ONCOLOGY KITABIS PAK TOBRAMYCIN/NEBULIZER SPECIALTY - CORE KOATE ANTIHEMOPHILIC FACTOR,HUMAN SPECIALTY - CORE KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN SPECIALTY - CORE KOGENATE FS ANTIHEMOPHILIC FACTOR, HUM REC SPECIALTY - CORE KOGENATE FS ANTIHEMOPH.FVIII,FULL LENGTH SPECIALTY - CORE KORLYM MIFEPRISTONE SPECIALTY - CORE KOVALTRY ANTIHEMOPH.FVIII,FULL LENGTH SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

KOVALTRY ANTIHEMOPHILIC FACTOR, HUM REC SPECIALTY - CORE KRYSTEXXA PEGLOTICASE SPECIALTY - CORE KUVAN SAPROPTERIN DIHYDROCHLORIDE SPECIALTY - CORE KYMRIAH TISAGENLECLEUCEL SPECIALTY - ONCOLOGY KYNAMRO MIPOMERSEN SODIUM SPECIALTY - CORE KYPROLIS SPECIALTY - ONCOLOGY LAMIVUDINE-ZIDOVUDINE LAMIVUDINE/ZIDOVUDINE SPECIALTY - HIV LARTRUVO OLARATUMAB SPECIALTY - ONCOLOGY LEDIPASVIR-SOFOSBUVIR LEDIPASVIR/SOFOSBUVIR SPECIALTY - CORE LEMTRADA SPECIALTY - CORE LENVIMA MESYLATE SPECIALTY - ONCOLOGY LETAIRIS SPECIALTY - CORE LEUKERAN SPECIALTY - ONCOLOGY LEUKINE SPECIALTY - CORE LEUPROLIDE ACETATE LEUPROLIDE ACETATE SPECIALTY - ONCOLOGY LEVOLEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM SPECIALTY - CORE LEVOLEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM SPECIALTY - CORE LEXIVA FOSAMPRENAVIR CALCIUM SPECIALTY - HIV LEXIVA FOSAMPRENAVIR CALCIUM SPECIALTY - HIV LIBTAYO CEMIPLIMAB-RWLC SPECIALTY - ONCOLOGY LIPODOX DOXORUBICIN HCL LIPOSOMAL SPECIALTY - ONCOLOGY LIPODOX 50 DOXORUBICIN HCL LIPOSOMAL SPECIALTY - ONCOLOGY LOMUSTINE LOMUSTINE SPECIALTY - ONCOLOGY LONSURF /TIPIRACIL HCL SPECIALTY - ONCOLOGY LOPINAVIR-RITONAVIR LOPINAVIR/RITONAVIR SPECIALTY - HIV LORBRENA SPECIALTY - ONCOLOGY LOVENOX ENOXAPARIN SODIUM SPECIALTY - ANTICOAG LUCENTIS SPECIALTY - CORE LUMIZYME SPECIALTY - CORE LUMOXITI MOXETUMOMAB PASUDOTOX-TDFK SPECIALTY - ONCOLOGY LUPANETA PACK LEUPROLIDE/NORETHINDRONE ACET SPECIALTY - CORE LUPRON DEPOT LEUPROLIDE ACETATE SPECIALTY - ONCOLOGY LUPRON DEPOT LEUPROLIDE ACETATE SPECIALTY - CORE LUPRON DEPOT (LUPANETA) LEUPROLIDE ACETATE SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

LUPRON DEPOT-PED LEUPROLIDE ACETATE SPECIALTY - CORE LUPRON DEPOT-PED LEUPROLIDE ACETATE SPECIALTY - ONCOLOGY LUTATHERA LUTETIUM LU 177 DOTATATE SPECIALTY - ONCOLOGY LUXTURNA VORETIGENE NEPARVOVEC-RZYL SPECIALTY - CORE LYNPARZA SPECIALTY - ONCOLOGY LYSODREN SPECIALTY - ONCOLOGY MACRILEN MACIMORELIN ACETATE SPECIALTY - CORE MACUGEN SODIUM SPECIALTY - CORE MAKENA HYDROXYPROGESTERONE CAPROATE SPECIALTY - CORE MAKENA HYDROXYPROGESTERONE CAPROAT/PF SPECIALTY - CORE MAKENA HYDROXYPROGESTERONE CAPROAT/PF SPECIALTY - CORE MARQIBO SULFATE LIPOSOMAL SPECIALTY - ONCOLOGY MATULANE HCL SPECIALTY - ONCOLOGY MAVENCLAD CLADRIBINE SPECIALTY - CORE MAVYRET GLECAPREVIR/PIBRENTASVIR SPECIALTY - CORE MAYZENT SIPONIMOD SPECIALTY - CORE MEKINIST DIMETHYL SULFOXIDE SPECIALTY - ONCOLOGY MEKTOVI SPECIALTY - ONCOLOGY MELPHALAN HCL MELPHALAN HCL SPECIALTY - ONCOLOGY MENOPUR MENOTROPINS SPECIALTY - FERTILITY MEPSEVII VESTRONIDASE ALFA-VJBK SPECIALTY - CORE MIGLUSTAT SPECIALTY - CORE MIRCERA METHOXY PEG- SPECIALTY - CORE MITOMYCIN MITOMYCIN SPECIALTY - ONCOLOGY MITOMYCIN-STERILE WATER MITOMYCIN SPECIALTY - ONCOLOGY HCL MITOXANTRONE HCL SPECIALTY - ONCOLOGY MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN SPECIALTY - CORE MONONINE FACTOR IX SPECIALTY - CORE MOZOBIL SPECIALTY - ONCOLOGY MULPLETA LUSUTROMBOPAG SPECIALTY - CORE MUSTARGEN MECHLORETHAMINE HCL SPECIALTY - ONCOLOGY MUTAMYCIN MITOMYCIN SPECIALTY - ONCOLOGY MYALEPT SPECIALTY - CORE MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL HCL SPECIALTY - TRANSPLANT MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

MYFORTIC MYCOPHENOLATE SODIUM SPECIALTY - TRANSPLANT MYLERAN BUSULFAN SPECIALTY - ONCOLOGY MYLOTARG SPECIALTY - ONCOLOGY MYOBLOC BOTULINUM TOXIN TYPE B SPECIALTY - CORE NAGLAZYME GALSULFASE SPECIALTY - CORE NATPARA PARATHYROID SPECIALTY - CORE NAVELBINE TARTRATE SPECIALTY - ONCOLOGY NEORAL CYCLOSPORINE, MODIFIED SPECIALTY - TRANSPLANT NERLYNX MALEATE SPECIALTY - ONCOLOGY NEULASTA PEGFILGRASTIM SPECIALTY - CORE NEUMEGA SPECIALTY - CORE NEUPOGEN FILGRASTIM SPECIALTY - CORE NEXAVAR TOSYLATE SPECIALTY - ONCOLOGY NILANDRON NILUTAMIDE SPECIALTY - ONCOLOGY NILUTAMIDE NILUTAMIDE SPECIALTY - ONCOLOGY NINLARO CITRATE SPECIALTY - ONCOLOGY NIPENT SPECIALTY - ONCOLOGY NITYR SPECIALTY - CORE NIVESTYM FILGRASTIM-AAFI SPECIALTY - CORE NORDITROPIN FLEXPRO SOMATROPIN SPECIALTY - CORE NORDITROPIN NORDIFLEX SOMATROPIN SPECIALTY - CORE NORTHERA SPECIALTY - CORE NORVIR RITONAVIR SPECIALTY - HIV NORVIR RITONAVIR SPECIALTY - HIV NOVOEIGHT ANTIHEMOPH.FVIII,B-DOM TRUNCAT SPECIALTY - CORE NOVOSEVEN RT FACTOR VIIA,RECOMB(BHK CELLS) SPECIALTY - CORE NPLATE SPECIALTY - CORE NUCALA MEPOLIZUMAB (RECOMBINANT) SPECIALTY - CORE NULOJIX BELATACEPT SPECIALTY - TRANSPLANT NUPLAZID TARTRATE SPECIALTY - CORE NUTROPIN AQ SOMATROPIN SPECIALTY - CORE NUTROPIN AQ NUSPIN SOMATROPIN SPECIALTY - CORE NUWIQ ANTIHEMOPH.FVIII,HEK B-DELETE SPECIALTY - CORE NYMALIZE NIMODIPINE SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

OBIZUR ANTIHEMOPHILIC FVIII,PORCI REC SPECIALTY - CORE OCALIVA OBETICHOLIC ACID SPECIALTY - CORE OCREVUS OCRELIZUMAB SPECIALTY - CORE OCTAGAM IMM GLOB,GAMM (IGG)/MALTOSE SPECIALTY - CORE OCTREOTIDE ACETATE OCTREOTIDE ACETATE SPECIALTY - ONCOLOGY ODEFSEY EMTRICITAB/RILPIVIRI/TENOF ALA SPECIALTY - HIV ODOMZO PHOSPHATE SPECIALTY - ONCOLOGY OFEV ESYLATE SPECIALTY - CORE OLUMIANT SPECIALTY - CORE OLYSIO SIMEPREVIR SODIUM SPECIALTY - CORE OMNITROPE SOMATROPIN SPECIALTY - CORE ONCASPAR SPECIALTY - ONCOLOGY ONIVYDE IRINOTECAN LIPOSOMAL SPECIALTY - ONCOLOGY ONPATTRO PATISIRAN SODIUM, COMPLEX SPECIALTY - CORE ONXOL PACLITAXEL,SEMI-SYNTHETIC SPECIALTY - ONCOLOGY OPDIVO NIVOLUMAB SPECIALTY - ONCOLOGY OPSUMIT SPECIALTY - CORE ORENCIA ABATACEPT/MALTOSE SPECIALTY - CORE ORENCIA ABATACEPT SPECIALTY - CORE ORENCIA CLICKJECT ABATACEPT SPECIALTY - CORE ORENITRAM ER DIOLAMINE SPECIALTY - CORE ORFADIN NITISINONE SPECIALTY - CORE ORKAMBI LUMACAFTOR/IVACAFTOR SPECIALTY - CORE OTEZLA APREMILAST SPECIALTY - CORE OTREXUP /PF SPECIALTY - CORE OXALIPLATIN OXALIPLATIN SPECIALTY - ONCOLOGY OXERVATE CENEGERMIN-BKBJ SPECIALTY - CORE PACLITAXEL PACLITAXEL,SEMI-SYNTHETIC SPECIALTY - ONCOLOGY PACLITAXEL PACLITAXEL SPECIALTY - ONCOLOGY PALYNZIQ -PQPZ SPECIALTY - CORE PANHEMATIN HEMIN SPECIALTY - CORE PANRETIN SPECIALTY - CORE PANZYGA IMMUN GLOB G(IGG)-IFAS/GLYCINE SPECIALTY - CORE PARSABIV ETELCALCETIDE HYDROCHLORIDE SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

PEGASYS PEGINTERFERON ALFA-2A SPECIALTY - CORE PEGASYS PROCLICK PEGINTERFERON ALFA-2A SPECIALTY - CORE PEGINTRON PEGINTERFERON ALFA-2B SPECIALTY - CORE PEGINTRON REDIPEN PEGINTERFERON ALFA-2B SPECIALTY - CORE PERJETA PERTUZUMAB SPECIALTY - ONCOLOGY PERSERIS SPECIALTY - BEHAVIORAL HEALTH PHENOXYBENZAMINE HCL PHENOXYBENZAMINE HCL SPECIALTY - CORE PHOTOFRIN SPECIALTY - ONCOLOGY PIFELTRO UNKNOWN SPECIALTY - HIV PLEGRIDY PEGINTERFERON BETA-1A SPECIALTY - CORE PLEGRIDY PEN PEGINTERFERON BETA-1A SPECIALTY - CORE POMALYST POMALIDOMIDE SPECIALTY - ONCOLOGY PORTRAZZA NECITUMUMAB SPECIALTY - ONCOLOGY POTELIGEO MOGAMULIZUMAB-KPKC SPECIALTY - ONCOLOGY PRALUENT PEN ALIROCUMAB SPECIALTY - CORE PRALUENT SYRINGE ALIROCUMAB SPECIALTY - CORE PRAXBIND IDARUCIZUMAB SPECIALTY - CORE PREVYMIS LETERMOVIR SPECIALTY - CORE PREZCOBIX DARUNAVIR/COBICISTAT SPECIALTY - HIV PREZISTA DARUNAVIR ETHANOLATE SPECIALTY - HIV PRIALT ZICONOTIDE ACETATE SPECIALTY - CORE PRIVIGEN IMMU GLOBULIN,GAMMA (IGG) SPECIALTY - CORE PRIVIGEN IMMUN GLOB G(IGG)/PRO/IGA 0-50 SPECIALTY - CORE PROBUPHINE BUPRENORPHINE HCL SPECIALTY - CORE PROCRIT EPOETIN ALFA SPECIALTY - CORE PROCYSBI CYSTEAMINE BITARTRATE SPECIALTY - CORE PROFILNINE FACTOR IX COMPLEX HUMAN SPECIALTY - CORE PROGRAF TACROLIMUS SPECIALTY - TRANSPLANT PROGRAF TACROLIMUS SPECIALTY - TRANSPLANT PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR SPECIALTY - CORE PROLEUKIN ALDESLEUKIN SPECIALTY - ONCOLOGY PROLIA SPECIALTY - CORE PROMACTA OLAMINE SPECIALTY - CORE PROVENGE SIPULEUCEL-T/LACTATED RINGERS SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

PULMOZYME DORNASE ALFA SPECIALTY - CORE PURIXAN SPECIALTY - ONCOLOGY RADICAVA EDARAVONE SPECIALTY - CORE RAPAMUNE SIROLIMUS SPECIALTY - TRANSPLANT RASUVO METHOTREXATE/PF SPECIALTY - CORE RAVICTI SPECIALTY - CORE REBIF INTERFERON BETA-1A/ALBUMIN SPECIALTY - CORE REBIF REBIDOSE INTERFERON BETA-1A/ALBUMIN SPECIALTY - CORE REBINYN FACTOR IX HUMAN REC,PEGYLATED SPECIALTY - CORE RECLAST ZOLEDRONIC ACID/MANNITOL/WATER SPECIALTY - CORE RECOMBINATE ANTIHEMOPHILIC FACTOR, HUM REC SPECIALTY - CORE REMICADE INFLIXIMAB SPECIALTY - CORE REMODULIN TREPROSTINIL SODIUM SPECIALTY - CORE RENFLEXIS INFLIXIMAB-ABDA SPECIALTY - CORE REOPRO SPECIALTY - ANTICOAG REPATHA PUSHTRONEX EVOLOCUMAB SPECIALTY - CORE REPATHA SURECLICK EVOLOCUMAB SPECIALTY - CORE REPATHA SYRINGE EVOLOCUMAB SPECIALTY - CORE RETACRIT EPOETIN ALFA-EPBX SPECIALTY - CORE REVATIO CITRATE SPECIALTY - CORE REVCOVI ELAPEGADEMASE-LVLR SPECIALTY - CORE REVLIMID LENALIDOMIDE SPECIALTY - ONCOLOGY REYATAZ ATAZANAVIR SULFATE SPECIALTY - HIV REYATAZ ATAZANAVIR SULFATE SPECIALTY - HIV RIDAURA AURANOFIN SPECIALTY - CORE RISPERDAL CONSTA RISPERIDONE MICROSPHERES SPECIALTY - BEHAVIORAL HEALTH RITONAVIR RITONAVIR SPECIALTY - HIV RITUXAN SPECIALTY - ONCOLOGY RITUXAN HYCELA RITUXIMAB/HYALURONIDASE,HUMAN SPECIALTY - ONCOLOGY RIXUBIS FACTOR IX HUMAN RECOMBINANT SPECIALTY - CORE ROMIDEPSIN ROMIDEPSIN SPECIALTY - ONCOLOGY RUBRACA CAMSYLATE SPECIALTY - ONCOLOGY RUCONEST C1 ESTERASE INHIBITOR, RECOMB SPECIALTY - CORE RYDAPT MIDOSTAURIN SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

SABRIL VIGABATRIN SPECIALTY - CORE SABRIL VIGABATRIN SPECIALTY - CORE SAIZEN SOMATROPIN SPECIALTY - CORE SAIZEN-SAIZENPREP SOMATROPIN SPECIALTY - CORE SAMSCA TOLVAPTAN SPECIALTY - CORE SANDIMMUNE CYCLOSPORINE SPECIALTY - TRANSPLANT SANDIMMUNE CYCLOSPORINE SPECIALTY - TRANSPLANT SANDOSTATIN OCTREOTIDE ACETATE SPECIALTY - ONCOLOGY SANDOSTATIN LAR OCTREOTIDE ACETATE SPECIALTY - ONCOLOGY SANDOSTATIN LAR DEPOT OCTREOTIDE ACETATE,MI-SPHERE SPECIALTY - ONCOLOGY SELZENTRY MARAVIROC SPECIALTY - HIV SENSIPAR CINACALCET HCL SPECIALTY - CORE SEROSTIM SOMATROPIN SPECIALTY - CORE SIGNIFOR PASIREOTIDE DIASPARTATE SPECIALTY - CORE SIGNIFOR LAR PASIREOTIDE PAMOATE SPECIALTY - CORE SILIQ BRODALUMAB SPECIALTY - CORE SIMPONI GOLIMUMAB SPECIALTY - CORE SIMPONI ARIA GOLIMUMAB SPECIALTY - CORE SIMULECT BASILIXIMAB SPECIALTY - TRANSPLANT SIROLIMUS SIROLIMUS SPECIALTY - TRANSPLANT SIRTURO BEDAQUILINE FUMARATE SPECIALTY - CORE SODIUM PHENYLBUTYRATE SODIUM PHENYLBUTYRATE SPECIALTY - CORE SOFOSBUVIR-VELPATASVIR SOFOSBUVIR/VELPATASVIR SPECIALTY - CORE SOLESTA DEXTRANOMER/HYALURONATE/SOD CL SPECIALTY - CORE SOLIRIS ECULIZUMAB SPECIALTY - CORE SOMATULINE DEPOT LANREOTIDE ACETATE SPECIALTY - ONCOLOGY SOMAVERT PEGVISOMANT SPECIALTY - CORE SORIATANE ACITRETIN SPECIALTY - CORE SOVALDI SOFOSBUVIR SPECIALTY - CORE SPINRAZA NUSINERSEN/PRESERVATIVE FREE SPECIALTY - CORE SPRAVATO ESKETAMINE HCL SPECIALTY - BEHAVIORAL HEALTH SPRYCEL SPECIALTY - ONCOLOGY STELARA USTEKINUMAB SPECIALTY - CORE STIVARGA SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

STRENSIQ SPECIALTY - CORE STRIBILD ELVITEGR/COBICIST/EMTRIC/TENOF SPECIALTY - HIV SUBLOCADE BUPRENORPHINE SPECIALTY - CORE SUCRAID SPECIALTY - CORE SUPPRELIN LA HISTRELIN AC SPECIALTY - ONCOLOGY SUSTIVA EFAVIRENZ SPECIALTY - HIV SUTENT MALATE SPECIALTY - ONCOLOGY SYLATRON PEGINTERFERON ALFA-2B SPECIALTY - ONCOLOGY SYLVANT SILTUXIMAB SPECIALTY - CORE SYMDEKO TEZACAFTOR/IVACAFTOR SPECIALTY - CORE SYMFI EFAVIRENZ/LAMIVU/TENOFOV DISOP SPECIALTY - HIV SYMFI LO EFAVIRENZ/LAMIVU/TENOFOV DISOP SPECIALTY - HIV SYMTUZA DARUNAVIR/COB/EMTRI/TENOF ALAF SPECIALTY - HIV SYNAGIS PALIVIZUMAB SPECIALTY - CORE SYNAREL NAFARELIN ACETATE SPECIALTY - CORE SYNRIBO HOMOHARRINGTONINE SPECIALTY - ONCOLOGY SYPRINE TRIENTINE HCL SPECIALTY - CORE TABLOID THIOGUANINE SPECIALTY - ONCOLOGY TACROLIMUS TACROLIMUS SPECIALTY - TRANSPLANT TADALAFIL TADALAFIL SPECIALTY - CORE TAFINLAR MESYLATE SPECIALTY - ONCOLOGY TAGRISSO MESYLATE SPECIALTY - ONCOLOGY TAKHZYRO LANADELUMAB-FLYO SPECIALTY - CORE TALTZ AUTOINJECTOR IXEKIZUMAB SPECIALTY - CORE TALTZ AUTOINJECTOR (2 PACK) IXEKIZUMAB SPECIALTY - CORE TALTZ AUTOINJECTOR (3 PACK) IXEKIZUMAB SPECIALTY - CORE TALTZ SYRINGE IXEKIZUMAB SPECIALTY - CORE TALTZ SYRINGE (2 PACK) IXEKIZUMAB SPECIALTY - CORE TALTZ SYRINGE (3 PACK) IXEKIZUMAB SPECIALTY - CORE TALZENNA TOSYLATE SPECIALTY - ONCOLOGY TARCEVA HCL SPECIALTY - ONCOLOGY TARGRETIN BEXAROTENE SPECIALTY - ONCOLOGY TARGRETIN BEXAROTENE SPECIALTY - ONCOLOGY TASIGNA HYDROCHLORIDE SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

TAVALISSE FOSTAMATINIB DISODIUM SPECIALTY - CORE TAXOTERE DOCETAXEL SPECIALTY - ONCOLOGY TECENTRIQ ATEZOLIZUMAB SPECIALTY - ONCOLOGY TECFIDERA DIMETHYL FUMARATE SPECIALTY - CORE TECHNIVIE OMBITASVIR/PARITAPREV/RITONAV SPECIALTY - CORE TEGSEDI INOTERSEN SODIUM SPECIALTY - CORE TEMODAR SPECIALTY - ONCOLOGY TEMODAR TEMOZOLOMIDE SPECIALTY - ONCOLOGY TEMOZOLOMIDE TEMOZOLOMIDE SPECIALTY - ONCOLOGY TEMSIROLIMUS SPECIALTY - ONCOLOGY TENIPOSIDE SPECIALTY - ONCOLOGY FUMARATE TENOFOVIR DISOPROXIL FUMARATE SPECIALTY - HIV TEPADINA SPECIALTY - ONCOLOGY TEPADINA THIOTEPA SPECIALTY - ONCOLOGY TETRABENAZINE TETRABENAZINE SPECIALTY - CORE TEV-TROPIN SOMATROPIN SPECIALTY - CORE THALOMID THALIDOMIDE SPECIALTY - ONCOLOGY THIOLA TIOPRONIN SPECIALTY - CORE THIOTEPA THIOTEPA SPECIALTY - ONCOLOGY THYMOGLOBULIN LYMPHOCYTE IMMU GLOB.,RABBIT SPECIALTY - TRANSPLANT THYROGEN THYROTROPIN ALFA SPECIALTY - ONCOLOGY TIBSOVO SPECIALTY - ONCOLOGY TIGLUTIK RILUZOLE SPECIALTY - CORE TIVICAY DOLUTEGRAVIR SODIUM SPECIALTY - HIV TOBI TOBRAMYCIN/0.25 NORMAL SALINE SPECIALTY - CORE TOBI PODHALER TOBRAMYCIN SPECIALTY - CORE TOBRAMYCIN TOBRAMYCIN/0.25 NORMAL SALINE SPECIALTY - CORE TOBRAMYCIN TOBRAMYCIN/NEBULIZER SPECIALTY - CORE TOPOTECAN HCL TOPOTECAN HCL SPECIALTY - ONCOLOGY TOREMIFENE CITRATE TOREMIFENE CITRATE SPECIALTY - ONCOLOGY TORISEL TEMSIROLIMUS SPECIALTY - ONCOLOGY TRACLEER SPECIALTY - CORE TREANDA BENDAMUSTINE HCL SPECIALTY - ONCOLOGY TRELSTAR TRIPTORELIN PAMOATE SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

TREMFYA GUSELKUMAB SPECIALTY - CORE TREPROSTINIL TREPROSTINIL SODIUM SPECIALTY - CORE TRETINOIN SPECIALTY - ONCOLOGY TRETTEN FACTOR XIII A-SUBUNIT,RECOMB SPECIALTY - CORE TRIENTINE HCL TRIENTINE HCL SPECIALTY - CORE TRIPTODUR TRIPTORELIN PAMOATE SPECIALTY - CORE TRISENOX ARSENIC TRIOXIDE SPECIALTY - ONCOLOGY TRIUMEQ ABACAVIR/DOLUTEGRAVIR/LAMIVUDI SPECIALTY - HIV TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE SPECIALTY - HIV TROGARZO IBALIZUMAB-UIYK SPECIALTY - HIV TRUVADA EMTRICITABINE/TENOFOVIR SPECIALTY - HIV TYKERB DITOSYLATE SPECIALTY - ONCOLOGY TYMLOS ABALOPARATIDE SPECIALTY - CORE TYSABRI NATALIZUMAB SPECIALTY - CORE TYVASO TREPROSTINIL SPECIALTY - CORE TYVASO INSTITUTIONAL START KIT TREPROSTINIL/NEBULIZER/ACCESOR SPECIALTY - CORE TYVASO REFILL KIT TREPROSTINIL/NEB ACCESSORIES SPECIALTY - CORE TYVASO STARTER KIT TREPROSTINIL/NEBULIZER/ACCESOR SPECIALTY - CORE TYZEKA SPECIALTY - CORE UDENYCA PEGFILGRASTIM-CBQV SPECIALTY - CORE ULTOMIRIS RAVULIZUMAB-CWVZ SPECIALTY - CORE UNITUXIN DINUTUXIMAB SPECIALTY - ONCOLOGY UPTRAVI SPECIALTY - CORE VALCHLOR MECHLORETHAMINE HCL SPECIALTY - ONCOLOGY VALSTAR SPECIALTY - ONCOLOGY VANTAS HISTRELIN AC SPECIALTY - ONCOLOGY VECTIBIX SPECIALTY - ONCOLOGY VELCADE BORTEZOMIB SPECIALTY - ONCOLOGY VELETRI EPOPROSTENOL SODIUM () SPECIALTY - CORE VEMLIDY FUMARATE SPECIALTY - CORE VENCLEXTA SPECIALTY - ONCOLOGY VENCLEXTA STARTING PACK VENETOCLAX SPECIALTY - ONCOLOGY VENTAVIS SPECIALTY - CORE VERZENIO SPECIALTY - ONCOLOGY MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

VIDAZA AZACITIDINE SPECIALTY - ONCOLOGY VIEKIRA PAK OMBITA/PARITAP/RITON/DASABUVIR SPECIALTY - CORE VIEKIRA XR OMBITA/PARITAP/RITON/DASABUVIR SPECIALTY - CORE VIGABATRIN VIGABATRIN SPECIALTY - CORE VIGADRONE VIGABATRIN SPECIALTY - CORE VIMIZIM ELOSULFASE ALFA SPECIALTY - CORE SULFATE VINBLASTINE SULFATE SPECIALTY - ONCOLOGY VINORELBINE TARTRATE VINORELBINE TARTRATE SPECIALTY - ONCOLOGY VIRACEPT NELFINAVIR MESYLATE SPECIALTY - HIV VIREAD TENOFOVIR DISOPROXIL FUMARATE SPECIALTY - HIV VIREAD TENOFOVIR DISOPROXIL FUMARATE SPECIALTY - HIV VISTOGARD TRIACETATE SPECIALTY - ONCOLOGY VISUDYNE SPECIALTY - CORE VITEKTA ELVITEGRAVIR SPECIALTY - HIV VITRAKVI SULFATE SPECIALTY - ONCOLOGY VIVITROL NALTREXONE MICROSPHERES SPECIALTY - CORE VIZIMPRO SPECIALTY - ONCOLOGY VONVENDI VON WILLEBRAND FACTOR SPECIALTY - CORE VORAXAZE GLUCARPIDASE SPECIALTY - ONCOLOGY VOSEVI SOFOSBUVIR/VELPATAS/VOXILAPREV SPECIALTY - CORE VOTRIENT HYDROCHLORIDE SPECIALTY - ONCOLOGY VPRIV SPECIALTY - CORE VYXEOS DAUNORUBICIN/CYTARABINE LIPOS SPECIALTY - ONCOLOGY WILATE AHF,HUMAN/VWF,HUMAN SPECIALTY - CORE WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE SPECIALTY - CORE XALKORI SPECIALTY - ONCOLOGY XATMEP METHOTREXATE SPECIALTY - CORE XELJANZ CITRATE SPECIALTY - CORE XELJANZ XR TOFACITINIB CITRATE SPECIALTY - CORE XELODA CAPECITABINE SPECIALTY - ONCOLOGY XENAZINE TETRABENAZINE SPECIALTY - CORE XEOMIN INCOBOTULINUMTOXINA SPECIALTY - CORE XERMELO TELOTRISTAT ETIPRATE SPECIALTY - CORE XGEVA DENOSUMAB SPECIALTY - CORE MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

XOFIGO RADIUM-223 DICHLORIDE SPECIALTY - ONCOLOGY XOLAIR OMALIZUMAB SPECIALTY - CORE XOSPATA FUMARATE SPECIALTY - ONCOLOGY XTANDI ENZALUTAMIDE SPECIALTY - ONCOLOGY XURIDEN SPECIALTY - CORE XYNTHA ANTIHEMOPHILIC FACTOR,HUMAN SPECIALTY - CORE XYNTHA SOLOFUSE ANTIHEMOPHILIC FACTOR,HUMAN SPECIALTY - CORE XYNTHA SOLOFUSE ANTIHEMOPH.FVIII PLAS/ALB FREE SPECIALTY - CORE XYNTHA SOLOFUSE ANTIHEMOPH.FVIII,B-DOMAIN DEL SPECIALTY - CORE XYREM SPECIALTY - CORE YERVOY IPILIMUMAB SPECIALTY - ONCOLOGY YESCARTA AXICABTAGENE CILOLEUCEL SPECIALTY - ONCOLOGY YONDELIS SPECIALTY - ONCOLOGY YONSA ABIRATERONE ACET,SUBMICRONIZED SPECIALTY - ONCOLOGY ZALTRAP AFLIBERCEPT SPECIALTY - ONCOLOGY ZANOSAR STREPTOZOCIN SPECIALTY - ONCOLOGY ZARXIO FILGRASTIM-SNDZ SPECIALTY - CORE ZAVESCA MIGLUSTAT SPECIALTY - CORE ZEJULA TOSYLATE SPECIALTY - ONCOLOGY ZELBORAF SPECIALTY - ONCOLOGY ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR SPECIALTY - CORE ZEPATIER ELBASVIR/GRAZOPREVIR SPECIALTY - CORE ZEVALIN KIT FOR Y-90/IBRITUMOMAB/ALBMN SPECIALTY - ONCOLOGY ZIAGEN ABACAVIR SULFATE SPECIALTY - HIV ZINBRYTA DACLIZUMAB SPECIALTY - CORE ZOLADEX GOSERELIN ACETATE SPECIALTY - ONCOLOGY ZOLEDRONIC ACID ZOLEDRONIC ACID SPECIALTY - CORE ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL/WATER SPECIALTY - CORE ZOLINZA SPECIALTY - ONCOLOGY ZOMACTON SOMATROPIN SPECIALTY - CORE ZOMETA ZOLEDRONIC ACID SPECIALTY - CORE ZOMETA ZOLEDRONIC ACID/MANNITOL/WATER SPECIALTY - CORE ZORBTIVE SOMATROPIN SPECIALTY - CORE ZORTRESS EVEROLIMUS SPECIALTY - TRANSPLANT MedImpact April 2019 Specialty Drug List

Brand Name Generic Name Specialty Drug Group Code

ZYDELIG SPECIALTY - ONCOLOGY ZYKADIA SPECIALTY - ONCOLOGY ZYPREXA RELPREVV PAMOATE SPECIALTY - BEHAVIORAL HEALTH ZYTIGA ABIRATERONE ACETATE SPECIALTY - ONCOLOGY ZYTIGA ABIRATERONE ACETATE SPECIALTY - ONCOLOGY