INJECTABLE DRUGS REQUIRING PRIOR AUTHORIZATION/PRECERTIFICATION Drugs Usually Self-Administered Brand Name Generic Name Brand Name Generic Name Actimmune Interferon gamma Lovenox Enoxaparin Sodium Advate Antihemophilic Factor XIII Lupron Leuprolide Alphanate Antihemophilic Factor VIII-AHF Monoclate-P Antihemophilic Factor VIII-AHF AlphaNine SD Factor IX Concentrates Mononine Factor IX Concentrates Apokyn Apomorphine Mozobil Plerixafor Aranesp Darbepoetin Natpara Parathyroid hormone (Recombinant) Arixtra Fondaparinux Neumega Oprelvekin Avonex Interferon Beta-1a Neulasta Pegfilgrastim Bebulin VH Factor IX Concentrates Neupogen Filgrastim Benefix Factor IX Concentrates Norditropin Somatropin, HGH Betaseron Interferon Beta-1b NovoSeven Coagulation Factor VIIa Bydureon Exenatide NovoSeven RT Coagulation Factor VIIa Byetta Extenatide Nutropin/AQ Somatropin, HGH Caverject Alprostadil Obizur Antihemophilic Factor IV (Recomb Porc) rpFVIII Cimzia Certolizumab Pegol Orbactiv Oritavancin Diphosphate Copaxone Glatiramer Orencia Abatacept Corifact Factor XIII Otrexup methotrexate soln PF Eloctate Factor VIII (Recomb) Pegasys Peginterferon Alfa-2a Edex Alprostadil PEG-Intron Peginterferon Alfa-2b Egrifta Tesamorelin acetate Praluent Alirocumab Enbrel Etanercept Procrit Epoetin Alfa Epogen Epoetin Alfa Profilnine Factor IX Concentrates Extavia Interferon Beta-1B Proplex T Factor IX Concentrates Fibrogammin P Antihemophilic Factor XIII Rasuvo Methotrexate Firazyr Icatibant acetate Rebif Interferon Beta-1a Forteo Teriparatide Recombinate Antihemophilic Factor VIII-AHF Fragmin Daltaparin Refacto Antihemophilic Factor VIII-AHF Fuzeon Enfuvirtide Relistor Methylnaltrexone Bromide Gattex Teduglutide Remodulin Treprostinil Genotropin Somatropin, HGH Roferon-A Interferon Alfa-2a Glatopa Glatiramer) Sandostatin Octreotide (Not Depot) Helixate FS Antihemophilic Factor VIII-AHF Serostim Somatropin, HGH Hemofil M Antihemophilic Factor VIII-AHF Signifor Pasireotide Diaspartate Humatrope Somatropin, HGH Simponi Golimumab Humira Adalimumab Somatuline Lanreotide Acetate Extended Rel. Imitrex Sumatriptan Somavert Pegvisomant Ilaris Canakinumab Stelara Ustekinumab Infergen Interferon Alfacon-1 Stensiq Asfotase Alfa Innohep Tinzaparin Sylatron Peginterferon alfa-2B Intron-A Interferon Alfa-2b Symlin Pramlintide Iplex Mecasermin Rinfabate Tanzeum Albiglutide Iprivask Desirudin Tev-Tropin Somatropin, rDNA Ixinity Coagulation Factor IX (Recomb) Trulicity Dulaglutide Kineret Anakinra Wilate Antihemophilic Factor/VWF Koate-DVI Antihemophilic Factor VIII-AHF Xyntha Antihemophilic Factor Kogenate Antihemophilic Factor VIII-AHF Zarxio Filgastrim-SNDZ Kogenate FS Antihemophilic Factor VIII-AHF Zoladex Goserelin Acetate Kynamro Mipomersen Sodium Zorbtive Somatropin, rDNA Leukine Sargramostim * List subject to change as new brand name equivalents become available. ** Subject to plan benefit limitations and/or exclusions. September 1, 2016

* List subject to change as new brand name equivalents become available. ** Subject to plan benefit limitations and/or exclusions. September 1, 2016