UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change
£Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy
CARDIOLOGY ENDOCRINOLOGY (cont’d) GASTROENTEROLOGY (cont’d)
ANTILIPIDEMICS GROWTH DEFICIENCY HEPATITIS B Praluent® (Alirocumab) Genotropin® (Somatropin) Baraclude® (Entecavir) Repatha® (Evolocumab) Humatrope® (Somatropin) Epivir HBV® (Lamivudine) Norditropin® (Somatropin) Hepsera® (Adefovir dipivoxil) PULMONARY ARTERIAL ® HYPERTENSION Novarel (Chorionic Gonadotropin) Lamivudine ® Adcirca® (Tadalafil) Nutropin AQ (Somatropin) Tenofovir disoproxil fumerate ® ® Revatio® (Sildenafil) Omnitrope (Somatropin) Vemlidy (Tenofovir alafenamide) ® ® Sildenafil Saizen (Somatropin) Viread (Tenofovir disoproxil ® Serostim (Somatropin fumarate)
DERMATOLOGY Zorbtive® (Somatropin) HEPATITIS C ATOPIC DERMATITIS METABOLISM DISORDER Daklinza® (Daclatasvir)
Dupixent® (Dupilumab) Aldurazyme® (Laronidase) £ Epclusa® (Sofosbuvir/Velpatasvir) Buphenyl® (Sodium phenylbutyrate) Harvoni® (Ledipasvir/Sofosbuvir) HIDRADENITIS SUPPURATIVA ® £ ® ® Cerezyme (Imiglucerase) Intron A (Interferon alfa-2b) Humira (Adalimumab) ® £ Elaprase (Idursulfase) Ledipasvir/Sofosbuvir PLAQUE PSORIASIS Elelyso® (Taliglucerase alfa) £ Mavyret® (Glecaprevir/Pibrentasvir) ® Cimzia (Certolizumab pegol) Fabrazyme® (Agalsidase beta) £ Olysio® (Simeprevir) ® Cosentyx (Secukinumab) Kanuma® (Sebelipase alfa) Pegasys® (Peginterferon alfa-2a) ® Enbrel (Etanercept) Kuvan® (Sapropterin PegIntron® (Peginterferon alfa-2b) ® Humira (Adalimumab) dihydrochloride) Rebetol® (Ribavirin) ® Otezla (Apremilast) Lumizyme® (Alglucosidase alfa) Ribasphere® (Ribavirin) ® Remicade (Infliximab) £ Naglazyme® (Galsulfase) Riba-Pak® (Ribavirin) RenflexisTM (Infliximab-abda) £ Vimizim® (Elosulfase alfa) Ribavirin
Stelara® (Ustekinumab) Vpriv® (Velaglucerase alfa) Sofosbuvir/Velpatasvir Taltz® (Ixekizumab) ® OSTEOPOROSIS Sovaldi (Sofosbuvir) ® ™ Tremfya (Guselkumab) ® Technivie (Ombitasvir/ Forteo (Teriparatide) Prolia® (Denosumab) Paritaprevir/ Ritonavir) ™ ENDOCRINOLOGY TYMLOS® (Abaloparatide) Viekira Pak (Ombitasvir/ Paritaprevir/ Ritonavir; Dasabuvir) ACROMEGALY Viekira XR™ Ombitasvir/ Octreotide acetate GASTROENTEROLOGY Paritaprevir/ Ritonavir/ Dasabuvir) Sandostatin® (Octreotide acetate) CROHN’S DISEASE/ Vosevi® (Sofosbuvir/Velpatasvir/ Sandostatin LAR® (Octreotide ULCERATIVE COLITIS ® Voxilaprevir) acetate) Cimzia (Certolizumab pegol) ® (Elbasvir/Grazoprevir) ® £ Zepatier ELECTROLYTE IMBALANCE Entyvio (Vedolizumab) ® Other Jadenu® (Deferasirox) Humira (Adalimumab) ® Doptelet® (Avatrombopag) Veltassa® (Patiromer) Kineret (Anakinra) ® £ Remicade (Infliximab) RenflexisTM (Infliximab-abda) £
Simponi® (Golimumab)
Stelara® (Ustekinumab)
Last Updated: February 2019
unitypoint.org/specialty-pharmacy
UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change
£Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy
HEMATOLOGY HEMATOLOGY (cont’d) INFECTIOUS DISEASE (cont’d)
HEMATOPOIETIC GROWTH HEMOPHILIA & RELATED HIV/AIDS (con’td) £ ® FACTORS DISORDERS (con’td) Crixivan (Indinavir sulfate) Aranesp® (Darbepoetin alfa) Kovaltry® (Antihemophilic Factor Descovy® (Emtricitabine/ Tenofovir) Epogen® (Epoetin alfa) (Recombinant) Didanosine Granix® (TBO Filgrastim) Monoclate-P® (Antihemophilic Edurant®(Rilpivirine) Leukine® (Sargramostim) factor) Egrifta® (Tesamorelin) Neulasta® (Pegfilgrastim) Novoeight® (Antihemophilic Factor) Emtriva® (Emtricitabine) Neupogen® (Filgrastim) Novoseven® RT (Coagulation Factor Entecavir Procrit® (Epoetin alfa) VIIa) Epivir® (Lamivudine) Promacta® (Eltrombopag) Nuwiq® (Human coagulation factor Epzicom® (Abacavir/ Lamivudine) Zarxio® (Filgrastim-sndz) VIII recombinant DNA, simoctocog Evotaz™ (Atazanavir/ Cobicistat) ® HEMOPHILIA & RELATED alfa) Fuzeon (Enfuvirtide) ® ® DISORDERS £ Profilnine (Factor IX Complex) Genvoya (Elvitegravir/ Cobicistat/ ® Advate® (Antihemophilic Factor Recombinate (Antihemophilic Emtricitabine/ Tenofovir (Recombinant)) Factor) alafenamide) ® ™ Afstyla® (Antihemophilic Factor Rixubis (Coagulation Factor IX) Intelence (Entravirine) ® (recombinant), Single Chain Thrombate III (Antithrombin III) Invirase® (Saquinavir) ® ® Alphanate® (Antihemophilic Wilate (von Willebrand factor / Isentress (Raltegravir)
factor/von Willebrand factor Coagulation Factor VIII complex) Juluca® (Dolutegravir/ Rilpivirine) ® ® Xyntha (Antihemophilic Factor) Kaletra (Lopinavir/ Ritonavir) complex) AlphaNine SD® (Coagulation Factor OTHER Lamivudine IX) Soliris® (Eculizumab) Lamivudine/Zidovudine ® Alprolix® (Coagulation Factor IX) RiaSTAP® (Fibrinogen Concentrate) Lexiva (Fosamprenavir) Bebulin® (Factor IX Complex) Lopinavir/ritonavir BeneFIX® (Coagulation Factor IX) INFECTIOUS DISEASE Nevirapine ® Norvir® (Ritonavir) Eloctate (Antihemophilic Factor/ HEPATITIS B / HEPATITIS C Odefsey® (Emtricitabine/ Rilpivirine/ Fc-Fusion Protein) *See Gastroenterology Section* Feiba NF® (Anti-Inhibitor Coagulant Tenofovir alafenamide)
Complex) HIV/AIDS PREZCOBIX® (Darunavir/ Cobicistat) ® Helixate® FS (Antihemophilic Factor) Abacavir Prezista (Darunavir) ® Helimbra® (emicizumab-kxwh) Abacavir Sulfate/ Lamivudine/ Rescriptor (Dalavirdine mesylate) ® Hemofil M® (Antihemophilic Factor) Zidovudine Retrovir (Zidovudine) ® Humate-P® (Antihemophilic Abacavir/ Lamivudine Reyataz (Atazanavir)
Factor/von Willebrand Factor Adefovir dipivoxil Selzentry® (Maraviroc) ® (VWF) Complex) Aptivus (Tipranavir) Stavudine ® ® Idelvion® (Coagulation Factor IX Atripla (Efavirenz/ Emtricitabine/ Stribild (Elvitegravir/ Cobicistat/ (Recombinant), Albumin fusion Tenofovir) Emtricitabine/tenofovir) ® protein) Biktarvy (Bictegravir/emtricitibine/ Sustiva® (Efavirenz) ® Koāte®-DVI (Antihemophilic Factor) tenofovir alafenamide) Tivicay (Dolutegravir) ® ® (Antihemophilic Combivir (Lamivudine/ Zidovudine) Triumeq® (Abacavir/ Dolutegravir/ Kogenate FS ® Factor) Complera (Emtricitabine/ Lamivudine) Rilpivirine/ tenofovir)
Last Updated: February 2019
unitypoint.org/specialty-pharmacy
UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change
£Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy
INFECTIOUS DISEASE (cont’d) NEUROLOGY PULMONOLOGY (cont’d)
HIV/AIDS (con’td) BOTULINUM TOXINS HEREDITARY ANGIOEDEMA Trizivir® (Abacavir/ Lamivudine/ Botox® (OnabotulinumtoxinA) Firazyr® (Icatibant) Zidovudine) Myobloc® (RimabotulinumtoxinB) Kalbitor® (Ecallantide) Truvada® (Emtricitabine/ Tenofovir) Xeomin® (IncobotulinumtoxinA) ® PULMONARY ARTERIAL Tybost (Cobicistat) HYPERTENSION ® MIGRANE PREVENTION Valcyte (Valganciclovir Aimovig® (Erenumab) Adcirca® (Tadalafil) hydrochloride) ® (Fremanezumab) Revatio® (Sildenafil) ® Ajovy VIDEX (Didanosine) ® (OnabotulinumtoxinA) Sildenafil ® Botox Viracept (Nelfinavir mesylate) ® (Galcanezumab) ® Emgality Viramune (Nevirapine) RHEUMATOLOGY Voriconazole MOVEMENT DISORDER ® ANKYLOSING SPONDYLITIS Zerit® (Stavudine) Austedo (Deutetrabenazine) Cimzia® (Certolizumab pegol) Ziagen® (Abacavir) Dalfampridine Tetrabenazine Cosentyx® (Secukinumab) Zidovudine ® Xadago® (Safinamide) Humira (Adalimumab) OTHER Simponi® (Golimumab) Dificid® (Fidoximicin) MULTIPLE SCLEROSIS ® CRYOPYRIN-ASSOCIATED Noxafil® (Posaconazole) Aubagio (Teriflunomide) Avonex® (Interferon beta-1a) PERIODIC SYNDROMES ® ® (Interferon beta-1b) Ilaris (Canakinumab) MEN’S / WOMEN’S HEALTH BETASERON Copaxone® (Glatiramer acetate) PSORIATIC ARTHRITIS HORMONE THERAPY ® ® ® Extavia (Interferon beta-1b) Cimzia (Certolizumab pegol) Eligard (Leuprolide acetate) Gilenya® (Fingolimod) Cosentyx® (Secukinumab) Firmagon® (Degarelix) Glatiramer acetate Enbrel® (Etanercept) Leuprolide acetate Glatopa® (Glatiramer acetate) Humira® (Adalimumab) Lupron DEPOT® (Leuprolide acetate) Rebif® (Interferon beta-1a) Otezla® (Apremilast) Makena® (Hydroxyprogesterone Tysabri® (Natalizumab) £ Simponi® (Golimumab) caproate) Stelara® (Ustekinumab) Supprelin® LA (Histrelin acetate) PULMONOLOGY ® (Ixekizumab) ® Taltz Synarel (Nafarelin acetate) Thyrogen® (Thyrotropin alfa) ASTHMA RHEUMATOID ARTHRITIS ® £ Trelstar® (Triptorelin pamoate) Cinqair (Reslizumab) Actemra® (Tocilizumab) ® Vantas® (Histrelin) Dupixent (Dupilumab) Cimzia® (Certolizumab pegol) ® Zoladex® (Goserelin acetate) Fasenra (Benralizumab) Enbrel® (Etanercept) Nucala® (Mepolizumab) ® Humira (Adalimumab) NEPHROLOGY CYSTIC FIBROSIS Kevzara® (Sarilumab) ® ® ANEMIA Bethkis (Tobramycin) Kineret (Anakinra) ® ® Aranesp® (Darbepoetin alfa) Kitabis Pak (Tobramycin) Olumiant (Baricitinib) ® ® ® Epoetin alfa) Pertzye (Pancrelipase) Orencia (Abatacept) Epogen ( ® ® Pulmozyme® (Dornase Alfa) Simponi (Golimumab) Procrit (Epoetin alfa) ® Tobramycin Simponi Aria (Golimumab) ELECTROLYTE IMBALANCE Xeljanz® (Tofacitinib) Jadenu® (Deferasirox) Veltassa® (Patiromer)
Last Updated: February 2019
unitypoint.org/specialty-pharmacy
UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change
£Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy
RHEUMATOLOGY (cont’d) PEDIATRICS PSYCHIATRY
SYSTEMIC LUPUS CROHN’S DISEASE PARKINSON’S RELATED ERYTHEMATOSUS (SLE) Humira® (Adalimumab) PSYCHOSIS Benlysta® (Belimumab) RenflexisTM (Infliximab-abda) £ Nuplazid® (Pimavenserin)
JUVENILE IDIOPATHIC PSYCHIATRIC DISORDERS ONCOLOGY ARTHRITIS Abilify Maintena® (Aripiprazole) *See Chemotherapy and Humira® (Adalimumab) Aristada® (Aripiprazole lauroxil) Supportive Care Drug List* ® ® Ilaris (Canakinumab) Invega Sustenna (Paliperidone) ® OPTHALMOLOGY NEONATAL ONSET Invega Trinza (Paliperidone) ® MULTISYSTEM Risperdal Consta (Risperidone) BLEPHAROSPASM Botox® (OnabotulinumtoxinA) INFLAMMATORY DISEASE SUBSTANCE DEPENDENCY ® ® Xeomin® (IncobotulinumtoxinA) Kineret (Anakinra) Vivitrol (Naltrexone)
NON-INFECTIOUS UVEITIS RESPIRATORY SYNCTIAL VIRUS TARDIVE DYSKINESIA ® ® ® (Adalimumab) Synagis (Palivizumab) Austedo (Deutetrabenazine) Humira
MACULAR DEGENERATION UROLOGY ® Macugen® (Pegaptanib sodium) Botox (OnabotulinumtoxinA) ® Erleada (Apalutamide)
Lupron® (Leuprolide acetate)
Is there a medication not listed above? Contact UnityPoint at Home Specialty Pharmacy or your Specialty Pharmacy Program Coordinator to see if UnityPoint at Home Specialty Pharmacy can facilitate access to the medication!
* Oncology and Supportive Care Medications can be found on the UnityPoint at Home Specialty Pharmacy Chemotherapy and Supportive Care drug list.
Contact us Today! UnityPoint at Home Specialty Pharmacy 11333 Aurora Avenue Urbandale, IA 50322 Ph: 515-557-3110 Fax: 855-806-7285 www.unitypoint.org/specialty-pharmacy
Last Updated: February 2019
unitypoint.org/specialty-pharmacy