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Separately Chargeable Drugs List 15 SEPTEMBER 2021 Separately Chargeable Drugs List Also known to customers as: List of specialist drugs Important information for providers only Listed below are the drugs which may be billed in addition to the charges that have been agreed as part of current hospital contracts. Drugs marked with * are those which may be charged separately when used as part of eligible treatment for cancer only. All separately chargeable drugs require pre-authorisation, we ask providers to call Bupa Provider Services on 0345 755 3333. Lines are open 9am to 5pm, Monday to Friday (calls may be recorded and may be monitored). Bupa Generic name (Brand name) Dosage, Cancer Pre- code formulation and only authorisation pack size required AD001 abciximab (ReoPro) 2mg/mL - 5mL vial No Yes injection AD002 aldesleukin (Interleukin-2) (Proleukin) 18million iu vial - Yes Yes powder for reconstitution AD006 alteplase (Actilyse) Powder for No Yes reconstitution - 20 mg (11.6 million units)/vial AD007 alteplase (Actilyse) 50 mg (29 million No Yes units)/vial injection AD008 alteplase (Actilyse) 10 mg (5.8 million No Yes units)/vial injection AD010 amphotericin (AmBisome) 50mg vial - powder No Yes for reconstitution AD011 amsacrine (Amsidine) 1.5mL (75mg) Yes Yes ampoule and 13.5mL diluent vial AD012 anagrelide (Xagrid) 100 x 500 mcg Yes Yes capsules AD013 anastrozole (Arimidex) 28 x 1mg tablets Yes Yes AD014 aprepitant (Emend) 2 x 80mg capsules Yes Yes AD015 aprepitant (Emend) 5 x 125mg capsules Yes Yes Please note that printed or downloaded versions of this document may be out of date. Bupa separately chargeable drugs list – 15 September 2021 Valid until 15 October 2021 © Bupa Insurance Services Limited 2021 15 SEPTEMBER 2021 Separately Chargeable Drugs List Also known to customers as: List of specialist drugs Bupa Generic name (Brand name) Dosage, Cancer Pre- code formulation and only authorisation pack size required AD016 aprepitant (Emend) 1 x 125mg capsule Yes Yes and 2 x 80mg capsules AD017 arsenic trioxide (Trisenox) 1mg/ml - 10mL Yes Yes ampoule for iv infusion AD018 azacitidine (Vidaza) 100mg vial injection - Yes Yes powder for reconstitution AD019 basiliximab (Simulect) 10mg vial injection - No Yes powder for reconsitution AD020 basiliximab (Simulect) 20mg vial injection - No Yes powder for reconsitution AD021 bendamustine hydrochloride (Levact) 25mg vial injection - Yes Yes powder for reconsitution AD022 bendamustine hydrochloride (Levact) 100mg vial injection - Yes Yes powder for reconsitution AD023 bevacizumab (Avastin) 25mg/mL - 16mL No Yes (400mg) vial for iv infusion AD024 bevacizumab (Avastin) 25mg/mL - 4mL No Yes (100mg) vial for iv infusion AD025 bexarotene (Targretin) 100 x 75mg capsules Yes Yes AD026 bicalutamide (Casodex) 28 x 50mg tablets Yes Yes AD027 bicalutamide (Casodex) 28 x 150mg tablets Yes Yes AD028 bivalirudin (Angiox) 250mg vial injection - No Yes powder for reconstitution AD029 bleomycin (Non Proprietary) 15,000 unit vial Yes Yes injection AD030 bortezomib (Velcade) 3.5mg vial injection - Yes Yes powder for reconstitution Please note that printed or downloaded versions of this document may be out of date. Bupa separately chargeable drugs list – 15 September 2021 Valid until 15 October 2021 © Bupa Insurance Services Limited 2021 15 SEPTEMBER 2021 Separately Chargeable Drugs List Also known to customers as: List of specialist drugs Bupa Generic name (Brand name) Dosage, Cancer Pre- code formulation and only authorisation pack size required AD031 botulinum A toxin (Botox) 100 unit vial injection No Yes AD032 botulinum A toxin (Botox) 200 unit vial injection No Yes AD033 botulinum A toxin (Botox) 50 unit vial injection No Yes AD034 botulinum A toxin (Dysport) 500 unit vial injection No Yes AD035 busulfan (Busilvex) 6mg/mL - 10mL vial Yes Yes concentrate for iv infusion AD036 buserelin (Suprefact) 1mg/ml - 2 x 5.5 ml Yes Yes vial injection AD037 buserelin (Suprefact) 100 mcg/metered Yes Yes spray - 4 x 10g bottle AD038 capecitabine (Xeloda) 60 x 150mg tablets Yes Yes AD039 capecitabine (Xeloda) 120 x 500mg tablets Yes Yes AD040 carboplatin (Non Proprietary) 10mg/mL - 15mL vial Yes Yes injection AD041 carboplatin (Non Proprietary) 10mg/mL - 45mL vial Yes Yes injection AD042 carboplatin (Non Proprietary) 10mg/mL - 5mL vial Yes Yes injection AD043 carboplatin (Non Proprietary) 10mg/mL - 60mL vial Yes Yes injection AD044 carmustine (Gliadel) 7.7mg implant Yes Yes AD045 caspofungin (Cancidas) 50mg vial - powder No Yes for iv infusion AD046 caspofungin (Cancidas) 70mg vial - powder No Yes for iv infusion AD047 cetuximab (Erbitux) 5mg/mL - 100mL vial Yes Yes for iv infusion AD048 cetuximab (Erbitux) 5mg/mL - 20mL vial Yes Yes for iv infusion AD049 chlorambucil (Leukeran) 25 x 2mg tablets Yes Yes AD050 chlorpromazine (Non Proprietary) 28 x 25mg tablets Yes Yes AD051 chlorpromazine (Non Proprietary) 28 x 50mg tablets Yes Yes AD052 chlorpromazine (Non Proprietary) 28 x 100mg tablets Yes Yes AD053 chlorpromazine (Non Proprietary) 25mg/5mL - 150mL Yes Yes oral solution Please note that printed or downloaded versions of this document may be out of date. Bupa separately chargeable drugs list – 15 September 2021 Valid until 15 October 2021 © Bupa Insurance Services Limited 2021 15 SEPTEMBER 2021 Separately Chargeable Drugs List Also known to customers as: List of specialist drugs Bupa Generic name (Brand name) Dosage, Cancer Pre- code formulation and only authorisation pack size required AD054 chlorpromazine (Non Proprietary) 100mg/5mL - 150mL Yes Yes oral solution AD055 chlorpromazine (Non Proprietary) 25mg/mL - 1mL Yes Yes ampoule injection AD056 chlorpromazine (Non Proprietary) 25mg/mL - 2mL Yes Yes ampoule injection AD057 cisplatin (Non Proprietary) 1mg/mL - 10mL vial Yes Yes injection AD058 cisplatin (Non Proprietary) 1mg/mL - 50mL vial Yes Yes injection AD059 cisplatin (Non Proprietary) 1mg/mL - 100mL vial Yes Yes injection AD065 cladribine (Leustat) 1mg/mL - 10mL vial Yes Yes injection AD066 clodronate (Bonefos) 120 x 400mg Yes Yes capsules AD067 clodronate (Bonefos) 60 x 800mg tablets Yes Yes AD068 clodronate (Loron 520) 60 x 520mg tablets Yes Yes AD069 clofarabine (Evoltra) 1 mg/mL, 20mL vial Yes Yes AD070 crisantaspase (Erwinase) 10 000 unit vial Yes Yes powder for reconstitution AD071 cyclophosphamide (Non Proprietary) 100 x 50mg tablets Yes Yes AD072 cyclophosphamide (Non Proprietary) 500mg vial injection - Yes Yes powder for reconstitution AD073 cyclophosphamide (Non Proprietary) 1g vial injection - Yes Yes powder for reconstitution AD074 cyproterone acetate (Cyprostat) 168 x 50mg tablets Yes Yes AD075 cyproterone acetate (Cyprostat) 80 x 100mg tablets Yes Yes AD076 cytarabine (DepoCyte) 50mg vial intrathecal Yes Yes injection AD077 cytarabine (Non Proprietary) 20mg/mL- 5mL vial Yes Yes intrathecal injection Please note that printed or downloaded versions of this document may be out of date. Bupa separately chargeable drugs list – 15 September 2021 Valid until 15 October 2021 © Bupa Insurance Services Limited 2021 15 SEPTEMBER 2021 Separately Chargeable Drugs List Also known to customers as: List of specialist drugs Bupa Generic name (Brand name) Dosage, Cancer Pre- code formulation and only authorisation pack size required AD078 cytarabine (Non Proprietary) 20 mg/mL - 5mL vial Yes Yes iv or subcutaneous injection AD079 cytarabine (Non Proprietary) 20 mg/mL - 25mL vial Yes Yes iv or subcutaneous injection AD080 cytarabine (Non Proprietary) 100 mg/mL - 1mL vial Yes Yes iv or subcutaneous injection AD081 cytarabine (Non Proprietary) 100 mg/mL - 5mL vial Yes Yes iv or subcutaneous injection AD082 cytarabine (Non Proprietary) 100 mg/mL - 10mL Yes Yes vial iv or subcutaneous injection AD083 cytarabine (Non Proprietary) 100 mg/mL - 20mL Yes Yes vial iv or subcutaneous injection AD084 dacarbazine (Non Proprietary) 100mg vial injection - Yes Yes powder for reconstitution AD085 dacarbazine (Non Proprietary) 200mg vial injection - Yes Yes powder for reconstitution AD086 dacarbazine (Non Proprietary) 500mg vial injection - Yes Yes powder for reconstitution AD088 dacarbazine (Non Proprietary) 1g vial injection - Yes Yes powder for reconstitution AD089 dactinomycin (Cosmegen Lyovac) 0.5mg vial injection - Yes Yes powder for reconstitution AD090 dasatinib (Sprycel) 60 x 20mg tablets Yes Yes AD091 dasatinib (Sprycel) 60 x 50mg tablets Yes Yes AD093 dasatinib (Sprycel) 60 x 100mg tablets Yes Yes Please note that printed or downloaded versions of this document may be out of date. Bupa separately chargeable drugs list – 15 September 2021 Valid until 15 October 2021 © Bupa Insurance Services Limited 2021 15 SEPTEMBER 2021 Separately Chargeable Drugs List Also known to customers as: List of specialist drugs Bupa Generic name (Brand name) Dosage, Cancer Pre- code formulation and only authorisation pack size required AD094 daunorubicin (Non Proprietary) 20mg vial injection - Yes Yes powder for reconstitution AD095 daunorubicin lipid form (DaunoXome 50mg vial - Yes Yes (liposomal daunorubicin)) concentrate for iv infusion AD096 dexrazoxane (Cardioxane) 500mg vial - powder Yes Yes for iv infusion AD097 dexrazoxane (Savene) 10 x 500mg vials - Yes Yes powder for iv infusion AD098 dibotermin alfa (InductOs) 1.5mg/mL - 10mL vial No Yes - powder for reconstitution AD099 diethylstilbestrol (Non Proprietary) 28 x 1mg tablets Yes Yes AD100 diethylstilbestrol (Non Proprietary) 28 x 5mg tablets Yes Yes AD101 disodium pamidronate (Aredia) 15mg vial injection - Yes Yes powder for reconstitution AD102 disodium pamidronate (Aredia) 30mg vial injection - Yes Yes
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