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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 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 (Amsidine) 1.5mL (75mg) Yes Yes ampoule and 13.5mL diluent vial

AD012 (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Please note that printed or downloaded versions of this document may be out of date.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 (Trisenox) 1mg/ml - 10mL Yes Yes ampoule for iv infusion AD018 (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 hydrochloride (Levact) 25mg vial injection - Yes Yes powder for reconsitution AD022 bendamustine hydrochloride (Levact) 100mg vial injection - Yes Yes powder for reconsitution AD023 (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 (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 (Non Proprietary) 15,000 unit vial Yes Yes injection AD030 (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 (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 (Xeloda) 60 x 150mg tablets Yes Yes AD039 capecitabine (Xeloda) 120 x 500mg tablets Yes Yes AD040 (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 (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 (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 (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 (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 (Evoltra) 1 mg/mL, 20mL vial Yes Yes AD070 crisantaspase (Erwinase) 10 000 unit vial Yes Yes powder for reconstitution AD071 (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 (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 (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 (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 (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 powder for reconstitution AD103 disodium pamidronate (Aredia) 90mg vial injection - Yes Yes powder for reconstitution AD104 (Taxotere) 20mg/mL - 1mL vial Yes Yes for infusion AD105 docetaxel (Taxotere) 20mg/mL - 4mL vial Yes Yes for infusion AD106 docetaxel (Taxotere) 20mg/mL - 8mL vial Yes Yes for infusion AD107 (Non Proprietary) 10mg vial injection - Yes Yes powder for reconstitution AD108 doxorubicin (Non Proprietary) 50mg 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 AD109 doxorubicin (Non Proprietary) 2mg/mL - 5mL vial Yes Yes injection AD110 doxorubicin (Non Proprietary) 2mg/Ml - 25mL vial Yes Yes injection AD111 doxorubicin (Non Proprietary) 2mg/Ml - 100mL vial Yes Yes injection AD112 doxorubicin HCl lipid form (Caelyx) 2mg/mL - 10mL vial Yes Yes concentrate for iv infusion AD113 doxorubicin HCl lipid form (Caelyx) 2mg/mL - 25mL vial Yes Yes concentrate for iv infusion AD114 doxorubicin HCl lipid form (Myocet) 50mg vial injection - Yes Yes powder for reconstitution AD115 (Non Proprietary) 2mg/mL - 5mL vial Yes Yes injection AD116 epirubicin (Non Proprietary) 2mg/mL - 25mL vial Yes Yes injection AD117 epirubicin (Non Proprietary) 2mg/mL - 50mL vial Yes Yes injection AD118 epirubicin (Non Proprietary) 2mg/mL, 100mL vial Yes Yes injection AD122 epoetin (Binocrit) 1000 units injection - Yes Yes prefilled syringe AD124 epoetin (Binocrit) 3000 units injection - Yes Yes prefilled syringe AD125 epoetin (Binocrit) 4000 units injection - Yes Yes prefilled syringe AD126 epoetin (Binocrit) 5000 units injection - Yes Yes prefilled syringe AD127 epoetin (Binocrit) 6000 units injection - Yes Yes prefilled syringe AD128 epoetin (Binocrit) 8000 units injection - Yes Yes prefilled syringe AD129 epoetin (Binocrit) 10000 units injection Yes Yes - prefilled syringe

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 AD130 epoetin (NeoRecormon) 500 units injection - Yes Yes prefilled syringe AD131 epoetin (NeoRecormon) 2000 units injection - Yes Yes prefilled syringe AD132 epoetin (NeoRecormon) 3000 units injection - Yes Yes prefilled syringe AD133 epoetin (NeoRecormon) 4000 units injection - Yes Yes prefilled syringe AD134 epoetin (NeoRecormon) 5000 units injection - Yes Yes prefilled syringe AD135 epoetin (NeoRecormon) 6000 units injection - Yes Yes prefilled syringe AD136 epoetin (NeoRecormon) 10,000 units Yes Yes injection - prefilled syringe AD137 epoetin (NeoRecormon) 20,000 units Yes Yes injection - prefilled syringe AD138 epoetin (NeoRecormon) 30,000 units Yes Yes injection - prefilled syringe AD139 epoetin alfa (Eprex) 1000 units injection - Yes Yes prefilled syringe AD140 epoetin alfa (Eprex) 10,000 units Yes Yes injection - prefilled syringe AD141 epoetin alfa (Eprex) 2000 units injection - Yes Yes prefilled syringe AD142 epoetin alfa (Eprex) 20,000 units Yes Yes injection - prefilled syringe AD143 epoetin alfa (Eprex) 3000 units injection - Yes Yes prefilled syringe AD144 epoetin alfa (Eprex) 30,000 units Yes Yes injection - prefilled syringe AD145 epoetin alfa (Eprex) 4000 units injection - Yes Yes prefilled syringe

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 AD146 epoetin alfa (Eprex) 40,000 units Yes Yes injection - prefilled syringe AD147 epoetin alfa (Eprex) 5000 units injection - Yes Yes prefilled syringe AD148 epoetin alfa (Eprex) 6000 units injection - Yes Yes prefilled syringe AD149 epoetin alfa (Eprex) 8000 units injection - Yes Yes prefilled syringe AD152 eptacog alfa (NovoSeven) 1mg vial injection - No Yes powder for reconstitution AD153 eptacog alfa (NovoSeven) 2mg vial injection - No Yes powder for reconstituton AD154 eptacog alfa (NovoSeven) 5mg vial injection - No Yes powder for reconsitution AD155 eptacog alfa (NovoSeven) 8mg vial injection - No Yes powder for reconsitution AD157 erlotinib (Tarceva) 30 x 25mg tablets Yes Yes AD158 erlotinib (Tarceva) 30 x 100mg tablets Yes Yes AD159 erlotinib (Tarceva) 30 x 150mg tablets Yes Yes AD160 estramustine (Estracyt) 100 x 140mg Yes Yes capsules AD161 (Etopophos) 100mg vial injection - Yes Yes powder for reconstitution AD165 etoposide (Vepesid) 20 x 50mg capsules Yes Yes AD166 etoposide (Vepesid) 10 x 100mg capsules Yes Yes AD167 everolimus (Afinitor) 30 x 5mg tablets Yes Yes AD168 everolimus (Afinitor) 30 x 10mg tablets Yes Yes AD169 exemestane (Aromasin) 30 x 25mg tablets Yes Yes AD170 exemestane (Aromasin) 90 x 25mg tablets Yes Yes AD171 Factor IX (AlphaNine) 1000 iu vial No Yes AD172 Factor IX (AlphaNine) 1500 iu vial No 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 AD174 Factor IX (Mononine) 1000 iu vial No Yes AD175 Factor IX (Replenine-VF) 500 iu vial No Yes AD176 Factor IX (Replenine-VF) 1000 iu vial No Yes AD177 filgrastim (Neupogen) 30 million units (300 Yes Yes mcg)/mL - 1mL vial AD178 filgrastim (Neupogen) 60 million units (600 Yes Yes mcg)/mL - 0.5mL vial AD179 filgrastim (Neupogen) 96 million units (960 Yes Yes mcg)/mL - 0.5mL vial AD180 filgrastim (Nivestim) 12 million units (120 Yes Yes mcg)/0.2 mL vial AD181 filgrastim (Nivestim) 30 million units (300 Yes Yes micrograms)/0.5 mL vial AD182 filgrastim (Nivestim) 48 million units (480 Yes Yes micrograms) - 0.5 mL vial AD183 filgrastim (Ratiograstim) 30 million units (300 Yes Yes mcg)/0.5 mL vial AD185 filgrastim (Zarzio) 30 million-units (300 Yes Yes mcg)/0.5 mL vial AD186 filgrastim (Zarzio) 48 million-units (480 Yes Yes mcg)/0.5 mL vial AD187 PHOS (Fludara) 50mg vial injection - Yes Yes powder for reconstitution AD188 fludarabine PHOS (Fludara) 15 x 10mg tablets Yes Yes AD189 fludarabine PHOS (Fludara) 20 x 10mg tablets Yes Yes AD190 (Efudix) 40g 5% cream Yes Yes AD191 fluorouracil (Non Proprietary) 25mg/mL - 10mL vial Yes Yes injection AD192 fluorouracil (Non Proprietary) 25mg/mL - 20mL vial Yes Yes injection AD193 fluorouracil (Non Proprietary) 25mg/mL - 100mL Yes Yes vial injection AD194 fluorouracil (Non Proprietary) 50mg/mL - 10mL vial Yes Yes 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 AD195 fluorouracil (Non Proprietary) 50mg/mL - 20mL vial Yes Yes injection AD196 fluorouracil (Non Proprietary) 50mg/mL - 50mL vial Yes Yes injection AD197 fluorouracil (Non Proprietary) 50mg/mL - 100mL Yes Yes injection AD198 flutamide (Non Proprietary) 84 x 250mg tablets Yes Yes AD199 folinic acid (Sodiofolin) 50mg/mL - 2mL vial Yes Yes injection AD200 folinic acid (Sodiofolin) 50mg/mL - 8mL vial Yes Yes injection AD203 (Faslodex) 50mg - 2 x 5mL Yes Yes injections, prefilled syringe AD204 gefitinib (Iressa) 30 x 250mg tablets Yes Yes AD205 (Gemzar) 1g vial injection - Yes Yes powder for reconstitution AD206 gemcitabine (Gemzar) 200mg vial injection - Yes Yes powder for reconstitution AD207 goserelin (Zoladex) 3.6mg implant in No Yes SafeSystem syringe applicator AD208 granisetron (Kytril) 10 x 1mg tablets Yes Yes AD209 granisetron (Kytril) 5 x 2mg tablets Yes Yes AD210 granisetron (Kytril) 1mg/mL - 1mL Yes Yes ampoule injection AD211 granisetron (Kytril) 1mg/mL - 3mL Yes Yes ampoule injection AD212 haloperidol (Serenace) 30 x 500mcg Yes Yes capsules AD213 haloperidol (Serenace) 30 x 1.5mg tablets Yes Yes AD214 haloperidol (Serenace) 30 x 5mg tablets Yes Yes AD215 haloperidol (Serenace) 30 x 10mg tablets Yes Yes AD217 hydrocortisone (Colifoam) 14 x 10% foam in Yes Yes aerosol pack AD218 hydrocortisone (Non Proprietary) 30 x 10mg 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 AD219 hydrocortisone (Non Proprietary) 30 x 20mg tablets Yes Yes AD220 hydrocortisone (Solu-Cortef) 100mg vial injection - Yes Yes powder for reconstitution AD221 hydrocortisone (Solu-Cortef) 100mg vial with 2mL Yes Yes amp water for injections AD222 (Hydrea) 100 x 500mg Yes Yes capsules AD223 ibandronic acid (Bondronat) 1mg/mL - 2mL Yes Yes ampoule concentrate for iv infusion AD224 ibandronic acid (Bondronat) 1mg/mL - 6mL Yes Yes ampoule concentrate for iv infusion AD225 ibandronic acid (Bondronat) 28 x 50mg tablets Yes Yes AD226 (Zavedos) 1x 5mg capsule Yes Yes AD227 idarubicin (Zavedos) 1 x 10mg capsule Yes Yes AD228 idarubicin (Zavedos) 10mg vial injection - Yes Yes powder for reconstitution AD229 idarubicin (Zavedos) 5mg vial injection - Yes Yes powder for reconstitution AD230 (Non Proprietary) 1g vial injection - Yes Yes powder for reconstitution AD231 ifosfamide (Non Proprietary) 2g vial injection - Yes Yes powder for reconstitution AD232 imatinib (Glivec) 60 x 100mg tablets Yes Yes AD233 imatinib (Glivec) 30 x 400mg tablets Yes Yes AD234 infliximab (Remicade) 100mg vial powder No Yes for iv infusion AD235 interferon alpha (IntronA) 10 million units/mL - No Yes 1mL vial injection AD236 interferon alpha (IntronA) 10 million units/mL - No Yes 2.5mL vial 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 AD237 interferon alpha (IntronA) 15 million units/mL - No Yes 1.5mL injection pen AD238 interferon alpha (IntronA) 25 million Units/mL - No Yes 1.5mL injection pen AD239 interferon alpha (IntronA) 50 million units/mL - No Yes 1.5mL injection pen AD240 interferon alpha (Roferon-A) 6 million units/mL - No Yes 0.5mL prefilled syringe AD241 interferon alpha (Roferon-A) 9 million units/mL - No Yes 0.5mL prefilled syringe AD242 interferon alpha (Roferon-A) 12 million units/mL 0 No Yes .5mL prefilled syringe AD243 interferon alpha (Roferon-A) 18 million units/mL - No Yes 0 .5mL prefilled syringe AD245 (Campto) 20 mg/mL - 15mL vial Yes Yes for infusion AD246 irinotecan (Campto) 20 mg/mL - 2mL vial Yes Yes for infusion AD247 irinotecan (Campto) 20 mg/mL - 5mL vial Yes Yes for infusion AD250 lanreotide (Somatuline) 30mg vial injection Yes Yes AD252 (Tyverb) 84 x 250mg tablets Yes Yes AD253 lenalidomide (Revlimid) 21 x 15mg capsules Yes Yes AD254 lenalidomide (Revlimid) 21 x 10mg capsules Yes Yes AD255 lenalidomide (Revlimid) 21 x 25mg capsules Yes Yes AD256 lenalidomide (Revlimid) 21 x 5mg capsules Yes Yes AD257 lenograstim (Granocyte) 13.4 million unit Yes Yes (105mcg) vial injection AD258 lenograstim (Granocyte) 33.6 million unit Yes Yes (263mcg) vial injection AD259 letrozole (Femara) 14 x 2.5mg tablets Yes Yes AD260 letrozole (Femara) 28 x 2.5mg 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 AD261 leuprorelin (Prostap 3 DCS) 11.25mg vial with Yes Yes 2mL vehicle filled syringe AD262 leuprorelin (Prostap SR DCS) 3.75mg prefilled No Yes syringe AD263 levomepromazine (Nozinan) 84 x 25mg tablets Yes Yes AD264 levomepromazine (Nozinan) 25mg/mL - 1mL Yes Yes ampoule injection AD265 (CCNU) 20 x 40mg capsules Yes Yes AD272 megestrol acetate (Megace) 30 x 160mg tablets Yes Yes AD273 (Alkeran) 25 x 2mg tablets Yes Yes AD274 melphalan (Alkeran) 50mg vial injection - Yes Yes powder for reconstitution AD276 mesna (Non Proprietary) 10 x 400mg tablets Yes Yes AD277 mesna (Non Proprietary) 10 x 600mg tablets Yes Yes AD278 mesna (Non Proprietary) 100mg/mL - 4mL Yes Yes ampoule injection AD279 mesna (Non Proprietary) 100mg/mL - 10mL Yes Yes ampoule injection AD280 (Non Proprietary) 2.5mg/mL - 2mL vial Yes Yes injection AD281 methotrexate (Non Proprietary) 25mg/mL - 2mL vial Yes Yes injection AD282 methotrexate (Non Proprietary) 25mg/mL - 20mL vial Yes Yes injection AD283 methotrexate (Non Proprietary) 100mg/mL - 10mL Yes Yes vial injection AD284 methotrexate (Non Proprietary) 100mg/mL - 50mL Yes Yes vial injection AD285 methylprednisolone (Depo-Medrone) 40mg/mL - 1mL vial Yes Yes injection AD286 methylprednisolone (Depo-Medrone) 40mg/mL - 2mL vial Yes Yes injection AD287 methylprednisolone (Depo-Medrone) 40mg/mL - 3mL vial Yes Yes injection AD288 methylprednisolone (Medrone) 30 x 2mg 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 AD289 methylprednisolone (Medrone) 30 x 4mg tablets Yes Yes AD290 methylprednisolone (Medrone) 30 x 16mg tablets Yes Yes AD291 methylprednisolone (Medrone) 20 x 100mg tablets Yes Yes AD292 methylprednisolone (Solu-Medrone) 40mg vial injection - Yes Yes powder for reconstitution AD293 methylprednisolone (Solu-Medrone) 125mg vial injection - Yes Yes powder for reconstitution AD294 methylprednisolone (Solu-Medrone) 500mg vial injection - Yes Yes powder for reconstitution AD295 methylprednisolone (Solu-Medrone) 1g vial injection - Yes Yes powder for reconstitution AD296 methylprednisolone (Solu-Medrone) 2g vial injection - Yes Yes powder for reconstitution AD297 mitomycin ( Kyowa) 2mg injection - Yes Yes powder for reconstitution AD298 mitomycin (Mitomycin C Kyowa) 10mg injection - Yes Yes powder for reconstitution AD299 mitomycin (Mitomycin C Kyowa) 20mg injection - Yes Yes powder for reconstitution AD300 mitomycin (Mitomycin C Kyowa) 40mg injection - Yes Yes powder for reconstitution AD301 (Non Proprietary) 2mg/mL - 10mL vial Yes Yes concentrate for iv infusion AD302 (Atriance) 5mg/mL - 50mL vial Yes Yes concentrate for iv infusion AD303 nilotinib (Tasigna) 112 x 200mg Yes Yes capsules

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 AD308 normal immunoglobulin (Flebogamma DIF) 0.5g - 10mL vial for iv No Yes infusion AD309 normal immunoglobulin (Flebogamma DIF) 2.5g - 50mL vial for iv No Yes infusion AD310 normal immunoglobulin (Flebogamma DIF) 5g - 100mL vial for iv No Yes infusion AD311 normal immunoglobulin (Flebogamma DIF) 10g - 200mL vial for No Yes iv infusion AD312 normal immunoglobulin (Flebogamma DIF) 20g - 400mL vial for No Yes iv infusion AD315 normal immunoglobulin (Gammagard S/D) 5 or 10% 5g with No Yes diluent for iv infusion AD316 normal immunoglobulin (Gammagard S/D) 5 or 10% 10g with No Yes diluent for iv infusion AD317 normal immunoglobulin (Gammaplex) 5%, 2.5g - 50mL vial No Yes for iv infusion AD318 normal immunoglobulin (Gammaplex) 5%, 5g - 100mL vial No Yes for iv infusion AD319 normal immunoglobulin (Gammaplex) 5%, 10g - 200mL vial No Yes for iv infusion AD320 normal immunoglobulin (Intratect) 5% - 1g (20mL) for iv No Yes infusion AD321 normal immunoglobulin (Intratect) 5% - 2.5g (50mL) for No Yes iv infusion AD322 normal immunoglobulin (Intratect) 5% - 5g (100mL) for No Yes iv infusion AD323 normal immunoglobulin (Intratect) 5% - 10g (200mL) for No Yes iv infusion AD324 normal immunoglobulin (Kiovig) 10% - 1g (10mL) for No Yes iv infusion AD325 normal immunoglobulin (Kiovig) 10% - 2.5g (25mL) for No Yes iv infusion AD326 normal immunoglobulin (Kiovig) 10% - 5g (50mL) for No Yes iv infusion AD327 normal immunoglobulin (Kiovig) 10% - 10g (100mL) No Yes for iv infusion

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 AD328 normal immunoglobulin (Kiovig) 10% - 20g (200mL) No Yes for iv infusion AD329 normal immunoglobulin (Privigen) 10% - 2.5g (25mL) for No Yes iv infusion AD330 normal immunoglobulin (Privigen) 10% - 5g (50mL) for No Yes iv infusion AD331 normal immunoglobulin (Privigen) 10% - 10g (100mL) No Yes for iv infusion AD332 normal immunoglobulin (Privigen) 10% - 20g (200mL) No Yes for iv infusion AD333 normal immunoglobulin (Octagam) 5% - 2.5g (50mL) for No Yes iv infusion AD334 normal immunoglobulin (Octagam) 5% - 5g (100mL) for No Yes iv infusion AD335 normal immunoglobulin (Octagam) 5% - 10g (200mL) for No Yes iv infusion AD336 normal immunoglobulin (Octagam) 10% - 2g (20mL) for No Yes iv infusion AD337 normal immunoglobulin (Octagam) 10% - 5g (50mL) for No Yes iv infusion AD338 normal immunoglobulin (Octagam) 10% - 10g (100mL) No Yes for iv infusion AD339 normal immunoglobulin (Octagam) 10% - 20g (200mL) No Yes for iv infusion AD340 normal immunoglobulin (Vigam) 5% - 2.5g (50mL) for No Yes iv infusion AD341 normal immunoglobulin (Vigam) 5% - 5g (100mL) for No Yes iv infusion AD342 normal immunoglobulin (Vigam) 5% - 10g (200mL) for No Yes iv infusion AD343 normal immunoglobulin (Subcuvia) 0.8g (5ml) vial No Yes injection AD344 normal immunoglobulin (Subcuvia) 1.6g (10mL) vial No Yes injection AD346 normal immunoglobulin (Subgam) 750mg vial injection No Yes AD347 normal immunoglobulin (Subgam) 1.5g vial injection No Yes AD350 normal immunoglobulin (Vivaglobin) 3.2g (20mL) injection No Yes

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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 AD351 octreotide (Sandostatin LAR) 10mg vial injection Yes Yes with diluent filled syringe AD352 octreotide (Sandostatin LAR) 20mg vial injection Yes Yes with diluent filled syringe AD353 octreotide (Sandostatin LAR) 30mg vial injection Yes Yes with diluent filled syringe AD354 ofatumumab (Arzerra) 100mg/5mL, 50mL Yes Yes vial (concentrate for infusion) AD355 (Non Proprietary) 5mg/mL - 10mLvial Yes Yes concentrate for infusion AD356 oxaliplatin (Non Proprietary) 5mg/mL - 20mL vial Yes Yes concentrate for infusion AD357 oxaliplatin (Non Proprietary) 5mg/mL - 40mL vial Yes Yes concentrate for infusion AD363 palonosetron (Aloxi) 50 mcg/mL - 5ml Yes Yes Ampoule for injection AD364 panitumumab (Vectibix) 20mg/mL - 5mL vial Yes Yes concentrate for iv infusion AD365 panitumumab (Vectibix) 20mg/mL - 20mL vial Yes Yes concentrate for iv infusion AD366 pazopanib (Votrient) 30 X 200mg tablets Yes Yes AD367 pazopanib (Votrient) 30 x 400mg tablets Yes Yes AD369 pegfilgrastim (Neulasta) 10mg/mL - 0.6mL Yes Yes (6mg) prefilled syringe AD370 peginterferon (Pegasys) 135mcg prefilled No Yes syringe

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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 AD371 peginterferon (Pegasys) 180mcg prefilled No Yes syringe AD372 (Alimta) 100mg vial injection Yes Yes AD373 pemetrexed (Alimta) 500 mg vial injection Yes Yes AD374 (Nipent) 10mg vial injection - Yes Yes powder for reconstitution AD375 (Photofrin) 15mg vial injection - Yes Yes powder for reconstitution AD376 porfimer sodium (Photofrin) 75mg vial injection - Yes Yes powder for reconstitution

AD377 (Lodotra) 30 x 1mg tablets Yes Yes AD378 prednisone (Lodotra) 30 x 2mg tablets Yes Yes AD379 prednisone (Lodotra) 100 x 2mg tablets Yes Yes AD380 prednisone (Lodotra) 30 x 5mg tablets Yes Yes AD381 prednisone (Lodotra) 100 x 5mg tablets Yes Yes AD382 (Non Proprietary) 50 x 50mg tablets Yes Yes AD385 (Tomudex) 2mg vial injection - Yes Yes powder for reconstitution AD386 ranibizumab (Lucentis) 10mg/ml - 0.23mL No Yes vial - solution for injection AD387 rasburicase (Fasturtec) 1.5mg vial for iv Yes Yes infusion AD388 rasburicase (Fasturtec) 7.5mg vial for iv Yes Yes infusion AD391 rituximab (MabThera) 10mg/mL - 10mL vial Yes Yes for iv infusion AD392 rituximab (MabThera) 10mg/mL - 50mL vial Yes Yes for iv infusion AD393 romiplostim (Nplate) 250mcg vial injection No Yes - powder for reconstitution

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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 AD400 sorafenib (Nexavar) 112 x 200mg tablets Yes Yes AD401 sunitinib (Sutent) 28 x 50mg capsules Yes Yes AD402 sunitinib (Sutent) 28 x 25mg capsules Yes Yes AD403 sunitinib (Sutent) 28 x 12.5mg capsules Yes Yes AD409 tamoxifen (Non Proprietary) 30 x 10mg tablets Yes Yes AD410 tamoxifen (Non Proprietary) 30 x 20mg tablets Yes Yes AD411 tamoxifen (Non Proprietary) 30 x 40mg tablets Yes Yes AD412 tamoxifen (Non Proprietary) 10mg/5mL - 150mL Yes Yes oral solution AD416 (Foscan) 1mg/mL - 3mL vial Yes Yes injection AD417 temoporfin (Foscan) 1mg/mL - 6mL vial Yes Yes injection AD418 (Temodal) 5 x 140mg capsules Yes Yes AD419 temozolomide (Temodal) 5 x 5mg capsules Yes Yes AD420 temozolomide (Temodal) 5 x 180mg capsules Yes Yes AD421 temozolomide (Temodal) 5 x 100mg capsules Yes Yes AD422 temozolomide (Temodal) 5 x 250mg capsules Yes Yes AD423 temozolomide (Temodal) 5 x 20mg capsules Yes Yes AD424 temsirolimus (Torisel) 25mg/mL - 1.2mL Yes Yes ampoule for iv infusion AD425 terlipressin (Glypressin) 1mg vial injection - No Yes powder for reconstitution AD426 terlipressin (Glypressin) 0.12mg/mL - 1mg No Yes vial (8.5mL) injection AD427 thalidomide (Thalidomide Celgene) 28 x 50mg capsules Yes Yes AD428 (Tepadina) 15mg vial injection - Yes Yes powder for reconstitution AD429 thiotepa (Tepadina) 100 mg vial injection Yes Yes - powder for reconstitution AD431 (Lanvis) 25 x 40mg tablets Yes Yes AD432 tirofiban (Aggrastat) 250mcg/mL - 50mL No Yes vial for iv infusion 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 AD433 tirofiban (Aggrastat) 50mcg/mL - 250mL No Yes vial for iv infusion AD434 (Hycamtin) 10 x 1mg capsules Yes Yes AD435 topotecan (Hycamtin) 10 x 250mcg Yes Yes capsules AD436 topotecan (Hycamtin) 1mg vial for iv Yes Yes infusion AD437 topotecan (Hycamtin) 4mg vial for iv Yes Yes infusion AD438 toremifene (Fareston) 30 x 60mg tablets Yes Yes AD439 (Yondelis) 250mcg vial injection Yes Yes - powder for reconstitution AD440 trabectedin (Yondelis) 1mg vial injection - Yes Yes powder for reconstitution AD441 trastuzumab (Herceptin) 150mg vial for iv Yes Yes infusion AD442 (Treosulfan) 100 x 250mg Yes Yes capsules AD443 treosulfan (Treosulfan) 1g vial injection - Yes Yes powder for reconstitution AD444 treosulfan (Treosulfan) 5g vial injection - Yes Yes powder for reconstitution AD445 (Vesanoid) 100 x 10mg capsules Yes Yes AD447 triptorelin (Decapeptyl SR) 11.25mg vial Yes Yes injection - powder for suspension AD448 triptorelin (Decapeptyl SR) 3mg vial injection - Yes Yes powder for suspension AD449 triptorelin (Gonapeptyl Depot) 3.75mg vial injection Yes Yes - powder for suspension

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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 AD450 (Visudyne) 15mg vial injection - No Yes powder for reconstitution AD451 (Non Proprietary) 1mg/mL - 10mL vial Yes Yes injection AD453 (Non proprietary) 1mg/mL - 1mL vial Yes Yes injection AD454 vincristine (Non proprietary) 1mg/mL - 2mL vial Yes Yes injection AD455 vincristine (Non proprietary) 1mg/mL - 5mL vial Yes Yes injection AD458 (Eldisine) 5mg vial injection - Yes Yes powder for reconstitution AD459 (Navelbine) 1 x 20mg capsule Yes Yes AD460 vinorelbine (Navelbine) 1 x 30mg capsule Yes Yes AD461 vinorelbine (Navelbine) 1 x 80mg capsule Yes Yes AD462 vinorelbine (Navelbine) 10mg/mL - 1mL vial Yes Yes for iv infusion AD463 vinorelbine (Navelbine) 10mg/mL - 5mL vial Yes Yes for iv infusion AD464 (Zometa) 800mcg/mL - 5mL Yes Yes vial for iv infusion AD466 etoposide (Eposin) 20mg/mL - 5mL vial Yes Yes for iv infusion AD467 etoposide (Eposin) 20mg/mL - 25mL vial Yes Yes for iv infusion AD468 hydrocortisone (Efcortesol) 100mg/ml - 1ml Yes Yes ampoule injection AD469 hydrocortisone (Efcortesol) 100mg/ml - 5ml Yes Yes ampoule injection AD477 methotrexate (Maxtrex) 28 x 2.5mg tablets Yes Yes AD478 methotrexate (Maxtrex) 100 x 10mg tablets Yes Yes AD481 tamoxifen (Soltamox) 10mg/5mL - 150mL Yes Yes oral solution AD482 BCG (ImmuCyst) 81mg vial for bladder Yes Yes instillation

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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 AD483 BCG (OncoTICE) 12.5mg vial for Yes Yes bladder instillation AD484 dexamethasone (Non Proprietary) 28 x 500mcg tablets Yes Yes AD485 dexamethasone (Non Proprietary) 50 x 2mg tablets Yes Yes AD486 dexamethasone (Non Proprietary) 100 x 2mg tablets Yes Yes AD487 dexamethasone (Dexsol) 2mg/5mL - 150mL Yes Yes oral solution AD489 dexamethasone (Non Proprietary) 3.3mg/mL - 1mL vial Yes Yes injection AD490 dexamethasone (Non Proprietary) 3.3mg/mL - 2mL vial Yes Yes injection AD491 Factor VIII (8Y) 500 iu No Yes AD492 ibritumomab tiuxetan (Zevalin) [90Y]-radiolabelled Yes Yes solution for iv infusion AD493 leucovorin (Refolinon) 10 x 15mg tablets Yes Yes AD494 calcium leucovorin (Refolinon) 30 x 15mg tablets Yes Yes AD495 prednisolone (Non Proprietary) 28 x 1mg tablets Yes Yes AD496 prednisolone (Non Proprietary) 28 x 5mg tablets Yes Yes AD497 prednisolone (Non Proprietary) 56 x 25mg tablets Yes Yes AD503 prednisolone (Deltastab) 25 mg/mL - 1mL Yes Yes ampoule injection AD504 prednisolone (Deltacortril) 28 x 2.5mg tablets Yes Yes AD505 prednisolone (Deltacortril) 100 x 2.5mg tablets Yes Yes AD506 prednisolone (Deltacortril) 28 x 5mg tablets Yes Yes AD507 prednisolone (Deltacortril) 100 x 5mg tablets Yes Yes AD510 cyclizine (Valoid) 50mg/mL - 1mL Yes Yes ampoule injection AD511 darbepoetin (Aranesp) 25mcg/mL - 0.4mL Yes Yes injection - prefilled syringe AD513 darbepoetin (Aranesp) 40mcg/mL - 0.5mL Yes Yes injection - prefilled syringe AD514 darbepoetin (Aranesp) 100mcg/mL - 0.3mL Yes Yes injection - prefilled syringe

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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 AD515 darbepoetin (Aranesp) 100mcg/mL - 0.4mL Yes Yes injection - prefilled syringe AD516 darbepoetin (Aranesp) 100mcg/mL - 0.5mL Yes Yes injection - prefilled syringe AD517 darbepoetin (Aranesp) 200mcg/mL - 0.3mL Yes Yes injection - prefilled syringe AD518 darbepoetin (Aranesp) 200mcg/mL - 0.4mL Yes Yes injection - prefilled syringe AD519 darbepoetin (Aranesp) 200mcg/mL - 0.5mL Yes Yes injection - prefilled syringe AD520 darbepoetin (Aranesp) 200mcg/mL - 0.65mL Yes Yes injection - prefilled syringe AD521 darbepoetin (Aranesp) 500mcg/mL - 0.3mL Yes Yes injection - prefilled syringe AD522 darbepoetin (Aranesp) 500mcg/mL - 0.6mL Yes Yes injection - prefilled syringe AD523 darbepoetin (Aranesp) 500mcg/mL - 1mL Yes Yes injection - prefilled syringe AD524 darbepoetin (Aranesp®SureClick) 40mcg/mL - 0.5mL Yes Yes prefilled injection device AD525 darbepoetin (Aranesp®SureClick) 100mcg/mL - 0.4mL Yes Yes prefilled injection device AD526 darbepoetin (Aranesp®SureClick) 200mcg/mL - 0.3mL Yes Yes prefilled injection device

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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 AD527 darbepoetin (Aranesp®SureClick) 200mcg/mL - 0.4mL Yes Yes prefilled injection device AD528 darbepoetin (Aranesp®SureClick) 200mcg/mL - 0.5mL Yes Yes prefilled injection device AD529 darbepoetin (Aranesp®SureClick) 500mcg/mL - 0.3mL Yes Yes prefilled injection device AD530 darbepoetin (Aranesp®SureClick) 500mcg/mL - 0.6mL Yes Yes prefilled injection device AD531 darbepoetin (Aranesp®SureClick) 500mcg/mL - 1mL Yes Yes prefilled injection device AD532 domperidone (Motilium) 30 x 10mg tabs Yes Yes AD533 domperidone (Motilium) 100 x 10mg tabs Yes Yes AD535 fosaprepitant (Ivemend) 150mg vial Yes Yes AD536 medroxyprogesterone acetate (Depo-Provera) 150mg/mL - 1mL No Yes injection - prefilled syringe AD537 medroxyprogesterone acetate (Depo-Provera) 150mg/mL, 1mL vial No Yes

AD542 medroxyprogesterone acetate (Provera) 60 x 100mg tablets Yes Yes

AD543 medroxyprogesterone acetate (Provera) 100 x 100mg tablets Yes Yes

AD544 medroxyprogesterone acetate (Provera) 30 x 200mg tablets Yes Yes

AD545 medroxyprogesterone acetate (Provera) 30 x 400mg tablets Yes Yes

AD546 metoclopramide (Maxolon) 84 x 10mg tablets Yes Yes AD547 metoclopramide (Maxolon) 5mg/mL - 2mL Yes Yes ampoule injection AD548 (Zofran) 30 x 4mg tablets Yes Yes AD549 ondansetron (Zofran) 10 x 8mg tablets Yes Yes

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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 AD550 ondansetron (Zofran) 4mg/5mL - 50mL oral Yes Yes solution AD551 ondansetron (Zofran) 2mg/mL - 2mL Yes Yes ampoule injection AD552 ondansetron (Zofran) 2mg/mL - 4mL Yes Yes ampoule injection AD553 ondansetron (Zofran) 16mg suppositories Yes Yes AD554 ondansetron (Zofran) 10 x 4mg oral Yes Yes lyophilisates AD555 ondansetron (Zofran) 10 x 8mg oral Yes Yes lyophilisates AD556 prochlorperazine (Buccastem) 10 x3mg tablets - 5 Yes Yes packs AD557 prochlorperazine (Stemetil) 28 x 5mg tablets Yes Yes AD558 prochlorperazine (Stemetil) 84 x 5mg tablets Yes Yes AD559 prochlorperazine (Stemetil) 5mg/5mL - 100mL Yes Yes oral solution AD560 prochlorperazine (Stemetil) 12.5mg/mL - 1mL Yes Yes ampoule injection AD561 botulinum A toxin (Dysport) 300 unit vial injection No Yes AD562 busulfan (Myleran) 25 x 2mg tablets Yes Yes AD563 dasatinib (Sprycel) 30 x 80mg tablets Yes Yes AD564 dasatinib (Sprycel) 30 x 140mg tablets Yes Yes AD565 abiraterone (Zytiga) 120 x 250mg tablets Yes Yes AD566 amphotericin B lipid complex (Abelcet) 5mg/mL - 20ml vial No Yes

AD567 anidulafungin (Ecalta) 100mg vial for iv No Yes infusion AD568 antithymocyte immunoglobulin 25mg powder for iv No Yes (Thymoglobuline) infusion AD569 (Jevtana) 40 mg/mL, 1.5mL vial Yes Yes (and solvent) for iv infusion AD570 calcium leucovorin (Refolinon) 3mg/mL - 5 x 10mL Yes Yes vial ampoule injections AD571 ciclosporin (Neoral) 60 x 10mg tablets Yes Yes

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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 AD572 ciclosporin (Neoral) 30 x 25 mg tablets Yes Yes AD573 ciclosporin (Neoral) 30 x 50mg tablets Yes Yes AD574 ciclosporin (Neoral) 30 x 100mg tablets Yes Yes AD575 ciclosporin (Neoral) 100mg/mL - 50mL Yes Yes oral solution AD576 degarelix acetate (Firmagon) 80-mg vial Yes Yes injection(with diluent) AD577 degarelix acetate (Firmagon) 2 × 120-mg vial Yes Yes injection (with diluent) AD578 ferric carboxymaltose (Ferinject) 50mg/mL - 2mL vial No Yes AD579 ferric carboxymaltose (Ferinject) 50mg/mL - 10mL vial No Yes AD581 iron isomaltoside 1000 (Monofer) 100 mg/mL, 1mL vial No Yes AD582 iron isomaltoside 1000 (Monofer) 100 mg/mL - 5mL vial No Yes AD583 iron isomaltoside 1000 (Monofer) 100 mg/mL - 10mL No Yes vial AD585 dexamethasone (Ozurdex) 700 mcg in No Yes disposable applicator AD586 plerixafor (Mozobil) 20 mg/mL - 1.2mL Yes Yes vial AD587 (Prolia) 60mg/mL - 1mL Yes Yes prefilled syringe AD588 denosumab (Xgeva) 70mg/mL - 1.7mL Yes Yes (120mg) vial injection AD589 urokinase (Syner-Kinase) 10,000 unit vial No Yes injection - powder for reconstitution AD590 urokinase (Syner-Kinase) 25,000 unit vial No Yes injection - powder for reconstitution AD591 urokinase (Syner-Kinase) 100,000 unit vial No Yes injection - powder for reconstitution AD592 collagenase (Xiapex) Injection 900mcg vial No Yes + solvent - 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 AD593 Factor VIII (Haemate) 500 iu injection - No Yes powder and solvent AD594 Factor VIII (Haemate) 1000 iu injection - No Yes powder and solvent AD595 human Prothrombin Complex (Octaplex) 500 iu vial for iv No Yes infusion AD596 imiquimod (Aldara) 5% cream - 12 sachet Yes Yes pack AD597 normal immunoglobulin (Flebogamma DIF) 10%, 5g - 50mL vial No Yes for iv infusion AD598 normal immunoglobulin (Flebogamma DIF) 10%, 10g - 100mL No Yes vial for iv infusion AD599 normal immunoglobulin (Flebogamma DIF) 10%, 20g - 200mL No Yes vial for iv infusion AD600 ofatumumab (Arzerra) 100mg/5mL, 5mL vial Yes Yes (concentrate for infusion) AD601 ondansetron (Non Proprietary) 30 x 4mg tablets Yes Yes AD602 ondansetron (Non Proprietary) 10 x 8mg tablets Yes Yes AD603 ondansetron (Non Proprietary) 4mg/5mL - 50mL oral Yes Yes solution AD604 ondansetron (Non Proprietary) 2mg/mL - 2mL Yes Yes ampoule injection AD605 ondansetron (Non Proprietary) 2mg/mL - 4mL Yes Yes ampoule injection AD608 thyrotropin alfa (Thyrogen) 900mcg/vial injection Yes Yes - powder for reconstitution AD609 triptorelin (Decapeptyl SR) 22.5mg vial injection Yes Yes - powder for suspension AD610 (Javlor) 25mg/mL - 2mL vial Yes Yes for iv infusion AD611 vinflunine (Javlor) 25mg/mL - 10mL vial Yes Yes for iv infusion AD612 iron dextran (CosmoFer) 50 mg/mL - 2mL No Yes ampoule

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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 AD613 iron dextran (CosmoFer) 50 mg/mL - 10mL No Yes ampoule AD614 vandetanib (Caprelsa) 100mg tablets Yes Yes AD615 vandetanib (Caprelsa) 300mg tablets Yes Yes AD616 (Halaven) 440mcg/mL - 2mL Yes Yes vial injection AD617 vemurafenib (Zelboraf) 56 x 240mg tablets Yes Yes AD622 ipilimumab (Yervoy) 5mg/mL - 10mL vial Yes Yes for iv infusion AD623 ipilimumab (Yervoy) 5mg/mL - 40mL vial Yes Yes for iv infusion AD624 calcium folinate (Calcium Folinate) 3mg/mL - 1mL Yes Yes injection AD625 calcium folinate (Calcium Folinate) 3mg/mL - 10mL Yes Yes injection AD626 calcium folinate (Calcium Folinate) 7.5mg/mL - 2mL Yes Yes injection AD627 calcium folinate (Calcium Folinate) 10mg/mL - 5mL Yes Yes injection AD628 calcium folinate (Calcium Folinate) 10mg/mL - 10mL Yes Yes injection AD629 calcium folinate (Calcium Folinate) 10mg/mL - 30mL Yes Yes injection AD631 calcium folinate (Calcium Folinate) 10 x 15mg tablets Yes Yes AD632 calcium folinate (Calcium Folinate) 30 x 15mg tablets Yes Yes AD633 human prothrombin complex (Beriplex) 250iu injection - No Yes powder for reconstitution AD634 human prothrombin complex (Beriplex) 500iu injection - No Yes powder for reconstitution AD635 methylthioninium chloride (Methylthioninium 5mg/mL - 5 x10mL No Yes chloride Proveblue) injections

AD636 dalteparin sodium (Fragmin) 12,500/mL - 0.2mL Yes Yes (2,500 unit) injection - single dose syringe

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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 AD637 dalteparin sodium (Fragmin) 25,000/mL - 0.2mL Yes Yes (5,000 unit) injection - single dose syringe AD638 dalteparin sodium (Fragmin) 25,000/mL - 0.3mL Yes Yes (7,500 unit) injection - single dose syringe AD639 dalteparin sodium (Fragmin) 25,000/mL - 0.4mL Yes Yes (10,000 unit) injection - single dose syringe AD640 dalteparin sodium (Fragmin) 25,000/mL - 0.5mL Yes Yes (12,500 unit) injection - single dose syringe AD641 dalteparin sodium (Fragmin) 25,000/mL - 0.6mL Yes Yes (15,000 unit) injection - single dose syringe AD642 dalteparin sodium (Fragmin) 25,000/mL - 0.72mL Yes Yes (18,000 unit) injection - single dose syringe AD643 dalteparin sodium (Fragmin) 2,500 units/mL - 4mL Yes Yes (10,000 unit) injection AD644 dalteparin sodium (Fragmin) 10,000 units/mL - Yes Yes 1mL (10,000 unit) injection AD645 dalteparin sodium (Fragmin) 25,000 units/mL - Yes Yes 4mL (100,000 unit) injection AD646 dalteparin sodium (Fragmin) 10,000 units/mL - Yes Yes 1mL (10,000 unit) injection/graduated syringe AD647 temocillin (Negaban) 1g, powder for Yes Yes solution for injection/infusion

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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 AD648 catumaxomab (Removab) 10-microgram Yes Yes prefilled syringe AD649 catumaxomab (Removab) 50-microgram Yes Yes prefilled syringe AD650 voriconazole (Vfend (iv infusion)) 200mg vial for iv No Yes infusion AD651 voriconazole (Vfend) 28 x 50mg tablets Yes Yes AD652 voriconazole (Vfend) 28 x 200mg tablets Yes Yes AD653 voriconazole (Vfend) 200mg/5mL - 75mL Yes Yes oral solution AD654 nilotinib (Tasigna) 112 x 150mg Yes Yes capsules AD655 axitinib (Inlyta) 56 x 1 mg film- Yes Yes coated tablets AD656 axitinib (Inlyta) 56 x 5 mg film- Yes Yes coated tablets AD657 Factor VIII (Kogenate) 500units No Yes AD658 Factor VIII (Kogenate) 1000units No Yes AD659 Factor VIII (Kogenate) 2000units No Yes AD660 Factor VIII (Kogenate) 3000units No Yes AD661 Factor VIII (Recombinant) (Advate) 250 IU powder and No Yes solvent for solution for injection AD662 Factor VIII (Recombinant) (Advate) 500 IU powder and No Yes solvent for solution for injection AD663 Factor VIII (Recombinant) (Advate) 1000 IU powder and No Yes solvent for solution for injection AD664 Factor VIII (Recombinant) (Advate) 1500 IU powder and No Yes solvent for solution for injection AD665 Factor VIII (Recombinant) (Advate) 2000 IU powder and No Yes solvent for solution for injection AD666 Factor VIII (Recombinant) (Advate) 3000 IU powder and No Yes solvent for solution for 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 AD667 crizotinib (Xalkori) 200mg hard capsule Yes Yes x 60 AD668 crizotinib (Xalkori) 250mg hard capsule Yes Yes x 60 AD669 albumin (Abraxane) powder for Yes Yes reconstitution, 100- mg vial AD670 aflibercept (Eylea) 40mg/ml solution No Yes AD671 brentuximab vedotin (Adcetris) 50mg vial Yes Yes AD672 Factor VIII (Helixate Nexgen) 250 IU powder and No Yes solvent for solution for injection AD673 Factor VIII (Helixate Nexgen) 500 IU powder and No Yes solvent for solution for injection AD674 Factor VIII (Helixate Nexgen) 1000 IU powder and No Yes solvent for solution for injection AD675 Factor VIII (Helixate Nexgen) 2000 IU powder and No Yes solvent for solution for injection AD676 danaparoid sodium (Orgaran) 1250 units/mL, No Yes 0.6mL ampoule AD677 capsaicin (Qutenza) 179 mg cutaneous Yes Yes patch AD678 calcium levofolinate (Isovorin) Solution for Injection Yes Yes 10 mg/ml AD679 mifamurtide (MEPACT) 4 mg powder for Yes Yes suspension for infusion AD680 (Lysodren) 500mg tablets Yes Yes AD681 goserelin (Zoladex) 10.8 mg implant in No Yes SafeSystem syringe applicator AD682 oxaliplatin (Non Proprietary) 50-mg vial Yes Yes AD683 oxaliplatin (Non Proprietary) 100-mg vial Yes Yes AD685 pertuzumab (Perjeta) 420mg - 30ml vial Yes Yes

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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 AD686 fluocinolone acetonide (Iluvien) 190mcg intravitreal No Yes implant in applicator AD687 aflibercept (Zaltrap) 4ml (100 mg) No Yes AD688 aflibercept (Zaltrap) 8ml (200 mg) No Yes AD689 , gimeracil, oteracil (Teysuno) 15mg tegafur, No Yes 4.35mg gimeracil, 11.8mg oteracil AD690 tegafur, gimeracil, oteracil (Teysuno) 20mg tegafur, 5.8mg No Yes gimeracil, 15.8mg oteracil AD691 docetaxel (Non-proprietary) 10mg/mL, 2mL vial Yes Yes AD692 docetaxel (Non-proprietary) 10mg/mL, 8mL vial Yes Yes AD693 docetaxel (Non-proprietary) 10mg/mL, 16mL vial Yes Yes AD694 docetaxel (Non-proprietary) 20mg/mL, 1mL vial Yes Yes AD695 docetaxel (Non-proprietary) 20mg/mL, 4mL vial Yes Yes AD696 docetaxel (Non-proprietary) 20mg/mL, 7mL vial Yes Yes AD697 ibandronic acid (Bonviva) 150mg, 1 tab-pack Yes Yes AD698 fludarabine (Non-proprietary) 50mg vial Yes Yes AD699 gemcitabine (Non-proprietary) 200mg vial Yes Yes AD700 gemcitabine (Non-proprietary) 1g vial Yes Yes AD701 gemcitabine (Non-proprietary) 1.5g vial Yes Yes AD702 gemcitabine (Non-proprietary) 2g vial Yes Yes AD703 irinotecan (Non-proprietary) 20mg/mL, 2mL vial Yes Yes AD704 irinotecan (Non-proprietary) 20mg/mL, 5mL vial Yes Yes AD705 irinotecan (Non-proprietary) 20mg/mL, 15mL vial Yes Yes AD706 irinotecan (Non-proprietary) 20mg/mL, 25mL vial Yes Yes AD707 paclitaxel (Non-proprietary) 6mg/mL, 5mL vial Yes Yes AD708 paclitaxel (Non-proprietary) 6mg/mL, 16.7mL vial Yes Yes AD709 paclitaxel (Non-proprietary) 6mg/mL, 25mL vial Yes Yes AD710 paclitaxel (Non-proprietary) 6mg/mL, 50mL vial Yes Yes AD711 disodium pamidronate (Non-proprietary) 3mg/mL, 5mL vial Yes Yes

AD712 disodium pamidronate (Non-proprietary) 3mg/mL, 10mL vial Yes Yes

AD713 disodium pamidronate (Non-proprietary) 6mg/mL, 10mL vial Yes Yes

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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 AD714 disodium pamidronate (Non-proprietary) 9mg/mL, 10mL vial Yes Yes

AD715 disodium pamidronate (Non-proprietary) 15mg/mL, 1mL vial Yes Yes

AD716 disodium pamidronate (Non-proprietary) 15mg/mL, 2mL vial Yes Yes

AD717 disodium pamidronate (Non-proprietary) 15mg/mL, 4mL vial Yes Yes

AD718 disodium pamidronate (Non-proprietary) 15mg/mL, 6mL vial Yes Yes

AD719 vinorelbine (Non-proprietary) 10mg/mL, 1mL vial Yes Yes AD720 vinorelbine (Non-proprietary) 10mg/mL, 5mL vial Yes Yes AD721 botulinum toxin type A (Xeomin) 50-unit vial No Yes AD722 botulinum toxin type A (Xeomin) 100-unit vial No Yes AD723 Factor VIII (Wilate) 500 units vial No Yes AD724 Factor VIII (Wilate) 1000 units vial No Yes AD725 (Xtandi) 40mg 112-cap pack Yes Yes AD726 ocriplasmin (Jetrea) 0.5mg/0.2ml No Yes concentrate for solution for injection vial AD727 bosutinib (Bosulif) 28 x 500mg tablets Yes Yes AD728 bosutinib (Bosulif) 28 x 100mg tablets Yes Yes AD729 trastuzumab (Herceptin) 600mg/5mL solution Yes Yes vial for subcutaneous injection AD730 pomalidomide (Imnovid) 21 x 1mg capsules Yes Yes AD731 pomalidomide (Imnovid) 21 x 2mg capsules Yes Yes AD732 pomalidomide (Imnovid) 21 x 3mg capsules Yes Yes AD733 pomalidomide (Imnovid) 21 x 4mg capsules Yes Yes AD734 ponatinib (Iclusig) 60 x 15mg tablets Yes Yes AD735 ponatinib (Iclusig) 30 x 45mg tablets Yes Yes AD736 regorafenib (Stivarga) 84 x 40mg film- Yes Yes coated tablets

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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 AD737 radium Ra 223 dichloride (Xofigo) 1000 kBq/mL Yes Yes solution vial for intravenous injection AD738 dabrafenib (Tafinlar) 28 x 50mg capsules Yes Yes AD739 dabrafenib (Tafinlar) 28 x 75mg capsules Yes Yes AD740 ruxolitinib (Jakavi) 60 x 5mg tablets Yes Yes AD741 ruxolitinib (Jakavi) 60 x 15mg tablets Yes Yes AD742 ruxolitinib (Jakavi) 60 x 20mg tablets Yes Yes AD743 (Dacogen) 50mg vial - powder Yes Yes for reconstitution AD744 trastuzumab emtansine (Kadcyla) 100mg vial - powder Yes Yes for reconstitution AD745 trastuzumab emtansine (Kadcyla) 160mg vial - powder Yes Yes for reconstitution AD746 lipegfilgrastim (Lonquex) 6mg/0.6ml vial Yes Yes AD747 Botulinum toxin type B (NeuroBloc) 2,500 unit vial No Yes injection AD748 Botulinum toxin type B (NeuroBloc) 5,000 unit vial No Yes injection AD749 Botulinum toxin type B (NeuroBloc) 10,000 unit vial No Yes injection AD750 Characterised autologous human cartilage 10,000 cells/µl vial No Yes (ChondroCelect) AD751 (Non Proprietary) 25 x 50mg tablets Yes Yes AD752 lapatinib (Tyverb) 105 x 250mg tablets Yes Yes AD753 vismodegib (Erivedge) 28 x 150mg capsules Yes Yes AD754 obinutuzumab (Gazyvaro) 1,000mg concentrate Yes Yes for solution for infusion, 40mL vial AD755 rituximab (MabThera) 1400mg solution for Yes Yes subcutaneous injection AD756 afatinib (Giotrif) 28 x 20mg tablets Yes Yes AD757 afatinib (Giotrif) 28 x 30mg tablets Yes Yes AD758 afatinib (Giotrif) 28 x 40mg tablets Yes Yes AD759 afatinib (Giotrif) 28 x 50mg tablets Yes Yes AD761 spironolactone (Non proprietary) 28 x 50mg 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 AD762 tolvaptan (Samsca) 10 x 15mg tablets Yes Yes AD763 tolvaptan (Samsca) 10 x 30mg tablets Yes Yes AD764 (Zydelig) 60 x 100mg tablets Yes Yes AD765 idelalisib (Zydelig) 60 x 150mg tablets Yes Yes AD766 lanreotide (Somatuline) 60mg prefilled Yes Yes syringe AD767 lanreotide (Somatuline) 90mg prefilled Yes Yes syringe AD768 lanreotide (Somatuline) 120mg prefilled Yes Yes syringe AD769 fidaxomicin (Dificlir) 20 x 200mg tablets No Yes AD770 ibrutinib (Imbruvica) 90 x 140mg capsules Yes Yes AD771 micafungin (Mycamine) 100mg daily No Yes AD780 ramucirumab (Cyramza) 8 mg/kg on days 1 Yes Yes and 15 of a 28 day cycle, prior to paclitax AD781 ramucirumab (Cyramza) Dependant on Yes Yes weight (10ml vial would also be charged) AD782 nintedanib (Vargatefis) 120 x 100mg Yes No capsules AD783 nintedanib (Vargatefis) 60 x 150mg capsules Yes Yes AD785 strontium-89 chloride (Metastron) The recommended Yes Yes dose is 150 MBq (4 mCi) per injection AD786 lenvatinib (Lenvima) The recommended Yes Yes daily dose of lenvatinib is 24 mg taken once daily AD787 lenvatinib (Lenvima) Daily dose of Yes Yes lenvatinib is 24 mg taken once daily AD878 (Pixuvri) Recommended dose: Yes Yes 50 mg/m2 of pixantrone on days 1, 8, and 15 of each 28- 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 day cycle for up to 6 cycle

AD879 nivolumab (Opdivo) 10 mg/mL Yes Yes concentrate for solution infusion, 4ml vial AD880 nivolumab (Opdivo) 10 mg/mL Yes Yes concentrate for solution infusion, 10ml vial AD881 (Lynparza) 400 mg (eight Yes Yes capsules) taken twice daily, equivalent to a total daily dose of 800 mg AD882 cabozantinib (Cometriq) 80mg and 20mg Yes Yes capsules ? 28 day treatment AD883 pembrolizumab (Keytruda) 2 mg/kg Yes Yes administered intravenously over 30 minutes every 3 weeks. AD884 Factor IX fraction (BeneFIX) 250 IU No Yes AD885 Factor IX fraction (BeneFIX) 500 IU No Yes AD886 Factor IX fraction (BeneFIX) 1000 IU No Yes AD887 Factor IX fraction (BeneFIX) 2000 IU No Yes AD888 Factor IX fraction (BeneFIX) 3000 IU No Yes AD889 netupitant and palonosetron (Akynzeo) One 300 mg / 0.5 mg Yes Yes capsule should be administered approximately one hour before each cycle AD890 (Kyprolis) 60 mg powder for No No solution for infusion

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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 AD891 disodium levofolinate (levofolinic acid) 50 mg/ml Solution No No (Levofolinic acid 50 mg/ml) for injection or infusion AD892 disodium levofolinate (levofolinic acid) 200 mg/ml Solution No No (levofolinic acid 200mg) for injection or infusion AD893 cobimetinib hemifumarate (Cotellic) The recommended Yes Yes dose of Cotellic is 60 mg (3 tablets of 20 mg) once daily AD894 ferric carboxymaltose (Ferinject) The maximum single No No dose is 20 mg iron/kg body weight, but should not exceed 1,000 mg iron AD895 ceritinib (Zykadia) 750 mg taken orally Yes Yes once daily at the same time each day AD896 adalimumab (Humira) 40mg/0.8ml solution No Yes for injection AD897 golimumab (Simponi) 100 mg/ml, 1ml No Yes solution for injection AD898 vedolizumab (Entyvio) 300 mg powder for No Yes concentrate for solution for infusion AD899 Ceftolozane / Tazobactam (Zerbaxa) Ceftolozane 1g / No Yes Tazobactam 500mg (Zerbaxa) powder for solution AD900 blinatumomab (Blincyto) One vial of 38.5 Yes Yes micrograms AD901 daratumumab (Darzalex) 100mg/5ml Yes Yes concentrate for solution for infusion AD902 osimertinib (Tagrisso) 40mg tablets Yes Yes AD903 cabozantinib (Cabometyx) 60mg tablets x 28 Yes Yes AD904 trifluridine/tipiracil (Lonsurf) 15mg/6.14mg tablet Yes Yes AD905 trametinib (Mekinist) 2mg 7 or 30 pack size Yes Yes

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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 AD906 (Ibrance) 125mg tablet Yes Yes

AD907 necitumumab (Portrazza) 16mg/ml - 50ml vial Yes Yes

AD908 (Oncaspar) 750iu/ml, 5ml vial Yes Yes

AD909 irinotecan hydrochloride trihydrate (Onivyde) 5mg/ml, 50mg vial Yes Yes

AD910 human fibrinogen (Riastap) 1g powder for No Yes injection -2 vials AD911 (Venclyxto) 7 x 100mg tablets Yes Yes

AD912 Venetoclax (Venclyxto) 14 x 100mg tablets Yes Yes

AD913 Venetoclax (Venclyxto) 112 x 100mg tablets Yes Yes

AD914 Venetoclax (Venclyxto) 14 x 10mg tablets Yes Yes

AD915 Venetoclax (Venclyxto) 7 x 50mg tablets Yes Yes

AD916 Posaconazole (Noxafil) 200mg/5ml, 105ml Yes Yes

AD917 atovaquone (Wellvone) 750mg/5ml, 226ml No Yes Bottle AD918 olaratumab (Lartruvo) 500mg vial Yes Yes AD919 5- (Giolan) The recommended Yes Yes dose is 20 mg 5-ALA HCl per kilogram body weight 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 AD920 (Ninlaro) 3 x 2.3mg capsules Yes Yes AD921 ixazomib (Ninlaro) 3 x 3mg capsules Yes Yes AD922 ixazomib (Ninlaro) 3 x 4mg capsules Yes Yes AD923 atezolizumab (Tecentriq) 1200mg Yes Yes AD924 rolapitant (Varuby) Yes No AD927 Talimogene laherparepvec (Imlygic) 1 million PFU/1 mL Yes Yes AD928 rituximab (Truxima) 500mg/50ml Yes No concentrate for solution for infusion vial AD929 prednisolone (Non Proprietary) 30ml bottle Yes Yes AD930 palbociclib (Ibrance) 21 x 75mg capsules Yes Yes AD931 palbociclib (Ibrance) Yes Yes AD932 Human Fibrinogen, Human Thrombin (TachoSil TachoSil matrix Large No No sealant matrix) (9.5 x 4.8 cm) AD933 alectinib (Alecensa) 224 x 150mg Yes Yes capsules AD934 ustekinumab (Stelara) 130mg. 3 vials for No Yes <85kg, 4 vials for >85kg. One injection only AD935 (Kisqali) 200mg tablets Yes Yes AD936 tivozanib (Fotivda) 890mcg capsules Yes Yes AD937 tivozanib (Fotivda) 1340mcg capsules Yes Yes AD938 domperidone (Motilium) 1mg/ml, 200ml Yes Yes AD939 rivaroxaban (Xarelto) 20mg Yes Yes AD940 (Zejula) 100mg Yes Yes AD942 telotristat etiprate (Xermelo) 250mg Yes Yes AD943 olaparib (Lynparza) 150mg Yes Yes AD944 olaparib (Lynparza) 100mg Yes Yes AD945 dalteparin sodium (Fragmin) 15,000 units in 0.6ml Yes Yes AD946 streptozocin (Zanosar) 1001-2000MG INF Yes Yes AD948 (Verzenios) 50mg Yes Yes AD949 abemaciclib (Verzenios) 100mg tablet Yes Yes AD950 abemaciclib (Verzenios) 150 mg tablets Yes Yes AD951 encorafenib (Braftovi) 50mg No 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 AD952 binimetinib (Mektovi) 15mg No Yes AD953 (Farydak) 10mg Capsules No Yes AD954 panobinostat (Farydak) 15mg Capsules No Yes AD955 panobinostat (Farydak) 20mg Capsules No Yes AD956 Durvalumab (Imfinzi) IV Infusion Yes Yes Yes Yes AD957 lenvatinib (Kisplyx) 10mg capsule Yes Yes AD958 lenvatinib (Kisplyx) 4mg capsule 30mcg/0.3ml Yes Yes Injection pre filled AD959 darbepoetin (Aranesp) syringe AD960 camsylate (Rubraca) 200mg tablet Yes Yes

AD961 rucaparib camsylate (Rubraca) 250mg tablet Yes Yes

AD962 rucaparib camsylate (Rubraca) 300mg tablet Yes Yes

AD963 dexamethasone (Non Proprietary) 4mg tablet Yes Yes

AD964 Trastuzumab (Trazimera) 420mg powder Yes Yes

AD965 Trastuzumab (Trazimera) 150mg powder Yes Yes

AD966 apalutamide (Erleada) 112 x 60mg tablet Yes Yes

AD967 Trastuzumab (Ontruzant) 150mg vial for iv Yes Yes infusion

150mg vial for IV Yes Yes infusion - powder for AD968 Trastuzumab (Herzuma) reconstitution

420mg vial for IV Yes Yes infusion - powder for AD969 Trastuzumab (Herzuma) reconstitution

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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 150mg vial for IV Yes Yes infusion - powder for AD970 Trastuzumab (Kanjinti) reconstitution

420mg vial for IV Yes Yes infusion - powder for AD971 Trastuzumab (Kanjinti) reconstitution

AD972 Dacomitinib (Vizimpro) 15mg Tablets Yes Yes

AD973 Dacomitinib (Vizimpro) 30mg Tablets Yes Yes

AD974 Dacomitinib (Vizimpro) 45mg Tablets Yes Yes

AD975 Midostaurin (Rydapt) 25 mg soft capsules Yes Yes

AD976 100 mg/ml, solution No Yes Gamunex 10% (immunoglobulin), for infusion

AD977 20mg/ml Yes Yes concentrate for Avelumab (Bavencio) infusion

AD978 350 mg for solution Yes Yes Cimiplimab (Libtayo) for infusion

AD979 Ibrutinib (Imbrivica) 420mg tablets x 28 Yes Yes

AD980 Brigatinib (Alunbrig) 90mg tablets x 7 Yes Yes

AD981 Axitinib (Inlyta) 3mg tablets x 56 Yes Yes

AD982 Neratinib (Nerlynx) 40mg tablets x 180 Yes Yes

AD983 Trametinib (Mekinist) 0.5mg tablets Yes Yes

30million units (300 Yes Yes AD984 Filgrastim (Accofil) micrograms)/0.5ml

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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 solution for injection pre-filled syringes

48million units (480 Yes Yes mcg)/0.5ml solution for injection pre- AD985 Filgrastim (Accofil) filled syringes

AD986 rituximab (Rixathon) 100mg/10mL vial Yes Yes

AD987 rituximab (Rixathon) 500mg/50mL vial Yes Yes

6mg/0.6mL pre-filled Yes Yes AD988 pegfilgrastim (Pelmeg) syringe

6mg/0.6mL prefilled Yes Yes AD989 pegfilgrastim (Ziextenzo) syringe

AD990 Ibrutinib (Imbruvica) 280mg tablets Yes Yes

140 mg powder for Yes Yes concentrate for AD991 Polatuzumab vedotin (Polivy) solution for infusion

AD992 Lorlatinib (Lorviqua) 30 x 100mg tablets Yes Yes

AD993 Bosutinib (Bosulif) 28 x 400mg tablets Yes Yes

AD994 brolucizumab (Beovu) 19.8mg/0.165ml No Yes solution for injection in pre-filled syringe

AD995 daratumumab (Darzalex) 1800mg/15ml Yes Yes solution for injection

AD996 gemtuzumab ozogamicin (Mylotarg) 5mg powder for Yes Yes concentrate for

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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 solution for infusion vials

AD997 valganciclovir hydrochloride (Valcyte) 60 x 450mg tablets Yes Yes

AD998 valganciclovir hydrochloride (Valganciclovir) 60 x 450mg tablets Yes Yes

AD791 isatuximab (Sarclisa) 100 mg/5mL Yes Yes concentrate for solution for infusion

AD792 isatuximab (Sarclisa) 500 mg/25mL Yes Yes concentrate for solution for infusion

AD793 normal Immunoglobulin (Intratect) 10% - 20g (200mL) No Yes for iv infusion

AD794 normal Immunoglobulin (Intratect) 10% - 10g (100mL) No Yes for iv infusion

AD788 Deferasirox (Exjade) 360mg tablets Yes Yes

AD789 Deferasirox (Exjade) 180mg tablets Yes Yes

AD790 Deferasirox (Exjade) 90mg tablets Yes Yes

AD795 Ibrutinib (Imbruvica) 560mg tablets Yes Yes

AD797 capecitabine (non-proprietary) 150mg tablets Yes Yes

AD798 capecitabine (non-proprietary) 500mg tablets Yes Yes

AD799 (Piqray) 50mg tablets Yes Yes

AD800 alpelisib (Piqray) 150mg tablets Yes Yes

AD801 alpelisib (Piqray) 200mg tablets Yes Yes

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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 AD802 entrectinib (Rozlytrek) 100mg capsule Yes Yes

AD803 entrectinib (Rozlytrek) 200mg capsule Yes Yes

AD804 abiraterone (Zytiga) 500mg tablet Yes Yes

AD805 (Talzenna) 0.25mg capsules Yes Yes

AD806 dalbavancin (Xydalba) 500mg powder for No Yes concentrate for solution for infusion vials

AD807 talazoparib (Talzenna) 1mg capsules Yes Yes

AD808 granisetron (Sancuso) 3.1mg transdermal Yes Yes patch

AD809 foscarnet sodium (Foscavir) 6g/250ml solution No Yes for infusion bottle

Solution for injection Yes Yes - 2mg/mL, 100mL vial AD119 epirubicin (Pharmorubicin)

Solution for injection Yes Yes AD120 epirubicin (Pharmorubicin) - 25mg/mL, 5mL vial

AD810 lenalidomide (Revlimid) 20mg capsules Yes Yes

150mg/1ml solution Yes Yes for injection pre- AD811 omalizumab (Xolair) filled syringes

AD812 lorlatinib (Lorviqua) 25mg tablets Yes Yes

AD813 levomepromazine (non proprietary) 6mg tablets Yes Yes

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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 8mg orodispersible Yes Yes AD814 ondansetron (non proprietary) tablets

AD815 erlotinib (non-proprietary) 25mg tablets Yes Yes

AD816 erlotinib (non-proprietary) 100mg tablets Yes Yes

AD817 erlotinib (non-proprietary) 150mg tablets Yes Yes

AD818 acalabrutinib (Calquence) 100mg capsules Yes Yes

AD819 axitinib (Inlyta) 7 mg tablets Yes Yes

600mg,600mg/10ml Yes Yes solution for injection AD820 Pertuzumab,trastuzumab (Phesgo) vials

1200mg,600mg/15ml Yes Yes solution for injection AD821 pertuzumab/trastuzumab (Phesgo) vials

100mg/4ml solution Yes Yes AD822 bevacizumab (Zirabev) for infusion vials

400mg/16ml solution Yes Yes AD823 bevacizumab (Zirabev) for infusion vials

250mg/5ml solution Yes Yes for injection pre- AD824 fulvestrant (non-proprietary) filled syringes

AD825 aprepitant (non-proprietary) 125mg capsules Yes Yes

AD826 ibandronic acid (non-proprietary) 50mg tablets Yes Yes

AD827 darolutamide (Nubeqa) 300mg tablets Yes Yes

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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 3.6mg/90microlitres No Yes solution for injection AD828 ibercept (Eylea) pre-filled syringes

30mg powder for Yes Yes solution for infusion AD829 carfilzomib (Kyprolis) vials

AD830 temozolomide (Non-proprietary) 5mg capsules Yes Yes

AD831 temozolomide (Non-proprietary) 140mg capsules Yes Yes

AD832 isavuconazole (Cresemba) 100mg capsules No Yes

AD833 palbociclib (Ibrance) 75mg tablets Yes Yes

AD834 cabozantinib (Cabometyx) 20mg tablets Yes Yes

AD835 temozolomide (Non-proprietary) 100mg capsules Yes Yes

AD836 trifluridine/tipiracil (Lonsurf) 20mg/8.19mg tablets Yes Yes

840mg/14ml concentrate for solution for infusion AD837 atezolizumab (Tecentriq) vials Yes Yes

AD838 palbociclib (Ibrance) 125mg capsules Yes Yes

4mg/4ml concentrate for solution for infusion AD839 topotecan (non-proprietary) vials Yes Yes

10mg/5ml solution AD840 cladribine (Litak) for injection vials Yes Yes

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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 AD841 everolimus (Afinitor) 2.5mg tablets Yes Yes

AD842 cabozantinib (Cabometyx) 40mg tablets Yes Yes

AD843 ruxolitinib (Jakavi) 10mg tablets Yes Yes

100mg gastro- AD844 posaconazole (Noxafil) resistant tablets Yes Yes

AD845 lenalidomide (Revlimid) 2.5mg capsules Yes Yes

AD846 osimertinib (Tagrisso) 80mg tablets Yes Yes

AD847 docetaxel (Non-Proprietary) 20mg/mL, 8mL vial Yes Yes

150mg powder for concentrate for solution for infusion AD848 trastuzumab (Zercepac) vials Yes Yes

5mg/1ml solution for AD849 haloperidol (non-proprietary) injection ampoules Yes Yes

500microgram AD850 haloperidol (non-proprietary) tablets Yes Yes

200mg powder for concentrate for solution for infusion AD851 isavuconazole (Cresemba) vials No Yes

250mg tablets

AD852 gefitinib (non-proprietary) Yes Yes

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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 100 mg powder for concentrate for solution for infusion AD853 trastuzumab deruxtecan (Enhertu) Yes Yes

100mg gastro- resistant tablets AD854 posaconazole (non-proprietary) Yes Yes

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Bupa separately chargeable drugs list – 15 September 2021 Valid until 15 October 2021 © Bupa Insurance Services Limited 2021