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
ACROMEGALY GROWTH DEFICIENCY Neulasta® (Pegfilgrastim) ® ® Octreotide acetate Genotropin (Somatropin) Neupogen (Filgrastim) Sandostatin® (Octreotide acetate) Humatrope® (Somatropin) Novoeight® (Antihemophilic Factor) Somatuline® Depot (Lanreotide) Norditropin® (Somatropin) Novoseven® RT (Coagulation Factor Omnitrope® (Somatropin) VIIa) BOTULINUM TOXINS Saizen® (Somatropin) Procrit® (Epoetin alfa) ® Botox (OnabotulinumtoxinA) Serostim® (Somatropin Profilnine® (Factor IX Complex) ® Dysport (AbobotulinumtoxinA) Zorbtive® (Somatropin) Promacta® (Eltrombopag) ® Myobloc (RimabotulinumtoxinB) Recombinate® (Antihemophilic ® Xeomin (IncobotulinumtoxinA) HEMATOLOGY Factor) ® Promacta (Eltrombopag) Rixubis® (Coagulation Factor IX) ® CARDIOLOGY Soliris (Eculizumab) Thrombate III® (Antithrombin III) ® ® Praluent (Alirocumab) RiaSTAP (Fibrinogen Concentrate) Wilate® (von Willebrand factor / ® Repatha (Evolocumab) Coagulation Factor VIII complex) ® Tikosyn (Dofetilide) HEMOPHILIA & RELATED Xyntha® (Antihemophilic Factor) DISORDERS Zarxio® (Filgrastim-sndz) ® CROHN’S DISEASE/ Advate (Antihemophilic Factor ULCERATIVE COLITIS (Recombinant)) HEPATITIS B ® ® Cimzia (Certolizumab pegol) Alphanate (Antihemophilic Baraclude® (Entecavir) ® Entyvio (Vedolizumab) factor/von Willebrand factor Epivir HBV® (Lamivudine) ® Humira (Adalimumab) complex) Hepsera® (Adefovir dipivoxil) ® ® Kineret (Anakinra) AlphaNine SD (Coagulation Factor Lamivudine ® Remicade (Infliximab) £ IX) Tyzeka® (Telbivudine) ® ® Simponi (Golimumab) Alprolix (Coagulation Factor IX) Vemlidy® (Tenofovir alafenamide) ® Aranesp (Darbepoetin alfa) Viread® (Tenofovir disoproxil ® CRYOPYRIN-ASSOCIATED Bebulin (Factor IX Complex) fumarate) PERIODIC SYNDROMES BeneFIX® (Coagulation Factor IX) ® Ilaris (Canakinumab) Eloctate® (Antihemophilic Factor/ HEPATITIS C Fc Fusion Protein) Daklinza® (Daclatasvir) CYSTIC FIBROSIS ® ® ® Epogen (Epoetin alfa) Epclusa (Sofosbuvir/Velpatasvir) Bethkis (Tobramycin) ® ® ® Feiba NF (Anti-Inhibitor Coagulant Harvoni (Ledipasvir/Sofosbuvir) Pertzye (Pancrelipase) ® ® Complex) Intron A (Interferon alfa-2b) Pulmozyme (Dornase Alfa) ® ® Helixate FS (Antihemophilic Olysio (Simeprevir) Tobramycin ® Factor) Pegasys (Peginterferon alfa-2a) ® ® Hemofil M (Antihemophilic Factor) PegIntron (Peginterferon alfa-2b) DERMATOLOGIC DISORDER ® ® ® Humate-P (Antihemophilic Rebetol (Ribavirin) Cosentyx (Secukinumab) ® ® Factor/von Willebrand Factor Ribasphere (Ribavirin) Dupixent (Dupilumab) ® ® (VWF) Complex) Riba-Pak (Ribavirin) Enbrel (Etanercept) ® ® Koāte -DVI (Antihemophilic Factor) Ribavirin Humira (Adalimumab) ® ® ® Kogenate FS (Antihemophilic Sovaldi (Sofosbuvir) Otezla (Apremilast) ™ ® Factor) Technivie (Ombitasvir/ Remicade (Infliximab) £ ® ® Leukine (Sargramostim) Paritaprevir/ Ritonavir) Stelara (Ustekinumab) ® Monoclate-P (Antihemophilic Viekira Pak™ (Ombitasvir/
factor) Paritaprevir/ Ritonavir; Dasabuvir)
Last Updated: 06/29/2017
unitypoint.org/specialtypharmacy
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
HEPATITIS C (cont’d) Nevirapine Trelstar® (Triptorelin pamoate) ™ ® ® Viekira XR Ombitasvir/ Norvir (Ritonavir) Vantas (Histrelin) Paritaprevir/ Ritonavir/ Dasabuvir) Odefsey® (Emtricitabine/ Zoladex® (Goserelin acetate) Zepatier® (Elbasvir/Grazoprevir) Rilpivirine/ Tenofovir alafenamide) PREZCOBIX® (Darunavir/ Cobicistat) IMMUNE GLOBULIN HEREDITARY ANGIOEDEMA Prezista® (Darunavir) THERAPY ® ® Firazyr (Icatibant) Rescriptor® (Dalavirdine mesylate) Bivigam £ ® ® Kalbitor (Ecallantide) Retrovir® (Zidovudine) Carimune-NF £ ® Reyataz® (Atazanavir) Flebogamma £ ® HIV/AIDS Selzentry® (Maraviroc) Gammagard £ ® Abacavir Stavudine Gammagard S/D £ ® Abacavir Sulfate/ Lamivudine/ Stribild® (Elvitegravir/ Cobicistat/ Gammaplex £ ® Zidovudine Emtricitabine/ /tenofovir) Gamunex-C £ ® Abacavir/ Lamivudine Sustiva® (Efavirenz) Hizentra £ ® Adefovir dipivoxil Tivicay® (Dolutegravir) Octagam £ ® ® Aptivus (Tipranavir) Triumeq® (Abacavir/ Dolutegravir/ Privigen £ ® Atripla (Efavirenz/ Emtricitabine/ Lamivudine) Tenofovir) Trizivir® (Abacavir/ Lamivudine/ INFLAMMATORY ® Combivir (Lamivudine/ Zidovudine) CONDITIONS ® Zidovudine) Truvada® (Emtricitabine/ Tenofovir) Ilaris (Canakinumab) ® ® Complera (Emtricitabine/ Tybost® (Cobicistat) Kineret (Anakinra) ® Rilpivirine/ tenofovir) Tyzeka® (Telbivudine) Simponi (Golimumab) ® Crixivan (Indinavir sulfate) Valcyte® (Valganciclovir Descovy® (Emtricitabine/ Tenofovir) IRON OVERLOAD hydrochloride) ® Didanosine VIDEX® (Didanosine) Exjade (Deferasirox) ® ® Egrifta (Tesamorelin) Viracept® (Nelfinavir mesylate) Jadenu (Deferasirox) ® Emtriva (Emtricitabine) Viramune® (Nevirapine) Entecavir MACULAR DEGENERATION Voriconazole ® ® ® Macugen (Pegaptanib sodium) Epivir (Lamivudine) Zerit (Stavudine) ® ® Epzicom (Abacavir/ Lamivudine) Ziagen (Abacavir) Evotaz™ (Atazanavir/ Cobicistat) METABOLIC DISORDERS Zidovudine ® Fuzeon® (Enfuvirtide) Aldurazyme (Laronidase) ® Genvoya® (Elvitegravir/ Cobistat/ Buphenyl (Sodium phenylbutyrate) HORMONE THERAPIES ® Emtricitabine/ Tenofovir ® Cerezyme (Imiglucerase) Eligard (Leuprolide acetate) ® alafenamide) ® Elaprase (Idursulfase) Firmagon (Degarelix) ® Hepsera® (Adefovir dipivoxil) Fabrazyme (Agalsidase beta) Leuprolide acetate ® Intelence™ (Entravirine) ® Kanuma (Sebelipase alfa) Lupron DEPOT (Leuprolide ® ® Kuvan (Sapropterin Invirase (Saquinavir) acetate) Isentress® (Raltegravir) ® dihydrochloride) Lupron Depot-PED (Leuprolide ® Kaletra® (Lopinavir/ Ritonavir) Lumizyme (Alglucosidase alfa) acetate) ® Lamivudine ® Naglazyme (Galsulfase) Makena (Hydroxyprogesterone ® Lamivudine/Zidovudine Vimizim (Elosulfase alfa) caproate) ® ® ® Vpriv (Velaglucerase alfa) Lexiva (Fosamprenavir) Supprelin LA (Histrelin acetate) ® Lopinavir/ritonavir Synarel (Nafarelin acetate)
Last Updated: 06/29/2017
unitypoint.org/specialtypharmacy
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
MULTIPLE SCLEROSIS Otezla® (Apremilast) Kevzara® (Sarilumab) ® ® ® Aubagio (Teriflunomide) Remicade (Infliximab) £ Kineret (Anakinra) Avonex® (Interferon beta-1a) Simponi® (Golimumab) Orencia® (Abatacept) ® BETASERON (Interferon beta-1b) Remicade® (Infliximab) £ Copaxone® (Glatiramer acetate) PULMONARY ARTERIAL Simponi® (Golimumab) Extavia® (Interferon beta-1b) HYPERTENSION Simponi Aria® (Golimumab) ® Gilenya® (Fingolimod) Adcirca (Tadalafil) Xeljanz® (Tofacitinib) Glatopa® (Glatiramer acetate) Epoprostenol £ ® Rebif® (Interferon beta-1a) Flolan (Epoprostenol) £ OTHER ® Tysabri® (Natalizumab) £ Revatio (Sildenafil) Cinqair® (Reslizumab) £ Sildenafil Dificid® (Fidoximicin) OSTEOPOROSIS Nuplazid® (Pimavenserin) Forteo® (Teriparatide) RESPIRATORY SYNCTIAL Thyrogen® (Thyrotropin alfa) Prolia® (Denosumab) VIRUS Veltassa® (Patiromer) ® TYMLOS® (Abaloparatide) Synagis (Palivizumab) Vivitrol® (Naltrexone) Xiaflex® (Collagenase Clostridium PSORIATIC ARTHRITIS RHEUMATOID ARTHRITIS ® histolyticum) Cimzia® (Certolizumab pegol) Actemra (Tocilizumab) ® ® Zecuity (Sumatriptan Cosentyx® (Secukinumab) Cimzia (Certolizumab pegol) ® iontophoretic transdermal system) Enbrel® (Etanercept) Enbrel (Etanercept) ® Humira® (Adalimumab) Humira (Adalimumab)
Last Updated: 06/29/2017
unitypoint.org/specialtypharmacy