CareSource Pharmacy Policy Statement Marketplace Table of Contents Amevive (alefacept) ............................................................................................................................................................... 4 Antihemophilic Agents (Advate, Adynovate, Afstyla, Alphanate, Alphanate/VWF Complex/Human, AlphaNine SD, Alprolix, Bebulin, Bebulin VH, BeneFIX, Coagadex, Corifact, Eloctate, Esperoct, Factor VIII SD (Human), Feiba, Feiba NF, Feiba VH Immuno, Fibryga, Helixate, Helixate FS, Hemlibra, Hemofil M, Humate-P, Humate-P Human, Idelvion, Ixinity, Jivi, Kcentra, Koate, Koate-DVI, Koate-HP, Kogenate, Kogenate FS, Kogenate FS Bio-Set, Kovaltry, Monoclate-P, Mononine, Novoeight, NovoSeven RT, Nuwiq, Obizur, Profilnine, Profilnine SD, Rebinyn, Recombinate, RiaSTAP, Rixubis, Tretten, Vonvendi, Wilate, Xyntha, and Xyntha Solofuse) ........................................................................................ 7 Benlysta (belimumab) .......................................................................................................................................................... 11 Berinert (C1 esterase inhibitor [human]) .............................................................................................................................. 13 Boniva (ibandronate) ............................................................................................................................................................ 15 Botox (onabotulinumtoxinA) ................................................................................................................................................. 17 Brineura (cerliponase alfa) ................................................................................................................................................... 24 Cinryze (C1 esterase inhibitor [human]) ............................................................................................................................... 26 Crysvita (burosumab-twza) .................................................................................................................................................. 28 Durolane (sodium hyaluronate) ............................................................................................................................................ 31 Dysport (abobotulinumtoxinA).............................................................................................................................................. 33 Entyvio (vedolizumab) .......................................................................................................................................................... 36 Epogen (epoetin alfa) ........................................................................................................................................................... 39 Euflexxa (sodium hyaluronate)............................................................................................................................................. 42 Evenity (romosozumab-aggg) .............................................................................................................................................. 45 Exondys 51 (eteplirden) ....................................................................................................................................................... 47 Fasenra (benralizumab) ....................................................................................................................................................... 49 Firazyr (icatibant) .................................................................................................................................................................. 51 Fulphila (pegfilgrastim-jmdb) ................................................................................................................................................ 53 Gamifant (emapalumab-lzsg) ............................................................................................................................................... 58 Gel-One (sodium hyaluronate) ............................................................................................................................................. 60 Gelsyn-3 (sodium hyaluronate) ............................................................................................................................................ 63 GenVisc 850 (sodium hyaluronate) ...................................................................................................................................... 65 Granix (tbo-filgrastim) ........................................................................................................................................................... 67 1 CareSource Pharmacy Policy Statement Marketplace H.P Acthar Gel (respiratory corticotropin injection) .............................................................................................................. 69 Haegarda (C1 inhibitor(human)] ........................................................................................................................................... 71 Hyalgan (sodium hyaluronate) ............................................................................................................................................. 73 Hymovis (sodium hyaluronate) ............................................................................................................................................ 75 Ilumya (tildrakizumab-asmn) ................................................................................................................................................ 77 Immune Globulin (Intravenous[IVIG]) ................................................................................................................................. 80 Intravenous: Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked,Gammaplex, Gamunex-C, Octagam, Privigen, and Thymoglobulin Subcutaneous: Cuvitru, Hizentra, HyQvia and Xembify Inflectra (infliximab-dyyb) ..................................................................................................................................................... 92 Kalbitor (ecallantide) ............................................................................................................................................................ 99 Kanuma (sebelipase alfa) ................................................................................................................................................... 101 Kymriah (tisangenlecleucel) ............................................................................................................................................... 103 Lemtrada (alemtuzumab) ................................................................................................................................................... 106 Lupron (leuprolide acetate) ................................................................................................................................................ 108 Luxturna (voretigene neparvovec-rzyl) .............................................................................................................................. 113 Makena (hydroxyprogesterone caproate) ........................................................................................................................... 115 Mepsevii (vestronidase alfa-vjbk) ....................................................................................................................................... 117 Monovisc (sodium hyaluronate) ......................................................................................................................................... 119 Myobloc (rimabotulinumtoxinB) .......................................................................................................................................... 121 Novantrone (mitoxantrone) ................................................................................................................................................ 124 NPlate (romiplostim) ........................................................................................................................................................... 126 Ocrevus (ocrelizumab) ....................................................................................................................................................... 128 Onpattro (patisiran) ............................................................................................................................................................ 131 Orencia (abatacept) ............................................................................................................................................................ 133 Orthovisc (sodium hyaluronate)......................................................................................................................................... 137 Procrit (epoetin alfa) ........................................................................................................................................................... 139 Prolia (denosumab) ............................................................................................................................................................ 142 Radicava (edaravone injection) .........................................................................................................................................