UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change £Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy CARDIOLOGY ENDOCRINOLOGY (cont’d) GASTROENTEROLOGY (cont’d) ANTILIPIDEMICS GROWTH DEFICIENCY HEPATITIS B Praluent® (Alirocumab) Genotropin® (Somatropin) Baraclude® (Entecavir) Repatha® (Evolocumab) Humatrope® (Somatropin) Epivir HBV® (Lamivudine) Norditropin® (Somatropin) Hepsera® (Adefovir dipivoxil) PULMONARY ARTERIAL ® HYPERTENSION Novarel (Chorionic Gonadotropin) Lamivudine ® Adcirca® (Tadalafil) Nutropin AQ (Somatropin) Tenofovir disoproxil fumerate ® ® Revatio® (Sildenafil) Omnitrope (Somatropin) Vemlidy (Tenofovir alafenamide) ® ® Sildenafil Saizen (Somatropin) Viread (Tenofovir disoproxil Serostim® (Somatropin fumarate) DERMATOLOGY Zorbtive® (Somatropin) HEPATITIS C ATOPIC DERMATITIS METABOLISM DISORDER Daklinza® (Daclatasvir) Dupixent® (Dupilumab) Aldurazyme® (Laronidase) £ Epclusa® (Sofosbuvir/Velpatasvir) Buphenyl® (Sodium phenylbutyrate) Harvoni® (Ledipasvir/Sofosbuvir) HIDRADENITIS SUPPURATIVA ® £ ® ® Cerezyme (Imiglucerase) Intron A (Interferon alfa-2b) Humira (Adalimumab) ® £ Elaprase (Idursulfase) Ledipasvir/Sofosbuvir PLAQUE PSORIASIS Elelyso® (Taliglucerase alfa) £ Mavyret® (Glecaprevir/Pibrentasvir) ® Cimzia (Certolizumab pegol) Fabrazyme® (Agalsidase beta) £ Olysio® (Simeprevir) ® Cosentyx (Secukinumab) Kanuma® (Sebelipase alfa) Pegasys® (Peginterferon alfa-2a) ® Enbrel (Etanercept) Kuvan® (Sapropterin PegIntron® (Peginterferon alfa-2b) ® Humira (Adalimumab) dihydrochloride) Rebetol® (Ribavirin) ® Otezla (Apremilast) Lumizyme® (Alglucosidase alfa) Ribasphere® (Ribavirin) ® Remicade (Infliximab) £ Naglazyme® (Galsulfase) Riba-Pak® (Ribavirin) RenflexisTM (Infliximab-abda) £ Vimizim® (Elosulfase alfa) Ribavirin Stelara® (Ustekinumab) Vpriv® (Velaglucerase alfa) Sofosbuvir/Velpatasvir Taltz® (Ixekizumab) ® OSTEOPOROSIS Sovaldi (Sofosbuvir) ® ™ Tremfya (Guselkumab) ® Technivie (Ombitasvir/ Forteo (Teriparatide) Prolia® (Denosumab) Paritaprevir/ Ritonavir) ™ ENDOCRINOLOGY TYMLOS® (Abaloparatide) Viekira Pak (Ombitasvir/ Paritaprevir/ Ritonavir; Dasabuvir) ACROMEGALY Viekira XR™ Ombitasvir/ Octreotide acetate GASTROENTEROLOGY Paritaprevir/ Ritonavir/ Dasabuvir) Sandostatin® (Octreotide acetate) CROHN’S DISEASE/ Vosevi® (Sofosbuvir/Velpatasvir/ Sandostatin LAR® (Octreotide ULCERATIVE COLITIS ® Voxilaprevir) acetate) Cimzia (Certolizumab pegol) ® (Elbasvir/Grazoprevir) ® £ Zepatier ELECTROLYTE IMBALANCE Entyvio (Vedolizumab) ® Other Jadenu® (Deferasirox) Humira (Adalimumab) ® Doptelet® (Avatrombopag) ® Kineret (Anakinra) Veltassa (Patiromer) ® £ Remicade (Infliximab) TM (Infliximab-abda) £ Renflexis ® Simponi (Golimumab) ® Stelara (Ustekinumab) Last Updated: February 2019 unitypoint.org/specialty-pharmacy UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change £Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy HEMATOLOGY HEMATOLOGY (cont’d) INFECTIOUS DISEASE (cont’d) HEMATOPOIETIC GROWTH HEMOPHILIA & RELATED HIV/AIDS (con’td) £ ® FACTORS DISORDERS (con’td) Crixivan (Indinavir sulfate) Aranesp® (Darbepoetin alfa) Kovaltry® (Antihemophilic Factor Descovy® (Emtricitabine/ Tenofovir) Epogen® (Epoetin alfa) (Recombinant) Didanosine Granix® (TBO Filgrastim) Monoclate-P® (Antihemophilic Edurant®(Rilpivirine) Leukine® (Sargramostim) factor) Egrifta® (Tesamorelin) Neulasta® (Pegfilgrastim) Novoeight® (Antihemophilic Factor) Emtriva® (Emtricitabine) Neupogen® (Filgrastim) Novoseven® RT (Coagulation Factor Entecavir Procrit® (Epoetin alfa) VIIa) Epivir® (Lamivudine) Promacta® (Eltrombopag) Nuwiq® (Human coagulation factor Epzicom® (Abacavir/ Lamivudine) Zarxio® (Filgrastim-sndz) VIII recombinant DNA, simoctocog Evotaz™ (Atazanavir/ Cobicistat) ® HEMOPHILIA & RELATED alfa) Fuzeon (Enfuvirtide) ® ® DISORDERS £ Profilnine (Factor IX Complex) Genvoya (Elvitegravir/ Cobicistat/ ® Advate® (Antihemophilic Factor Recombinate (Antihemophilic Emtricitabine/ Tenofovir (Recombinant)) Factor) alafenamide) ® ™ ® (Coagulation Factor IX) Afstyla (Antihemophilic Factor Rixubis Intelence (Entravirine) ® (recombinant), Single Chain Thrombate III (Antithrombin III) Invirase® (Saquinavir) ® ® Alphanate® (Antihemophilic Wilate (von Willebrand factor / Isentress (Raltegravir) factor/von Willebrand factor Coagulation Factor VIII complex) Juluca® (Dolutegravir/ Rilpivirine) ® ® Xyntha (Antihemophilic Factor) Kaletra (Lopinavir/ Ritonavir) complex) AlphaNine SD® (Coagulation Factor OTHER Lamivudine IX) Soliris® (Eculizumab) Lamivudine/Zidovudine ® Alprolix® (Coagulation Factor IX) RiaSTAP® (Fibrinogen Concentrate) Lexiva (Fosamprenavir) Bebulin® (Factor IX Complex) Lopinavir/ritonavir BeneFIX® (Coagulation Factor IX) INFECTIOUS DISEASE Nevirapine ® Norvir® (Ritonavir) Eloctate (Antihemophilic Factor/ HEPATITIS B / HEPATITIS C Odefsey® (Emtricitabine/ Rilpivirine/ Fc-Fusion Protein) *See Gastroenterology Section* Feiba NF® (Anti-Inhibitor Coagulant Tenofovir alafenamide) Complex) HIV/AIDS PREZCOBIX® (Darunavir/ Cobicistat) ® Helixate® FS (Antihemophilic Factor) Abacavir Prezista (Darunavir) ® Helimbra® (emicizumab-kxwh) Abacavir Sulfate/ Lamivudine/ Rescriptor (Dalavirdine mesylate) ® Hemofil M® (Antihemophilic Factor) Zidovudine Retrovir (Zidovudine) ® Humate-P® (Antihemophilic Abacavir/ Lamivudine Reyataz (Atazanavir) Factor/von Willebrand Factor Adefovir dipivoxil Selzentry® (Maraviroc) ® (VWF) Complex) Aptivus (Tipranavir) Stavudine ® ® Idelvion® (Coagulation Factor IX Atripla (Efavirenz/ Emtricitabine/ Stribild (Elvitegravir/ Cobicistat/ (Recombinant), Albumin fusion Tenofovir) Emtricitabine/tenofovir) ® protein) Biktarvy (Bictegravir/emtricitibine/ Sustiva® (Efavirenz) ® tenofovir alafenamide) ® (Antihemophilic Factor) Tivicay (Dolutegravir) Koāte -DVI ® ® Combivir (Lamivudine/ Zidovudine) ® (Antihemophilic Triumeq (Abacavir/ Dolutegravir/ Kogenate FS ® Factor) Complera (Emtricitabine/ Lamivudine) Rilpivirine/ tenofovir) Last Updated: February 2019 unitypoint.org/specialty-pharmacy UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change £Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy INFECTIOUS DISEASE (cont’d) NEUROLOGY PULMONOLOGY (cont’d) HIV/AIDS (con’td) BOTULINUM TOXINS HEREDITARY ANGIOEDEMA Trizivir® (Abacavir/ Lamivudine/ Botox® (OnabotulinumtoxinA) Firazyr® (Icatibant) Zidovudine) Myobloc® (RimabotulinumtoxinB) Kalbitor® (Ecallantide) Truvada® (Emtricitabine/ Tenofovir) Xeomin® (IncobotulinumtoxinA) ® PULMONARY ARTERIAL Tybost (Cobicistat) HYPERTENSION ® MIGRANE PREVENTION Valcyte (Valganciclovir Aimovig® (Erenumab) Adcirca® (Tadalafil) hydrochloride) ® ® (Fremanezumab) Revatio (Sildenafil) ® Ajovy VIDEX (Didanosine) ® (OnabotulinumtoxinA) Sildenafil ® Botox Viracept (Nelfinavir mesylate) ® (Galcanezumab) ® Emgality Viramune (Nevirapine) RHEUMATOLOGY Voriconazole MOVEMENT DISORDER ® ANKYLOSING SPONDYLITIS Zerit® (Stavudine) Austedo (Deutetrabenazine) Cimzia® (Certolizumab pegol) Ziagen® (Abacavir) Dalfampridine Tetrabenazine Cosentyx® (Secukinumab) Zidovudine ® Xadago® (Safinamide) Humira (Adalimumab) OTHER Simponi® (Golimumab) Dificid® (Fidoximicin) MULTIPLE SCLEROSIS ® CRYOPYRIN-ASSOCIATED Noxafil® (Posaconazole) Aubagio (Teriflunomide) Avonex® (Interferon beta-1a) PERIODIC SYNDROMES ® ® (Interferon beta-1b) Ilaris (Canakinumab) MEN’S / WOMEN’S HEALTH BETASERON Copaxone® (Glatiramer acetate) PSORIATIC ARTHRITIS HORMONE THERAPY ® ® ® Extavia (Interferon beta-1b) Cimzia (Certolizumab pegol) Eligard (Leuprolide acetate) Gilenya® (Fingolimod) Cosentyx® (Secukinumab) Firmagon® (Degarelix) Glatiramer acetate Enbrel® (Etanercept) Leuprolide acetate Glatopa® (Glatiramer acetate) Humira® (Adalimumab) Lupron DEPOT® (Leuprolide acetate) Rebif® (Interferon beta-1a) Otezla® (Apremilast) Makena® (Hydroxyprogesterone Tysabri® (Natalizumab) £ Simponi® (Golimumab) caproate) ® ® Stelara (Ustekinumab) Supprelin LA (Histrelin acetate) PULMONOLOGY ® (Ixekizumab) ® Taltz Synarel (Nafarelin acetate) Thyrogen® (Thyrotropin alfa) ASTHMA RHEUMATOID ARTHRITIS ® £ Trelstar® (Triptorelin pamoate) Cinqair (Reslizumab) Actemra® (Tocilizumab) ® Vantas® (Histrelin) Dupixent (Dupilumab) Cimzia® (Certolizumab pegol) ® Zoladex® (Goserelin acetate) Fasenra (Benralizumab) Enbrel® (Etanercept) Nucala® (Mepolizumab) ® Humira (Adalimumab) NEPHROLOGY CYSTIC FIBROSIS Kevzara® (Sarilumab) ® ® ANEMIA Bethkis (Tobramycin) Kineret (Anakinra) ® ® Aranesp® (Darbepoetin alfa) Kitabis Pak (Tobramycin) Olumiant (Baricitinib) ® ® ® Epoetin alfa) Pertzye (Pancrelipase) Orencia (Abatacept) Epogen ( ® ® Pulmozyme® (Dornase Alfa) Simponi (Golimumab) Procrit (Epoetin alfa) ® Tobramycin Simponi Aria (Golimumab) ELECTROLYTE IMBALANCE Xeljanz® (Tofacitinib) Jadenu® (Deferasirox) Veltassa® (Patiromer) Last Updated: February 2019 unitypoint.org/specialty-pharmacy UnityPoint at Home Specialty Pharmacy Formulary This is a listing by therapy of specialty medications that UnityPoint at Home Specialty Pharmacy can provide or facilitate access to and is subject to change £Infusion Product – may be provided by UnityPoint at Home Infusion Pharmacy RHEUMATOLOGY (cont’d) PEDIATRICS