Specialty Medications, Attachment A Effective 11/14/2018 Brand Name Generic Name ACTEMRA Tocilizumab injection ACTHAR H.P. Repository Corticotropin injection ACTIMMUNE Interferon Gamma-1b injection ADAGEN pegademase bovine injection ADCETRIS brentuximab vedotin injection ALECENSA alectinib hydrochloride capsule ALFERON N interferon alfa-n3 injection AMPYRA dalfampridine tablet, film coated, extended release APOKYN apomorphine hydrochloride injection ARALAST alpha.1-proteinase inhibitor human ARZERRA ofatumumab injection AUBAGIO teriflunomide tablet AVASTIN bevacizumab injection testosterone undecanoate injection BENDEKA bendamustine hydrochloride injection BENLYSTA belimumab injection BERINERT human c1-esterase inhibitor BETHKIS tobramycin solution for inhalation BOSULIF bosutinib monohydrate tablet BUPHENYL sodium phenylbutyrate tablet, powder CABOMETYX cabozantinib tablet CAYSTON aztreonam solution for inhalation CERDELGA eliglustat capsule COPEGUS ribavirin tablet COSENTYX secukinumab injection COTELLIC cobimetinib tablet CYSTARAN cysteamine hydrochloride ophth soln. DACOGEN decitabine injection DAKLINZA daclatasvir tablet DARAPRIM pyrimethamine tablet DARZALEX daratumumab injection EGRIFTA tesamorelin injection EPCLUSA velpatasvir and sofosbuvir tablet ERGOMAR ergotamine tartrate tablet ERIVEDGE vismodegib capsule ESBRIET pirfenidone capsule & tablets EXJADE deferasirox tablet, for suspension EYLEA aflibercept injection
Specialty Medications, Attachment A Effective 11/14/2018 Brand Name Generic Name ACTEMRA Tocilizumab injection ACTHAR H.P. Repository Corticotropin injection ACTIMMUNE Interferon Gamma-1b injection ADAGEN pegademase bovine injection ADCETRIS brentuximab vedotin injection ALECENSA alectinib hydrochloride capsule ALFERON N interferon alfa-n3 injection AMPYRA dalfampridine tablet, film coated, extended release APOKYN apomorphine hydrochloride injection ARALAST alpha.1-proteinase inhibitor human ARZERRA ofatumumab injection AUBAGIO teriflunomide tablet AVASTIN bevacizumab injection testosterone undecanoate injection BENDEKA bendamustine hydrochloride injection BENLYSTA belimumab injection BERINERT human c1-esterase inhibitor BETHKIS tobramycin solution for inhalation BOSULIF bosutinib monohydrate tablet BUPHENYL sodium phenylbutyrate tablet, powder CABOMETYX cabozantinib tablet CAYSTON aztreonam solution for inhalation CERDELGA eliglustat capsule COPEGUS ribavirin tablet COSENTYX secukinumab injection COTELLIC cobimetinib tablet CYSTARAN cysteamine hydrochloride ophth soln. DACOGEN decitabine injection DAKLINZA daclatasvir tablet DARAPRIM pyrimethamine tablet DARZALEX daratumumab injection EGRIFTA tesamorelin injection EPCLUSA velpatasvir and sofosbuvir tablet ERGOMAR ergotamine tartrate tablet ERIVEDGE vismodegib capsule ESBRIET pirfenidone capsule & tablets EXJADE deferasirox tablet, for suspension EYLEA aflibercept injection