UK-HMO Specialty Pharmacy Medical Management Drug List Effective 7-1-201 – CODE GENERIC NAME TRADE CODE GENERIC NAME TRADE J1438** Etanercept Enbrel J7328 – J1442 Filgrastim Neupogen J1458 Galsulfase 1 mg Naglazyme J1459 Immune Privigen liquid 500mg J1460 Gamma globulin, Gamastan IM, 1cc J1555 Immune globulin Cuvitru (Ig) therapy J1556 Immune globulin Bivigam (IG) Therapy J1557 Immune globulin, Gammaplex 500mg J1559 Immune globulin Hizentra Subcutaneous (Human) J1560 Gamma globulin, Gamastan IM, over 10cc J1561 Immune Globulin Gammaked J1561 Immune Gamunex J1566 Immune 500mg J1568 Immune Octagam 500mg J1569 Immune Gammagard 500 mg J1572 Immune Flebogamma J1575 Immune Globulin HyQvia (Ig) Therapy J1595** Glatiramer Copaxone Acetate/Glatopa J1599 Immune Immune globulin, 500mg intravenous nonlyophilized 500mg J1602 Golimumab Simponi Aria
UK-HMO Specialty Pharmacy Medical Management Drug List – Effective 7-1-201 CODE GENERIC NAME TRADE CODE GENERIC NAME TRADE J1438** Etanercept Enbrel – J7328 J1442 Filgrastim Neupogen J1458 Galsulfase 1 mg Naglazyme J1459 Immune 500mg Privigen J1460 Gamma globulin, IM, 1cc Gamastan J1555 Immune globulin (Ig) therapy Cuvitru J1556 Immune globulin (IG) Therapy Bivigam J1557 Immune globulin, liquid 500mg Gammaplex J1559 Immune globulin Subcutaneous (Human) Hizentra J1560 Gamma globulin, IM, over 10cc Gamastan J1561 Immune Globulin Gammaked J1561 Immune Gamunex J1566 Immune 500mg J1568 Immune 500mg Octagam J1569 Immune 500 mg Gammagard J1572 Immune Flebogamma J1575 Immune Globulin (Ig) Therapy HyQvia J1595** Glatiramer Acetate/Glatopa Copaxone J1599 Immune 500mg Immune globulin, intravenous nonlyophilized 500mg J1602 Golimumab Simponi Aria