Miscellaneous Therapeutic Agents

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NAME
ALSO KNOW AS
DRUG CATEGORY
FORMULARY CATEGORY
WHAT WE COVER
COST SHARE
Abobotulinumtoxina Solr 300Unit (Generic)

Dysport Solr 300 Unit (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Abobotulinumtoxina Solr 500Unit (Generic)

Dysport Solr 500 Unit (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Actimmune Soln 2000000 Unit/0.5Ml (Brand)

Interferon Gamma-1B Soln 2000000Unit/0.5Ml (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Amondys 45 Soln 100Mg/2mL (Brand)

Casimersen Soln 100Mg/2mL (Generic)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Arcalyst Solr 220 Mg (Brand)

Rilonacept Solr 220Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Betaine Powd (Generic)

Cystadane Powd (Brand)
Miscellaneous Therapeutic Agents
1
Generic
$14
Burosumab-Twza Soln 10Mg/Ml (Generic)

Crysvita Soln 10 Mg/Ml (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Burosumab-Twza Soln 20Mg/Ml (Generic)

Crysvita Soln 20 Mg/Ml (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Burosumab-Twza Soln 30Mg/Ml (Generic)

Crysvita Soln 30 Mg/Ml (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Bylvay Caps 1200 mcg (Brand)

Odevixibat Caps 1200 mcg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Bylvay Caps 400 mcg (Brand)

Odevixibat Caps 400 mcg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Bylvay Caps Sprinkle 200 mcg (Brand)

Odevixibat Caps Sprinkle 200 mcg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Bylvay Caps Sprinkle 600 mcg (Brand)

Odevixibat Caps Sprinkle 600 mcg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Carnitor Soln 1 Gm/10Ml (Brand)

Levocarnitine (Metabolic Modifiers) Soln 1Gm/10Ml (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Carnitor Tabs 330 Mg (Brand)

Levocarnitine (Metabolic Modifiers) Tabs 330Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Cystadane Powd (Brand)

Betaine Powd (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Cystagon Caps 150 Mg (Brand)

Cysteamine Bitartrate Caps 150Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Cystagon Caps 50 Mg (Brand)

Cysteamine Bitartrate Caps 50Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Dimethyl Sulfoxide Soln 50%(Generic)

Rimso-50 Soln 50 % (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Elmiron Caps 100 Mg (Brand)

Pentosan Polysulfate Sodium Caps 100Mg (Generic)
Miscellaneous Therapeutic Agents
2
Formulary Brand
$38
Empaveli Soln 1080Mg/20Ml (Brand)

Pegcetacoplan Soln 1080 Mg/20Ml (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Endari Pack 5 Gm (Brand)

Glutamine (Sickle Cell) Pack 5Gm (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Eteplirsen Soln 100Mg/2Ml (Generic)

Exondys 51 Soln 100 Mg/2Ml (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Eteplirsen Soln 500Mg/10Ml (Generic)

Exondys 51 Soln 500 Mg/10Ml (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Firdapse Tabs 10 Mg (Brand)

Amifampridine Phosphate Tabs 10Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Galafold Caps 123 Mg (Brand)

Migalastat Hcl Caps 123Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Givlaari Soln 189 Mg/Ml (Brand)

Givosiran Soln 189Mg/Ml (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Haegarda Solr 2000 Unit (Brand)

C1 Esterase Inhibitor (Human) Solr 2000Unit (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Haegarda Solr 3000 Unit (Brand)

C1 Esterase Inhibitor (Human) Solr 3000Unit (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Incobotulinumtoxina Solr 100Unit (Generic)

Xeomin Solr 100 Unit (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Incobotulinumtoxina Solr 200Unit (Generic)

Xeomin Solr 200 Unit (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Incobotulinumtoxina Solr 50Unit (Generic)

Xeomin Solr 50 Unit (Brand)
Miscellaneous Therapeutic Agents
MA
Administered in Medical Office
N/A
Kerendia Tabs 10 Mg (Brand)

Finerenone Tabs 10 Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Kerendia Tabs 20 Mg (Brand)

Finerenone Tabs 20 Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
Keveyis Tabs 50 Mg (Brand)

Dichlorphenamide Tabs 50Mg (Generic)
Miscellaneous Therapeutic Agents
3
Non-Formulary Brand
$68
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