Miscellaneous Therapeutic Agents
Showing 1–12 of 98 results
NAME | ALSO KNOW AS | DRUG CATEGORY | FORMULARY CATEGORY | WHAT WE COVER | COST SHARE |
|---|---|---|---|---|---|
|
Sapropterin Dihydrochloride Pack 100Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Sapropterin Dihydrochloride Pack 500Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Sapropterin Dihydrochloride Tbso 100Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Carnitor Soln 1 Gm/10Ml (Brand) |
Miscellaneous Therapeutic Agents |
1 |
Generic |
$14 |
|
|
Carnitor Tabs 330 Mg (Brand) |
Miscellaneous Therapeutic Agents |
1 |
Generic |
$14 |
|
|
Mesna Tabs 400Mg (Generic) |
Miscellaneous Therapeutic Agents |
2 |
Formulary Brand |
$38 |
|
|
Metreleptin Solr 11.3Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Orfadin Caps 10 Mg (Brand) |
Miscellaneous Therapeutic Agents |
1 |
Generic |
$14 |
|
|
Orfadin Caps 2 Mg (Brand) |
Miscellaneous Therapeutic Agents |
1 |
Generic |
$14 |
|
|
Orfadin Caps 5 Mg (Brand) |
Miscellaneous Therapeutic Agents |
1 |
Generic |
$14 |
|
|
Nitisinone Tabs 10Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Nitisinone Tabs 2Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Nitisinone Tabs 5Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Fosdenopterin Soln 9.5Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
N/A |
|
|
Dust Mite Mixed Allergen Extract Subl (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Botox Solr 100 Unit (Brand) |
Miscellaneous Therapeutic Agents |
MA |
Administered in Medical Office |
N/A |
|
|
Botox Solr 200 Unit (Brand) |
Miscellaneous Therapeutic Agents |
MA |
Administered in Medical Office |
N/A |
|
|
Patisiran Sodium Soln 10Mg/5Ml (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Grass Mixed Pollens Allergen Extract Subl (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Nitisinone Caps 10Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Nitisinone Caps 2Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Nitisinone Caps 20Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Nitisinone Caps 5Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Nitisinone Susp 4Mg/Ml (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Berotralstat Caps 110Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Berotralstat Caps 150Mg (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Initial Escalation Therapy Pack 0.5 & 1 & 1.5 &3 & 6Mg (Generic) |
Miscellaneous Therapeutic Agents |
MA |
Administered in Medical Office |
N/A |
|
|
Peanut Allergen Powder Therapy Pack 120Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Therapy Pack 12Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Therapy Pack 160Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Therapy Pack 200Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Therapy Pack 20Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Therapy Pack 240Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Therapy Pack 3Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |
|
|
Peanut Allergen Powder Therapy Pack 40Mg Daily Dose (Generic) |
Miscellaneous Therapeutic Agents |
3 |
Non-Formulary Brand |
$68 |