Miscellaneous Therapeutic Agents

Showing 1–12 of 98 results

NAME	ALSO KNOW AS	DRUG CATEGORY	FORMULARY CATEGORY	WHAT WE COVER	COST SHARE
Palforzia Sprinkle Caps Therapy Pack 6Mg Daily Dose (Brand)	Peanut Allergen Powder Therapy Pack 6Mg Daily Dose (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Palforzia Sprinkle Caps Therapy Pack 80Mg Daily Dose (Brand)	Peanut Allergen Powder Therapy Pack 80Mg Daily Dose (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Palforzia Sprinkle Packet 300Mg (Brand)	Peanut Allergen Powder Sprinkle Packet 300Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Procysbi Cpdr 25 Mg (Brand)	Cysteamine Bitartrate Cpdr 25Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Procysbi Cpdr 75 Mg (Brand)	Cysteamine Bitartrate Cpdr 75Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Ravulizumab-Cwvz Soln 300Mg/30Ml (Generic)	Ultomiris Soln 300 Mg/30Ml (Brand)	Miscellaneous Therapeutic Agents	MA	Administered in Medical Office	N/A
Ridaura Caps 3 Mg (Brand)	Auranofin Caps 3Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Ruzurgi Tabs 10 Mg (Brand)	Amifampridine Tabs 10Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Saxenda Sopn 18 Mg/3Ml (Brand)	Liraglutide Sopn 18Mg/3Ml (Generic)	Anorexigenic Agents	3	Non-Formulary Brand	$68
Sodium Chloride (Gu Irrigant) Soln .9% (Generic)	No Brand Option Available	Miscellaneous Therapeutic Agents	1	Generic	$14
Sodium Fluoride Tabs 1Mg (Generic)	No Brand Option Available	Miscellaneous Therapeutic Agents	1	Generic	$14
Takhzyro Soln 300 Mg/2Ml (Brand)	Lanadelumab-Flyo Soln 300Mg/2Ml (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Tavneos Tabs 10 mg (Brand)	Avacopan Tabs 10 mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Tegsedi Sosy 284 Mg/1.5Ml (Brand)	Inotersen Sodium Sosy 284Mg/1.5Ml (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Thiola Ec Tbec 100 Mg (Brand)	Tiopronin Tbec 100Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Thiola Ec Tbec 300 Mg (Brand)	Tiopronin Tbec 300Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Thiola Tabs 100 Mg (Brand)	Tiopronin Tabs 100Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Tiopronin Tabs 100Mg (Generic)	Thiola Tabs 100Mg (Brand)	Miscellaneous Therapeutic Agents	1	Generic	$14
Vumerity (Starter) Cpdr 231 Mg (Brand)	Diroximel Fumarate Cpdr 231Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Vumerity Cpdr 231 Mg (Brand)	Diroximel Fumarate Cpdr 231Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Wegovy Sopn 0.25 Mg/0.5 Ml (Brand)	Semaglutide Sopn 0.25Mg/0.5Ml (Generic)	Anorexigenic Agents	3	Non-Formulary Brand	$68
Wegovy Sopn 0.5 Mg/0.5 Ml (Brand)	Semaglutide Sopn 0.5Mg/0.5Ml (Generic)	Anorexigenic Agents	3	Non-Formulary Brand	$68
Wegovy Sopn 1 Mg/0.5 Ml (Brand)	Semaglutide Sopn 1Mg/0.5Ml (Generic)	Anorexigenic Agents	3	Non-Formulary Brand	$68
Wegovy Sopn 1.7 Mg/0.75 Ml (Brand)	Semaglutide Sopn 1.7Mg/0.75Ml (Generic)	Anorexigenic Agents	3	Non-Formulary Brand	$68
Wegovy Sopn 2.4 Mg/0.75 Ml (Brand)	Semaglutide Sopn 2.4Mg/0.75Ml (Generic)	Anorexigenic Agents	3	Non-Formulary Brand	$68
Xuriden Pack 2 Gm (Brand)	Uridine Triacetate Pack 2Gm (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Zokinvy Caps 50Mg (Brand)	Lonafarnib Caps 50Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68
Zokinvy Caps 75Mg (Brand)	Lonafarnib Caps 75Mg (Generic)	Miscellaneous Therapeutic Agents	3	Non-Formulary Brand	$68

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