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Unity Point Health Group #32116Specialty Pharmacy Network ListSpecialty medicines are usually prescribed by doctors who treat chronic and complex disease. These medications usuallyrequire a higher degree of management, have a high price and are not generally stocked at retail pharmacies. Professionallyadministered drugs are generally billed on the medical benefit. Self-administered drugs are generally billed on thepharmacy benefit. Many specialty drugs require approval prior to use.All medications listed on this drug list must be filled at Unity Point at Home Pharmacy. Please ask your provider to sendprescriptions for specialty drugs to your pharmacy. UnityPoint at Home Pharmacy: 515-557-3100 or 1-888-584-6311If your specialty medication is not listed here, then find the disease state and you can choose from the below pharmacies:InfertilityAlliance RX/Walgreens Prime Specialty Pharmacy (mail order)Phone: 1-800-424-9002 Fax: 1-800-874-9179Clomid isn’t restricted to the specialty network. You can pick it up at any retailpharmacy.Cystic FibrosisFairview Specialty Pharmacy (mail order)Phone: 1-800-595-7140PulmonaryHypertensionAccredo Specialty Pharmacy (mail order)Phone: 1-866-344-4874Sildenafil and Tadalafil oral tablets aren’t restricted to the specialty network. You canpick it up at any retail pharmacy.Hemophilia and other CVS Caremark Specialty Pharmacy (mail order or CVS retail pick up)clotting disordersPhone: 1-800-368-1624All other drugsCVS Caremark Specialty Pharmacy (mail order or CVS retail pick up)Phone: 1-800-368-1624To learn more about your Specialty, Growth Hormone, Infertility network or benefits, see your Summary of Benefits andCoverage (SBC) or call the member services phone number on the back of your card.Last update: January 1, 2021Note: In limited instances CVS Caremark Specialty will have to supply a specialty medication due to manufacturer limitations res tricting the sale ofmedications to pharmacies. This list applies to the pharmacy benefit, can change and doesn’t apply to Medicare Part D benefit plans.Please see healthpartners.com for full coverage criteria.
DRUGNOTESANTI-INFLAMMATORY AGENTS (RESPIRATORY)INTERLEUKIN ANTAGONISTSDUPIXENT 200 MG/1.14 ML SYRINGUnityPoint At HomeFASENRA 30 MG/ML SYRINGEUnityPoint At HomeFASENRA PEN 30 MG/MLUnityPoint At HomeNUCALA (100 MG/ML SYRINGE, 100 MG VIAL, 100 MG/ML AUTO-INJECTOR)UnityPoint At HomeANTIBACTERIALSAMINOGLYCOSIDE ANTIBIOTICSBETHKIS 300 MG/4 ML AMPULEUnityPoint At HomeKITABIS PAK 300 MG/5 MLUnityPoint At HomeTOBI 300 MG/5 ML SOLUTIONUnityPoint At Hometobramycin in 0.225% sod chlor 300 mg/5ml ampul-nebUnityPoint At Hometobramycin/nebulizer 300 mg/5ml ampul-nebUnityPoint At HomeANTICOAGULANTSANTICOAGULANTS, MISCELLANEOUSTHROMBATE III 500 UNIT VIALUnityPoint At HomeANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUSVIGADRONE 500 MG POWDER PACKETUnityPoint At HomeANTIHEMORRHAGIC AGENTSHEMOSTATICSADVATE (200-400 UNIT VIAL, 801-1,200 UNIT VIAL, 2,401-3,600 UNIT VIAL,3,601-4,800 UNIT VIAL)UnityPoint At HomeADVATE (401-800 UNIT VIAL, 1,801-2,400 UNIT VIAL)UnityPoint At HomeADYNOVATE (200-400 UNIT VIAL, 3,000 UNIT VIAL)UnityPoint At HomeLast Updated: January 1, 20212
DRUGNOTESADYNOVATE (401-800 UNIT VIAL, 750 UNIT VIAL, 801-1,250 UNIT VIAL, 1,2512,500 UNIT VL, 1,500 UNIT VIAL)UnityPoint At HomeAFSTYLA (250 UNIT VIAL, 500 UNIT VIAL, 1,000 UNIT VIAL, 1,500 UNIT RANGEVIAL, 2,000 UNIT VIAL, 2,500 UNIT RANGE VIAL, 3,000 UNIT VIAL)UnityPoint At HomeALPHANATE (250-100 UNIT VIAL, 500-200 UNIT VIAL, 1,000-400 UNIT VIAL,1,500-600 UNIT VIAL, 2,000-800 UNIT VIAL)UnityPoint At HomeALPHANINE SD (SD 500 UNIT VIAL, SD 1,000 UNIT VIAL, SD 1,500 UNIT VIAL)UnityPoint At HomeALPROLIX (250 UNIT, 500 UNIT, 1,000 UNIT, 2,000 UNIT, 3,000 UNIT)UnityPoint At HomeBENEFIX (250 UNIT, 500 UNIT, 2,000 UNIT, 3,000 UNIT)UnityPoint At HomeBENEFIX 1,000 UNIT RANGEUnityPoint At HomeCORIFACT KITUnityPoint At HomeELOCTATE (1,500 UNIT, 3,000 UNIT)UnityPoint At HomeELOCTATE (250 UNIT, 500 UNIT, 750 UNIT, 1,000 UNIT, 2,000 UNIT)UnityPoint At HomeESPEROCT (500 UNIT VIAL, 1,000 UNIT VIAL, 1,500 UNIT VIAL, 2,000 UNITVIAL, 3,000 UNIT VIAL)UnityPoint At HomeFEIBA NF 2,500 UNIT (NOMINAL)UnityPoint At HomeHELIXATE FS (250 UNIT VIAL, 500 UNIT VIAL, 1,000 UNIT VIAL, 2,000 UNITVIAL, 3,000 UNITS VIAL)UnityPoint At HomeHEMOFIL M 500 UNIT NOMINALUnityPoint At HomeHUMATE-P (600 UNIT, 1,200 UNIT, 2,400 UNIT)UnityPoint At HomeIDELVION (250 UNIT VIAL, 500 UNIT VIAL, 1,000 UNIT VIAL, 2,000 UNIT VIAL,3,500 UNIT VIAL)UnityPoint At HomeJIVI (1,000 UNIT VIAL, 2,000 UNIT VIAL, 3,000 UNIT VIAL)UnityPoint At HomeJIVI 500 UNIT VIALUnityPoint At HomeKOATE (250 UNIT VIAL, 500 UNIT VIAL)UnityPoint At HomeKOGENATE FS (250 UNIT VIAL, 500 UNIT VIAL, 2,000 UNIT VIAL, 3,000 UNITSVIAL)UnityPoint At HomeKOGENATE FS 1,000 UNITS VIALUnityPoint At HomeKOVALTRY (250 UNIT VIAL, 500 UNIT VIAL, 500 UNIT KIT, 1,000 UNIT VIAL,1,000 UNIT KIT, 2,000 UNIT VIAL, 2,000 UNIT KIT, 3,000 UNIT KIT, 3,000 UNITVIAL)UnityPoint At HomeLast Updated: January 1, 20213
DRUGNOTESKOVALTRY 250 UNIT KITUnityPoint At HomeNOVOEIGHT (250 UNIT VIAL, 500 UNIT VIAL, 1,000 UNIT VIAL, 1,500 UNITVIAL, 2,000 UNIT VIAL, 3,000 UNIT VIAL)UnityPoint At HomeNOVOSEVEN RT (1 MG VIAL, 2 MG VIAL, 5 MG VIAL, 8 MG VIAL)UnityPoint At HomeNUWIQ (250 UNIT VIAL, 250 UNIT VIAL PACK, 500 UNIT VIAL, 1,000 UNIT VIAL,1,000 UNIT VIAL PACK, 2,000 UNIT VIAL, 2,000 UNIT VIAL PACK, 2,500 UNITVIAL, 2,500 UNIT VIAL PACK, 3,000 UNIT VIAL, 3,000 UNIT VIAL PACK, 4,000UNIT VIAL, 4,000 UNIT VIAL PACK)UnityPoint At HomeNUWIQ 500 UNIT VIAL PACKUnityPoint At HomePROFILNINE (500 UNIT VIAL, 1,000 UNIT VIAL)UnityPoint At HomePROFILNINE 1,500 UNIT VIALUnityPoint At HomeRECOMBINATE (220-400 UNIT VIAL, 401-800 UNIT VIAL, 801-1,240 UNIT VL,1,241-1,800 UNIT V)UnityPoint At HomeRECOMBINATE 1,801-2,400 UNIT VUnityPoint At HomeRIXUBIS (250 UNIT, 500 UNIT, 1,000 UNIT, 2,000 UNIT, 3,000 UNIT)UnityPoint At HomeTRETTEN 2,500 UNIT VIALUnityPoint At HomeWILATE (450-450 UNIT VIAL, 900-900 UNIT VIAL)UnityPoint At HomeXYNTHA SOLOFUSE (1,000 UNIT KIT, 1,000 UNIT SYR, 3,000 UNIT SYR, 3,000UNIT KIT)UnityPoint At HomeANTIMIGRAINE AGENTSCALCITONIN GENE-RELATED PEPTIDE ANTAG.AIMOVIG 140 MG DOSE-2 AUTOINJUnityPoint At HomeAIMOVIG AUTOINJECTOR (70 MG/ML, 140 MG/ML)UnityPoint At HomeAJOVY 225 MG/1.5 ML AUTOINJECTUnityPoint At HomeAJOVY 225 MG/1.5 ML SYRINGEUnityPoint At HomeEMGALITY 120 MG/ML PENUnityPoint At HomeEMGALITY 120 MG/ML SYRINGEUnityPoint At HomeLast Updated: January 1, 20214
DRUGNOTESANTINEOPLASTIC AGENTSANTINEOPLASTIC AGENTSabiraterone acetate (250 mg tablet, 500 mg tablet)UnityPoint At HomeAFINITOR (2.5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET)UnityPoint At HomeAFINITOR 5 MG TABLETUnityPoint At HomeAFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5 MG TABLET)UnityPoint At HomeBALVERSA (3 MG TABLET, 4 MG TABLET, 5 MG TABLET)UnityPoint At Homebexarotene 75 mg capsuleUnityPoint At HomeBOSULIF (100 MG TABLET, 500 MG TABLET)UnityPoint At HomeCABOMETYX (20 MG TABLET, 40 MG TABLET, 60 MG TABLET)UnityPoint At HomeCALQUENCE 100 MG CAPSULEUnityPoint At Homecapecitabine (150 mg tablet, 500 mg tablet)UnityPoint At HomeCOMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK)UnityPoint At HomeDAURISMO (25 MG TABLET, 100 MG TABLET)UnityPoint At HomeERLEADA 60 MG TABLETUnityPoint At Homeerlotinib hcl (25 mg tablet, 100 mg tablet, 150 mg tablet)UnityPoint At HomeFARYDAK (15 MG CAPSULE, 20 MG CAPSULE)UnityPoint At HomeFARYDAK 10 MG CAPSULEUnityPoint At HomeGLEEVEC (100 MG TABLET, 400 MG TABLET)UnityPoint At HomeHYCAMTIN (0.25 MG CAPSULE, 4 MG VIAL)UnityPoint At HomeHYCAMTIN 1 MG CAPSULEUnityPoint At HomeIBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 100 MG TABLET, 125 MGCAPSULE, 125 MG TABLET)UnityPoint At HomeIBRANCE 75 MG TABLETUnityPoint At Homeimatinib mesylate (100 mg tablet, 400 mg tablet)UnityPoint At HomeINLYTA (1 MG TABLET, 5 MG TABLET)UnityPoint At HomeLast Updated: January 1, 20215
DRUGNOTESINREBIC 100 MG CAPSULEUnityPoint At HomeIRESSA 250 MG TABLETUnityPoint At HomeKISQALI (200 MG DAILY, 400 MG DAILY, 600 MG DAILY)UnityPoint At HomeKISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG)UnityPoint At HomeLORBRENA 100 MG TABLETUnityPoint At HomeLORBRENA 25 MG TABLETUnityPoint At HomeLYNPARZA (100 MG TABLET, 150 MG TABLET)UnityPoint At HomeMEKINIST (0.5 MG TABLET, 2 MG TABLET)UnityPoint At HomeNEXAVAR 200 MG TABLETUnityPoint At HomeNINLARO (2.3 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE)UnityPoint At HomeNUBEQA 300 MG TABLETUnityPoint At HomeODOMZO 200 MG CAPSULEUnityPoint At HomeONUREG 200 MG TABLETUnityPoint At HomeONUREG 300 MG TABLETUnityPoint At HomeOPDIVO (100 MG/10 ML VIAL, 240 MG/24 ML VIAL)UnityPoint At HomeOPDIVO 40 MG/4 ML VIALUnityPoint At HomePIQRAY (200 MG DAILY, 250 MG DAILY, 300 MG DAILY)UnityPoint At HomePURIXAN 20 MG/ML ORAL SUSPUnityPoint At HomeREVLIMID 2.5 MG CAPSULEUnityPoint At HomeRYDAPT 25 MG CAPSULEUnityPoint At HomeSPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 100 MG TABLET, 140MG TABLET)UnityPoint At HomeSPRYCEL 80 MG TABLETUnityPoint At HomeSTIVARGA 40 MG TABLETUnityPoint At HomeSUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MGCAPSULE)UnityPoint At HomeTAFINLAR (50 MG CAPSULE, 75 MG CAPSULE)UnityPoint At HomeLast Updated: January 1, 20216
DRUGNOTESTAGRISSO (40 MG TABLET, 80 MG TABLET)UnityPoint At HomeTALZENNA (0.25 MG CAPSULE, 1 MG CAPSULE)UnityPoint At HomeTARCEVA (25 MG TABLET, 100 MG TABLET, 150 MG TABLET)UnityPoint At HomeTARGRETIN (1% GEL, 75 MG CAPSULE)UnityPoint At HomeTASIGNA (50 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE)UnityPoint At HomeTEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 180 MGCAPSULE, 250 MG CAPSULE)UnityPoint At HomeTEMODAR 140 MG CAPSULEUnityPoint At Hometemozolomide (5 mg capsule, 20 mg capsule, 100 mg capsule, 140 mgcapsule, 180 mg capsule, 250 mg capsule)UnityPoint At Hometretinoin 10 mg capsuleUnityPoint At HomeTUKYSA (50 MG TABLET, 150 MG TABLET)UnityPoint At HomeTYKERB 250 MG TABLETUnityPoint At HomeVERZENIO (50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)UnityPoint At HomeVOTRIENT 200 MG TABLETUnityPoint At HomeXALKORI (200 MG CAPSULE, 250 MG CAPSULE)UnityPoint At HomeXELODA (150 MG TABLET, 500 MG TABLET)UnityPoint At HomeXOSPATA 40 MG TABLETUnityPoint At HomeXPOVIO (40 MG ONCE, 40 MG TWICE, 60 MG ONCE, 60 MG TWICE, 80 MGONCE, 80 MG TWICE, 100 MG ONCE)UnityPoint At HomeYONSA 125 MG TABLETUnityPoint At HomeZEJULA 100 MG CAPSULEUnityPoint At HomeZOLINZA 100 MG CAPSULEUnityPoint At HomeZYKADIA (150 MG CAPSULE, 150 MG TABLET)UnityPoint At HomeZYTIGA (250 MG TABLET, 500 MG TABLET)UnityPoint At HomeANTIPSYCHOTIC AGENTSATYPICAL ANTIPSYCHOTICSNUPLAZID 17 MG TABLETLast Updated: January 1, 2021UnityPoint At Home7
DRUGNOTESANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESANTITOXINS AND IMMUNE GLOBULINSPRIVIGEN 10% VIALUnityPoint At HomeANTIVIRALS (SYSTEMIC)INTERFERON ANTIVIRALSINTRON A (10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 18 MILLION UNIT/3ML, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)UnityPoint At HomePEGASYS 180 MCG/0.5 ML SYRINGEUnityPoint At HomePEGASYS 180 MCG/ML VIALUnityPoint At HomePEGASYS PROCLICK (135 MCG/0.5, 180 MCG/0.5)UnityPoint At HomeSYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG KIT)UnityPoint At HomeNUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSMODERIBA 200 MG TABLETUnityPoint At HomeREBETOL 40 MG/ML SOLUTIONUnityPoint At HomeRIBASPHERE 200 MG CAPSULEUnityPoint At HomeRIBASPHERE 600 MG TABLETUnityPoint At HomeRIBASPHERE RIBAPAK (600-400 MG, 600-600 MG)UnityPoint At Homeribavirin (200 mg capsule, 200 mg tablet)UnityPoint At HomeVIRAZOLE 6 GM VIALUnityPoint At HomeBLOOD FORMATION, COAGULATION, THROMBOSISHEMATOPOIETIC AGENTSARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/MLVIAL, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/ML VIAL, 100MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE, 150 MCG/0.3 ML SYRINGE, 150MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 500 MCG/1 ML SYRINGE)UnityPoint At HomeARANESP 60 MCG/0.3 ML SYRINGEUnityPoint At HomeDOPTELET ((10 TAB 20 MG TAB, (15 TAB 20 MG TAB)UnityPoint At HomeLast Updated: January 1, 20218
DRUGNOTESEPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL,20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL)UnityPoint At HomeEPOGEN 10,000 UNITS/ML VIALUnityPoint At HomeGRANIX (300 MCG/0.5 ML SYRINGE, 300 MCG/ML VIAL, 300 MCG/0.5 MLSAFE SYR, 480 MCG/0.8 ML SYRINGE)UnityPoint At HomeGRANIX (480 MCG/0.8 ML SAFE SYR, 480 MCG/1.6 ML VIAL)UnityPoint At HomeLEUKINE 250 MCG VIALUnityPoint At HomeMULPLETA 3 MG TABLETUnityPoint At HomeNEULASTA 6 MG/0.6 ML SYRINGEUnityPoint At HomeNEULASTA ONPRO 6 MG/0.6 ML KITUnityPoint At HomeNEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 ML SYR)UnityPoint At HomeNIVESTYM (300 MCG/0.5 ML SYRING, 300 MCG/ML VIAL, 480 MCG/0.8 MLSYRING, 480 MCG/1.6 ML VIAL)UnityPoint At HomePROCRIT (3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/MLVIAL, 20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL)UnityPoint At HomePROCRIT 2,000 UNITS/ML VIALUnityPoint At HomePROMACTA (12.5 MG SUSPEN PACKET, 12.5 MG TABLET, 25 MG SUSPENSIONPCKT, 50 MG TABLET, 75 MG TABLET)UnityPoint At HomePROMACTA 25 MG TABLETUnityPoint At HomeZARXIO (300 MCG/0.5 ML SYRINGE, 480 MCG/0.8 ML SYRINGE)UnityPoint At HomeCENTRAL NERVOUS SYSTEM AGENTSVESICULAR MONOAMINE TRANSPORT2 INHIBITORAUSTEDO (6 MG TABLET, 9 MG TABLET, 12 MG TABLET)UnityPoint At Hometetrabenazine 12.5 mg tabletUnityPoint At Hometetrabenazine 25 mg tabletUnityPoint At HomeXENAZINE 12.5 MG TABLETUnityPoint At HomeXENAZINE 25 MG TABLETUnityPoint At HomeLast Updated: January 1, 20219
DRUGNOTESDIAGNOSTIC AGENTSPITUITARY FUNCTIONMACRILEN 60 MG/120 ML SOLUTIONUnityPoint At HomeDIURETICSVASOPRESSIN ANTAGONISTSSAMSCA (15 MG TABLET, 30 MG TABLET)UnityPoint At Hometolvaptan (15 mg tablet, 30 mg tablet)UnityPoint At HomeGASTROINTESTINAL DRUGSGI DRUGS, MISCELLANEOUSHUMIRA(CF) PEDI CROHN 80-40 MGUnityPoint At HomeHCV ANTIVIRALSHCV POLYMERASE INHIBITOR ANTIVIRALSEPCLUSA (200 MG-50 MG TABLET, 400 MG-100 MG TABLET)UnityPoint At HomeHARVONI 90-400 MG TABLETUnityPoint At Homeledipasvir/sofosbuvir 90mg-400mg tabletUnityPoint At Homesofosbuvir/velpatasvir 400-100 mg tabletUnityPoint At HomeSOVALDI 200 MG TABLETUnityPoint At HomeSOVALDI 400 MG TABLETUnityPoint At HomeVOSEVI 400-100-100 MG TABLETUnityPoint At HomeHCV PROTEASE INHIBITOR ANTIVIRALSMAVYRET 100-40 MG TABLETUnityPoint At HomeHCV REPLICATION COMPLEX INHIBITORSDAKLINZA (30 MG TABLET, 60 MG TABLET)UnityPoint At HomeVIEKIRA PAKUnityPoint At HomeZEPATIER 50-100 MG TABLETUnityPoint At HomeLast Updated: January 1, 202110
DRUGNOTESHEAVY METAL ANTAGONISTSHEAVY METAL ANTAGONISTSdeferasirox (90 mg gran pack, 125 mg tab disper, 180 mg gran pack, 180 mgtablet, 250 mg tab disper, 500 mg tab disper)UnityPoint At Homedeferasirox 360 mg gran packUnityPoint At HomeEXJADE (125 MG TABLET, 250 MG TABLET, 500 MG TABLET)UnityPoint At HomeJADENU (90 MG TABLET, 360 MG TABLET)UnityPoint At HomeJADENU 180 MG TABLETUnityPoint At HomeJADENU SPRINKLE (90 MG GRANULE, 180 MG GRANULE, 360 MG GRANULE)UnityPoint At Homepenicillamine 250 mg tabletUnityPoint At HomeSYPRINE 250 MG CAPSULEUnityPoint At Hometrientine hcl 250 mg capsuleUnityPoint At HomeHORMONES AND SYNTHETIC SUBSTITUTESPITUITARYGENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG,MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MGCARTRIDGE)UnityPoint At HomeGENOTROPIN MINIQUICK 0.4 MGUnityPoint At HomeHUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, 24 MGCARTRIDGE)UnityPoint At HomeNORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15 MG/1.5, 30 MG/3 ML)UnityPoint At HomeOMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG)UnityPoint At HomeSAIZEN (5 MG VIAL, 8.8 MG VIAL)UnityPoint At HomeSAIZEN 8.8 MG SAIZENPREP CARTUnityPoint At HomeSEROSTIM (5 MG VIAL, 6 MG VIAL)UnityPoint At HomeSEROSTIM 4 MG VIALUnityPoint At HomeZORBTIVE 8.8 MG VIALUnityPoint At HomeLast Updated: January 1, 202111
DRUGNOTESPROGESTINShydroxyprogesterone caproat/pf 250 mg/ml vialUnityPoint At HomeMAKENA 250 MG/ML VIALUnityPoint At HomeMISCELLANEOUS THERAPEUTIC AGENTSCOMPLEMENT INHIBITORSFIRAZYR 30 MG/3 ML SYRINGEUnityPoint At Homeicatibant acetate 30 mg/3 ml syringeUnityPoint At HomeKALBITOR 10 MG/ML VIALUnityPoint At HomeDISEASE-MODIFYING ANTIRHEUMATIC AGENTSACTEMRA 162 MG/0.9 ML SYRINGEUnityPoint At HomeACTEMRA ACTPEN 162 MG/0.9 MLUnityPoint At HomeCIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT)UnityPoint At HomeENBREL (25 MG/0.5 ML SYRINGE, 25 MG KIT)UnityPoint At HomeENBREL 50 MG/ML MINI CARTRIDGEUnityPoint At HomeENBREL 50 MG/ML SYRINGEUnityPoint At HomeHUMIRA (10 MG/0.2 ML SYRINGE, 20 MG/0.4 ML SYRINGE, 40 MG/0.8 MLSYRINGE)UnityPoint At HomeHUMIRA PEDI CROHN 40 MG/0.8 MLUnityPoint At HomeHUMIRA PEN 40 MG/0.8 MLUnityPoint At HomeHUMIRA PEN CROHN-UC-HS 40 MGUnityPoint At HomeHUMIRA PEN PS-UV-ADOL HS 40 MGUnityPoint At HomeHUMIRA(CF) (10 MG/0.1 ML SYRING, 20 MG/0.2 ML SYRING, 40 MG/0.4 MLSYRING)UnityPoint At HomeHUMIRA(CF) PEDI CROHN 80MG/0.8UnityPoint At HomeHUMIRA(CF) PEN (PEN 40 MG/0.4 ML, PEN 80 MG/0.8 ML)UnityPoint At HomeHUMIRA(CF) PEN CRHN-UC-HS 80MGUnityPoint At HomeLast Updated: January 1, 202112
DRUGNOTESHUMIRA(CF) PEN PS-UV-AHS 80-40UnityPoint At HomeKEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 ML SYRINGE, 200 MG/1.14ML PEN INJ, 200 MG/1.14 ML SYRINGE)UnityPoint At HomeKINERET 100 MG/0.67 ML SYRINGEUnityPoint At HomeOLUMIANT 2 MG TABLETUnityPoint At HomeORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE, 125 MG/MLSYRINGE)UnityPoint At HomeORENCIA CLICKJECT 125 MG/MLUnityPoint At HomeOTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTER PACK)UnityPoint At HomeRINVOQ ER 15 MG TABLETUnityPoint At HomeSIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/ML PENINJECTOR, 100 MG/ML SYRINGE)UnityPoint At HomeSIMPONI ARIA 50 MG/4 ML VIALUnityPoint At HomeXELJANZ (5 MG TABLET, 10 MG TABLET)UnityPoint At HomeXELJANZ XR 11 MG TABLETUnityPoint At HomeXELJANZ XR 22 MG TABLETUnityPoint At HomeIMMUNOMODULATORY AGENTSACTIMMUNE 100 MCG/0.5 ML VIALUnityPoint At HomeAUBAGIO (7 MG TABLET, 14 MG TABLET)UnityPoint At HomeAVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT)UnityPoint At HomeAVONEX PEN 30 MCG/0.5 ML KITUnityPoint At HomeBAFIERTAM DR 95 MG CAPSULEUnityPoint At HomeBETASERON 0.3 MG KITUnityPoint At HomeCOPAXONE (20 MG/ML SYRINGE, 40 MG/ML SYRINGE)UnityPoint At Homedimethyl fumarate (120 mg capsule dr, 120-240 mg capsule dr, 240 mgcapsule dr)UnityPoint At HomeEXTAVIA 0.3 MG KITUnityPoint At HomeGILENYA (0.25 MG CAPSULE, 0.5 MG CAPSULE)UnityPoint At HomeLast Updated: January 1, 202113
DRUGNOTESglatiramer acetate (20 mg/ml syringe, 40 mg/ml syringe)UnityPoint At HomeGLATOPA 20 MG/ML SYRINGEUnityPoint At HomeGLATOPA 40 MG/ML SYRINGEUnityPoint At HomeKESIMPTA 20 MG/0.4 ML PENUnityPoint At HomeREBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE)UnityPoint At HomeREBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML, TITRATION PACK)UnityPoint At HomeREBIF TITRATION PACKUnityPoint At HomeTECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE, STARTER PACK)UnityPoint At HomeIMMUNOSUPPRESSIVE AGENTSBENLYSTA 200 MG/ML AUTOINJECTUnityPoint At HomeBENLYSTA 200 MG/ML SYRINGEUnityPoint At HomeOTHER MISCELLANEOUS THERAPEUTIC AGENTSAMPYRA ER 10 MG TABLETUnityPoint At Homedalfampridine 10 mg tab er 12hUnityPoint At HomeILARIS 150 MG/ML VIALUnityPoint At HomeKUVAN (100 MG TABLET, 100 MG POWDER PACKET, 500 MG POWDERPACKET)UnityPoint At Homemiglustat 100 mg capsuleUnityPoint At Homesapropterin dihydrochloride (100 mg tablet sol, 100 mg powd pack, 500 mgpowd pack)UnityPoint At HomePARATHYROID AND ANTIPARATHYROID AGENTSPARATHYROID AGENTSFORTEO 600 MCG/2.4 ML PEN INJUnityPoint At Hometeriparatide 20mcg/dose pen injctrUnityPoint At HomeTYMLOS 80 MCG DOSE PEN INJECTRUnityPoint At HomeLast Updated: January 1, 202114
DRUGNOTESRESPIRATORY TRACT AGENTSMUCOLYTIC AGENTSPULMOZYME 1 MG/ML AMPULUnityPoint At HomeRESPIRATORY TRACT AGENTS, MISCELLANEOUSGLASSIA 1 GM/50 ML VIALU
Jan 01, 2021 · Coverage (SBC) or call the member services phone number on the back of your card. Last update: January 1, 2021 . NINLARO (2.3 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE) UnityPoint At Home NUBEQA 300 MG TABLET Un
