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This is not an all-inclusive list of medications covered under this policy. Medications may be added or removed at any time as determined to be eligible for administration as clinically appropriate.

Alpha 1 Proteinase Inhibitors

Aralast

J0256

Glassia

J0257

Prolastin-C

J0256

Zemaira

J0256

Enzyme Replacement Drugs

Aldurazyme (laronidase)

J1931

Cerezyme (Imiglucerase)

J1786

Eleyso (taliglucerase alfa)

J3060

Fabrazyme (agalsidase)

J0180

Lumizyme (alglucosidase alfa)

J0221

Vimizim (elosulfase alfa)

J1322

Vpriv (velaglucerase alfa)

J3385

Blood Clotting Factors

Afstyla (antihemophilic factor (recombinant) single chain)

J7210

Advate (antihemophilic factor, human (recombinant))

J7192

Alphanate (antihemophilic factor/von Willebrand factor complex (human))

J7186

AlphaNine (coagulation factor IX (human))

J7194

Alprolix (coagulation factor IX (recombinant), Fc fusion protein)

J7201

Bebulin (factor IX complex)

J7194

Benefix (coagulation factor IX(recombinant))

J7195

Coagadex (coagulation factor X (human))

J7175

Corifact (factor XIII concentrate (human))

J7180

Eloctate (antihemophilic factor (recombinant), Fc fusion protein)

J7205

Feiba NH (anti‐inhibitor coagulant complex)

J7198

Helixate (antihemophilic factor (recombinant))

J7192

Hemofil M (antihemophilic factor (human))

J7190

Hemlibra (emicizumab)

Q9995

Humate‐P (antihemophilic factor/von Willebrand factor complex)

J7187

Idelvion (antihemophilic factor (recombinant))

J7202

Ixinity (coagulation factor IX (recombinant))

J7195

Koate‐DVI (antihemophilic factor (human))

J7190

Kogenate FS (antihemophilic factor (recombinant))

J7192

Kovaltry (antihemophilic factor (recombinant))

J7211

Monoclate‐P (antihemophilic factor (human))

J7190

Mononine (coagulation factor IX (human))

J7193, J7194

NovoEight (turoctocog alfa)

J7182

NovoSeven RT (coagulation factor VIIa (recombinant))

J7189

Nuwiq (simoctocog alfa)

J7209

Obizur (antihemophilic factor (recombinant), porcine sequence)

J7191

Profilnine (factor IX complex)

J7194

Rebinyn (factor IX (recombinant), glycopegylated)

C9468

Recombinate (antihemophilic factor (recombinant))

J7192

Rixubis (coagulation factor IX (recombinant))

J7200

Tretten (coagulation factor XIIIa‐ subunit (recombinant))

J7181

Vonvendi (von Willebrand factor (recombinant))

J7179

Wilate (von Willebrand factor/coagulation factor VIII complex (human))

J7183

Xyntha (antihemophilic factor (recombinant))

J7185

Immune Globulin

Bivigam

J1556

Carimune NF

 

Cuvitru

J1555

Flebogamma

J1572

Gamastan S/D

J1566

Gammagard S/D

J1569

Gammaked

J1561

Gamunex

J1561

Hizentra

J1559

HyQvia

J1460, J1560

Octagam

J1568

Privigen

J1459

Rheumatology/Immunology

Actemra IV (toclizumab)

J3262

Entyvio (vedolizumab)

J3380

Inflectra (infliximab-dyyb)

Q5103

Orencia IV (abatacept)

J0129

Remicade (infliximab)

J1745

Reflexis (infliximab-abda)

Q5104

Simponi Aria (golimumab)

J1602

Other

Adynovate

J7207

Benlysta (belimumab)

J0490

Berinert

J0597

Feraheme (ferumoxytol)

Q0318, Q0319

Granix

J1447

Ilumya

J3245

Infed (iron dextran)

J1750

Injectafer (ferric carboxymaltose)

J1439

Lemtrada

J0202

Leukine

J2820

Neupogen

J1442

Ocrevus (ocrelizumab)

J2350

Prolia (denosumab)

J0897

Reclast (zoledronic acid)

J3489

Rituxan (rituximab)

J9312

Ruconest

J0596

Stelara (ustekinumab)

J3358

Tysabri (natalizumab)

J2323

Venofer (iron sucrose)

J1756

Zarxio

Q5101