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Antilipemic
Asthma
Asthma
Apolipoprotein B Antisense Oligonucleotide
Interleukin-4 Receptor Antagonist
Interleukin-5 Antagonist
Kynamro
Dupixent
Fasenra
Mipomersen
Dupilumab
Benralizumab
Antilipemic PCSK9 Inhibitor Repatha Evolocumab
Anemia
Antilipemic
Anemia
Anemia
Anemia
Anemia
Activin Receptor Ligand Trap
PCSK9 Inhibitor
Erythropoiesis-Stimulating Agent (ESA)
Erythropoiesis-Stimulating Agent (ESA)
Erythropoiesis-Stimulating Agent (ESA)
Erythropoiesis-Stimulating Agent (ESA)
Reblozyl
Praluent
Aranesp
Epogen
Procrit
Retacrit
Luspatercept
Alirocumab
Darbepoetin Alfa
Epoetin Alfa
Epoetin Alfa
Epoetin Alfa
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Acromegaly
Acromegaly
Acromegaly
Acromegaly
Allergen Immunotherapy
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
Amyloidosis
Somatostatin Analog
Somatostatin Analog
Somatostatin Analog
Growth Hormone Receptor Antagonist
Allergen-Specific Immunotherapy
Antitrypsin Deficiency Agent
Antitrypsin Deficiency Agent
Antitrypsin Deficiency Agent
Antitrypsin Deficiency Agent
Anti-Transthyretin Small Interfering Ribonucleic Acid
(siRNA) Agent
Somatuline Depot
Sandostatin
Sandostatin Lar
Somavert
Oralair
Aralast Np
Glassia
Prolastin-C
Zemaira
Onpattro
Lanreotide
Octreotide
Octreotide
Pegvisomant
Grass Pollen Allergen Extract (5 Grass Extract)
Alpha1-Proteinase Inhibitor
Alpha1-Proteinase Inhibitor
Alpha1-Proteinase Inhibitor
Alpha1-Proteinase Inhibitor
Patisiran
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
Asthma
Asthma
Asthma
Biosimilar
Biosimilar
Atopic Dermatitis
Interleukin-5 Antagonist
Monoclonal Antibody
Interleukin-5 Antagonist
Colony Stimulating Factor
Colony Stimulating Factor
Interleukin-4 Receptor Antagonist
Nucala
Xolair
Cinqair
Nivestym
Nyvepria
Dupixent
Mepolizumab
Omalizumab
Reslizumab
Filgrastim
Pegfilgrastim
Coronavirus Antiviral Veklury Remdesivir
Coronavirus Monoclonal Antibody Bamlanivimab
Coronavirus Monoclonal Antibody Casirivimab and Imdevimab
Coagulation Disorders Blood Product Ceprotin Protein C Concentrate
Biosimilar
Biosimilar
Biosimilar
Biosimilar
Botulinum Toxins
Botulinum Toxins
Botulinum Toxins
Botulinum Toxins
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Neuromuscular Blocker Agent
Neuromuscular Blocker Agent
Neuromuscular Blocker Agent
Neuromuscular Blocker Agent
Zarxio
Fulphila
Udenyca
Ziextenzo
Dysport
Xeomin
Botox
Myobloc
Filgrastim
Pegfilgrastim
Pegfilgrastim
Pegfilgrastim
AbobotulinumtoxinA
IncobotulinumtoxinA
OnabotulinumtoxinA
RimabotulinumtoxinB
Dupilumab
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Cystic Fibrosis
Cystic Fibrosis
Duchenne Muscular Dystrophy
Aminoglycoside Antibiotic
Aminoglycoside Antibiotic
Antisense Oligonucleotide
Tobi
Tobi Podhaler
Viltepso
Tobramycin (Oral Inhalation)
Tobramycin (Oral Inhalation)
Viltolarsen
Cystic Fibrosis
Cystic Fibrosis
Cystic Fibrosis
Cystic Fibrosis
Cryopyrin-Associated Periodic Syndromes
Cryopyrin-Associated Periodic Syndromes
Monobactam Antibiotic
Mucolytic Agent
Aminoglycoside Antibiotic
Aminoglycoside Antibiotic
Interleukin-1β Antagonist
Interleukin-1 Antagonist
Cayston
Pulmozyme
Bethkis
Kitabis Pak
Ilaris
Arcalyst
Aztreonam (Oral Inhalation)
Dornase Alfa
Tobramycin (Oral Inhalation)
Tobramycin (Oral Inhalation)
Canakinumab
Rilonacept
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Hematopoietics
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Growth Hormone
Growth Hormone
Growth Hormone
Growth Hormone
Hematopoietic Stem Cell Mobilizer
Antihemophilic Agent
Saizen
Serostim
Zomacton
Zorbtive
Mozobil
Sevenfact
Somatropin
Somatropin
Somatropin
Somatropin
Plerixafor
Factor VIIa (Recombinant)
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone
Growth Hormone
Growth Hormone
Growth Hormone
Growth Hormone
Genotropin
Humatrope
Norditropin
Nutropin Aq
Omnitrope
Somatropin
Somatropin
Somatropin
Somatropin
Somatropin
Gaucher Disease
Gaucher Disease
Gout
Lysosomal Storage Disorder Agents
Lysosomal Storage Disorder Agents
Urate-Oxidase
Elelyso
Vpriv
Krystexxa
Taliglucerase Alfa
Velaglucerase Alfa
Pegloticase
Gaucher DiseaseLysosomal Storage Disorder
AgentsCerezyme Imiglucerase
Gaucher DiseaseLysosomal Storage Disorder
AgentsCeredase Alglucerase
Gastrointestinal DisordersGlucagon-Like Peptide-2
(GLP-2) AnalogGattex Teduglutide
Gastrointestinal DisordersSkin and Mucous Membrane
AgentSolesta
Dextranomer and Hyaluronate Derivatives
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Novoeight
Nuwiq
Recombinate
Xyntha
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Eloctate
Adynovate
Jivi
Advate
Afstyla
Helixate Fs
Kogenate Fs
Kovaltry
Obizur
Antihemophilic Factor (Recombinant [Fc Fusion
Protein])
Antihemophilic Factor (Recombinant [Pegylated])
Antihemophilic Factor (Recombinant [Pegylated])
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant [Porcine
Sequence])
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent; Prothrombin Complex
Concentrate (PCC)
Benefix
Ixinity
Rixubis
Bebulin
Factor IX (Recombinant)
Factor IX (Recombinant)
Factor IX (Recombinant)
Factor IX Complex (Human) [(Factors II, IX, X)]
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hormonal
Hereditary Angioedema
C1 Esterase Inhibitor
C1 Esterase Inhibitor
C1 Esterase Inhibitor
C1 Esterase Inhibitor
Kallikrein Inhibitor
Selective Bradykinin B2 Receptor Antagonist
Gonadotropin Releasing Hormone Antagonist
Kallikrein Inhibitor
Berinert
Cinryze
Haegarda
Ruconest
Kalbitor
Firazyr
Firmagon
Takhzyro
C1 Inhibitor (Human)
C1 Inhibitor (Human)
C1 Inhibitor (Human)
C1 Inhibitor (Recombinant)
Ecallantide
Icatibant
Degarelix
Lanadelumab
Hepatitis
Hepatitis
Interferon
Interferon
Pegasys
Pegintron
Peginterferon Alfa-2a
Peginterferon Alfa-2b
Hepatitis Interferon Intron-A Interferon Alfa-2b
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Blood Product Derivative
Blood Product Derivative
Antihemophilic Agent
Coagadex
Tretten
Corifact
Fibryga
Riastap
Vonvendi
Factor X (Human)
Factor XIII A-Subunit (Recombinant)
Factor XIII Concentrate (Human)
Fibrinogen Concentrate (Human)
Fibrinogen Concentrate (Human)
Von Willebrand Factor (Recombinant)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent Novoseven Rt Factor VIIa (Recombinant)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent; Prothrombin Complex
Concentrate (PCC)Profilnine Sd
Factor IX Complex (Human) [(Factors II, IX, X)]
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent; Prothrombin Complex
Concentrate (PCC)Profilnine
Factor IX Complex (Human) [(Factors II, IX, X)]
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hormonal
Hormonal
Hormonal
Hormonal
Hormonal
Hormonal
Igf-1 Deficiency
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Parathyroid Hormone Analog
Androgen
Growth Hormone
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Eligard
Lupron
Lupron Depot
Trelstar
Natpara
Aveed
Increlex
Cytogam
Hepagam B
Hyperhep B
Nabi-Hb
Asceniv
Bivigam
Cuvitru
Gamastan
Leuprolide
Leuprolide
Leuprolide
Triptorelin
Parathyroid Hormone
Testosterone
Mecasermin
Cytomegalovirus Immune Globulin
Hepatitis B Immune Globulin
Hepatitis B Immune Globulin
Hepatitis B Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
HormonalGonadotropin Releasing
Hormone AntagonistLupaneta Pack
Leuprolide and Norethindrone
HormonalGonadotropin Releasing
Hormone AntagonistVantas Histrelin
Hormonal
Hormonal
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Zoladex
Supprelin La
Goserelin
Histrelin
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Gammaplex
Gamunex C
Hizentra
Hyqvia
Octagam
Panzyga
Privigen
Xembify
Hyperrho S/D
Micrhogam
Rhogam
Rhophylac
Winrho Sdf
Varizig
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Varicella-Zoster Immune Globulin
Immune Deficiencies & Related Disorders
Immune Globulin Gammaked Immune Globulin
Immune Deficiencies & Related Disorders
Immune Globulin Gammagard S/D Immune Globulin
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Globulin
Immune Globulin
Gamastan S/D
Gammagard Liquid
Immune Globulin
Immune Globulin
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Kadcyla
Mvasi
Zirabev
Avastin
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
Enhertu
Ado-Trastuzumab Emtasine
Bevacizumab-awwb
Bevacizumab-bvzr
Bevacizumab
Trastuzumab
Trastuzumab-pkrb
Trastuzumab-anns
Trastuzumab-dkst
Trastuzumab-dttb
Trastuzumab-qyyp
Fam-Trastuzumab Deruxtecan
ThrombocytopeniaColony Stimulating Factor/
Thrombopoietin Receptor AgonistNplate Romiplostim
Spinal Muscular Atrophy
Systemic Lupus Erythematosus
Spinal Muscular Atrophy
Antisense Oligonucleotide
Monoclonal Antibody
Gene Therapy
Spinraza
Benlysta
Zolgensma
Nusinersen
Belimumab
Onasemnogene Abeparvovec
Sickle Cell Anti-P-Selectin Adakveo Crizanlizumab
Rheumatoid Arthritis
Rheumatoid Arthritis
Interleukin-6 Antagonist
Interleukin-6 Antagonist
Kevzara
Actemra
Sarilumab
Tocilizumab
Rheumatoid Arthritis Anti-CD20 Truxima Rituximab
Rheumatoid Arthritis
Rheumatoid Arthritis
Anti-CD20
Anti-CD20
Rituxan
Ruxience
Rituximab
Rituximab
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
TNF Inhibitor
TNF Inhibitor
TNF Inhibitor
Antimetabolite/Antifolate
Antimetabolite/Antifolate
Inflectra
Remicade
Renflexis
Otrexup
Rasuvo
Infliximab
Infliximab
Infliximab
Methotrexate
Methotrexate
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Oncology
Oncology
Antineoplastic Antibiotics
Nitrogen Mustards
Nitrogen Mustards
Idarubicin
Ifex
Ifosfamide
Tegsedi
Idarubicin HCl
Ifosfamide
Ifosfamide
Inotersen Sodium
Oncology
Oncology
Oncology
LHRH Analogs
LHRH Analogs
Antineoplastic Antibiotics
Zoladex
Vantas
Idamycin
Goserelin Acetate
Histrelin Acetate
Idarubicin HCl
OncologyCarboxypeptidase Enzyme
AgentsVoraxaze Glucarpidase
OncologyAntineoplastic Antibody-Drug
ComplexesMylotarg Gemtuzumab Ozogamicin
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antimetabolites
Antimetabolites
Estrogen Receptor Antagonist
Estrogen Receptor Antagonist
Antimetabolites
Antimetabolites
Adrucil
Fluorouracil
Faslodex
Fulvestrant
Gemcitabine
Infugem
Fluorouracil
Fluorouracil
Fulvestrant
Fulvestrant
Gemcitabine
Gemcitabine HCl-NaCl
Oncology
Oncology
Antimetabolites
Antimetabolites
Floxuridine
Fludarabine
Floxuridine
Fludarabine
OncologyAntineoplastic Antibody-Drug
ComplexesEnhertu
Fam-Trastuzumab Deruxtec-nxki
Oncology
Oncology
Mitotic Inhibitors
Mitotic Inhibitors
Toposar
Etopophos
Etoposide
Etoposide Phosphate
Oncology Mitotic Inhibitors Etoposide Etoposide
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic Antibiotics
Antineoplastic Antibiotics
Mitotic Inhibitors
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Antineoplastic Antibody-Drug Complexes
Ellence
Epirubicin HCl
Halaven
Imfinzi
Empliciti
Padcev
Epirubicin HCl
Epirubicin HCl
Eribulin Mesylate
Durvalumab
Elotuzumab
Enfortumab Vedotin-ejfv
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Nitrogen Mustards
Antisense Oligonucleotide (ASO) Inhibitor Agents
Antineoplastic Antibody-Drug Complexes
Antineoplastic - Monoclonal Antibodies
Topoisomerase I Inhibitors
Topoisomerase I Inhibitors
Ifosfamide
Tegsedi
Besponsa
Yervoy
Camptosar
Irinotecan
Ifosfamide
Inotersen Sodium
Inotuzumab Ozogamicin
Ipilimumab
Irinotecan HCl
Irinotecan HCl
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology Topoisomerase I Inhibitors Onivyde Irinotecan HCl Liposome
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Hymovis
Monovisc
OrthoVisc
Supartz FX
Synvisc
Synvisc One
Triluron
TriVisc
Visco-3
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version