Product Label Generic Name AHFS Therapeutic Class ...

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Product Label Generic Name AHFS Therapeutic Class Description ABIRATERONE TAB 250MG ABIRATERONE ACETATE TAB 250 MG ANTINEOPLASTIC AGENTS ABIRATERONE TAB 500MG ABIRATERONE ACETATE TAB 500 MG ANTINEOPLASTIC AGENTS ACTEMRA INJ 162/0.9 TOCILIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 162 MG/0.9ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA INJ ACTPEN TOCILIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 162 MG/0.9ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTHAR INJ 80UNIT CORTICOTROPIN INJ GEL 80 UNIT/ML PITUITARY ACTIMMUNE INJ 2MU/0.5 INTERFERON GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML) IMMUNOMODULATORY AGENTS ADEFOV DIPIV TAB 10MG ADEFOVIR DIPIVOXIL TAB 10 MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS ADEMPAS TAB 0.5MG RIOCIGUAT TAB 0.5 MG VASODILATING AGENTS (RESPIRATORY TRACT) ADEMPAS TAB 1.5MG RIOCIGUAT TAB 1.5 MG VASODILATING AGENTS (RESPIRATORY TRACT) ADEMPAS TAB 1MG RIOCIGUAT TAB 1 MG VASODILATING AGENTS (RESPIRATORY TRACT) ADEMPAS TAB 2.5MG RIOCIGUAT TAB 2.5 MG VASODILATING AGENTS (RESPIRATORY TRACT) ADEMPAS TAB 2MG RIOCIGUAT TAB 2 MG VASODILATING AGENTS (RESPIRATORY TRACT) ADVATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 1000 UNIT HEMOSTATICS ADVATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 1500 UNIT HEMOSTATICS ADVATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 2000 UNIT HEMOSTATICS ADVATE INJ 250UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 250 UNIT HEMOSTATICS ADVATE INJ 3000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 3000 UNIT HEMOSTATICS ADVATE INJ 4000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 4000 UNIT HEMOSTATICS ADVATE INJ 500UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 500 UNIT HEMOSTATICS ADYNOVATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 1000 UNIT HEMOSTATICS ADYNOVATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 1500 UNIT HEMOSTATICS ADYNOVATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 2000 UNIT HEMOSTATICS ADYNOVATE INJ 250UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 250 UNIT HEMOSTATICS ADYNOVATE INJ 3000UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 3000 UNIT HEMOSTATICS ADYNOVATE INJ 500UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 500 UNIT HEMOSTATICS ADYNOVATE INJ 750UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 750 UNIT HEMOSTATICS AFSTYLA KIT 1000UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 1000 UNIT HEMOSTATICS AFSTYLA KIT 1500UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 1500 UNIT HEMOSTATICS AFSTYLA KIT 2000UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 2000 UNIT HEMOSTATICS AFSTYLA KIT 2500UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 2500 UNIT HEMOSTATICS AFSTYLA KIT 250UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 250 UNIT HEMOSTATICS AFSTYLA KIT 3000UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 3000 UNIT HEMOSTATICS AFSTYLA KIT 500UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 500 UNIT HEMOSTATICS AIMOVIG INJ 140MG/ML ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG. AIMOVIG INJ 70MG/ML ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 70 MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG. ALECENSA CAP 150MG ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTS ALFERON N INJ 5MU/ML INTERFERON ALFA-N3 INJ 5000000 UNIT/ML ANTINEOPLASTIC AGENTS ALKERAN TAB 2MG MELPHALAN TAB 2 MG ANTINEOPLASTIC AGENTS ALPHANATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 1000 UNIT HEMOSTATICS ALPHANATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 1500 UNIT HEMOSTATICS Atrium Health Specialty Drug List - July 2022

Transcript of Product Label Generic Name AHFS Therapeutic Class ...

Product Label Generic Name AHFS Therapeutic Class DescriptionABIRATERONE TAB 250MG ABIRATERONE ACETATE TAB 250 MG ANTINEOPLASTIC AGENTSABIRATERONE TAB 500MG ABIRATERONE ACETATE TAB 500 MG ANTINEOPLASTIC AGENTSACTEMRA INJ 162/0.9 TOCILIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 162 MG/0.9ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSACTEMRA INJ ACTPEN TOCILIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 162 MG/0.9ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSACTHAR INJ 80UNIT CORTICOTROPIN INJ GEL 80 UNIT/ML PITUITARYACTIMMUNE INJ 2MU/0.5 INTERFERON GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML) IMMUNOMODULATORY AGENTSADEFOV DIPIV TAB 10MG ADEFOVIR DIPIVOXIL TAB 10 MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSADEMPAS TAB 0.5MG RIOCIGUAT TAB 0.5 MG VASODILATING AGENTS (RESPIRATORY TRACT)ADEMPAS TAB 1.5MG RIOCIGUAT TAB 1.5 MG VASODILATING AGENTS (RESPIRATORY TRACT)ADEMPAS TAB 1MG RIOCIGUAT TAB 1 MG VASODILATING AGENTS (RESPIRATORY TRACT)ADEMPAS TAB 2.5MG RIOCIGUAT TAB 2.5 MG VASODILATING AGENTS (RESPIRATORY TRACT)ADEMPAS TAB 2MG RIOCIGUAT TAB 2 MG VASODILATING AGENTS (RESPIRATORY TRACT)ADVATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 1000 UNIT HEMOSTATICSADVATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 1500 UNIT HEMOSTATICSADVATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 2000 UNIT HEMOSTATICSADVATE INJ 250UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 250 UNIT HEMOSTATICSADVATE INJ 3000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 3000 UNIT HEMOSTATICSADVATE INJ 4000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 4000 UNIT HEMOSTATICSADVATE INJ 500UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 500 UNIT HEMOSTATICSADYNOVATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 1000 UNIT HEMOSTATICSADYNOVATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 1500 UNIT HEMOSTATICSADYNOVATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 2000 UNIT HEMOSTATICSADYNOVATE INJ 250UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 250 UNIT HEMOSTATICSADYNOVATE INJ 3000UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 3000 UNIT HEMOSTATICSADYNOVATE INJ 500UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 500 UNIT HEMOSTATICSADYNOVATE INJ 750UNIT ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED FOR INJ 750 UNIT HEMOSTATICSAFSTYLA KIT 1000UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 1000 UNIT HEMOSTATICSAFSTYLA KIT 1500UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 1500 UNIT HEMOSTATICSAFSTYLA KIT 2000UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 2000 UNIT HEMOSTATICSAFSTYLA KIT 2500UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 2500 UNIT HEMOSTATICSAFSTYLA KIT 250UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 250 UNIT HEMOSTATICSAFSTYLA KIT 3000UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 3000 UNIT HEMOSTATICSAFSTYLA KIT 500UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 500 UNIT HEMOSTATICSAIMOVIG INJ 140MG/ML ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 140 MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG.AIMOVIG INJ 70MG/ML ERENUMAB-AOOE SUBCUTANEOUS SOLN AUTO-INJECTOR 70 MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG.ALECENSA CAP 150MG ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSALFERON N INJ 5MU/ML INTERFERON ALFA-N3 INJ 5000000 UNIT/ML ANTINEOPLASTIC AGENTSALKERAN TAB 2MG MELPHALAN TAB 2 MG ANTINEOPLASTIC AGENTSALPHANATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 1000 UNIT HEMOSTATICSALPHANATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 1500 UNIT HEMOSTATICS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionALPHANATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 2000 UNIT HEMOSTATICSALPHANATE INJ 250 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 250 UNIT HEMOSTATICSALPHANATE INJ 500 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500 UNIT HEMOSTATICSALPHANATE INJ VWF/HUM ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 1500 UNIT HEMOSTATICSALPHANINE SD INJ 1000UNIT COAGULATION FACTOR IX FOR INJ 1000 UNIT HEMOSTATICSALPHANINE SD INJ 1500UNIT COAGULATION FACTOR IX FOR INJ 1500 UNIT HEMOSTATICSALPHANINE SD INJ 500UNIT COAGULATION FACTOR IX FOR INJ 500 UNIT HEMOSTATICSALPROLIX INJ 1000UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 1000 UNIT HEMOSTATICSALPROLIX INJ 2000UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 2000 UNIT HEMOSTATICSALPROLIX INJ 250UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 250 UNIT HEMOSTATICSALPROLIX INJ 3000UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 3000 UNIT HEMOSTATICSALPROLIX INJ 4000UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 4000 UNIT HEMOSTATICSALPROLIX INJ 500UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 500 UNIT HEMOSTATICSALUNBRIG PAK BRIGATINIB TAB INITIATION THERAPY PACK 90 MG & 180 MG ANTINEOPLASTIC AGENTSALUNBRIG TAB 180MG BRIGATINIB TAB 180 MG ANTINEOPLASTIC AGENTSALUNBRIG TAB 30MG BRIGATINIB TAB 30 MG ANTINEOPLASTIC AGENTSALUNBRIG TAB 90MG BRIGATINIB TAB 90 MG ANTINEOPLASTIC AGENTSALYQ TAB 20MG TADALAFIL TAB 20 MG (PAH) PHOSPHODIESTERASE TYPE 5 INHIBITORSAMBRISENTAN TAB 10MG AMBRISENTAN TAB 10 MG VASODILATING AGENTS (RESPIRATORY TRACT)AMBRISENTAN TAB 5MG AMBRISENTAN TAB 5 MG VASODILATING AGENTS (RESPIRATORY TRACT)AMICAR SOL 0.25/ML AMINOCAPROIC ACID ORAL SOLN 0.25 GM/ML HEMOSTATICSAMICAR TAB 1000MG AMINOCAPROIC ACID TAB 1000 MG HEMOSTATICSAMICAR TAB 500MG AMINOCAPROIC ACID TAB 500 MG HEMOSTATICSAMINOCAPR AC TAB 1000MG AMINOCAPROIC ACID TAB 1000 MG HEMOSTATICSAMINOCAPR AC TAB 500MG AMINOCAPROIC ACID TAB 500 MG HEMOSTATICSAMINOCAPROIC SOL 0.25/ML AMINOCAPROIC ACID ORAL SOLN 0.25 GM/ML HEMOSTATICSAMPYRA TAB 10MG DALFAMPRIDINE TAB ER 12HR 10 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSAPOKYN INJ 10MG/ML APOMORPHINE HCL SOLN CARTRIDGE 30 MG/3ML NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTAPOMORPHINE INJ 30MG/3ML APOMORPHINE HCL SOLN CARTRIDGE 30 MG/3ML NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTARANESP INJ 100MCG DARBEPOETIN ALFA SOLN INJ 100 MCG/ML HEMATOPOIETIC AGENTSARANESP INJ 10MCG DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 10 MCG/0.4ML HEMATOPOIETIC AGENTSARANESP INJ 150MCG DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 150 MCG/0.3ML HEMATOPOIETIC AGENTSARANESP INJ 200MCG DARBEPOETIN ALFA SOLN INJ 200 MCG/ML HEMATOPOIETIC AGENTSARANESP INJ 25MCG DARBEPOETIN ALFA SOLN INJ 25 MCG/ML HEMATOPOIETIC AGENTSARANESP INJ 300MCG DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 300 MCG/0.6ML HEMATOPOIETIC AGENTSARANESP INJ 40MCG DARBEPOETIN ALFA SOLN INJ 40 MCG/ML HEMATOPOIETIC AGENTSARANESP INJ 500MCG DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 500 MCG/ML HEMATOPOIETIC AGENTSARANESP INJ 60MCG DARBEPOETIN ALFA SOLN INJ 60 MCG/ML HEMATOPOIETIC AGENTSARCALYST INJ 220MG RILONACEPT FOR INJ 220 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSARIKAYCE SUS AMIKACIN SULFATE LIPOSOME INHAL SUSP 590 MG/8.4ML (BASE EQ) AMINOGLYCOSIDE ANTIBIOTICS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionARIXTRA INJ 10/0.8ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML ANTICOAGULANTS, MISCELLANEOUSARIXTRA INJ 2.5/0.5 FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML ANTICOAGULANTS, MISCELLANEOUSARIXTRA INJ 5/0.4ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML ANTICOAGULANTS, MISCELLANEOUSARIXTRA INJ 7.5/0.6 FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML ANTICOAGULANTS, MISCELLANEOUSAROMASIN TAB 25MG EXEMESTANE TAB 25 MG ANTIESTROGENSAUBAGIO TAB 14MG TERIFLUNOMIDE TAB 14 MG IMMUNOMODULATORY AGENTSAUBAGIO TAB 7MG TERIFLUNOMIDE TAB 7 MG IMMUNOMODULATORY AGENTSAUSTEDO TAB 12MG DEUTETRABENAZINE TAB 12 MG VESICULAR MONOAMINE TRANSPORT2 INHIBITORAUSTEDO TAB 6MG DEUTETRABENAZINE TAB 6 MG VESICULAR MONOAMINE TRANSPORT2 INHIBITORAUSTEDO TAB 9MG DEUTETRABENAZINE TAB 9 MG VESICULAR MONOAMINE TRANSPORT2 INHIBITORAVONEX PEN KIT 30MCG INTERFERON BETA-1A IM AUTO-INJECTOR KIT 30 MCG/0.5ML IMMUNOMODULATORY AGENTSAVONEX PREFL KIT 30MCG INTERFERON BETA-1A IM PREFILLED SYRINGE KIT 30 MCG/0.5ML IMMUNOMODULATORY AGENTSAYVAKIT TAB 100MG AVAPRITINIB TAB 100 MG ANTINEOPLASTIC AGENTSAYVAKIT TAB 200MG AVAPRITINIB TAB 200 MG ANTINEOPLASTIC AGENTSAYVAKIT TAB 25MG AVAPRITINIB TAB 25 MG ANTINEOPLASTIC AGENTSAYVAKIT TAB 300MG AVAPRITINIB TAB 300 MG ANTINEOPLASTIC AGENTSAYVAKIT TAB 50MG AVAPRITINIB TAB 50 MG ANTINEOPLASTIC AGENTSAZACITIDINE INJ 100MG AZACITIDINE FOR INJ 100 MG ANTINEOPLASTIC AGENTSBAFIERTAM CAP 95MG MONOMETHYL FUMARATE CAPSULE DELAYED RELEASE 95 MG IMMUNOMODULATORY AGENTSBALVERSA TAB 3MG ERDAFITINIB TAB 3 MG ANTINEOPLASTIC AGENTSBALVERSA TAB 4MG ERDAFITINIB TAB 4 MG ANTINEOPLASTIC AGENTSBALVERSA TAB 5MG ERDAFITINIB TAB 5 MG ANTINEOPLASTIC AGENTSBARACLUDE SOL ENTECAVIR ORAL SOLN 0.05 MG/ML NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSBENEFIX INJ 1000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 1000 UNIT HEMOSTATICSBENEFIX INJ 2000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 2000 UNIT HEMOSTATICSBENEFIX INJ 250UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 250 UNIT HEMOSTATICSBENEFIX INJ 3000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 3000 UNIT HEMOSTATICSBENEFIX INJ 500UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 500 UNIT HEMOSTATICSBENLYSTA INJ 200MG/ML BELIMUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML IMMUNOSUPPRESSIVE AGENTSBETAINE ANHY POW *BETAINE POWDER FOR ORAL SOLUTION*** OTHER MISCELLANEOUS THERAPEUTIC AGENTSBETASERON INJ 0.3MG INTERFERON BETA-1B FOR INJ KIT 0.3 MG IMMUNOMODULATORY AGENTSBEVACIZUMAB INJ 1.25MG BEVACIZUMAB INTRAVIT PREF SYR 3 MG/0.12ML (1.25 MG/0.05ML) ANTINEOPLASTIC AGENTSBEVACIZUMAB INJ 2.5/.1ML BEVACIZUMAB INTRAVITREAL SOLN PREF SYR 2.5 MG/0.1ML ANTINEOPLASTIC AGENTSBEVACIZUMAB INJ 3.25/.13 BEVACIZUMAB INTRAVITREAL SOLN PREF SYR 3.25 MG/0.13ML ANTINEOPLASTIC AGENTSBEVACIZUMAB INJ 3.75/.15 BEVACIZUMAB INTRAVITREAL SOLN PREF SYR 3.75 MG/0.15ML ANTINEOPLASTIC AGENTSBEXAROTENE CAP 75MG BEXAROTENE CAP 75 MG ANTINEOPLASTIC AGENTSBEXAROTENE GEL 1% BEXAROTENE GEL 1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC.BLEOMYCIN INJ 15UNIT BLEOMYCIN SULFATE FOR INJ 15 UNIT ANTINEOPLASTIC AGENTSBLEOMYCIN INJ 30UNIT BLEOMYCIN SULFATE FOR INJ 30 UNIT ANTINEOPLASTIC AGENTSBORTEZOMIB INJ 1MG BORTEZOMIB FOR INJ 1 MG ANTINEOPLASTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionBORTEZOMIB INJ 2.5MG BORTEZOMIB FOR INJ 2.5 MG ANTINEOPLASTIC AGENTSBORTEZOMIB INJ 3.5MG BORTEZOMIB FOR INJ 3.5 MG ANTINEOPLASTIC AGENTSBOSENTAN TAB 125MG BOSENTAN TAB 125 MG VASODILATING AGENTS (RESPIRATORY TRACT)BOSENTAN TAB 62.5MG BOSENTAN TAB 62.5 MG VASODILATING AGENTS (RESPIRATORY TRACT)BOSULIF TAB 100MG BOSUTINIB TAB 100 MG ANTINEOPLASTIC AGENTSBOSULIF TAB 400MG BOSUTINIB TAB 400 MG ANTINEOPLASTIC AGENTSBOSULIF TAB 500MG BOSUTINIB TAB 500 MG ANTINEOPLASTIC AGENTSBOTOX INJ 100UNIT ONABOTULINUMTOXINA FOR INJ 100 UNIT OTHER MISCELLANEOUS THERAPEUTIC AGENTSBOTOX INJ 200UNIT ONABOTULINUMTOXINA FOR INJ 200 UNIT OTHER MISCELLANEOUS THERAPEUTIC AGENTSBRAFTOVI CAP 75MG ENCORAFENIB CAP 75 MG ANTINEOPLASTIC AGENTSBRUKINSA CAP 80MG ZANUBRUTINIB CAP 80 MG ANTINEOPLASTIC AGENTSBYLVAY CAP 1200MCG ODEVIXIBAT CAP 1200 MCG GI DRUGS, MISCELLANEOUSBYLVAY CAP 200MCG ODEVIXIBAT PELLETS CAP SPRINKLE 200 MCG GI DRUGS, MISCELLANEOUSBYLVAY CAP 400MCG ODEVIXIBAT CAP 400 MCG GI DRUGS, MISCELLANEOUSBYLVAY CAP 600MCG ODEVIXIBAT PELLETS CAP SPRINKLE 600 MCG GI DRUGS, MISCELLANEOUSCABLIVI KIT 11MG CAPLACIZUMAB-YHDP FOR INJ KIT 11 MG ANTITHROMBOTIC AGENTS, MISCELLANEOUSCABOMETYX TAB 20MG CABOZANTINIB S-MALATE TAB 20 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSCABOMETYX TAB 40MG CABOZANTINIB S-MALATE TAB 40 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSCABOMETYX TAB 60MG CABOZANTINIB S-MALATE TAB 60 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSCALQUENCE CAP 100MG ACALABRUTINIB CAP 100 MG ANTINEOPLASTIC AGENTSCAPECITABINE TAB 150MG CAPECITABINE TAB 150 MG ANTINEOPLASTIC AGENTSCAPECITABINE TAB 500MG CAPECITABINE TAB 500 MG ANTINEOPLASTIC AGENTSCAPRELSA TAB 100MG VANDETANIB TAB 100 MG ANTINEOPLASTIC AGENTSCAPRELSA TAB 300MG VANDETANIB TAB 300 MG ANTINEOPLASTIC AGENTSCARBAGLU TAB 200MG CARGLUMIC ACID SOLUBLE TAB 200 MG AMMONIA DETOXICANTSCARGLUMIC TAB 200MG CARGLUMIC ACID SOLUBLE TAB 200 MG AMMONIA DETOXICANTSCELLCEPT CAP 250MG MYCOPHENOLATE MOFETIL CAP 250 MG IMMUNOSUPPRESSIVE AGENTSCELLCEPT SUS 200MG/ML MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML IMMUNOSUPPRESSIVE AGENTSCELLCEPT TAB 500MG MYCOPHENOLATE MOFETIL TAB 500 MG IMMUNOSUPPRESSIVE AGENTSCERDELGA CAP 84MG ELIGLUSTAT TARTRATE CAP 84 MG (BASE EQUIVALENT) OTHER MISCELLANEOUS THERAPEUTIC AGENTSCHENODAL TAB 250MG CHENODIOL TAB 250 MG CHOLELITHOLYTIC AGENTSCHOLBAM CAP 250MG CHOLIC ACID CAP 250 MG GI DRUGS, MISCELLANEOUSCHOLBAM CAP 50MG CHOLIC ACID CAP 50 MG GI DRUGS, MISCELLANEOUSCHOR GONADOT INJ 10000UNT CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT GONADOTROPINSCIMZIA KIT 200MG CERTOLIZUMAB PEGOL FOR INJ KIT 2 X 200 MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTSCIMZIA PREFL KIT 200MG/ML CERTOLIZUMAB PEGOL PREFILLED SYRINGE KIT 2 X 200 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSCIMZIA START KIT 200MG/ML CERTOLIZUMAB PEGOL PREFILLED SYRINGE KIT 6 X 200 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSCINACALCET TAB 30MG CINACALCET HCL TAB 30 MG (BASE EQUIV) ANTIPARATHYROID AGENTSCINACALCET TAB 60MG CINACALCET HCL TAB 60 MG (BASE EQUIV) ANTIPARATHYROID AGENTSCINACALCET TAB 90MG CINACALCET HCL TAB 90 MG (BASE EQUIV) ANTIPARATHYROID AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionCLOVIQUE CAP 250MG TRIENTINE HCL CAP 250 MG HEAVY METAL ANTAGONISTSCOAGADEX INJ 250UNIT COAGULATION FACTOR X (HUMAN) FOR INJ 250 UNIT HEMOSTATICSCOAGADEX INJ 500UNIT COAGULATION FACTOR X (HUMAN) FOR INJ 500 UNIT HEMOSTATICSCOMETRIQ KIT 100MG CABOZANTINIB S-MAL CAP 1 X 80 MG & 1 X 20 MG (100 DOSE) KIT ANTINEOPLASTIC AGENTSCOMETRIQ KIT 140MG CABOZANTINIB S-MAL CAP 1 X 80 MG & 3 X 20 MG (140 DOSE) KIT ANTINEOPLASTIC AGENTSCOMETRIQ KIT 60MG CABOZANTINIB S-MALATE CAP 3 X 20 MG (60 MG DOSE) KIT ANTINEOPLASTIC AGENTSCOPAXONE INJ 20MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML IMMUNOMODULATORY AGENTSCOPAXONE INJ 40MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML IMMUNOMODULATORY AGENTSCOPIKTRA CAP 15MG DUVELISIB CAP 15 MG ANTINEOPLASTIC AGENTSCOPIKTRA CAP 25MG DUVELISIB CAP 25 MG ANTINEOPLASTIC AGENTSCORIFACT KIT FACTOR XIII CONCENTRATE (HUMAN) FOR INJ KIT 1000-1600 UNIT HEMOSTATICSCORTROPHIN GEL 80UNIT CORTICOTROPIN INJ GEL 80 UNIT/ML PITUITARYCOTELLIC TAB 20MG COBIMETINIB FUMARATE TAB 20 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSCRESEMBA CAP 186 MG ISAVUCONAZONIUM SULFATE CAP 186 MG (ISAVUCONAZOLE 100 MG) AZOLE ANTIFUNGALSCRYSVITA INJ 10MG/ML BUROSUMAB-TWZA INJ 10 MG/ML ELECTROLYTIC,CALORIC,WATER BALANCE MISC,CRYSVITA INJ 20MG/ML BUROSUMAB-TWZA INJ 20 MG/ML ELECTROLYTIC,CALORIC,WATER BALANCE MISC,CRYSVITA INJ 30MG/ML BUROSUMAB-TWZA INJ 30 MG/ML ELECTROLYTIC,CALORIC,WATER BALANCE MISC,CUVITRU INJ 2GM/10ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 2 GM/10ML ANTITOXINS AND IMMUNE GLOBULINSCUVITRU INJ 4GM/20ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 4 GM/20ML ANTITOXINS AND IMMUNE GLOBULINSCUVITRU INJ 8GM/40ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 8 GM/40ML ANTITOXINS AND IMMUNE GLOBULINSCUVITRU SOL 10GM/50M IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 10 GM/50ML ANTITOXINS AND IMMUNE GLOBULINSCUVITRU SOL 1GM/5ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 1 GM/5ML ANTITOXINS AND IMMUNE GLOBULINSCYCLOPHOSPH CAP 25MG CYCLOPHOSPHAMIDE CAP 25 MG ANTINEOPLASTIC AGENTSCYCLOPHOSPH CAP 50MG CYCLOPHOSPHAMIDE CAP 50 MG ANTINEOPLASTIC AGENTSCYCLOPHOSPH INJ 1GM CYCLOPHOSPHAMIDE FOR INJ 1 GM ANTINEOPLASTIC AGENTSCYCLOPHOSPH INJ 2GM CYCLOPHOSPHAMIDE FOR INJ 2 GM ANTINEOPLASTIC AGENTSCYCLOPHOSPH INJ 500MG CYCLOPHOSPHAMIDE FOR INJ 500 MG ANTINEOPLASTIC AGENTSCYCLOPHOSPH TAB 25MG CYCLOPHOSPHAMIDE TAB 25 MG ANTINEOPLASTIC AGENTSCYCLOPHOSPH TAB 50MG CYCLOPHOSPHAMIDE TAB 50 MG ANTINEOPLASTIC AGENTSCYSTADANE POW *BETAINE POWDER FOR ORAL SOLUTION*** OTHER MISCELLANEOUS THERAPEUTIC AGENTSCYSTADROPS SOL 0.37% CYSTEAMINE HCL OPHTH SOLN 0.37% (BASE EQUIVALENT) EENT DRUGS, MISCELLANEOUSCYSTAGON CAP 150MG CYSTEAMINE BITARTRATE CAP 150 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSCYSTAGON CAP 50MG CYSTEAMINE BITARTRATE CAP 50 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSCYSTARAN SOL 0.44% CYSTEAMINE HCL OPHTH SOLN 0.44% (BASE EQUIVALENT) EENT DRUGS, MISCELLANEOUSCYTARABINE INJ 100MG/ML CYTARABINE INJ PF 100 MG/ML ANTINEOPLASTIC AGENTSCYTARABINE INJ 20MG/ML CYTARABINE INJ PF 20 MG/ML ANTINEOPLASTIC AGENTSDALFAMPRIDIN TAB 10MG ER DALFAMPRIDINE TAB ER 12HR 10 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSDARAPRIM TAB 25MG PYRIMETHAMINE TAB 25 MG ANTIMALARIALSDAURISMO TAB 100MG GLASDEGIB MALEATE TAB 100 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSDAURISMO TAB 25MG GLASDEGIB MALEATE TAB 25 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionDEFERASIROX GRA 180MG DEFERASIROX GRANULES PACKET 180 MG HEAVY METAL ANTAGONISTSDEFERASIROX GRA 360MG DEFERASIROX GRANULES PACKET 360 MG HEAVY METAL ANTAGONISTSDEFERASIROX GRA 90MG DEFERASIROX GRANULES PACKET 90 MG HEAVY METAL ANTAGONISTSDEFERASIROX TAB 125MG DEFERASIROX TAB FOR ORAL SUSP 125 MG HEAVY METAL ANTAGONISTSDEFERASIROX TAB 180MG DEFERASIROX TAB 180 MG HEAVY METAL ANTAGONISTSDEFERASIROX TAB 250MG DEFERASIROX TAB FOR ORAL SUSP 250 MG HEAVY METAL ANTAGONISTSDEFERASIROX TAB 360MG DEFERASIROX TAB 360 MG HEAVY METAL ANTAGONISTSDEFERASIROX TAB 500MG DEFERASIROX TAB FOR ORAL SUSP 500 MG HEAVY METAL ANTAGONISTSDEFERASIROX TAB 90MG DEFERASIROX TAB 90 MG HEAVY METAL ANTAGONISTSDEFERIPRONE TAB 1000MG DEFERIPRONE TAB 1000 MG HEAVY METAL ANTAGONISTSDEPEN TITRA TAB 250MG PENICILLAMINE TAB 250 MG HEAVY METAL ANTAGONISTSDIACOMIT CAP 250MG STIRIPENTOL CAP 250 MG ANTICONVULSANTS, MISCELLANEOUSDIACOMIT CAP 500MG STIRIPENTOL CAP 500 MG ANTICONVULSANTS, MISCELLANEOUSDIACOMIT PAK 250MG STIRIPENTOL PACKET 250 MG ANTICONVULSANTS, MISCELLANEOUSDIACOMIT PAK 500MG STIRIPENTOL PACKET 500 MG ANTICONVULSANTS, MISCELLANEOUSDIMETHYL FUM CAP 120MG DR DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG IMMUNOMODULATORY AGENTSDIMETHYL FUM CAP 240MG DR DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 240 MG IMMUNOMODULATORY AGENTSDIMETHYL FUM MIS STARTER DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG IMMUNOMODULATORY AGENTSDOPTELET TAB 20MG AVATROMBOPAG MALEATE TAB 20 MG (BASE EQUIV) HEMATOPOIETIC AGENTSDROXIDOPA CAP 100MG DROXIDOPA CAP 100 MG ALPHA- AND BETA-ADRENERGIC AGONISTSDROXIDOPA CAP 200MG DROXIDOPA CAP 200 MG ALPHA- AND BETA-ADRENERGIC AGONISTSDROXIDOPA CAP 300MG DROXIDOPA CAP 300 MG ALPHA- AND BETA-ADRENERGIC AGONISTSDUPIXENT INJ 100/0.67 DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/0.67ML INTERLEUKIN ANTAGONISTSDUPIXENT INJ 200/1.14 DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML INTERLEUKIN ANTAGONISTSDUPIXENT INJ 200MG DUPILUMAB SUBCUTANEOUS SOLN PEN-INJECTOR 200 MG/1.14ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.DUPIXENT INJ 300/2ML DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 300 MG/2ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.DYSPORT INJ 300UNIT ABOBOTULINUMTOXINA FOR IM INJ 300 UNIT OTHER MISCELLANEOUS THERAPEUTIC AGENTSDYSPORT INJ 500UNIT ABOBOTULINUMTOXINA FOR IM INJ 500 UNIT OTHER MISCELLANEOUS THERAPEUTIC AGENTSEGRIFTA SOL 1MG TESAMORELIN ACETATE FOR INJ 1 MG (BASE EQUIV) SOMATOTROPIN AGONISTSEGRIFTA SV INJ 2MG TESAMORELIN ACETATE FOR INJ 2 MG (BASE EQUIV) SOMATOTROPIN AGONISTSELIGARD INJ 22.5MG LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG GONADOTROPINSELIGARD INJ 30MG LEUPROLIDE ACETATE (4 MONTH) FOR SUBCUTANEOUS INJ KIT 30 MG GONADOTROPINSELIGARD INJ 45MG LEUPROLIDE ACETATE (6 MONTH) FOR SUBCUTANEOUS INJ KIT 45 MG GONADOTROPINSELIGARD INJ 7.5MG LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG GONADOTROPINSELOCTATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 1000 UNIT HEMOSTATICSELOCTATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 1500 UNIT HEMOSTATICSELOCTATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 2000 UNIT HEMOSTATICSELOCTATE INJ 250UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 250 UNIT HEMOSTATICSELOCTATE INJ 3000UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 3000 UNIT HEMOSTATICSELOCTATE INJ 4000UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 4000 UNIT HEMOSTATICS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionELOCTATE INJ 5000UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 5000 UNIT HEMOSTATICSELOCTATE INJ 500UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 500 UNIT HEMOSTATICSELOCTATE INJ 6000UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 6000 UNIT HEMOSTATICSELOCTATE INJ 750UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) FOR INJ 750 UNIT HEMOSTATICSEMCYT CAP 140MG ESTRAMUSTINE PHOSPHATE SODIUM CAP 140 MG ANTINEOPLASTIC AGENTSEMGALITY INJ 100MG/ML GALCANEZUMAB-GNLM SUBCUTANEOUS SOLN PREFILLED SYR 100 MG/ML CALCITONIN GENE-RELATED PEPTIDE ANTAG.EMPAVELI INJ 1080MG PEGCETACOPLAN SUBCUTANEOUS SOLN 1080 MG/20ML (54 MG/ML) COMPLEMENT INHIBITORSENBREL INJ 25/0.5ML ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 25 MG/0.5ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSENBREL INJ 25MG ETANERCEPT SUBCUTANEOUS INJ 25 MG/0.5ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSENBREL INJ 50MG/ML ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSENBREL MINI INJ 50MG/ML ETANERCEPT SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSENBREL SRCLK INJ 50MG/ML ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSENDARI POW 5GM GLUTAMINE (SICKLE CELL) POWD PACK 5 GM OTHER MISCELLANEOUS THERAPEUTIC AGENTSENOXAPARIN INJ 100MG/ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML HEPARINSENOXAPARIN INJ 120/0.8 ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML HEPARINSENOXAPARIN INJ 150MG/ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML HEPARINSENOXAPARIN INJ 30/0.3ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML HEPARINSENOXAPARIN INJ 300/3ML ENOXAPARIN SODIUM INJ 300 MG/3ML HEPARINSENOXAPARIN INJ 40/0.4ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML HEPARINSENOXAPARIN INJ 60/0.6ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML HEPARINSENOXAPARIN INJ 80/0.8ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML HEPARINSENSPRYNG INJ SATRALIZUMAB-MWGE SUBCUTANEOUS SOLN PREF SYRINGE 120 MG/ML IMMUNOMODULATORY AGENTSENTECAVIR TAB 0.5MG ENTECAVIR TAB 0.5 MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSENTECAVIR TAB 1MG ENTECAVIR TAB 1 MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSEPCLUSA PAK 150-37.5 SOFOSBUVIR-VELPATASVIR PELLET PACK 150-37.5 MG HCV POLYMERASE INHIBITOR ANTIVIRALSEPCLUSA PAK 200-50MG SOFOSBUVIR-VELPATASVIR PELLET PACK 200-50 MG HCV POLYMERASE INHIBITOR ANTIVIRALSEPCLUSA TAB 200-50MG SOFOSBUVIR-VELPATASVIR TAB 200-50 MG HCV POLYMERASE INHIBITOR ANTIVIRALSEPCLUSA TAB 400-100 SOFOSBUVIR-VELPATASVIR TAB 400-100 MG HCV POLYMERASE INHIBITOR ANTIVIRALSEPIDIOLEX SOL 100MG/ML CANNABIDIOL SOLN 100 MG/ML ANTICONVULSANTS, MISCELLANEOUSEPIVIR HBV SOL 5MG/ML LAMIVUDINE ORAL SOLN 5 MG/ML (HBV) HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORSEPIVIR HBV TAB 100MG LAMIVUDINE TAB 100 MG (HBV) HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORSERIVEDGE CAP 150MG VISMODEGIB CAP 150 MG ANTINEOPLASTIC AGENTSERLEADA TAB 60MG APALUTAMIDE TAB 60 MG ANTINEOPLASTIC AGENTSERLOTINIB TAB 100MG ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSERLOTINIB TAB 150MG ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSERLOTINIB TAB 25MG ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSERWINASE INJ 10000UNT ASPARAGINASE ERWINIA CHRYSANTHEMI FOR INJ 10000 UNIT ANTINEOPLASTIC AGENTSERWINAZE INJ 10000UNT ASPARAGINASE ERWINIA CHRYSANTHEMI FOR INJ 10000 UNIT ANTINEOPLASTIC AGENTSESBRIET CAP 267MG PIRFENIDONE CAP 267 MG ANTIFIBROTIC AGENTSESBRIET TAB 267MG PIRFENIDONE TAB 267 MG ANTIFIBROTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionESBRIET TAB 801MG PIRFENIDONE TAB 801 MG ANTIFIBROTIC AGENTSETOPOSIDE CAP 50MG ETOPOSIDE CAP 50 MG ANTINEOPLASTIC AGENTSEVENITY INJ 105MG ROMOSOZUMAB-AQQG INJ SOLN PREFILLED SYRINGE 105 MG/1.17ML BONE ANABOLIC AGENTSEVEROLIMUS TAB 0.25MG EVEROLIMUS TAB 0.25 MG IMMUNOSUPPRESSIVE AGENTSEVEROLIMUS TAB 0.5 MG EVEROLIMUS TAB 0.5 MG IMMUNOSUPPRESSIVE AGENTSEVEROLIMUS TAB 0.75MG EVEROLIMUS TAB 0.75 MG IMMUNOSUPPRESSIVE AGENTSEVEROLIMUS TAB 10MG EVEROLIMUS TAB 10 MG ANTINEOPLASTIC AGENTSEVEROLIMUS TAB 1MG EVEROLIMUS TAB 1 MG IMMUNOSUPPRESSIVE AGENTSEVEROLIMUS TAB 2.5MG EVEROLIMUS TAB 2.5 MG ANTINEOPLASTIC AGENTSEVEROLIMUS TAB 2MG EVEROLIMUS TAB FOR ORAL SUSP 2 MG ANTINEOPLASTIC AGENTSEVEROLIMUS TAB 3MG EVEROLIMUS TAB FOR ORAL SUSP 3 MG ANTINEOPLASTIC AGENTSEVEROLIMUS TAB 5MG EVEROLIMUS TAB 5 MG ANTINEOPLASTIC AGENTSEVEROLIMUS TAB 7.5MG EVEROLIMUS TAB 7.5 MG ANTINEOPLASTIC AGENTSEVRYSDI SOL RISDIPLAM FOR SOLN 0.75 MG/ML OTHER MISCELLANEOUS THERAPEUTIC AGENTSEXEMESTANE TAB 25MG EXEMESTANE TAB 25 MG ANTIESTROGENSEXJADE TAB 125MG DEFERASIROX TAB FOR ORAL SUSP 125 MG HEAVY METAL ANTAGONISTSEXJADE TAB 250MG DEFERASIROX TAB FOR ORAL SUSP 250 MG HEAVY METAL ANTAGONISTSEXJADE TAB 500MG DEFERASIROX TAB FOR ORAL SUSP 500 MG HEAVY METAL ANTAGONISTSEXKIVITY CAP 40MG MOBOCERTINIB SUCCINATE CAP 40 MG ANTINEOPLASTIC AGENTSEYLEA INJ 2/0.05ML AFLIBERCEPT INTRAVITREAL SOLN PREF SYR 2 MG/0.05ML VASCULAR ENDOTHELIAL GROWTH FACTOR ANTAGFARESTON TAB 60MG TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT) ESTROGEN AGONIST-ANTAGONISTSFARYDAK CAP 10MG PANOBINOSTAT LACTATE CAP 10 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSFARYDAK CAP 15MG PANOBINOSTAT LACTATE CAP 15 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSFARYDAK CAP 20MG PANOBINOSTAT LACTATE CAP 20 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSFASENRA INJ 30MG/ML BENRALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 30 MG/ML INTERLEUKIN ANTAGONISTSFASENRA PEN INJ 30MG/ML BENRALIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 30 MG/ML INTERLEUKIN ANTAGONISTSFASLODEX INJ 250/5ML FULVESTRANT INJ 250 MG/5ML ANTINEOPLASTIC AGENTSFEIBA INJ ANTIINHIBITOR COAGULANT COMPLEX FOR IV SOLN 1000 UNIT HEMOSTATICSFENSOLVI INJ 45MG LEUPROLIDE ACET (6 MONTH) FOR INJ PEDIATRIC KIT 45 MG GONADOTROPINSFERRIPROX SOL 100MG/ML DEFERIPRONE ORAL SOLN 100 MG/ML HEAVY METAL ANTAGONISTSFERRIPROX TAB 1000MG DEFERIPRONE TAB 1000 MG HEAVY METAL ANTAGONISTSFIBRYGA INJ 1GM FIBRINOGEN CONC (HUMAN) INJ APPROXIMATELY 1 GM (900-1300 MG) HEMOSTATICSFINTEPLA SOL 2.2MG/ML FENFLURAMINE HCL ORAL SOLN 2.2 MG/ML ANTICONVULSANTS, MISCELLANEOUSFIRMAGON INJ 120MG DEGARELIX ACETATE FOR INJ 120 MG/VIAL (240 MG DOSE) ANTIGONADTROPINSFIRMAGON INJ 80MG DEGARELIX ACETATE FOR INJ 80 MG (BASE EQUIV) ANTIGONADTROPINSFLOXURIDINE INJ 0.5GM FLOXURIDINE FOR INJ 0.5 GM ANTINEOPLASTIC AGENTSFOLLISTIM AQ INJ 300UNIT FOLLITROPIN BETA INJ 300 UNIT/0.36ML GONADOTROPINSFOLLISTIM AQ INJ 600UNIT FOLLITROPIN BETA INJ 600 UNIT/0.72ML GONADOTROPINSFOLLISTIM AQ INJ 900UNIT FOLLITROPIN BETA INJ 900 UNIT/1.08ML GONADOTROPINSFONDAPARINUX INJ 10/0.8ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML ANTICOAGULANTS, MISCELLANEOUS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionFONDAPARINUX INJ 2.5/0.5 FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML ANTICOAGULANTS, MISCELLANEOUSFONDAPARINUX INJ 5/0.4ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML ANTICOAGULANTS, MISCELLANEOUSFONDAPARINUX INJ 7.5/0.6 FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML ANTICOAGULANTS, MISCELLANEOUSFRAGMIN INJ 10000/ML DALTEPARIN SODIUM SOLN PREFILLED SYR 10000 UNIT/ML HEPARINSFRAGMIN INJ 12500UNT DALTEPARIN SODIUM SOLN PREFILLED SYR 12500 UNIT/0.5ML HEPARINSFRAGMIN INJ 15000UNT DALTEPARIN SODIUM SOLN PREFILLED SYR 15000 UNIT/0.6ML HEPARINSFRAGMIN INJ 18000UNT DALTEPARIN SODIUM SOLN PREFILLED SYR 18000 UNIT/0.72ML HEPARINSFRAGMIN INJ 2500/0.2 DALTEPARIN SODIUM SOLN PREFILLED SYR 2500 UNIT/0.2ML HEPARINSFRAGMIN INJ 5000/0.2 DALTEPARIN SODIUM SOLN PREFILLED SYR 5000 UNIT/0.2ML HEPARINSFRAGMIN INJ 7500/0.3 DALTEPARIN SODIUM SOLN PREFILLED SYR 7500 UNIT/0.3ML HEPARINSFRAGMIN INJ 95000UNT DALTEPARIN SODIUM INJ 95000 UNIT/3.8ML HEPARINSFULVESTRANT INJ 250/5ML FULVESTRANT INJ 250 MG/5ML ANTINEOPLASTIC AGENTSFUZEON INJ 90MG ENFUVIRTIDE FOR INJ 90 MG HIV ENTRY AND FUSION INHIBITORSFYREMADEL SOL 250/0.5 GANIRELIX ACETATE SOLN PREFILLED SYRINGE 250 MCG/0.5ML ANTIGONADTROPINSGALAFOLD CAP 123MG MIGALASTAT HCL CAP 123 MG (BASE EQUIVALENT) OTHER MISCELLANEOUS THERAPEUTIC AGENTSGAMASTAN INJ IMMUNE GLOBULIN (HUMAN) IM INJ ANTITOXINS AND IMMUNE GLOBULINSGAMMAGARD INJ 10GM/100 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 10 GM/100ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAGARD INJ 1GM/10ML IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 1 GM/10ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAGARD INJ 2.5GM/25 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 2.5 GM/25ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAGARD INJ 20GM/200 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 20 GM/200ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAGARD INJ 30GM/300 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 30 GM/300ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAGARD INJ 5GM/50ML IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 5 GM/50ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAKED INJ 10GM/100 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 10 GM/100ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAKED INJ 1GM/10ML IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 1 GM/10ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAKED INJ 20GM/200 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 20 GM/200ML ANTITOXINS AND IMMUNE GLOBULINSGAMMAKED INJ 5GM/50ML IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 5 GM/50ML ANTITOXINS AND IMMUNE GLOBULINSGAMUNEX-C INJ 10GM/100 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 10 GM/100ML ANTITOXINS AND IMMUNE GLOBULINSGAMUNEX-C INJ 1GM/10ML IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 1 GM/10ML ANTITOXINS AND IMMUNE GLOBULINSGAMUNEX-C INJ 2.5GM/25 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 2.5 GM/25ML ANTITOXINS AND IMMUNE GLOBULINSGAMUNEX-C INJ 20GM/200 IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 20 GM/200ML ANTITOXINS AND IMMUNE GLOBULINSGAMUNEX-C INJ 40/400ML IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 40 GM/400ML ANTITOXINS AND IMMUNE GLOBULINSGAMUNEX-C INJ 5GM/50ML IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS SOLN 5 GM/50ML ANTITOXINS AND IMMUNE GLOBULINSGANIRELIX AC INJ 250/0.5 GANIRELIX ACETATE SOLN PREFILLED SYRINGE 250 MCG/0.5ML ANTIGONADTROPINSGATTEX KIT 5MG TEDUGLUTIDE (RDNA) FOR INJ KIT 5 MG GI DRUGS, MISCELLANEOUSGAVRETO CAP 100MG PRALSETINIB CAP 100 MG ANTINEOPLASTIC AGENTSGILENYA CAP 0.25MG FINGOLIMOD HCL CAP 0.25 MG (BASE EQUIV) IMMUNOMODULATORY AGENTSGILENYA CAP 0.5MG FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV) IMMUNOMODULATORY AGENTSGILOTRIF TAB 20MG AFATINIB DIMALEATE TAB 20 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSGILOTRIF TAB 30MG AFATINIB DIMALEATE TAB 30 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSGILOTRIF TAB 40MG AFATINIB DIMALEATE TAB 40 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionGLATIRAMER INJ 20MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML IMMUNOMODULATORY AGENTSGLATIRAMER INJ 40MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML IMMUNOMODULATORY AGENTSGLATOPA INJ 20MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML IMMUNOMODULATORY AGENTSGLATOPA INJ 40MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML IMMUNOMODULATORY AGENTSGLEOSTINE CAP 100MG LOMUSTINE CAP 100 MG ANTINEOPLASTIC AGENTSGLEOSTINE CAP 10MG LOMUSTINE CAP 10 MG ANTINEOPLASTIC AGENTSGLEOSTINE CAP 40MG LOMUSTINE CAP 40 MG ANTINEOPLASTIC AGENTSGONAL-F INJ 1050UNIT FOLLITROPIN ALFA FOR INJ 1050 UNIT GONADOTROPINSGONAL-F INJ 450UNIT FOLLITROPIN ALFA FOR INJ 450 UNIT GONADOTROPINSGONAL-F RFF INJ 300/0.5 FOLLITROPIN ALFA SUBCUTANEOUS SOLN PEN-INJ 300 UNIT/0.5ML GONADOTROPINSGONAL-F RFF INJ 450/0.75 FOLLITROPIN ALFA SUBCUTANEOUS SOLN PEN-INJ 450 UNIT/0.75ML GONADOTROPINSGONAL-F RFF INJ 75UNIT FOLLITROPIN ALFA FOR SUBCUTANEOUS INJ 75 UNIT GONADOTROPINSGONAL-F RFF INJ 900/1.5 FOLLITROPIN ALFA SUBCUTANEOUS SOLN PEN-INJ 900 UNIT/1.5ML GONADOTROPINSGRASTEK SUB 2800BAU TIMOTHY GRASS POLLEN ALLERGEN EXT SL TAB 2800 BAU ALLERGENIC EXTRACTS (THERAPEUTIC)HARVONI PAK LEDIPASVIR-SOFOSBUVIR PELLET PACK 33.75-150 MG HCV REPLICATION COMPLEX INHIBITORSHARVONI PAK 45-200MG LEDIPASVIR-SOFOSBUVIR PELLET PACK 45-200 MG HCV REPLICATION COMPLEX INHIBITORSHARVONI TAB 45-200MG LEDIPASVIR-SOFOSBUVIR TAB 45-200 MG HCV REPLICATION COMPLEX INHIBITORSHARVONI TAB 90-400MG LEDIPASVIR-SOFOSBUVIR TAB 90-400 MG HCV REPLICATION COMPLEX INHIBITORSHEMLIBRA INJ 105/0.7 EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 105 MG/0.7ML (150 MG/ML) HEMOSTATICSHEMLIBRA INJ 150/ML EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 150 MG/ML HEMOSTATICSHEMLIBRA INJ 30MG/ML EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 30 MG/ML HEMOSTATICSHEMLIBRA INJ 60/0.4 EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 60 MG/0.4ML (150 MG/ML) HEMOSTATICSHEMOFIL M INJ 1000UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 1000 UNIT HEMOSTATICSHEMOFIL M INJ 1700UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 1700 UNIT HEMOSTATICSHEMOFIL M INJ 250UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 250 UNIT HEMOSTATICSHEMOFIL M INJ 500UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 500 UNIT HEMOSTATICSHEPSERA TAB 10MG ADEFOVIR DIPIVOXIL TAB 10 MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSHERCEP HYLEC SOL 60-10000 TRASTUZUMAB-HYALURONIDASE-OYSK INJ 600-10000 MG-UNIT/5ML ANTINEOPLASTIC AGENTSHIZENTRA INJ 10/50ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 10 GM/50ML ANTITOXINS AND IMMUNE GLOBULINSHIZENTRA INJ 1GM/5ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 1 GM/5ML ANTITOXINS AND IMMUNE GLOBULINSHIZENTRA INJ 2GM/10ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 2 GM/10ML ANTITOXINS AND IMMUNE GLOBULINSHIZENTRA INJ 4GM/20ML IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS INJ 4 GM/20ML ANTITOXINS AND IMMUNE GLOBULINSHIZENTRA SOL 20% IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS SOLN PREF SYR 4 GM/20ML ANTITOXINS AND IMMUNE GLOBULINSHUMATE-P SOL 2400UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 1000-2400 UNIT HEMOSTATICSHUMATE-P SOL 250-600 ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 250-600 UNIT HEMOSTATICSHUMATE-P SOL 500-1200 ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500-1200 UNIT HEMOSTATICSHUMIRA INJ 10/0.1ML ADALIMUMAB PREFILLED SYRINGE KIT 10 MG/0.1ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA INJ 20/0.2ML ADALIMUMAB PREFILLED SYRINGE KIT 20 MG/0.2ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA INJ 40/0.4ML ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA KIT 40MG/0.8 ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionHUMIRA PEDIA INJ CROHNS ADALIMUMAB PREFILLED SYRINGE KIT 80 MG/0.8ML & 40 MG/0.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN INJ 40/0.4ML ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN INJ 40MG/0.8 ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN INJ 80/0.8ML ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN INJ CD/UC/HS ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN INJ PS/UV ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN KIT CD/UC/HS ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN KIT PED UC ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHUMIRA PEN KIT PS/UV ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML & 40 MG/0.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHYCAMTIN CAP 0.25MG TOPOTECAN HCL CAP 0.25 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSHYCAMTIN CAP 1MG TOPOTECAN HCL CAP 1 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSHYDROXY CAPR INJ 1.25/5ML HYDROXYPROGESTERONE CAPROATE IM IN OIL 1.25 GM/5ML PROGESTINSHYDROXYPROG INJ 250MG/ML HYDROXYPROGESTERONE CAPROATE IM IN OIL 250 MG/ML PROGESTINSHYPERRHO S/D INJ 300MCG RHO D IMMUNE GLOBULIN IM SOLN PREF SYR 1500 UNIT (300MCG) ANTITOXINS AND IMMUNE GLOBULINSHYPERRHO S/D INJ 50MCG RHO D IMMUNE GLOBULIN IM SOLN PREF SYR 250 UNIT (50 MCG) ANTITOXINS AND IMMUNE GLOBULINSHYQVIA INJ 10-800 IMMUN GLOB INJ 10 GM/100ML-HYALURON INJ 800 UNT/5 ML KIT ANTITOXINS AND IMMUNE GLOBULINSHYQVIA INJ 2.5-200 IMMUN GLOB INJ 2.5 GM/25ML-HYALURON INJ 200 UNT/1.25 ML KIT ANTITOXINS AND IMMUNE GLOBULINSHYQVIA INJ 20-1600 IMMUN GLOB INJ 20 GM/200ML-HYALURON INJ 1600 UNT/10 ML KIT ANTITOXINS AND IMMUNE GLOBULINSHYQVIA INJ 30-2400 IMMUN GLOB INJ 30 GM/300ML-HYALURON INJ 2400 UNT/15 ML KIT ANTITOXINS AND IMMUNE GLOBULINSHYQVIA INJ 5-400 IMMUN GLOB INJ 5 GM/50ML-HYALURON INJ 400 UNT/2.5 ML KIT ANTITOXINS AND IMMUNE GLOBULINSIBRANCE CAP 100MG PALBOCICLIB CAP 100 MG ANTINEOPLASTIC AGENTSIBRANCE CAP 125MG PALBOCICLIB CAP 125 MG ANTINEOPLASTIC AGENTSIBRANCE CAP 75MG PALBOCICLIB CAP 75 MG ANTINEOPLASTIC AGENTSIBRANCE TAB 100MG PALBOCICLIB TAB 100 MG ANTINEOPLASTIC AGENTSIBRANCE TAB 125MG PALBOCICLIB TAB 125 MG ANTINEOPLASTIC AGENTSIBRANCE TAB 75MG PALBOCICLIB TAB 75 MG ANTINEOPLASTIC AGENTSICATIBANT INJ 30MG/3ML ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT) BRADYKININ RECEPTOR ANTAGONISTSICLUSIG TAB 10MG PONATINIB HCL TAB 10 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSICLUSIG TAB 15MG PONATINIB HCL TAB 15 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSICLUSIG TAB 30MG PONATINIB HCL TAB 30 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSICLUSIG TAB 45MG PONATINIB HCL TAB 45 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSIDELVION SOL 1000UNIT COAGULATION FACTOR IX (RECOMB) (RIX-FP) FOR INJ 1000 UNIT HEMOSTATICSIDELVION SOL 2000UNIT COAGULATION FACTOR IX (RECOMB) (RIX-FP) FOR INJ 2000 UNIT HEMOSTATICSIDELVION SOL 250UNIT COAGULATION FACTOR IX (RECOMB) (RIX-FP) FOR INJ 250 UNIT HEMOSTATICSIDELVION SOL 3500UNIT COAGULATION FACTOR IX (RECOMB) (RIX-FP) FOR INJ 3500 UNIT HEMOSTATICSIDELVION SOL 500UNIT COAGULATION FACTOR IX (RECOMB) (RIX-FP) FOR INJ 500 UNIT HEMOSTATICSIDHIFA TAB 100MG ENASIDENIB MESYLATE TAB 100 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSIDHIFA TAB 50MG ENASIDENIB MESYLATE TAB 50 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSILARIS INJ 150MG/ML CANAKINUMAB SUBCUTANEOUS INJ 150 MG/ML ANALGESICS AND ANTIPYRETICS, MISC.ILUMYA SOL 100MG/ML TILDRAKIZUMAB-ASMN SUBCUTANEOUS SOLN PREF SYRINGE 100 MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionIMATINIB MES TAB 100MG IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSIMATINIB MES TAB 400MG IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSIMBRUVICA CAP 140MG IBRUTINIB CAP 140 MG ANTINEOPLASTIC AGENTSIMBRUVICA CAP 70MG IBRUTINIB CAP 70 MG ANTINEOPLASTIC AGENTSIMBRUVICA TAB 140MG IBRUTINIB TAB 140 MG ANTINEOPLASTIC AGENTSIMBRUVICA TAB 280MG IBRUTINIB TAB 280 MG ANTINEOPLASTIC AGENTSIMBRUVICA TAB 420MG IBRUTINIB TAB 420 MG ANTINEOPLASTIC AGENTSIMBRUVICA TAB 560MG IBRUTINIB TAB 560 MG ANTINEOPLASTIC AGENTSINBRIJA CAP 42MG LEVODOPA INHAL POWDER CAP 42 MG DOPAMINE PRECURSORSINCRELEX INJ 40MG/4ML MECASERMIN INJ 40 MG/4ML (10 MG/ML) SOMATOTROPIN AGONISTSINGREZZA CAP 40-80MG VALBENAZINE TOSYLATE CAP THERAPY PACK 40 MG (7) & 80 MG (21) VESICULAR MONOAMINE TRANSPORT2 INHIBITORINGREZZA CAP 40MG VALBENAZINE TOSYLATE CAP 40 MG (BASE EQUIV) VESICULAR MONOAMINE TRANSPORT2 INHIBITORINGREZZA CAP 60MG VALBENAZINE TOSYLATE CAP 60 MG (BASE EQUIV) VESICULAR MONOAMINE TRANSPORT2 INHIBITORINGREZZA CAP 80MG VALBENAZINE TOSYLATE CAP 80 MG (BASE EQUIV) VESICULAR MONOAMINE TRANSPORT2 INHIBITORINLYTA TAB 1MG AXITINIB TAB 1 MG ANTINEOPLASTIC AGENTSINLYTA TAB 5MG AXITINIB TAB 5 MG ANTINEOPLASTIC AGENTSINREBIC CAP 100MG FEDRATINIB HCL CAP 100 MG ANTINEOPLASTIC AGENTSINTRON A INJ 10MU INTERFERON ALFA-2B FOR INJ 10000000 UNIT ANTINEOPLASTIC AGENTSINTRON A INJ 18MU INTERFERON ALFA-2B INJ 6000000 UNIT/ML ANTINEOPLASTIC AGENTSINTRON A INJ 25MU INTERFERON ALFA-2B INJ 10000000 UNIT/ML ANTINEOPLASTIC AGENTSINTRON A INJ 50MU INTERFERON ALFA-2B FOR INJ 50000000 UNIT ANTINEOPLASTIC AGENTSIRESSA TAB 250MG GEFITINIB TAB 250 MG ANTINEOPLASTIC AGENTSIXINITY INJ 1000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 1000 UNIT HEMOSTATICSIXINITY INJ 1500UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 1500 UNIT HEMOSTATICSIXINITY INJ 2000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 2000 UNIT HEMOSTATICSIXINITY INJ 250UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 250 UNIT HEMOSTATICSIXINITY INJ 3000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 3000 UNIT HEMOSTATICSIXINITY INJ 500UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 500 UNIT HEMOSTATICSJADENU SPRKL GRA 180MG DEFERASIROX GRANULES PACKET 180 MG HEAVY METAL ANTAGONISTSJADENU SPRKL GRA 360MG DEFERASIROX GRANULES PACKET 360 MG HEAVY METAL ANTAGONISTSJADENU SPRKL GRA 90MG DEFERASIROX GRANULES PACKET 90 MG HEAVY METAL ANTAGONISTSJAKAFI TAB 10MG RUXOLITINIB PHOSPHATE TAB 10 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSJAKAFI TAB 15MG RUXOLITINIB PHOSPHATE TAB 15 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSJAKAFI TAB 20MG RUXOLITINIB PHOSPHATE TAB 20 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSJAKAFI TAB 25MG RUXOLITINIB PHOSPHATE TAB 25 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSJAKAFI TAB 5MG RUXOLITINIB PHOSPHATE TAB 5 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSJIVI INJ 1000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII PEG-AUCL)FOR INJ 1000 UNIT HEMOSTATICSJIVI INJ 2000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII PEG-AUCL)FOR INJ 2000 UNIT HEMOSTATICSJIVI INJ 3000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII PEG-AUCL)FOR INJ 3000 UNIT HEMOSTATICSJIVI INJ 500 UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII PEG-AUCL) FOR INJ 500 UNIT HEMOSTATICS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionJUXTAPID CAP 10MG LOMITAPIDE MESYLATE CAP 10 MG (BASE EQUIV) ANTILIPEMIC AGENTS, MISCELLANEOUSJUXTAPID CAP 20MG LOMITAPIDE MESYLATE CAP 20 MG (BASE EQUIV) ANTILIPEMIC AGENTS, MISCELLANEOUSJUXTAPID CAP 30MG LOMITAPIDE MESYLATE CAP 30 MG (BASE EQUIV) ANTILIPEMIC AGENTS, MISCELLANEOUSJUXTAPID CAP 40MG LOMITAPIDE MESYLATE CAP 40 MG (BASE EQUIV) ANTILIPEMIC AGENTS, MISCELLANEOUSJUXTAPID CAP 5MG LOMITAPIDE MESYLATE CAP 5 MG (BASE EQUIV) ANTILIPEMIC AGENTS, MISCELLANEOUSJUXTAPID CAP 60MG LOMITAPIDE MESYLATE CAP 60 MG (BASE EQUIV) ANTILIPEMIC AGENTS, MISCELLANEOUSKALBITOR INJ 10MG/ML ECALLANTIDE INJ 10 MG/ML KALLIKREIN INHIBITORSKALYDECO PAK 25MG IVACAFTOR PACKET 25 MG CYSTIC FIBROSIS (CFTR) POTENTIATORSKALYDECO PAK 50MG IVACAFTOR PACKET 50 MG CYSTIC FIBROSIS (CFTR) POTENTIATORSKALYDECO PAK 75MG IVACAFTOR PACKET 75 MG CYSTIC FIBROSIS (CFTR) POTENTIATORSKALYDECO TAB 150MG IVACAFTOR TAB 150 MG CYSTIC FIBROSIS (CFTR) POTENTIATORSKESIMPTA INJ 20/.4ML OFATUMUMAB SOLN AUTO-INJECTOR 20 MG/0.4ML IMMUNOMODULATORY AGENTSKEVEYIS TAB 50MG DICHLORPHENAMIDE TAB 50 MG CARBONIC ANHYDRASE INHIBITORS (MISC.)KEVZARA INJ 150/1.14 SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSKEVZARA INJ 200/1.14 SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSKINERET INJ ANAKINRA SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/0.67ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSKISQALI TAB 200DOSE RIBOCICLIB SUCCINATE TAB PACK 200 MG DAILY DOSE ANTINEOPLASTIC AGENTSKISQALI TAB 400DOSE RIBOCICLIB SUCCINATE TAB PACK 400 MG DAILY DOSE (200 MG TAB) ANTINEOPLASTIC AGENTSKISQALI TAB 600DOSE RIBOCICLIB SUCCINATE TAB PACK 600 MG DAILY DOSE (200 MG TAB) ANTINEOPLASTIC AGENTSKISQALI 200 PAK FEMARA RIBOCICLIB 200 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK ANTIESTROGENSKISQALI 400 PAK FEMARA RIBOCICLIB 400 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK ANTIESTROGENSKISQALI 600 PAK FEMARA RIBOCICLIB 600 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK ANTIESTROGENSKOATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 1000 UNIT HEMOSTATICSKOATE INJ 250UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 250 UNIT HEMOSTATICSKOATE INJ 500 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 500 UNIT HEMOSTATICSKOATE-DVI INJ 1000UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 1000 UNIT HEMOSTATICSKOATE-DVI INJ 500UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ 500 UNIT HEMOSTATICSKOGENATE FS INJ 1000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ KIT 1000 UNIT HEMOSTATICSKOGENATE FS INJ 2000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ KIT 2000 UNIT HEMOSTATICSKOGENATE FS INJ 250UNIT ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ KIT 250 UNIT HEMOSTATICSKOGENATE FS INJ 3000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ KIT 3000 UNIT HEMOSTATICSKOGENATE FS INJ 500UNIT ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ KIT 500 UNIT HEMOSTATICSKORLYM TAB 300MG MIFEPRISTONE TAB 300 MG ANTIDIABETIC AGENTS, MISCELLANEOUSKOSELUGO CAP 10MG SELUMETINIB SULFATE CAP 10 MG ANTINEOPLASTIC AGENTSKOSELUGO CAP 25MG SELUMETINIB SULFATE CAP 25 MG ANTINEOPLASTIC AGENTSKOVALTRY INJ 1000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 1000 UNIT HEMOSTATICSKOVALTRY INJ 2000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 2000 UNIT HEMOSTATICSKOVALTRY INJ 250UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 250 UNIT HEMOSTATICSKOVALTRY INJ 3000UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 3000 UNIT HEMOSTATICSKOVALTRY INJ 500UNIT ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) FOR INJ 500 UNIT HEMOSTATICS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionKYNMOBI KIT TITRATIO APOMORPHINE HCL FILM 10/15/20/25/30 MG TITRATION KIT NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTKYNMOBI MIS 10MG APOMORPHINE HYDROCHLORIDE FILM 10 MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTKYNMOBI MIS 15MG APOMORPHINE HYDROCHLORIDE FILM 15 MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTKYNMOBI MIS 20MG APOMORPHINE HYDROCHLORIDE FILM 20 MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTKYNMOBI MIS 25MG APOMORPHINE HYDROCHLORIDE FILM 25 MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTKYNMOBI MIS 30MG APOMORPHINE HYDROCHLORIDE FILM 30 MG NONERGOT-DERIV.DOPAMINE RECEPTOR AGONISTLAMIVUDINE TAB 100MG LAMIVUDINE TAB 100 MG (HBV) HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORSLAPATINIB TAB 250MG LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSLENALIDOMIDE CAP 10MG LENALIDOMIDE CAP 10 MG ANTINEOPLASTIC AGENTSLENALIDOMIDE CAP 15MG LENALIDOMIDE CAP 15 MG ANTINEOPLASTIC AGENTSLENALIDOMIDE CAP 25MG LENALIDOMIDE CAP 25 MG ANTINEOPLASTIC AGENTSLENALIDOMIDE CAP 5MG LENALIDOMIDE CAP 5 MG ANTINEOPLASTIC AGENTSLENVIMA CAP 10 MG LENVATINIB CAP THERAPY PACK 10 MG (10 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLENVIMA CAP 12MG LENVATINIB CAP THERAPY PACK 3 X 4 MG (12 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLENVIMA CAP 14 MG LENVATINIB CAP THERAPY PACK 10 & 4 MG (14 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLENVIMA CAP 18 MG LENVATINIB CAP THER PACK 10 MG & 2 X 4 MG (18 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLENVIMA CAP 20 MG LENVATINIB CAP THERAPY PACK 2 X 10 MG (20 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLENVIMA CAP 24 MG LENVATINIB CAP THER PACK 2 X 10 MG & 4 MG (24 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLENVIMA CAP 4MG LENVATINIB CAP THERAPY PACK 4 MG (4 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLENVIMA CAP 8 MG LENVATINIB CAP THERAPY PACK 2 X 4 MG (8 MG DAILY DOSE) ANTINEOPLASTIC AGENTSLEUKERAN TAB 2MG CHLORAMBUCIL TAB 2 MG ANTINEOPLASTIC AGENTSLEUKINE INJ 250MCG SARGRAMOSTIM LYOPHILIZED FOR INJ 250 MCG HEMATOPOIETIC AGENTSLEUPROLIDE INJ 1MG/0.2 LEUPROLIDE ACETATE INJ KIT 5 MG/ML GONADOTROPINSLEUPROLIDE KIT 1MG/0.2 LEUPROLIDE ACETATE INJ KIT 5 MG/ML GONADOTROPINSLIVTENCITY TAB 200MG MARIBAVIR TAB 200 MG ANTIVIRALS, MISCELLANEOUSLONSURF TAB 15-6.14 TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG ANTINEOPLASTIC AGENTSLONSURF TAB 20-8.19 TRIFLURIDINE-TIPIRACIL TAB 20-8.19 MG ANTINEOPLASTIC AGENTSLORBRENA TAB 100MG LORLATINIB TAB 100 MG ANTINEOPLASTIC AGENTSLORBRENA TAB 25MG LORLATINIB TAB 25 MG ANTINEOPLASTIC AGENTSLOVENOX INJ 100MG/ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 100 MG/ML HEPARINSLOVENOX INJ 120/0.8 ENOXAPARIN SODIUM INJ SOLN PREF SYR 120 MG/0.8ML HEPARINSLOVENOX INJ 150MG/ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 150 MG/ML HEPARINSLOVENOX INJ 30/0.3ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 30 MG/0.3ML HEPARINSLOVENOX INJ 300/3ML ENOXAPARIN SODIUM INJ 300 MG/3ML HEPARINSLOVENOX INJ 40/0.4ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 40 MG/0.4ML HEPARINSLOVENOX INJ 60/0.6ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 60 MG/0.6ML HEPARINSLOVENOX INJ 80/0.8ML ENOXAPARIN SODIUM INJ SOLN PREF SYR 80 MG/0.8ML HEPARINSLUCENTIS INJ 0.3MG RANIBIZUMAB INTRAVITREAL SOLN PREF SYR 0.3 MG/0.05ML VASCULAR ENDOTHELIAL GROWTH FACTOR ANTAGLUCENTIS INJ 0.5MG RANIBIZUMAB INTRAVITREAL SOLN PREF SYR 0.5 MG/0.05ML VASCULAR ENDOTHELIAL GROWTH FACTOR ANTAGLUCENTIS SOL 0.3MG RANIBIZUMAB INTRAVITREAL INJ 0.3 MG/0.05ML (6 MG/ML) VASCULAR ENDOTHELIAL GROWTH FACTOR ANTAG

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionLUCENTIS SOL 0.5MG RANIBIZUMAB INTRAVITREAL INJ 0.5 MG/0.05ML (10 MG/ML) VASCULAR ENDOTHELIAL GROWTH FACTOR ANTAGLUMAKRAS TAB 120MG SOTORASIB TAB 120 MG ANTINEOPLASTIC AGENTSLUPANETA KIT 11.25-5 LEUPROLIDE (3 MON) INJ 11.25 MG & NORETHINDRONE TAB 5 MG KIT GONADOTROPINSLUPANETA KIT 3.75-5 LEUPROLIDE (1 MON) INJ 3.75 MG & NORETHINDRONE TAB 5 MG KIT GONADOTROPINSLUPR DEP-PED INJ 11.25MG LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 11.25 MG GONADOTROPINSLUPR DEP-PED INJ 15MG LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 15 MG GONADOTROPINSLUPR DEP-PED INJ 3M 30MG LEUPROLIDE ACETATE (3 MONTH) FOR INJ PEDIATRIC KIT 30 MG GONADOTROPINSLUPR DEP-PED INJ 7.5MG LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 7.5 MG GONADOTROPINSLUPRON DEPOT INJ 11.25MG LEUPROLIDE ACETATE (3 MONTH) FOR INJ KIT 11.25 MG GONADOTROPINSLUPRON DEPOT INJ 22.5MG LEUPROLIDE ACETATE (3 MONTH) FOR INJ KIT 22.5 MG GONADOTROPINSLUPRON DEPOT INJ 3.75MG LEUPROLIDE ACETATE FOR INJ KIT 3.75 MG GONADOTROPINSLUPRON DEPOT INJ 30MG LEUPROLIDE ACETATE (4 MONTH) FOR INJ KIT 30 MG GONADOTROPINSLUPRON DEPOT INJ 45MG LEUPROLIDE ACETATE (6 MONTH) FOR INJ KIT 45 MG GONADOTROPINSLUPRON DEPOT INJ 7.5MG LEUPROLIDE ACETATE FOR INJ KIT 7.5 MG GONADOTROPINSLYNPARZA TAB 100MG OLAPARIB TAB 100 MG ANTINEOPLASTIC AGENTSLYNPARZA TAB 150MG OLAPARIB TAB 150 MG ANTINEOPLASTIC AGENTSLYSODREN TAB 500MG MITOTANE TAB 500 MG ANTINEOPLASTIC AGENTSMAKENA INJ 250MG/ML HYDROXYPROGESTERONE CAPROATE IM IN OIL 250 MG/ML PROGESTINSMAKENA INJ 275MG HYDROXYPROGESTERONE CAPROATE SOLN AUTO-INJECTOR 275 MG/1.1ML PROGESTINSMATULANE CAP 50MG PROCARBAZINE HCL CAP 50 MG ANTINEOPLASTIC AGENTSMAVENCLAD PAK 10MG(10) CLADRIBINE TAB THERAPY PACK 10 MG (10 TABS) IMMUNOSUPPRESSIVE AGENTSMAVENCLAD PAK 10MG(4) CLADRIBINE TAB THERAPY PACK 10 MG (4 TABS) IMMUNOSUPPRESSIVE AGENTSMAVENCLAD PAK 10MG(5) CLADRIBINE TAB THERAPY PACK 10 MG (5 TABS) IMMUNOSUPPRESSIVE AGENTSMAVENCLAD PAK 10MG(6) CLADRIBINE TAB THERAPY PACK 10 MG (6 TABS) IMMUNOSUPPRESSIVE AGENTSMAVENCLAD PAK 10MG(7) CLADRIBINE TAB THERAPY PACK 10 MG (7 TABS) IMMUNOSUPPRESSIVE AGENTSMAVENCLAD PAK 10MG(8) CLADRIBINE TAB THERAPY PACK 10 MG (8 TABS) IMMUNOSUPPRESSIVE AGENTSMAVENCLAD PAK 10MG(9) CLADRIBINE TAB THERAPY PACK 10 MG (9 TABS) IMMUNOSUPPRESSIVE AGENTSMAVYRET PAK 50-20MG GLECAPREVIR-PIBRENTASVIR PELLET PACK 50-20 MG HCV PROTEASE INHIBITOR ANTIVIRALSMAVYRET TAB 100-40MG GLECAPREVIR-PIBRENTASVIR TAB 100-40 MG HCV PROTEASE INHIBITOR ANTIVIRALSMAYZENT PAK STARTER SIPONIMOD FUMARATE TAB 0.25 MG (12) STARTER PACK IMMUNOMODULATORY AGENTSMAYZENT TAB 0.25MG SIPONIMOD FUMARATE TAB 0.25 MG (BASE EQUIV) IMMUNOMODULATORY AGENTSMAYZENT TAB 1MG SIPONIMOD FUMARATE TAB 1 MG (BASE EQUIV) IMMUNOMODULATORY AGENTSMAYZENT TAB 2MG SIPONIMOD FUMARATE TAB 2 MG (BASE EQUIV) IMMUNOMODULATORY AGENTSMEKINIST TAB 0.5MG TRAMETINIB DIMETHYL SULFOXIDE TAB 0.5 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSMEKINIST TAB 2MG TRAMETINIB DIMETHYL SULFOXIDE TAB 2 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSMEKTOVI TAB 15MG BINIMETINIB TAB 15 MG ANTINEOPLASTIC AGENTSMELPHALAN TAB 2MG MELPHALAN TAB 2 MG ANTINEOPLASTIC AGENTSMENOPUR INJ 75UNIT MENOTROPINS FOR SUBCUTANEOUS INJ 75 UNIT GONADOTROPINSMESNEX TAB 400MG MESNA TAB 400 MG PROTECTIVE AGENTSMICRHOGAM PL INJ 50MCG RHO D IMMUNE GLOBULIN IM SOLN PREF SYR 250 UNIT (50 MCG) ANTITOXINS AND IMMUNE GLOBULINS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionMIGLUSTAT CAP 100MG MIGLUSTAT CAP 100 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSMIRCERA INJ 100MCG METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 100 MCG/0.3ML HEMATOPOIETIC AGENTSMIRCERA INJ 150MCG METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 150 MCG/0.3ML HEMATOPOIETIC AGENTSMIRCERA INJ 200MCG METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 200 MCG/0.3ML HEMATOPOIETIC AGENTSMIRCERA INJ 30MCG METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 30 MCG/0.3ML HEMATOPOIETIC AGENTSMIRCERA INJ 50MCG METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 50 MCG/0.3ML HEMATOPOIETIC AGENTSMIRCERA INJ 75MCG METHOXY PEG-EPOETIN BETA SOLN PREFILLED SYR 75 MCG/0.3ML HEMATOPOIETIC AGENTSMONONINE INJ 1000UNIT COAGULATION FACTOR IX FOR INJ 1000 UNIT HEMOSTATICSMOZOBIL INJ PLERIXAFOR SUBCUTANEOUS INJ 24 MG/1.2ML (20 MG/ML) HEMATOPOIETIC AGENTSMULPLETA TAB 3MG LUSUTROMBOPAG TAB 3 MG HEMATOPOIETIC AGENTSMYALEPT INJ 11.3MG METRELEPTIN FOR SUBCUTANEOUS INJ 11.3 MG LEPTINSMYCOPHENOLAT CAP 250MG MYCOPHENOLATE MOFETIL CAP 250 MG IMMUNOSUPPRESSIVE AGENTSMYCOPHENOLAT SUS 200MG/ML MYCOPHENOLATE MOFETIL FOR ORAL SUSP 200 MG/ML IMMUNOSUPPRESSIVE AGENTSMYCOPHENOLAT TAB 500MG MYCOPHENOLATE MOFETIL TAB 500 MG IMMUNOSUPPRESSIVE AGENTSMYCOPHENOLIC TAB 180MG DR MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV) IMMUNOSUPPRESSIVE AGENTSMYCOPHENOLIC TAB 360MG DR MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV) IMMUNOSUPPRESSIVE AGENTSMYFORTIC TAB 180MG MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV) IMMUNOSUPPRESSIVE AGENTSMYFORTIC TAB 360MG MYCOPHENOLATE SODIUM TAB DR 360 MG (MYCOPHENOLIC ACID EQUIV) IMMUNOSUPPRESSIVE AGENTSMYLERAN TAB 2MG BUSULFAN TAB 2 MG ANTINEOPLASTIC AGENTSMYOBLOC INJ 10000/2 RIMABOTULINUMTOXINB IM INJ 10000 UNIT/2ML OTHER MISCELLANEOUS THERAPEUTIC AGENTSMYOBLOC INJ 2500/0.5 RIMABOTULINUMTOXINB IM INJ 2500 UNIT/0.5ML OTHER MISCELLANEOUS THERAPEUTIC AGENTSMYOBLOC INJ 5000/ML RIMABOTULINUMTOXINB IM INJ 5000 UNIT/ML OTHER MISCELLANEOUS THERAPEUTIC AGENTSNATPARA INJ 100MCG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 100 MCG PARATHYROID AGENTSNATPARA INJ 25MCG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 25 MCG PARATHYROID AGENTSNATPARA INJ 50MCG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 50 MCG PARATHYROID AGENTSNATPARA INJ 75MCG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 75 MCG PARATHYROID AGENTSNERLYNX TAB 40MG NERATINIB MALEATE TAB 40 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSNEULASTA INJ 6MG/0.6M PEGFILGRASTIM SOLN PREFILLED SYRINGE 6 MG/0.6ML HEMATOPOIETIC AGENTSNEULASTA KIT 6MG/0.6M PEGFILGRASTIM SOLN PREFILLED SYRINGE KIT 6 MG/0.6ML HEMATOPOIETIC AGENTSNEXAVAR TAB 200MG SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSNILANDRON TAB 150MG NILUTAMIDE TAB 150 MG ANTINEOPLASTIC AGENTSNILUTAMIDE TAB 150MG NILUTAMIDE TAB 150 MG ANTINEOPLASTIC AGENTSNINLARO CAP 2.3MG IXAZOMIB CITRATE CAP 2.3 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSNINLARO CAP 3MG IXAZOMIB CITRATE CAP 3 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSNINLARO CAP 4MG IXAZOMIB CITRATE CAP 4 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSNITISINONE CAP 10MG NITISINONE CAP 10 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSNITISINONE CAP 2MG NITISINONE CAP 2 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSNITISINONE CAP 5MG NITISINONE CAP 5 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSNITYR TAB 10MG NITISINONE TAB 10 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSNITYR TAB 2MG NITISINONE TAB 2 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionNITYR TAB 5MG NITISINONE TAB 5 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSNIVESTYM INJ 300/0.5 FILGRASTIM-AAFI SOLN PREFILLED SYRINGE 300 MCG/0.5ML HEMATOPOIETIC AGENTSNIVESTYM INJ 300MCG FILGRASTIM-AAFI INJ 300 MCG/ML HEMATOPOIETIC AGENTSNIVESTYM INJ 480/0.8 FILGRASTIM-AAFI SOLN PREFILLED SYRINGE 480 MCG/0.8ML HEMATOPOIETIC AGENTSNIVESTYM INJ 480MCG FILGRASTIM-AAFI INJ 480 MCG/1.6ML (300 MCG/ML) HEMATOPOIETIC AGENTSNORDITROPIN INJ 10/1.5ML SOMATROPIN SOLUTION PEN-INJECTOR 10 MG/1.5ML SOMATOTROPIN AGONISTSNORDITROPIN INJ 15/1.5ML SOMATROPIN SOLUTION PEN-INJECTOR 15 MG/1.5ML SOMATOTROPIN AGONISTSNORDITROPIN INJ 30/3ML SOMATROPIN SOLUTION PEN-INJECTOR 30 MG/3ML SOMATOTROPIN AGONISTSNORDITROPIN INJ 5/1.5ML SOMATROPIN SOLUTION PEN-INJECTOR 5 MG/1.5ML SOMATOTROPIN AGONISTSNOVAREL INJ 10000UNT CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT GONADOTROPINSNOVAREL INJ 5000UNIT CHORIONIC GONADOTROPIN FOR IM INJ 5000 UNIT GONADOTROPINSNOVOEIGHT INJ 1000UNIT ANTIHEMOPHILIC FACT RCMB (BD TRUNC-RFVIII) FOR INJ 1000 UNIT HEMOSTATICSNOVOEIGHT INJ 1500UNIT ANTIHEMOPHILIC FACT RCMB (BD TRUNC-RFVIII) FOR INJ 1500 UNIT HEMOSTATICSNOVOEIGHT INJ 2000UNIT ANTIHEMOPHILIC FACT RCMB (BD TRUNC-RFVIII) FOR INJ 2000 UNIT HEMOSTATICSNOVOEIGHT INJ 250UNIT ANTIHEMOPHILIC FACT RCMB (BD TRUNC-RFVIII) FOR INJ 250 UNIT HEMOSTATICSNOVOEIGHT INJ 3000UNIT ANTIHEMOPHILIC FACT RCMB (BD TRUNC-RFVIII) FOR INJ 3000 UNIT HEMOSTATICSNOVOEIGHT INJ 500UNIT ANTIHEMOPHILIC FACT RCMB (BD TRUNC-RFVIII) FOR INJ 500 UNIT HEMOSTATICSNOVOSEVEN RT INJ 1MG COAGULATION FACTOR VIIA (RECOMB) FOR INJ 1 MG (1000 MCG) HEMOSTATICSNOVOSEVEN RT INJ 2MG COAGULATION FACTOR VIIA (RECOMB) FOR INJ 2 MG (2000 MCG) HEMOSTATICSNOVOSEVEN RT INJ 5MG COAGULATION FACTOR VIIA (RECOMB) FOR INJ 5 MG (5000 MCG) HEMOSTATICSNOVOSEVEN RT INJ 8MG COAGULATION FACTOR VIIA (RECOMB) FOR INJ 8 MG (8000 MCG) HEMOSTATICSNOXAFIL SUS 40MG/ML POSACONAZOLE SUSP 40 MG/ML AZOLE ANTIFUNGALSNOXAFIL TAB 100MG POSACONAZOLE TAB DELAYED RELEASE 100 MG AZOLE ANTIFUNGALSNPLATE INJ 125MCG ROMIPLOSTIM FOR INJ 125 MCG HEMATOPOIETIC AGENTSNPLATE INJ 250MCG ROMIPLOSTIM FOR INJ 250 MCG HEMATOPOIETIC AGENTSNPLATE INJ 500MCG ROMIPLOSTIM FOR INJ 500 MCG HEMATOPOIETIC AGENTSNUBEQA TAB 300MG DAROLUTAMIDE TAB 300 MG ANTINEOPLASTIC AGENTSNUCALA INJ 100MG MEPOLIZUMAB FOR INJ 100 MG ANTI-INFLAMMATORY AGENTS (RESPIRATORY)NUCALA INJ 100MG/ML MEPOLIZUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML ANTI-INFLAMMATORY AGENTS (RESPIRATORY)NUCALA INJ 40MG/0.4 MEPOLIZUMAB SUBCUTANEOUS SOLUTION PREF SYRINGE 40 MG/0.4ML ANTI-INFLAMMATORY AGENTS (RESPIRATORY)NUTROPIN AQ INJ 10MG/2ML SOMATROPIN SOLUTION PEN-INJECTOR 10 MG/2ML SOMATOTROPIN AGONISTSNUTROPIN AQ INJ 20MG/2ML SOMATROPIN SOLUTION PEN-INJECTOR 20 MG/2ML SOMATOTROPIN AGONISTSNUTROPIN AQ INJ NUSPIN 5 SOMATROPIN SOLUTION PEN-INJECTOR 5 MG/2ML SOMATOTROPIN AGONISTSNUWIQ INJ 1000UNIT ANTIHEMOPHILIC FACT RCMB (BDD-RFVIII,SIM) FOR INJ 1000 UNIT HEMOSTATICSNUWIQ INJ 1500UNIT ANTIHEMOPHILIC FACT RCMB (BDD-RFVIII,SIM) FOR INJ 1500 UNIT HEMOSTATICSNUWIQ INJ 2000UNIT ANTIHEMOPHILIC FACT RCMB (BDD-RFVIII,SIM) FOR INJ 2000 UNIT HEMOSTATICSNUWIQ INJ 2500UNIT ANTIHEMOPHILIC FACT RCMB (BDD-RFVIII,SIM) FOR INJ 2500 UNIT HEMOSTATICSNUWIQ INJ 250UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIII,SIM) FOR INJ 250 UNIT HEMOSTATICSNUWIQ INJ 3000UNIT ANTIHEMOPHILIC FACT RCMB (BDD-RFVIII,SIM) FOR INJ 3000 UNIT HEMOSTATICSNUWIQ INJ 4000UNIT ANTIHEMOPHILIC FACT RCMB (BDD-RFVIII,SIM) FOR INJ 4000 UNIT HEMOSTATICS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionNUWIQ INJ 500UNIT ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIII,SIM) FOR INJ 500 UNIT HEMOSTATICSNUWIQ KIT 1000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,SIM) FOR INJ KIT 1000 UNIT HEMOSTATICSNUWIQ KIT 1500UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,SIM) FOR INJ KIT 1500 UNIT HEMOSTATICSNUWIQ KIT 2000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,SIM) FOR INJ KIT 2000 UNIT HEMOSTATICSNUWIQ KIT 2500UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,SIM) FOR INJ KIT 2500 UNIT HEMOSTATICSNUWIQ KIT 250UNIT ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,SIM) FOR INJ KIT 250 UNIT HEMOSTATICSNUWIQ KIT 3000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,SIM) FOR INJ KIT 3000 UNIT HEMOSTATICSNUWIQ KIT 4000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,SIM) FOR INJ KIT 4000 UNIT HEMOSTATICSNUWIQ KIT 500UNIT ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,SIM) FOR INJ KIT 500 UNIT HEMOSTATICSOBIZUR INJ 500 UNIT ANTIHEMOPHILIC FACTOR (RECOMB PORC) RPFVIII FOR INJ 500 UNIT HEMOSTATICSOCALIVA TAB 10MG OBETICHOLIC ACID TAB 10 MG GI DRUGS, MISCELLANEOUSOCALIVA TAB 5MG OBETICHOLIC ACID TAB 5 MG GI DRUGS, MISCELLANEOUSOCTREOTIDE INJ 1000/5ML OCTREOTIDE ACETATE INJ 200 MCG/ML (0.2 MG/ML) SOMATOSTATIN AGONISTSOCTREOTIDE INJ 1000MCG OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML) SOMATOSTATIN AGONISTSOCTREOTIDE INJ 100MCG OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML) SOMATOSTATIN AGONISTSOCTREOTIDE INJ 200MCG OCTREOTIDE ACETATE INJ 200 MCG/ML (0.2 MG/ML) SOMATOSTATIN AGONISTSOCTREOTIDE INJ 5000/5ML OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML) SOMATOSTATIN AGONISTSOCTREOTIDE INJ 500MCG OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML) SOMATOSTATIN AGONISTSOCTREOTIDE INJ 50MCG/ML OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML) SOMATOSTATIN AGONISTSODOMZO CAP 200MG SONIDEGIB PHOSPHATE CAP 200 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSOFEV CAP 100MG NINTEDANIB ESYLATE CAP 100 MG (BASE EQUIVALENT) ANTIFIBROTIC AGENTSOFEV CAP 150MG NINTEDANIB ESYLATE CAP 150 MG (BASE EQUIVALENT) ANTIFIBROTIC AGENTSONCASPAR INJ 750/ML PEGASPARGASE INJ 750 UNIT/ML ANTINEOPLASTIC AGENTSONUREG TAB 200MG AZACITIDINE TAB 200 MG ANTINEOPLASTIC AGENTSONUREG TAB 300MG AZACITIDINE TAB 300 MG ANTINEOPLASTIC AGENTSOPSUMIT TAB 10MG MACITENTAN TAB 10 MG VASODILATING AGENTS (RESPIRATORY TRACT)ORALAIR SUB 300 IR *GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)* ALLERGENIC EXTRACTS (THERAPEUTIC)ORALAIR ADLT SUB 300 IR *GRASS MIXED POLLEN EXT SL TAB 300 IR (INDEX OF REACTIVITY)* ALLERGENIC EXTRACTS (THERAPEUTIC)ORALAIR CHLD PAK SAMPLE *GRASS MIXED POLLEN SL TAB THERPAK 3 X 100 IR & 6 X 300 IR* ALLERGENIC EXTRACTS (THERAPEUTIC)ORALAIR CHLD SUB 100 IR *GRASS MIXED POLLEN EXT SL TAB 100 IR (INDEX OF REACTIVITY)* ALLERGENIC EXTRACTS (THERAPEUTIC)ORENCIA INJ 125MG/ML ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 125 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSORENCIA INJ 50/0.4ML ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/0.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSORENCIA INJ 87.5/0.7 ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 87.5 MG/0.7ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSORENCIA CLCK INJ 125MG/ML ABATACEPT SUBCUTANEOUS SOLN AUTO-INJECTOR 125 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSORENITRAM TAB 0.125MG TREPROSTINIL DIOLAMINE TAB ER 0.125 MG (BASE EQUIV) VASODILATING AGENTS (RESPIRATORY TRACT)ORENITRAM TAB 0.25MG TREPROSTINIL DIOLAMINE TAB ER 0.25 MG (BASE EQUIV) VASODILATING AGENTS (RESPIRATORY TRACT)ORENITRAM TAB 1MG TREPROSTINIL DIOLAMINE TAB ER 1 MG (BASE EQUIV) VASODILATING AGENTS (RESPIRATORY TRACT)ORENITRAM TAB 2.5MG TREPROSTINIL DIOLAMINE TAB ER 2.5 MG (BASE EQUIV) VASODILATING AGENTS (RESPIRATORY TRACT)ORENITRAM TAB 5MG TREPROSTINIL DIOLAMINE TAB ER 5 MG (BASE EQUIV) VASODILATING AGENTS (RESPIRATORY TRACT)ORFADIN CAP 10MG NITISINONE CAP 10 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionORFADIN CAP 20MG NITISINONE CAP 20 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSORFADIN CAP 2MG NITISINONE CAP 2 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSORFADIN CAP 5MG NITISINONE CAP 5 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSORFADIN SUS 4MG/ML NITISINONE SUSP 4 MG/ML OTHER MISCELLANEOUS THERAPEUTIC AGENTSORGOVYX TAB 120MG RELUGOLIX TAB 120 MG ANTIGONADTROPINSORKAMBI GRA 100-125 LUMACAFTOR-IVACAFTOR GRANULES PACKET 100-125 MG CYSTIC FIBROSIS (CFTR) CORRECTORSORKAMBI GRA 150-188 LUMACAFTOR-IVACAFTOR GRANULES PACKET 150-188 MG CYSTIC FIBROSIS (CFTR) CORRECTORSORKAMBI TAB 100-125 LUMACAFTOR-IVACAFTOR TAB 100-125 MG CYSTIC FIBROSIS (CFTR) CORRECTORSORKAMBI TAB 200-125 LUMACAFTOR-IVACAFTOR TAB 200-125 MG CYSTIC FIBROSIS (CFTR) CORRECTORSORLADEYO CAP 110MG BEROTRALSTAT HCL CAP 110 MG KALLIKREIN INHIBITORSORLADEYO CAP 150MG BEROTRALSTAT HCL CAP 150 MG KALLIKREIN INHIBITORSOTEZLA TAB 10/20/30 APREMILAST TAB STARTER THERAPY PACK 10 MG & 20 MG & 30 MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTSOTEZLA TAB 30MG APREMILAST TAB 30 MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTSOVIDREL INJ CHORIOGONADOTROPIN ALFA INJ 250 MCG/0.5ML GONADOTROPINSOXERVATE SOL 20MCG/ML CENEGERMIN-BKBJ OPHTH SOLN 0.002% (20 MCG/ML) EENT DRUGS, MISCELLANEOUSOXLUMO INJ 94.5/0.5 LUMASIRAN SODIUM SUBCUTANEOUS SOLN 94.5 MG/0.5ML OTHER MISCELLANEOUS THERAPEUTIC AGENTSPALYNZIQ INJ 10/0.5ML PEGVALIASE-PQPZ SUBCUTANEOUS SOLN PREF SYRINGE 10 MG/0.5ML ENZYMESPALYNZIQ INJ 2.5/0.5 PEGVALIASE-PQPZ SUBCUTANEOUS SOLN PREF SYRINGE 2.5 MG/0.5ML ENZYMESPALYNZIQ INJ 20MG/ML PEGVALIASE-PQPZ SUBCUTANEOUS SOLN PREF SYRINGE 20 MG/ML ENZYMESPANRETIN GEL 0.1% ALITRETINOIN GEL 0.1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC.PARICALCITOL CAP 1 MCG PARICALCITOL CAP 1 MCG VITAMIN DPARICALCITOL CAP 2 MCG PARICALCITOL CAP 2 MCG VITAMIN DPARICALCITOL CAP 4 MCG PARICALCITOL CAP 4 MCG VITAMIN DPEGASYS INJ PEGINTERFERON ALFA-2A SOLN PREFILLED SYR 180 MCG/0.5ML INTERFERON ANTIVIRALSPEGASYS INJ 180MCG/M PEGINTERFERON ALFA-2A INJ 180 MCG/ML INTERFERON ANTIVIRALSPEGASYS INJ PROCLICK PEGINTERFERON ALFA-2A SOLN AUTO-INJECTOR 180 MCG/0.5ML INTERFERON ANTIVIRALSPEGINTRON KIT 50MCG PEGINTERFERON ALFA-2B FOR INJ KIT 50 MCG/0.5ML INTERFERON ANTIVIRALSPENICILLAMIN TAB 250MG PENICILLAMINE TAB 250 MG HEAVY METAL ANTAGONISTSPHESGO SOL PERTUZUMAB-TRASTUZ-HYALURON-ZZXF INJ 80 MG-40 MG-2000 UNT/ML ANTINEOPLASTIC AGENTSPIQRAY 200MG TAB DOSE ALPELISIB TAB THERAPY PACK 200 MG DAILY DOSE ANTINEOPLASTIC AGENTSPIQRAY 250MG TAB DOSE ALPELISIB TAB PACK 250 MG DAILY DOSE (200 MG & 50 MG TABS) ANTINEOPLASTIC AGENTSPIQRAY 300MG TAB DOSE ALPELISIB TAB PACK 300 MG DAILY DOSE (2X150 MG TAB) ANTINEOPLASTIC AGENTSPIRFENIDONE TAB 267MG PIRFENIDONE TAB 267 MG ANTIFIBROTIC AGENTSPIRFENIDONE TAB 801MG PIRFENIDONE TAB 801 MG ANTIFIBROTIC AGENTSPOMALYST CAP 1MG POMALIDOMIDE CAP 1 MG ANTINEOPLASTIC AGENTSPOMALYST CAP 2MG POMALIDOMIDE CAP 2 MG ANTINEOPLASTIC AGENTSPOMALYST CAP 3MG POMALIDOMIDE CAP 3 MG ANTINEOPLASTIC AGENTSPOMALYST CAP 4MG POMALIDOMIDE CAP 4 MG ANTINEOPLASTIC AGENTSPOSACONAZOLE TAB 100MG DR POSACONAZOLE TAB DELAYED RELEASE 100 MG AZOLE ANTIFUNGALSPREGNYL INJ 10000UNT CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT GONADOTROPINS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionPREVYMIS TAB 240MG LETERMOVIR TAB 240 MG ANTIVIRALS, MISCELLANEOUSPREVYMIS TAB 480MG LETERMOVIR TAB 480 MG ANTIVIRALS, MISCELLANEOUSPROCRIT INJ 10000/ML EPOETIN ALFA INJ 10000 UNIT/ML HEMATOPOIETIC AGENTSPROCRIT INJ 2000/ML EPOETIN ALFA INJ 2000 UNIT/ML HEMATOPOIETIC AGENTSPROCRIT INJ 20000/ML EPOETIN ALFA INJ 20000 UNIT/ML HEMATOPOIETIC AGENTSPROCRIT INJ 3000/ML EPOETIN ALFA INJ 3000 UNIT/ML HEMATOPOIETIC AGENTSPROCRIT INJ 4000/ML EPOETIN ALFA INJ 4000 UNIT/ML HEMATOPOIETIC AGENTSPROCRIT INJ 40000/ML EPOETIN ALFA INJ 40000 UNIT/ML HEMATOPOIETIC AGENTSPROFILNINE INJ 1000UNIT FACTOR IX COMPLEX FOR INJ 1000 UNIT HEMOSTATICSPROFILNINE INJ 1500UNIT FACTOR IX COMPLEX FOR INJ 1500 UNIT HEMOSTATICSPROFILNINE INJ 500UNIT FACTOR IX COMPLEX FOR INJ 500 UNIT HEMOSTATICSPROLIA SOL 60MG/ML DENOSUMAB INJ SOLN PREFILLED SYRINGE 60 MG/ML BONE RESORPTION INHIBITORSPROMACTA PAK 25MG ELTROMBOPAG OLAMINE POWDER PACK FOR SUSP 25 MG (BASE EQUIV) HEMATOPOIETIC AGENTSPROMACTA POW 12.5MG ELTROMBOPAG OLAMINE POWDER PACK FOR SUSP 12.5 MG (BASE EQ) HEMATOPOIETIC AGENTSPROMACTA TAB 12.5MG ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV) HEMATOPOIETIC AGENTSPROMACTA TAB 25MG ELTROMBOPAG OLAMINE TAB 25 MG (BASE EQUIV) HEMATOPOIETIC AGENTSPROMACTA TAB 50MG ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV) HEMATOPOIETIC AGENTSPROMACTA TAB 75MG ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV) HEMATOPOIETIC AGENTSPULMOZYME SOL 1MG/ML DORNASE ALFA INHAL SOLN 2.5 MG/2.5ML MUCOLYTIC AGENTSPURIXAN SUS 20MG/ML MERCAPTOPURINE SUSP 2000 MG/100ML (20 MG/ML) ANTINEOPLASTIC AGENTSPYRIMETHAMIN TAB 25MG PYRIMETHAMINE TAB 25 MG ANTIMALARIALSPYRUKYND TAB 20MG MITAPIVAT SULFATE TAB 20 MG BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.PYRUKYND TAB 20MGX5MG MITAPIVAT SULFATE TAB THERAPY PACK 7 X 20 MG & 7 X 5 MG BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.PYRUKYND TAB 50MG MITAPIVAT SULFATE TAB 50 MG BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.PYRUKYND TAB 50MGX20M MITAPIVAT SULFATE TAB THERAPY PACK 7 X 50 MG & 7 X 20 MG BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.PYRUKYND TAB 5MG MITAPIVAT SULFATE TAB 5 MG BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.PYRUKYND TAB 5MG TP MITAPIVAT SULFATE TAB THERAPY PACK 5 MG BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.QINLOCK TAB 50MG RIPRETINIB TAB 50 MG ANTINEOPLASTIC AGENTSRADIOGARDASE CAP 0.5GM PRUSSIAN BLUE INSOLUBLE CAP 0.5 GM OTHER ION-REMOVING AGENTSRAGWITEK SUB SHORT RAGWEED POLLEN ALLERGEN EXTRACT SL TAB 12 AMB A 1-U ALLERGENIC EXTRACTS (THERAPEUTIC)RAPAMUNE SOL 1MG/ML SIROLIMUS ORAL SOLN 1 MG/ML IMMUNOSUPPRESSIVE AGENTSRAPAMUNE TAB 0.5MG SIROLIMUS TAB 0.5 MG IMMUNOSUPPRESSIVE AGENTSRAPAMUNE TAB 1MG SIROLIMUS TAB 1 MG IMMUNOSUPPRESSIVE AGENTSRAPAMUNE TAB 2MG SIROLIMUS TAB 2 MG IMMUNOSUPPRESSIVE AGENTSRASUVO INJ 10MG METHOTREXATE SOLN PF AUTO-INJECTOR 10 MG/0.2ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRASUVO INJ 12.5MG METHOTREXATE SOLN PF AUTO-INJECTOR 12.5 MG/0.25ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRASUVO INJ 15MG METHOTREXATE SOLN PF AUTO-INJECTOR 15 MG/0.3ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRASUVO INJ 17.5MG METHOTREXATE SOLN PF AUTO-INJECTOR 17.5 MG/0.35ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRASUVO INJ 20MG METHOTREXATE SOLN PF AUTO-INJECTOR 20 MG/0.4ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRASUVO INJ 22.5MG METHOTREXATE SOLN PF AUTO-INJECTOR 22.5 MG/0.45ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionRASUVO INJ 25MG METHOTREXATE SOLN PF AUTO-INJECTOR 25 MG/0.5ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRASUVO INJ 30MG METHOTREXATE SOLN PF AUTO-INJECTOR 30 MG/0.6ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRASUVO INJ 7.5MG METHOTREXATE SOLN PF AUTO-INJECTOR 7.5 MG/0.15ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRAVICTI LIQ 1.1GM/ML GLYCEROL PHENYLBUTYRATE LIQUID 1.1 GM/ML AMMONIA DETOXICANTSREBINYN SOL 1000UNIT COAGULATION FACTOR IX RECOMB GLYCOPEGYLATED FOR INJ 1000 UNT HEMOSTATICSREBINYN SOL 2000UNIT COAGULATION FACTOR IX RECOMB GLYCOPEGYLATED FOR INJ 2000 UNT HEMOSTATICSREBINYN SOL 500UNIT COAGULATION FACTOR IX RECOMB GLYCOPEGYLATED FOR INJ 500 UNT HEMOSTATICSREBLOZYL INJ 25MG LUSPATERCEPT-AAMT FOR SUBCUTANEOUS INJ 25 MG HEMATOPOIETIC AGENTSREBLOZYL INJ 75MG LUSPATERCEPT-AAMT FOR SUBCUTANEOUS INJ 75 MG HEMATOPOIETIC AGENTSRECOMBINATE INJ ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ 1241-1800 UNIT HEMOSTATICSRECOMBINATE INJ 220-400 ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ 220-400 UNIT HEMOSTATICSRECOMBINATE INJ 401-800 ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ 401-800 UNIT HEMOSTATICSRECOMBINATE INJ 801-1240 ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) FOR INJ 801-1240 UNIT HEMOSTATICSRETACRIT INJ 10000UNT EPOETIN ALFA-EPBX INJ 10000 UNIT/ML HEMATOPOIETIC AGENTSRETACRIT INJ 20000UNI EPOETIN ALFA-EPBX INJ 20000 UNIT/ML HEMATOPOIETIC AGENTSRETACRIT INJ 2000UNIT EPOETIN ALFA-EPBX INJ 2000 UNIT/ML HEMATOPOIETIC AGENTSRETACRIT INJ 3000UNIT EPOETIN ALFA-EPBX INJ 3000 UNIT/ML HEMATOPOIETIC AGENTSRETACRIT INJ 40000UNT EPOETIN ALFA-EPBX INJ 40000 UNIT/ML HEMATOPOIETIC AGENTSRETACRIT INJ 4000UNIT EPOETIN ALFA-EPBX INJ 4000 UNIT/ML HEMATOPOIETIC AGENTSRETEVMO CAP 40MG SELPERCATINIB CAP 40 MG ANTINEOPLASTIC AGENTSRETEVMO CAP 80MG SELPERCATINIB CAP 80 MG ANTINEOPLASTIC AGENTSREVCOVI INJ 1.6MG/ML ELAPEGADEMASE-LVLR IM SOLN 2.4 MG/1.5ML (1.6 MG/ML) ENZYMESREVLIMID CAP 10MG LENALIDOMIDE CAP 10 MG ANTINEOPLASTIC AGENTSREVLIMID CAP 15MG LENALIDOMIDE CAP 15 MG ANTINEOPLASTIC AGENTSREVLIMID CAP 2.5MG LENALIDOMIDE CAPS 2.5 MG ANTINEOPLASTIC AGENTSREVLIMID CAP 20MG LENALIDOMIDE CAP 20 MG ANTINEOPLASTIC AGENTSREVLIMID CAP 25MG LENALIDOMIDE CAP 25 MG ANTINEOPLASTIC AGENTSREVLIMID CAP 5MG LENALIDOMIDE CAP 5 MG ANTINEOPLASTIC AGENTSRHOGAM PLUS INJ 300MCG RHO D IMMUNE GLOBULIN IM SOLN PREF SYR 1500 UNIT (300MCG) ANTITOXINS AND IMMUNE GLOBULINSRIASTAP SOL 1GM FIBRINOGEN CONC (HUMAN) INJ APPROXIMATELY 1 GM (900-1300 MG) HEMOSTATICSRIBAVIRIN CAP 200MG RIBAVIRIN CAP 200 MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSRIBAVIRIN TAB 200MG RIBAVIRIN TAB 200 MG NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSRIDAURA CAP 3MG AURANOFIN CAP 3 MG GOLD COMPOUNDSRILUTEK TAB 50MG RILUZOLE TAB 50 MG CENTRAL NERVOUS SYSTEM AGENTS, MISC.RILUZOLE TAB 50MG RILUZOLE TAB 50 MG CENTRAL NERVOUS SYSTEM AGENTS, MISC.RINVOQ TAB 15MG ER UPADACITINIB TAB ER 24HR 15 MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRINVOQ TAB 30MG ER UPADACITINIB TAB ER 24HR 30 MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRINVOQ TAB 45MG ER UPADACITINIB TAB ER 24HR 45 MG DISEASE-MODIFYING ANTIRHEUMATIC AGENTSRITUXAN INJ HYCELA RITUXIMAB-HYALURONIDASE HUMAN INJ 1400-23400 MG-UNIT/11.7ML ANTINEOPLASTIC AGENTSRIXUBIS INJ 1000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 1000 UNIT HEMOSTATICS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionRIXUBIS INJ 2000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 2000 UNIT HEMOSTATICSRIXUBIS INJ 250 UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 250 UNIT HEMOSTATICSRIXUBIS INJ 3000UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 3000 UNIT HEMOSTATICSRIXUBIS INJ 500UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ 500 UNIT HEMOSTATICSROZLYTREK CAP 100MG ENTRECTINIB CAP 100 MG ANTINEOPLASTIC AGENTSROZLYTREK CAP 200MG ENTRECTINIB CAP 200 MG ANTINEOPLASTIC AGENTSRUBRACA TAB 200MG RUCAPARIB CAMSYLATE TAB 200 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSRUBRACA TAB 250MG RUCAPARIB CAMSYLATE TAB 250 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSRUBRACA TAB 300MG RUCAPARIB CAMSYLATE TAB 300 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSRYDAPT CAP 25MG MIDOSTAURIN CAP 25 MG ANTINEOPLASTIC AGENTSSAJAZIR INJ 30MG/3ML ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT) BRADYKININ RECEPTOR ANTAGONISTSSAMSCA TAB 15MG TOLVAPTAN TAB 15 MG VASOPRESSIN ANTAGONISTSSAMSCA TAB 30MG TOLVAPTAN TAB 30 MG VASOPRESSIN ANTAGONISTSSAPROPTERIN POW 100MG SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSSAPROPTERIN POW 500MG SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSSAPROPTERIN TAB 100MG SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSSCEMBLIX TAB 20MG ASCIMINIB HCL TAB 20 MG ANTINEOPLASTIC AGENTSSCEMBLIX TAB 40MG ASCIMINIB HCL TAB 40 MG ANTINEOPLASTIC AGENTSSCENESSE IMP 16MG AFAMELANOTIDE ACETATE IMPLANT 16 MG SKIN AND MUCOUS MEMBRANE AGENTS, MISC.SEROSTIM INJ 4MG SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 4 MG SOMATOTROPIN AGONISTSSEROSTIM INJ 5MG SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 5 MG SOMATOTROPIN AGONISTSSEROSTIM INJ 6MG SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 6 MG SOMATOTROPIN AGONISTSSIGNIFOR LAR INJ 10MG PASIREOTIDE PAMOATE FOR IM ER SUSP 10 MG (BASE EQUIV) SOMATOSTATIN AGONISTSSIGNIFOR LAR INJ 20MG PASIREOTIDE PAMOATE FOR IM ER SUSP 20 MG (BASE EQUIV) SOMATOSTATIN AGONISTSSIGNIFOR LAR INJ 30MG PASIREOTIDE PAMOATE FOR IM ER SUSP 30 MG (BASE EQUIV) SOMATOSTATIN AGONISTSSIGNIFOR LAR INJ 40MG PASIREOTIDE PAMOATE FOR IM ER SUSP 40 MG (BASE EQUIV) SOMATOSTATIN AGONISTSSIGNIFOR LAR INJ 60MG PASIREOTIDE PAMOATE FOR IM ER SUSP 60 MG (BASE EQUIV) SOMATOSTATIN AGONISTSSILDENAFIL SUS 10MG/ML SILDENAFIL CITRATE FOR SUSPENSION 10 MG/ML PHOSPHODIESTERASE TYPE 5 INHIBITORSSILDENAFIL TAB 20MG SILDENAFIL CITRATE TAB 20 MG PHOSPHODIESTERASE TYPE 5 INHIBITORSSILIQ INJ 210/1.5 BRODALUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 210 MG/1.5ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.SIMPONI INJ 100MG/ML GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSSIMPONI INJ 50/0.5ML GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/0.5ML DISEASE-MODIFYING ANTIRHEUMATIC AGENTSSIROLIMUS SOL 1MG/ML SIROLIMUS ORAL SOLN 1 MG/ML IMMUNOSUPPRESSIVE AGENTSSIROLIMUS TAB 0.5MG SIROLIMUS TAB 0.5 MG IMMUNOSUPPRESSIVE AGENTSSIROLIMUS TAB 1MG SIROLIMUS TAB 1 MG IMMUNOSUPPRESSIVE AGENTSSIROLIMUS TAB 2MG SIROLIMUS TAB 2 MG IMMUNOSUPPRESSIVE AGENTSSKYRIZI INJ 150DOSE RISANKIZUMAB-RZAA SOL PREFILLED SYRINGE 2 X 75 MG/0.83ML KIT SKIN AND MUCOUS MEMBRANE AGENTS, MISC.SKYRIZI INJ 150MG/ML RISANKIZUMAB-RZAA SOLN PREFILLED SYRINGE 150 MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.SKYRIZI PEN INJ 150MG/ML RISANKIZUMAB-RZAA SOLN AUTO-INJECTOR 150 MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.SODIUM PHENY TAB 500MG SODIUM PHENYLBUTYRATE TAB 500 MG AMMONIA DETOXICANTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionSOLESTA INJ 50-15ML DEXTRANOMER-SODIUM HYALURONATE INJ GEL 50-15 MG/ML OTHER MISCELLANEOUS THERAPEUTIC AGENTSSOMATULINE INJ 120/.5ML LANREOTIDE ACETATE EXTENDED RELEASE INJ 120 MG/0.5ML SOMATOSTATIN AGONISTSSOMATULINE INJ 60/0.2ML LANREOTIDE ACETATE EXTENDED RELEASE INJ 60 MG/0.2ML SOMATOSTATIN AGONISTSSOMATULINE INJ 90/0.3ML LANREOTIDE ACETATE EXTENDED RELEASE INJ 90 MG/0.3ML SOMATOSTATIN AGONISTSSOMAVERT INJ 10MG PEGVISOMANT FOR INJ 10 MG (AS PROTEIN) SOMATOTROPIN ANTAGONISTSSOMAVERT INJ 15MG PEGVISOMANT FOR INJ 15 MG (AS PROTEIN) SOMATOTROPIN ANTAGONISTSSOMAVERT INJ 20MG PEGVISOMANT FOR INJ 20 MG (AS PROTEIN) SOMATOTROPIN ANTAGONISTSSOMAVERT INJ 25MG PEGVISOMANT FOR INJ 25 MG (AS PROTEIN) SOMATOTROPIN ANTAGONISTSSOMAVERT INJ 30MG PEGVISOMANT FOR INJ 30 MG (AS PROTEIN) SOMATOTROPIN ANTAGONISTSSORAFENIB TAB 200MG SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSSOVALDI PAK 150MG SOFOSBUVIR PELLET PACK 150 MG HCV POLYMERASE INHIBITOR ANTIVIRALSSOVALDI PAK 200MG SOFOSBUVIR PELLET PACK 200 MG HCV POLYMERASE INHIBITOR ANTIVIRALSSOVALDI TAB 200MG SOFOSBUVIR TAB 200 MG HCV POLYMERASE INHIBITOR ANTIVIRALSSOVALDI TAB 400MG SOFOSBUVIR TAB 400 MG HCV POLYMERASE INHIBITOR ANTIVIRALSSPRAVATO SOL 56MG DOS ESKETAMINE HCL NASAL SOLN 28 MG/DEVICE X 2 (56 MG DOSE PACK) ANTIDEPRESSANTS, MISCELLANEOUSSPRAVATO SOL 84MG DOS ESKETAMINE HCL NASAL SOLN 28 MG/DEVICE X 3 (84 MG DOSE PACK) ANTIDEPRESSANTS, MISCELLANEOUSSPRYCEL TAB 100MG DASATINIB TAB 100 MG ANTINEOPLASTIC AGENTSSPRYCEL TAB 140MG DASATINIB TAB 140 MG ANTINEOPLASTIC AGENTSSPRYCEL TAB 20MG DASATINIB TAB 20 MG ANTINEOPLASTIC AGENTSSPRYCEL TAB 50MG DASATINIB TAB 50 MG ANTINEOPLASTIC AGENTSSPRYCEL TAB 70MG DASATINIB TAB 70 MG ANTINEOPLASTIC AGENTSSPRYCEL TAB 80MG DASATINIB TAB 80 MG ANTINEOPLASTIC AGENTSSTELARA INJ 45MG/0.5 USTEKINUMAB INJ 45 MG/0.5ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.STELARA INJ 90MG/ML USTEKINUMAB SOLN PREFILLED SYRINGE 90 MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.STIMATE SOL 1.5MG/ML DESMOPRESSIN ACETATE NASAL SOLN 1.5 MG/ML PITUITARYSTIVARGA TAB 40MG REGORAFENIB TAB 40 MG ANTINEOPLASTIC AGENTSSTRENSIQ INJ 18/0.45 ASFOTASE ALFA SUBCUTANEOUS INJ 18 MG/0.45ML ENZYMESSTRENSIQ INJ 28/0.7ML ASFOTASE ALFA SUBCUTANEOUS INJ 28 MG/0.7ML ENZYMESSTRENSIQ INJ 40MG/ML ASFOTASE ALFA SUBCUTANEOUS INJ 40 MG/ML ENZYMESSTRENSIQ INJ 80/0.8ML ASFOTASE ALFA SUBCUTANEOUS INJ 80 MG/0.8ML ENZYMESSUBLOCADE INJ 100/0.5 BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 100 MG/0.5ML OPIATE PARTIAL AGONISTSSUBLOCADE INJ 300/1.5 BUPRENORPHINE EXTENDED RELEASE SOLN PREF SYR 300 MG/1.5ML OPIATE PARTIAL AGONISTSSUCRAID SOL 8500/ML SACROSIDASE SOLN 8500 UNIT/ML ENZYMESSUNITINIB CAP 12.5MG SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSSUNITINIB CAP 25MG SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSSUNITINIB CAP 37.5MG SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSSUNITINIB CAP 50MG SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSSUPPRELIN LA KIT 50MG HISTRELIN ACETATE (CPP) IMPLANT KIT 50 MG GONADOTROPINSSUSVIMO INJ 10/0.1ML RANIBIZUMAB INTRAVITREAL (IMPLANT REFILL) INJ 10 MG/0.1ML VASCULAR ENDOTHELIAL GROWTH FACTOR ANTAGSYMDEKO TAB 100-150 TEZACAFTOR-IVACAFTOR 100-150 MG & IVACAFTOR 150 MG TAB TBPK CYSTIC FIBROSIS (CFTR) CORRECTORS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionSYMDEKO TAB 50-75MG TEZACAFTOR-IVACAFTOR 50-75 MG & IVACAFTOR 75 MG TAB TBPK CYSTIC FIBROSIS (CFTR) CORRECTORSSYMPROIC TAB 0.2MG NALDEMEDINE TOSYLATE TAB 0.2 MG (BASE EQUIVALENT) GI DRUGS, MISCELLANEOUSSYNAGIS INJ 100MG/ML PALIVIZUMAB IM SOLN 100 MG/ML MONOCLONAL ANTIBODY ANTIVIRALSSYNAGIS INJ 50/0.5ML PALIVIZUMAB IM SOLN 50 MG/0.5ML MONOCLONAL ANTIBODY ANTIVIRALSSYNAGIS INJ 50MG PALIVIZUMAB IM SOLN 50 MG/0.5ML MONOCLONAL ANTIBODY ANTIVIRALSSYNAREL SOL 2MG/ML NAFARELIN ACETATE NASAL SOLN 2 MG/ML (200 MCG/ACT) (BASE EQ) GONADOTROPINSSYNRIBO INJ 3.5MG OMACETAXINE MEPESUCCINATE FOR INJ 3.5 MG ANTINEOPLASTIC AGENTSTABLOID TAB 40MG THIOGUANINE TAB 40 MG ANTINEOPLASTIC AGENTSTABRECTA TAB 150MG CAPMATINIB HCL TAB 150 MG ANTINEOPLASTIC AGENTSTABRECTA TAB 200MG CAPMATINIB HCL TAB 200 MG ANTINEOPLASTIC AGENTSTAFINLAR CAP 50MG DABRAFENIB MESYLATE CAP 50 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTAFINLAR CAP 75MG DABRAFENIB MESYLATE CAP 75 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTAGRISSO TAB 40MG OSIMERTINIB MESYLATE TAB 40 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTAGRISSO TAB 80MG OSIMERTINIB MESYLATE TAB 80 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTAKHZYRO INJ 300/2ML LANADELUMAB-FLYO INJ 300 MG/2ML (150 MG/ML) KALLIKREIN INHIBITORSTALTZ INJ 80MG/ML IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.TALZENNA CAP 0.25MG TALAZOPARIB TOSYLATE CAP 0.25 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTALZENNA CAP 0.5MG TALAZOPARIB TOSYLATE CAP 0.5 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTALZENNA CAP 0.75MG TALAZOPARIB TOSYLATE CAP 0.75 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTALZENNA CAP 1MG TALAZOPARIB TOSYLATE CAP 1 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTARGRETIN GEL 1% BEXAROTENE GEL 1% SKIN AND MUCOUS MEMBRANE AGENTS, MISC.TASIGNA CAP 150MG NILOTINIB HCL CAP 150 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTASIGNA CAP 200MG NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTASIGNA CAP 50MG NILOTINIB HCL CAP 50 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTAVALISSE TAB 100MG FOSTAMATINIB DISODIUM TAB 100 MG (BASE EQUIVALENT) BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.TAVALISSE TAB 150MG FOSTAMATINIB DISODIUM TAB 150 MG (BASE EQUIVALENT) BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.TEGSEDI INJ 284/1.5 INOTERSEN SOD SUBCUTANEOUS PREF SYR 284 MG/1.5ML (BASE EQ) ANTISENSE OLIGONUCLEOTIDESTEMOZOLOMIDE CAP 100MG TEMOZOLOMIDE CAP 100 MG ANTINEOPLASTIC AGENTSTEMOZOLOMIDE CAP 140MG TEMOZOLOMIDE CAP 140 MG ANTINEOPLASTIC AGENTSTEMOZOLOMIDE CAP 180MG TEMOZOLOMIDE CAP 180 MG ANTINEOPLASTIC AGENTSTEMOZOLOMIDE CAP 20MG TEMOZOLOMIDE CAP 20 MG ANTINEOPLASTIC AGENTSTEMOZOLOMIDE CAP 250MG TEMOZOLOMIDE CAP 250 MG ANTINEOPLASTIC AGENTSTEMOZOLOMIDE CAP 5MG TEMOZOLOMIDE CAP 5 MG ANTINEOPLASTIC AGENTSTEPADINA INJ 100MG THIOTEPA FOR INJ 100 MG ANTINEOPLASTIC AGENTSTEPADINA INJ 15MG THIOTEPA FOR INJ 15 MG ANTINEOPLASTIC AGENTSTERIPARATIDE INJ TERIPARATIDE (RECOMBINANT) SOLN PEN-INJ 620 MCG/2.48ML PARATHYROID AGENTSTETRABENAZIN TAB 12.5MG TETRABENAZINE TAB 12.5 MG VESICULAR MONOAMINE TRANSPORT2 INHIBITORTETRABENAZIN TAB 25MG TETRABENAZINE TAB 25 MG VESICULAR MONOAMINE TRANSPORT2 INHIBITORTHALOMID CAP 100MG THALIDOMIDE CAP 100 MG IMMUNOMODULATORY AGENTSTHALOMID CAP 150MG THALIDOMIDE CAP 150 MG IMMUNOMODULATORY AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionTHALOMID CAP 200MG THALIDOMIDE CAP 200 MG IMMUNOMODULATORY AGENTSTHALOMID CAP 50MG THALIDOMIDE CAP 50 MG IMMUNOMODULATORY AGENTSTHIOLA TAB 100MG TIOPRONIN TAB 100 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSTHIOLA EC TAB 100MG TIOPRONIN TAB DELAYED RELEASE 100 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSTHIOLA EC TAB 300MG TIOPRONIN TAB DELAYED RELEASE 300 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSTHIOTEPA INJ 100MG THIOTEPA FOR INJ 100 MG ANTINEOPLASTIC AGENTSTHIOTEPA INJ 15MG THIOTEPA FOR INJ 15 MG ANTINEOPLASTIC AGENTSTIBSOVO TAB 250MG IVOSIDENIB TAB 250 MG ANTINEOPLASTIC AGENTSTICE BCG INJ BCG LIVE INTRAVESICAL FOR SUSP 50 MG ANTINEOPLASTIC AGENTSTIGLUTIK SUS 50/10ML RILUZOLE SUSP 50 MG/10ML CENTRAL NERVOUS SYSTEM AGENTS, MISC.TIOPRONIN TAB 100MG TIOPRONIN TAB 100 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSTOBI PODHALR CAP 28MG TOBRAMYCIN INHAL CAP 28 MG AMINOGLYCOSIDE ANTIBIOTICSTOBRAMYCIN NEB 300/4ML TOBRAMYCIN NEBU SOLN 300 MG/4ML AMINOGLYCOSIDE ANTIBIOTICSTOBRAMYCIN NEB 300/5ML TOBRAMYCIN NEBU SOLN 300 MG/5ML AMINOGLYCOSIDE ANTIBIOTICSTOLVAPTAN TAB 15MG TOLVAPTAN TAB 15 MG VASOPRESSIN ANTAGONISTSTOLVAPTAN TAB 30MG TOLVAPTAN TAB 30 MG VASOPRESSIN ANTAGONISTSTOREMIFENE TAB 60MG TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT) ESTROGEN AGONIST-ANTAGONISTSTRACLEER TAB 32MG BOSENTAN TAB FOR ORAL SUSP 32 MG VASODILATING AGENTS (RESPIRATORY TRACT)TRELSTAR MIX INJ 11.25MG TRIPTORELIN PAMOATE FOR IM SUSP 11.25 MG GONADOTROPINSTRELSTAR MIX INJ 22.5MG TRIPTORELIN PAMOATE FOR IM SUSP 22.5 MG GONADOTROPINSTRELSTAR MIX INJ 3.75MG TRIPTORELIN PAMOATE FOR IM SUSP 3.75 MG GONADOTROPINSTREMFYA INJ 100MG/ML GUSELKUMAB SOLN PREFILLED SYRINGE 100 MG/ML SKIN AND MUCOUS MEMBRANE AGENTS, MISC.TREPROSTINIL INJ 10MG/ML TREPROSTINIL INJ SOLN 200 MG/20ML (10 MG/ML) VASODILATING AGENTS (RESPIRATORY TRACT)TREPROSTINIL INJ 1MG/ML TREPROSTINIL INJ SOLN 20 MG/20ML (1 MG/ML) VASODILATING AGENTS (RESPIRATORY TRACT)TREPROSTINIL INJ 2.5MG/ML TREPROSTINIL INJ SOLN 50 MG/20ML (2.5 MG/ML) VASODILATING AGENTS (RESPIRATORY TRACT)TREPROSTINIL INJ 5MG/ML TREPROSTINIL INJ SOLN 100 MG/20ML (5 MG/ML) VASODILATING AGENTS (RESPIRATORY TRACT)TRETINOIN CAP 10MG TRETINOIN CAP 10 MG ANTINEOPLASTIC AGENTSTRETTEN INJ COAGULATION FACTOR XIII A-SUBUNIT FOR INJ 2000-3125 UNIT HEMOSTATICSTRIENTINE CAP 250MG TRIENTINE HCL CAP 250 MG HEAVY METAL ANTAGONISTSTRIKAFTA TAB ELEXACAF-TEZACAF-IVACAF 50-25-37.5 MG & IVACAFTOR 75 MG TBPK CYSTIC FIBROSIS (CFTR) CORRECTORSTRIPTODUR SUS 22.5MG TRIPTORELIN PAMOATE FOR IM ER SUSP 22.5 MG (BASE EQUIV) GONADOTROPINSTRUSELTIQ CAP 100MG INFIGRATINIB PHOS CAP THER PACK 100 MG (100 MG DAILY DOSE) ANTINEOPLASTIC AGENTSTRUSELTIQ CAP 125MG INFIGRATINIB PHOS CAP PACK 100 & 25 MG (125 MG DAILY DOSE) ANTINEOPLASTIC AGENTSTRUSELTIQ CAP 50MG INFIGRATINIB PHOS CAP THER PACK 2 X 25 MG (50 MG DAILY DOSE) ANTINEOPLASTIC AGENTSTRUSELTIQ CAP 75MG INFIGRATINIB PHOS CAP THER PACK 3 X 25 MG (75 MG DAILY DOSE) ANTINEOPLASTIC AGENTSTUKYSA TAB 150MG TUCATINIB TAB 150 MG ANTINEOPLASTIC AGENTSTUKYSA TAB 50MG TUCATINIB TAB 50 MG ANTINEOPLASTIC AGENTSTURALIO CAP 200MG PEXIDARTINIB HCL CAP 200 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSTYMLOS INJ ABALOPARATIDE SUBCUTANEOUS SOLN PEN-INJECTOR 3120 MCG/1.56ML PARATHYROID AGENTSTYVASO SOL 0.6MG/ML TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML VASODILATING AGENTS (RESPIRATORY TRACT)

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionTYVASO REFIL SOL 0.6MG/ML TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML VASODILATING AGENTS (RESPIRATORY TRACT)TYVASO START SOL 0.6MG/ML TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML VASODILATING AGENTS (RESPIRATORY TRACT)UKONIQ TAB 200MG UMBRALISIB TOSYLATE TAB 200 MG ANTINEOPLASTIC AGENTSUPTRAVI TAB 1000MCG SELEXIPAG TAB 1000 MCG VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 1200MCG SELEXIPAG TAB 1200 MCG VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 1400MCG SELEXIPAG TAB 1400 MCG VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 1600MCG SELEXIPAG TAB 1600 MCG VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 200/800 SELEXIPAG TAB THERAPY PACK 200 MCG (140) & 800 MCG (60) VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 200MCG SELEXIPAG TAB 200 MCG VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 400MCG SELEXIPAG TAB 400 MCG VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 600MCG SELEXIPAG TAB 600 MCG VASODILATING AGENTS (RESPIRATORY TRACT)UPTRAVI TAB 800MCG SELEXIPAG TAB 800 MCG VASODILATING AGENTS (RESPIRATORY TRACT)VALCHLOR GEL 0.016% MECHLORETHAMINE HCL GEL 0.016% (BASE EQUIVALENT) SKIN AND MUCOUS MEMBRANE AGENTS, MISC.VALRUBICIN SOL 40MG/ML VALRUBICIN SOLN FOR INTRAVESICAL INSTILLATION 40 MG/ML ANTINEOPLASTIC AGENTSVALSTAR SOL 40MG/ML VALRUBICIN SOLN FOR INTRAVESICAL INSTILLATION 40 MG/ML ANTINEOPLASTIC AGENTSVANTAS KIT 50MG HISTRELIN ACETATE IMPLANT KIT 50 MG GONADOTROPINSVELCADE INJ 3.5MG BORTEZOMIB FOR INJ 3.5 MG ANTINEOPLASTIC AGENTSVENCLEXTA TAB 100MG VENETOCLAX TAB 100 MG ANTINEOPLASTIC AGENTSVENCLEXTA TAB 10MG VENETOCLAX TAB 10 MG ANTINEOPLASTIC AGENTSVENCLEXTA TAB 50MG VENETOCLAX TAB 50 MG ANTINEOPLASTIC AGENTSVENCLEXTA TAB START PK VENETOCLAX TAB THERAPY STARTER PACK 10 & 50 & 100 MG ANTINEOPLASTIC AGENTSVENTAVIS SOL 10MCG/ML ILOPROST INHALATION SOLUTION 10 MCG/ML VASODILATING AGENTS (RESPIRATORY TRACT)VENTAVIS SOL 20MCG/ML ILOPROST INHALATION SOLUTION 20 MCG/ML VASODILATING AGENTS (RESPIRATORY TRACT)VERZENIO TAB 100MG ABEMACICLIB TAB 100 MG ANTINEOPLASTIC AGENTSVERZENIO TAB 150MG ABEMACICLIB TAB 150 MG ANTINEOPLASTIC AGENTSVERZENIO TAB 200MG ABEMACICLIB TAB 200 MG ANTINEOPLASTIC AGENTSVERZENIO TAB 50MG ABEMACICLIB TAB 50 MG ANTINEOPLASTIC AGENTSVFEND SUS 40MG/ML VORICONAZOLE FOR SUSP 40 MG/ML AZOLE ANTIFUNGALSVFEND TAB 200MG VORICONAZOLE TAB 200 MG AZOLE ANTIFUNGALSVFEND TAB 50MG VORICONAZOLE TAB 50 MG AZOLE ANTIFUNGALSVIDAZA INJ 100MG AZACITIDINE FOR INJ 100 MG ANTINEOPLASTIC AGENTSVIEKIRA PAK TAB OMBITAS-PARITAPRE-RITON & DASAB TAB PAK 12.5-75-50 & 250 MG HCV REPLICATION COMPLEX INHIBITORSVIGABATRIN PAK 500MG VIGABATRIN POWD PACK 500 MG ANTICONVULSANTS, MISCELLANEOUSVIGABATRIN TAB 500MG VIGABATRIN TAB 500 MG ANTICONVULSANTS, MISCELLANEOUSVIGADRONE POW 500MG VIGABATRIN POWD PACK 500 MG ANTICONVULSANTS, MISCELLANEOUSVITRAKVI CAP 100MG LAROTRECTINIB SULFATE CAP 100 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSVITRAKVI CAP 25MG LAROTRECTINIB SULFATE CAP 25 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSVITRAKVI SOL 20MG/ML LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSVIVITROL INJ 380MG NALTREXONE FOR IM EXTENDED RELEASE SUSP 380 MG OPIATE ANTAGONISTSVIZIMPRO TAB 15MG DACOMITINIB TAB 15 MG ANTINEOPLASTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionVIZIMPRO TAB 30MG DACOMITINIB TAB 30 MG ANTINEOPLASTIC AGENTSVIZIMPRO TAB 45MG DACOMITINIB TAB 45 MG ANTINEOPLASTIC AGENTSVONVENDI INJ 1300UNIT VON WILLEBRAND FACTOR (RECOMBINANT) FOR INJ 1300 UNIT HEMOSTATICSVONVENDI INJ 650UNIT VON WILLEBRAND FACTOR (RECOMBINANT) FOR INJ 650 UNIT HEMOSTATICSVORICONAZOLE SUS 40MG/ML VORICONAZOLE FOR SUSP 40 MG/ML AZOLE ANTIFUNGALSVORICONAZOLE TAB 200MG VORICONAZOLE TAB 200 MG AZOLE ANTIFUNGALSVORICONAZOLE TAB 50MG VORICONAZOLE TAB 50 MG AZOLE ANTIFUNGALSVOSEVI TAB SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR TAB 400-100-100 MG HCV POLYMERASE INHIBITOR ANTIVIRALSVOTRIENT TAB 200MG PAZOPANIB HCL TAB 200 MG (BASE EQUIV) ANTINEOPLASTIC AGENTSVOXZOGO INJ 0.4MG VOSORITIDE FOR SUBCUTANEOUS INJ 0.4 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSVOXZOGO INJ 0.56MG VOSORITIDE FOR SUBCUTANEOUS INJ 0.56 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSVOXZOGO INJ 1.2MG VOSORITIDE FOR SUBCUTANEOUS INJ 1.2 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSVUMERITY CAP 231MG DIROXIMEL FUMARATE CAPSULE DELAYED RELEASE 231 MG IMMUNOMODULATORY AGENTSVYNDAMAX CAP 61MG TAFAMIDIS CAP 61 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSVYNDAQEL CAP 20MG TAFAMIDIS MEGLUMINE (CARDIAC) CAP 20 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSWAKIX TAB 17.8MG PITOLISANT HCL TAB 17.8 MG (BASE EQUIVALENT) WAKEFULNESS-PROMOTING AGENTSWAKIX TAB 4.45MG PITOLISANT HCL TAB 4.45 MG (BASE EQUIVALENT) WAKEFULNESS-PROMOTING AGENTSWELIREG TAB 40MG BELZUTIFAN TAB 40 MG ANTINEOPLASTIC AGENTSWILATE INJ ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500-500 UNIT KIT HEMOSTATICSWINRHO SDF INJ 15000UNT RHO D IMMUNE GLOBULIN (HUMAN) INJ 15000 UNIT/13ML ANTITOXINS AND IMMUNE GLOBULINSWINRHO SDF INJ 1500UNIT RHO D IMMUNE GLOBULIN (HUMAN) INJ 1500 UNIT/1.3ML ANTITOXINS AND IMMUNE GLOBULINSWINRHO SDF INJ 2500UNIT RHO D IMMUNE GLOBULIN (HUMAN) INJ 2500 UNIT/2.2ML ANTITOXINS AND IMMUNE GLOBULINSWINRHO SDF INJ 5000UNIT RHO D IMMUNE GLOBULIN (HUMAN) INJ 5000 UNIT/4.4ML ANTITOXINS AND IMMUNE GLOBULINSXALKORI CAP 200MG CRIZOTINIB CAP 200 MG ANTINEOPLASTIC AGENTSXALKORI CAP 250MG CRIZOTINIB CAP 250 MG ANTINEOPLASTIC AGENTSXATMEP SOL 2.5MG/ML METHOTREXATE ORAL SOLN 2.5 MG/ML ANTINEOPLASTIC AGENTSXELJANZ SOL 1MG/ML TOFACITINIB CITRATE ORAL SOLN 1 MG/ML (BASE EQUIVALENT) DISEASE-MODIFYING ANTIRHEUMATIC AGENTSXELJANZ TAB 10MG TOFACITINIB CITRATE TAB 10 MG (BASE EQUIVALENT) DISEASE-MODIFYING ANTIRHEUMATIC AGENTSXELJANZ TAB 5MG TOFACITINIB CITRATE TAB 5 MG (BASE EQUIVALENT) DISEASE-MODIFYING ANTIRHEUMATIC AGENTSXELJANZ XR TAB 11MG TOFACITINIB CITRATE TAB ER 24HR 11 MG (BASE EQUIVALENT) DISEASE-MODIFYING ANTIRHEUMATIC AGENTSXELJANZ XR TAB 22MG TOFACITINIB CITRATE TAB ER 24HR 22 MG (BASE EQUIVALENT) DISEASE-MODIFYING ANTIRHEUMATIC AGENTSXEMBIFY INJ 10G/50ML IMMUNE GLOBULIN (HUMAN)-KLHW SUBCUTANEOUS INJ 10 GM/50ML ANTITOXINS AND IMMUNE GLOBULINSXEMBIFY INJ 1GM/5ML IMMUNE GLOBULIN (HUMAN)-KLHW SUBCUTANEOUS INJ 1 GM/5ML ANTITOXINS AND IMMUNE GLOBULINSXEMBIFY INJ 2GM/10ML IMMUNE GLOBULIN (HUMAN)-KLHW SUBCUTANEOUS INJ 2 GM/10ML ANTITOXINS AND IMMUNE GLOBULINSXEMBIFY INJ 4GM/20ML IMMUNE GLOBULIN (HUMAN)-KLHW SUBCUTANEOUS INJ 4 GM/20ML ANTITOXINS AND IMMUNE GLOBULINSXEOMIN INJ 100UNIT INCOBOTULINUMTOXINA FOR IM INJ 100 UNIT OTHER MISCELLANEOUS THERAPEUTIC AGENTSXEOMIN INJ 200UNIT INCOBOTULINUMTOXINA FOR IM INJ 200 UNIT OTHER MISCELLANEOUS THERAPEUTIC AGENTSXEOMIN INJ 50 UNIT INCOBOTULINUMTOXINA FOR IM INJ 50 UNIT OTHER MISCELLANEOUS THERAPEUTIC AGENTSXERMELO TAB 250MG TELOTRISTAT ETHYL TAB 250 MG (AS TELOTRISTAT ETIPRATE) ANTIDIARRHEA AGENTSXGEVA INJ DENOSUMAB INJ 120 MG/1.7ML BONE RESORPTION INHIBITORS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionXIAFLEX INJ 0.9MG COLLAGENASE CLOSTRIDIUM HISTOLYTICUM FOR INJ 0.9 MG ENZYMESXOLAIR INJ 150MG/ML OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML RESPIRATORY TRACT AGENTS, MISCELLANEOUSXOLAIR INJ 75/0.5 OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML RESPIRATORY TRACT AGENTS, MISCELLANEOUSXOLAIR SOL 150MG OMALIZUMAB FOR INJ 150 MG RESPIRATORY TRACT AGENTS, MISCELLANEOUSXOSPATA TAB 40MG GILTERITINIB FUMARATE TABLET 40 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSXPOVIO PAK 100MG SELINEXOR TAB THERAPY PACK 20 MG (100 MG ONCE WEEKLY) ANTINEOPLASTIC AGENTSXPOVIO PAK 40MG SELINEXOR TAB THERAPY PACK 20 MG (40 MG TWICE WEEKLY) ANTINEOPLASTIC AGENTSXPOVIO PAK 50MG SELINEXOR TAB THERAPY PACK 50 MG (100 MG ONCE WEEKLY) ANTINEOPLASTIC AGENTSXPOVIO PAK 60MG SELINEXOR TAB THERAPY PACK 20 MG (60 MG ONCE WEEKLY) ANTINEOPLASTIC AGENTSXPOVIO PAK 80MG SELINEXOR TAB THERAPY PACK 20 MG (80 MG ONCE WEEKLY) ANTINEOPLASTIC AGENTSXTANDI CAP 40MG ENZALUTAMIDE CAP 40 MG ANTINEOPLASTIC AGENTSXTANDI TAB 40MG ENZALUTAMIDE TAB 40 MG ANTINEOPLASTIC AGENTSXTANDI TAB 80MG ENZALUTAMIDE TAB 80 MG ANTINEOPLASTIC AGENTSXURIDEN POW 2GM URIDINE TRIACETATE ORAL GRANULES PACKET 2 GM OTHER MISCELLANEOUS THERAPEUTIC AGENTSXYNTHA INJ 1000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,MOR) FOR INJ KIT 1000 UNIT HEMOSTATICSXYNTHA INJ 2000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,MOR) FOR INJ KIT 2000 UNIT HEMOSTATICSXYNTHA INJ 250UNIT ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,MOR) FOR INJ KIT 250 UNIT HEMOSTATICSXYNTHA INJ 500UNIT ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,MOR) FOR INJ KIT 500 UNIT HEMOSTATICSXYNTHA SOLOF INJ 1000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,MOR) FOR INJ KIT 1000 UNIT HEMOSTATICSXYNTHA SOLOF INJ 2000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,MOR) FOR INJ KIT 2000 UNIT HEMOSTATICSXYNTHA SOLOF INJ 3000UNIT ANTIHEMOPHIL FACT RCMB(BDD-RFVIII,MOR) FOR INJ KIT 3000 UNIT HEMOSTATICSXYNTHA SOLOF INJ 500UNIT ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,MOR) FOR INJ KIT 500 UNIT HEMOSTATICSXYNTHA SOLOF KIT 250UNIT ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,MOR) FOR INJ KIT 250 UNIT HEMOSTATICSXYREM SOL 500MG/ML SODIUM OXYBATE ORAL SOLUTION 500 MG/ML CENTRAL NERVOUS SYSTEM AGENTS, MISC.XYWAV SOL 0.5GM/ML CALCIUM, MAG, POTASSIUM, & SOD OXYBATES ORAL SOLN 500 MG/ML CENTRAL NERVOUS SYSTEM AGENTS, MISC.ZARXIO INJ 300/0.5 FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 300 MCG/0.5ML HEMATOPOIETIC AGENTSZARXIO INJ 480/0.8 FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 480 MCG/0.8ML HEMATOPOIETIC AGENTSZEJULA CAP 100MG NIRAPARIB TOSYLATE CAP 100 MG (BASE EQUIVALENT) ANTINEOPLASTIC AGENTSZELBORAF TAB 240MG VEMURAFENIB TAB 240 MG ANTINEOPLASTIC AGENTSZEMPLAR CAP 1MCG PARICALCITOL CAP 1 MCG VITAMIN DZEMPLAR CAP 2MCG PARICALCITOL CAP 2 MCG VITAMIN DZEPATIER TAB 50-100MG ELBASVIR-GRAZOPREVIR TAB 50-100 MG HCV REPLICATION COMPLEX INHIBITORSZEPOSIA CAP .92MG OZANIMOD HCL CAP 0.92 MG IMMUNOMODULATORY AGENTSZEPOSIA CAP STR KIT OZANIMOD CAP PACK 4 X 0.23 MG & 3 X 0.46 MG & 30 X 0.92 MG IMMUNOMODULATORY AGENTSZEPOSIA 7DAY CAP STR PACK OZANIMOD CAP PACK 4 X 0.23 MG & 3 X 0.46 MG IMMUNOMODULATORY AGENTSZIEXTENZO INJ 6/0.6ML PEGFILGRASTIM-BMEZ SOLN PREFILLED SYRINGE 6 MG/0.6ML HEMATOPOIETIC AGENTSZOKINVY CAP 50MG LONAFARNIB CAP 50 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSZOKINVY CAP 75MG LONAFARNIB CAP 75 MG OTHER MISCELLANEOUS THERAPEUTIC AGENTSZOLADEX IMP 10.8MG GOSERELIN ACETATE IMPLANT 10.8 MG GONADOTROPINSZOLINZA CAP 100MG VORINOSTAT CAP 100 MG ANTINEOPLASTIC AGENTS

Atrium Health Specialty Drug List - July 2022

Product Label Generic Name AHFS Therapeutic Class DescriptionZORBTIVE INJ 8.8MG SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 8.8 MG SOMATOTROPIN AGONISTSZORTRESS TAB 0.25MG EVEROLIMUS TAB 0.25 MG IMMUNOSUPPRESSIVE AGENTSZORTRESS TAB 0.5MG EVEROLIMUS TAB 0.5 MG IMMUNOSUPPRESSIVE AGENTSZORTRESS TAB 0.75MG EVEROLIMUS TAB 0.75 MG IMMUNOSUPPRESSIVE AGENTSZORTRESS TAB 1MG EVEROLIMUS TAB 1 MG IMMUNOSUPPRESSIVE AGENTSZYDELIG TAB 100MG IDELALISIB TAB 100 MG ANTINEOPLASTIC AGENTSZYDELIG TAB 150MG IDELALISIB TAB 150 MG ANTINEOPLASTIC AGENTSZYKADIA TAB 150MG CERITINIB TAB 150 MG ANTINEOPLASTIC AGENTS

Atrium Health Specialty Drug List - July 2022