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Antilipemic
Asthma
Asthma
Apolipoprotein B Antisense Oligonucleotide
Interleukin-4 Receptor Antagonist
Interleukin-5 Antagonist
Kynamro
Dupixent
Fasenra
Mipomersen
Dupilumab
Benralizumab
Antilipemic PCSK9 Inhibitor Repatha Evolocumab
Anemia
Antilipemic
Anemia
Anemia
Anemia
Anemia
Activin Receptor Ligand Trap
PCSK9 Inhibitor
Erythropoiesis-Stimulating Agent (ESA)
Erythropoiesis-Stimulating Agent (ESA)
Erythropoiesis-Stimulating Agent (ESA)
Erythropoiesis-Stimulating Agent (ESA)
Reblozyl
Praluent
Aranesp
Epogen
Procrit
Retacrit
Luspatercept
Alirocumab
Darbepoetin Alfa
Epoetin Alfa
Epoetin Alfa
Epoetin Alfa
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Acromegaly
Acromegaly
Acromegaly
Acromegaly
Allergen Immunotherapy
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
Amyloidosis
Somatostatin Analog
Somatostatin Analog
Somatostatin Analog
Growth Hormone Receptor Antagonist
Allergen-Specific Immunotherapy
Antitrypsin Deficiency Agent
Antitrypsin Deficiency Agent
Antitrypsin Deficiency Agent
Antitrypsin Deficiency Agent
Anti-Transthyretin Small Interfering Ribonucleic Acid
(siRNA) Agent
Somatuline Depot
Sandostatin
Sandostatin Lar
Somavert
Oralair
Aralast Np
Glassia
Prolastin-C
Zemaira
Onpattro
Lanreotide
Octreotide
Octreotide
Pegvisomant
Grass Pollen Allergen Extract (5 Grass Extract)
Alpha1-Proteinase Inhibitor
Alpha1-Proteinase Inhibitor
Alpha1-Proteinase Inhibitor
Alpha1-Proteinase Inhibitor
Patisiran
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
Asthma
Asthma
Asthma
Biosimilar
Biosimilar
Atopic Dermatitis
Interleukin-5 Antagonist
Monoclonal Antibody
Interleukin-5 Antagonist
Colony Stimulating Factor
Colony Stimulating Factor
Interleukin-4 Receptor Antagonist
Nucala
Xolair
Cinqair
Nivestym
Nyvepria
Dupixent
Mepolizumab
Omalizumab
Reslizumab
Filgrastim
Pegfilgrastim
Coronavirus Antiviral Veklury Remdesivir
Coronavirus Monoclonal Antibody Bamlanivimab
Coronavirus Monoclonal Antibody Casirivimab and Imdevimab
Coagulation Disorders Blood Product Ceprotin Protein C Concentrate
Biosimilar
Biosimilar
Biosimilar
Biosimilar
Botulinum Toxins
Botulinum Toxins
Botulinum Toxins
Botulinum Toxins
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Neuromuscular Blocker Agent
Neuromuscular Blocker Agent
Neuromuscular Blocker Agent
Neuromuscular Blocker Agent
Zarxio
Fulphila
Udenyca
Ziextenzo
Dysport
Xeomin
Botox
Myobloc
Filgrastim
Pegfilgrastim
Pegfilgrastim
Pegfilgrastim
AbobotulinumtoxinA
IncobotulinumtoxinA
OnabotulinumtoxinA
RimabotulinumtoxinB
Dupilumab
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Cystic Fibrosis
Cystic Fibrosis
Duchenne Muscular Dystrophy
Aminoglycoside Antibiotic
Aminoglycoside Antibiotic
Antisense Oligonucleotide
Tobi
Tobi Podhaler
Viltepso
Tobramycin (Oral Inhalation)
Tobramycin (Oral Inhalation)
Viltolarsen
Cystic Fibrosis
Cystic Fibrosis
Cystic Fibrosis
Cystic Fibrosis
Cryopyrin-Associated Periodic Syndromes
Cryopyrin-Associated Periodic Syndromes
Monobactam Antibiotic
Mucolytic Agent
Aminoglycoside Antibiotic
Aminoglycoside Antibiotic
Interleukin-1β Antagonist
Interleukin-1 Antagonist
Cayston
Pulmozyme
Bethkis
Kitabis Pak
Ilaris
Arcalyst
Aztreonam (Oral Inhalation)
Dornase Alfa
Tobramycin (Oral Inhalation)
Tobramycin (Oral Inhalation)
Canakinumab
Rilonacept
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Hematopoietics
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Growth Hormone
Growth Hormone
Growth Hormone
Growth Hormone
Hematopoietic Stem Cell Mobilizer
Antihemophilic Agent
Saizen
Serostim
Zomacton
Zorbtive
Mozobil
Sevenfact
Somatropin
Somatropin
Somatropin
Somatropin
Plerixafor
Factor VIIa (Recombinant)
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone & Related Disorders
Growth Hormone
Growth Hormone
Growth Hormone
Growth Hormone
Growth Hormone
Genotropin
Humatrope
Norditropin
Nutropin Aq
Omnitrope
Somatropin
Somatropin
Somatropin
Somatropin
Somatropin
Gaucher Disease
Gaucher Disease
Gout
Lysosomal Storage Disorder Agents
Lysosomal Storage Disorder Agents
Urate-Oxidase
Elelyso
Vpriv
Krystexxa
Taliglucerase Alfa
Velaglucerase Alfa
Pegloticase
Gaucher DiseaseLysosomal Storage Disorder
AgentsCerezyme Imiglucerase
Gaucher DiseaseLysosomal Storage Disorder
AgentsCeredase Alglucerase
Gastrointestinal DisordersGlucagon-Like Peptide-2
(GLP-2) AnalogGattex Teduglutide
Gastrointestinal DisordersSkin and Mucous Membrane
AgentSolesta
Dextranomer and Hyaluronate Derivatives
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Novoeight
Nuwiq
Recombinate
Xyntha
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Eloctate
Adynovate
Jivi
Advate
Afstyla
Helixate Fs
Kogenate Fs
Kovaltry
Obizur
Antihemophilic Factor (Recombinant [Fc Fusion
Protein])
Antihemophilic Factor (Recombinant [Pegylated])
Antihemophilic Factor (Recombinant [Pegylated])
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant)
Antihemophilic Factor (Recombinant [Porcine
Sequence])
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent Koate-DviAntihemophilic Factor
(Human)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent KoateAntihemophilic Factor
(Human)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent Hemofil MAntihemophilic Factor
(Human)
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent; Prothrombin Complex
Concentrate (PCC)
Benefix
Ixinity
Rixubis
Bebulin
Factor IX (Recombinant)
Factor IX (Recombinant)
Factor IX (Recombinant)
Factor IX Complex (Human) [(Factors II, IX, X)]
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent; Activated Prothrombin Complex
Concentrate (aPCC)
Antihemophilic Agent; Posterior Pituitary Hormone; Vasopressin
Analog
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent; Prothrombin Complex
Concentrate (PCC)
Feiba
Stimate
Hemlibra
Alphanine Sd
Mononine
Idelvion
Alprolix
Rebinyn
Anti-Inhibitor Coagulant Complex (Human)
Desmopressin
Emicizumab
Factor IX (Human)
Factor IX (Human)
Factor IX (Recombinant [Albumin Fusion Protein])
Factor IX (Recombinant [Fc Fusion Protein])
Factor IX (Recombinant [Glycopegylated])
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent Humate-PAntihemophilic Factor/Von Willebrand Factor Complex
(Human)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent WilateAntihemophilic Factor/Von Willebrand Factor Complex
(Human)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent AlphanateAntihemophilic Factor/Von Willebrand Factor Complex
(Human)
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hereditary Angioedema
Hormonal
Hereditary Angioedema
C1 Esterase Inhibitor
C1 Esterase Inhibitor
C1 Esterase Inhibitor
C1 Esterase Inhibitor
Kallikrein Inhibitor
Selective Bradykinin B2 Receptor Antagonist
Gonadotropin Releasing Hormone Antagonist
Kallikrein Inhibitor
Berinert
Cinryze
Haegarda
Ruconest
Kalbitor
Firazyr
Firmagon
Takhzyro
C1 Inhibitor (Human)
C1 Inhibitor (Human)
C1 Inhibitor (Human)
C1 Inhibitor (Recombinant)
Ecallantide
Icatibant
Degarelix
Lanadelumab
Hepatitis
Hepatitis
Interferon
Interferon
Pegasys
Pegintron
Peginterferon Alfa-2a
Peginterferon Alfa-2b
Hepatitis Interferon Intron-A Interferon Alfa-2b
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent
Antihemophilic Agent
Antihemophilic Agent
Blood Product Derivative
Blood Product Derivative
Antihemophilic Agent
Coagadex
Tretten
Corifact
Fibryga
Riastap
Vonvendi
Factor X (Human)
Factor XIII A-Subunit (Recombinant)
Factor XIII Concentrate (Human)
Fibrinogen Concentrate (Human)
Fibrinogen Concentrate (Human)
Von Willebrand Factor (Recombinant)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent Novoseven Rt Factor VIIa (Recombinant)
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent; Prothrombin Complex
Concentrate (PCC)Profilnine Sd
Factor IX Complex (Human) [(Factors II, IX, X)]
Hemophilia, Von Willebrand Disease & Related Bleeding Disorders
Antihemophilic Agent; Prothrombin Complex
Concentrate (PCC)Profilnine
Factor IX Complex (Human) [(Factors II, IX, X)]
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Hormonal
Hormonal
Hormonal
Hormonal
Hormonal
Hormonal
Igf-1 Deficiency
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Parathyroid Hormone Analog
Androgen
Growth Hormone
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Eligard
Lupron
Lupron Depot
Trelstar
Natpara
Aveed
Increlex
Cytogam
Hepagam B
Hyperhep B
Nabi-Hb
Asceniv
Bivigam
Cuvitru
Gamastan
Leuprolide
Leuprolide
Leuprolide
Triptorelin
Parathyroid Hormone
Testosterone
Mecasermin
Cytomegalovirus Immune Globulin
Hepatitis B Immune Globulin
Hepatitis B Immune Globulin
Hepatitis B Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
HormonalGonadotropin Releasing
Hormone AntagonistLupaneta Pack
Leuprolide and Norethindrone
HormonalGonadotropin Releasing
Hormone AntagonistVantas Histrelin
Hormonal
Hormonal
Gonadotropin Releasing Hormone Antagonist
Gonadotropin Releasing Hormone Antagonist
Zoladex
Supprelin La
Goserelin
Histrelin
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Gammaplex
Gamunex C
Hizentra
Hyqvia
Octagam
Panzyga
Privigen
Xembify
Hyperrho S/D
Micrhogam
Rhogam
Rhophylac
Winrho Sdf
Varizig
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Rho(D) Immune Globulin
Varicella-Zoster Immune Globulin
Immune Deficiencies & Related Disorders
Immune Globulin Gammaked Immune Globulin
Immune Deficiencies & Related Disorders
Immune Globulin Gammagard S/D Immune Globulin
Immune Deficiencies & Related Disorders
Immune Deficiencies & Related Disorders
Immune Globulin
Immune Globulin
Gamastan S/D
Gammagard Liquid
Immune Globulin
Immune Globulin
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Multiple Sclerosis Anti-CD52 Lemtrada Alemtuzumab
Movement Disorders
Multiple Sclerosis
Dopamine Precursor
CD20-Directed Cytolytic Antibody
Inbrija
Kesimpta
Levodopa
Ofatumumab
Movement Disorders
Movement Disorders
Complement Inhibitor
Free Radical Scavenger
Soliris
Radicava
Eculizumab
Edaravone
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Movement Disorders
Enzyme
Enzyme
Enzyme
Enzyme
Enzyme
Enzyme
Enzyme
Enzyme
Dopamine Agonist
Vimizim
Naglazyme
Elaprase
Cerezyme
Aldurazyme
Kanuma
Elelyso
Vpriv
Apokyn
Elosulfase Alfa
Galsulfase
Idursulfase
Imiglucerase
Laronidase
Sebelipase Alfa
Taliglucerase Alfa
Velaglucerase Alfa
Apomorphine
Iron Overload
Lysosomal Storage Disorders
Lysosomal Storage Disorders
Chelating Agent
Enzyme
Enzyme
Desferal
Fabrazyme
Lumizyme
Deferoxamine
Agalsidase Beta
Alglucosidase Alfa
Inflammatory Bowel Disease
Inflammatory Bowel Disease
Selective Adhesion-Molecule Inhibitor
Interleukin-12 Inhibitor / Interleukin-23 Inhibitor
Entyvio
Stelara
Vedolizumab
Ustekinumab
Inflammatory Bowel Disease Selective Adhesion-Molecule
InhibitorTysabri Natalizumab
Inflammatory Bowel Disease
Inflammatory Bowel Disease
TNF Inhibitor
TNF Inhibitor
Remicade
Renflexis
Infliximab
Infliximab
Inflammatory Bowel Disease TNF Inhibitor Inflectra Infliximab
Inflammatory Bowel Disease
Inflammatory Bowel Disease
Inflammatory Bowel Disease
TNF Inhibitor
TNF Inhibitor
TNF Inhibitor
Humira
Cimzia
Simponi
Adalimumab
Certolizumab Pegol
Golimumab
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Psoriasis
Psoriasis
Psoriasis
Psoriasis
Anti-interleukin 17A Monoclonal Antibody
TNF Inhibitor
TNF Inhibitor
Interleukin-23 Inhibitor
Siliq
Cimzia
Enbrel
Tremfya
Brodalumab
Certolizumab Pegol
Etanercept
Guselkumab
Psoriasis TNF Inhibitor Humira Adalimumab
Neutropenia
Neutropenia
Neutropenia
Neutropenia
Neutropenia
Neutropenia
Neutropenia
Neutropenia
Paroxysmal Nocturnal Hemoglobinuria
Paroxysmal Nocturnal Hemoglobinuria
Phenylketonuria
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Colony Stimulating Factor
Complement Inhibitor
Complement Inhibitor
Phenylalanine Ammonia Lyase Enzyme
Neupogen
Nivestym
Zarxio
Leukine
Fulphila
Neulasta
Udenyca
Ziextenzo
Soliris
Ultomiris
Palynziq
Filgrastim
Filgrastim
Filgrastim
Leukine
Pegfilgrastim
Pegfilgrastim
Pegfilgrastim
Pegfilgrastim
Eculizumab
Ravulizumab
Pegvaliase
Neutropenia Colony Stimulating Factor Granix Filgrastim
Multiple Sclerosis Interferon Plegridy Peginterferon Beta-1a
Multiple Sclerosis
Multiple Sclerosis
Selective Adhesion-Molecule Inhibitor
Anti-CD20
Tysabri
Ocrevus
Natalizumab
Ocrelizumab
Multiple Sclerosis Interferon Extavia Interferon Beta-1b
Multiple Sclerosis Interferon Betaseron Interferon Beta-1b
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulator
Interferon
Interferon
Copaxone
Avonex
Rebif
Glatiramer Acetate
Interferon Beta-1a
Interferon Beta-1a
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Pulmonary Hypertension
Pulmonary Hypertension
Rare Disease
Rare Disease
Rare Disease
Rare Disease
Rare Disease
Prostacyclin; Prostaglandin
Prostacyclin; Prostaglandin
Anti-FGF23
Monoclonal Antibody
MC4 Receptor Agonist
Monoclonal Antibody
mRNA Interference
Remodulin
Tyvaso
Crysvita
Gamifant
Imcivree
Uplinza
Oxlumo
Treprostinil
Treprostinil
Burosumab
Emapalumab
Setmelanotide
Inebilizumab-cdon
Lumasiran
Rheumatoid Arthritis
Rheumatoid Arthritis
TNF Inhibitor
TNF Inhibitor
Simponi
Simponi Aria
Golimumab
Golimumab
Rheumatoid Arthritis
Rheumatoid Arthritis
TNF Inhibitor
TNF Inhibitor
Cimzia
Enbrel
Certolizumab Pegol
Etanercept
Respiratory Syncytial Virus
Rheumatoid Arthritis
Rheumatoid Arthritis
Monoclonal Antibody
T-Cell Costimulation Blocker
TNF Inhibitor
Synagis
Orencia
Humira
Palivizumab
Abatacept
Adalimumab
Pulmonary Hypertension
Pulmonary Hypertension
Pulmonary Hypertension
Prostacyclin; Prostaglandin
Prostacyclin; Prostaglandin
Prostacyclin; Prostaglandin
Flolan
Veletri
Ventavis
Epoprostenol
Epoprostenol
Iloprost
PsoriasisInterleukin-12
Inhibitor; Interleukin-23 InhibitorStelara Ustekinumab
PsoriasisAnti-Interleukin 17A Monoclonal
AntibodyCosentyx Secukinumab
Psoriasis Interleukin-23 Inhibitor Ilumya Tildrakizumab
Psoriasis
Psoriasis
Antimetabolite/Antifolate
Interleukin-23 Inhibitor
Rasuvo
Skyrizi
Methotrexate
Risankizumab
Psoriasis Antimetabolite/Antifolate Otrexup Methotrexate
PsoriasisAnti-Interleukin 17A Monoclonal
AntibodyTaltz Ixekizumab
Psoriasis
Psoriasis
Psoriasis
TNF Inhibitor
TNF Inhibitor
TNF Inhibitor
Inflectra
Remicade
Renflexis
Infliximab
Infliximab
Infliximab
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Antineoplastic Agents
Kadcyla
Mvasi
Zirabev
Avastin
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
Enhertu
Ado-Trastuzumab Emtasine
Bevacizumab-awwb
Bevacizumab-bvzr
Bevacizumab
Trastuzumab
Trastuzumab-pkrb
Trastuzumab-anns
Trastuzumab-dkst
Trastuzumab-dttb
Trastuzumab-qyyp
Fam-Trastuzumab Deruxtecan
ThrombocytopeniaColony Stimulating Factor/
Thrombopoietin Receptor AgonistNplate Romiplostim
Spinal Muscular Atrophy
Systemic Lupus Erythematosus
Spinal Muscular Atrophy
Antisense Oligonucleotide
Monoclonal Antibody
Gene Therapy
Spinraza
Benlysta
Zolgensma
Nusinersen
Belimumab
Onasemnogene Abeparvovec
Sickle Cell Anti-P-Selectin Adakveo Crizanlizumab
Rheumatoid Arthritis
Rheumatoid Arthritis
Interleukin-6 Antagonist
Interleukin-6 Antagonist
Kevzara
Actemra
Sarilumab
Tocilizumab
Rheumatoid Arthritis Anti-CD20 Truxima Rituximab
Rheumatoid Arthritis
Rheumatoid Arthritis
Anti-CD20
Anti-CD20
Rituxan
Ruxience
Rituximab
Rituximab
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
TNF Inhibitor
TNF Inhibitor
TNF Inhibitor
Antimetabolite/Antifolate
Antimetabolite/Antifolate
Inflectra
Remicade
Renflexis
Otrexup
Rasuvo
Infliximab
Infliximab
Infliximab
Methotrexate
Methotrexate
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
OncologyAntineoplastic - Monoclonal
AntibodiesTecentriq Atezolizumab
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic - Histone Deacetylase Inhibitors
Alkylating Agents
Alkylating Agents
Alkylating Agents
Alkylating Agents
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Beleodaq
Belrapzo
Bendamustine
Bendeka
Treanda
Avastin
Zaltrap
Belinostat
Bendamustine HCl
Bendamustine HCl
Bendamustine HCl
Bendamustine HCl
Bevacizumab
Ziv-Aflibercept
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Autologous Cellular Immunotherapy
Antimetabolites
Antimetabolites
Antineoplastics Misc.
Bavencio
Yescarta
Azacitidine
Vidaza
Tice BCG
Avelumab
Axicabtagene Ciloleucel
Azacitidine
Azacitidine
BCG Live
OncologyAntineoplastic - Monoclonal
AntibodiesTrodelvy
Sacituzumab govitecan-hziy
Oncology Antineoplastic Enzymes ErwinazeAsparaginase Erwinia
Chrysanth
Oncology
Oncology
Antineoplastics Misc.
Antineoplastics Misc.
Arsenic Trioxide
Trisenox
Arsenic Trioxide
Arsenic Trioxide
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic Antibody-Drug Complexes
Antineoplastics - Interleukins
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Urinary Tract Protective Agents
Kadcyla
Proleukin
Campath
Riabni
Ethyol
Ado-Trastuzumab Emtansine
Aldesleukin
Alemtuzumab
Rituximab-arrx
Amifostine
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Oncology
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Antimetabolites
Libtayo
Erbitux
Cladribine
Cemiplimab-rwlc
Cetuximab
Cladribine
Oncology
Oncology
Oncology
Nitrosoureas
Nitrosoureas
Nitrosoureas
BiCNU
Carmustine
Gliadel
Carmustine
Carmustine
Carmustine in Polifeprosan
OncologyAntineoplastic - Proteasome
InhibitorsKyprolis Carfilzomib
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Alkylating Agents
Mitotic Inhibitors
Antineoplastic Enzymes
Alkylating Agents
Alkylating Agents
Antineoplastic Antibody-Drug Complexes
Busulfex
Jevtana
Asparlas
Carboplatin
Paraplatin
Adcetris
Busulfan
Cabazitaxel
Calaspargase Pegol-mknl
Carboplatin
Carboplatin
Brentuximab Vedotin
OncologyAntineoplastic - Proteasome
InhibitorsVelcade Bortezomib
OncologyAntineoplastic - Proteasome
InhibitorsBortezomib Bortezomib
OncologyAntineoplastic - Bispecific T-cell
EngagersBlincyto Blinatumomab
Oncology Antineoplastic Antibiotics Bleomycin Sulfate Bleomycin Sulfate
Oncology
Oncology
Oncology
Ophthalmic
Ophthalmic
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Mvasi
Zaltrap
Zirabev
Eylea
Lucentis
Bevacizumab-awwb
Ziv-Aflibercept
Bevacizumab-bvzr
Aflibercept
Ranibizumab
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Oncology
Antineoplastic Antibiotics
Antineoplastic Antibiotics
Antineoplastic - Monoclonal Antibodies
Doxil
Doxorubicin HCl Liposomal
Imfinzi
Doxorubicin HCl Liposomal
Doxorubicin HCl Liposomal
Durvalumab
Oncology
Oncology
Oncology
Mitotic Inhibitors
Antineoplastic Antibiotics
Antineoplastic Antibiotics
Taxotere
Adriamycin
Doxorubicin
Docetaxel
Doxorubicin HCl
Doxorubicin HCl
Oncology Mitotic Inhibitors Docetaxel Docetaxel
OncologyAntineoplastic - Monoclonal
AntibodiesUnituxin Dinutuximab
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antimetabolites
Antimetabolites
Gonadotropin Releasing Hormone (GnRH) Antagonists
Cardiac Protective Agents
Cardiac Protective Agents
Cardiac Protective Agents
Dacogen
Decitabine
Firmagon
Dexrazoxane
Totec
Zinecard
Decitabine
Decitabine
Degarelix Acetate
Dexrazoxane HCl
Dexrazoxane HCl
Dexrazoxane HCl
Oncology
Oncology
Antineoplastic Antibiotics
Antineoplastic Combinations
Daunorubicin
Vyxeos
Daunorubicin
Daunorubicin-Cytarabine Lipo
OncologyAntineoplastic - Monoclonal
AntibodiesDarzalex Faspro
Daratumumab-Hyaluronidase-fihj
OncologyAntineoplastic - Monoclonal
AntibodiesDarzalex Daratumumab
Oncology Antineoplastic Antibiotics Dactinomycin Dactinomycin
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Alkylating Agents
Antimetabolites
Antimetabolites
Antimetabolites
Nitrogen Mustards
Antimetabolites
Antineoplastics Misc.
Antineoplastic Antibiotics
Cisplatin
Cladribine
Clofarabine
Clolar
Cyclophosphamide
Cytarabine
Dacarbazine
Cosmegen
Cisplatin
Cladribine
Clofarabine
Clofarabine
Cyclophosphamide
Cytarabine
Dacarbazine
Dactinomycin
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Oncology
Oncology
Antineoplastic Antibiotics
Nitrogen Mustards
Nitrogen Mustards
Idarubicin
Ifex
Ifosfamide
Tegsedi
Idarubicin HCl
Ifosfamide
Ifosfamide
Inotersen Sodium
Oncology
Oncology
Oncology
LHRH Analogs
LHRH Analogs
Antineoplastic Antibiotics
Zoladex
Vantas
Idamycin
Goserelin Acetate
Histrelin Acetate
Idarubicin HCl
OncologyCarboxypeptidase Enzyme
AgentsVoraxaze Glucarpidase
OncologyAntineoplastic Antibody-Drug
ComplexesMylotarg Gemtuzumab Ozogamicin
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antimetabolites
Antimetabolites
Estrogen Receptor Antagonist
Estrogen Receptor Antagonist
Antimetabolites
Antimetabolites
Adrucil
Fluorouracil
Faslodex
Fulvestrant
Gemcitabine
Infugem
Fluorouracil
Fluorouracil
Fulvestrant
Fulvestrant
Gemcitabine
Gemcitabine HCl-NaCl
Oncology
Oncology
Antimetabolites
Antimetabolites
Floxuridine
Fludarabine
Floxuridine
Fludarabine
OncologyAntineoplastic Antibody-Drug
ComplexesEnhertu
Fam-Trastuzumab Deruxtec-nxki
Oncology
Oncology
Mitotic Inhibitors
Mitotic Inhibitors
Toposar
Etopophos
Etoposide
Etoposide Phosphate
Oncology Mitotic Inhibitors Etoposide Etoposide
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic Antibiotics
Antineoplastic Antibiotics
Mitotic Inhibitors
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Antineoplastic Antibody-Drug Complexes
Ellence
Epirubicin HCl
Halaven
Imfinzi
Empliciti
Padcev
Epirubicin HCl
Epirubicin HCl
Eribulin Mesylate
Durvalumab
Elotuzumab
Enfortumab Vedotin-ejfv
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Nitrogen Mustards
Antisense Oligonucleotide (ASO) Inhibitor Agents
Antineoplastic Antibody-Drug Complexes
Antineoplastic - Monoclonal Antibodies
Topoisomerase I Inhibitors
Topoisomerase I Inhibitors
Ifosfamide
Tegsedi
Besponsa
Yervoy
Camptosar
Irinotecan
Ifosfamide
Inotersen Sodium
Inotuzumab Ozogamicin
Ipilimumab
Irinotecan HCl
Irinotecan HCl
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Antineoplastic Antibiotics
Antineoplastic Antibiotics
Mitomycin
Mutamycin
Mitomycin
Mitomycin
Oncology Antineoplastic Antibiotics Mitoxantrone HCl Mitoxantrone HCl
Oncology
Oncology
Oncology
Nitrogen Mustards
Urinary Tract Protective Agents
Antimetabolites
Evomela
Mesnex
Methotrexate Sodium
Melphalan HCl (PG Free)
Mesna
Methotrexate Sodium
Oncology Nitrogen Mustards Melphalan HCl Melphalan HCl
Oncology Nitrogen Mustards Alkeran Melphalan HCl
Oncology Progestins-Antineoplastic Depo-ProveraMedroxyPROGESTERone
Acetate
Oncology
Oncology
Oncology
Oncology
LHRH Analogs
LHRH Analogs
LHRH Analogs
Antineoplastic - Hormonal and Related Agent Combinations
Eligard
Leuprolide Acetate
Lupron Depot
Leuprolide Acetate Bupivacaine
Leuprolide Acetate
Leuprolide Acetate
Leuprolide Acetate
Leuprolide Acetate Bupivacaine
Oncology
Oncology
Plasma Kallikrein Inhibitors - Monoclonal Antibodies
LHRH/GnRH Agonist Analog Combinations
Takhzyro
Lupaneta
Lanadelumab-flyo
Leuprolide & Norethindrone
Oncology Mitotic Inhibitors Ixempra Ixabepilone
OncologyAntineoplastic - Monoclonal
AntibodiesSarclisa Isatuximab-irfc
Oncology Topoisomerase I Inhibitors Onivyde Irinotecan HCl Liposome
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
Oncology Antineoplastic Antibiotics Jelmyto Mitomycin
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic Antibiotics
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Antimetabolites
Mitoxantrone HCl
Poteligeo
Lumoxiti
Portrazza
Arranon
Mitoxantrone HCl
Mogamulizumab-kpkc
Moxetumomab Pasudotox-tdfk
Necitumumab
Nelarabine
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Oncology
Antineoplastic - Monoclonal Antibodies
Antimetabolites
Antimetabolites
Keytruda
Alimta
Pemfexy
Pembrolizumab
Pemetrexed Disodium
Pemetrexed Disodium
OncologyAntineoplastic Antibody-Drug
ComplexesPolivy Polatuzumab Vedotin-piiq
Oncology Antineoplastics Misc. Nipent Pentostatin
Oncology Antineoplastic Enzymes Oncaspar Pegaspargase
OncologyAntineoplastic - Monoclonal
AntibodiesVectibix Panitumumab
OncologyChemotherapy Adjuncts -
Keratinocyte Growth FactorsKepivance Palifermin
Oncology
Oncology
Oncology
Alkylating Agents
Mitotic Inhibitors
Mitotic Inhibitors
Oxaliplatin
Paclitaxel
Abraxane
Oxaliplatin
Paclitaxel
Paclitaxel Protein Bound Part
Oncology Antineoplastics Misc. Synribo Omacetaxine Mepesuccinate
Oncology
Oncology
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Arzerra
Lartruvo
Ofatumumab
Olaratumab
OncologyAntineoplastic - Monoclonal
AntibodiesGazyva Obinutuzumab
OncologyAntineoplastic - Monoclonal
AntibodiesOpdivo Nivolumab
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic - Monoclonal Antibodies
Antineoplastic Antibody-Drug Complexes
Antineoplastics - Photoactivated Agents
Antimetabolites
Vascular Endothelial Growth Factor (VEGF) Inhibitors
Antineoplastic - Monoclonal Antibodies
Perjeta
Polivy
Photofrin
Folotyn
Cyramza
Rituxan
Pertuzumab
Polatuzumab Vedotin-piiq
Porfimer Sodium
Pralatrexate
Ramucirumab
Rituximab
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Oncology
Oncology
Topoisomerase I Inhibitors
Topoisomerase I Inhibitors
Hycamtin
Topotecan
Topotecan HCl
Topotecan HCl
Oncology
Oncology
Oncology
Mitotic Inhibitors
Alkylating Agents
Alkylating Agents
Teniposide
Tepadina
Thiotepa
Teniposide
Thiotepa
Thiotepa
OncologyAntineoplastic - mTOR Kinase
InhibitorsTorisel Temsirolimus
OncologyAntineoplastic - mTOR Kinase
InhibitorsTemsirolimus Temsirolimus
Oncology Imidazotetrazines Temodar Temozolomide
Oncology Antineoplastics - Interleukins Elzonris Tagraxofusp-erzs
Oncology
OncologyAntineoplastic - Autologous
Cellular Immunotherapy
Oncology
Antineoplastic - Histone Deacetylase Inhibitors
Nitrosoureas
Romidepsin
Provenge
Zanosar
Romidepsin
Sipuleucel-T
Streptozocin
Oncology
Oncology
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Histone Deacetylase Inhibitors
Ruxience
Istodax
Rituximab-pvvr
Romidepsin
Oncology Antineoplastic Combinations Rituxan HycelaRituximab-Hyaluronidase
Human
OncologyAntineoplastic - Monoclonal
AntibodiesTruxima Rituximab-abbs
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Oncology
Antineoplastic - Autologous Cellular Immunotherapy
Topoisomerase I Inhibitors
Topoisomerase I Inhibitors
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Antineoplastic - Monoclonal Antibodies
Antineoplastic Combinations
Kymriah
Hycamtin
Topotecan
Herceptin
Kanjinti
Ogivri
Herceptin Hylecta
Tisagenlecleucel
Topotecan HCl
Topotecan HCl
Trastuzumab
Trastuzumab-anns
Trastuzumab-dkst
Trastuzumab-Hyaluronidase-oysk
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Osteoarthritis Anti-Inflammatory/Antiarthritic Gel-One Hyaluronic Acid
Osteoarthritis Anti-Inflammatory/Antiarthritic Monovisc Hyaluronic Acid
Osteoarthritis
Osteoarthritis
Osteoarthritis
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Gelsyn-3
GenVisc 850
Hyalgan
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Osteoarthritis Anti-Inflammatory/Antiarthritic Euflexxa Hyaluronic Acid
Osteoarthritis Anti-Inflammatory/Antiarthritic Durolane Hyaluronic Acid
OncologyVascular Endothelial Growth
Factor (VEGF) InhibitorsZaltrap Ziv-Aflibercept
Oncology Mitotic Inhibitors Vinorelbine Tartrate Vinorelbine Tartrate
Oncology
Oncology
Oncology
Mitotic Inhibitors
Mitotic Inhibitors
Mitotic Inhibitors
Vincristine Sulfate
Marqibo
Navelbine
Vincristine Sulfate
Vincristine Sulfate Liposome
Vinorelbine Tartrate
Oncology
Oncology
Oncology
LHRH Analogs
Antineoplastic Antibiotics
Antineoplastic Antibiotics
Trelstar
Valrubicin
Valstar
Triptorelin Pamoate
Valrubicin
Valrubicin
OncologyAntineoplastic - Monoclonal
AntibodiesTrazimera Trastuzumab-qyyp
OncologyAntineoplastic - Monoclonal
AntibodiesHerzuma Trastuzumab-pkrb
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
DISEASE CATEGORY DRUG CATEGORY BRAND NAME GENERIC NAME
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Anti-Inflammatory/Antiarthritic
Hymovis
Monovisc
OrthoVisc
Supartz FX
Synvisc
Synvisc One
Triluron
TriVisc
Visco-3
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
Hyaluronic Acid
www.gpatpa.com
MEDICAL PLAN SELF-INJECTABLE, PHYSICIAN ADMINISTERED, AND INFUSION DRUG PROGRAM2021-FEBRUARY-01 *This list is subject to change and will be updated every 6 months based on the last revised version
