Self-Injectable Drug List - AmeriHealth

[Pages:2]Self-Injectable Drug List

EFFECTIVE JANUARY 1, 2010

The self-injectable drugs listed below are subject to change as new medications come to market or new determinations are made by AmeriHealth. This list contains only those drugs and biologics that are determined by AmeriHealth to be self-injectable.

BRAND NAME

Actimmune Alprostadil Apokyn

GENERIC NAME

interferon gamma?1b alprostadil apomorphine

Arixtra

fondaparinux

Avonex Avonex Avonex

interferon beta?1a interferon beta?1a interferon beta?1a

Betaseron Bravelle Caverject

interferon beta?1b urofollitropin alprostadil

Cetrotide Cimzia Cimzia Copaxone

cetrorelix acetate certolizumab pegol certolizumab pegol glatiramer

Depo Sub-Q Provera 104

Depo-Provera 150mg ONLY

Edex

Eligard

Enbrel

medroxyprogesterone acetate

medroxyprogesterone acetate

alprostadil

leuprolide

etanercept

Extavia Fertinex Follistim AQ Forteo Fragmin

interferon beta?1b urofollitropin follitropin beta teriparatide dalteparin

Fuzeon

enfuvirtide

Ganirelix Acetate Genotropin Genotropin Miniquick Gonal-F Gonal-F RFF

ganirelix somatropin somatropin follitropin alpha follitropin alpha

DRUG CLASS

Interferons Peripheral Vasodilators Anti-Parkinson's, Others Anticoagulants, Injectable, Other Interferons Interferons Interferons

Interferons Gonadotropins Peripheral Vasodilators Anabolic Hormones GI Anti-Inflammatory GI Anti-Inflammatory Nervous System Disorders, Other Contraceptives, Others

Contraceptives, Others

Peripheral Vasodilators GRH Analogs Antiarthritic, Syst.Bio. Response Modifier Interferons Gonadotropins Gonadotropins Bone Formation Agents Anticoagulants, Fractionated Heparins HIV Entry/Fusion Inhibitor Gonadotropins Anabolic Hormones Anabolic Hormones Gonadotropins Gonadotropins

CODE

J9216 J0270 J0364

J1652

J1825 Q3025 Q3026

J1830 J3355 J0270

J3490 C9249 J3490 J1595

J1055

J1055

J0270 J9218 J1438

J1830 J3355 S0128 J3110 J1645

J1324

S0132 J2941 J2941 S0126 S0126

DESCRIPTION

Injection, interferon, gamma-1b, 3 million units Injection, alprostadil, 1.25 mcg Injection, apomorphine HCl, 1 mg

Injection, fondaparinux sodium, 0.5 mg

Injection, interferon beta-1a, 33 mcg Injection, interferon beta-1a, 11 mcg for intramuscular use Injection, interferon beta-1a, 11 mcg for subcutaneous use Injection interferon beta-1b, 0.25 mg Injection, urofollitropin, 75 IU Injection, alprostadil, 1.25 mcg

Unclassified drugs Injection, certolizumab pegol, 1 mg Unclassified drugs Injection, glatiramer acetate, 20 mg

Injection, medroxyprogesterone acetate for contraceptive use, 150 mg Injection, medroxyprogesterone acetate for contraceptive use, 150 mg Injection, alprostadil, 1.25 mcg Leuprolide acetate, per 1 mg Injection, etanercept, 25 mg

Injection interferon beta-1b, 0.25 mg Injection, urofollitropin, 75 IU Injection, follitropin beta, 75 IU Injection, teriparatide, 10 mcg Injection, dalteparin sodium, per 2500 IU

Injection, enfuvirtide, 1 mg

Injection, ganirelix acetate, 250 mcg Injection, somatropin, 1 mg Injection, somatropin, 1 mg Injection, follitropin alfa, 75 IU Injection, follitropin alfa, 75 IU

OVER

BRAND NAME

Humatrope Humira

GENERIC NAME

somatropin adalimumab

Imitrex

sumatriptan

Increlex Infergen Innohep

mecasermin interferon alfacon?1 tinzaparin

Intron A Intron A Pen Kineret

interferon alfa-2B interferon alfa-2B anakinra

Lovenox

enoxaparin

Lupron (2-week kit only) leuprolide

Luveris

lutropin alpha

Menopur

menotropins

Miacalcin

calcitonin?salmon

Norditropin Norditropin Nodiflex Novarel Nutropin Nutropin AQ Omnitrope Ovidrel Pegasys PEG-Intron PEG-Intron Redi-Pen Pergonal Pregnyl Profasi Prostin VR Pediatric Rebif Rebif Rebif

somatropin somatropin chorionic gonadotropin somatropin somatropin somatropin chorionic gonadotropin peginterferon alfa?2a peginterferon alfa?2b peginterferon alfa?2b menotropins chorionic gonadotropin chorionic gonadotropin alprostadil interferon beta?1a interferon beta?1a interferon beta?1a

Relistor

methylnaltrexone bromide

Repronex Saizen Serostim Simponi

menotropins somatropin somatropin golimumab

Somavert Supprelin Tev Tropin *Victoza Zorbtive

pegvisomant histrelin somatropin liraglutide somatropin

DRUG CLASS

Anabolic Horomones Antiarthritic, Syst.Bio. Response Modifier Serotonin 5ht-1 Receptor Agonists Anabolic Hormones Interferons Anticoagulants, Fractionated Heparins Interferons Interferons Antiarthritic, Syst.Bio. Response Modifier Anticoagulants, Fractionated Heparins GRH Analogs Gonadotropins Gonadotropins Bone Density Regulators, Calcitonins Anabolic Hormones Anabolic Hormones Gonadotropins Anabolic Hormones Anabolic Hormones Anabolic Hormones Gonadotropins Interferons Interferons Interferons Gonadotropins Gonadotropins Gonadotropins Peripheral Vasodilators Interferons Interferons Interferons

MU-Opioid Receptor Antagonists Gonadotropins Anabolic Hormones Anabolic Hormones Antiarthritic, Syst.Bio. Response Modifier Anabolic Hormones Sex Hormones, Other Anabolic Hormones Incretin Mimetics Anabolic Hormones

CODE

J2941 J0135

J3030

J2170 J9212 J1655

J9214 J9214 J3490

J1650

J9218 J3490 S0122 J0630

J2941 J2941 J0725 J2941 J2941 J2941 J0725 S0145 S0146 S0146 S0122 J0725 J0725 J0270 J1825 Q3025 Q3026

J3490

S0122 J2941 J2941 J3490

J3490 J1675 J2941 J3490 J2941

DESCRIPTION

Injection, somatropin, 1 mg Injection, adalimumab, 20 mg

Injection, sumatriptan succinate, 6 mg

Injection, mecasermin, 1 mg Injection, interferon alfacon-1, recombinant, 1 mcg Injection, tinzaparin sodium, 1000 IU

Injection, interferon, alfa-2b, recombinant, 1 million units Injection, interferon, alfa-2b, recombinant, 1 million units Unclassified drugs

Injection, enoxaparin sodium, 10 mg Leuprolide acetate, per 1 mg Unclassified drugs Injection, menotropins, 75 IU Injection, calcitonin salmon, up to 400 units

Injection, somatropin, 1 mg Injection, somatropin, 1mg Injection, chorionic gonadotropin, per 1,000 USP units Injection, somatropin, 1 mg Injection, somatropin, 1 mg Injection, somatropin, 1 mg Injection, chorionic gonadotropin, per 1,000 USP units Injection, pegylated interferon alfa-2a, 180 mcg per ml Injection, pegylated interferon alfa-2b, 10 mcg per 0.5 ml Injection, pegylated interferon alfa-2b, 10 mcg per 0.5 ml Injection, menotropins, 75 IU Injection, chorionic gonadotropin, per 1,000 USP units Injection, chorionic gonadotropin, per 1,000 USP units Injection, alprostadil, 1.25 mcg Injection, interferon beta-1a, 33 mcg Injection, interferon beta-1a, 11 mcg for intramuscular use Injection, interferon beta-1a, 11 mcg for subcutaneous use Unclassified drugs

Injection, menotropins, 75 IU Injection, somatropin, 1 mg Injection, somatropin, 1 mg Unclassified drugs

Unclassified drugs Injection, histrelin acetate, 10 mcg Injection, somatropin, 1 mg Unclassified drugs Injection, somatropin, 1 mg

*Pending FDA approval

AmeriHealth HMO, Inc. ? QCC Insurance Company, d/b/a AmeriHealth Insurance Company

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