Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Aranesp darbepoetin alfa-albumin 25 mcg/mL Solution; 200 mcg/mL Solution; 60 mcg/mL Solution; 100 mcg/mL Solution; 40 mcg/mL Solution; 150 mcg/0.75 mL Solution; 300 mcg/mL Solution   Not Applicable Aranesp darbepoetin alfa-albumin 60 mcg/0.3 mL Syringe; 100 mcg/0.5 mL Syringe; 200 mcg/0.4 mL Syringe; 300 mcg/0.6 mL Syringe; 40 mcg/0.4 mL Syringe; 500 mcg/mL Syringe; 25 mcg/0.42 mL Syringe; 150 mcg/0.3 mL Syringe   Not Applicable Aranesp (polysorbate) darbepoetin alfa in polysorbat 300 mcg/0.6 mL Syringe; 25 mcg/0.42 mL Syringe; 200 mcg/0.4 mL Syringe; 40 mcg/0.4 mL Syringe; 60 mcg/0.3 mL Syringe; 100 mcg/0.5 mL Syringe; 500 mcg/mL Syringe; 150 mcg/0.3 mL Syringe   Not Applicable Aranesp (polysorbate) darbepoetin alfa in polysorbat 300 mcg/mL Solution; 25 mcg/mL Solution; 40 mcg/mL Solution; 60 mcg/mL Solution; 100 mcg/mL Solution; 150 mcg/0.75 mL Solution; 200 mcg/mL Solution   Not Applicable Epogen epoetin alfa 4,000 unit/mL Solution; 20,000 unit/mL Solution; 2,000 unit/mL Solution; 10,000 unit/mL Solution; 40,000 unit/mL Solution; 3,000 unit/mL Solution; 20,000 unit/2 mL Solution   $$$$$+ Leukine sargramostim 250 mcg Recon Soln   $$$$$+ Leukine sargramostim 500 mcg/mL Solution   $$$$$+ Neulasta pegfilgrastim 6 mg/0.6mL Syringe   Not Applicable Neupogen filgrastim 300 mcg/mL Solution; 480 mcg/1.6 mL Solution   $$$$$+ Procrit epoetin alfa 10,000 unit/mL Solution; 3,000 unit/mL Solution; 40,000 unit/mL Solution; 4,000 unit/mL Solution; 2,000 unit/mL Solution; 20,000 unit/mL Solution; 20,000 unit/2 mL Solution   $$$$$+

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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