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Home infusion drugs

Effective 1/1/2019 home infusion drugs are covered by all plans from Security Health Plan with the exception of BadgerCare (Medicaid), Medicare – MSA, Medicare Supplement with Riders, Medicare Select and Family Health Center (FHC). Below you will find the most up to date home infusion drug list. Home infusion drugs may be added or removed from this list quarterly on a calendar year basis. Home infusion drugs may require prior authorization call our Customer Service Department at 1-844-293-9624 to find out what medical benefit drugs require prior authorization for home infusion.

2019 Home Infusion List

Generic Names Brand Names
ANALGESICS
Fentanyl Citrate
Hydromorphone
Hydromorphone DILAUDID®
Meperidine Hcl DEMEROL®
Morphine Sulfate ASTRAMORPH-PF®
Morphine Sulfate
Morphine Sulfate INFUMORPH®
Ropivacaine
Ziconotide PRIALT®
ANTIBACTERIALS
Amikacin
Ampicillin
Ampicillin/Sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
Cefotaxime
Cefotetan
Cefoxitin
Ceftaroline TEFLARO®
Ceftazidime
Ceftolozane/Tazobactam ZERBAXA®
Ceftriaxone
Cefuroxime
Chloramphenicol
Ciprofloxacin In 5 % Dextrose
Clindamycin
Colistimethate
Daptomycin
Doxycycline Hyclate
Ertapenem INVANZ®
Erythromycin
Gentamicin In Nacl, Iso-Osm
Gentamicin
Imipenem/Cilastatin
Levofloxacin
Linezolid
Meropenem
Meropenem/Vaborbactam VABOMERE®
Metronidazole
Moxifloxacin In Nacl (Iso-Osm) AVELOX®
Moxifloxacin In Nacl (Iso-Osm)
Nafcillin
Oxacillin
Pen G Pot/Dextrose-Water
Penicillin G Potassium
Penicillin G Sodium
Piperacillin /Tazobactam
Piperacillin-Tazo-Dextrose,Iso
Polymyxin B
Streptomycin
Sulfamethoxazole/Trimethoprim
Tedizolid SIVEXTRO®
Telavancin VIBATIV®
Tigecycline
Tobramycin
Vancomycin
ANTICANCER AGENTS
Bleomycin
Cladribine
Cyclophosphamide
Cytarabine
Daunorubicin
Daunorubicin/Cytarabine Lipos VYXEOS®
Doxorubicin ADRIAMYCIN®
Doxorubicin
Doxorubicin Peg-Liposomal
Etoposide
Etoposide ETOPOPHOS®
Fluorouracil
Methotrexate
Mitomycin
Mitoxantrone
Streptozocin ZANOSAR®
Vinblastine
Vincristine
Vincristine Liposomal MARQIBO®
ANTIFUNGALS
Amphotericin B Lipid Complex ABELCET®
Amphotericin B
Amphotericin B Liposome AMBISOME®
Anidulafungin ERAXIS ®
Caspofungin
Fluconazole In Nacl,Iso-Osm
Micafungin MYCAMINE®
Posaconazole NOXAFIL®
Voriconazole
ANTINAUSEA AGENTS
Metoclopramide
Ondansetron
Palonosetron Aloxi®
ANTIPARASITIC AGENTS
Pentamidine PENTAM 300®
ANTIVIRALS (SYSTEMIC)
Acyclovir
Foscarnet
Ganciclovir
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
Aminocaproic Acid
Cathflo Alteplase ACTIVASE®
Desmopressin
Emicizumab-Kxwh HEMLIBRA®
Factor Ix ALPHANINE SD®
Factor Ix ALPROLIX®
Factor Ix BENEFIX®
Factor Ix IDELVION®
Factor Ix IXINITY®
Factor Ix MONONINE®
Factor Viia NOVOSEVEN®
Factor X COAGADEX®
Factor Xiii ADVATE®
Factor Xiii AFSTYLA®
Factor Xiii ALPHANATE®
Factor Xiii CORIFACT®
Factor Xiii ELOCTATE®
Factor Xiii HELIXATE FS®
Factor Xiii HEMOFIL M®
Factor Xiii HUMATE P®
Factor Xiii KOATE®
Factor Xiii KOGENATE FS®
Factor Xiii KOVALTRY®
Factor Xiii MONOCLATE P®
Factor Xiii NOVOEIGHT®
Factor Xiii NUWIQ®
Factor Xiii RECOMINATE®
Factor Xiii WILATE®
Factor Xiii XYNTHA®
Heparin
Phytonadione
Vonwildebrand Factor VONVENDI®
C1 ESTERASE INHIBITOR (HEREDITARY ANGIOEDEMA)
C1 Esterase Inhibitor BERINERT®
C1 Esterase Inhibitor CINRYZE®
C1 Esterase Inhibitor, Recomb RUCONEST®
CALORIC AGENTS
Aa 2.36%/D6.8W/Fat/E-Lytes No9 PERIKABIVEN®
Aa 2.75 %/Calcium/Lytes/D10W CLINIMIX E®
Aa 3.31 %/D9.8W/Fat/E-Lytes 10 KABIVEN®
Amino Ac 3%/Electrolyte/Glycer PROCALAMINE®
Amino Acid 4.25 %/Dextrose 25% CLINIMIX®
Amino Acids 10 % TROPHAMINE®
Amino Acids 3.5%/Electrolyte M AMINOSYN M®
Amino Acids 5.4 % NEPHRAMINE®
Amino Acids 6.9 % FREAMINE HBC®
Amino Acids 7 % AMINOSYN-HBC®
Amino Acids 7 %/Electrolytes AMINOSYN WITH ELECTROLYTES®
Amino Acids 8 % HEPATAMINE®
Amino Acids 8.5 %/Electrolytes AMINOSYN II WITH ELECTROLYTES®
Dextrose 10 % In Water
Dextrose 5 % In Ringer'S
Fat Emulsions INTRALIPID®
Fat Emulsions NUTRILIPID®
Parent Amino Ac 5.2 % (Renal) AMINOSYN-RF®
Parent. Amino Acid 8.5 % No.2 AMINOSYN®
Parent. Amino Acid 8.5 % No.3 AMINOSYN II®
Parent.Amino Acid 10% No5(Ped) AMINOSYN-PF®
Parenteral Amino Acid 10% No.4 FREAMINE III®
Parenteral Amino Acid 10% No.6 TRAVASOL®
Parenteral Amino Acid 10% No.7 PREMASOL®
Parenteral Amino Acid 15% No.1 CLINISOL®
Parenteral Amino Acid 15% No.1 PLENAMINE®
Parenteral Amino Acid 20% No.1 PROSOL®
CARDIOVASCULAR AGENTS
Bumetanide
Chlorothiazide
Dobutamine
Dopamine
Furosemide
Milrinone
CENTRAL NERVOUS SYSTEM AGENTS
Alemtuzumab LEMTRADA®
Edaravone RADICAVA®
Nusinersen SPINRAZA®
CORTICOSTEROIDS
Dexamethasone Sodium Phosp
Methylprednisolone Acetate
Methylprednisolone Sod Succ
ENZYME REPLACEMENT/MODIFIERS
Agalsidase Beta FABRAZYME®
Alglucosidase Alfa LUMIZYME®
Galsulfase NAGLAZYME®
Idursulfase ELAPRASE®
Imiglucerase CEREZYME®
Laronidase ALDURAZYME®
Pegloticase KRYSTEXXA®
Taliglucerase ELELYSO®
Velaglucerase VPRIV®
IRON REPLACEMENT AGENTS
Deferoxamine
Ferric carboxymaltose INJECTAFER®
ferumoxytro FERAHEME®
Iron Dextran INFED®
Iron sucrose VENOFER®
Sodium Ferric Gluconate
IMMUNOLOGICAL AGENTS
Abatacept ORENCIA®
Basiliximab SIMULECT®
Belimumab BENLYSTA®
Certolizumab CIMZIA®
Cyclosporine
Cytomegalovirus Immune Globuln CYTOGAM®
Dupilumab DUPIXENT®
Eculizumab SOLIRIS®
Golimumab SIMPONI ARIA®
Hepatitis B Immun Glob/Maltose HEPAGAM B®
Hepatitis B Immune Globulin HYPERHEP B S-D®
Hepatitis B Immune Globulin NABI-HB®
Igg/Hyaluronidase,Recombinant HYQVIA®
Imm Glob G (Igg)/Sorb/Iga 0-50 FLEBOGAMMA DIF®
Immun Glob G(Igg)/Gly/Iga 0-50 GAMMAPLEX®
Immun Glob G(Igg)/Gly/Iga Ov50 BIVIGAM®
Immun Glob G(Igg)/Gly/Iga Ov50 GAMMAGARD LIQUID®
Immun Glob G(Igg)/Pro/Iga 0-50 HIZENTRA®
Immun Glob G(Igg)/Pro/Iga 0-50 PRIVIGEN®
Immun Glob G/Gly/Gluc/Iga 0-50 GAMMAGARD S-D®
Immun Globg(Igg)/Malt/Iga Ov50 OCTAGAM®
Immun Globg(Igg)/Sucr/Iga Ov50 CARIMUNE NF NANOFILTERED®
Immune Globul G (Igg)/Glycine GAMASTAN S-D®
Immune Globul G/Gly/Iga Avg 46 GAMMAKED®
Immune Globul G/Gly/Iga Avg 46 GAMUNEX-C®
Infliximab REMICADE®
Infliximab-Abda RENFLEXIS®
Infliximab-Dyyb INFLECTRA®
Lymphocyte Ig, Antithymocyte ATGAM®
Lymphocyte Immune Glob,Rabbit THYMOGLOBULIN®
Natalizumab TYSABRI®
Rho(D) Immune Globulin HYPERRHO®
Rho(D) Immune Globulin MICRHOGAM®
Rho(D) Immune Globulin RHOGAM®
Rho(D) Immune Globulin RHOPHYLAC®
Rho(D) Immune Globulin/Maltose WINRHO SDF®
Tocilizumab ACTEMRA®
Ustekinumab STELARA®
Vedolizumab ENTYVIO®
METABOLIC BONE DISEASE AGENTS
Zoledronic Acid
Zoledronic Acid ZOMETA®
denosumab PROLIA®
denosumab XGEVA®
MUSCULAR DYSTROPHY AGENTS
Eteplirsen EXONDYS 51®
REPLACEMENT PREPARATIONS
0.9 % Sodium Chloride
Dextrose 10 % And 0.2 % Nacl
Dextrose 10 % And 0.45 % Nacl
Dextrose 2.5 % And 0.45 % Nacl
Dextrose 5 % And 0.3 % Nacl
Dextrose 5 % And 0.9 % Nacl
Dextrose 5 %-0.2 % Sod Chlorid
Dextrose 5 %-0.45 % Sod Chlord
Dextrose 5%-Lactated Ringers
DEXTROSE 5%-0.2% NACL-KCL
DEXTROSE 5%-0.225% NACL
DEXTROSE 5%-0.225% NACL-KCL
DEXTROSE 5%-0.3% NACL-KCL
DEXTROSE 5%-0.45% NACL-KCL
DEXTROSE 5%-1/4NS-KCL
DEXTROSE 5%-NS-KCL
DEXTROSE 5%-POTASSIUM CHLORIDE
DEXTROSE 5%-1/2NS-KCL
DEXTROSE IN WATER
DEXTROSE IN LACTATED RINGERS
Magnesium
Potassium Chloride
Potassium Chloride In 0.9%Nacl
Potassium Chloride In D5W
Potassium Chloride In Lr-D5
Potassium Chloride/D5-0.2%Nacl
Potassium Chloride/D5-0.3%Nacl
Potassium Chloride/D5-0.45Nacl
Potassium Chloride/D5-0.9%Nacl
Potassium Chloride-0.45% Nacl
Thiamine
RESPIRATORY TRACT AGENTS
Alpha-1-Proteinase Inhibitor ARALAST NP®
Alpha-1-Proteinase Inhibitor GLASSIA®
Alpha-1-Proteinase Inhibitor PROLASTIN C®
Alpha-1-Proteinase Inhibitor ZEMAIRA®
Aminophylline
Benralizumab FASENRA®
Mepolizumab NUCALA®
Omalizumab XOLAIR®
Reslizumab CINQAIR®
VASODILATING AGENTS
Epoprostenol VELETRI®
Treprostinil REMODULIN®