Drug List

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Drug Formulary

2024 Marketplace Drug Formulary

Physician Administered Preferred Drug List

Physician Administered Preferred Drug List

Physician Administered Preferred Drug List - 2024


Specialty Medication Administration Site of Care Policy

Specialty Medication Administration Site of Care Coverage Criteria Policy

 

Court-Ordered Prescription Drug Coverage Policy

Court-Ordered Prescription Drugs California CARE Act 

 

Medication Prior Authorization Criteria and Clinical Policies 

Abilify MyCite Kit (aripiprazole with biosensor) C15913-A

Actemra (tocilizumab) C10265-A

Acthar Gel (repository corticotropin injection) C8373-A

Adakveo (crizanlizumab-tmca) C17920-A

Adbry (tralokinumab) C23078-A 

Adcetris (brentuximab vedotin) C15428-A

Aduhelm (aducanumab-avwa) C21304-A

Adzynma (adamts13, recombinant-krhn) C27325-A

Aldara_Zyclara (imiquimod) C4194-C

Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A

Amondys 45 (casimersen) NC C21153-A

Ampyra (dalfampridine) C6480-A

Amvuttra (vutrisiran) C24213-A

Antidiabetic Agents C21116-A 

Antiemetics C20780-A 

Antimalarial Agents C8633-A

Aphexda (motixafortide) C27171-A

Apokyn_Kynmobi (apomorphine) C6918-A

Arcalyst (rilonacept) C2434-A

Arixtra (fondaparinux) C9084-A 

Atypical Antipsychotics C5016-A

Austedo (deutetrabenazine) C12650-A

Azactam (aztreonam) C10143-A (2)

Baxdela (delafloxacin) C16332-A

Benlysta (belimumab) C2722A

Beovu (brolucizumab) C17923-A

Bimzelx (bimekizumab) C27172-A

Botulinum Toxin C8755-A

Brineura (cerliponase alfa) C11526-A

Briumvi (ublituximab) C25204-A

Brixadi (buprenorphine ER inj) C27170-A

Buprenorphine-Naloxone and Buprenorphine for Opioid Dependence C10899-A

Bylvay (odevixibat) C22109-A

Cablivi (caplacizumab) Criteria C19481-A

Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C

Camzyos (mavacamten) C23723-A

Cancidas (caspofungin) C17928-A

Carisoprodol Products C11268-A

Cayston (aztreonam) C6481-A

Cerdelga (eliglustat) C6633-A

Chemet (succimer) C9816-A

Cholbam (cholic acid) C17319-A 

Cibinqo (abrocitnib) C23363-A

Cimzia (certolizumab pegol) C10269-A

Cinqair (reslizumab) C9761-A

CNS Stimulants C4191-A

Colcrys, Mitigare, Gloperba (colchicine) C4205-A

Constipation Agents C24671-A

Continuous Glucose Monitoring Systems (CGMS) C17737-A

Copaxone_Glatopa (glatiramer acetate) C10270-A

Cosela (trilaciclib) C21205-A

Cosentyx (secukinumab) C10410-A

Crysvita (Burosumab-twza) C14517-A

Cubicin (daptomycin) C10467-A

Cuvposa (glycopyrrolate) oral solution C8453-A

Cystic Fibrosis Agents C2436-A

Cytogam (cytomegalovirus immune globulin) C9970-A

Dalvance (dalbavancin) C9351-A

Daraprim (pyrimethamine) C8631-A

Daybue (trofinetide) C25469-A

Desmopressin Nasal and Oral (DDAVP) C17861-A

Dextenza (dexamethasone intracanalicular insert) C24242-A 

Dexycu (dexamethasone intraocular suspension) C16320-A

Diabetic Testing Supplies C5108-A

Diclofenac Topical C4962-A

Direct Oral Anticoagulants C20784-A

Disposable Insulin Delivery Device C17724-A

Doptelet (avatrombopag) C16445-A 

Dry Eye Therapies C4728-A

Dupixent (dupilumab) C11152-A

Duplication of Therapy-High Risk Combination C15341-A

Durysta (bimatoprost implant) C19830-A

Egrifta SV (tesamorelin) NC C16187-A

Elaprase (idursulfase) C2720-A

Elfabrio (pegunigalsidase alfa) C25604-A

Elidel-Protopic-Eucrisa C8268-A

Emflaza (deflazacort) NC C10904-A

Empaveli (pegcetacoplan) C21423-A

Enbrel (etanercept) C10411-A

Endari (L-glutamine oral powder) C12651-A

Enjaymo (sutimlimab) C22996-A

Enspryng (satralizumab-mwge) 20849-A

Entresto (sacubitril_valsartan) C8675-A

Entyvio (vedolizumab) C6773-A

Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A

Epidiolex (cannabidiol) C19326-A 

Evkeeza (evinacumab_dgnb) C21101-A

ERT for Lysosomal Storage Disorders (MPS I, VI) [Aldurazyme, Naglazyme] C9997-A

Erythropoiesis-stimulating Agents (ESAs) C15389-A

Esbriet (pirfenidone) C16582-A

Evenity (romosozumab-aqqg) C17324-A

Evrysdi (risdiplam) C20580-A

Exondys 51 (eteplirsen) NC C9941-A

Eylea (aflibercept) C5674-A

Fabrazyme (agalsidase beta) C4865-A

Fasenra (benralizumab) C13643-A

Filgrastim C2437-A

Filspari (sparsentan) C25282-A

Firdapse (amifampridine) C15969-A

Forteo (teriparatide) C8523-A

Furoscix (furosemide on-body infusor) C24669-A

Fuzeon (enfuvirtide) C9573-A

Galafold (migalastat) C15445-A

Gamifant (emapalumab-lzsg) C15970-A

Gattex (teduglutide [rDNA origin]) C5774-A

Gender Dysphoria Hormone Therapy C17908-A

Givlaari (givosiran) C17924-A

Global Formulary Exception Criteria (NF, QL, ST, etc) C10169-A

Gocovri_Osmolex (amantadine ER caps and tabs) C13296-A

Growth Hormone (hGH, somatropin) Therapy C6925-A

Hemophilia and Blood Factor Products C15607-A

Hemostatic Agents C14570-A

Hepatitis B Immune Globulin C9971-A

Hepatitis C Antiviral Therapy C12049-A

Hereditary Angioedema Agents C21463-A

Hetlioz (tasimelteon) C8920-A

High-Cost Outlier Targeted Drug Exceptions (HOT) C17973-A

Humira (adalimumab) C10412-A

Hyaluronic Acid (HA) Injections_Viscosupplementation for Knee OsteoArthritis C14676-A

Igalmi (dexmedetomidine) C23724-A

Ilaris (canakinumab) C2435-A

Ilumya (tildrakizumab) C15971-A

Iluvien (fluocinolone acetonide intravitreal implant) C11728-A

Imcivree (setmelanotide) NC C22214-A

Impetigo Agents- Altabax, Centany, Xepi C8409-A

Immunoglobulin (SCIg, IVIg) C21554-A

Increlex (mecasermin) C8891-A

Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A

Ingrezza (valbenazine) C12649-A

Inpefa (sotagliflozin) C26204-A

InPen (Smart Insulin Pen) C21865-A

Inrebic (fedratinib) C17941-A

Insulin Patch NC C24238-A

Intravenous Bisphosphonates C16790-A

Iron Chelating Agents (Desferal Exjade Ferriprox Jadenu) C15214-A

Iron Deficiency Anemia Agents C14569-A

Isotretinoin C4231-C

Isturisa (osilodrostat) C19328-A

Izervay (avacincaptad intravitreal) C26436-A

Jakafi (ruxolitinib) C17367-A

Jesduvroq (daprodustat) C27174-A

Joenja (leniolisib) C25485-A

Juxtapid (lomitapide) C3893-A

Kanuma (sebelipase alfa) C9974-A

Kesimpta (ofatumumab) C21104-A

Keveyis (dichlorphenamide) C14599-A

Kevzara (sarilumab) C14653-A

Kerendia (finerenone) C21829-A

Kineret (anakinra) C10415-A

Korlym (mifepristone) C10881-A

Korsuva (difelikefalin) C23743-A

Koselugo (selumetinib) C19330-A

Krystexxa (pegloticase) C2729-A

Kuvan (sapropterin dihydrochloride) C7067-A

Lamzede (velmanase alfa) C25436-A

Lemtrada (alemtuzumab) C6919-A

Leqembi (lecanemab) C25201-A

Leqvio (inclisiran) C23141-A

Leukine (sargramostim) C2439-A

Leuprolide long acting (Lupron Depot Eligard Lupaneta Lupron Depot Ped Triptodur) C8756-A

Lidocaine Patch C5168-A

Linezolid C8632-A

Litfulo (ritlecitinib) NC C26206-A

Livmarli (maralixibant) C22224-A

Livtencity (maribavir) C22246-A

Lucemyra (lofexidine) C16350-A

Lumizyme (Alglucosidase alfa) C8716-A

Lupkynis (voclosporin) C21124-A

Lyrica Lyrica CR (pregabalin_pregabalin ER) C4709-A

Medical Necessity Review C20326-A

Mepron (atovaquone) C8408-A

Mepsevii (vestronidase alfa-vjbk) C1794-A

Mozobil (plerixafor injection) C9017-A

Mulpleta (lusutrombopag) C16446-A

Multiple Sclerosis Agents - Interferons C10267-A

Myalept (metreleptin) C17341-A

Mycamine (micafungin) C9347-A

Nasal Steroids C4730-A

Natpara (parathyroid hormone) C16013-A

Nexletol (bempedoic acid) and Nexlizet (bempedoic acid and ezetimibe) C18441-A

NexoBrid (anacaulase gel) C25200-A

Nexviazyme (avalglucosidase alfa-ngpt) C21948-A

Nitisinone (Orfadin_Nityr) C13398-A

Northera (droxidopa) C13402-A

Nplate (romiplostim)_Chronic ITP C6662-A

Nucala (mepolizumab) C9704-A

Nuedexta (dextromethorphan-quinidine) C12971-C

Nulojix (belatacept) C9968-A

Nulibry (fosdenopterin) C21306-A

Nuplazid (pimavanserin) C12066-A

Nuzyra (omadacycline tosylate) C15914-A

Ocaliva (obeticholic acid) C16447-A

Ocrevus (ocrelizumab) C11250-A

Octreotide C8839-A

Ofev (nintedanib) C16583-A

Off-Label Use of Drugs and Biologic Agents C4141-A

Ojjaara (momelotinib) C27175-A

Olumiant (baricitinib) C15447-A

Omvoh (mirikizumab-mrkz) C27293-A

Onpattro (patisiran) C17894-A

Opfolda (miglustat) C27241-A

Opioid Global Criteria C16263-A

Opzelura (ruxolitinib) C22277-A

Oral MS Disease-Modifying Therapies C21142-A

Orencia (abatacept) C10420-A

Orgovyx (relugolix), Myfembree (relugolix, estradiol, and norethindrone) C21100-A

Orilissa (elagolix) Oriahn (elagolix estradiol and norethindrone acetate capsules) C15417-A

Orladeyo (berotralstat) C21230-A

Otezla (apremilast) C6356-B

Otrexup and Rasuvo (methotrexate) C14770-A

Oxbryta (voxelotor) C17965-A

Oxervate (cenegermin) C16015-A

Oxlumo (lumasiran) C21126-A

Ozurdex  (dexamethasone intravitreal implant) C9975-A

Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] C18457-A

Palynziq (pegvaliase-pqpz) C15432-A

Parsabiv (etelcalcetide) C17883-A

PCSK9 Inhibitors C10800-A

Penicillamine (Depen, Cuprimine) C15418-A

Physician Administered Drugs C11251-A

Pombiliti (cipaglucosidase alfa) C27242-A

Prescription Compounded Product C20382-A

Prevymis (letermovir) C15922-A

Procysbi and Cystagon (cysteamine bitartrate) C6355-B

Prolia (denosumab) C8848-A

Promacta (eltrombopag) C6663-A

Pulmicort Respules (budesonide) C4724-A

Pulmonary Arterial Hypertension (PAH) C9837-A

Pulmozyme (dornase alfa) C9796-A

Pyrukynd (mitapivat) C22822-A

Qalsody (tofersen) C25487-A

Qutenza (capsaicin) C2809-A

Radicava (edaravone) C11528-A

Ranibizumab (Lucentis, Byooviz, Cimerli) C10417-A

Ravicti (glycerol phenylbutyrate) C7041-A

Reblozyl (luspatercept-aamt) C18002-A

Rebyota (fecal microbiota) C25213-A

Recorlev (levoketoconazole) C23359-A

Regranex (becaplermin) C13432-C

Relizorb (immobilized lipase cartridge) C12081-A

Relyvrio (sodium phenylbutyrate;sodium taurufsodiol) C24678-A

Revcovi (elapegademase) Criteria C16106-A

Reyvow (lasmiditan) C18446-A

Rezurock (belumosudil) C22106-A

Rezzayo (rezafungin) C26183-A

Riluzole (Rilutek, Tiglutik, Exservan) C9697-A

Rinvoq (Upadacitinib) C17882-A

Rituxan (rituximab) Rituxan Hycela (rituximab and hyaluronidase human) C10423-A

Rolvedon, Neulasta and Related Biosimilars C10419-A 

Ryplazim (plasminogen, human) C22238-A

Rystiggo (rozanolixizumab) C26210-A

Santyl (collagenase) C15159-C

Saphnelo (anifrolumab) C21970-A.pdf

Savella (milnacipran) C4731-A

Sensipar (cinacalcet) C9721-A

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) C4719-A

Sexual Dysfunction Criteria - Non-Coverage C16658-A

Seysara (sarecycline) C15974-A

Signifor (pasireotide diaspartate) C15367-A

Siliq (brodalumab) C17334-A

Simponi and Simponi Aria (golimumab) C10422-A

Sivextro (tedizolid) C9353-A

Skyclarys (omaveloxolone) C25422-A

Skyrizi (risankizumab-rzaa) C17336-A

Sodium Oxybate (Lumryze, Xyrem, Xywav) C3925-A

Sohonos (palovarotene) C27173-A

Soliris and Ultomiris (eculizumab_ravulizumab) C4867-A

Sotyktu (deucravacitinib) C24672-A

Spevigo (spesolimab-sbzo) C24676-A

Spiriva (tiotropium) C5109-A

Sporanox, Tolsura (itraconazole) C4734-A

Spravato (esketamine) C16762-A

Standard Oncology Criteria C16154-A

Stelara (ustekinumab) C10424-A

Strensiq (asfotase alfa) C9425-A

Sublocade buprenorphine extended-release injection C15161-A

Sunlenca (lenacapavir) C25206-A

Sunosi (solriamfetol) C17632-A

Supprelin LA (histrelin acetate) Implant C20611-A

Syfovre (pegcetacoplan) C25311-A

Symlin (pramlintide) C4957-A

Synagis (palivizumab) C6074-A

Synarel (nafarelin acetate, nasal solution) C4958-A

Tadalafil and combinations C6121-C

Taltz (ixekizumab) C16448-A

Tarpeyo (budesonide) C24199-A

Tavalisse (fostamatinib) C16449-A

Tavneos (avacopan) C22223-A

Tepezza (teprotumumab-trbw) C18462-A

Testosterone C2270-A

Tezspire (tezepelumab) C23042-A

Thiola (tiopronin) C18004-A

Tobramycin for inhalation C8665-A

Tolvaptan C21091-A

Topical Acne C4190-A

Topical Antibacterials C8409-A

Topical Retinoids C4729-A

Tremfya (guselkumab) C14612-A

Triptodur (triptorelin pamoate) C14649-A

Trogarzo (ibalizumab-uiyk) C14522-A 

Tymlos (abaloparatide) C17354-A

Tysabri (natalizumab) C10276-A

Tzield (teplizumab) C24729-A

Uplizna (inebilizumab) C20171-A

Vabysmo (faricimab) C22795-A

Valcyte (valganciclovir) C4960-A

Vancocin (vancomycin) C5325-C

Veozah (fezolinetant) C25593-A

Verquvo (vericiguat) C21141-A

Veklury (remdesivir) C20763-A

Velsipity (etrasimod) C27181-A

Veopoz (pozelimab-bbfg) C26434-A

Vibativ (telavancin) C14575-A

Vibrant (transient device for constipation capsule) NC C25205-A

Vijoice (alpelisib) C23736-A

Viltepso (vitolarsen) NC C20585-A

Vimizim (elosulfase alfa) C7068-A 

Vonjo (pacritinib) C23019-A

Vowst (fecal microbiota spores live-brpk)

Voxzogo (vosoritide) C22221-A

Vtama (tapinarof) cream C23729-A

Vyondys 53 (golodirsen) NC C17926-A

Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis) C17345-A

Vyvgart (efgartigimiod alfa)

Wakix (pitolisant) C17997-A

Wegovy (semaglutide) NC C27682-A

Xacduro (sulbactam and durlobactam) C26432-A

Xeljanz and Xeljanz XR (tocilizumab) C2721-A

Xenazine (tetrabenazine) C3894-A

Xenpozyme (olipudase alfa-rpcp) C24670-A

Xermelo (telotristat ethyl) C16325-A

Xgeva (denosumab) C8849-A

Xiaflex (collagenase clostridium histolyticum) C24319-A

Xifaxan (rifaximin)_Aemcolo (rifamycin) C4964-C

Xipere (triamcinolone ocular inj) C22222-A

Xolair (omalizumab) C8757-A

Xphozah (tenapanor) C27292-A 

Zavesca (miglustat) C9646-A

Zemplar (paricalcitol) C4967-C

Zilretta (Triamcinolone ER Injection) C16855-A

Zinplava (bexlotoxumab) C14821-A

Zokinvy (lonafarnib) C21125-A

Zoladex (goserelin acetate) C8757-A

Zortress (everolimus) C9720-A

Zoryve (roflumilast) C24324-A

Zovirax (acyclovir) C4349-A

Ztalmy (ganaxolone) C24321-A

Zulresso (brexanolone) C16319-A

Zurzuvae (zuranolone) C27296-A