Drug List

Drug Formulary

2021 Marketplace Drug Formulary

2022 Marketplace Drug Formulary

Physician Administered Preferred Drug List

Specialty Medication Administration Site of Care Policy

Specialty Medication Administration Site of Care Coverage Criteria Policy

Medication Prior Authorization Criteria and Clinical Policies

Abecma (idecabtagene vicleucel)

Abilify MyCite Kit (aripiprazole with biosensor) C15913-A

Actemra (tocilizumab) C10265-A

Acthar Gel (repository corticotropin injection) C8373-A

Adbry (tralokinumab)

Adcetris (brentuximab vedotin) C15428-A

Aduhelm (aducanumab-avwa) NC C21305-A

Aldara_Zyclara (imiquimod) C4194-C

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

Amitiza (lubiprostone) C5113-C

Amondys 45 (casimersen) NC

Ampyra (dalfampridine) C6480-A

Antidiabetics Criteria C21116-A

Antiemetics C20780-A

Antimalarial Agents C8633-A

Apokyn_Kynmobi (apomorphine) C6918-A

Arcalyst (rilonacept) C2434-A

Arixtra (fondaparinux) C9084-A

Atopic Dermatitis (Elidel-Protopic-Eucrisa) C8268-A

Atypical Antipsychotics C5016-A

Austedo (deutetrabenazine) C12650-A

Azactam (aztreonam) C10143-A (2)

Baxdela (delafloxacin) C16332-A

Belbuca_ Butrans C4199-A

Benlysta (belimumab) C2722A

Beovu (brolucizumab) C17923-A

Botulinum Toxin C8755-A

Brineura (cerliponase alfa) C11526-A

Buprenorphine-Naloxone and Buprenorphine for Opioid Dependence C10899-A

Bylvay (odevixibat).pdf

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

Cablivi (caplacizumab) Criteria C19481-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

Cialis (tadalafil) - BPH Coverage Only C6121-C

Cibinqo (abrocitnib)

Cimzia (certolizumab pegol) C10269-A

Cinqair (reslizumab) C9761-A

CNS Stimulants C4191-A

Colcrys_Mitigare (colchicine) C4205-C

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

Desmopressin Nasal and Oral (DDAVP) C17861-A

Dexamethasone intraocular suspension (Dexycu) MCP

Diabetic Testing Supplies C5108-A

Diclofenac Topical C4962-A

Direct Oral Anticoagulants C20784-A

Disposable Insulin Delivery Device C17724-A

Doptelet (avatrombopag) C16445-A

Doxylamine_Pyridoxine C15190-A

Dry Eye Therapies C4728-A

Dupixent (dupilumab) C11152-A

Duplication of Therapy-High Risk Combination

Durysta (bimatoprost implant) MCP-370

Egrifta SV (tesamorelin) NC C16187-A

Elaprase (idursulfase) C2720-A

Emflaza (deflazacort) NC C10904-A

Empaveli (pegcetacoplan) C21423-A

Enbrel (etanercept) C10411-A

Endari (L-glutamine oral powder) C12651-A

Enjaymo (sutimlimab)

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) MCP-191

Eylea (aflibercept) C5674-A

Fabrazyme (agalsidase beta) C4865-A

Fasenra (benralizumab) C13643-A

Fentanyl Patch C4220-A

Filgrastim C2437-A

Firdapse (amifampridine) C15969-A

Forteo (teriparatide) C8523-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

Global Compound Product C20382-A

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

Global J-Code CriteriaC11251-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

Hetlioz (tasimelteon) C8920-A

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

Humira (adalimumab) C10412-A

Ilaris (canakinumab) C2435-A

Ilumya (tildrakizumab) C15971-A

Iluvien (fluocinolone acetonide intravitreal implant) MCP-301

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

InPen (Smart Insulin Pen) C21865-A

Inrebic (fedratinib)

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

Itraconzaole (Sporanox, Tolsura) C4734-A

Jakafi (ruxolitinib) C17367-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

Koselugo (selumetinib) C19330-A

Krystexxa (pegloticase) C2729-A

Kuvan (sapropterin dihydrochloride) C7067-A

Lemtrada (alemtuzumab) C6919-A

Leqvio (inclisiran)

Leukine (sargramostim) C2439-A

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

Lidocaine Patch C5168-A

Linezolid C8632-A

Linzess (linaclotide) C17874-A

Livmarli (maralixibant)

Livtencity (maribavir)

Lokelma (sodium zirconium cyclosilicate) C17652-A

Lucemyra (lofexidine) C16350-A

Lucentis (ranibizumab) C10417-A

Lumizyme (Alglucosidase alfa) C8716-A

Lupkynis (voclosporin) C21124-A

Lutathera (lutetium Lu 177 dotatate) MCP-322

Luxturna (Voretigene neparvovec-rzyl) MCP-318

Lyrica Lyrica CR (pregabalin_pregabalin ER) C4709-A

Makena (hydroxyprogesterone caproate injection) C10447-A

Medical Necessity Review C20326-A

Mepron (atovaquone) C8408-A

Mepsevii (vestronidase alfa-vjbk) C1794-A

Methadone C9698-A

Motegrity (prucalopride) C16791-A

Mozobil (plerixafor injection) C9017-A

Mulpleta (lusutrombopag) C16446-A

Multiple Sclerosis Agents - Interferons C10267-A

Myalept (metreleptin) C17341-A

Mycamine (micafungin) C9347-A

Narcolepsy Agents C4723-A

Nasal Steroids C4730-A

Natpara (parathyroid hormone) C16013-A

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

Nexviazyme (avalglucosidase alfa-ngpt)

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 MCP-162

Olumiant (baricitinib) C15447-A

Omega-3 Fatty Acids C4708-A

Onpattro (patisiran) C17894-A

Opioid Global Criteria C16263-A

Opioid Induced Constipation Agents C9529-C

Opzelura (ruxolitinib)

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)

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) MCP-282

Palynziq (pegvaliase-pqpz) C15432-A

Parsabiv (etelcalcetide) C17883-A

PCSK9 Inhibitors C10800-A

Pegfilgrastim C10419-A

Penicillamine (Depen, Cuprimine) C15418-A

Prevymis (letermovir) C15922-A

Procysbi and Cystagon (cysteamine bitartrate) C6355-B

Prolia (denosumab) C8848-A

Promacta (eltrombopag) C6663-A

Provenge (sipuleucel-T) MCP-105

Pulmicort Respules (budesonide) C4724-A

Pulmonary Arterial Hypertension (PAH) C9837-A

Pulmozyme (dornase alfa)

Pyrukynd (mitapivat)

Qutenza (capsaicin) C2809-A

Radicava (edaravone) C11528-A

Ravicti (glycerol phenylbutyrate) C7041-A

Reblozyl (luspatercept-aamt) C18002-A

Recorlev (levoketoconazole)

Regranex (becaplermin)

Relizorb (immobilized lipase cartrdige) C12081-A

Restasis and Cequa (cyclosporine ophthalmic) C4728-A

Retisert and Yutiq (fluocinolone acetonide) Intravitreal Corticosteroid Implants MCP-302

Revcovi (elapegademase) Criteria C16106-A

Reyvow (lasmiditan)

Rezurock (belumosudil)

Riluzole (Rilutek, Tiglutik, Exservan) C9697-A

Rinvoq (Upadacitinib) C17882-A

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

Rozlytrek (entrectinib) C17881-A

Ryplazim (plasminogen, human)

Santyl (collagenase) C15159-C

Saphnelo (anifrolumab) C21970-A.pdf

Savella (milnacipran) C4731-A

Scenesse (afamelanotide) Implant MCP-367

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

SINUVA (Mometasone Furoate Sinus Implant)MCP-333

Sivextro (tedizolid) C9353-A

Skyrizi (risankizumab-rzaa) C17336-A

Smoking Cessation C2902-A

Soliris and Ultomiris (eculizumab_ravulizumab) C4867-A

Spinraza (nusinersen) MCP-293

Spiriva (tiotropium) C5109-A

Spravato (esketamine) C16762-A

Stadol (butorphanol tartrate nasal solution) C4735-A

Standard Oncology Criteria C16154-A

Stelara (ustekinumab) C10424-A

Strensiq (asfotase alfa) C9425-A

Sublocade buprenorphine extended-release injection C15161-A

Sunosi (solriamfetol) C17632-A

Supprelin LA (histrelin acetate) Implant C20611-A

Symlin (pramlintide) C4957-A

Synagis (palivizumab) C6074-A

Synarel (nafarelin acetate, nasal solution) C4958-A

Taltz (ixekizumab) C16448-A

Tavalisse (fostamatinib) C16449-A

Tavneos (avacopan) C22223-A

Tegsedi (inotersen) C17325-A

Tepezza (teprotumumab-trbw) C18462-A

Testosterone C2270-A

Tezspire (tezepelumab) C23042-A

Thiola (tiopronin) C18004-A

Tobramycin for inhalation C8665A

Tolvaptan C21091-A

Topical Acne C4190-A

Topical Retinoids C4729-A

Tremfya (guselkumab) C14612-A

Triptodur (triptorelin pamoate) C14649-A

Trogarzo (ibalizumab-uiyk) C14522-A

Tygacil (tigecycline) C14555-A

Tymlos (abaloparatide) C17354-A

Tysabri (natalizumab) C10276-A

Uplizna (inebilizumab) C20171-A

Vabysmo (faricimab) C22795-A

Valcyte (valganciclovir) C4960-A

Vancocin (vancomycin) C5325-C

Veltassa (patriomer) C8840-A

Verquvo (vericiguat) C21141-A

Veklury (remdesivir) C20763-A

Vibativ (telavancin)

Viltepso (vitolarsen) NC C20585-A

Vimizim (elosulfase alfa) C7068-A

Visudyne (verteporfin) Ocular Photodynamic Therapy MCP-308

Vitrakvi (larotrectinib) C16017-A

Vonjo (pacritinib)

Voxzogo (vosoritide) C22221-A

Vyondys 53 (golodirsen) NC C17926-A

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

Vyvgart (efgartigimiod alfa)

Wakix (pitolisant) C17997-A

Xeljanz and Xeljanz XR (tocilizumab) C2721-A

Xenazine (tetrabenazine) C3894-A

Xermelo (telotristat ethyl) C16325-A

Xgeva (denosumab) C8849-A

Xiaflex (collagenase, clostridium histolyticum)_Dupuytrens Contracture MCP-259

Xiaflex (collagenase, clostridium histolyticum)_Peyronie Disease MCP-279

Xifaxan (rifaximin)_Aemcolo (rifamycin) C4964-C

Xipere (triamcinolone ocular inj) C22222-A

Xolair (omalizumab) C8757-A

Xyrem (sodium oxybate) Xywav (calcium, magnesium, potassium, and sodium oxybates) C3925-A

Zavesca (miglustat) C9646-A

Zemplar (paricalcitol) C4967-C

Zilretta (Triamcinolone ER Injection) MCP-349

Zinplava (bexlotoxumab) C14821-A

Zokinvy (lonafarnib) C21125-A

Zoladex (goserelin acetate) C8757-A

Zolgensma (onasemnogene abeparvovec) MCP-348

Zortres (everolimus) C9720-A

Zovirax (acyclovir) C4349-A

Zulresso (brexanolone) C16319-A