2020 Marketplace Drug Formulary
2021 Marketplace Drug Formulary
Physician Administered Preferred Drug List
AAT Deficiency (Aralast NP, Glassia, Prolastin, Zemaira) MCP-042
Abelecet (ampho B, lipid complex) C10144-A
Abilify MyCite Kit (aripiprazole with biosensor) C15913-A
Actemra (tocilizumab) C10265-A
Acthar Gel (repository corticotropin) MCP-262
Adakveo (crizanlizumab-tmca) MCP-358
Adcetris (brentuximab vedotin) C15428-A
Akynzeo (fosnetupitant palonosetron; netupitant palonosetron) C9350-A
Aldara_Zyclara (imiquimod) C4194-C
Ambisome (ampho B, lipoSOME) C9530-A
Amitiza (lubiprostone) C5113-C
Ampyra (dalfampridine) C6480-A
Aprepitant; fosaprepitant C4222-C
Arixtra (fondaparinux) C9084-A
Atopic Dermatitis (Elidel-Protopic-Eucrisa) C8268-A
Atypical Antipsychotics C5016-A
Aubagio (teriflunomide) C3890-A
Austedo (deutetrabenazine) C12650-A
Azactam (aztreonam) C10143-A (2)
Baxdela (delafloxacin) C16332-A
Berinert [C1 esterase inhibitor (human)] C6770-A
Brineura (cerliponase alfa) MCP-299
Buprenorphine-Naloxone and Buprenorphine for Opioid Dependence C10899-A
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C
Cablivi (caplacizumab) Criteria XXXXXX-X
Cancidas (caspofungin) C9348-A
Carisoprodol Products C11268-A
Cholbam (cholic acid) C17319-A
Cialis (tadalafil) - BPH Coverage Only C6121-C
Cimzia (certolizumab pegol) C10269-A
Cinryze [C1 esterase inhibitor (human)] C6771-A
Colcrys_Mitigare (colchicine) C4205-C
Continuous Glucose Monitoring Systems (CGMS) C17737-A
Copaxone_Glatopa (glatiramer acetate) C10270-A
Cosentyx (secukinumab) C10410-A
Crysvita (Burosumab-twza) C14517-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-342
Diabetic Testing Supplies C5108-A
Dipeptidyl Peptidase-4 Inhibitors and Combinations C5169-A
Disposable Insulin Delivery Device C17724-A
Doptelet (avatrombopag) C16445-A
Doxylamine_Pyridoxine C15190-A
Duplication of Therapy-High Risk Combination
Durysta (bimatoprost implant) MCP-370
Egrifta (tesamorelin) MCP-131 (Non-coverage)
Elaprase (idursulfase) MCP-024
Emflaza (deflazacort) MCP-298 (Non-coverage)
Endari (L-glutamine oral powder) C12651-A
Entresto (sacubitril_valsartan) C8675-A
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A
Epidiolex (cannabidiol) XXXXX-X
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
Exondys 51 (eteplirsen) MCP-290
Fabrazyme (agalsidase beta) C4865-A
Fasenra (benralizumab) C13643-A
Firdapse_Ruzurgi (Amifamipridine) C15969-A
Galafold (migalastat) C15445-A
Gamifant (emapalumab-lzsg) C15970-A
Gattex (teduglutide [rDNA origin]) C5774-A
Gender Dysphoria Hormone Therapy C17908-A
Global Formulary Exception Criteria (NF, QL, ST, etc) C10169-A
Global J-Code CriteriaC11251-A
Glucagon-like Peptide-1 (GLP-1) receptor agonist C5015-A
Gocovri_Osmolex (amantadine ER caps and tabs) C13296-A
Growth Hormone (hGH, somatropin) Therapy C6925-A
Haegarda (C1 Esterase Inhibitor Subcutaneous [human]) C12157-A
Hemophilia and Blood Factor Products C15607-A
Hepatitis B Immune Globulin C9971-A
Hepatitis C Antiviral Therapy C12049-A
High-Cost Outlier Targeted Drug Exceptions (HOT) C17973-A
Human Growth Hormone Therapy C6925-A
Hyaluronic Acid Injections_Viscosupplementation for Knee OA MCP-046
Ilumya (tildrakizumab) C15971-A
Iluvien (fluocinolone acetonide intravitreal implant) MCP-301
Impetigo Agents-Altabax, Centany (mupirocin), Xepi C8409-A
Infliximab (Remicade_Inflectra_Renflexis) C10421-A
Ingrezza (valbenazine) C12649-A
Intravenous Bisphosphonates C16790-A
Intravenous Immune Globulin for Solid Organ Transplant MCP-237
Intravenous Immunoglobulin (IVIg) MCP-043
Iron Chelating Agents (Desferal Exjade Ferriprox Jadenu) C15214-A
Iron Deficiency Anemia Agents C14569-A
Isturisa (osilodrostat) CXXXXX-X
Jetrea (ocriplasmin) Vitreomacular Adhesion MCP-297
Kalbitor (ecallantide) C6772-A
Kanuma (sebelipase alfa) C9974-A
Keveyis (dichlorphenamide) C14599-A
Korlym (mifepristone) C10881-A
Koselugo (selumetinib) CXXXXX-X
Krystexxa (pegloticase) C2729-A
Kuvan (sapropterin dihydrochloride) C7067-A
Lemtrada (alemtuzumab) C6919-A
Leukine (sargramostim) C2439-A
Leuprolide long acting (Lupron Depot Eligard Lupaneta Lupron Depot Ped Triptodur) C8756-A
Linzess (linaclotide) C17874-A
Lokelma (sodium zirconium cyclosilicate) C17652-A
Lucemyra (lofexidine) C16350-A
Lucentis (ranibizumab) C10417-A
Lumizyme (Alglucosidase alfa) C8716-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
Mavenclad (cladribine) C17329-A
Mepsevii (vestronidase alfa-vjbk) C1794-A
Motegrity (prucalopride) C16791-A
Mozobil (plerixafor injection) C9017-A
Mulpleta (lusutrombopag) C16446-A
Multiple Sclerosis Agents - Interferons C10267-A
Myalept (metreleptin) C17341-A
Natpara (parathyroid hormone) C16013-A
Nexletol (bempedoic acid) and Nexlizet (bempedoic acid and ezetimibe) XXXXXXX
Nitisinone (Orfadin_Nityr) C13398-A
Nplate (romiplostim)_Chronic ITP C6662-A
Nuedexta (dextromethorphan-quinidine) C12971-C
Nuplazid (pimavanserin) C12066-A
Nuzyra (omadacycline tosylate) C15914-A
Ocaliva (obeticholic acid) C16447-A
Ocrevus (ocrelizumab) C11250-A
Off-Label Use of Drugs and Biologic Agents MCP-162
Olumiant (baricitinib) C15447-A
Opioid Global Criteria C16263-A
Opioid Induced Constipation Agents C9529-C
Otrexup and Rasuvo (methotrexate) C14770-A
Oxervate (cenegermin) C16015-A
Ozurdex (dexamethasone intravitreal implant) MCP-282
Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] MCP-360
Palynziq (pegvaliase-pqpz) C15432-A
Parsabiv (etelcalcetide) C17883-A
Penicillamine (Depen, Cuprimine) C15418-A
Pradaxa (dabigatran etexilate mesylate) C17731-A
Prevymis (letermovir) C15922-A
Probuphine (buprenorphine implant) C10952-A
Procysbi and Cystagon (cysteamine bitartrate) C6355-B
Promacta (eltrombopag) C6663-A
Proton Pump Inhibitors C4714-A
Provenge (sipuleucel-T) MCP-105
Pulmicort Respules (budesonide) C4724-A
Pulmonary Arterial Hypertension (PAH) C9837-A
Ravicti (glycerol phenylbutyrate) C7041-A
Reblozyl (luspatercept-aamt) C18002-A
Relizorb (immobilized lipase cartrdige) C12081-A
Remicade (infliximab) C10421-A
Restasis and Cequa (cyclosporine ophthalmic) C4728-A
Retisert and Yutiq (fluocinolone acetonide) Intravitreal Corticosteroid Implants MCP-302
Revcovi (elapegademase) Criteria C16106-A
Riluzole (Rilutek_Tiglutik) C9697-A
Rituxan (rituximab) Rituxan Hycela (rituximab and hyaluronidase human) C10423-A
Rozlytrek (entrectinib) C17881-A
Ruconest (C1 esterase inhibitor [recombinant]) C6774-A
Rukobia (fostemsavir) C20172-A
Scenesse (afamelanotide) Implant MCP-367
Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) C4719-A
Sexual Dysfunction Criteria - Non-Coverage C16658-A
Seysara (sarecycline) C15974-A
Signifor (pasireotide diaspartate) C15367-A
Simponi and Simponi Aria (golimumab) C10422-A
Simulect (basiliximab) C9972-A
SINUVA (Mometasone Furoate Sinus Implant)MCP-333
Skyrizi (risankizumab-rzaa) C17336-A
Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitors and Combinations C17804-A
Soliris and Ultomiris (eculizumab_ravulizumab) C4867-A
Sporanox_Onmel (itraconazole) C4734-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
Subcutaneous Immune Globulin (SCIg) MCP-268
Sublocade (buprenorphine) extended-release inj. C15161-A
Sunosi (solriamfetol) C17632-A
Synarel (nafarelin acetate, nasal solution) C4958-A
Takhzyro (lanadelumab) C15446-A
Tavalisse (fostamatinib) C16449-A
Tecfidera (dimethyl fumarate) C3891-A
Tepezza (teprotumumab-trbw) MCP-365
Tindamax (tinidazole) C15431-C
Tobramycin for inhalation C8665A
Transderm Scop (scopolamine) transdermal patch C8559-A
Triptodur (triptorelin pamoate) C14649-A
Trogarzo (ibalizumab-uiyk) C14522-A
Tymlos (abaloparatide) C17354-A
Tysabri (natalizumab) C10276-A
Uplizna (inebilizumab) C20171-A
Valcyte (valganciclovir) C4960-A
Vaprisol (conivaptan) C15199-A
Vimizim (elosulfase alfa) C7068-A
Visudyne (verteporfin) Ocular Photodynamic Therapy MCP-308
Vitrakvi (larotrectinib) C16017-A
Vivitrol (naltrexone for extended-release injectable suspension) C5775-A
Vumerity (diroximel fumarate) C3891-A
Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis) C17345-A
Vyondys 53 (golodirsen) MCP-359_Non-coverage
Xeljanz and Xeljanz XR (tocilizumab) C2721-A
Xenazine (tetrabenazine) C3894-A
Xermelo (telotristat ethyl) C16325-A
Xifaxan (rifaximin) and Aemcolo (rifamycin)
Xiaflex (collagenase, clostridium histolyticum)_Dupuytrens Contracture MCP-259
Xiaflex (collagenase, clostridium histolyticum)_Peyronie Disease MCP-279
Xifaxan (rifaximin)_Aemcolo (rifamycin) C4964-C
Xyrem (sodium oxybate) C3925-A
Zemplar (paricalcitol) C4967-C
Zilretta (Triamcinolone ER Injection) MCP-349
Zinplava (bexlotoxumab) C14821-A
Zoladex (goserelin acetate) C8757-A