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2022 Marketplace Drug Formulary
2023 Marketplace Drug Formulary
Physician Administered Preferred Drug List
Specialty Medication Administration Site of Care Coverage Criteria Policy
Abilify MyCite Kit (aripiprazole with biosensor) C15913-A
Actemra (tocilizumab) C10265-A
Acthar Gel (repository corticotropin injection) C8373-A
Adakveo (crizanlizumab-tmca) C17920-A
Adcetris (brentuximab vedotin) C15428-A
Aduhelm (aducanumab-avwa) NC C21305-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
Antidiabetics Criteria C21116-A
Apokyn_Kynmobi (apomorphine) C6918-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
Brineura (cerliponase alfa) C11526-A
Buprenorphine-Naloxone and Buprenorphine for Opioid Dependence C10899-A
Cablivi (caplacizumab) Criteria C19481-A
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C
Cancidas (caspofungin) C17928-A
Carisoprodol Products C11268-A
Cholbam (cholic acid) C17319-A
Cimzia (certolizumab pegol) C10269-A
Colcrys, Mitigare, Gloperba (colchicine) C4205-A
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
Diabetic Testing Supplies C5108-A
Direct Oral Anticoagulants C20784-A
Disposable Insulin Delivery Device C17724-A
Doptelet (avatrombopag) C16445-A
Duplication of Therapy-High Risk Combination C15341-A
Egrifta SV (tesamorelin) NC C16187-A
Elaprase (idursulfase) C2720-A
Emflaza (deflazacort) NC C10904-A
Empaveli (pegcetacoplan) C21423-A
Endari (L-glutamine oral powder) C12651-A
Enspryng (satralizumab-mwge) 20849-A
Entresto (sacubitril_valsartan) C8675-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
Exondys 51 (eteplirsen) NC C9941-A
Fabrazyme (agalsidase beta) C4865-A
Fasenra (benralizumab) C13643-A
Firdapse (amifampridine) C15969-A
Furoscix (furosemide on-body infusor) C24669-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
Gocovri_Osmolex (amantadine ER caps and tabs) C13296-A
Growth Hormone (hGH, somatropin) Therapy C6925-A
Hemophilia and Blood Factor Products C15607-A
Hepatitis B Immune Globulin C9971-A
Hepatitis C Antiviral Therapy C12049-A
Hereditary Angioedema Agents C21463-A
High-Cost Outlier Targeted Drug Exceptions (HOT) C17973-A
Hyaluronic Acid (HA) Injections_Viscosupplementation for Knee OsteoArthritis C14676-A
Igalmi (dexmedetomidine) C23724-A
Ilumya (tildrakizumab) C15971-A
Imcivree (setmelanotide) NC C22214-A
Impetigo Agents- Altabax, Centany, Xepi C8409-A
Immunoglobulin (SCIg, IVIg) C21554-A
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A
Ingrezza (valbenazine) C12649-A
InPen (Smart Insulin Pen) C21865-A
Intravenous Bisphosphonates C16790-A
Iron Chelating Agents (Desferal Exjade Ferriprox Jadenu) C15214-A
Iron Deficiency Anemia Agents C14569-A
Isturisa (osilodrostat) C19328-A
Itraconzaole (Sporanox, Tolsura) C4734-A
Kanuma (sebelipase alfa) C9974-A
Kesimpta (ofatumumab) C21104-A
Keveyis (dichlorphenamide) C14599-A
Kerendia (finerenone) C21829-A
Korlym (mifepristone) C10881-A
Korsuva (difelikefalin) C23743-A
Koselugo (selumetinib) C19330-A
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
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
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
Natpara (parathyroid hormone) C16013-A
Nexletol (bempedoic acid) and Nexlizet (bempedoic acid and ezetimibe) C18441-A
Nexviazyme (avalglucosidase alfa-ngpt) C21948-A
Nitisinone (Orfadin_Nityr) C13398-A
Nplate (romiplostim)_Chronic ITP C6662-A
Nuedexta (dextromethorphan-quinidine) C12971-C
Nulibry (fosdenopterin) C21306-A
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 C4141-A
Olumiant (baricitinib) C15447-A
Opioid Global Criteria C16263-A
Opzelura (ruxolitinib) C22277-A
Oral MS Disease-Modifying Therapies C21142-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
Otrexup and Rasuvo (methotrexate) C14770-A
Oxervate (cenegermin) C16015-A
Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] C18457-A
Palynziq (pegvaliase-pqpz) C15432-A
Parsabiv (etelcalcetide) C17883-A
Penicillamine (Depen, Cuprimine) C15418-A
Physician Administered Drugs C11251-A
Prescription Compounded Product C20382-A
Prevymis (letermovir) C15922-A
Procysbi and Cystagon (cysteamine bitartrate) C6355-B
Promacta (eltrombopag) C6663-A
Pulmicort Respules (budesonide) C4724-A
Pulmonary Arterial Hypertension (PAH) C9837-A
Pulmozyme (dornase alfa) C9796-A
Ranibizumab (Lucentis, Byooviz, Cimerli) C10417-A
Ravicti (glycerol phenylbutyrate) C7041-A
Reblozyl (luspatercept-aamt) C18002-A
Recorlev (levoketoconazole) C23359-A
Regranex (becaplermin) C13432-C
Relizorb (immobilized lipase cartrdige) C12081-A
Relyvrio (sodium phenylbutyrate;sodium taurufsodiol) C24678-A
Revcovi (elapegademase) Criteria C16106-A
Rezurock (belumosudil) C22106-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
Rozlytrek (entrectinib) C17881-A
Ryplazim (plasminogen, human) C22238-A
Saphnelo (anifrolumab) C21970-A.pdf
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
Skyrizi (risankizumab-rzaa) C17336-A
Soliris and Ultomiris (eculizumab_ravulizumab) C4867-A
Sotyktu (deucravacitinib) C24672-A
Spevigo (spesolimab-sbzo) C24676-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
Sunosi (solriamfetol) C17632-A
Supprelin LA (histrelin acetate) Implant C20611-A
Synarel (nafarelin acetate, nasal solution) C4958-A
Tadalafil and combinations C6121-C
Tavalisse (fostamatinib) C16449-A
Tepezza (teprotumumab-trbw) C18462-A
Tezspire (tezepelumab) C23042-A
Tobramycin for inhalation C8665-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
Valcyte (valganciclovir) C4960-A
Viltepso (vitolarsen) NC C20585-A
Vimizim (elosulfase alfa) C7068-A
Vitrakvi (larotrectinib) C16017-A
Vtama (tapinarof) cream C23729-A
Vyondys 53 (golodirsen) NC C17926-A
Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis) C17345-A
Xeljanz and Xeljanz XR (tocilizumab) C2721-A
Xenazine (tetrabenazine) C3894-A
Xenpozyme (olipudase alfa-rpcp) C24670-A
Xermelo (telotristat ethyl) C16325-A
Xiaflex (collagenase clostridium histolyticum) C24319-A
Xifaxan (rifaximin)_Aemcolo (rifamycin) C4964-C
Xipere (triamcinolone ocular inj) C22222-A
Xyrem (sodium oxybate) Xywav (calcium, magnesium, potassium, and sodium oxybates) C3925-A
Zemplar (paricalcitol) C4967-C
Zilretta (Triamcinolone ER Injection) C16855-A
Zinplava (bexlotoxumab) C14821-A