2021 Marketplace Drug Formulary
2022 Marketplace Drug Formulary
Physician Administered Preferred Drug List
Specialty Medication Administration Site of Care Coverage Criteria Policy
Abecma (idecabtagene vicleucel)
Abilify MyCite Kit (aripiprazole with biosensor) C15913-A
Actemra (tocilizumab) C10265-A
Acthar Gel (repository corticotropin injection) C8373-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
Amitiza (lubiprostone) C5113-C
Ampyra (dalfampridine) C6480-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
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C
Cablivi (caplacizumab) Criteria C19481-A
Cancidas (caspofungin) C17928-A
Carisoprodol Products C11268-A
Cholbam (cholic acid) C17319-A
Cialis (tadalafil) - BPH Coverage Only C6121-C
Cimzia (certolizumab pegol) C10269-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
Diabetic Testing Supplies C5108-A
Direct Oral Anticoagulants C20784-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 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
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
Hepatitis B Immune Globulin C9971-A
Hepatitis C Antiviral Therapy C12049-A
High-Cost Outlier Targeted Drug Exceptions (HOT) C17973-A
Ilumya (tildrakizumab) C15971-A
Iluvien (fluocinolone acetonide intravitreal implant) MCP-301
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
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
Linzess (linaclotide) C17874-A
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
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) C18441-A
Nexviazyme (avalglucosidase alfa-ngpt)
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 MCP-162
Olumiant (baricitinib) C15447-A
Opioid Global Criteria C16263-A
Opioid Induced Constipation Agents C9529-C
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
Otrexup and Rasuvo (methotrexate) C14770-A
Oxervate (cenegermin) C16015-A
Ozurdex (dexamethasone intravitreal implant) MCP-282
Palynziq (pegvaliase-pqpz) C15432-A
Parsabiv (etelcalcetide) C17883-A
Penicillamine (Depen, Cuprimine) C15418-A
Prevymis (letermovir) C15922-A
Procysbi and Cystagon (cysteamine bitartrate) C6355-B
Promacta (eltrombopag) C6663-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
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, Exservan) C9697-A
Rinvoq (Upadacitinib) C17882-A
Rituxan (rituximab) Rituxan Hycela (rituximab and hyaluronidase human) C10423-A
Rozlytrek (entrectinib) C17881-A
Saphnelo (anifrolumab) C21970-A.pdf
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
SINUVA (Mometasone Furoate Sinus Implant)MCP-333
Skyrizi (risankizumab-rzaa) C17336-A
Soliris and Ultomiris (eculizumab_ravulizumab) C4867-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
Synarel (nafarelin acetate, nasal solution) C4958-A
Tavalisse (fostamatinib) C16449-A
Tepezza (teprotumumab-trbw) C18462-A
Tezspire (tezepelumab) C23042-A
Tobramycin for inhalation C8665A
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
Visudyne (verteporfin) Ocular Photodynamic Therapy MCP-308
Vitrakvi (larotrectinib) C16017-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
Xermelo (telotristat ethyl) C16325-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
Xyrem (sodium oxybate) Xywav (calcium, magnesium, potassium, and sodium oxybates) C3925-A
Zemplar (paricalcitol) C4967-C
Zilretta (Triamcinolone ER Injection) MCP-349
Zinplava (bexlotoxumab) C14821-A
Zoladex (goserelin acetate) C8757-A