Drug Lists and Policies

Drug Formulary  

2024 Marketplace Drug Formulary

Physician Administered Preferred Drug List

Physician Administered Preferred Drug List - 2024

Physician Administered Preferred Drug List - 2025

 

Specialty Medication Administration Site of Care Policy

Specialty Medication Administration Site of Care Coverage Criteria Policy

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

Agamree (vamorolone) C27685-A

Aldara_Zyclara (imiquimod) C4194-C

Aldurazyme (laronidase) C28302-A

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

Duvyzat (givinostat) C28336-A

Egrifta SV (tesamorelin) NC C16187-A

Elaprase (idursulfase) C2720-A

Elfabrio (pegunigalsidase alfa) C25604-A

Elidel-Protopic-Eucrisa C8268-A

Eltrombopag (Alvaiz, Promacta) C6663-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

Eohilia (budesonide oral susp) C27704-A

Epidiolex (cannabidiol) C19326-A  

Erythropoiesis-stimulating Agents (ESAs) C15389-A

Esbriet (pirfenidone) C16582-A

Evenity (romosozumab-aqqg) C17324-A

Evkeeza (evinacumab_dgnb) C21101-A

Evrysdi (risdiplam) C20580-A

Exondys 51 (eteplirsen) NC C9941-A

Eylea (aflibercept) C5674-A

Fabhalta (iptacopan) C27697-A

Fabrazyme (agalsidase beta) C4865-A

Fasenra (benralizumab) C13643-A

Filgrastim C2437-A

Filspari (sparsentan) C25282-A

Filsuvez (birch triterpenes gel) C27686-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

iDose TR (travoprost intracameral implant) C27707-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

Immunoglobulin (SCIg, IVIg) C21554-A

Impetigo Agents- Altabax, Centany, Xepi C8409-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

Iqirvo (elafibranor) C28551-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

Kerendia (finerenone) C21829-A

Kesimpta (ofatumumab) C21104-A

Keveyis (dichlorphenamide) C14599-A

Kevzara (sarilumab) C14653-A

Kineret (anakinra) C10415-A

Kisunla (donanemab-azbt) C28657-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

Livdelzi (seladelpar lysine) C28776-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

Naglazyme (galsulfase) C28288-A

Nasal Steroids C4730-A

Nemluvio (nemolizumab-ilto) C28777-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

Nulibry (fosdenopterin) C21306-A

Nulojix (belatacept) C9968-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

PiaSky (crovalimab) C28638-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 

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

Retisert_Yutiq (fluocinolone acetonide_Intravitreal Implants) C11706-A

Revcovi (elapegademase) Criteria C16106-A

Reyvow (lasmiditan) C18446-A

Rezdiffra (resmetirom) C28242-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

Rivfloza (nedosiran) C27705-A

Rolvedon, Neulasta and Related Biosimilars C10419-A 

Ryplazim (plasminogen, human) C22238-A

Rystiggo (rozanolixizumab) C26210-A

Rytelo (imetelstat) C28720-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

Susvimo (ranibizumab) Intravitreal Implant C24231-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

Vafseo (vadadustat) C28641-A

Valcyte (valganciclovir) C4960-A

Vancocin (vancomycin) C5325-C

Veklury (remdesivir) C20763-A

Velsipity (etrasimod) C27181-A

Veopoz (pozelimab-bbfg) C26434-A

Veozah (fezolinetant) C25593-A

Verquvo (vericiguat) C21141-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

Voydeya (danicopan) C28251-A

Vtama (tapinarof) cream C23729-A

Vyondys 53 (golodirsen) NC C17926-A

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

Vyvgart (efgartigimiod alfa)

Wainua (eplontersen) C27703-A

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

Xolremdi (mavorixafor) C28289-A

Xphozah (tenapanor) C27292-A 

Zavesca (miglustat) C9646-A

Zemplar (paricalcitol) C4967-C

Zilbrysq (zilucoplan) C27709-A

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