Drug List

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Drug Formulary


2021 Marketplace Drug Formulary

2022 Marketplace Drug Formulary


Physician Administered Preferred Drug List


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

 

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

Aloxi (palonosetron) C10484-A

Ambisome (ampho B, lipoSOME) C9530-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

Aprepitant; fosaprepitant C4222-C

Arcalyst (rilonacept) MCP-110

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

Belbuca_ Butrans C4199-A

Benlysta (belimumab) C2722A

Beovu (brolucizumab) MCP-354

Berinert [C1 esterase inhibitor (human)] C6770-A

Bevyxxa (betrixaban) C16349-A

Botulinum Toxin C8755-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

Cayston (aztreonam) C6481-A

Cerdelga (eliglustat) C6633-A

Chemet (succimer) C9816-A

Cholbam (cholic acid) C17319-A

Cialis (tadalafil) - BPH Coverage Only C6121-C

Cimzia (certolizumab pegol) C10269-A

Cinqair (reslizumab) C9761-A

Cinryze [C1 esterase inhibitor (human)] C6771-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-342

Diabetic Testing Supplies C5108-A

Diclofenac Topical C4962-A

Dipeptidyl Peptidase-4 Inhibitors and Combinations C5169-A

Disposable Insulin Delivery Device C17724-A

Doptelet (avatrombopag) C16445-A

Doxylamine_Pyridoxine C15190-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

Eliquis (apixaban) C15354-A

Emflaza (deflazacort) MCP-298

Emflaza (deflazacort) MCP-298 (Non-coverage)

Enbrel (etanercept) C10411-A

Endari (L-glutamine oral powder) C12651-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

Evzio (naloxone) C9085-A

Exondys 51 (eteplirsen) NC C9941-A

Eylea (aflibercept) MCP-191

Fabrazyme (agalsidase beta) C4865-A

Fasenra (benralizumab) C13643-A

Fentanyl Patch C4220-A

Filgrastim C2437-A

Firazyr (icatibant) C5675-A

Firdapse_Ruzurgi (Amifamipridine) 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

Gilenya (fingolimod) C10274-A

Givlaari (givosiran) MCP-356

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

Granisetron C4227-C

Growth Hormone (hGH, somatropin) Therapy C6925-A

Haegarda (C1 Esterase Inhibitor Subcutaneous [human]) C12157-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

Human Growth Hormone Therapy C6925-A

Humira (adalimumab) C10412-A

Hyaluronic Acid Injections_Viscosupplementation for Knee OA MCP-046 

Ilaris (canakinumab) C2435-A

Ilumya (tildrakizumab) C15971-A

Iluvien (fluocinolone acetonide intravitreal implant) MCP-301

Imcivree (setmelanotide)

Impetigo Agents-Altabax, Centany (mupirocin), Xepi C8409-A

Increlex (mecasermin) C8891-A

Infliximab (Remicade_Inflectra_Renflexis) C10421-A

Ingrezza (valbenazine) C12649-A

Inrebic (fedratinib)

Insulin Pen C5106-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

Isotretinoin

Isturisa (osilodrostat) CXXXXX-X

Jakafi (ruxolitinib) C17367-A

Jetrea (ocriplasmin) Vitreomacular Adhesion MCP-297

Juxtapid (lomitapide) MCP-155

Jynarque (tolvaptan) C15434-A

Kalbitor (ecallantide) C6772-A

Kanuma (sebelipase alfa) C9974-A

Kesimpta (ofatumumab) C21104-A

Keveyis (dichlorphenamide) C14599-A

Kevzara (sarilumab) C14653-A

Kineret (anakinra) C10415-A

Korlym (mifepristone) C10881-A

Koselugo (selumetinib) CXXXXX-X

Krystexxa (pegloticase) C2729-A

Kuvan (sapropterin dihydrochloride) C7067-A

Kynamro (mipomersen)C3892-A

Lemtrada (alemtuzumab) C6919-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

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

Macugen (pegaptanib) C10418-A

Makena (hydroxyprogesterone caproate injection) C10447-A

Mavenclad (cladribine) C17329-A

Mayzent (siponimod) C16713-A

Mepron (atovaquone) C8408-A

Mepsevii (vestronidase alfa-vjbk) C1794-A

Methadone C9698-A

Mitoxantrone C10292-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) XXXXXXX

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

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

Opioid Global Criteria C16263-A

Opioid Induced Constipation Agents C9529-C

Oral MS Disease-Modifying Therapies C21142-A

Orencia (abatacept) C10420-A

Orgovyx (relugolix) 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

Ozurdex (dexamethasone intravitreal implant) MCP-282

Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] MCP-360

Palynziq (pegvaliase-pqpz) C15432-A

Parsabiv (etelcalcetide) C17883-A

PCSK9 Inhibitors C10800-A

Pegfilgrastim C10419-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

Prolia (denosumab) C8848-A

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

Pulmozyme (dornase alfa)

Qutenza (capsaicin) C2809-A

Radicava (edaravone) C11528-A

Rapamune (sirolimus) C4725-A

Ravicti (glycerol phenylbutyrate) C7041-A

Reblozyl (luspatercept-aamt) C18002-A

Regranex (becaplermin)

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

Reyvow (lasmiditan)

Ridaura (auranofin) C14523-A

Riluzole (Rilutek_Tiglutik) C9697-A

Rinvoq (Upadacitinib)

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 

Samsca (tolvaptan) C8048-A

Santyl (collagenase) C15159-C

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

Simulect (basiliximab) C9972-A

SINUVA (Mometasone Furoate Sinus Implant)MCP-333

Sivextro (tedizolid) C9353-A

Skyrizi (risankizumab-rzaa) C17336-A

Smoking Cessation C2902-A

Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitors and Combinations C17804-A

Soliris and Ultomiris (eculizumab_ravulizumab) C4867-A

Spinraza (nusinersen) MCP-293

Spiriva (tiotropium) C5109-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

Symlin (pramlintide) C4957-A

Synagis (palivizumab) C6074-A

Synarel (nafarelin acetate, nasal solution) C4958-A

Takhzyro (lanadelumab) C15446-A

Taltz (ixekizumab) C16448-A

Tavalisse (fostamatinib) C16449-A

Tecfidera (dimethyl fumarate) C3891-A

Tegsedi (inotersen) C17325-A

Tepezza (teprotumumab-trbw) MCP-365

Testosterone C2270-A

Thiola (tiopronin) C18004-A

Tindamax (tinidazole) C15431-C

Tobramycin for inhalation C8665A

Tolvaptan C21091-A

Topical Acne C4190-A

Topical Retinoids C4729-A

Transderm Scop (scopolamine) transdermal patch C8559-A

Tremfya (guselkumab) C14612-A

Triptans C9612-J

Triptodur (triptorelin pamoate) C14649-A

Trogarzo (ibalizumab-uiyk) C14522-A

Truvada_Descovy C11359-A

Tybost (cobicistat) C7081-A

Tygacil (tigecycline)

Tymlos (abaloparatide) C17354-A 

Tysabri (natalizumab) C10276-A

Uplizna (inebilizumab) C20171-A

Urea Cream C14551-A

Valcyte (valganciclovir) C4960-A

Vancocin (vancomycin) C5325-C

Vaprisol (conivaptan) C15199-A

Varubi (rolapitant) C9528-C

Veltassa (patriomer) C8840-A

Verquvo (vericiguat) C21141-A

Vibativ (telavancin)

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

Vyondys 53 (golodirsen) NC C17926-A

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

Wakix (pitolisant) C17997-A

Xarelto (rivaroxaban) C6373-A

Xeljanz and Xeljanz XR (tocilizumab) C2721-A

Xenazine (tetrabenazine) C3894-A

Xermelo (telotristat ethyl) C16325-A

Xgeva (denosumab) C8849-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

Xolair (omalizumab) C8757-A

Xyrem (sodium oxybate) C3925-A

Zavesca (miglustat) C9646-A

Zemplar (paricalcitol) C4967-C

Zeposia (ozanimod) CXXXXX-X

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