Coverage criteria policies by medication
A
- acalabrutinib (Calquence)
- ALK+ Non-Small Cell Lung Cancer
- Allergen Immunotherapy
- Alpelisib (Piqray®)
- Amifampridine (Firdapse®, Ruzurgi®)
- amikacin liposomal (Arikayce)
- Anabolic Steroids
- apomorphine (Apokyn®)
- Asfotase Alfa (Strensiq™)
- avacopan (Tavneos™)
- avapritinib (Ayvakit)
- avatrombopag (Doptelet®), eltrombopag (Promacta®), lusutrombopag (Mulpleta®), fostamatinib (Tavalisse™)
- Axitinib (Inlyta®)
- azacitidine (Onureg®)
- aztreonam (Cayston®)
B
- betaine anhydrous (Cystadane®)
- bempedoic acid, bempedoic acid&ezetimibe (Nexletol, Nexlizet)
- benralizumab (Fasenra Pen™) (Updated February 2020)
- betrixaban (Bevyxxa)
- Bevacizumab Intravitrea
- bexarotene (Targretin)
- bosutinib (Bosulif)
- budesonide (Tarpeyo™)
- Bypassing Agents – Hemophilia A & B
C
- Cabozantin (Cabometyx®, Cometriq®)
- calcifediol (Rayaldee®)
- Calcitonin Gene-Related Peptide (CGRP) Agents
- cannabidiol (Epidolex®)
- Caplacizumab-yhdp (Cablivi®)
- capmatinib (Tabrecta™)
- carglumic acid (Carbaglu®)
- cenegermin-bkbi (Oxervate™)
- chenodiol (Chenodal®)
- cholic acid (Cholbam®)
- Chronic Inflammatory Disease
- Coagulation Factor X, human (Coagadex®)
- cobimetinib (Cotellic®), vemurafenib (Zelboraf®)
- Continuous Glucose Monitoring (FreeStyle Libre®, Dexcom G6®)
- Cushing's Syndrome/Disease
- Cyclin-Dependent Kinase (CDK) 4/6 Inhibitors
- cysteamine (Cystaran)
- cysteamine bitartrate (Cystagon; Procysbi)
- Cystic Fibrosis, CFTR Modulators
D
- dalfampridine ER (Ampyra®)
- dasatinib (Sprycel®)
- Deflazacort, (Emflaza®)
- diabetic test strip and glucometer
- dichlorphenamide (Keveyis)
- digital therapy (Somryst®)
- dornase alfa (Pulmozyme®)
- Droxidopa (Northera)
- duvelisib (Copiktra®)
- Dupilumab (Dupixent®)
E
- eliglustat (Celderga), miglustat (Zavesca)
- eluxadoline (Viberzi®)
- Emicizumab-kxwh (Hemlilbra ®)-Hemophilia A
- emtricitabine/tenofovir alafenamide (Descovy®)
- encorafenib (Braftovi®), binimetinib (Mektovi®)
- entrectinib (Rozlytrek®)
- Epidermal Growth Factor Receptor (EGFR) Tyrosine Kinase Inhibitors (TKI)
- Erdafitinib (Balversa™)
- Erythropoeitin stimulating agents
- everolimus (Afinitor, Afinitor Disperz)
- Extended Half-Life Factor IX Products-Hemophilia B
- Extended Half-Life Factor VIII Products – Hemophilia A
F
- Factor VIII/VWF Complex (Alphanate®, Humate-P®, Wilate®)
- fedratinib (Inrebic®)
- fenfluramine (Fintepla®)
- finerenone (Kerendia™)
- fostemsavir (Rukobia)
G
- gabapentin ER (Gralise®); gabapentin enacarbil (Horizant®)
- ganaxolone (Ztalmy®)
- gilteritinib (Xospata®)
- glasdegib (Daurismo™)
- glycopyrronium (Qbrexza™)
- GnRH Antagonists for Gynecologic Conditions
- Gonadotropin-releasing hormone (GnRH)
- Growth Hormone
H
- Hepatitis C
- Hereditary Angioedema
- human chorionic gonadotropin (Novarel; Pregnyl)
- hydrocortisone (Alkindi Sprinkle™)
- hydroxyprogesterone caproate (Makena®)
I
- ibrutinib (Imbruvica®
- idelalisib (Zydelig®)
- imatinib (Gleevec)
- Immunoglobulin G (Hizentra®, Gammagard liquid®, Gamunex-C®, HyQvia®, Cuvitru®, Cutaquig®)
- Interferon Gamma-1B (Actimmune®)
- inotersen (Tegsedi™)
- istradefylline (Nourianz™)
- ivabradine (Corlanor®)
- ivosidenib (Tibsovo®); enasidenib (Idhifa®)
- ixazomib (Ninlaro)
J
K
L
- lapatinib (Tykerb®)
- larotrectinib (Vitrakvi®)
- lenalidomide (Revlimid®), pomalidomide (Pomalyst®), thalidomide (Thalomid®)
- letermovir (Prevymis)
- levodopa (Inbrija ™)
- lomitapide (Juxtapid)
- lonafarnib (Zokinvy)
- Long-acting Granulocyte Colony Stimulating Factor
M
- mannitol (Bronchitol®)
- mavacamten (Camzyos™)
- mecamylamine (Vecamyl®)
- mecasermin (Increlex)
- mechlorethamine (Valchlor)
- mepolizumab (Nucala®)
- metreleptin (Myalept™)
- metyrosine (Demser®)
- midostaurin (Rydapt®)
- migalastat (Galafold®)
- Migraine Abortive Therapies, Quantity Exception
- miltefeosine (Impavido®)
- mitapivat (Pyrukynd®)
- Multiple Sclerosis
- Multi-Targeted Tyrosine Kinase Inhibitors (Multi-TKI)
N
- neratinib (Nerlynx®)
- nilotinib (Tasigna)
- nilutamide (Nilandron®)
- nintedanib (Ofev) prifenidone (Esbriet)
- niraparib (Zejula)
- nitisinone (Nityr; Orfadin)
O
- obeticholic acid (Ocaliva)
- octreotide acetate (Sandostatin)
- olaparib (Lynparza)
- omacetaxine mepesuccinate (Synribo)
- omalizumab (Xolair®)
- Opioid-Induced Constipation
- Opioid Cumulative Dosing Override
- Opioid Naïve
- Oral Iron Chelating Agents
- Oral Nutritional Supplements
- ospemifene (Osphena®)
- oteseconazole (Vivjoa™)
P
- pacritinib (Vonjo™)
- PAH medications
- Palivizumab (Synagis®)
- panobinostat (Farydak®)
- parathyroid hormone (Natpara)
- Parathyroid Hormones: teriparatide, teriparatide (Forteo®), abaloparatide (Tymlos®)
- Peanut allergen powder-dnfp (Palforzia)
- Pegcetacoplan (Empaveli™)
- peginterferon alfa-2a (Pegasys®)
- peginterferon alfa-2B (Sylatron®)
- pegvisomant (Somavert)
- pemigatinib (Pemazyre™)
- pexidartinib (Turalio™)
- Phenylketonuria Agents
- pimavanserin (Nuplazid®)
- ponatinib (Iclusig®)
- pralsetinib (Gavreto™)
- Pretomanid
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors
- Pulmonary Arterial Hypertension
- pyrimethamine (Daraprim®)
Q
R
- Recombinant Antihemophilic factor (Obizur®) – Acquired Hemophilia A
- regorafenib (Stivarga)
- relugolix (Orgovyx)
- repository corticotropin (Acthar® Gel, Cortrophin™ Gel)
- rifaximin (Xifaxan®)
- riluzole (Rilutek®, Tiglutik®)
- risdiplam (Evrysdi®)
- roflumilast (Daliresp®)
- ropeginterferon alfa-2b-njft (Besremi®)
- rucaparib (Rubraca)
- Ruxolitinib (Jakafi®)
S
- Second Generation Anti-Androgen Agents
- selinexor (Xpovio™)
- selpercatinib (Retevmo™)
- selumetinib (Koselugo™)
- Short-acting Granulocyte-colony stimulating factor (CSF) and Granulocyte macrophage-CSF
- sildenafil (Revatio®); tadalafil (Adcirca®, Alyq®, Cialis®)
- simvastatin (Zocor®) 80 mg
- sirolimus (Hyftor™)
- sodium oxybate (Xyrem®); calcium, magnesium, potassium, sodium oxybates (Xywav™))
- Solriamfetol (Sunosi); pitolisant (Wakix®)
- sonidegib (Odomzo)
- Standard Half-life Factor IX Products – Hemophilia B
- Standard Half-Life Factor VIII Products – Hemophilia A
- Stiripentol (Diacomit®)
- sunitinib (Sutent)
- Systemic Janus Associated Kinase (JAK) Inhibitors in Chronic Inflammatory Disease
T
- Tafamidis Meglumine (Vyndaqel, Vyndamax)
- talazoparib (Talzenna®)
- tapinarof (Vtama®)
- tasimelteon (Hetlioz®)
- tazemetostat (Tazverik)
- Teduglutide (Gattex®)
- tegaserod (Zelnorm®)
- temozolomide (Temodar®)
- tenapanor (Ibsrela®)
- tepotinib (Tepmetko)
- Testosterone_Products
- tetrabenazine (Xenazine); deutetrabenazine (Austedo); valbenazine (Ingrezza)
- tirbanibulin (Klisyri)
- tiopronin (Thiola; Thiola EC)
- tivozanib (Fotivda)
- Tobramycin (KITABIS_TOBI_TOBI_Podhaler_Bethkis)
- tolvaptan (Jynarque™)
- tolvaptan (Samsca®)
- tralokinumab (Adbry™)
- trametinib (Mekinist®), dabrafenib (Tafinlar®)
- trifluridine/tipiracil (Lonsurf®)
- tucatinib (Tukysa™)
U
V
- vandetanib (Caprelsa®)
- vemurafenib (Zelboraf®)
- venetoclax (Venclexta®)
- vigabatrin (Sabril®)
- vismodegib (Erivedge®)
- voclosporin (Lupkynis)
- Von Willebrand factor (Vonvendi®)
- vorinostat (Zolinza®)
- voxelotor (Oxbryta™)
