Coverage criteria policies by medication
A
- Acalabrutinib (Calquence)
- ALK+ Inhibitors
- Allergen Immunotherapy
- Alpelisib (Piqray®)
- Amifampridine (Firdapse®, Ruzurgi®)
- Amikacin liposomal (Arikayce)
- Anabolic Steroids
- Apomorphine (Apokyn®)
- Asfotase Alfa (Strensiq™)
- Avacopan (Tavneos™)
- Avapritinib (Ayvakit)
- Avatrombopag (Doptelet®), eltrombopag olamine (Promacta®), eltrombopag choline (Alvaiz®), 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®)
- Colchicine (Lodoco®)
- Constipation Agents
- Continuous Glucose Monitoring Systems
- 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)
- Fruquintinib (Fruzaqla™)
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
I
- Ibrexafungerp (Brexafemme®)
- Ibrutinib (Imbruvica®
- Idelalisib (Zydelig®)
- IDH Inhibitors
- 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®)
- Leniolisib (Joenja™)
- Letermovir (Prevymis)
- Levodopa (Inbrija ™)
- Lomitapide (Juxtapid)
- Lonafarnib (Zokinvy)
- Long-acting Granulocyte Colony Stimulating Factor
M
- Mannitol (Bronchitol®)
- Maralixibat (Livmarli™)
- Mavacamten (Camzyos™)
- Mecamylamine (Vecamyl®)
- Mecasermin (Increlex)
- Mechlorethamine (Valchlor)
- Medications for Weight Management
- Mepolizumab (Nucala®)
- Metreleptin (Myalept™)
- Metyrosine (Demser®)
- Midostaurin (Rydapt®)
- Migalastat (Galafold®)
- Migraine Abortive Therapies, Quantity Exception
- Miltefeosine (Impavido®)
- Mitapivat (Pyrukynd®)
- Mobocertinib (Exkivity™)
- Multiple Sclerosis
- Multi-Targeted Tyrosine Kinase Inhibitors (Multi-TKI)
N
- Nedosiran (Rivfloza™)
- Neratinib (Nerlynx®)
- Nilotinib (Tasigna)
- Nilutamide (Nilandron®)
- Nintedanib (Ofev) prifenidone (Esbriet)
- Niraparib (Zejula®), niraparib-abiraterone (Akeega®)
- Nirogacestat (Ogsiveo™)
- Nitisinone (Nityr; Orfadin)
O
- Obeticholic acid (Ocaliva)
- Octreotide acetate (Sandostatin)
- Odevixibat (Bylvay™)
- Olaparib (Lynparza)
- Omacetaxine mepesuccinate (Synribo)
- Omalizumab (Xolair®)
- Opioid Cumulative Dosing Override
- Opioid Naïve
- Oral Iron Chelating Agents
- Oral Nutritional Supplements
- Ospemifene (Osphena®)
- Oteseconazole (Vivjoa™)
P
- Pacritinib (Vonjo™)
- PAH medications
- Palivizumab (Synagis®)
- Palovarotene (Sohonos™)
- Panobinostat (Farydak®)
- Paprathyroid hormone (Natpara)
- Parathyroid Hormones: teriparatide, teriparatide (Forteo®), abaloparatide (Tymlos®)
- Paroxysmal Nocturnal Hemoglobinuria Agents
- Peanut allergen powder-dnfp (Palforzia)
- Peginterferon alfa-2a (Pegasys®)
- Peginterferon alfa-2B (Sylatron®)
- Pegvisomant (Somavert)
- Pemigatinib (Pemazyre™)
- Pexidartinib (Turalio™)
- Phenylketonuria Agents
- Phosphodiesterase Type 5 (PDE5) Inhibitors
- Pimavanserin (Nuplazid®)
- Ponatinib (Iclusig®)
- Pralsetinib (Gavreto™)
- Pretomanid
- Prescription Digital Therapeutics
- 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)
- Resmetirom (Rezdiffra™)
- 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™)
- Setmelanotide (Imcivree®)
- Short-acting Granulocyte-colony stimulating factor (CSF) and Granulocyte macrophage-CSF
- 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®)
- Trofinetide (Daybue™)
- Tucatinib (Tukysa™)
U
V
- Vandetanib (Caprelsa®)
- Vemurafenib (Zelboraf®)
- Venetoclax (Venclexta®)
- Vigabatrin (Sabril®)
- Vismodegib (Erivedge®)
- Voclosporin (Lupkynis)
- Von Willebrand factor (Vonvendi®)
- Vorinostat (Zolinza®)
- Vosoritide (Voxzogo™)
- Voxelotor (Oxbryta™)
