Pharmacy
The management of outpatient prescription drugs is an integral part of the medical management program to improve the health and well-being of our members.
Search for a drug using our online tool. You can also view or print the PDL.
Printed Preferred Drug Lists
Coverage Determination Requests
Request a coverage decision and/or exception or file an appeal of a drug coverage decision.
Maximum Allowable Cost prices
This is a prior authorization form for Zubsolv treatment.
Pharmacy Clinical Policies
Hydroxyprogesterone caproate (Makena®/compound) is a progestin.
Eculizumab (Soliris®) is a complement inhibitor.
Mogamulizumab-kpkc (Poteligeo®) is a CC chemokine receptor type 4 (CCR4)-directed monoclonal antibody.
The following are factor VIII products requiring prior authorization: human – Hemofil M®, Koate-DVI®; recombinant – Advate®, Adynovate®, Afstyla®, Eloctate®, Esperoct®, Helixate FS®, Jivi®, Kogenate FS®, Kogenate FS with Vial Adapter®, Kogenate FS with Bio-Set®, Kovaltry®, NovoEight®, Nuwiq®, Obizur®, Recombinate®, ReFacto®, Xyntha®, and Xyntha® Solofuse™.
Factor VIIa, recombinant (NovoSeven® RT) and coagulation factor VIIa (recombinant)-jncw (SevenFact®) are coagulation factors.
AbobotulinumtoxinA (Dysport®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.
IncobotulinumtoxinA (Xeomin®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.
OnabotulinumtoxinA (Botox®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.
RimabotulinumtoxinB (Myobloc®) is an acetylcholine release inhibitor and a neuromuscular blocking agent.
Eteplirsen (Exondys 51™) is an antisense oligonucleotide.
Ocrelizumab (Ocrevus™) is a CD20-directed cytolytic antibody.
Cerliponase alfa (Brineura®) is a hydrolytic lysosomal N-terminal tripeptidyl peptidase.
Edaravone (Radicava™) is a member of the substituted 2-pyrazolin-5-one class that acts as a free-radical scavenger of peroxyl radicals and peroxynitrite.
Testosterone pellet (Testopel®) is an implantable androgen. Testosterone undecanoate (Jatenzo®) is an oral androgen.
Tisagenlecleucel (Kymriah™) is a CD19-directed, genetically modified, autologous T-cell immunotherapy.
Axicabtagene ciloleucel (Yescarta™) is a CD19-directed, genetically modified, autologous T-cell immunotherapy.
Voretigene neparvovec-rzyl (Luxturna™) is an adeno-associated virus vector-based gene therapy.
Ibalizumab-uiyk (Trogarzo™) is a CD4-directed post-attachment human immunodeficiency virus type 1 (HIV-1) inhibitor.
Patisiran (Onpattro™) is a double-stranded small interfering ribonucleic acid, formulated as a lipid complex for delivery to hepatocytes.
Ravulizuamb-cwvz (Ultomiris®) is a complement inhibitor.
Caplacizumab-yhdp (Cablivi®) is a von Willebrand factor (vWF)-directed antibody fragment.
Elapegademase-lvlr (Revcovi®) is a recombinant adenosine deaminase.
Onasemnogene abeparvovec (Zolgensma®) is an adeno-associated virus (AAV) vector-based gene therapy.
Trientine (Syprine®) is a chelating agent.
Crizanlizumab-tmca (Adakveo®) is a selectin blocker.
Golodirsen (Vyondys 53TM) is an antisense oligonucleotide.
Inebilizumab-cdon (Uplizna ™ ) is an anti-CD19 monoclonal antibody.
Belantamab mafodotin (Blenrep®/™ ) is an anti-B-cell maturation antigen (BCMA) monoclonal antibody and microtubule inhibitor conjugate.
