Medical Drug Policies

• Abecma® (idecabtagene vicleucel)
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• Abraxane® (paclitaxel albumin-bound)
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• Actemra® IV (tocilizumab)
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• Acthar_HP® (corticotropin)
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• Adakveo® (crizanlizumab-tmca)
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• Adcetris® (brentuximab vedotin)
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• Adstiladrin® (nadofaragene firadenovec-vncg)
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• Aduhelm® (aducanumab-avwa)
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• Adzynma® (ADAMTS13, recombinant-krhn)
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• Ahzantive® (aflibercept-mrbb)
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• Akynzeo IV® (fosnetupitant/palonosetron)
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• Aldurazyme® (laronidase)
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• Alimta® (pemetrexed)
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• Alyglo® (intravenous immune globulin)
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• Alymsys® (bevacizumab-maly)
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• Amondys 45™ (casimersen )
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• Amtagvi® (lifileucel)
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• Amvuttra® (vutrisiran)
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• Anktiva® (nogapendekin alfa inbakicept-pmln)
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• Aphexda® (motixafortide)
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• Aralast® (alpha1-proteinase inhibitor) COMMERCIAL POLICY ONLY
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• Aranesp® (darbepoetin)
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• Asceniv® (intravenous immune globulin)
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• Asparlas® (calaspargase pegol-mknl)
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• Aucatzyl® (obecabtagene autolecel)
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• Avastin® (bevacizumab)
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• Avsola® (infliximab-axxq)
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• Avzivi® (bevacizumab-tnjn)
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• Bavencio® (avelumab)
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• Belrapzo® (bendamustine)
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• bendamustine hydrochloride (apotex)
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• bendamustine hydrochloride (baxter)
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• Bendeka® (bendamustine)
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• Benlysta® (belimumab )
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• Beovu® (brolucizumab intravitreal injection )
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• Beqvez® (fidanacogene elaparvovec-dzkt)
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• Berinert® (C1 esterase inhibitor )
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• Besponsa® (inotuzumab ozogamicin)
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• Bivigam® (intravenous immune globulin)
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• Bkemv® (eculizumab-aeeb)
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• Blenrep® (belantamab mefadontin-blmf)
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• Blincyto® (blinatumomab)
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• Botox® (onabotulinumtoxin a)
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• Breyanzi® (lisocabtagene maraleucel)
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• Brineura® (cerliponase alfa )
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• Briumvi™ (ublituximab-xiiy )
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• Byooviz™ (ranibizumab-nuna intravitreal)
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• Carvykti® (ciltacabtagene autoleucel)
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• Casgevy® (exagamglogene autotemcel)
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• Cerezyme® (imiglucerase) - COMMERCIAL POLICY ONLY
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• Cimerli® (ranibizumab-eqrn)
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• Cimzia® (certolizumab pegol )
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• Cinqair® (reslizumab )
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• Cinryze® (C1 esterase inhibitor )
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• Coagadex® (coagulation Factor X [human]
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• Columvi® (glofitamab-gxbm)
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• Corifact® (Factor XIII Concentrate [human]
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• Cosela® (trilaciclib)
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• Cosentyx® IV (secukinumab)
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• Cosentyx® SQ (secukinumab)
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• Crysvita® (burosumab-twxa)
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• Cutaquig® (subcutaneous immune globulin)
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• Cuvitru® (subcutaneous immune globulin)
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• Cyramza® (ramucirumab)
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• Danyelza® (naxitamab-gqgk)
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• Darzalex Faspro® (daratumumab+hyaluronidase-fihj)
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• Darzalex® (daratumumab)
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• Daxxify® (daxibotulinumtoxin a-lanm)
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• Durolane® (sodium hyaluronate)
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• Dysport® (abobotulinumtoxin a)
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• Elahere® (mirvetuximab soravtansine-gynx)
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• Elaprase® (idursulfase)
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• Elelyso® (taliglucerase)
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• Elevidys® (delandistrogene moxeparvovec-rokl)
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• Elfabrio® (pegunigalsidase alfa)
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• Elitek® (rasburicase)
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• Elrexfio® (elranatamab-bcmm)
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• Elzonris® (tagraxofusp-erzs)
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• Empliciti® (elotuzumab)
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• Enbrel® (etanercept)
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• Enhertu® (fam-trastuzumab deruxtecan-nxki)
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• Enjaymo® (sutimlimab-jome)
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• Entyvio® (vedolizumab )
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• Enzeevu® (aflibercept-abzv)
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• Epkinly® (epcoritamab-bysp)
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• Epysqli® (eculizumab-aagh)
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• Erbitux® (cetuximab)
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• Euflexxa® (sodium hyaluronate)
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• Evenity® (romosozumab-aqqg subcutaneous)
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• Evkeeza® (evinacumab-dgnb)
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• Exondys 51™ (eteplirsen )
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• Eylea HD® (aflibercept)
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• Eylea® (aflibercept intravitreal injection )
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• Fabrazyme® (agalsidase)
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• Fasenra® (benralizumab )
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• Faslodex® (injection, fulvestrant)
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• Fensolvi® (leuprolide acetate for depot suspension)
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• Feraheme® (ferumoxytol)
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• Fibryga® (human fibrinogen concentrate (fibryga))
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• Firazyr® (icatibant )
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• Firmagon® (degarelix)
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• Flebogamma® (intravenous immune globulin)
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• Fulphila® (pegfilgrastim-cbqv)
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• fulvestrant (Fresenius) (fulvestrant (fresenius kabi))
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• fulvestrant (Teva) (fulvestrant (teva))
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• Fusilev® (levoleucovorin calcium)
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• Fyarro® (sirolimus-albumin-bound)
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• Fylnetra® (pegfilgrastim-pbbk)
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• Gamifant® (emapalumab-lzsg)
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• Gammagard Liquid® (intravenous immune globulin)
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• Gammagard S/D® (immune globulin)
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• Gammaked® (intravenous immune globulin)
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• Gammaplex® (intravenous immune globulin)
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• Gamunex-C® (intravenous immune globulin)
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• Gazyva® (obinutuzumab)
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• Gel-One® (sodium hyaluronate)
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• Gelsyn® (sodium hyaluronate)
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• Genvisc® (sodium hyaluronate)
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• Givlaari™ (givosiran)
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• Glassia® (Injection, alpha 1 proteinase inhibitor (human)) COMMERCIAL POLICY ONLY
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• Granix® (tbo-filgrastim)
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• Haegarda® (C1 esterase inhibitor )
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• Halaven® (eribulin)
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• Hemgenix® (etranacogene dezaparvovec-drlb)
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• Herceptin Hylecta® (trastuzumab-hyaluronidase-oysk)
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• Herceptin® (trastuzumab)
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• Hercessi® (trastuzumab-strf)
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• Herzuma® (trastuzumab-pkrb)
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• Hizentra® (subcutaneous immune globulin)
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• Hyalgan® (sodium hyaluronate)
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• Hymovis® (high molecular weight viscoelastic hyaluronan)
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• Hyqvia® (subcutaneous immune globulin)
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• Ilaris® (canakinumab )
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• Ilumya® (tildrakizumab-asmn )
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• Imdelltra® (tarlatamab-dlle)
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• Imfinzi® (durvalumab)
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• Imjudo® (tremelimumab-actl)
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• Imlygic® (talimogene laherparepvec)
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• Immune Globulin - Intravenous
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• Immune Globulin - Subcutaneous
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• Imuldosa® (ustekinumab-srlf)
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• Inflectra® (infliximab-dyyb)
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• Injectafer® (ferric carboxymaltose )
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• Ixempra® (ixabepilone)
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• Izervay™ (avacincaptad pegol intravitreal )
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• Jelmyto® (mitomycin)
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• Jemperli® (dostarlimab-gxly)
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• Jevtana® (cabazitaxel) COMMERCIAL POLICY ONLY
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• Kadcyla® (ado-trastuzumab emtansine)
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• Kalbitor® (ecallantide )
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• Kanjinti® (trastuzumab-anns)
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• Kanuma® (sebelipase alfa)
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• Keytruda® (pembrolizumab)
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• Khapzory® (levoleucovorin sodium)
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• Kimmtrak® (tebentafusp-tebn)
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• Kisunla® (donanemab-azbt)
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• Krystexxa® (pegloticase)
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• Kymriah® (tisagenlecleucel)
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• Kyprolis® (carfilzomib)
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• Lamzede® (velmanase alfa-tycv)
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• Lanreotide subcutaneous injection – Cipla
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• Lemtrada® (alemtuzumab )
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• Lenmeldy® (atidarsagene autotemcel)
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• Leqembi™ (lecanemab-irmb )
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• Leqvio® (inclisiran subcutaneous injection – Novartis)
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• Leukine® (sargramostim)
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• leuprolide acetate (cipla) (leuprolide acetate for depot suspension (cipla))
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• Libtayo® (cemiplimab-rwlc)
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• Loqtorzi® (toripalimab-tpzi)
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• Lucentis® (ranibizumab)
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• Lumizyme® (alglucosidase)
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• Lumoxiti® (moxetumomab pasudotox-tdfk)
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• Lunsumio® (mosunetuzumab-axgb)
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• Lupron Depot® (leuprolide acetate (for depot suspension), 7.5 mg)
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• Lupron Depot® (leuprolide acetate)
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• Lupron® (leuprolide acetate)
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• Luxturna® (voretigene neparvovec-rzyl )
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• Lyfgenia® (lovotibeglogene autotemcel)
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• Lymphir® (denileukin difitox-cxdl)
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• Margenza® (margetuximab-cmkb)
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• Mepsevii® (vestronidase alfa-vjbk)
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• Monjuvi® (tafasitamab-cxix)
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• Monoferric® (ferric derisomaltose )
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• Monovisc® (high molecular weight viscoelastic hyaluronan)
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• Mvasi® (bevacizumab-awwb)
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• Mylotarg® (gemtuzumab ozogamicin)
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• Myobloc® (rimabotulinumtoxin b)
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• Naglazyme® (galsulfase)
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• Neulasta® (pegfilgrastim)
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• Neupogen® (filgrastim)
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• Nexviazyme® (avalglucosidase alfa-ngpt)
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• Niktimvo® (axatilimab-csfr)
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• Nivestym® (filgrastim-aafi, biosimilar)
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• Nplate® (romiplostim)
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• Nucala® (mepolizumab)
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• Nulibry™ (fosdenopterin )
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• Nypozi® (filgrastim-txid)
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• Nyvepria® (pegfilgrastim-apgf)
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• Ocrevus Zunovo® (ocrelizumab/hyaluronidase-ocsq)
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• Ocrevus® (ocrelizumab)
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• Octagam® (intravenous immune globulin)
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• Ogivri® (trastuzumab-dkst)
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• Omvoh® IV (mirikizumab-mrkz)
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• Omvoh® SQ (mirikizumab-mrkz)
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• Oncaspar® (pegaspargase)
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• Onivyde® (irinotecan liposome) COMMERCIAL POLICY ONLY
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• Onpattro® (patisiran)
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• Ontruzant® (trastuzumab-dttb)
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• Opdivo® (nivolumab)
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• Opdualag® (nivolumab/relatlimab-rmbw)
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• Opuviz® (aflibercept-yszy)
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• Orencia® (abatacept )
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• Orthovisc® (high molecular weight viscoelastic hyaluronan)
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• Otulfi® (ustekinumab-aauz)
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• Oxlumo™ (lumasiran subcutaneous injection )
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• Paclitaxel Albumin-Bound (paclitaxel albumin-bound (Teva))
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• Padcev® (enfortumab vedotin-ejfv)
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• Panzyga® (intravenous immune globulin)
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• Pavblu® (aflibercept-ayyh)
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• Pemetrexed (pemetrexed (accord))
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• Pemetrexed (pemetrexed (avyxa))
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• Pemetrexed (pemetrexed (bluepoint))
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• Pemetrexed (pemetrexed (hospira))
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• Pemetrexed (pemetrexed (sandoz))
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• Pemetrexed (pemetrexed (teva))
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• Pemetrexed (pemetrexed (various))
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• Pemetrexed (pemetrexed ditromethamine (Hospira))
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• Pemfexy® (pemetrexed)
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• Perjeta® (pertuzumab)
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• Phesgo® (pertuzumab, trastuzumab, hyaluronidase-zzxf)
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• Piasky® (crovalimab-akkz)
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• Polivy® (polatuzumab vedotin-piiq)
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• Pombiliti® (cipaglucosidase alfa-atga)
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• Portrazza® (necitumumab)
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• Poteligeo® (mogamulizumab-kpkc)
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• Privigen® (intravenous immune globulin)
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• Procrit/Epogen® (epoetin alfa)
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• Prolastin-C® (alpha-1 proteinase inhibitor (human)) COMMERCIAL POLICY ONLY
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• Provenge® (sipuleucel-t)
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• Purified Cortrophin™ Gel (repository corticotropin )
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• Qalsody® (tofersen)
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• Radicava® (edaravone )
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• Reblozyl® (luspatercept-aamt)
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• Releuko® (filgrastim-ayow, biosimilar)
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• Remicade® (infliximab)
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• Renflexis® (infliximab-abda)
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• Retacrit® (epoetin alfa-epbx)
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• Rethymic® (allogenic processed thymus tissue-agdc)
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• Revcovi® (elapegademase-lvlr)
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• Riabni® (rituximab-arrx)
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• RiaSTAP® (fibrinogen concentrate [human]
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• Rituxan Hycela® (rituximab and hyaluronidase human)
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• Rituxan® (rituximab)
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• Roctavian® (valoctocogene roxaparvovec-rvox)
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• Rolvedon® (eflapegrastim-xnst)
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• Ruconest® (C1 esterase inhibitor )
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• Ruxience® (rituximab-pvvr)
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• Rybrevant® (amivantamab-vmjw)
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• Rylaze® (asparaginase erwinia chrysanthemi recombinant-rywn)
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• Ryplazim® (plasminogen, human-tvmh)
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• Rystiggo® (rozanolixizumab-noli)
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• Rytelo® (imetelstat)
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• Ryzneuta® (efbemalenograstim alfa-vuxw)
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• Sajazir™ (icatibant )
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• Sandostatin® LAR Depot (octreotide acetate )
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• Saphnelo™ (anifrolumab-fnia )
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• Sarclisa® (isatuximab-irfc)
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• Scenesse® (afamelanotide)
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• Simponi Aria® (golimumab )
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• Skyrizi® (risankizumab-rzaa )
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• Skysona® (elivaldogene autotemcel )
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• Soliris (eculizumab intravenous infusion)
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• Somatuline® Depot (lanreotide )
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• Spevigo® (spesolimab-sbzo )
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• Spinraza® (nusinersen intrathecal injection )
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• Spravato® (esketamine nasal spray)
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• Stelara® (ustekinumab )
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• Steqeyma® (ustekinumab-stba)
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• Stimufend® (pegfilgrastim-fpgk)
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• Supartz® (sodium hyaluronate)
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• Supprelin LA® (histrelin implant)
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• Sustol® (granisetron extended-release)
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• Susvimo™ (ranibizumab intravitreal injection)
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• Syfovre™ (pegcetacoplan intravitreal injection)
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• Sylvant® (siltuximab)
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• Synagis® (palivizumab) COMMERCIAL POLICY ONLY
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• Synojoint® (sodium hyaluronate)
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• Synvisc/Synvisc-One® (hylan G-F 20 sodium hyaluronate)
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• Takhzyro® (lanadelumab-flyo)
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• Talvey® (talquetamab-tgvs)
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• Tecartus® (brexucabtagene autoleucel)
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• Tecelra® (afamitresgene autoleucel)
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• Tecentriq Hybreza® (atezolizumab-hyaluronidase-tqjs)
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• Tecentriq® (atezolizumab)
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• Tecvayli® (teclistamab-cqyv)
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• Tegsedi® (inotersen)
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• Tepezza™ (teprotumumab )
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• Tevimbra® (tislelizumab-jsgr)
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• Tezspire® (tezepelumab-ekko)
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• Tivdak® (tisotumab vedotin-tftv)
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• Tofidence® (tocilizumab-bavi)
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• Trazimera® (trastuzumab-qyyp)
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• Treanda® (bendamustine)
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• Trelstar® (triptorelin pamoate)
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• Tremfya® IV (guselkumab)
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• Tremfya® SC (guselkumab)
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• Tretten® (coagulation Factor XIII A-Subunit)
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• Triluron® (sodium hyaluronate)
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• Triptodur® (triptorelin, extended-release)
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• Trivisc® (sodium hyaluronate)
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• Trodelvy® (sacituzumab govitecan-hziy)
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• Trogarzo® (ibalizumab-uiyk )
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• Truxima® (rituximab-abbs)
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• Tyenne® IV (tocilizumab-aazg)
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• Tyruko® (natalizumab-sztn)
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• Tysabri® (natalizumab )
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• Tzield® (teplizumab-mzwv)
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• Udenyca® (pegfilgrastim-jmdb)
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• Ultomiris® (ravulizumab-cwvz)
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• Uplizna® (inebilizumab-cdon)
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• Vabysmo™ (faricimab-svoa intravitreal )
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• Vantas® (histrelin implant)
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• Vectibix® (panitumumab)
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• Vegzelma® (bevacizumab-adcd)
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• Veopoz® (pozelimab-bbfg)
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• Viltepso™ (viltolarsen )
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• Vimizim® (elosulfase alfa)
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• Visudyne (verteporfin)
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• Vivimusta (bendamustine)
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• Vonvendi® (von Willebrand factor)
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• Vpriv® (velaglucerase)
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• Vyepti® (eptinezumab-jjmr)
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• Vyjuvek® (beremagene geperpavec-svdt)
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• Vyloy® (zolbetuximab-clzb)
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• Vyondys 53™ (golodirsen )
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• Vyvgart Hytrulo® (efgartigimod alfa-fcab and hyaluronidase-qvfc)
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• Vyvgart™ (efgartigimod alfa-fcab)
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• Vyxeos® (daunorubicin; cytarabine liposomal)
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• Wezlana® (ustekinumab-auub)
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• Xembify® (subcutaneous immune globulin)
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• Xenpozyme™ (olipudase alfa-rpcp)
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• Xeomin® (incobotulinumtoxin a)
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• Xiaflex® (collagenase clostridium histolyticum intralesional injection)
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• Xipere® (injection, triamcinolone acetonide)
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• Xolair® (omalizumab)
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• Yervoy® (ipilimumab)
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• Yesafili® (aflibercept-jbvfv)
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• Yescarta® (axicabtagene ciloleucel)
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• Yesintek® (ustekinumab-kfce)
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• Yimmugo® (intravenous immune globulin)
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• Yondelis® (trabectedin)
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• Zaltrap® (ziv-aflibercept)
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• Zarxio® (filgrastim-sndz, biosimilar)
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• Zemaira® (alpha-1 proteinase inhibitor) - COMMERCIAL POLICY ONLY
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• Zepzelca® (lurbinectedin)
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• Ziextenzo® (pegfilgrastim-bmez)
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• Ziihera® (zanidatamab-hrii)
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• Zirabev® (bevacizumab-bvzr)
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• Zoladex® (goserelin acetate implant, per 3.6 mg)
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• Zolgensma® (onasemnogene abeparvovec-xioi )
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• Zymfentra® (infliximab-dyyb)
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• Zynlonta® (loncastuximab tesirine-lpyl)
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• Zynteglo™ (betibeglogene autotemcel)
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• Zynyz® (retifanlimab-dlwr)
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