Drug Therapy Guidelines

• Abbreviated Criteria Abbreviated Criteria: Austedo, Carbaglu, Dificid, Doptelet, Gralise, Hetlioz, Jetrea, Kanuma, Keveyis, Mulpleta, Nuedexta, Nuplazid, Strensiq, Sylvant, Syprine, Xatmep, Xenazine, Xuriden
• Abiraterone Abiraterone acetate (Zytiga™, Yonsa®)
• Actemra Actemra® (tocilizumab)
• Actimmune Actimmune® (interferon gamma 1b)
• Adalimumab Adalimumab (Humira® [adalimumab], HyrimozTM [adalimumab-adaz])
• Adcetris Adcetris™ (brentuximab vedotin)
• Addyi AddyiTM (flibanserin)
• Afinitor Afinitor® (everolimus)
• Afrezza Afrezza® (insulin human)
• Alecensa Alecensa® (alectinib)
• Alimta Alimta® (pemetrexed)
• Aliqopa Aliqopa™ (copanlisib)
• Alpha-1 Proteinase Inhibitors (Human) Aralast NP, Glassia, Prolastin-C®, Zemaira®
• Alunbrig AlunbrigTM (brigatinib)
• Amantadine ER Amantadine ER (Gocovri®, Osmolex ERTM)
• Ampyra Ampyra® (dalfampridine)
• Antiemetic Agents Antiemetic Agents: Zofran®/ODT® (ondansetron/ondansetron ODT/ondansetron oral solution), Zuplenz® (ondansetron oral film), Kytril® (granisetron), granisetron, Sancuso® (granisetron topical), Anzemet® (dolasetron), Emend® (aprepitant), Akynzeo® (netupitant/palonosetron), Varubi® (rolapitant)
• Antifungal Agents Antifungal Agents: Lamisil® (terbinafine), Sporanox®(itraconazole), Tolsura™ (itraconazole), Vfend® (voriconazole), Noxafil®(posaconazole), Cresemba® (isavuconazonium)
• Antinarcoleptic Agents armodafinil, modafinil, Nuvigil®, Provigil®
• Apokyn Apokyn® (Apomorphine)
• Appetite Suppressants Appetite Suppressants (Anorexiants) & Weight Loss Agents: Adipex®, phentermine, Bontril®, phendimetrazine, Didrex®, benzphetamine, Suprenza®, diethylpropion, Xenical®, Qsymia®, Belviq®, Belviq XR®, Contrave®, LomairaTM, Saxenda®
• Arcalyst Arcalyst® (rilonacept)
• Arzerra Arzerra® (ofatumumab)
• Asparagine Specific Enzymes Asparagine Specific Enzymes: Asparlas™ (calaspargase pegol-mknl), Oncaspar® (pegaspargase)
• Aubagio Aubagio® (teriflunomide)
• Azedra Azedra® (iobenguane I 131)

• Bavencio Bavencio® (avelumab)
• Beleodaq Beleodaq® (belinostat)
• Benlysta Benlysta® (belimumab)
• Besponsa Besponsa™ (inotuzumab ozogamicin)
• Bevacizumab Bevacizumab (Avastin® [bevacizumab], Mvasi® [bevacizumab-awwb])
• Blincyto Blincyto® (blinatumomab)
• Bortezumib Bortezomib (bortezomib, Velcade® [bortezomib])
• Bosulif Bosulif® (bosutinib)
• Botulinum Toxins Botulinum Toxins: Botox® (onabotulinumtoxinA), Dysport™ (abobotulinumtoxinA), Myobloc® (rimabotulinumtoxinB), Xeomin® (incobotulinumtoxinA)
• Braftovi Braftovi™ (encorafenib)
• Brineura BrineuraTM (cerliponase alfa)
• Cablivi Cablivi® (caplacizumab-yhdp)
• Cabometyx Cabometyx® (cabozantinib)
• Calcitonin Gene-Related Peptide (CGRP) Antagonists Calcitonin Gene-Related Peptide (CGRP) Antagonists: Aimovig™ (erenumab-aooe), AjovyTM (fremanezumab-vfrm) , EmgalityTM (galcanezumabgnlm)
• Calquence Calquence ® (acalabrutinib)
• Cambia CambiaTM (diclofenac potassium for oral solution)
• Caprelsa Caprelsa® (vandetanib)
• Cimzia Cimzia® (certolizumab pegol)
• Cinqair Cinqair® (reslizumab)
• Chenodal Chenodal™ (chenodiol)
• Cholbam Cholbam® (cholic acid)
• Colony Stimulating Factors (CSFs) Colony Stimulating Factors (CSFs): Fulphila™ (pegfilgrastim-jmdb), Granix® (Tbo-filgrastim), Leukine® (sargramostim), Neupogen® (filgrastim), Neulasta® (pegfilgrastim), Nivestym™ (filgrastim-aafi), Udenyca™ (pegfilgrastim-cbqv), Zarxio™ (filgrastim-sndz)
• Cometriq Cometriq® (cabozantinib)
• Compounded Medications Compounded Medications
• Copiktra Copiktra™ (duvelisib)
• Corlanor Corlanor® (ivabradine)
• Cosentyx Cosentyx® (secukinumab)
• Cotellic Cotellic™ (cobimetinib)
• Crysvita Crysvita® (burosumab-twza)
• Cyramza Cyramza® (ramucirumab)
• Dacogen Dacogen® (decitabine)
• Daklinza DaklinzaTM (daclatasvir)
• Darzalex Darzalex™ (daratumumab)
• Daurismo Daurismo™ (glasdegib)
• Desmopressin acetate Desmopressin acetate (Nocdurna®, NoctivaTM)
• Diacomit Diacomit® (stiripentol)
• Doxepin cream Doxepin cream: doxepin 5% cream, Prudoxin™, Zonalon®
• Duopa DuopaTM (carbidopa/levodopa enteral suspension)
• Dupixent Dupixent (dupilumab)
• Duzallo Duzallo® (lesinurad and allopurinol)

• Egrifta Egrifta® (tesamorelin)
• Elaprase Elaprase® (idursulfase)
• Elzonris ElzonrisTM (tagraxofusp-erzs)
• Emflaza EmflazaTM (deflazacort)
• Empliciti EmplicitiTM (elotuzumab)
• Enbrel Enbrel® (etanercept)
• Endari EndariTM (L-glutamine)
• Entyvio Entyvio® (vedolizumab)
• Epaned Epaned® (enalapril powder for oral solution)
• Epclusa EpclusaTM (sofosbuvir and velpatasvir)
• Epidiolex Epidiolex® (cannabidiol)
• Erbitux Erbitux® (cetuximab)
• Erectile Dysfunction (ED) Agents Erectile Dysfunction (ED) Agents: Cialis® (tadalafil), tadalafil, Levitra® (vardenafil), vardenafil, Viagra® (sildenafil), sildenafil, Caverject® (alprostadil), Edex® (alprostadil), Muse® (alprostadil), Staxyn® (vardenafil), Stendra™ (avanafil)
• Erivedge Erivedge® (vismodegib)
• Erleada Erleada™ (apalutamide)
• Esbriet Esbriet® (pirfenidone)
• Exondys 51 Exondys 51™ (eteplirsen)
• Eylea Eylea™ (aflibercept)
• Fabrazyme Fabrazyme® (agalsidase beta)
• Farydak Farydak® (panobinostat)
• Fasenra FasenraTM (benralizumab)
• Ferriprox Ferriprox® (deferiprone)
• Firdapse Firdapse® (amifampridine)
• Forteo Forteo® (teriparatide)
• Galafold Galafold™(migalastat)
• Gamifant Gamifant™ (emapalumab-lzsg)
• Gattex Gattex® (teduglutide [rDNA origin])
• Gaucher’s Disease Agents Gaucher’s Disease Agents: Cerdelga® (eliglustat), Cerezyme® (imiglucerase), Elelyso® (taliglucerase alfa), Vpriv (velaglucerase alfa), Zavesca® (miglustat)
• Gazyva Gazyva® (obinutuzumab)
• Gilenya GilenyaTM (fingolimod)
• Gilotrif Gilotrif® (afatinib)
• Glassia Glassia [Alpha-1 Proteinase Inhibitor (Human), Intravenous]
• Gleevec Gleevec® imatinib
• Gonadotropin-Releasing Hormone Agonists Gonadotropin-Releasing Hormone Agonists- Eligard®, Lupron®, Lupron-Depot®, Lupron Depot-Ped®, Lupaneta® (leuprolide, norethindrone pack), Lutrate® Depot, Triptodur™ (triptorelin), Trelstar® (triptorelin, including Depot and LA), Synarel ®(nafarelin acetate)
• Grastek Grastek® (Timothy Grass Pollen Allergen Extract)
• Growth Stimulating Drugs Growth Stimulating Drugs: Norditropin®, Genotropin®, Humatrope®, Omnitrope®, Nutropin®, Saizen®, Serostim®, ZomactonTM, Zorbtive® (somatropin, recombinant growth hormone)

• H.P. Acthar Gel H.P. Acthar® Gel (repository corticotropin)
• Halaven Halaven™ (eribulin mesylate)
• Harvoni Harvoni® (ledipasvir and sofosbuvir)
• Hemlibra Hemlibra® (emicizumab-kxwh)
• Hepatitis C Antivirals Pegasys®, Peg-Intron®, ribavirin, ribasphere, ribapak, Copegus®, Rebetol®, Infergen®, Intron-A®
• Hereditary Angioedema (HAE) Agents Hereditary Angioedema (HAE) Agents: Berinert® (C1 esterase inhibitor [human]), Cinryze® (C1 esterase inhibitor [human]), Haegarda® (C1 esterase inhibitor [human]) Kalbitor® (ecallantide), Firazyr® (icatibant), Ruconest® (C1 esterase inhibitor [recombinant]), TakhzyroTM (lanadelumab-flyo)
• Horizant Horizant® (gabapentin enacarbil ER)
• Humira Humira® (adalimumab)

• Ibrance Ibrance® (palbociclib)
• Iclusig Iclusig® (ponatinib)
• Idhifa Idhifa® (enasidenib)
• Ilaris Ilaris® (canakinumab)
• Ilumya Ilumya™ (tildrakizumab-asmn)
• Imbruvica Imbruvica® (ibrutinib)
• Imfinzi Imfinzi (durvalumab)
• Imlygic ImlygicTM (talimogene laherparepvec)
• Immune Globulin Intravenous: Carimune® NF, Flebogamma®, Flebogamma® DIF, Gammagard®, Gammagard® S/D, Gammaplex®, Gamunex®, Gamunex-C®, Octagam®, Gammaked® and BIVIGam®, Privigen® Subcutaneous: Hizentra®, Gamunex-C®, Gammaked®, Gammagard®, HyQvia®, Cuvitru™
• Impoyz Impoyz™ (clobetasol propionate)
• Inbrija Inbrija™ (levodopa) oral inhalation powder
• Increlex Increlex® (mecasermin)
• Incretin Mimetics Incretin Mimetics – AdlyxinTM (lixisenatide) Bydureon® (exenatide), Bydureon®BCiseTM (exenatide extended-release) Byetta® (exenatide), Ozempic® (semaglutide), TanzeumTM (albiglutide), TrulicityTM (dulaglutide), Victoza® (liraglutide)
• Infliximab Infliximab (Remicade®, Inflectra®/infliximab-dyyb, RenflexisTM/infliximab-abda)
• Ingrezza Ingrezza™ (valbenazine)
• Injectable Fertility Medications Injectable Fertility Medications: Bravelle®, Cetrotide®, Follistim AQ®, Ganirelix®, Gonal-F®, human chorionic gonadotropin, leuprolide, Menopur®, Novarel®, Ovidrel®, Pregnyl®, progesterone in oil
• Inlyta Inlyta® (axitinib)
• Iressa Iressa® (gefitinib)
• Istodax Istodax® (romidepsin)
• Jakafi Jakafi® (ruxolitinib)
• Jevtana Jevtana® (cabazitaxel)
• Juxtapid Juxtapid™ (lomitapide)
• Jynarque Jynarque™ (tolvaptan)

• Kadcyla Kadcyla® (ado-trastuzumab emtansine)
• Kalydeco Kalydeco® (ivacaftor)
• Kevzara Kevzara® (sarilumab)
• Keytruda Keytruda® (pembrolizumab)
• Kineret Kineret® (anakinra)
• Kisqali Kisqali ® (ribociclib), Kisqali®Femara® Co-Pack (ribociclib; letrozole)
• Korlym KorlymTM (mifepristone)
• Krystexxa KrystexxaTM (pegloticase)
• Kuvan Kuvan® (sapropterin dihydrochloride)
• Kymriah Kymriah® (tisagenlecleucel)
• Kyprolis Kyprolis™ (carfilzomib injection)
• Lartruvo Lartruvo™ (olaratumab)
• Lemtrada Lemtrada® (alemtuzumab)
• Lenvima Lenvima® (lenvatinib)
• Libtayo Libtayo® (cemiplimab-rwlc)
• Lonsurf Lonsurf® (trifluridine and tipiracil)
• Lorbrena Lorbrena® (lorlatinib)
• Lumoxiti Lumoxiti™ (moxetumomab pasudotox-tdfk)
• Lutathera Lutathera ® (lutetium Lu 177 dotatate)
• Luxturna Luxturna® (voretigene neparvovec-rzyl)
• Lynparza Lynparza® (olaparib)
• Lyrica CR Lyrica CR® (pregabalin ER)

• Macugen Macugen® (pegaptanib)
• Marqibo Marqibo™ (vincristine liposomal)
• Mavyret Mavyret® (glecaprevir and pibrentasvir)
• Medical Benefit Reference Guide
• Mekinist Mekinist™ (trametinib)
• Mektovi Mektovi®(binimetinib)
• Mepsevii MepseviiTM (vestronidase alfa-vjbk)
• Movantik Movantik® (naloxegol oxalate)
• Mozobil Mozobil™ (plerixafor)
• MS Agents Multiple Sclerosis (MS) Self-Injectable Agents: Avonex®, Betaseron®, Copaxone®, Extavia®, glatopa™, Plegridy™, Rebif®
• Myalept MyaleptTM (metreleptin)
• Mylotarg MylotargTM (gemtuzumab ozogamicin)
• Natpara Natpara® (parathyroid hormone)
• Nerlynx Nerlynx™ (neratinib)
• Nexavar Nexavar® (sorafenib)
• Ninlaro Ninlaro® (ixazomib)
• Northera Northera® (droxidopa)
• Nplate Nplate® (romiplostim)
• Nucala Nucala® (mepolizumab)
• Nutritional Supplements Nutritional Supplements, Enteral Formulas
• Ocaliva Ocaliva® (obeticholic acid)
• Ocrevus OcrevusTM (ocrelizumab)
• Odactra OdactraTM (House Dust Mite [Dermatophagoides farinae and Dermatophagoides pteronyssinus] Allergen Extract)
• Odomzo Odomzo® (sonidegib)
• Ofev Ofev® (nintedanib)
• Olumiant Olumiant®(baricitinib)
• Olysio OlysioTM (simeprevir)
• Onpattro Onpattro™ (patisiran)
• Opdivo Opdivo® (nivolumab)
• Opioid Management Opioid Management
• Oralair Oralair® (Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract)
• Orencia Orencia® (abatacept)
• Orilissa OrilissaTM (elagolix)
• Orkambi Orkambi® (lumacaftor/ivacaftor)
• Otezla Otezla® (apremilast)
• Oxervate Oxervate™ (cenegermin-bkbj)

• Palynziq Palynziq (pegvaliase-pqpz)
• PCSK9 Inhibitors PCSK9 Inhibitors: Praluent™, Repatha™
• Penicillamine Therapy Penicillamine Therapy – Cuprimine®, Depen®, D-PENAMINE*
• Perjeta Perjeta™ (pertuzumab)
• Pomalyst Pomalyst® (pomalidomide)
• Portrazza Portrazza® (necitumumab)
• Poteligeo Poteligeo® (mogamulizumab-kpkc)
• Preferred Drug Step Therapy Angiotensin Receptor Blockers (ARBs); Antipsychotics, 2nd generation; BPH (alpha-antagonists); Beta Agonist Inhalers; Calcipotriene Agents; CNS Stimulants; Consensi, Constipation Agents; Desvenlafaxine; DPP-4 Inhibitors; Duexis; Epaned, Epinephrine Products; Fenofibrates; Incretin Mimetics, Inhaled Combinations; Inhaled Corticosteroids; Insulin; Insulin, Basal; Intranasal Steroids; Metformin ER Products; Select NSAIDs, Osteoporosis Agents; Pancreatic Enzymes; Prexxartan, Prostaglandin Analogs; Proton Pump Inhibitors (PPIs); Qbrelis, Rayos (prednisone delayed-release); Renin Inhibitors; Rhopressa; Selective Serotonin Reuptake Inhibitors (SSRIs); SGLT-2 Inhibitors; Sympazan, Test Strips for Blood Glucose; Testosterone Replacements; Select Tetracyclines, Tiglutik, Topical Dermatologics; Urinary Agents; Verzacloz; Vimovo; Yupelri
• Prevymis PrevymisTM (letermovir)
• Procysbi Procysbi® (cysteamine bitartrate delayed release capsules)
• Promacta Promacta® (eltrombopag)
• Provenge Provenge® (sipuleucel-T)
• Pulmonary Arterial Hypertension (PAH) Agents Pulmonary Arterial Hypertension (PAH) Agents: Revatio™ (sildenafil), Ventavis® (iloprost), Tracleer® (bosentan), Letairis™ (ambrisentan), Adcirca® (tadalafil), Tyvaso® (treprostinil), Remodulin® (treprostinil), Flolan®/Veletri® (epoprostenol), Adempas® (riociguat), Opsumit® (macitentan), Orenitram® (treprostinil), Uptravi® (selexipag)
• Qbrelis Qbrelis™ (lisinopril oral solution)
• Qbrexza QbrexzaTM(glycopyrronium 2.4% cloth)
• Qutenza Qutenza® (8% capsaicin patch)

• Radicava Radicava® (edaravone)
• Ragwitek Ragwitek® (Short Ragweed Pollen Allergen Extract)
• Ravicti Ravicti™ (glycerol phenylbutyrate)
• Relistor Relistor® (methylnaltrexone bromide)
• Revcovi Revcovi™ (elapegademase-lvlr)
• Revlimid Revlimid® (lenalidomide)
• Rituximab Rituximab (Rituxan® [rituximab], Rituxan Hycela® [rituximab/hyaluronidase human, recombinant], Truxima® [rituximab-abbs])
• Rubraca Rubraca® (rucaparib)
• Rydapt Rydapt® (midostaurin)
• Samsca Samsca® (tolvaptan)
• Sedative Hypnotics Sedative Hypnotics: zolpidem, Ambien®, zolpidem CR, Ambien CR®, zaleplon, Sonata®, Lunesta®, Rozerem®, EdluarTM, ZolpimistTM, Silenor®, Intermezzo®/zolpidem SL, Belsomra®
• Signifor Signifor®, Signifor® LAR (pasireotide)
• Siliq Siliq (brodalumab)
• Simponi Simponi®, Simponi Aria® (golimumab)
• Solaraze Solaraze®, diclofenac 3% gel
• Soliris Soliris™ (eculizumab)
• Somavert Somavert® (pegvisomant)
• Sovaldi Sovaldi (sofosbuvir)
• Spinraza Spinraza™ (nusinersen)
• Sprycel Sprycel® (dasatinib)
• Stelara Stelara® (ustekinumab)
• Stivarga Stivarga® (regorafenib)
• Sucraid Sucraid® (sacrosidase)
• Sutent Sutent® (sunitinib)
• Sylatron Sylatron™ (peginterferon alfa-2b)
• Symdeko Symdeko™ (tezacaftor/ivacaftor)
• Symlin Symlin® (pramlintide acetate)
• Symproic Symproic® (naldemedine)
• Synagis Synagis® (palivizumab injection)
• Synribo Synribo® (omacetaxine mepesuccinate)

• Tafinlar Tafinlar® (dabrafenib)
• Tagrisso TagrissoTM (osimertinib)
• Taltz Taltz® (ixekizumab)
• Talzenna Talzenna™ (talazoparib)
• Tarceva Tarceva® (erlotinib)
• Targretin Targretin®/bexarotene capsules, Targretin® gel
• Tasigna Tasigna® (nilotinib)
• Tavalisse Tavalisse™ (fostamatinib)
• Tecentriq Tecentriq® (atezolizumab)
• Tecfidera Tecfidera® (dimethyl fumarate)
• Technivie TechnivieTM (ombitasvir, paritaprevir, ritonavir)
• Tegsedi Tegsedi™ (inotersen)
• Temodar Temodar®, temozolomide
• Tibsovo Tibsovo® (ivosidenib)
• Topical Immunomodulators Topical Immunomodulators- Elidel® (pimecrolimus cream), Eucrisa® (crisaborole ointment)
• Torisel Torisel® (temsirolimus)
• Transmucosal Immediate Release Fentanyl Abstral® (sublingual tablet), Actiq® (oral transmucosal lozenge), fentanyl powder, Fentora® (buccal tablet), Lazanda® (nasal spray), Onsolis® (buccal soluble film), Subsys® (sublingual spray) (buccal soluble film), Subsys® (sublingual spray)
• Trastuzumab Trastuzumab (Herceptin® [trastuzumab], Herzuma® [trastuzumab-pkrb], Ontruzant® [trastuzumab-dttb])
• Tremfya TremfyaTM (guselkumab)
• Triptans Triptans: almotriptan, Amerge®, Axert®, Frova®, Imitrex® and sumatriptan tablets/nasal spray/injection, Maxalt/MLT®, naratriptan, Onzetra™ Xsail™, Relpax® and eletriptan tablets, rizatriptan/ODT, Sumavel®, Tosymra™, Treximet®, Zembrace™ SymTouch™, zolmitriptan/ODT tablets, Zomig/ZMT® tablets/nasal spray
• Trogarzo Trogarzo™ (ibalizumab-uiyk)
• Tykerb Tykerb® (lapatinib)
• Tymlos Tymlos® (abaloparatide)
• Tysabri Tysabri® (natalizumab)
• Uloric Uloric® (febuxostat)
• Ultomiris Ultomiris™ (ravulizumab-cwvz)
• Unituxin UnituxinTM (dinutuximab)
• Valchlor Valchlor® (mechlorethamine gel)
• Vectibix Vectibix® (panitumumab)
• Venclexta Venclexta® (venetoclax)
• Verzenio Verzenio™ (abemaciclib)
• Vidaza Vidaza® (azacitidine)
• Viekira Viekira Pak™ (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets), Viekira XR™ (dasabuvir, ombitasvir, paritaprevir, and ritonavir) extendedrelease tablets
• Vimizim Vimizim (elosulfase alfa)
• Vitrakvi Vitrakvi® (larotrectinib)
• Vizimpro Vizimpro® (dacomitinib)
• Vosevi Vosevi™ (sofosbuvir, velpatasvir, and voxilaprevir)
• Votrient Votrient™ (pazopanib)
• Vyxeos Vyxeos™ (daunorubicin and cytarabine) liposome for injection

• Xalkori Xalkori® (crizotinib)
• Xeljanz Xeljanz®, Xeljanz® XR (tofacitinib)
• Xepi XepiTM (oxenoxacin)
• Xermelo XermeloTM (telotristat ethyl)
• Xhance Xhance® (fluticasone propionate)
• Xifaxan Xifaxan® (rifaximin)
• Xolair Xolair® (omalizumab)
• Xospata Xospata® (gilteritinib)
• Xtandi Xtandi® (enzalutamide)
• Xyrem Xyrem® (sodium oxybate oral solution)
• Yervoy YervoyTM (ipilimumab)
• Yescarta Yescarta® (axicabtagene ciloleucel)
• Yondelis Yondelis® (trabectedin)
• Yutiq Yutiq™ (fluocinolone acetonide intravitreal implant)
• Zaltrap Zaltrap® (ziv-aflibercept)
• Zelboraf ZelborafTM (vemurafenib)
• Zejula Zejula (niraparib)
• Zepatier Zepatier® (elbasvir and grazoprevir tablets)
• Zinplava Zinplava™ (bezlotoxumab)
• Zolinza Zolinza® (vorinostat)
• Zurampic Zurampic® (lesinurad)
• Zydelig Zydelig® (idelalisib)
• Zykadia Zykadia® (ceritinib)