A

Actemra - Criteria | Non-Preferred Exception Criteria
Adakveo
Aduhelm
Advate
Adynovate
Afstyla
Aliqopa
Alphanate
Alphanine SD
Alprolix
Altuviiio
Alyglo
Alymsys (Oncology)
Alymsys (Ocular & Other Conditions)
Aralast NP - Criteria | Non-Preferred Exception Criteria
Aranesp
Asceniv
Avastin (Oncology) - Criteria | Non-Preferred Exception Criteria
Avastin (Ocular & Other Conditions)
Avsola

B

Bavencio
Bebulin
Belrapzo
Bendamustine
Bendeka
Benefix
Benlysta
Beovu - Criteria | Non-Preferred Exception Criteria
Berinert
Besponsa
Bivigam
Blincyto
Briumvi
Botox - Criteria | Non-Preferred Exception Criteria
Byooviz - Criteria | Non-Preferred Exception Criteria

C

Camcevi - Criteria | Non-Preferred Exception Criteria
Cerezyme
Cimerli - Criteria | Non-Preferred Exception Criteria
Cimzia - Criteria | Non-Preferred Exception Criteria
Cinqair - Criteria | Non-Preferred Exception Criteria
Cinryze
Coagadex
Corifact
Crysvita
Cutaquig
Cuvitru
Cyramza

D

Darzalex
Daxxify
Durolane - Criteria | Non-Preferred Exception Criteria
Dysport

E

Elelyso
Eligard
Eloctate
Elrexfio
Entyvio - Criteria | Non-Preferred Exception Criteria
Epogen - Criteria | Non-Preferred Exception Criteria
Erbitux
Esperoct
Euflexxa - Criteria | Non-Preferred Exception Criteria
Evenity
Exondys 51
Eylea - Criteria | Non-Preferred Exception Criteria
Eylea HD - Criteria | Non-Preferred Exception Criteria

F

Fasenra - Criteria | Non-Preferred Exception Criteria
FEIBA
Firazyr
Firmagon
Flebogamma DIF
Forteo
Fulphila
Fusilev
Fylnetra

G

Gammagard Liquid
Gammagard S/D
Gammaked
Gammaplex
Gamunex-C
Gel-one - Criteria | Non-Preferred Exception Criteria
Gelsyn-3 - Criteria | Non-Preferred Exception Criteria
GenVisc 850 - Criteria | Non-Preferred Exception Criteria
Givlaari
Glassia - Criteria | Non-Preferred Exception Criteria
Granix - Criteria | Non-Preferred Exception Criteria

H

Hemgenix
Hemlibra
Hemofil M
Herceptin - Criteria | Non-Preferred Exception Criteria
Herceptin Hylecta
Herzuma
Hizentra
Humate-P
Hyalgan - Criteria | Non-Preferred Exception Criteria
Hymovis - Criteria | Non-Preferred Exception Criteria
Hyqvia

I

Icatibant acetate
Idelvion
Ilaris
Ilumya - Criteria | Non-Preferred Exception Criteria
Imfinzi
Inflectra
Ixinity

J

Jivi

K

Kadcyla
Kalbitor
Kanjinti
Kanuma
Keytruda
Khapzory
Koate
Kogenate FS
Kogenate FS Bio Set
Kovaltry
Krystexxa
Kymriah

L

Lanreotide Injection
Lemtrada - Criteria | Non-Preferred Exception Criteria
Leukine - Criteria | Non-Preferred Exception Criteria
Levoleucovorin Solution
Libtayo
Lucentis - Criteria | Non-Preferred Exception Criteria
Lumizyme
Lupron Depot - Criteria | Non-Preferred Exception Criteria
Lupron Depot Endometriosis-Fibroid
Lupron Depot, leuprolide depot Prostate Cancer
Luxturna

M

Mepsevii
Mircera - Criteria | Non-Preferred Exception Criteria
Mononine
Monovisc - Criteria | Non-Preferred Exception Criteria
Mvasi (Oncology)
Mvasi (Ocular & Other Conditions)
Myobloc - Criteria | Non-Preferred Exception Criteria

N

Naglazyme
Neupogen - Criteria | Non-Preferred Exception Criteria
Neulasta - Criteria | Non-Preferred Exception Criteria
Neulasta Onpro - Criteria | Non-Preferred Exception Criteria
Nivestym
Novoeight
Novoseven RT
Nplate
Nucala - Criteria | Non-Preferred Exception Criteria
Nuwiq
Nyvepria

O

Obizur
Ocrevus
Octagam
Ogivri
Onpattro
Ontruzant
Opdivo
Orencia - Criteria | Non-Preferred Exception Criteria
Orthovisc

P

Perjeta
Privigen
Procrit - Criteria | Non-Preferred Exception Criteria
Profilnine
Profilnine SD
Prolastin-C
Proleukin
Prolia
Provenge

Q

 

R

Radicava
Rebinyn
Reclast
Recombinate
Releuko
Remicade-Infliximab - Criteria | Non-Preferred Exception Criteria
Renflexis
Retacrit
Riabni
Rituxan Hycela - Criteria | Non-Preferred Exception Criteria
Rituxan - Criteria | Non-Preferred Exception Criteria
Rixubis
Rolvedon
Ruconest
Ruxience

S

Sajazir
Sandostatin LAR Depot
Sevenfact
Signifor LAR - Criteria | Non-Preferred Exception Criteria
Simponi Aria - Criteria | Non-Preferred Exception Criteria
Soliris
Somatuline Depot
Spinraza
Stelara - Criteria | Non-Preferred Exception Criteria
Stimufend
Supartz FX - Criteria | Non-Preferred Exception Criteria
Susvimo - Criteria | Non-Preferred Exception Criteria
Synvisc
Synvisc One

T

Takhzyro
Talvey
Tecartus
Tecentriq
Teriparatide
Tezspire - Criteria | Non-Preferred Exception Criteria
Trazimera
Treanda
Trelstar - Criteria | Non-Preferred Exception Criteria
Tretten
TriVisc - Criteria | Non-Preferred Exception Criteria
Truxima (Oncology)
Truxima
Tyruko
Tysabri

U

Udenyca, Udenyca Onbody
Ultomiris

V

Vabysmo - Criteria | Non-Preferred Exception Criteria
Vegzelma (Oncology)
Vegzelma (Ocular & Other Conditions)
Vimizim
Visco-3 - Criteria | Non-Preferred Exception Criteria
Visudyne
Vivimusta
Vonvendi
VPRIV - Criteria | Non-Preferred Exception Criteria

W

Wilate

X

Xembify
Xeomin
Xgeva
Xiaflex
Xolair - Criteria | Non-Preferred Exception Criteria
Xyntha
Xyntha Solofuse

Y

Yervoy
Yescarta

Z

Zarxio
Zemaira - Criteria | Non-Preferred Exception Criteria
Ziextenzo
Zirabev (Oncology)
Zirabev (Ocular & Other Conditions)
Zoladex - Criteria | Non-Preferred Exception Criteria
Zoledronic acid (Reclast)
Zolgensma