Value
Prescription
Drug List -
(1602)
Actimmune® (interferon gamma1b)
Acthar® Gel (repository corticotropin)
Actiq® (transmucosal fentanyl)
Addyi™ (flibanserin)
Alpha1-Proteinase Inhibitors
Ampyra® (dalfampridine)
Anadrol® (oxymetholone)
Antiemetic Therapy
Antifungals, Topical
Antivirals, Topical
Apokyn®
(apomorphine)
Arcalyst™ (rilonacept)
Austedo™ (deutetrabenazine)
Baxdela™ (delafloxacin)
Benlysta® (belimumab)
Botulinum Therapy
Brineura® (cerliponase alfa)
Ceprotin® (protein C concentrate)
Chimeric Antigen Receptor T-Cell (CAR-T) & Advanced Cellular/Immune Effector Cell Therapy
Cholbam® (cholic acid)
Clotting Factors & Antithrombin
Compounded Medications
Controlled Substance Analgesic & Narcotic Antagonist Quantity Limitations
Corlanor® (ivabradine)
Cresemba® (isavuconazonium)
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators
Daraprim® (pyrimethamine)
Denosumab
Depen® (penicillamine & trientine hydrochloride)
Dimercaprol & Edetate Calcium Disodium
Dose Optimization
Duopa®
(carbidopa & levodopa enteral suspension)
Dupixent® (dupilumab)
Egrifta® (tesamorelin)
Emflaza™ (deflazacort)
Endometrin® (progesterone)
Entresto™ (sacubitril/valsartan)
Epinephrine
Erythropoiesis Stimulating Agents (ESA)
Evzio® (naloxone)
Exondys 51™ (eteplirsen)
Filgrastim
Gattex® (teduglutide)
Glycopyrrolate Inhalation Solution
Hepatitis C Therapy
Hereditary Angioedema (HAE) Therapy
Hetlioz® (tasimelteon)
HIV/AIDS
HMG-CoA Reductase Inhibitors (Statins)
Human Papillomavirus Vaccine
Idiopathic Pulmonary Fibrosis Therapy
Ilaris® (canakinumab)
Immune Globulin (IVIG)
Immunomodulators
Impavido® (miltefosine)
Increlex® (mecasermin)
Infertility Injectables
Ingrezza™ (valbenazine)
Insulin
glargine
Interferon Therapy
Interleukin (IL)-5 Antagonists: Mepolizumab
&
Reslizumab
Jakafi® (ruxolitinib)
Jetrea® (ocriplasmin)
Korlym® (mifepristone)
Krystexxa® (pegloticase)
Kuvan® (sapropterin)
Lesinurad
Luxturna™ (voretigene neparvovec)
Lysosomal Storage Disorders Therapy
Makena® (hydroxyprogesterone caproate Injection)
Medication Administration Site of Care
Modafinil/Armodafinil
Mozobil®
(plerixafor)
Multiple Sclerosis Therapy
Neulasta® (pegfilgrastim
Nplate® (romiplostim)
Ocaliva® (obeticholic acid)
Oncology Medications
Opioid Therapy
Oral Phosphodiesterase-5 (PDE5) Inhibitors
Otezla® (apremilast)
PCSK9
Inhibitors
Performance Prescription Drug List
Pharmacy
Prior Authorization
Promacta® (eltrombopag)
Pulmonary Hypertension (PH) Therapy
Quantity Limitations
Radicava™ (edaravone)
Rituxan® (rituximab for Non-Oncology Indications)
Routine Immunizations
Sandostatin®, Sandostatin LAR ® Depot (octreotide)
Soliris® (eculizumab)
Somatropin
Spinraza™ (nusinersen)
Standard Prescription Drug List
Step
Therapy
Step Therapy Individual & Family Plan
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans
Step Therapy - Standard Prescription Drug Lists (Employer Group Plans)
Step Therapy – Value Prescription Drug Lists (Employer Group Plans)
Supprelin® LA (histrelin acetate subcutaneous implant)
Synagis® (palivizumab)
Testopel® (implantable hormone pellets)
Testosterone Therapy
Topical Alpha Adrenergic Agonists
Topical Doxepin
Unassigned Drug or Biologic Code Medical Precertification
Value
Prescription
Drug List
(1601)
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use
Vfend® voriconazole
Visco-supplementation
for Osteoarthritis
Xiaflex® (collagenase clostridium histolyticum)
Xolair® (omalizumab)
Zilretta® (triamcinolone acetonide extended-release injection)
Zyvox® (oxazolidinone) Antibiotics