2024 Marketplace Drug Formulary
Physician Administered Preferred Drug List
Physician Administered Preferred Drug List - 2024
Physician Administered Preferred Drug List - 2025
Specialty Medication Administration Site of Care Policy
Specialty Medication Administration Site of Care Coverage Criteria Policy
Court-Ordered Prescription Drug Coverage Policy
Court-Ordered Prescription Drugs California CARE Act
Medication Prior Authorization Criteria and Clinical Policies
Abilify MyCite Kit (aripiprazole with biosensor) C15913-A
Actemra (tocilizumab) C10265-A
Acthar Gel (repository corticotropin injection) C8373-A
Adakveo (crizanlizumab-tmca) C17920-A
Adbry (tralokinumab) C23078-A
Adcetris (brentuximab vedotin) C15428-A
Aduhelm (aducanumab-avwa) C21304-A
Adzynma (adamts13, recombinant-krhn) C27325-A
Agamree (vamorolone) C27685-A
Aldara_Zyclara (imiquimod) C4194-C
Aldurazyme (laronidase) C28302-A
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A
Amondys 45 (casimersen) NC C21153-A
Ampyra (dalfampridine) C6480-A
Amvuttra (vutrisiran) C24213-A
Antidiabetic Agents C21116-A
Antiemetics C20780-A
Antimalarial Agents C8633-A
Aphexda (motixafortide) C27171-A
Apokyn_Kynmobi (apomorphine) C6918-A
Arcalyst (rilonacept) C2434-A
Arixtra (fondaparinux) C9084-A
Atypical Antipsychotics C5016-A
Austedo (deutetrabenazine) C12650-A
Azactam (aztreonam) C10143-A (2)
Baxdela (delafloxacin) C16332-A
Benlysta (belimumab) C2722A
Beovu (brolucizumab) C17923-A
Bimzelx (bimekizumab) C27172-A
Botulinum Toxin C8755-A
Brineura (cerliponase alfa) C11526-A
Briumvi (ublituximab) C25204-A
Brixadi (buprenorphine ER inj) C27170-A
Buprenorphine-Naloxone and Buprenorphine for Opioid Dependence C10899-A
Bylvay (odevixibat) C22109-A
Cablivi (caplacizumab) Criteria C19481-A
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C
Camzyos (mavacamten) C23723-A
Cancidas (caspofungin) C17928-A
Carisoprodol Products C11268-A
Cayston (aztreonam) C6481-A
Cerdelga (eliglustat) C6633-A
Chemet (succimer) C9816-A
Cholbam (cholic acid) C17319-A
Cibinqo (abrocitnib) C23363-A
Cimzia (certolizumab pegol) C10269-A
Cinqair (reslizumab) C9761-A
CNS Stimulants C4191-A
Colcrys, Mitigare, Gloperba (colchicine) C4205-A
Constipation Agents C24671-A
Continuous Glucose Monitoring Systems (CGMS) C17737-A
Copaxone_Glatopa (glatiramer acetate) C10270-A
Cosela (trilaciclib) C21205-A
Cosentyx (secukinumab) C10410-A
Crysvita (Burosumab-twza) C14517-A
Cubicin (daptomycin) C10467-A
Cuvposa (glycopyrrolate) oral solution C8453-A
Cystic Fibrosis Agents C2436-A
Cytogam (cytomegalovirus immune globulin) C9970-A
Dalvance (dalbavancin) C9351-A
Daraprim (pyrimethamine) C8631-A
Daybue (trofinetide) C25469-A
Desmopressin Nasal and Oral (DDAVP) C17861-A
Dextenza (dexamethasone intracanalicular insert) C24242-A
Dexycu (dexamethasone intraocular suspension) C16320-A
Diabetic Testing Supplies C5108-A
Diclofenac Topical C4962-A
Direct Oral Anticoagulants C20784-A
Disposable Insulin Delivery Device C17724-A
Doptelet (avatrombopag) C16445-A
Dry Eye Therapies C4728-A
Dupixent (dupilumab) C11152-A
Duplication of Therapy-High Risk Combination C15341-A
Durysta (bimatoprost implant) C19830-A
Duvyzat (givinostat) C28336-A
Egrifta SV (tesamorelin) NC C16187-A
Elaprase (idursulfase) C2720-A
Elfabrio (pegunigalsidase alfa) C25604-A
Elidel-Protopic-Eucrisa C8268-A
Eltrombopag (Alvaiz, Promacta) C6663-A
Emflaza (deflazacort) NC C10904-A
Empaveli (pegcetacoplan) C21423-A
Enbrel (etanercept) C10411-A
Endari (L-glutamine oral powder) C12651-A
Enjaymo (sutimlimab) C22996-A
Enspryng (satralizumab-mwge) 20849-A
Entresto (sacubitril_valsartan) C8675-A
Entyvio (vedolizumab) C6773-A
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A
Eohilia (budesonide oral susp) C27704-A
Epidiolex (cannabidiol) C19326-A
Erythropoiesis-stimulating Agents (ESAs) C15389-A
Esbriet (pirfenidone) C16582-A
Evenity (romosozumab-aqqg) C17324-A
Evkeeza (evinacumab_dgnb) C21101-A
Evrysdi (risdiplam) C20580-A
Exondys 51 (eteplirsen) NC C9941-A
Eylea (aflibercept) C5674-A
Fabhalta (iptacopan) C27697-A
Fabrazyme (agalsidase beta) C4865-A
Fasenra (benralizumab) C13643-A
Filgrastim C2437-A
Filspari (sparsentan) C25282-A
Filsuvez (birch triterpenes gel) C27686-A
Firdapse (amifampridine) C15969-A
Forteo (teriparatide) C8523-A
Furoscix (furosemide on-body infusor) C24669-A
Fuzeon (enfuvirtide) C9573-A
Galafold (migalastat) C15445-A
Gamifant (emapalumab-lzsg) C15970-A
Gattex (teduglutide [rDNA origin]) C5774-A
Gender Dysphoria Hormone Therapy C17908-A
Givlaari (givosiran) C17924-A
Global Formulary Exception Criteria (NF, QL, ST, etc) C10169-A
Gocovri_Osmolex (amantadine ER caps and tabs) C13296-A
Growth Hormone (hGH, somatropin) Therapy C6925-A
Hemophilia and Blood Factor Products C15607-A
Hemostatic Agents C14570-A
Hepatitis B Immune Globulin C9971-A
Hepatitis C Antiviral Therapy C12049-A
Hereditary Angioedema Agents C21463-A
Hetlioz (tasimelteon) C8920-A
High-Cost Outlier Targeted Drug Exceptions (HOT) C17973-A
Humira (adalimumab) C10412-A
Hyaluronic Acid (HA) Injections_Viscosupplementation for Knee OsteoArthritis C14676-A
iDose TR (travoprost intracameral implant) C27707-A
Igalmi (dexmedetomidine) C23724-A
Ilaris (canakinumab) C2435-A
Ilumya (tildrakizumab) C15971-A
Iluvien (fluocinolone acetonide intravitreal implant) C11728-A
Imcivree (setmelanotide) NC C22214-A
Immunoglobulin (SCIg, IVIg) C21554-A
Impetigo Agents- Altabax, Centany, Xepi C8409-A
Increlex (mecasermin) C8891-A
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A
Ingrezza (valbenazine) C12649-A
Inpefa (sotagliflozin) C26204-A
InPen (Smart Insulin Pen) C21865-A
Inrebic (fedratinib) C17941-A
Insulin Patch NC C24238-A
Intravenous Bisphosphonates C16790-A
Iron Chelating Agents (Desferal Exjade Ferriprox Jadenu) C15214-A
Iron Deficiency Anemia Agents C14569-A
Isotretinoin C4231-C
Isturisa (osilodrostat) C19328-A
Izervay (avacincaptad intravitreal) C26436-A
Jakafi (ruxolitinib) C17367-A
Jesduvroq (daprodustat) C27174-A
Joenja (leniolisib) C25485-A
Juxtapid (lomitapide) C3893-A
Kanuma (sebelipase alfa) C9974-A
Kerendia (finerenone) C21829-A
Kesimpta (ofatumumab) C21104-A
Keveyis (dichlorphenamide) C14599-A
Kevzara (sarilumab) C14653-A
Kineret (anakinra) C10415-A
Korlym (mifepristone) C10881-A
Korsuva (difelikefalin) C23743-A
Koselugo (selumetinib) C19330-A
Krystexxa (pegloticase) C2729-A
Kuvan (sapropterin dihydrochloride) C7067-A
Lamzede (velmanase alfa) C25436-A
Lemtrada (alemtuzumab) C6919-A
Leqembi (lecanemab) C25201-A
Leqvio (inclisiran) C23141-A
Leukine (sargramostim) C2439-A
Leuprolide long acting (Lupron Depot Eligard Lupaneta Lupron Depot Ped Triptodur) C8756-A
Lidocaine Patch C5168-A
Linezolid C8632-A
Litfulo (ritlecitinib) NC C26206-A
Livmarli (maralixibant) C22224-A
Livtencity (maribavir) C22246-A
Lucemyra (lofexidine) C16350-A
Lumizyme (Alglucosidase alfa) C8716-A
Lupkynis (voclosporin) C21124-A
Lyrica Lyrica CR (pregabalin_pregabalin ER) C4709-A
Medical Necessity Review C20326-A
Mepron (atovaquone) C8408-A
Mepsevii (vestronidase alfa-vjbk) C1794-A
Mozobil (plerixafor injection) C9017-A
Mulpleta (lusutrombopag) C16446-A
Multiple Sclerosis Agents - Interferons C10267-A
Myalept (metreleptin) C17341-A
Mycamine (micafungin) C9347-A
Naglazyme (galsulfase) C28288-A
Nasal Steroids C4730-A
Nexletol (bempedoic acid) and Nexlizet (bempedoic acid and ezetimibe) C18441-A
NexoBrid (anacaulase gel) C25200-A
Nexviazyme (avalglucosidase alfa-ngpt) C21948-A
Nitisinone (Orfadin_Nityr) C13398-A
Northera (droxidopa) C13402-A
Nplate (romiplostim)_Chronic ITP C6662-A
Nucala (mepolizumab) C9704-A
Nuedexta (dextromethorphan-quinidine) C12971-C
Nulibry (fosdenopterin) C21306-A
Nulojix (belatacept) C9968-A
Nuplazid (pimavanserin) C12066-A
Nuzyra (omadacycline tosylate) C15914-A
Ocaliva (obeticholic acid) C16447-A
Ocrevus (ocrelizumab) C11250-A
Octreotide C8839-A
Ofev (nintedanib) C16583-A
Off-Label Use of Drugs and Biologic Agents C4141-A
Ojjaara (momelotinib) C27175-A
Olumiant (baricitinib) C15447-A
Omvoh (mirikizumab-mrkz) C27293-A
Onpattro (patisiran) C17894-A
Opfolda (miglustat) C27241-A
Opioid Global Criteria C16263-A
Opzelura (ruxolitinib) C22277-A
Oral MS Disease-Modifying Therapies C21142-A
Orencia (abatacept) C10420-A
Orgovyx (relugolix), Myfembree (relugolix, estradiol, and norethindrone) C21100-A
Orilissa (elagolix) Oriahn (elagolix estradiol and norethindrone acetate capsules) C15417-A
Orladeyo (berotralstat) C21230-A
Otezla (apremilast) C6356-B
Otrexup and Rasuvo (methotrexate) C14770-A
Oxbryta (voxelotor) C17965-A
Oxervate (cenegermin) C16015-A
Oxlumo (lumasiran) C21126-A
Ozurdex (dexamethasone intravitreal implant) C9975-A
Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] C18457-A
Palynziq (pegvaliase-pqpz) C15432-A
Parsabiv (etelcalcetide) C17883-A
PCSK9 Inhibitors C10800-A
Penicillamine (Depen, Cuprimine) C15418-A
Physician Administered Drugs C11251-A
Pombiliti (cipaglucosidase alfa) C27242-A
Prescription Compounded Product C20382-A
Prevymis (letermovir) C15922-A
Procysbi and Cystagon (cysteamine bitartrate) C6355-B
Prolia (denosumab) C8848-A
Pulmicort Respules (budesonide) C4724-A
Pulmonary Arterial Hypertension (PAH) C9837-A
Pulmozyme (dornase alfa) C9796-A
Pyrukynd (mitapivat) C22822-A
Qalsody (tofersen) C25487-A
Qutenza (capsaicin) C2809-A
Radicava (edaravone) C11528-A
Ranibizumab (Lucentis, Byooviz, Cimerli) C10417-A
Ravicti (glycerol phenylbutyrate) C7041-A
Reblozyl (luspatercept-aamt) C18002-A
Rebyota (fecal microbiota) C25213-A
Recorlev (levoketoconazole) C23359-A
Regranex (becaplermin) C13432-C
Relizorb (immobilized lipase cartridge) C12081-A
Retisert_Yutiq (fluocinolone acetonide_Intravitreal Implants) C11706-A
Revcovi (elapegademase) Criteria C16106-A
Reyvow (lasmiditan) C18446-A
Rezdiffra (resmetirom) C28242-A
Rezurock (belumosudil) C22106-A
Rezzayo (rezafungin) C26183-A
Riluzole (Rilutek, Tiglutik, Exservan) C9697-A
Rinvoq (Upadacitinib) C17882-A
Rituxan (rituximab) Rituxan Hycela (rituximab and hyaluronidase human) C10423-A
Rivfloza (nedosiran) C27705-A
Rolvedon, Neulasta and Related Biosimilars C10419-A
Ryplazim (plasminogen, human) C22238-A
Rystiggo (rozanolixizumab) C26210-A
Santyl (collagenase) C15159-C
Saphnelo (anifrolumab) C21970-A.pdf
Savella (milnacipran) C4731-A
Sensipar (cinacalcet) C9721-A
Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) C4719-A
Sexual Dysfunction Criteria - Non-Coverage C16658-A
Seysara (sarecycline) C15974-A
Signifor (pasireotide diaspartate) C15367-A
Siliq (brodalumab) C17334-A
Simponi and Simponi Aria (golimumab) C10422-A
Sivextro (tedizolid) C9353-A
Skyclarys (omaveloxolone) C25422-A
Skyrizi (risankizumab-rzaa) C17336-A
Sodium Oxybate (Lumryze, Xyrem, Xywav) C3925-A
Sohonos (palovarotene) C27173-A
Soliris and Ultomiris (eculizumab_ravulizumab) C4867-A
Sotyktu (deucravacitinib) C24672-A
Spevigo (spesolimab-sbzo) C24676-A
Spiriva (tiotropium) C5109-A
Sporanox, Tolsura (itraconazole) C4734-A
Spravato (esketamine) C16762-A
Standard Oncology Criteria C16154-A
Stelara (ustekinumab) C10424-A
Strensiq (asfotase alfa) C9425-A
Sublocade buprenorphine extended-release injection C15161-A
Sunlenca (lenacapavir) C25206-A
Sunosi (solriamfetol) C17632-A
Supprelin LA (histrelin acetate) Implant C20611-A
Susvimo (ranibizumab) Intravitreal Implant C24231-A
Syfovre (pegcetacoplan) C25311-A
Symlin (pramlintide) C4957-A
Synagis (palivizumab) C6074-A
Synarel (nafarelin acetate, nasal solution) C4958-A
Tadalafil and combinations C6121-C
Taltz (ixekizumab) C16448-A
Tarpeyo (budesonide) C24199-A
Tavalisse (fostamatinib) C16449-A
Tavneos (avacopan) C22223-A
Tepezza (teprotumumab-trbw) C18462-A
Testosterone C2270-A
Tezspire (tezepelumab) C23042-A
Thiola (tiopronin) C18004-A
Tobramycin for inhalation C8665-A
Tolvaptan C21091-A
Topical Acne C4190-A
Topical Antibacterials C8409-A
Topical Retinoids C4729-A
Tremfya (guselkumab) C14612-A
Triptodur (triptorelin pamoate) C14649-A
Trogarzo (ibalizumab-uiyk) C14522-A
Tymlos (abaloparatide) C17354-A
Tysabri (natalizumab) C10276-A
Tzield (teplizumab) C24729-A
Uplizna (inebilizumab) C20171-A
Vabysmo (faricimab) C22795-A
Valcyte (valganciclovir) C4960-A
Vancocin (vancomycin) C5325-C
Veklury (remdesivir) C20763-A
Velsipity (etrasimod) C27181-A
Veopoz (pozelimab-bbfg) C26434-A
Veozah (fezolinetant) C25593-A
Verquvo (vericiguat) C21141-A
Vibativ (telavancin) C14575-A
Vibrant (transient device for constipation capsule) NC C25205-A
Vijoice (alpelisib) C23736-A
Viltepso (vitolarsen) NC C20585-A
Vimizim (elosulfase alfa) C7068-A
Vonjo (pacritinib) C23019-A
Vowst (fecal microbiota spores live-brpk)
Voxzogo (vosoritide) C22221-A
Voydeya (danicopan) C28251-A
Vtama (tapinarof) cream C23729-A
Vyondys 53 (golodirsen) NC C17926-A
Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis) C17345-A
Vyvgart (efgartigimiod alfa)
Wainua (eplontersen) C27703-A
Wakix (pitolisant) C17997-A
Wegovy (semaglutide) NC C27682-A
Xacduro (sulbactam and durlobactam) C26432-A
Xeljanz and Xeljanz XR (tocilizumab) C2721-A
Xenazine (tetrabenazine) C3894-A
Xenpozyme (olipudase alfa-rpcp) C24670-A
Xermelo (telotristat ethyl) C16325-A
Xgeva (denosumab) C8849-A
Xiaflex (collagenase clostridium histolyticum) C24319-A
Xifaxan (rifaximin)_Aemcolo (rifamycin) C4964-C
Xipere (triamcinolone ocular inj) C22222-A
Xolair (omalizumab) C8757-A
Xolremdi (mavorixafor) C28289-A
Xphozah (tenapanor) C27292-A
Zavesca (miglustat) C9646-A
Zemplar (paricalcitol) C4967-C
Zilbrysq (zilucoplan) C27709-A
Zilretta (Triamcinolone ER Injection) C16855-A
Zinplava (bexlotoxumab) C14821-A
Zokinvy (lonafarnib) C21125-A
Zoladex (goserelin acetate) C8757-A
Zortress (everolimus) C9720-A
Zoryve (roflumilast) C24324-A
Zovirax (acyclovir) C4349-A
Ztalmy (ganaxolone) C24321-A
Zulresso (brexanolone) C16319-A
Zurzuvae (zuranolone) C27296-A
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