NOTE: Not all plans cover these drugs nor require preauthorization. Please refer to the member's Individual Policy (also known as Certificate of Coverage, Master Contract or Plan Document) for information regarding coverage determination.

**This list does not guarantee coverage and is subject to change.**

  • Abecma, idecabtagene vicleucel (Q2055)

  • Actemra IV, tocilizumab  (J3262)

  • Acthar HP, corticotropin (J0801, J0802)

  • Adakveo, crizanlizumab-tmca (J0791)

  • Adstiladrin, nadofaragene firadenovec-vncg (J9029)

  • Adzynma, ADAMTS13, recombinant-krhn (J7171)

  • Ahzantive, aflibercept-mrbb (Q5150)

  • Aldurazyme, laronidase  (J1931)

  • Alferon N, interferon Alfa-n3 (J9215)

  • Alimta, pemetrexed (J9294, J9296, J9297, J9304, J9305, J9314, J9322, J9323, J9324)

  • Aliqopa , copanlisib (J9057)

  • Alyglo, immune globulin-stwk (J1552)#

  • Alymsys, bevacizumab-maly (Q5126)

  • Amondys 45, casimersen  (J1426)^^

  • Amtagvi, lifileucel

  • Amvuttra, vutrisiran (J0225)

  • Anktiva, nogapendekin alfa Inbakicept-pmln (J9028)

  • Aphexda, motixafortide  (J2277)

  • Aralast NP, alpha-1 proteinase inhibitor (J0256)

  • Arranon, nelarabine (J9261)

  • Arzerra, ofatumumab (J9302)

  • Asceniv, immune globulin-slra (J1554)#

  • Asparlas, calaspargase pegol-mknl (J9118)

  • Aucatzyl, obecabtagene autoleucel (Q2058)

  • Avastin (intravenous use), bevacizumab (J9035)

  • Avsola, infliximab-axxq (Q5121)#

  • Avtozma IV, tocilizumab-anoh (Q5156)

  • Bavencio, avelumab (J9023)

  • Beizray, docetaxel (J9174)

  • Beleodaq, belinostat (J9032)

  • Belrapzo, bendamustine (J9033, J9034, J9036, J9056, J9058, J9059)

  • Bendeka, bendamustine (J9033, J9034, J9036, J9056, J9058, J9059)

  • Benlysta, belimumab (J0490)

  • Beovu, brolucizumab-dbll (J0179)

  • Berinert, C1 esterase inhibitor (J0597)

  • Besponsa, inotuzumab ozogamicin (J9229)

  • Beyfortus, nirsevimab-alip (90380, 90381) (PA required > 8 months of age only)

  • BiCNU, carmustine (J9050, J9052)

  • Bivigam, immune globulin (J1556)#

  • Bizengri, zenocutuzumab-zbco (J9382)

  • Bkemv, eculizumab-aeeb (Q5152)#

  • Blenrep, belantamab mafodotin-blmf (J9037)

  • Blincyto, blinatumomab (J9039)

  • Bomyntra, denosumab-bnht (Q5158)

  • Boruzu, bortezomib (J9054)

  • Botox, onabotulinumtoxinA (J0585)

  • Breyanzi, lisocabtagene maraleucel (Q2054)

  • Brineura, cerliponase alfa (J0567)

  • Briumvi, ublituximab-xiiy (J2329)

  • Byooviz, ranibizumab-nuna (Q5124)

  • Cablivi, caplacizumab-yhdp (C9047) 

  • Camcevi, leuprolide (J1952)

  • Carimune, immune globulin (J1566)#

  • Carvykti, ciltacabtagene autoleucel (Q2056)

  • Casgevy, exagamglogene autotemcel (J3392)

  • Cerezyme, imiglucerase (J1786)

  • Cimerli, ranibizumab-eqrn (Q5128)

  • Cinqair, reslizumab (J2786)

  • Cinryze, C1 esterase inhibitor (J0598)

  • Clolar, clofarabine (J9027)

  • Columvi, glofitamab-gxbm (J9286)

  • Conexxence, denosumab-bnht (Q5158)

  • Cortrophin, corticotropin (J0801, J0802)

  • Cosela, trilaciclib (J1448)**

  • Cosentyx IV, secukinumab (J3247)#

  • Cosmegen, dactinomycin (J9120)

  • Crysvita, burosumab-twza (J0584)

  • Cutaquig, immune globulin-hipp (J1551)#

  • Cuvitru, immune globulin (J1555)#

  • Cyramza, ramucirumab (J9308)

  • Dacogen, decitabine (J0893, J0894)

  • Danyelza, naxitamab-gqgk (J9348)

  • Darzalex, daratumumab (J9145)

  • Darzalex Faspro, daratumumab/ hyaluronidase-fihj (J9144)

  • Datroway, datopotamab deruxtecan-dlnk (J9011)

  • Daxxify, daxibotulinumtoxinA-lanm (J0589)

  • Doxil, doxorubicin liposomal (Q2050)

  • Duopa, carbidopa/ levodopa (J7340)

  • Durolane, hyaluronic acid (J7318)

  • Durysta, bimatoprost (J7351)**

  • Dysport, abobotulinumtoxinA (J0586)

  • Elahere, mirvetuximab soravtansine-gynx (J9063)

  • Elaprase, idursulfase (J1743)

  • Elelyso, taliglucerase alfa (J3060)

  • Elevidys, delandistrogene moxeparvovec-rokl (J1413)^^

  • Elfabrio, pegunigalsidase alfa-iwxj (J2508)

  • Eligard, leuprolide (J9217)

  • Ellence, epirubicin (J9178)

  • Elrexfio, elranatamab-bcmm (J1323)

  • Elzonris, tagraxofusp-erzs (J9269)

  • Empaveli, pegcetacoplan

  • Empliciti, elotuzumab (J9176)

  • Emrelis, telisotuzumab vedotin-tllv (C9306)

  • Encelto, revakinagene taroretcel-lwey (J3403)

  • Enflonsia, clesrovimab-cfor (PA required > 8 months of age only)

  • Enhertu, fam-trastuzumab deruxtecan-nxki (J9358)

  • Enjaymo, sutimlimab-jome (J1302)

  • Entyvio, vedolizumab (J3380)#

  • Enzeevu, aflibercept-abzv (Q5149)

  • Epkinly, epcoritamab-bysp (J9321)

  • Epysqli, eculizumab-aagh (Q5151)#

  • Erbitux, cetuximab (J9055)

  • Erwinaze, asparaginase (J9019)

  • Euflexxa, hyaluronate sodium (J7323)

  • Evenity, romosozumab-aqqg (J3111)

  • Evkeeza, evinacumab-dgnb (J1305)

  • Evomela, melphalan (J9246)

  • Exondys 51, eteplirsen (J1428)^^

  • Eylea, aflibercept (J0178)

  • Eylea HD, aflibercept (J0177)

  • Fabrazyme, agalsidase beta (J0180)

  • Fasenra, benralizumab  (J0517)

  • Faslodex, fulvestrant (J9393, J9394, J9395)

  • Fensolvi, leuprolide (J1951)

  • Firmagon, degarelix (J9155)

  • Flebogamma, immune globulin (J1572)#

  • Flolan, epoprostenol (J1325)

  • floxuridine (J9200)

  • Folotyn, pralatrexate (J9307)

  • Fulphila, pegfilgrastim-jmdb (Q5108)

  • Fyarro, sirolimus (J9331)

  • Fylnetra, pegfilgrastim-pbbk (Q5130)

  • Gamastan, immune globulin (J1460/J1560)#

  • Gamifant, emapalumab-lzsg (J9210)

  • Gammagard, immune globulin (J1569/J1566)#

  • Gammaked, immune globulin (J1561)#

  • Gammaplex, immune globulin (J1557)#

  • Gammar-P, immune globulin (J1566)#

  • Gamunex-C, immune globulin (J1561)#

  • Gazyva, obinutuzumab (J9301)

  • Gel-One, hyaluronate sodium (J7326)

  • Gelsyn-3, hyaluronate sodium (J7328)

  • GenVisc, hyaluronate sodium (J7320)

  • Givlaari, givosiran (J0223)

  • Glassia, alpha-1 proteinase inhibitor (J0257)

  • Gliadel, carmustine

  • Granix, tbo-filgrastim (J1447)

  • Haegarda, C1 esterase inhibitor (J0599)

  • Halaven, eribulin (J9179)

  • Hemgenix, etranacogene dezaparvovec-drlb (J1411)

  • Hepzato, melphalan

  • Herceptin, trastuzumab (J9355)

  • Herceptin Hylecta, trastuzumab/ hyaluronidase-oysk (J9356)

  • Hercessi, trastuzumab-strf (Q5146)

  • Herzuma, trastuzumab-pkrb (Q5113)

  • Hizentra, immune globulin (J1559)#

  • Hyalgan, hyaluronate sodium (J7321)

  • Hymovis, hyaluronic acid (J7322)

  • HyQvia, immune globulin (J1575)#

  • iDose TR, travoprost (J7355)**

  • Ilaris, travoprost (J0638)

  • Ilumya, tildrakizumab-asmn (J3245)

  • Imaavy, nipocalimab-aahu (C9305)

  • Imdelltra, tarlatamab-dlle (J9026)

  • Imfinzi, durvalumab (J9173)

  • Imjudo, tremelimumab-actl (J9347)

  • Imlygic, talimogene laherparepvec (J9325)

  • Immune Globulins, IV (J1599)#

  • Imuldosa IV, ustekinumab-srlf (Q5098)

  • Inflectra, infliximab-dyyb (Q5103)#

  • Istodax, romidepsin (J9318, J9319)

  • Ivra, melphalan

  • Ixempra, ixabepilone (J9207)

  • Ixifi, infliximab-qbtx (Q5109)#

  • Izervay, avacincaptad pegol (J2782)

  • Jelmyto, mitomycin (J9281)

  • Jemperli, dostarlimab-gxly (J9272)

  • Jevtana, cabazitaxel (J9043, J9064)

  • Jobevne, bevacizumab-nwgd

  • Jubbonti, denosumab-bbdz (Q5136)

  • Kadcyla, ado-trastuzumab emtansine (J9354)

  • Kalbitor, ecallantide (J1290)

  • Kanjinti, trastuzumab-anns (Q5117)

  • Kanuma, sebelipase alfa (J2840)

  • Kebilidi, eladocagene exuparvovec-tneq

  • Keytruda, pembrolizumab (J9271)

  • Kimmtrak, tebentafusp-tebn (J9274)

  • Kisunla, donanemab-azbt (J0175)

  • Korsuva, difelikefalin (J0879)

  • Krystexxa, pegloticase  (J2507)

  • Kymriah, tisagenlecleucel (Q2042)

  • Kyprolis, carfilzomib (J9047)

  • Lamzede, velmanase alfa-tycv (J0217)

  • Lantidra, donislecel**

  • Lemtrada, alemtuzumab (J0202)

  • Lenmeldy, atidarsagene autotemcel (J3391)

  • Leqembi IV, lecanemab-irmb (J0174)

  • Leqvio, inclisiran (J1306)#

  • Leukine, sargramostim (J2820)

  • Libtayo, cemiplimab-rwlc (J9119)

  • Lipodox, doxorubicin liposomal (Q2049)

  • Loqtorzi, toripalimab-tpzi (J3263)

  • Lucentis, ranibizumab (J2778)

  • Lumizyme, alglucosidase alfa (J0221)

  • Lumoxiti, moxetumomab pasudotox-tdfk (J9313)

  • Lunsumio, mosunetuzumab-axgb (J9350)

  • Lupron Depot, leuprolide (J1950, J1954, J9217)

  • Luxturna, voretigene neparvovec-rzyl (J3398)

  • Lyfgenia, lovotibeglogene autotemcel (J3394)

  • Lymphir, denileukin diftitox-cxdl (J9161)

  • Lynozyfic, linvoseltamab-gcpt

  • Margenza, margetuximab-cmkb (J9353)**

  • Mepsevii, vestronidase alfa-vjbk (J3397)

  • mitoxantrone (J9293)

  • Monjuvi, tafasitamab-cxix (J9349)

  • Mvasi, bevacizumab-awwb (Q5107)

  • Mylotarg, gemtuzumab ozogamicin (J9203)

  • Myobloc, rimabotulinumtoxinB (J0587)

  • Myozyme, alglucosidase alfa (J0220)

  • Naglazyme, galsulfase (J1458)

  • Navelbine, vinorelbine (J9390)

  • Neulasta, Neulasta Onpro, pegfilgrastim (J2506)

  • Neupogen, filgrastim (J1442)

  • Nexviazyme, avalglucosidase alfa-ngpt (J0219)

  • Niktimvo, axatilimab-csfr (J9038)

  • Nipent, pentostatin (J9268)

  • Nplate, romiplostim (J2802)

  • Nucala, mepolizumab (J2182)

  • Nulibry, fosdenopterin (J1809)

  • Nypozi, filgrastim-txid (Q5148)

  • Ocrevus, ocrelizumab (J2350)#

  • Ocrevus Zunovo, ocrelizumab/hyaluronidase-ocsq (J2351)#

  • Octagam, immune globulin (J1568)#

  • Ogivri, trastuzumab-dkst (Q5114)

  • Omisirge, omidubicel-onlv

  • Omlyclo, omalizumab-igec (Q5154)

  • Omvoh IV, mirikizumab-mrkz (J2267)

  • Onapgo, apomorphine

  • Oncaspar, pegaspargase (J9266)

  • Onivyde, irinotecan liposome (J9205)

  • Onpattro, patisiran (J0222)

  • Ontruzant, trastuzumab-dttb (Q5112)

  • Opdivo, nivolumab (J9299)

  • Opdivo Qvantig, nivolumab/hyaluronidase-nvhy (J9289)

  • Opdualag, nivolumab/ relatlimab-rmbw (J9298)

  • Opuviz, aflibercept-yszy (Q5153)

  • Orencia IV, abatacept (J0129)

  • Orladeyo, berotralstat

  • Osenvelt, denosumab-bmwo (Q5157)

  • Ospomyv, denosumab-dssb (Q5159)

  • Otulfi IV, lumasiran (Q9999)

  • Oxlumo, ustekinumab-aauz (J0224)

  • Padcev, enfortumab vedotin-ejfv (J9177)

  • Panglobulin, immune globulin (J1566)#

  • Panzyga, immune globulin (J1576)#

  • Papzimeos, zopapogene imadenovec-drba

  • Pavblu, aflibercept-ayyh (Q5147)

  • Pemfexy, pemetrexed (J9292, J9294, J9296, J9297, J9304, J9305, J9314, J9322, J9323, J9324)

  • Pemrydi RTU, pemetrexed (J9292, J9294, J9296, J9297, J9304, J9305, J9314, J9322, J9323, J9324)

  • Perjeta, pertuzumab (J9306)

  • Phesgo, pertuzumab/ trastuzumab/ hyaluronidase-zzxf (J9316)

  • Photofrin, porfimer (J9600)

  • Photrexa, riboflavin 5-Phosphate (J2787)

  • Piasky, crovalimab-akkz (J1307)

  • Polivy, Polatuzumab vedotin-piiq (J9309)

  • Polygam S/D, immune globulin (J1566)#

  • Pombiliti, cipaglucosidase alfa-atga (J1203)

  • Portrazza, necitumumab (J9295)

  • Poteligeo, mogamulizumab-kpkc (J9204)

  • Privigen, immune globulin (J1459)#

  • Prolastin-C, alpha-1 proteinase Inhibitor (J0256)

  • Proleukin, aldesleukin (J9015)

  • Prolia, denosumab (J0897)

  • Propel, mometasone furoate (S1091)^^

  • Provenge, sipuleucel-T (Q2043)

  • Pyzchiva IV, ustekinumab-ttwe (Q9997)

  • Qalsody, tofersen (J1304)

  • Reblozyl, luspatercept-aamt (J0896)

  • Rebyota, fecal microbiota, live-jslm (J1440)

  • Releuko, filgrastim-ayow (Q5125)

  • Remicade, infliximab (J1745)#

  • Remodulin, treprostinil (J3285)

  • Renflexis, infliximab-abda (Q5104)#

  • Rethymic, allogeneic processed thymus tissue-agdc

  • Revatio injection, sildenafil

  • Revcovi, elapegademase-lvlr

  • Riabni, rituximab-arrx (Q5123)

  • Rituxan, rituximab (J9312)

  • Rituxan Hycela, rituximab/ hyaluronidase (J9311)

  • Roctavian, valoctocogene roxaparvovec-rvox (J1412)

  • Rolvedon, eflapegrastim-xnst (J1449)

  • Ruconest, C1 esterase inhibitor (J0596)

  • Ruxience, rituximab-pvvr (Q5119)

  • Rybrevant, amivantamab-vmjw (J9061)

  • Rylaze, asparaginase (J9021)

  • Ryoncil, remestemcel-L-rknd (J3402)

  • Ryplazim, plasminogen, human-tvmh (J2998)

  • Rystiggo, rozanolixizumab-noli (J9333)

  • Rytelo, imetelstat (J0870)

  • Ryzneuta, efbemalenograstim alfa-vuxw (J9361)

  • Sandostatin LAR, octreotide (J2353)

  • Saphnelo, anifrolumab-fnia (J0491)

  • Sarclisa, isatuximab-irfc (J9227)

  • Scenesse, afamelanotide (J7352)

  • Selarsdi IV, ustekinumab-aekn

  • Signifor LAR, pasireotide (J2502)

  • Simponi Aria, golimumab (J1602)

  • Sinuva, mometasone furoate (J7402)

  • Skyrizi IV, risankizumab-rzaa (J2327)

  • Skysona, elivaldogene autotemcel

  • Soliris, eculizumab (J1299)#

  • Somatuline, lanreotide acetate (J1930/J1932)

  • Spinraza, nusinersen (J2326)

  • Stelara IV, ustekinumab (J3358)

  • Steqeyma IV, ustekinumab-stba (Q5099)

  • Stimufend, pegfilgrastim-fpgk (Q5127)

  • Stoboclo, denosumab-bmwo (Q5157)

  • Supartz, hyaluronate sodium (J7321)

  • Supprelin LA, histrelin acetate (J9226)

  • Susvimo, ranibizumab (J2779)

  • Syfovre, pegcetacoplan (J2781)

  • Sylvant, siltuximab (J2860)

  • Synagis, palivizumab (90378)

  • Synojoynt, hyaluronate sodium (J7331)

  • Synribo, omacetaxine (J9262)

  • Talvey, talquetamab-tgvs (J3055)

  • Tecartus, brexucabtagene autoleucel (Q2053)

  • Tecelra, afamitresgene autoleucel (Q2057)

  • Tecentriq, atezolizumab (J9022)

  • Tecentriq Hybreza, atezolizumab/ hyaluronidase-tqjs (J9024)

  • Tecvayli, teclistamab-cqyv (J9380)

  • Temodar IV, temozolomide (J9328)

  • Tepadina, thiotepa  (J9342)

  • Tepezza, teprotumumab-trbw (J3241)

  • Tepylute, thiotepa (J9341)

  • Tevimbra, tislelizumab-jsgr (J9329)

  • Tice BCG, Bacillus of Calmette and Guerin vaccine, live (J9030)

  • Tivdak, tisotumab vedotin-tftv (J9273)

  • Tofidence, tocilizumab-bavi (Q5133)

  • Torisel, temsirolimus (J9330)

  • Trazimera, trastuzumab-qyyp (Q5116)

  • Treanda, bendamustine (J9033, J3034, J9036, J9056, J9058, J9059)

  • Trelstar, triptorelin (J3315)

  • Tremfya IV, guselkumab

  • Triluron, hyaluronate sodium (J7332)

  • Triptodur, triptorelin (J3316)

  • TriVisc, hyaluronate sodium (J7329)

  • Trodelvy, sacituzumab govitecan-hziy (J9317)

  • Truxima, rituximab-abbs (Q5115)

  • Tyenne IV, tocilizumab-aazg (Q5135)

  • Tyruko, natalizumab (Q5134)

  • Tysabri, natalizumab (J2323)

  • Tzield, teplizumab-mzwv (J9381)

  • Ultomiris, ravulizumab-cwvz (J1303)#

  • Unituxin (dinutuximab)

  • Unloxcyt, cosibelimab-ipdl (J9275)

  • Uplizna, inebilizumab-cdon (J1823)

  • Uptravi IV, selexipag

  • Vabrinty, leuprolide

  • Vabysmo, faricimab-svoa (J2777)

  • Valstar, valrubicin (J9357)

  • Vectibix, panitumumab (J9303)

  • Vegzelma, bevacizumab-adcd (Q5129)

  • Velcade, bortezomib (J9041, J9046, J9048, J9049, J9051)

  • Veletri, epoprostenol (J1325)

  • Veopoz, pozelimab-bbfg (J9376)

  • Viltepso, viltolarsen (J1427)^^

  • Vimizim, elosulfase alfa (J1322)

  • Visco-3, hyaluronate sodium (J7321)

  • Vivaglobin, immune globulin (J1562)#

  • Vivimusta, bendamustine (J9033, J3034, J9036, J9056, J9058, J9059)

  • Vpriv, velaglucerase alfa (J3385)

  • Vyalev, foscarbidopa/ foslevodopa (J7356)

  • Vyepti, eptinezumab-jjmr (J3032)

  • Vyjuvek, beremagene geperpavec-svdt (J3401)

  • Vyloy, zolbetuximab-clzb (J1326)

  • Vyondys 53, golodirsen (J1429)^^

  • Vyvgart, efgartigimod alfa-fcab (J9332)

  • Vyvgart Hytrulo, efgartigimod alfa/ hyaluronidase-qvfc (J9334)

  • Vyxeos, daunorubicin/ cytarabine, liposome (J9153)

  • Wezlana IV, ustekinumab-auub (Q5138)

  • Wyost, denosumab-bbdz (Q5136)

  • Xbryk, denosumab-dssb (Q5159)

  • Xembify, immune globulin (J1558)#

  • Xenpozyme, olipudase alfa-rpcp (J0218)

  • Xeomin, incobotulinumtoxinA (J0588)

  • Xgeva, denosumab (J0897)

  • Xolair, omalizumab (J2357)#

  • Ycanth, cantharidin (J7354)

  • Yervoy, ipilimumab (J9228)

  • Yesafili, aflibercept-jbvf (Q5155)

  • Yescarta, axicabtagene ciloleucel (Q2041)

  • Yesintek IV, ustekinumab-kfce (Q5100)

  • Yondelis, trabectedin (J9352)

  • Zaltrap, ziv-aflibercept (J9400)

  • Zanosar, streptozocin (J9320)

  • Zemaira, alpha-1 proteinase inhibitor (J0256)

  • Zepzelca, lurbinectedin (J9223)

  • Zevaskyn, prademagene zamikeracel

  • Ziextenzo, pegfilgrastim-bmez (Q5120)

  • Ziihera, zanidatamab-hrii (J9276)

  • Zinplava, bezlotoxumab  (J0565)

  • Zirabev, bevacizumab-bvzr (Q5118)

  • Zoladex, goserelin (J9202)

  • Zolgensma, onasemnogene abeparvovec-xioi (J3399)

  • Zusduri, mitomycin  

  • Zynlonta, loncastuximab tesirine-lpyl (J9359)

  • Zynteglo, betibeglogene Autotemcel (J3393)

  • Zynyz, retifanlimab-dlwr (J9345)

Reviewed by LJS 9/30/25 

**Drug is Not Covered

^^Drug is considered experimental and investigational

#Drug is subject to site-of-service restrictions