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.**

  • Abirtega (abiraterone)
  • Abrilada (adalimumab-afzb)
  • Actemra SQ (tocilizumab)
  • Acthar auto-injector (corticotropin)
  • Actimmune (interferon gamma-1b)
  • Adbry (tralokinumab-ldrm)
  • Adcirca (tadalafil)
  • Adempas (riociguat)
  • Adipex-P (phentermine) 
  • Afinitor (everolimus)
  • Aimovig (erenumab-aooe)
  • Ajovy (fremanezumab-vfrm)
  • Akeega (niraparib/ abiraterone acetate)
  • Alecensa (alectinib)
  • Alhemo (concizumab-mtci)
  • Alunbrig (brigatinib)
  • Alvaiz (eltrombopag)
  • Alyftrek (vanzacaftor/ tezacaftor/ deutivacaftor)
  • Alyq (tadalafil)
  • Amjevita (adalimumab-atto)
  • Ampyra (dalfampridine)
  • Anzupgo (delgocitinib)
  • Aqneursa (levacetylleucine)
  • Arcalyst (rilonacept)
  • Aubagio (teriflunomide)
  • Augtyro (repotrectinib)
  • Austedo (deutetrabenazine)
  • Austedo XR (deutetrabenazine)
  • Avmapki Fakzynja (avutometinib/ defactinib)
  • Avonex (interferon beta-1a)
  • Avtozma (tocilizumab-anoh)
  • Ayvakit (avapritinib)
  • Bafiertam (monomethyl fumarate)
  • Balversa (erdafitinib)
  • Benlysta SQ (belimumab)
  • Besremi (ropeginterferon alfa-2b-njft)
  • Betaseron (interferon beta-1b)
  • Bimzelx (bimekizumab-bkzx)
  • Bosulif (bosutinib)
  • Braftovi (encorafenib)
  • Brinsupri (brensocatib)
  • Brukinsa (zanubrutinib)
  • Bydureon (exenatide)
  • Byetta (exenatide)
  • Bylvay (odevixibat)
  • Cablivi (caplacizumab)
  • Cabometyx (cabozantinib)
  • Calquence (acalabrutinib)
  • Camzyos (mavacamten)
  • Caprelsa (vandetanib)
  • Carbaglu (carglumic acid)
  • Cerdelga (eliglustat)
  • Cholbam (cholic acid)
  • Cibinqo (abrocitinib)
  • Cimzia (certolizumab)
  • Cometriq (cabozantinib)
  • Contrave (buproprion/ naltrexone)
  • Copaxone (glatiramer)
  • Copiktra (duvelisib)
  • Cortrophin (corticotropin)
  • Cosentyx (secukinumab)
  • Cotellic (cobimetinib)
  • Crenessity (crinecerfont)
  • Cyltezo (adalimumab-adbm)
  • Daraprim (pyrimethamine)
  • Daurismo (glasdegib)
  • Daybue (trofinetide)
  • Diacomit (stiripentol)
  • Doptelet (avatrombopag)
  • Dupixent (dupilumab)
  • Ebglyss (lebrikizumab-lbkz)
  • Ekterly (sebetralstat)
  • Emcyt (estramustine)
  • Emgality (galcanezumab-gnlm)
  • Enbrel (etanercept)
  • Ensacove (ensartinib)
  • Enspryng (satralizumab-mwge)
  • Entyvio Pen (vedolizumab)
  • Eohilia (budesonide)
  • Epclusa (sofosbuvir/ velpatasvir)
  • Epidiolex (cannabidiol)
  • Erivedge (vismodegib)
  • Erleada (apalutamide)
  • Esbriet (pirfenidone)
  • Evrysdi (risdiplam)
  • Exjade (deferasirox)
  • Exkivity (mobocertinib)
  • Extavia (interferon beta-1b)
  • Fabhalta (iptacopan)
  • Fareston (toremifene)
  • Fasenra Pen (benralizumab)
  • Ferriprox (deferiprone)
  • Filspari (sparsentan)
  • Filsuvez (birch triterpenes)
  • Fintepla (fenfluramine)
  • Firazyr (icatibant)
  • Firdapse (amifampridine)
  • Forteo (teriparatide)
  • Fruzaqla (fruquintinib)
  • Galafold (migalastat)
  • Gattex (teduglutide)
  • Gavreto (pralsetinib)
  • Genotropin (somatropin)
  • Gilenya (fingolimod)
  • Gilotrif (afatinib)
  • Glatopa (glatiramer)
  • Gleevec (imatinib)
  • Gomekli (mirdametinib)
  • Hadlima (adalimumab-bwwd)
  • Harvoni (ledipasvir/ sofosbuvir)
  • Hernexeos (zongertinib)
  • Hetlioz (tasimelteon)
  • Hulio (adalimumab-fkjp)
  • Humatrope (somatropin)
  • Humira (adalimumab)
  • Hycamtin (topotecan)
  • Hyftor (sirolimus)
  • Hympavzi (marstacimab-hncq)
  • Hyrimoz (adalimumab-adaz)
  • Hyrnuo (sevabertinib)
  • Ibrance (palbociclib)
  • Ibtrozi (taletrectinib)
  • Iclusig (ponatinib)
  • Idacio (adalimumab-aacf)
  • Idhifa (enasidenib)
  • Iqirvo (elafibranor)
  • Imbruvica (ibrutinib)
  • Impavido (miltefosine)
  • Imuldosa SQ (ustekinumab-srlf)
  • Increlex (mecasermin)
  • Ingrezza (valbenazine)
  • Inluriyo (imlunestrant)
  • Inlyta (axitinib)
  • Inqovi (decitabine/ cedazuridine)
  • Inrebic (fedratinib)
  • Iressa (gefitinib)
  • Isturisa (osilodrostat)
  • Itovebi (inavolisib)
  • Iwilfin (eflornithine)
  • Jadenu (deferasirox)
  • Jakafi (ruxolitinib)
  • Jaypirca (pirtobrutinib)
  • Jesduvroq (daprodustat)
  • Joenja (leniolisib)
  • Jynarque (tolvaptan)
  • Kalydeco (ivacaftor)
  • Kesimpta (ofatumumab)
  • Keveyis (dichlorphenamide)
  • Kevzara (sarilumab)
  • Kineret (anakinra)
  • Kisqali (ribociclib)
  • Kisqali Femara (ribociclib/ letrozole)
  • Komzifti (ziftomenib)
  • Korlym (mifepristone)
  • Koselugo (selumetinib)
  • Krazati (adagrasib)
  • Kuvan (sapropterin)
  • Lazcluze (lazertinib)
  • Lenvima (lenvatinib)
  • Leqembi Iqlik (lecanemab)
  • Letairis (ambrisentan)
  • leuprolide non-depot
  • Litfulo (ritlecitinib)
  • Livdelzi (seladelpar)
  • Livmarli (maralixibat)
  • Lonsurf (trifluridine/ tipiracil)
  • Lorbrena (lorlatinib)
  • Lumakras (sotorasib)
  • Lumryz (sodium oxybate)
  • Lupkynis (voclosporin)
  • Lynparza (olaparib)
  • Lytgobi (futibatinib)
  • Matulane (procarbazine)
  • Mavenclad (cladribine)
  • Mavyret (glecaprevir/ pibrentasvir)
  • Mayzent (siponimod)
  • Mekinist (trametinib)
  • Mektovi (binimetinib)
  • Modeyso (dordaviprone)
  • Mounjaro (tirzepatide)
  • Mulpleta (lusutrombopag)
  • Mycapssa (octreotide)
  • Mytesi (crofelemer)
  • Nemluvio (nemolizumab-ilto)
  • Nerlynx (neratinib)
  • Nexavar (sorafenib)
  • Nexletol (bempedoic acid)
  • Nexlizet (bempedoic acid/ ezetimibe)
  • Ngenla (somatrogon-ghla)
  • Nilandron (nilutamide)
  • Ninlaro (ixazomib)
  • Nityr (nitisinone)
  • Norditropin (somatropin)
  • Nubeqa (darolutamide)
  • Nucala (mepolizumab)
  • Nuedexta (dextromethorphan/ quinidine)
  • Nuplazid (pimavanserin)
  • Nurtec (rimegepant)
  • Nutropin AQ (somatropin)
  • Odomzo (sonidegib)
  • Ofev (nintedanib)
  • Ogsiveo (nirogacestat)
  • Ojemda (tovorafenib)
  • Ojjaara (momelotinib)
  • Olpruva (sodium phenylbutyrate)
  • Olumiant (baricitinib)
  • Omnitrope (somatropin)
  • Omvoh (mirikizumab-mrkz)
  • Onureg (azacitidine)
  • Opfolda (miglustat)
  • Opsumit (macitentan)
  • Opzelura (ruxolitinib)
  • Oracea (doxycycline)
  • Orencia SQ (abatacept)
  • Orenitram (treprostinil)
  • Orfadin (nitisinone)
  • Orgovyx (relugolix)
  • Orkambi (lumacaftor/ ivacaftor)
  • Orladeyo (berotralstat)
  • Orserdu (elacestrant)
  • Otezla (apremilast)
  • Otulfi SQ (ustekinumab-aauz)
  • Oxervate (cenergermin-bkbj)
  • Ozempic (semaglutide)
  • Palsonify (paltusotine)
  • Palynziq (pegvaliase-pqpz)
  • Pemazyre (pemigatinib)
  • Piqray (alpelisib)
  • Plegridy (peginterferon beta-1a)
  • Pomalyst (pomalidomide)
  • Ponvory (ponesimod)
  • Praluent (alirocumab)
  • Procysbi (cysteamine bitartrate)
  • Promacta (eltrombopag)
  • Pyrukynd (mitapivat)
  • Pyzchiva SQ (ustekinumab-ttwe)
  • Qinlock (ripretinib)
  • Qsymia (phentermine/ topiramate)
  • Qulipta (atogepant)
  • Ravicti (glycerol phenylbutyrate)
  • Rebif (interferon beta-1a)
  • Reblozyl (luspatercept-aamt)
  • Redemplo (plozasiran)
  • Repatha (evolocumab)
  • Retevmo (selpercatinib)
  • Revlimid (lenalidomide)
  • Revuforj (revumenib)
  • Rezdiffra (resmetirom)
  • Rezlidhia (olutasidenib)
  • Rezurock (belumosudil)
  • Rhapsido (remibrutinib)
  • Rinvoq (upadacitinib)
  • Rivfloza (nedosiran)
  • Romvimza (vimseltinib)
  • Rozlytrek (entrectinib)
  • Rubraca (rucaparib)
  • Rybelsus (semaglutide)
  • Rydapt (midostaurin)
  • Saizen (somatropin)
  • Sajazir (icatibant)
  • Samsca (tolvaptan)
  • Scemblix (asciminib)
  • Selarsdi SQ (ustekinumab-aekn)
  • Sephience (sepiapterin)
  • Serostim (somatropin)
  • Signifor (pasireotide)
  • Siliq (brodalumab)
  • Simlandi (adalimumab-ryvk)
  • Simponi SQ (golimumab)
  • Skyclarys (omaveloxolone)
  • Skyrizi (risankizumab)
  • Skytrofa (lonapegsomatropin-tcgd)
  • Sogroya (somapacitan-beco)
  • Sohonos (palovarotene)
  • Somavert (pegvisomant)
  • Sotyktu (deucravacitinib)
  • Spevigo (spesolimab-sbzo)
  • Sprycel (dasatinib)
  • Starjemza SQ (ustekinumab-hmny)
  • Stelara SQ (ustekinumab)
  • Steqeyma SQ (ustekinumab-stba)
  • Stivarga (regorafenib)
  • Strensiq (asfotase alfa)
  • Sucraid (sacrosidase)
  • Sunosi (solriamfetol)
  • Sutent (sunitinib)
  • Symdeko (tezacaftor/ ivacaftor; ivacaftor)
  • Tabloid (thioguanine)
  • Tabrecta (capmatinib)
  • Tafinlar (dabrafenib)
  • Tagrisso (osimertinib)
  • Takhzyro (lanadelumab-flyo)
  • Taltz (ixekizumab)
  • Talzenna (talazoparib)
  • Tarceva (erlotinib)
  • Targretin (bexarotene)
  • Targretin gel (bexarotene)
  • Tarpeyo (budesonide)
  • Tascenso (fingolimod)
  • Tasigna (nilotinib)
  • Tavalisse (fostamatinib)
  • Tavneos (avacopan)
  • Tazverik (tazemetostat)
  • Tecfidera (dimethyl fumarate)
  • Tegsedi (inotersen)
  • Temodar (temozolomide)
  • Tepmetko (tepotinib)
  • Tezspire (tezepelumab-ekko)
  • Thalomid (thalidomide)
  • Tibsovo (ivosidenib)
  • Tracleer (bosentan)
  • Tremfya (guselkumab)
  • Trikafta (elexacaftor/ tezacaftor/ ivacaftor; ivacaftor)
  • Trulicity (dulaglutide)
  • Truqap (capivasertib)
  • Tukysa (tucatinib)
  • Turalio (pexidartinib)
  • Tyenne (tocilizumab-aazg)
  • Tykerb (lapatinib)
  • Tymlos (abaloparatide)
  • Tyvaso (treprostinil)
  • Tyvaso DPI (treprostinil)
  • Ubrelvy (ubrogepant)
  • Uptravi (selexipag)
  • Vanflyta (quizartinib)
  • Velsipity (etrasimod)
  • Venclexta (venetoclax)
  • Ventavis (iloprost)
  • Verzenio (abemaciclib)
  • Victoza (liraglutide)
  • Vijoice (alpelisib)
  • Vitrakvi (larotrectinib)
  • Vizimpro (dacomitinib)
  • Vonjo (pacritinib)
  • Voranigo (vorasidenib)
  • Vosevi (sofosbuvir/ velpatasvir/ voxilaprevir)
  • Votrient (pazopanib)
  • Vowst (fecal microbiota spores, live-brpk)
  • Voxzogo (vosoritide)
  • Voydeya (danicopan)
  • Voyxact (sibeprenlimab)
  • Vtama (tapinarof)
  • Vumerity (diroximel fumarate)
  • Vykat (diazoxide choline)
  • Vyndamax (tafamidis)
  • Vyndaqel (tafamidis)
  • Wainua (eplontersen)
  • Wakix (pitolisant)
  • Wayrilz (rilzabrutinib)
  • Wegovy (semaglutide)
  • Welireg (belzutifan)
  • Wezlana SQ (ustekinumab-auub)
  • Winrevair (sotatercept-csrk)
  • Xalkori (crizotinib)
  • Xeljanz (tofacitinib)
  • Xenazine (tetrabenazine)
  • Xermelo (telotristat ethyl)
  • Xolair Prefilled Syringe, auto-injector (omalizumab)
  • Xolremdi (mavorixafor)
  • Xospata (gilteritinib)
  • Xpovio (selinexor)
  • Xtandi (enzalutamide)
  • Xuriden (uridine triacetate)
  • Xyrem (sodium oxybate)
  • Yesintek SQ (ustekinumab-kfce)
  • Yonsa (abiraterone)
  • Yorvipath (palopegteriparatide)
  • Yuflyma (adalimumab-aaty)
  • Yusimry (adalimumab-aqvh)
  • Yutrepia (treprostinil)
  • Zavesca (miglustat)
  • Zavzpret (zavegepant)
  • Zejula (niraparib)
  • Zelboraf (vemurafenib)
  • Zelsuvmi (berdazimer)
  • Zepatier (elbasvir/ grazoprevir)
  • Zepbound (tirzepatide)
  • Zeposia (ozanimod)
  • Zilbrysq (zilucoplan)
  • Zokinvy (lonafarnib)
  • Zolinza (vorinostat)
  • Zomacton (somatropin)
  • Zydelig (idelalisib)
  • Zykadia (ceritinib)
  • Zymfentra (infliximab-dyyb)
  • Ztalmy (ganaxolone)
  • Zytiga (abiraterone)

Reviewed by LJS 12/11/25