Medical Injectable Drug Criteria

A

Abraxane
Actemra - Criteria | Non-Preferred Product Exception Criteria
Acthar Gel
Actimmune
Adagen
Adakveo
Adcetris
Aduhelm
Advate
Adynovate
Afstyla
Aldurazyme
Alimta
Aliqopa
Alphanate/VWF Complex/Human
Alphanine SD
Alprolix - Criteria | Non-Preferred Exception Criteria
Amondys
Apokyn
Aralast NP - Criteria | Non-Preferred Exception Criteria
Aranesp
Arcalyst
Arzerra
Asceniv
Avastin - Criteria | Non-Preferred Product Exception Criteria
Aveed
Avsola - Criteria | Non-Preferred Product Exception Criteria

B

Bavencio
Bebulin
Beleodaq
Belrapzo
Bendamustine HCI
Bendeka
Benefix
Benlysta
Beovu
Berinert - Criteria | Non-Preferred Exception Criteria
Besponsa
Bivigam
Blenrep
Blincyto
Bortezomib
Botox
Breyanzi
Brineura
Bynfezia Pen

C

Cabenuva
Cerezyme - Criteria | Non-Preferred Exception Criteria
Cimzia - Criteria | Non-Preferred Exception Criteria
Cinqair - Criteria | Non-Preferred Exception Criteria
Cinryze
Coagadex
Cosela
Crysvita
Cutaquig
Cuvitru
Cyramza

D

Darzalex
Darzalex Faspro
Decitabine
Docefrez
Docetaxel
Docetaxel (non- alcohol)
Durolane - Criteria | Non-Preferred Exception Criteria
Dysport

E

Elaprase
Elelyso
Eligard
Eloctate - Criteria | Non-Preferred Product Exception Criteria
Elzonris
Empliciti
Enhertu
Entyvio
Epogen - Criteria | Non-Preferred Product Exception Criteria
Epoprostenol sodium
Erbitux
Erwinaze
Esperoct
Euflexxa
Evenity
Evkeeza
Exondys 51
Eylea

F

Fabrazyme
Fasenra
Feiba
Fensolvi
Fibryga
Firazyr
Firmagon - Criteria | Non-Preferred Product Exception Criteria
Flebogamma DIF
Flolan
Fulphila
Fusilev
Fyarro

G

Gamifant
Gammagard
Gammagard S/D Less IgA
Gammaked
Gammaplex
Gamunex-C
Gazyva
Gel-one - Criteria | Non-Preferred Product Exception Criteria
Gelsyn-3 - Criteria | Non-Preferred Product Exception Criteria
Gemcitabine HCI
Gemzar
Genvisc 850 - Criteria | Non-Preferred Product Exception Criteria
Givlaari
Glassia - Criteria | Non-Preferred Product Exception Criteria
Granix

H

Haegarda
Halaven
Helixate FS - Criteria | Non-Preferred Product Exception Criteria
Hemlibra
Hemofil M
Herceptin - Criteria | Non-Preferred Product Exception Criteria
Herceptin Hylecta - Criteria | Non-Preferred Product Exception Criteria
Herzuma - Criteria | Non-Preferred Product Exception Criteria
Hizentra
Humate-P
Hyalgan - Criteria | Non-Preferred Product Exception Criteria
Hymovis - Criteria | Non-Preferred Product Exception Criteria
Hyqvia

I

Icatibant Acetate
Idelvion
Ilaris
Ilumya
Imfinzi
Imlygic
Inflectra
Ixempra Kit
Ixinity

J

Jetrea
Jevtana
Jivi

K

Kadcyla
Kalbitor
Kanjinti
Kanuma
Keytruda
Koate
Koate-DVI
Kogenate FS
Kogenate FS Bio-Set
Kovaltry
Krystexxa
Kymriah
Kyprolis - Criteria | Non-Preferred Product Exception Criteria

L

Lemtrada - Criteria | Non-Preferred Product Exception Criteria
Libtayo
Lucentis
Lumizyme
Lumoxiti
Lupron Depot (Endometriosis & Fibroids) - Criteria | Non-Preferred Product Exception Criteria
Lupron Depot (Prostate Cancer, Ovarian Cancer, Gender Dysphoria & Salivary Gland Tumors)
Lupron Depot-PED
Luxturna

M

Macugen
Margenza - Criteria | Non-Preferred Product Exception Criteria
Mepsevii
Mircera - Criteria | Non-Preferred Product Exception Criteria
Mitoxantrone HCI
Monjuvi
Monoclate-P
Mononine
Monovisc
Mvasi
Myobloc - Criteria | Non-Preferred Product Exception Criteria
Mycapssa

N

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

O

Obizur
Ocrevus
Octagam
Octreotide Acetate
Ogivri
Oncaspar
Onpattro
Ontruzant - Criteria | Non-Preferred Product Exception Criteria
Opdivo
Orencia - Criteria | Non-Preferred Product Exception Criteria
Orthovisc
Oxaliplatin

P

Padcev
Panzyga
Parsabiv
Perjeta
Phesgo
Polivy
Poteligeo
Purified Cortrophin Gel
Privigen
Procrit
Profilnine
Prolastin-C
Proleukin
Prolia

Q

 

R

Radicava
Rebinyn
Reblozyl
Recombinate
Remicade - Criteria | Non-Preferred Product Exception Criteria
Remodulin
Renflexis - Criteria | Non-Preferred Product Exception Criteria
Retacrit - Criteria | Non-Preferred Product Exception Criteria
Riabni (Oncology)
Riabni (Other) - Criteria | Non-Preferred Product Exception Criteria
Riastap
Rituxan (Oncology)
Rituxan (Other) - Criteria | Non-Preferred Product Exception Criteria
Rituxan Hycela - Criteria | Non-Preferred Product Exception Criteria
Rixubis
Ruconest
Ruxience (Oncology)
Ruxience (Other) - Criteria | Non-Preferred Product Exception Criteria

S

Sandostatin
Sandostatin LAR Depot
Sarclisa
Sevenfact
Signifor LAR - Criteria | Non-Preferred Product Exception Criteria
Simponi Aria
Soliris
Somatuline Depot
Spinraza
Stelara IV
Supartz
Supartz FX - Criteria | Non-Preferred Product Exception Criteria
Supprelin LA
Sylvant
Synvisc - Criteria | Non-Preferred Product Exception Criteria
Synvisc One - Criteria | Non-Preferred Product Exception Criteria

T

Takhzyro
Taxotere
Tecartus
Tecentriq
Tegsedi - Criteria | Non-Preferred Product Exception Criteria
Temodar
Temsirolimus
Tepezza
Tezspire
Torisel
Trazimera - Criteria | Non-Preferred Product Exception Criteria
Treanda
Trelstar - Criteria | Non-Preferred Product Exception Criteria
Treprostinil
Tretten
Triluron
Triptodur
Trivisc - Criteria | Non-Preferred Product Exception Criteria
Trodelvy
Truxima (Oncology)
Truxima (Other)
Tysabri

U

Udenyca - Criteria | Non-Preferred Product Exception Criteria
Ultomiris - Criteria | Non-Preferred Product Exception Criteria
Uplizna

V

Vantas
Vectibix
Velcade
Veletri
Vimizim
Visco-3 - Criteria | Non-Preferred Product Exception Criteria
Viltepso
Vonvendi
Vpriv - Criteria | Non-Preferred Product Exception Criteria
Vyondys

W

Wilate

X

Xembify
Xeomin
Xgeva
Xiaflex
Xolair
Xyntha
Xyntha Solofuse

Y

Yervoy
Yescarta

Z

Zaltrap
Zarxio
Zemaira - Criteria | Non-Preferred Product Exception Criteria
Zepzelca
Ziextenzo - Criteria | Non-Preferred Product Exception Criteria
Zirabev - Criteria | Non-Preferred Product Exception Criteria
Zoladex - Criteria | Non-Preferred Product Exception Criteria
Zolgensma