A
Actemra - Criteria | Non-Preferred Exception Criteria
Adakveo
Aduhelm
Advate
Adynovate
Afstyla
Aliqopa
Alphanate/VWF Complex/Human
Alphanine SD
Alprolix
Aralast NP - Criteria | Non-Preferred Exception Criteria
Aranesp
Avastin (Oncology) - Criteria | Non-Preferred Exception Criteria
Avastin (Other) - Criteria | Non-Preferred Exception Criteria
Avsola
B
Bavencio
Bebulin
Belrapzo
Bendeka
Benefix
Benlysta
Beovu - Criteria | Non-Preferred Exception Criteria
Berinert
Besponsa
Bivigam
Blincyto
Botox - Criteria | Non-Preferred Exception Criteria
C
Cerezyme - Criteria | Non-Preferred Exception Criteria
Cimzia - Criteria | Non-Preferred Exception Criteria
Cinqair - Criteria | Non-Preferred Exception Criteria
Cinryze
Coagadex
Corifact
Crysvita
Cutaquig
Cuvitru
Cyramza
Cytogam
D
Darzalex
Durolane - Criteria | Non-Preferred Exception Criteria
Dysport
E
Elelyso
Eligard
Eloctate
Entyvio
Epogen - Criteria | Non-Preferred Exception Criteria
Erbitux
Erwinaze
Esperoct
Euflexxa - Criteria | Non-Preferred Exception Criteria
Evenity
Exondys 51
Eylea - Criteria | Non-Preferred Exception Criteria
F
Fasenra - Criteria | Non-Preferred Exception Criteria
FEIBA
Firazyr
Firmagon
Flebogamma DIF
Forteo
Fulphila
Fusilev
G
Gammagard
Gammagard S/D less IgA
Gammaked
Gammaplex
Gamunex-C
Gel-one - Criteria | Non-Preferred Exception Criteria
Gelsyn-3 - Criteria | Non-Preferred Exception Criteria
GenVisc 850 - Criteria | Non-Preferred Exception Criteria
Givlaari
Glassia - Criteria | Non-Preferred Exception Criteria
Granix - Criteria | Non-Preferred Exception Criteria
H
Hemlibra
Hemofil M
Hepagam B
Herceptin - Criteria | Non-Preferred Exception Criteria
Herceptin Hylecta
Herzuma
Hizentra
Humate-P
Hyalgan - Criteria | Non-Preferred Exception Criteria
Hymovis - Criteria | Non-Preferred Exception Criteria
Hyqvia
I
Icatibant acetate
Idelvion
Ilaris
Ilumya - Criteria | Non-Preferred Exception Criteria
Imfinzi
Inflectra
Ixinity
J
K
Kadcyla
Kalbitor
Kanjinti
Kanuma
Keytruda
Khapzory
Koate
Kogenate FS
Kogenate FS Bio-Set
Kovaltry
Krystexxa
Kymriah
L
Lartruvo
Lemtrada - Criteria | Non-Preferred Exception Criteria
Leukine - Criteria | Non-Preferred Exception Criteria
Levoleucovorin calcium
Libtayo
Lucentis - Criteria | Non-Preferred Exception Criteria
Lumizyme
Lupron Depot - Criteria | Non-Preferred Exception Criteria
Lupron Depot Endometriosis-Fibroid
Lupron Depot Prostate Cancer 4694
Luxturna
M
Mepsevii
Mononine
Monovisc - Criteria | Non-Preferred Exception Criteria
Mvasi (Oncology)
Mvasi (Other)
Myobloc - Criteria | Non-Preferred Exception Criteria
N
Naglazyme
Neupogen - Criteria | Non-Preferred Exception Criteria
Neulasta - Criteria | Non-Preferred Exception Criteria
Neulasta Onpro - Criteria | Non-Preferred Exception Criteria
Nivestym
Novoeight
Novoseven RT
Nplate
Nucala
Nuwiq
Nyvepria
O
Obizur
Ocrevus
Octagam
Ogivri
Onpattro
Ontruzant
Opdivo
Orencia - Criteria | Non-Preferred Exception Criteria
Orthovisc
P
Panzyga
Perjeta
Privigen
Procrit
Profilnine
Profilnine SD
Prolastin-C
Proleukin
Prolia
Provenge
Q
R
Radicava
Rebinyn
Reclast
Recombinate
Remicade - Criteria | Non-Preferred Exception Criteria
Renflexis
Retacrit
Riabni
Rituxan Hycela - Criteria | Non-Preferred Exception Criteria
Rituxan (Oncology)
Rituxan (Other) - Criteria | Non-Preferred Exception Criteria
Rixubis
Ruconest
Ruxience
S
Sajazir
Sandostatin LAR Depot
Signifor LAR - Criteria | Non-Preferred Exception Criteria
Simponi Aria
Soliris
Somatuline Depot
Spinraza
Stelara Intravenous - Criteria | Non-Preferred Exception Criteria
Supartz FX
Supprelin LA
Synvisc
Synvisc One
T
Takhzyro
Tecartus
Tecentriq
Teriparatide
Trazimera
Treanda
Trelstar - Criteria | Non-Preferred Exception Criteria
Trelstar Mixject
Tretten
TriVisc - Criteria | Non-Preferred Exception Criteria
Truxima (Oncology)
Truxima (Other)
Tysabri
U
V
Vantas
Vimizim
Visco-3 - Criteria | Non-Preferred Exception Criteria
Visudyne
Vonvendi
Vpriv - Criteria | Non-Preferred Exception Criteria
W
X
Xembify
Xeomin
Xgeva
Xiaflex
Xolair
Xyntha
Xyntha Solofuse
Y
Z
Zarxio
Zemaira - Criteria | Non-Preferred Exception Criteria
Ziextenzo
Zirabev (Oncology)
Zirabev (Other)
Zoladex - Criteria | Non-Preferred Exception Criteria
Zoledronic acid (Reclast) - zoledronic acid-Reclast MedB P2020
Zoledronic acid (Zometa)
Zolgensma