Pharmacy Index (Drugs and Biologics)
Coverage Policies/Criteria Pharmacy Index for Drugs and Biologics
- abatacept (Orencia®) - (6112)
- abiraterone (Zytiga™) - (1115)
- adalimumab (Humira®)- (4062)
- aglasidase beta (Fabrazyme®) - (6015)
- aldesleukin (Proleukin®) - (6102)
- alefacept (Amevive®) - (4014)
- alpha1-proteinase inhibitor (human) (Aralast NP™, Aralast™, Glassia® , Prolastin®, Zemaira®) – (4037)
- alprostadil (Caverject® , Edex® , Muse®) - (7003)
- anakinra (Kineret®) - (4063)
- apomorphine (Apokyn™) - (5001)
- belatacept (Nulojix®) - (1124)
- belimumab (Benlysta® ) - (1114)
- bevacizumab (Avastin®)- (5025)
- Botulinum Therapy - (1106)
- Brentuximab Vedotin (Adcetris™) - (1203)
- butorphanol nasal spray - (5030)
- Cabazitaxel (Jevtana®) - (1205)
- canakinumab (Ilaris®) - (1110)
- certolizumab pegol (Cimzia®) - (9004)
- cetuximab (Erbitux®) - (1102)
- Chelation Therapy - (6019)
- Clotting Factors - (8007)
- collagenase clostridium histolyticum (Xiaflex®) - (1021)
- Crizontinib (Xalkori®) - (1202)
- dabigatran etexilate (Pradaxa®) - (1104)
- dalfampridline (Ampyra®) - (1022)
- dasatinib (Sprycel®) - (1025)
- degarelix (Firmagon®) - (1028)
- eculizumab (Soliris®) - (1103)
- eltrombopag (Promacta®) - (9003)
- enfuviritide (Fuzeon®) - (6010)
- Enzyme Replacement Therapy - (1010)
- Eribulin (Halaven®)- (1204)
- erlotinib (Tarceva®) - (5010)
- Erythropoietin Stimulating Agents (ESA): Epoetin Alfa (Epogen®, Procrit ®) and Darbepoetin alfa (Aranesp®) - (5016)
- etanercept (Enbrel®) - (5111)
- everolimus (Afinitor®) - (9015)
- fentanyl, transmucosal - (1018)
- fibrinogen concentrate (RiaSTAP®) - (1026)
- fingolimod (Gilenya®) - (1105)
- Gauchers Disease Therapy, Type 1 - (1011)
- gefitinib (Iressa®) - (4002)
- glatiramer acetate (Copaxone®) - (4027)
- golimumab (Simponi™) - (9014)
- goserelin (Zoladex®, Zoladex LA®) - (6115)
- Granulocyte Colony Stimulating Factors - (6008)
- Hepatitis C Protease Inhibitor Therapy - (1117)
- Hereditary Angioedema (HAE) Therapy - (1019)
- histrelin (Vantas™) - (6116)
- histrelin acetate subcutaneous implant (Supprelin LA) - (8008)
- human papillomavirus (types 6, 11, 16, 18) recombinant vaccine, quadrivalent (Gardasil®) - (6018)
- human papillomavirus (types 16 and 18) recombinant vaccine, bivalent (Cervarix®) - (9016)
- hydroxyprogesterone caproate injection (Makena®) - (1108)
- imatinib (Gleevec®) - (4003)
- immune globulin intravenous (human) (IVIG) - (5026)
- immune globulin subcutaneous (human) - (8004)
- Infertility Injectables - (1012)
- infliximab (Remicade®) - (5112)
- interferon alfa-2b (Intron® A) - (6012)
- interferon alfa-n3 (Alferon® N) - (6014)
- interferon alfacon-1 (Infergen®) - (5011)
- interferon gamma-1b (Actimmune™ ) - (5014)
- ipilimumab (Yervoy™) - (1111)
- lanreotide injection (Somatuline®Depot) - (9005)
- lapatinib (Tykerb®) - (8005)
- lenalidomide (Revlimid®) - (6120)
- leuprolide (Lupron, Lupron Depot, Lupron Depot PED) - (6117)
- linezolid (Zyvox®) - (1123)
- lymphocyte immune globulin, anti-thymocyte globulin (equine) (Atgam®) - (5004)
- mecasermin (Increlex®) - (6107)
- Multiple Sclerosis Interferon Products - (6006)
- natalizumab (Tysabri®) - (6017)
- nilotinib (Tasigna®) - (8009)
- octreotide (Sandostatin®, Sandostatin LAR® Depot) - (5015)
- omalizumab (Xolair®) - (4026)
- paclitaxel protein-bound particles for injectable suspension, Abraxane® - (1119)
- palivizumab (Synagis®) - (5012)
- panitumumab (Vectibix™) - (1101)
- pazopanib (Votrient®) - (1020)
- pegademase (Adagen™ ) - (5005)
- peginterferon alfa -2a (Pegasys®) - (6003)
- peginterferon alfa-2b (PEG Intron®) - (6004)
- peginterferon alfa-2b (Sylatron®) - (1120)
- pegloticase (Krystexxa®) - (1107)
- pemetrexed (Alimta®) - (1118)
- phosphodiesterase-5 inhibitors for erectile dysfuntion, oral (Viagra®, Levitra®, Cialis®) - (4030)
- plerixafor (Mozobil®) - (9008)
- pneumococcal 13-valent conjugate vaccine (diptheria CRM197 protein (Prevnar-13®) - (1014)
- Pulmonary Arterial Hypertension (PAH) Therapy - (6121)
- ranolazine (Ranexa®) - (6113)
- repository corticotropin (Achar®Gel) - (8001)
- rilonacept (Arcalyst &TM;) - (8011)
- rituximab (Rituxan®) - (5108)
- romiplostim (Nplate®) - (9002)
- rotavirus vaccine (Rotarix®, RotaTeq®) - (6114)
- Routine Immunizations - (9001)
- sipuleucel-T (Provenge®) - (1023)
- somatropin (Genotropin®, Humatrope®, Norditropin®, Nutropin®, Nutropin AQ®, Saizen®, Serostim®, Tev-Tropin®, Zorbtive®) - (4012)
- sorafenib (Nexavar®) - (6109)
- Step Therapy - (1109)
- sunitinib (Sutent®) - (6111)
- temozolomide (Temodar®) - (6104)
- tesamorelin (Egrifta®) - (1112)
- thalidomide (Thalomid®) (1027)
- tocilizumab (Actemra®) - (1024)
- tolvaptan (Samsca) - (1016)
- trastuzumab (Herceptin®) - (5106)
- ustekinumab (Stelara™) - (1017) Back to top
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- vandetanib (Caprelsa®) - (1116)
- vemurafenib (Zelboraf™) - (1122)
- voriconazole (Vfend®) - (4004)
- vorinostat (Zolinza™) - (8006)
- zoster vaccine live (Zostavax®) - (6020)
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