(continued)
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Immunosuppressant Agents
ENVARSUS XR
tacrolimus capsules methotrexate tablets
JYLAMVO, TREXALL, XATMEP
NIKTIMVO SOVUNA
IMBRUVICA, JAKAFI, JAKAFI XR
Inflammatory Conditions Agents Infused Non-TNF Biologics
hydroxychloroquine tablets
COSENTYX IV
COSENTYX SC
Infused Non-TNF Biologics - Tocilizumab Intravenous Agents
ACTEMRA IV, TOFIDENCE IV
AVTOZMA IV, TYENNE IV
Infused Non-TNF Biologics - Ustekinumab Agents OTULFI IV, PYZCHIVA IV, SELARSDI IV, STARJEMZA IV, STELARA IV, STEQEYMA IV, USTEKINUMAB IV, WEZLANA IV
IMULDOSA IV, USTEKINUMAB-TTWE IV (by Quallent), YESINTEK IV, ENTYVIO IV, OMVOH, SKYRIZI, TREMFYA
Infused TNF Antagonists Menkes Disease Agents
INFLECTRA, REMICADE, RENFLEXIS
AVSOLA, INFLIXIMAB
ZYCUBO
Coverage may be approved for the treatment of Menkes Disease under certain conditions. nitisinone 2mg capsules, NITYR 2 MG TABLETS Coverage may be approved for the treatment of Primary Hyperoxaluria Type 1 under certain conditions. Coverage may be approved for the treatment of Generalized Myasthenia Gravis.
Metabolic Agents
HARLIKU RIVFLOZA
Myasthenia Gravis Agents
IMAAVY, RYSTIGGO
ZILBRYSQ UPLIZNA
EPYSQLI
Neuromyelitis Optica Spectrum Disorder Agents NSAID and Acid Reducing Agent Combination Products
ENSPRYNG
ibuprofen/famotidine ibuprofen tablets plus famotidine tablets naproxen/esomeprazole magnesium, VIMOVO naproxen tablets, naproxen sodium tablets or naproxen ec tablets plus esomeprazole magnesium dr capsules
Osteoporosis (Bone Modifiers)
BOSAYA, CONEXXENCE, EVENITY, JUBBONTI, OSPOMYV (by Cordavis), PROLIA, STOBOCLO AUKELSO, BOMYNTRA, OSENVELT, WYOST, XGEVA
alendronate, ibandronate, risedronate, teriparatide, zoledronic acid, BILDYOS, ENOBY, TYMLOS
Other Bone Mineral Density Increasing Agents
BILPREVDA, XTRENBO
Potassium Replacement Agents Primary Biliary Cholangitis Agents Thymidine Kinase 2 Deficiency Agents
POKONZA, POTASSIUM CL 40MEQ PACKETS potassium chloride solution
LIVDELZI KYGEVVI
IQIRVO
Coverage may be approved for the treatment of Thymidine Kinase 2 Deficiency under certain conditions. liraglutide, FOUNDAYO, WEGOVY HD, WEGOVY PENS, WEGOVY TABLETS, ZEPBOUND PENS
Weight Loss
ZEPBOUND KWIKPENS, ZEPBOUND VIALS
Wilson’s Disease Agents
CUVRIOR, TRIENTINE 500MG CAPSULES
trientine 250mg capsules
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