Drug Class
Excluded Medications
Preferred Alternatives
HEMATOLOGICAL (continued) Erythropoiesis-Stimulating Agents
ARANESP, EPOGEN, MIRCERA
PROCRIT, RETACRIT
IXINITY, RIXUBIS NOVOSEVEN RT
BENEFIX
SEVENFACT
ADVATE, ADYNOVATE, AFSTYLA, ALTUVIIIO, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, XYNTHA, XYNTHA SOLOFUSE
Factor Deficiency Agents & Related Products
NUWIQ, RECOMBINATE
REBINYN
ALPROLIX, IDELVION
FYLNETRA, NEULASTA, NYVEPRIA, ROLVEDON, RYZNEUTA, STIMUFEND, UDENYCA GRANIX, NEUPOGEN, NYPOZI, RELEUKO, ZARXIO
FULPHILA, ZIEXTENZO
Granulocyte Colony Stimulating Factors
NIVESTYM
Hematopoietic & Thrombopoietic Agents
APHEXDA
plerixafor
For Hemophilia A with inhibitors: ALHEMO, HEMLIBRA
For Hemophilia A without inhibitors: ALHEMO, HEMLIBRA, HYMPAVZI For Hemophilia B with inhibitors: ALHEMO For Hemophilia B without inhibitors: ALHEMO, HYMPAVZI
Hemophilia Agents
QFITLIA
Hemophilia Gene Therapy Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors Iron Replacement Agents Sickle Cell Disease Agents
BEQVEZ
HEMGENIX
VAFSEO
PROCRIT, RETACRIT
MONOFERRIC SIKLOS, XROMI
sodium ferric gluconate complex, VENOFER
hydroxyurea, DROXIA eltrombopag, NPLATE
ALVAIZ
Thrombocytopenia Agents
MULPLETA
DOPTELET
Coverage may be approved for the treatment of Myelodysplastic Syndrome with Transfusion- Dependent Anemia under certain conditions.
Miscellaneous Hematology Agents RYTELO
HEPATITIS Hepatitis C
LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI
EPCLUSA, HARVONI, VOSEVI, ZEPATIER
atazanavir, darunavir, fosamprenavir, lopinavir/ritonavir, ritonavir, PREZISTA
PREZCOBIX
HIV Antiretrovirals
Coverage may be approved for the treatment of human immunodeficiency virus-1 infection in heavily treatment-experienced patients with multidrug-resistant infection.
Note: Current patients established on therapy are allowed to continue therapy.
RUKOBIA ER
STRIBILD
BIKTARVY, GENVOYA
MUSCULOSKELETAL & RHEUMATOLOGY Muscle Relaxants & Antispasmodic Agents
METHOCARBAMOL 1,000MG TABLETS
methocarbamol 500mg tablets
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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