Drug Class
Excluded Medications
Preferred Alternatives
MISCELLANEOUS AGENTS (continued) Gaucher Disease Agents
ELELYSO, VPRIV
CEREZYME
ALKINDI SPRINKLE
hydrocortisone tablets dexamethasone tablets CINRYZE, RUCONEST
Glucocorticoids
HEMADY BERINERT
Hereditary Angioedema
SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY IV: GAMMAGARD LIQUID, GAMMAGARD S-D, GAMUNEX-C SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY
CUTAQUIG, HYQVIA
Immune Globulins
GAMMAKED
ENVARSUS XR
tacrolimus capsules methotrexate tablets IMBRUVICA, JAKAFI methotrexate injection
JYLAMVO, TREXALL, XATMEP
Immunosuppressant Agents
NIKTIMVO
OTREXUP, RASUVO
Inflammatory Conditions Agents Infused Non-TNF Biologics - Tocilizumab Intravenous Agents Infused Non-TNF Biologics - Ustekinumab Agents
SOVUNA
hydroxychloroquine tablets
ACTEMRA IV, TOFIDENCE IV
TYENNE IV
SELARSDI IV, USTEKINUMAB-TTWE IV (by Quallent), YESINTEK IV, ENTYVIO IV, OMVOH, SKYRIZI, TREMFYA
OTULFI IV, PYZCHIVA IV, STELARA IV, STEQEYMA IV, USTEKINUMAB IV, WEZLANA IV
Infused TNF Antagonists
INFLECTRA, REMICADE, RENFLEXIS
AVSOLA, INFLIXIMAB
RAVICTI
sodium phenylbutyrate, PHEBURANE
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
RIVFLOZA
IMAAVY, RYSTIGGO
Myasthenia Gravis Agents
ZILBRYSQ
SOLIRIS
Neuromyelitis Optica Spectrum Disorder Agents
UPLIZNA
ENSPRYNG
ibuprofen/famotidine
ibuprofen tablets plus famotidine tablets naproxen tablets, naproxen sodium tablets or naproxen ec tablets plus esomeprazole magnesium capsules alendronate, ibandronate, risedronate, teriparatide, zoledronic acid, TYMLOS
NSAID & Acid Reducing Agent Combination Products
naproxen/esomeprazole magnesium, VIMOVO
Osteoporosis (Bone Modifiers)
EVENITY, PROLIA
Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis Potassium Replacement Agents
ONPATTRO, WAINUA
AMVUTTRA
POKONZA
potassium chloride
Weight Loss
SAXENDA, ZEPBOUND VIALS
WEGOVY, ZEPBOUND PENS
Wilson’s Disease Agents
CUVRIOR, TRIENTINE 500MG CAPSULES
trientine 250mg capsules
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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