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Pharmacy

The management of outpatient prescription drugs is an integral part of the medical management program to improve the health and well-being of our members.

Search for a drug using our online tool. You can also view or print the PDL.

Printed Preferred Drug Lists

Coverage Determination Requests

Request a coverage decision and/or exception or file an appeal of a drug coverage decision.

Maximum Allowable Cost prices

Preferred Drug Lists


Please carefully review these changes.

Pharmacy Forms

This is a prior authorization form for Zubsolv treatment.

Pharmacy Clinical Policies

Crizanlizumab-tmca (Adakveo®) is a selectin blocker.

Cerliponase alfa (Brineura®) is a hydrolytic lysosomal N-terminal tripeptidyl peptidase.

The following are factor VIII products requiring prior authorization: human – Hemofil M®, Koate-DVI®; recombinant – Advate®, Adynovate®, Afstyla®, Eloctate®, Esperoct®, Helixate FS®, Jivi®, Kogenate FS®, Kogenate FS with Vial Adapter®, Kogenate FS with Bio-Set®, Kovaltry®, NovoEight®, Nuwiq®, Obizur®, Recombinate®, ReFacto®, Xyntha®, and Xyntha® Solofuse™.

Hydroxyprogesterone caproate (Makena®/compound) is a progestin.

Factor VIIa, recombinant (NovoSeven® RT) and coagulation factor VIIa (recombinant)-jncw (SevenFact®) are coagulation factors.

Patisiran (Onpattro™) is a double-stranded small interfering ribonucleic acid, formulated as a lipid complex for delivery to hepatocytes.

Mogamulizumab-kpkc (Poteligeo®) is a CC chemokine receptor type 4 (CCR4)-directed monoclonal antibody.

Eculizumab (Soliris®) is a complement inhibitor.

Trientine (Syprine®) is a chelating agent.

Ravulizuamb-cwvz (Ultomiris®) is a complement inhibitor.

Golodirsen (Vyondys 53TM) is an antisense oligonucleotide.

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Last Updated On: 5/11/2021