| Amjevita (adalimumab-atto) [Nuvaila], Humira (Abbvie) - PA, NF - Standard Default |
Amjevita (adalimumab-atto), Humira (adalimumab) |
| Antipsychotics, Long-Acting Injectable |
Abilify Asimtufii, Abilify Maintena, Aristada, Aristada Initio, Erzofri, Haldol Decanoate, Invega Hafyera, Invega Sustenna, Invega Trinza, Perseris, Risperdal Consta, Rykindo, Uzedy, Zyprexa Relprevv |
| Brand Estradiol Transdermal Systems |
Alora (estradiol transdermal system), Menostar (estradiol transdermal system), Minivelle (estradiol transdermal system), Vivelle-Dot (estradiol transdermal system) |
| Coverage of Drugs for Off-Label or Non-FDA Approved Indications |
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| Diabetic GLP-1's |
Bydureon BCise (exenatide extended-release), Byetta (exenatide injection), Mounjaro (tirzepatide), Ozempic (semaglutide), Rybelsus (semaglutide), Trulicity (dulaglutide), Victoza (liraglutide injection) |
| Estrogen Products and Progesterone Product (Gender Dysphoria) |
DEPO-PROVERA INJ, ESTRADIOL/ESTROGEN, MEDROXYPR AC, MEDROXYPR AC INJ, PROGESTERONE, PROMETRIUM, PROVERA, VAGINAL ESTROGENS |
| Femring (estradiol acetate ring) |
Femring (estradiol acetate vaginal ring) |
| Gonadotropin-Releasing Hormone Agonists |
Camcevi (leuprolide), Generic leuprolide Acetate, Leuprolide Acetate Depot, Eligard (leuprolide acetate), Trelstar (triptorelin pamoate), Vabrinty (leuprolide acetate), Lupron Depot (leuprolide acetate) 1-Month 7.5 mg, Lupron Depot 3-Month 22.5 mg, Lupron Depot 4-Month 30 mg, Lupron Depot 6-Month 45 mg, Lupron Depot 1-Month 3.75 mg, Lupron Depot 3-Month 11.25 mg, Lupron Depot-PED (leuprolide acetate), Lutrate Depot (leuprolide acetate 22.5mg), Supprelin LA (histrelin acetate), Triptodur (triptorelin), Fensolvi (leuprolide acetate), Zoladex (goserelin) |
| Insulin Pump |
Omnipod 5 G6 and Omnipod 5 DASH: |
| Non-GLP-1 Agonist Anorexiants – PA, NF |
Contrave (naltrexone/bupropion), Generic phentermine, Adipex-P (phentermine), Lomaira (phentermine), generic phentermine-topiramate, Qsymia (phentermine and topiramate), Xenical (orlistat) |
| Nonpreferred Adalimumab - PA, NF - Standard Default |
Drug Name: Abrilada (adalimumab-afzb), Cyltezo (adalimumab-adbm), Hadlima (adalimumab-bwwd), Hulio (adalimumab-fkjp), Hyrimoz (adalimumab-adaz), Idacio (adalimumab-aacf), Simlandi (adalimumab-ryvk), Yuflyma (adalimumab-aaty), Yusimry (adalimumab-aqvh), Amjevita (adalimumab-atto), Humira (adalimumab) |
| Obesity GLP-1 Agonists – PA, NF |
Foundayo (orforglipron), Saxenda (liraglutide), Wegovy HD (semaglutide 7.2 mg), Wegovy Injection (semaglutide), Wegovy Tablet (semaglutide), Zepbound (tirzepatide) Injection |
| Testosterone |
Androderm, Androgel, Aveed, Azmiro, Depo-Testosterone, Fortesta, Methitest, Natesto, Testone CIK, Testim, Testopel, Vogelxo, Xyosted, Androgel (T gel and pump), Fortesta (T gel), Natesto (T nasal gel), Testim (T gel), and Vogelxo (T gel and pump), Aveed (testosterone undecanoate) injection, Azmiro (testosterone cypionate) injection, Depo-Testosterone (testosterone cypionate) injection, Jatenzo (testosterone undecanoate) capsule, Kyzatrex (testosterone undecanoate) capsule, Methitest (methyltestosterone) tablet, Testone CIK (testosterone cypionate) injection, Testopel (testosterone) pellet, Tlando (testosterone undecanoate) capsule, Xyosted (testosterone enanthate) injection |
| Ustekinumab – PA, NF – Standard Default |
Stelara IV (ustekinumab), Imuldosa IV (ustekinumab-srlf), Otulfi IV (ustekinumab-aauz), Pyzchiva IV (ustekinumab-ttwe), Selarsdi IV (ustekinumab-aekn), Steqeyma IV (ustekinumab-stba), Wezlana IV (ustekinumab-auub), Yesintek IV (ustekinumab-kfce), Stelara SC (ustekinumab), Imuldosa SC (ustekinumab-srlf), Otulfi SC (ustekinumab-aauz), Pyzchiva SC (ustekinumab-ttwe), Selarsdi SC (ustekinumab-aekn), Steqeyma SC (ustekinumab-stba), Wezlana SC (ustekinumab-auub), Yesintek SC (ustekinumab-kfce) |
HEALTHY LIVING