Pharmacy Policies Available Online for Migrated and Non-Migrated Members

Blue Cross Blue Shield of North Dakota (BCBSND) continually develops and revises pharmacy policies in response to rapidly changing pharmaceutical requirements. Our commitment is to update the provider community as pharmacy policies are adopted and/or revised.

Commercial Updates for Non-migrated Members - Medical Pharmacy

The following Commercial prior authorization medical drug policies are new and effective Jan. 1, 2027: 

• Aflibercept-boav 
• Aveed (testosterone undecanoate) 
• Beleodaq (belinostat) 
• Besponsa (inotuzumab ozogamicin) 
• Bexlutry (lutetium Lu 177 dotatate) 
• Bravnesta (lutetium Lu 177 dotatate) 
• Brineura (cerliponase alfa) 
• Denosumab-Adet 
• Degevma (denosumab‑adet) 
• Empliciti (elotuzumab) 
• Imlygic (talimogene laherparepvec) 
• Mylotarg (gemtuzumab ozogamicin) 
• Neulasta (pegfilgrastim) 
• Neulasta Onpro (pegfilgrastim) 
• Nulibry (fosdenopterin) 
• Pedmark (sodium thiosulfate injection) 
• Rivfloza (nedosiran) 
• Sandostatin LAR (octreotide acetate) 
• Signifor LAR (pasireotide) 
• Somatuline Depot (lanreotide) 
• Vyxeos (daunorubicin and cytarabine) 
• Xipere (triamcinolone acetonide injectable suspension) 

The following Commercial prior authorization medical drug policies will be archived effective Dec. 7, 2026:

• Azedra (iobenguane I-131) 
• Supartz (Hyaluronic Acid Derivative) 

Retail Pharmacy

The following retail pharmacy Utilization Management (UM) programs have updates effective Jan. 1, 2027:

The following retail pharmacy Utilization Management (UM) programs will be archived effective Jan. 1, 2027: 

• Esbriet (pirfenidone) 

Commercial Updates for Non-migrated and Migrated Members - Medical Pharmacy

The following Commercial prior authorization medical drug policies will be archived effective Jan. 1, 2027, for migrated and non-migrated members:

• Akynzeo IV 
• Aphexda 
• Avgemsi 
• Avsola 
• Axtle 
• Azedra 
• Belrapzo 
• Bendeka 
• Benlysta IV 
• Beqvez 
• Cabazitaxel 
• Danyelza 
• Erbitux 
• Feraheme 
• Fusilev 
• Fylnetra 
• Halaven 
• Inflectra 
• Injectafer 
• Ixempra 
• Jevtana 
• Kanjinti 
• Khapzory 
• Krystexxa 
• Kyxata 
• Monoferric 
• Mozobil 
• Mvasi 
• Ogivri 
• Oncaspar 
• Ontruzant 
• Orthovisc 
• Pemfexy 
• Pemrydi RTU 
• Posfrea 
• Poteligeo 
• Qutenza 
• Riabni 
• Ruxience 
• Rylaze 
• Sustol 
• Sylvant 
• Synribo 
• Synvisc 
• Synvisc-One 
• Trazimera 
• Treanda 
• Truxima 
• Vectibix 
• Vegzelma 
• Vivimusta 
• Zirabev 

The following Commercial prior authorization medical drug policies will have preferred products changes Jan. 1, 2027, for migrated and non-migrated members:

• Adalimumab: adalimumab-aaty* and adalimumab-adbm (preferred) 
  Preferred NDCs: 72606004101*, 72606002206*, 72606002210*, 72606002209*, 72606004004*, 72606004006*, 82009014422, 82009014622, 82009014822, 82009015022* no change 
  (Removal of adalimumab-adaz, Hadlima, Simlandi) 
• Bevacizumab: Mvasi, Vegzelma, Zirabev (preferred) 
• Denosumab: Bildyos/Bilprevda, Enoby/Xtrenbo, Stoboclo/Osenvelt (preferred) 
  (Removal of Jubbonti/Wyost as preferred) 
• Hyaluronan: Orthovisc, Synvisc, Synvisc-One (preferred) 
  (Removal of Gel-One as preferred) 
• Infliximab: Avsola, Inflectra (preferred) (no change) 
• IVIG: Gammagard S/D, Gammaked, Gamunex-C, Octagam, Privigen (preferred) 
• Myasthenia Gravis: Imaavy, Rystiggo, Uplizna, Vyvgart, Vyvgart Hytrulo (preferred) 
  Ultomirs, Zilbrysq (non-preferred) 
• Pegfilgrastim: Fulphila, Fylnetra (preferred) 
  (Removal of Neulasta/Neulasta Onpro as preferred) 
• Rituximab: Riabni, Ruxience, Truxima (preferred) 
  (no change) 
• SCIG: Cutaquiq, Hizentra, HyQvia, Xembify (preferred) 
• Tocilizumab: Avtozma, Tyenne (preferred) 
• Trastuzumab: Ogivri, Ontruzant, Trazimera (preferred) 
• Ustekinumab: Steqeyma, Yesintek (preferred) 
  (Removal of Selarsdi as preferred) 

The following Commercial medical drugs that currently have post service claim edit (PSCE) will no longer have PSCE effective Jan. 1, 2027, for migrated and non-migrated members:

• Alimta, Aloxi, Aranesp, Asparlas, Bortezomib, Boruzu, Camcevi, Cinvanti, Dextenza, Eligard, Emend, Epogen, Faslodex, Fensolvi, Firmagon, Flolan, Focinvez, Fosaprepitant, Fulphila, Fulvestrant, Granix, Iluvien, Lanreotide, Leukine, Lupron, Lupron Depot, Lupron Depot Ped, Lutrate, Mircera, Neupogen, Nivestym, Nypozi, Ozurdex, Pemetrexed, Portrazza, Procrit, Reclast, Releuko, Remodulin, Retacrit, Retisert, Supprelin LA, Torisel, Trelstar, Triptodur, Trogarzo, Velcade, Veletri, Xiaflex, Xofigo, Yutiq, Zarxio, Zoladex, Zometa 

Commercial Updates for Migrated Members - Medical Pharmacy

The following Commercial prior authorization medical drug policies are new and effective Jan. 1, 2027, for migrated members:

• Aveed (testosterone undecanoate) 
• Azmiro (testosterone cypionate) 
• Beleodaq (belinostat) 
• Besponsa (inotuzumab ozogamicin 
• Bexlutry (lutetium Lu 177 dotatate) 
• Brineura (cerliponase alfa) 
• Cabometyx (cabozantinib) 
• Ennumo (pegfilgrastim-pccg) 
• Empliciti (elotuzumab) 
• Hympavzi (marstacimab-hncq) 
• Imlygic (talimogene laherparepvec) 
• Lyrfigtu (lirafugratinib)
• Mylotarg (gemtuzumab ozogamicin) 
• naltrexone implant 
• Neulasta (pegfilgrastim) 
• Neulasta Onpro (pegfilgrastim) 
• Nulibry (fosdenopterin) 
• Omcazio (cabozantinib) 
• Palforzia (peanut allergen powder‑dnfp) 
• Pedmark (sodium thiosulfate) 
• Poherdy (pertuzumab-dpzb) 
• Ranluspec (ranibizumab-hkdz) 
• Rivfloza (nedosiran) 
• Sandostatin LAR (octreotide acetate) 
• Signifor LAR (pasireotide) 
• Somatuline Depot (lanreotide) 
• Somavert (pegvisomant) 
• Vyxeos (daunorubicin/cytarabine liposome) 
• Xipere (triamcinolone acetonide injectable susp.) 
• Ycanth (0.7% cantharidin) 
• Zycubo (copper histidinate) 

The following new to market drugs will have Commercial prior authorization medical drug policies adopted for migrated members:

• Atebrioz (zilurgisertib) 
• Emcitate (tiratricol) 
• Onswik (insulin efsitora alfa-gobe) 

The following Commercial prior authorization medical drug policies have criteria updates effective Jan. 1, 2027, for migrated members:

• Abecma, Abraxane, Actemra IV, Adakveo, Adcetris, Adstiladrin, Adzynma, Ahzantive, Aldurazyme, Alyglo, Alymsys, Amtagvi, Amvuttra, Anktiva, Aralast NP, Armlupeg, Asceniv, Aucatzyl, Aukelso, Avastin, Avlayah, Avtozma IV, Avzivi, Azedra, Bavencio, Beovu, Berinert, Bildyos, Bilprevda, Bivigam, Bizengri, Bkemv, Blenrep, Blincyto, Bomyntra, Boncresa, Bosaya, Breyanzi, Briumvi, Byooviz, Carvykti, Casgevy, Cerezyme, Cimerli, Cimzia, Cinqair, Cinryze, Columvi, Conexxence, Cosela, Cosentyx IV, Crysvita, Cutaquig, Cuvitru, Cyramza, Darzalex, Darzalex Faspro, Datroway, Decnupaz, Durolane, Elahere, Elaprase, Elelyso, Elfabrio, Elrexfio, Elzonris, Emrelis, Encelto, Enhertu, Enjaymo, Enoby, Entyvio IV, Enzeevu, Epkinly, Epysqli, Euflexxa, Evdi, Evenity, Evkeeza, Exdensur, Eydenzelt, Eylea, Eylea HD, Fabrazyme, Fasenra, Flebogamma, Folotyn, Fyarro, Gamifant, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Gazyva, Gel-One, Gelsyn-3, Genvisc 850, Givlaari, Glassia, Hemgenix, Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Hizentra, Hyalgan, Hymovis, Hymovis One, Hyqvia, Ilaris, Ilumya, Imaavy, Imdelltra, Imfinzi, Imjudo, Immgolis, Imuldosa IV, Infliximab unbranded, Inlexzo, Intravenous Immune Globulin, Istodax, Itvisma, Izervay, Jelmyto, Jemperli, Jobevne, Jubbonti, Jubereq, Kadcyla, Kalbitor, Kanuma, Kebilidi, Keytruda, Keytruda Qlex, Kimmtrak, Kinsula, Kresladi, Kymriah, Kyprolis, Lamzede, Lantidra, Lemtrada, Lenmeldy, Leqembi, Leqembi lqlik, Leqvio, Libtayo, Loargys, Loqtorzi, Lucentis, Lumizyme, Lumvoa, Lunsumio, Lunsumio Velo, Lutathera, Luxturna, Lyfgenia, Lymphir, Lynozyfic, Lytenava, Maci, Margenza, Mepsevii, Monjuvi, Monovisc, Naglazyme, Nexviazyme, Niktimvo, Nplate, Nucala, Nufymco, Nyvepria, Ocrevus, Ocrevus Zunovo, Octagam, Omisirge, Omlyclo, Omvoh IV, Onivyde, Onpattro, Opdivo, Opdivo Qvantig, Opdualag, Opuviz, Orencia IV, Osenvelt, Ospomyv, Osvyrti, Otarmeni, Otulfi IV, Oxlumo, Oziltus, Padcev, Panzyga, Papzimeos, Pavblu, Penpulimab-Kcqx, Perjeta, Phesgo, Piasky, Pluvicto, Polivy, Pombiliti, Ponlimsi, Privigen, Prolastin-C, Prolia, Xgeva, Provenge, Pyzchiva IV, Qalsody, Qivigy, Radicava, Reblozyl, Remicade, Renflexis, Rethymic, Revcovi, Revtorpyk, Rituxan, Rituxan Hycela, Roctavian, Rolvedon, Romidepsin, Ruconest, Rybrevant, Rybrevant Faspro, Ryoncil, Ryplazim, Rystiggo, Rytelo, Ryzneuta, Saphnelo, Sarclisa, Scenesse, Selarsdi IV, Simponi_ARIA, Skyrizi IV, Skysona, Soliris, Spevigo IV, Spinraza, Starjemza IV, Stelara IV, Steqeyma IV, Stimufend, Stoboclo, Supartz, Susvimo, Syfovre, Synagis, Synojoynt, Talvey, Tecartus, Tecelra, Tecentriq, Tecentriq Hybreza, Tecvayli, Tepezza, Tevimbra, Tezspire, Tivdak, Tofidence IV, Tremfya IV, Triluron, TriVisc, Trodelvy, Tyenne IV, Tyruko, Tysabri, Tzield, Udenyca, Ultomiris, Unloxcyt, Uplizna, Vabysmo, Veopoz, Vimizim, Visco-E, Vpriv, Vyepti, Vyjuvek, Vyloy, Vyvgart, Vyvgart Hytrulo, Waskyra, Wezlana IV, Wyost, Xbryk, Xembify, Xenpozyme, Xolair, Xtrenbo, Yartemlea, Yervoy, Yesafili, Yescarta, Yesintek IV, Yimmugo, Yondelis, Zaltrap, Zanvastro, Zemaira, Zepzelca, Zevaskyn, Ziextenzo, Ziihera, Zolgensma, Zusduri, Zynlonta, Zynteglo, Zynyz. 

The following Commercial medical drugs will no longer have coverage effective Jan. 1, 2027, for migrated members:

• Cablivi (caplacizumab-yhdp) 
• iDOSE implant (travoprost intracameral implant) 
• Rebyota (fecal microbiota, live‑jslm) 
• Uptravi IV (selexipag) 
• Zilretta (triamcinolone acetonide extended-release injectable suspension) 

PSCEs will apply to the following clinician-administered drugs billed under the medical drug benefit for eligible migrated members effective Jan.1, 2027: 

• Botulinum toxins: Botox, Dysport, Myobloc, Xeonim, Daxxify

Retail Pharmacy

The following retail pharmacy Utilization Management (UM) programs are new and effective Jan. 1, 2027, for migrated members:

• Airduo Respiclick (fluticasone-salmeterol aer powder) 
• Airsupra (albuterol-budesonide inhalation aerosol) 
• Apidra Solostar (insulin glulisine soln) 
• Baxfendy (baxdrostat) 
• Beclomethasone dipropionate hfa 
• Beqalzi (sonrotoclax) 
• Berinert (c1 esterase inhibitor (human)) 
• Bevespi Aerosphere (glycopyrrolate-formoterol fumarate aerosol) 
• Bexagliflozin 
• Bosaya (denosumab-kyqq inj) 
• Brenzavvy (bexagliflozin) 
• Bronchitol (mannitol inhal) 
• Butalbital/acetaminophen/caffeine/codeine 
• Butalbital/aspirin/caffeine/codeine 
• Butorphanol tartrate 
• Cholbam (cholic acid cap) 
• Codeine sulfate 
• Cuvrior (trientine tetrahydrochloride) 
• Dapagliflozin/saxagliptin 
• Demser (metyrosine) 
• Dichlorphenamide 
• Dilaudid (hydromorphone hcl) 
• Endocet (oxycodone w/ acetaminophen) 
• Eucrisa (crisaborole oint 2%) 
• Fioricet (butalbital-acetaminophen-caffeine) 
• Fioricet/codeine (butalbital-acetaminophen-caffeine w/ codeine) 
• Fluticasone furoate Ellipta (fluticasone furoate aerosol powder) 
• Fluticasone furoate/vilanterol Ellipta (fluticasone furoate-vilanterol aerosol powder) 
• Fluticasone propionate Diskus (fluticasone propionate aerosol powder) 
• Fluticasone propionate HFA (fluticasone propionate hfa inhal) 
• Fluticasone propionate/salmeterol (fluticasone-salmeterol aerosol powder) 
• Fluticasone propionate/salmeterol Diskus (fluticasone-salmeterol aerosol powder) 
• Fluticasone propionate/salmeterol HFA (fluticasone-salmeterol aerosol powder) 
• Forzinity (elamipretide hcl) 
• Hepcludex (bulevirtide acetate-gmod) 
• Hydrocodone bitartrate/acetaminophen 
• Hydrocodone/acetaminophen 
• Hydrocodone/ibuprofen 
• Hydromorphone HCL 
• Increlex (mecasermin inj) 
• Inpefa (sotagliflozin) 
• Invokamet (canagliflozin-metformin hcl) 
• Invokamet XR (canagliflozin-metformin hcl tab er) 
• Jentadueto (linagliptin-metformin hcl) 
• Jentadueto XR (linagliptin-metformin hcl tab er) 
• Jideytro (zidesamtinib) 
• Keveyis (dichlorphenamide) 
• Kirsty (insulin aspart-xjhz inj) 
• Kygevvi (doxecitine-doxribtimine powder) 
• Levalbuterol tartrate HFA (levalbuterol tartrate inhal aerosol) 
• Levorphanol tartrate
• Linagliptin/metformin hydrochloride (linagliptin-metformin hcl tab) 
• Lipfendra (enlicitide decanoate) 
• Lynavoy (linerixibat) 
• Lynkuet (elinzanetant) 
• Macitentan 
• Meperidine (meperidine hcl) 
• Merilog (insulin aspart-szjj subcutaneous soln) 
• Merilog Solostar (insulin aspart-szjj soln) 
• Metyrosine 
• Mirabegron ER
• Morphine sulfate 
• Mycapssa (octreotide acetate) 
• Myrbetriq (mirabegron) 
• Nalocet (oxycodone w/ acetaminophen) 
• Neulasta (pegfilgrastim) 
• Neulasta Onpro (pegfilgrastim soln) 
• Nitisinone 
• Nityr (nitisinone) 
• Novolin 70/30 Flexpen Relion (insulin NPH & regular susp pen-inj) 
• Novolin 70/30 Relion (insulin NPH isophane & regular human inj) 
• Novolin Flexpen Relion (insulin regular (human) soln) 
• Novolin N Flexpen Relion (insulin NPH (human) (isophane) susp) 
• Novolin N Relion (insulin NPH (human) (isophane)) 
• Novolin R Relion (insulin regular (human) inj) 
• Novolog Flexpen Relion (insulin aspart soln) 
• Novolog mix 70/30 Relion (insulin aspart prot & aspart (human) inj) 
• Novolog Relion (insulin aspart inj) 
• Nucynta (tapentadol hcl) 
• Nyvepria (pegfilgrastim-apgf soln) 
• Ocaliva (obeticholic acid) 
• Ohtuvayre (ensifentrine inhalation susp) 
• Onglyza (saxagliptin hcl) 
• Opzelura (ruxolitinib phosphate cream) 
• Orfadin (nitisinone) 
• Orlynvah (sulopenem etzadroxil-probenecid) 
• Ormalvi (dichlorphenamide) 
• Ospomyv (denosumab-dssb) 
• Oxycodone and acetaminophen 
• Oxycodone hydrochloride 
• Oxycodone hydrochloride/acetaminophen 
• Oxymorphone hydrochloride 
• Palforzia (peanut allergen powder-dnfp) 
• Palsonify (paltusotine hcl) 
• Pancreaze (pancrelipase (lip-prot-amyl) dr) 
• Pentazocine/naloxone HCL 
• Percocet (oxycodone w/ acetaminophen) 
• Pertzye (pancrelipase (lip-prot-amyl) dr) 
• Proventil HFA (albuterol sulfate inhal aero) 
• Pulmicort flexhaler (budesonide inhal aero powd) 
• Qbrexza (glycopyrronium tosylate) 
• Qtern (dapagliflozin-saxagliptin) 
• Rivfloza (nedosiran sodium subcutaneous soln) 
• Rolvedon (eflapegrastim-xnst soln) 
• Roxicodone (oxycodone hcl) 
• Roxybond (oxycodone hcl tab abuse deter) 
• Saxagliptin hydrochloride 
• Saxagliptin hydrochloride/metformin hydrochloride ER 
• Segluromet (ertugliflozin-metformin hcl) 
• Signifor (pasireotide diaspartate) 
• Sitagliptin 
• Sitagliptin phosphate 
• Sitagliptin phosphate/metformin hydrochloride 
• Sitagliptin phosphate/metformin hydrochloride ER 
• Sitagliptin/metformin hydrochloride 
• Sofdra (sofpironium bromide gel) 
• Steglatro (ertugliflozin l-pyroglutamic acid) 
• Steglujan (ertugliflozin-sitagliptin tab) 
• Stendra (avanafil tab) 
• Stimufend (pegfilgrastim-fpgk soln) 
• Syprine (trientine hcl) 
• Tapentadol hydrochloride 
• Tavneos (avacopan) 
• Tempo Smart Button (blood glucose monitoring) 
• Tempo Welcome (blood glucose monitoring kit with device) 
• Tradjenta (linagliptin) 
• Trezix (acetaminophen-caffeine-dihydrocodeine) 
• Trientine hydrochloride 
• Trutakna (atacicept-vymj subcutaneous soln) 
• Tudorza pressair (aclidinium bromide aerosol powd) 
• Tylenol/codeine #2 (acetaminophen w/ codeine) 
• Udenyca (pegfilgrastim-cbqv soln) 
• Udenyca onbody (pegfilgrastim-cbqv soln prefill) 
• Umeclidinium ellipta (umeclidinium br aero powd) 
• Umeclidinium/vilanterol ellipta (umeclidinium-vilanterol aero powd) 
• Vardenafil hydrochloride
• Vardenafil hydrochloride ODT 
• Veppanu (vepdegestrant) 
• Veozah (fezolinetant) 
• Viberzi (eluxadoline) 
• Viokace (pancrelipase (lip-prot-amyl)) 
• Voydeya (danicopan) 
• Voyxact (sibeprelimab-szsi subcutaneous soln) 
• Vtama (tapinarof cream) 
• Vybrique (sildenafil citrate) 
• Xdemvy (lotilaner ophth soln) 
• Xifaxan (rifaximin) 
• Xuriden (uridine triacetate) 
• Xyvona (levorphanol tartrate) 
• Yuviwel (navepegritide inj) 
• Ziextenzo (pegfilgrastim-bmez soln) 
• Zilbrysq (zilucoplan sodium) 
• Zituvimet (sitagliptin free base-metformin hcl) 
• Zituvimet xr (sitagliptin free base-metformin hcl tab er) 
• Zituvio (sitagliptin) 
• Zoryve (roflumilast) 
• Ztalmy (ganaxolone susp) 

The following retail pharmacy Utilization Management (UM) programs will be archived effective Jan. 1, 2027, for migrated members:

• Abirtega (abiraterone acetate) 
• Adapalene cream 
• Adapalene gel 
• Adapalene pump 
• Adapalene/benzoyl peroxide gel 
• Adcirca (tadalafil) 
• Adipex-p (phentermine hcl) 
• Adlarity (donepezil hydrochloride) 
• Agamree (vamorolone oral susp) 
• Aklief (trifarotene cream) 
• Albuterol sulfate hfa (albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)) 
• Alyq (tadalafil) 
• Arazlo (tazarotene (acne) lotion) 
• Arbli (losartan potassium) 
• Aspruzyo sprinkle (ranolazine er) 
• Atmeksi (methocarbamol) 
• Atralin (tretinoin gel) 
• Baclofen 
• Belbuca (buprenorphine) 
• Bexarotene gel 
• Bonjesta (doxylamine-pyridoxine tab er) 
• Brekiya (dihydroergotamine mesylate soln) 
• Buphenyl (sodium phenylbutyrate) 
• Buprenorphine
• Burn Gel (lidocaine hcl gel 2%) 
• Butrans (buprenorphine) 
• Cabtreo (adapalene-benzoyl peroxide-clindamycin gel) 
• Carac (fluorouracil cream) 
• Cardamyst (etripamil nasal soln) 
• Carospir (spironolactone susp) 
• Cetrorelix acetate
• Cetrotide (cetrorelix acetate) 
• Ciclodan (ciclopirox solution) 
• Ciclopirox nail lacquer 
• Cimetidine hydrochloride 
• Cinacalcet hydrochloride 
• Conzip (tramadol hcl cap er 24hr) 
• Cresemba (isavuconazonium sulfate) 
• Cuvposa (glycopyrrolate oral soln) 
• CVS adapalene (adapalene gel 0.1%) 
• Danazol 
• Deflazacort 
• Depo-testosterone (testosterone cypionate IM inj in oil) 
• Desloratadine 
• Desmoda (desmopressin acetate) 
• Dexcom G6 receiver 
• Dexcom G6 sensor 
• Dexcom G6 transmitter 
• Dexcom G7 15-day sensor 
• Dexcom G7 receiver 
• Dexcom G7 sensor 
• Dextromethorphan hydrobromide/quinidine sulfate 
• Diclegis (doxylamine-pyridoxine tab delayed release) 
• Diclofenac sodium (actinic keratoses) gel 3% 
• Differin cream (adapalene cream 0.1%) 
• Differin gel/pump (adapalene gel 0.1%) 
• Differin lotion (adapalene lotion 0.1%) 
• Digoxin 
• Dihydroergotamine mesylate 
• Dimethyl fumarate capsule delayed release 
• Diuril (chlorothiazide susp) 
• Doxepin hydrochloride 
• Doxylamine succinate/pyridoxine hydrochloride 
• Dronabinol solution 
• Efudex (fluorouracil cream 5%) 
• Elyxyb (celecoxib oral soln) 
• Emflaza (deflazacort) 
• Enalapril maleate 
• Enbumyst (bumetanide nasal spray) 
• Entresto (sacubitril-valsartan sprinkle cap) 
• Epaned (enalapril maleate oral soln 
• Epclusa (sofosbuvir-velpatasvir) 
• Epiduo (adapalene-benzoyl peroxide gel) 
• Epiduo forte (adapalene-benzoyl peroxide gel) 
• Exservan (riluzole) 
• Eysuvis (loteprednol etabonate ophth susp) 
• Fabior (tazarotene (acne) foam) 
• Famotidine 
• Fingolimod hydrochloride 
• Fintepla (fenfluramine hcl) 
• Fleqsuvy (baclofen susp) 
• Fluorouracil cream 
• Folic acid oral soln 
• Freestyle Libre 14 day/reader/flash monitoring system 
• Freestyle Libre 14 day/sensor/flash monitoring system 
• Freestyle Libre 2 plus/sensor/flash glucose monitor system 
• Freestyle Libre 2/reader/flash glucose monitoring system 
• Freestyle Libre 2/sensor/flash glucose monitoring system 
• Freestyle Libre 3 plus/sensor/glucose monitoring system 
• Freestyle Libre 3/reader/glucose monitoring system 
• Freestyle Libre 3/sensor/glucose monitoring system 
• Furoscix (furosemide subcutaneous cartridge kit) 
• Furoscix readyflow (furosemide subcutaneous soln) 
• Furosemide oral solution 
• Fyremadel (ganirelix acetate soln) 
• Glatiramer acetate 
• Glatopa (glatiramer acetate soln) 
• Glycopyrrolate 
• Glydo (lidocaine hcl urethral/mucosal gel) 
• Gnp adapalene (adapalene gel 0.1%) 
• Gonal-f (follitropin alfa for inj) 
• Gonal-f RFF (follitropin alfa for subcutaneous inj) 
• Gonal-f RFF rediject (follitropin alfa subcutaneous soln pen) 
• Granisol (granisetron hcl oral soln) 
• Harvoni (ledipasvir-sofosbuvir) 
• Hemofil M (antihemophilic factor (human) for inj) 
• Humate-P (antihemophilic factor/vwf (human) for inj) 
• Hycamtin (topotecan hcl) 
• Icosapent ethyl
• iLet insulin infusion kit - contact detach 23" 6mm 
• iLet insulin infusion kit - flex 23" 6mm 
• iLet insulin infusion kit - inset 23" 6mm 
• iLet insulin infusion kit - inset 32" 6mm 
• iLet insulin infusion kit- inset 32" 6mm 
• iLet insulin pump 
• iLet starter kit - contact detach 23" 6mm 
• iLet starter kit - inset 23" 6mm 
• Ile iLet t starter kit - inset 32" 6mm 
• Imiquimod (imiquimod cream 3.75%) 
• Imiquimod pump (imiquimod cream 3.75%) 
• Indocin (indomethacin suppository) 
• Indomethacin suppository 
• Insulin glargine max Solostar (insulin glargine soln pen-injector) 
• Insulin glargine Solostar (insulin glargine soln pen-injector) 
• Inzirqo (hydrochlorothiazide for susp) 
• Itraconazole 
• Ixinity (coagulation factor ix (recombinant) for inj) 
• Javadin (clonidine hcl oral soln) 
• Jaythari (deflazacort) 
• Jelcaine sterile (lidocaine hcl gel 2%) 
• Katerzia (amlodipine benzoate oral susp) 
• Kerendia (finerenone) 
• Klarity-C drops (cyclosporine (ophth) emulsion 0.1%) 
• Klisyri (tirbanibulin ointment 1%) 
• Koate (antihemophilic factor (human) for inj) 
• Koate-DVI (antihemophilic factor (human) for inj) 
• Kogenate FS (antihemophilic factor recomb (rfviii) for inj) 
• Korlym (mifepristone) 
• Kovaltry (antihemophilic factor recomb (rahf-pfm) for inj) 
• Kymbee (deflazacort) 
• Lantus (insulin glargine inj) 
• Lantus Solostar (insulin glargine soln pen-injector) 
• Lasix Onyu (furosemide subcutaneous cartridge kit) 
• Ledipasvir/sofosbuvir 
• Lidocaine HCL solution 4% 
• Lidocaine HCL urethral/mucosal gel 2% 
• Lidocaine HCL urethral/mucosal gel prefilled syringe 2% 
• Lidocaine ointment 5% 
• Lidocaine patch 5% 
• Lidoease (lidocaine hcl gel 2%) 
• Lidocan (lidocaine patch 5%) 
• Lidoderm (lidocaine patch 5%) 
• Likmez (metronidazole susp) 
• Linezolid for suspension 
• Lomaira (phentermine hcl) 
• Lopressor (metoprolol tartrate oral soln) 
• Lysodren (mitotane) 
• Lyvispah (baclofen granules) 
• Matulane (procarbazine hcl) 
• Mavyret (glecaprevir-pibrentasvir) 
• Memantine HCL oral solution 
• Menopur (menotropins for subcutaneous inj) 
• Metformin HCL oral solution 
• Migranal (dihydroergotamine mesylate nasal spray) 
• Mint refill kit (insulin infusion disposable pump reservoir) 
• Mint starter kit (insulin infusion disposable pump kit) 
• MODD1 patient welcome kit (insulin infusion disposable pump kit) 
• Nimodipine oral solution 
• Nitrofurantoin suspension 
• Norliqva (amlodipine besylate oral soln) 
• Novoeight (antihemophilic fact rcmb (bd trunc-rfviii) for inj) 
• Novoseven RT (coagulation factor viia (recomb) for inj) 
• Noxafil (posaconazole for delayed release susp) 
• Noxafil (posaconazole susp) 
• Nuedexta (dextromethorphan hbr-quinidine sulfate) 
• Nuplazid (pimavanserin tartrate) 
• Nutropin aq nuspin (somatropin solution) 
• Nuwiq (antihemophil fact rcmb (bdd-rfviii,sim) for inj) 
• Nymalize (nimodipine oral soln) 
• Omnipod 5 dexcom G7G6 intro kit (gen 5) 
• Omnipod 5 dexcom G7G6 pods (gen 5) 
• Omnipod 5 Libre intro kit 
• Omnipod 5 Libre pods 
• Omnipod classic pods (gen 3) 
• Omnipod Dash intro kit (gen 4) 
• Omnipod Dash PDM kit (gen 4) 
• Omnipod Dash pods (gen 4) 
• Omnipod GO 
• Ontralfy (tizanidine hcl oral soln) 
• Orlistat 
• Ovidrel (choriogonadotropin alfa soln prefilled syr) 
• Ozobax ds (baclofen oral soln) 
• Pheburane (sodium phenylbutyrate) 
• Phentermine hydrochloride 
• Pivot insulin pump starter kit 
• Pliaglis (lidocaine-tetracaine cream 7-7%) 
• Pokonza (potassium chloride oral soln 
• Posaconazole DR tablet 
• Posaconazole suspension 
• Pregnyl (chorionic gonadotropin for im inj) 
• Profilnine (factor ix complex for inj) 
• Propranolol hcl oral soln 
• Prudoxin (doxepin hcl cream 5%) 
• Pyquvi (deflazacort susp) 
• Qbrelis (lisinopril oral soln) 
• Quiofic (folic acid oral soln) 
• Raldesy (trazodone hcl oral soln) 
• Recombinate (antihemophilic factor recomb (rfviii) for inj) 
• Regenecare ha (lidocaine hcl gel 2%) 
• Retin-A cream (tretinoin cream) 
• Retin-A gel (tretinoin gel) 
• Retin-A micro (tretinoin microsphere gel) 
• Retin-A micro pump (tretinoin microsphere gel) 
• Revatio (sildenafil citrate) 
• Riomet (metformin hcl oral soln) 
• Rixubis (coagulation factor ix (recombinant) for inj) 
• Rybelsus (semaglutide tab) 
• Saizen (somatropin solution) 
• Samsca (tolvaptan (hyponatremia)) 
• Sdamlo (amlodipine besylate for oral soln) 
• Sensipar (cinacalcet hcl) 
• Sevenfact (coagulation factor viia (recom)-jncw for inj) 
• Sildenafil citrate for suspension 
• Sildenafil citrate tab 
• Sodium phenylbutyrate 
• Sofosbuvir/velpatasvir 
• Sotylize (sotalol hcl oral solution) 
• Sovaldi (sofosbuvir) 
• Spironolactone suspension 
• Sweet cherry allergenic extract (sweet cherry (prunus avium) (diagnostic) inj 1:20) 
• Syndros (dronabinol soln) 
• Tadalafil tab 20 mg (pah) 
• Tadliq (tadalafil oral susp 20 mg/5ml (pah)) 
• Targretin (bexarotene gel 1%) 
• Tavaborole soln 5% 
• Tazarotene (acne) foam 
• Tazarotene cream
• Tazarotene gel 
• Teglutik (riluzole susp) 
• Tegsedi (inotersen sod subcutaneous pref syr) 
• Teriflunomide 
• Testopel (testosterone implant pellets) 
• Testosterone cypionate IM inj in oil 
• Tezruly (terazosin hcl oral soln) 
• Thalomid (thalidomide capsule) 
• Tiglutik (riluzole susp) 
• Tolak (fluorouracil cream 4%) 
• Tolsura (itraconazole) 
• Tonmya (cyclobenzaprine hcl sublingual tab) 
• Topicaine ultra (lidocaine hcl gel 2% 
• Tramadol hydrochloride ER 
• Tretinoin cream 
• Tretinoin gel 
• Tretinoin microsphere gel 
• Tridacaine ii (lidocaine patch 5%) 
• Tridacaine iii (lidocaine patch 5%) 
• Trilitas (tazarotene gel 0.1% 
• Trudhesa (dihydroergotamine mesylate hfa nasal aerosol) 
• Twiist refill kit (insulin infusion disposable pump reservoir kit) 
• Twiist refill kit/infusion set (insulin infusion disposable pump reservoir/infus set kit) 
• Twiist starter kit (insulin infusion disposable pump kit) 
• Twyneo (tretinoin-benzoyl peroxide cream 0.1-3%) 
• Vascepa (icosapent ethyl cap) 
• Ventavis (iloprost inhalation solution) 
• Verkazia (cyclosporine (ophth) emulsion 0.1%) 
• Verquvo (vericiguat) 
• Vfend (voriconazole) 
• V-Go 20 (insulin infusion disposable pump kit 20 unit/24hr) 
• V-Go 30 (insulin infusion disposable pump kit 30 unit/24hr) 
• V-Go 40 (insulin infusion disposable pump kit 40 unit/24hr) 
• Vivjoa (oteseconazole) 
• Vonvendi (von willebrand factor (recombinant) for inj) 
• Voriconazole 
• Vosevi (sofosbuvir-velpatasvir-voxilaprevir) 
• Voxzogo (vosoritide for subcutaneous inj) 
• Wilate (antihemophilic factor/vwf (human) for inj) 
• Xenical (orlistat) 
• Xeroburn (lidocaine hcl gel 2%) 
• Xhance (fluticasone propionate nasal exhaler susp) 
• Xromi (hydroxyurea oral soln) 
• Xyntha (antihemophil fact rcmb (bdd-rfviii,mor) for inj kit) 
• Xyntha solofuse (antihemophil fact rcmb(bdd-rfviii,mor) for inj kit) 
• Zepatier (elbasvir-grazoprevir)
• Zonalon (doxepin hcl cream 5%) 
• Zorbtive (somatotropin)
• Ztlido (lidocaine patch 1.8% (36 mg)) 
• Zyclara (imiquimod cream) 
• Zyclara pump (imiquimod cream) 
• Zyvox (linezolid for susp) 

The following retail pharmacy Utilization Management (UM) programs have updates effective Jan. 1, 2027, for migrated members:

• Abiraterone Acetate, Adbry, Addyi, Adempas, Aimovig, Ajovy, Akeega, Alhemo, Alprolix, Altuviiio, Alyftrek, Ambrisentan, Andembry, Aqneursa, Aqvesme, Arikayce, Attruby, Augtyro, Austedo, Austedo Xr, Avmapki Fakzynja Co-Pack, Avonex, Avtozma, Awiqli Flextouch, Ayvakit, Bafiertam, Balversa, Basaglar Kwikpen, Basaglar Tempo Pen, Besremi, Betaseron, Bexarotene, Bimzelx, Bonsity, Bosentan, Bosulif, Bosutinib, Braftovi, Brinsupri, Brukinsa, Bydureon Bcise, Byetta, Bylva, Bylvay (Pellets), Cabometyx, Calquence, Camzyos, Capecitabine, Caprelsa, Carbaglu, Carglumic Acid, Cavhanza, Cequa, Cerdelga, Chorionic Gonadotropin, Cibinqo, Cimzia, Cinryze, Cladribine, Cometriq, Contrave, Copaxone, Copiktra, Corlanor, Cortrophin, Cosentyx, Cosentyx Sensoready, Cosentyx Unoready, Cotellic, Crenessity, Ctexli, Cyclosporine Emulsion, Cyltezo, Danziten, Dasatinib, Daurismo, Dawnzera, Daybue, Daybue Stix, Dojolvi, Doptelet, Dupixent, Duvyzat, Ebglyss, Ekterly, Elmiron, Eloctate, Eltrombopag Olamine, Emgality, Empaveli, Enbrel, Enbrel Mini, Enbrel Sureclick, Endari, Enspryng, Entyvio Pen, Epidiolex, Erivedge, Erleada, Erlotinib Hydrochloride, Esbriet, Esperoct, Everolimus, Evrysdi, Exenatide, Fabhalta, Fasenra Pen, Fentanyl, Fentanyl Citrate Oral Transmucosal, Fentora, Filspari, Filsuvez, Firazyr, Firdapse, Follistim Aq, Forteo, Fotivda, Foundayo, Fruzaqla, Galafold, Gattex, Gavreto, Gefitinib, Gilenya, Gilotrif, Gleevec, Glycerol Phenylbutyrat, Gomekli, Hadlima, Haegarda, Harliku, Hemlibra, Hepcludex, Hernexeos, Hetlioz, Hulio, Humatrope, Humira, Hydrocodone Bitartrate ER, Hydromorphone Hcl ER, Hyftor, Hympavzi, Hyrimoz, Hyrnuo, Hysingla ER, Ibrance, Ibsrela, Ibtrozi, Icatibant Acetate, Iclusig, Icotyde, Idacio, Idelvion, Idhifa, Imatinib Mesylate, Imbruvica, Imcivree, Imkeldi, Imuldosa, Ingrezza, Inluriyo, Inlyta, Inqovi, Inrebic, Insulin Glargine-Yfgn, Iqirv, Iressa, Isturisa, Itovebi, Ivabradine Hydrochloride, Jakafi, Jakafi XR, Jascayd, Jatenz, Javygtor, Jaypirca, Jivi, Joenja, Jublia, Jylamvo, Jynarque, Kalydeco, Kesimpta, Kevzara, Kineret, Kisqali, Komzifti, Koselugo, Kuvan, Kyzatrex, Langlara, Lapatinib Ditosylate, Lazcluze, Lederle Leucovorin, Lenalidomide, Lenvima, Leqembi Iqlik, Leqselvi, Lerochol, Letairis, Leucovorin Calcium, L-Glutamine, Lifyorli, Linzess, Liraglutide, Litfulo, Livdelzi, Livmarli, Lonsurf, Lorbrena, Lubiprostone, Lumakras, Lumryz, Lupkynis, Lynavoy, Lynparza, Lytgobi, Macitentan, Mavenclad, Mayzent, Mekinist, Mektovi, Methitest, Methyltestosterone, Miebo, Mifeprex, Mifepristone, Miglustat, Miplyffa, Modeyso, Morphine Sulfate ER, Motegrity, Mounjaro, Movantik, Ms Contin, Mulpleta, Myalept, Myfembree, Myqorzo, Natesto, Nemluvio, Nerlynx, Nexavar, Nexletol, Nexlizet, Ngenla, Nilotinib D-Tartrate, Nilotinib Hydrochloride, Ninlaro, Nintedanib Esylate, Norditropin Flexpro, Novarel, Nubeqa, Nucala, Nucynta ER, Nurtec, Octreotide Acetate, Odomzo, Ofev, Ogsiveo, Ojemda, Ojjaara, Olpruva, Olumiant, Omnitrope, Omvoh, Onureg, Opfolda, Opsumit, Opsynvi, Orencia, Orenitram, Orgovyx, Oriahnn, Orilissa, Orkambi, Orladeyo, Orserdu, Otezla, Otezla XR, Otulfi, Oxervate, Oxycontin, Oxymorphone Hydrochloride ER, Ozempic, Palynziq, Pazopanib Hydrochloride, Pemazyre, Phentermine/Topiramate Er, Phyrago, Piqray, Pirfenidone, Plegridy, Pomalidomide, Pomalyst, Ponvory, Praluent, Procysbi, Promacta, Prucalopride, Pyrukynd, Pyzchiva, Qfitlia, Qinlock, Qsymia, Qudexy XR, Qulipta, Ravicti, Rebif, Rebif Rebidose, Rebinyn, Recorlev, Redemplo, Relistor, Repatha, Repatha Pushtronex, Repatha Sureclick, Restasis, Retevmo, Revlimid, Revuforj, Reyvow, Rezdiffra, Rezlidhia, Rezurock, Rezvoglar Kwikpen, Rhapsido, Rinvoq, Ritonavir, Romvimza, Rozlytrek, Rubraca, Ruconest, Rydapt, Ryzneuta, Sajazir, Saphnelo Pen, Sapropterin Dihydrochloride, Saxenda, Scemblix, Selarsdi, Sephience, Serostim, Siliq, Simlandi, Simponi, Skyclarys, Skyrizi, Skytrofa, Sodium Oxybate, Sogroya, Sohonos, Sorafenib Tosylate, Sotyktu, Sprycel, Starjemza, Stelara, Steqeyma, Stivarga, Strensiq, Sucraid, Sunitinib Malate, Sunosi, Sutent, Symdeko, Tabrecta, Tafinlar, Tagrisso, Takhzyro, Taltz, Talzenna, Tapentadol Hydrochloride Er, Tarceva, Targretin, Tarpeyo, Tascenso Odt, Tasigna, Tasimelteon, Tavalisse, Tecfidera, Temozolomide, Tepmetko, Teriparatide, Testim, Testosterone Gel, Testosterone Pump, Testosterone Sol, Testosterone Topical Solution, Tetrabenazine, Tezspire, Tibsovo, Tlando, Tofacitinib Citrate, Tofacitinib Citrate ER, Tolvaptan, Topiramate ER, Torpenz, Tracleer, Tremfya, Tretinoin, Trikafta, Trokendi Xr, Trulance, Trulicity, Truqap, Tryngolza, Tryptyr, Tukysa, Turalio, Tyenne, Tykerb, Tymlos, Tyrvaya, Tyvaso, Ubrelvy, Undecatrex, Uptravi, Ustekinumab, Ustekinumab-Aauz, Ustekinumab-Aekn, Ustekinumab-Ttwe, Vanflyta, Vanrafia, Velsipity, Venclexta, Verzenio, Vevye, Victoza, Vijoice, Vitrakvi, Vizimpro, Vogelxo, Vonjo, Voranigo, Votrient, Vowst, Vumerity, Vyjuvek, Vykat Xr, Vyleesi, Vyndamax, Vyndaqel, Wainua, Wakix, Wayrilz, Wegovy, Wegovy HD, Welireg, Wezlana, Winrevair, Xalkori, Xatmep, Xeljanz, Xeljanz XR, Xeloda, Xenazine, Xiidra, Xolair, Xolremdi, Xospata, Xpovio, Xtampza ER, Xtandi, Xyosted, Xyrem, Xywav, Yargesa, Yesintek, Yonsa, Yorvipath, Yuflyma, Yulithira, Yusimry, Yutrepia, Zavesca, Zavzpret, Zejula, Zelboraf, Zelsuvmi, Zelvysia, Zepbound, Zepbound Kwikpen, Zeposia, Zokinvy, Zolinza, Zomacton, Zydelig, Zykadia, Zytiga