| Lynparza (olaparib) |
Lynparza (olaparib) |
| Mavyret (glecaprevir/pibrentasvir) |
Mavyret (glecaprevir/pibrentasvir) |
| Mekinist (trametinib) |
Mekinist (trametinib) |
| Mepsevii (vestronidase alfa-vjbk) |
Mepsevii (vestronidase alfa-vjbk) |
| Migraine Quantity Limit |
Amerge (naratriptan), Frova (frovatriptan), Imitrex (sumatriptan) tablets and nasal spray, Onzetra (sumatriptan), Relpax (eletriptan), Tosymra (sumatriptan), Zembrace SymTouch (sumatriptan), Zomig (zolmitriptan) tablets, Zomig-ZMT (zolmitriptan), Axert (almotriptan), D.H.E. 45 (dihydroergotamine mesylate) injection, Imitrex (sumatriptan) injection, Maxalt (rizatriptan), Maxalt-MLT (rizatriptan), Migranal (dihydroergotamine mesylate), Nurtec ODT (rimegepant sulfate), Treximet (sumatriptan/naproxen), Trudhesa (dihydroergotamine mesylate), Ubrelvy (ubrogepant), Zavzpret (zavegepant), Zomig (zolmitriptan) nasal spray |
| Mitoxantrone |
Mitoxantrone |
| Multiple Sclerosis (MS) Agents - PA, NF |
Aubagio (teriflunomide), Avonex (interferon beta-1a), Bafiertam (monomethyl fumarate), Betaseron (interferon beta-1b), Copaxone (glatiramer acetate), Glatopa (glatiramer acetate), Extavia (interferon beta-1b), Kesimpta (ofatumumab), Lemtrada (alemtuzumab), Mavenclad (cladribine), Mayzent (siponimod), Ocrevus (ocrelizumab), Plegridy (peginterferon beta-1a), Ponvory (ponesimod), Rebif (interferon beta-1a), Vumerity (diroximel fumarate) |
| Myalept (metreleptin for injection) |
Myalept (metreleptin for injection) |
| Naglazyme (galsulfase injection) |
Naglazyme (galsulfase injection) |
| Nexavar (sorafenib) |
Nexavar (sorafenib) |
| Nexletol (bempedoic acid) and Nexlizet (bempedoic acid-ezetimibe) |
Nexletol (bempedoic acid), Nexlizet (bempedoic acid-ezetimibe) |
| Ninlaro (ixazomib citrate) |
Ninlaro (ixazomib citrate) |
| Nityr and Orfadin |
Brand Orfadin capsules, Brand Orfadin oral suspension, Generic nitisinone capsules, Nityr (nitisinone) tablets |
| Non-Formulary & Excluded Drug Exceptions Process for Drugs of Clinical Concern |
APLENZIN, APTIOM, AUVELITY, AYVAKIT, BRUKINSA, BUPROPION HYDROCHLORIDE ER (XL), CAPLYTA, CITALOPRAM HYDROBROMIDE, COMBIVIR, DELSTRIGO, ELEPSIA XR, EMSAM, EMTRIVA, EPIVIR, EPRONTIA, EPZICOM, ESPEROCT, FINTEPLA, FORFIVO XL, GENVOYA, INTELENCE, JIVI, KALETRA, KCENTRA, LEXIVA, LYBALVI, NORVIR, NUBEQA, NUPLAZID, OXCARBAZEPINE ER, OXTELLAR XR, REBINYN, RETROVIR, RETROVIR IV INFUSION, REYATAZ, RYLAZE, SAVAYSA, SECUADO, SERTRALINE HYDROCHLORIDE, SPRITAM, STRIBILD, SUSTIVA, SYMFI, SYMFI LO, TROGARZO, VENLAFAXINE BESYLATE ER, VIMPAT, VIREAD, XEMBIFY, ZIAGEN, ZONISADE |
| Non-GLP-1 Agonist Anorexiants – PA, NF |
Contrave (naltrexone/bupropion), Generic phentermine, Adipex-P (phentermine), Lomaira (phentermine), Qsymia (phentermine and topiramate), Xenical (orlistat) |
| Non-steroidal Anti-Inflammatory Agents - PA, ST |
Cambia (diclofenac) powder, Celebrex (celecoxib), Indocin, Lofena, Meloxicam oral suspension 7.5mg/5mL, Pennsaid (diclofenac sodium) topical solution, Sprix (ketorolac tromethamine) nasal spray, Tivorbex (indomethacin) capsules, Vivlodex, Zipsor (diclofenac potassium), Zorvolex (diclofenac) |
| Non-steroidal Anti-Inflammatory Agents - PA, ST |
Cambia (diclofenac) powder, Celebrex (celecoxib), Indocin, Indomethacin Suspension 25mg/5ml, Lofena, Meloxicam oral suspension 7.5mg/5mL, Pennsaid (diclofenac sodium) topical solution, Sprix (ketorolac tromethamine) nasal spray, Tivorbex (indomethacin) capsules, Tolectin (tolmetin), Vivlodex, Zipsor (diclofenac potassium), Zorvolex (diclofenac) |
| Nonpreferred Adalimumab - PA, NF - Standard Default |
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), Humira (adalimumab) |
| Nonpreferred Adalimumab – Premium Value Formulary UM – PA, NF |
Abrilada (adalimumab-afzb), Amjevita (adalimumab-atto), Cyltezo (adalimumab-adbm), Hadlima (adalimumab-bwwd), Hulio (adalimumab-fkjp), Hyrimoz (adalimumab-adaz), Idacio (adalimumab-aacf), Simlandi (adalimumab-ryvk), Yuflyma (adalimumab-aaty), Yusimry (adalimumab-aqvh), Humira (adalimumab) |
| Nplate (romiplostim) |
Nplate (romiplostim) |
HEALTHY LIVING