| abatacept for polyarticular juvenile idiopathic arthritis |
Orencia® |
| abatacept for rheumatoid arthritis |
Orencia® |
| abobotulinumtoxinA |
Dysport Therapeutic™ |
| abrocitinib |
Cibinqo™ |
| acetaminophen 500 mg* |
Tylenol 500 mg® |
| aclidinium |
Tudorza™ Genuair™ |
| aclidinium-formoterol |
Duaklir™ Genuair® |
| adalimumab |
Abrilada™, Amgevita®, Hadlima®, Hulio®, Hyrimoz®, Idacio®, Simlandi™, Yuflyma® |
| adalimumab for non-infectious uveitis |
Abrilada™, Amgevita®, Hadlima®, Hulio®, Hyrimoz®, Idacio®, Simlandi™, Yuflyma® |
| alemtuzumab |
Lemtrada® |
| alitretinoin |
Toctino® |
| ambrisentan |
Volibris® |
| amifampridine |
Ruzurgi® |
| amifampridine phosphate |
Firdapse® |
| amlodipine oral solution |
Pendopharm |
| anifrolumab |
Saphnelo® |
| aprepitant |
Emend® |
| aripiprazole (Plan G) |
Abilify® |
| aripiprazole monohydrate (Plan G) |
Abilify Maintena®, Abilify Asimtufii® |
| asenapine (Plan G) |
Saphris™ |
| atogepant |
Qulipta® |
| atomoxetine (Plan G) |
Strattera® |
| aztreonam |
Cayston™ |
| baclofen intrathecal |
Lioresal® Intrathecal |
| belumosudil |
Rezurock® |
| benazepril (RDP: ACEI category) |
Lotensin® |
| benzydamine |
Tantum® |
| benralizumab |
Fasenra® |
| bimekizumab for ankylosing spondylitis |
Bimzelx® |
| bimekizumab for plaque psoriasis |
Bimzelx® |
| bimekizumab for psoriatic arthritis |
Bimzelx® |
| bosentan |
Tracleer® |
| botulinum neurotoxin type A, free from complexing proteins, also known as incobotulinumtoxinA |
Xeomin® |
| botulinum neurotoxin type A, with complexing proteins, also known as onabotulinumtoxinA |
Botox® |
| brexpiprazole (Plan G) |
Rexulti® |
| brivaracetam |
Brivlera® |
| budesonide capsules |
Entocort Capsules® |
| budesonide enema |
Entocort Enema® |
| budesonide-formoterol |
Symbicort® |
| budesonide in combination with glycopyrronium and formoterol |
Breztri Aerosphere™ |
| budesonide nebules |
Pulmicort® |
| bupropion (Plan G)* |
Wellbutrin® SR and XL, Zyban® |
| cannabidiol for Dravet syndrome |
Epidiolex® |
| cannabidiol for Lennox-Gastaut syndrome |
Epidiolex® |
| cannabidiol for tuberous sclerosis complex |
Epidiolex® |
| candesartan* |
Atacand®, Atacand Plus® |
| captopril (RDP: ACEI category) |
Capoten® |
| captropril oral solution |
Noyada® |
| cariprazine (Plan G) |
Vraylar® |
| carvedilol* |
Coreg® |
| celecoxib* |
Celebrex® |
| cenobamate |
Xcopri® |
| certolizumab for ankylosing spondylitis |
Cimzia® |
| certolizumab for psoriatic arthritis |
Cimzia® |
| certolizumab for rheumatoid arthritis |
Cimzia® |
| chlorambucil |
Leukeran® |
| chloroquine |
Aralen® |
| ciclopirox 1% |
Loprox® |
| cilazapril with/without HCTZ (RDP, ACEI category) |
Inhibace®, Inhibace Plus® |
| cimetidine: prescription strength (RDP, H2 blocker category) |
Tagamet® |
| ciprofloxacin ophthalmic |
Ciloxan® |
| cladribine |
Mavenclad® |
| clioquinol topical |
Locacorten Vioform, Vioform Hydrocortisone |
| clobazam (Plan G) |
Frisium® |
| clotrimazole |
Canesten Topical® |
| codeine sustained release |
Codeine Contin® |
| continuous glucose monitor |
Dexcom G6®, G7® |
| cyclosporine |
Neoral® |
| cyproterone (Plan G) |
Androcur® |
| cysteamine ophthalmic solution |
Cystadrops® |
| dabigatran* |
Pradaxa®, generics |
| dalteparin |
Fragmin® |
| deferasirox |
Exjade® |
| deferiprone |
generics |
| denosumab |
Jubbonti™, Stoboclo™, Bildyos® |
| desmopressin oral |
DDAVP Tablets®, DDAVP Melt® |
| dextroamphetamine-amphetamine (Plan G) |
Adderall XR® |
| diclofenac IR/SR |
Voltaren®, Arthrotec® |
| diclofenac IR with misoprostol |
Arthrotec® |
| dienogest |
Visanne® |
| diflunisal |
Dolobid® |
| dimethyl fumarate |
Tecfidera™ |
| diphenoxylate HCI-atropine sulfate |
Lomotil® |
| dipyridamole-acetylsalicylic acid |
Aggrenox® |
| donepezil (Plan G)* |
Aricept® |
| dorzolamide-timolol preservative free |
Cosopt non-preserved® |
| dronedarone |
Multaq® |
| duloxetine |
generics |
| dupilumab (for ages 6 years to 11 years) |
Dupixent® |
| dupilumab (for ages 12 and up) |
Dupixent® |
| dutasteride* |
Avodart® |
| edaravone (intravenous solution, oral suspension) |
Radicava® , Radicava ORS® |
| empagliflozin and empagliflozin-metformin are regular benefits under Plan NP as of March 1, 2026 |
Jardiance®, Synjardy® |
| enalapril without HCTZ (RDP, ACEI category) |
Vasotec® |
| enalapril with HCTZ (RDP, ACEI category) |
Vasotec Plus® |
| enoxaparin |
Inclunox®, Inclunox® HP, Noromby®, Noromby® HP, Redesca®, Redesca® HP, Elonox®, Elonox® HP |
| entacapone and entacapone/levodopa/carbidopa combination |
Comtan®, Stalevo® |
| entecavir |
Baraclude® |
| epoprostenol |
Caripul®, Flolan® |
| eptinezumab |
Vyepti® |
| eslicarbazepine acetate |
Aptiom™ |
| esomeprazole (RDP, PPI category and LCD) |
Nexium® |
| estradiol patches are a regular benefit under Plan NP as of March 1, 2026 |
Climara®, Estalis®, Estradot® |
| estradiol transdermal gel is a regular benefit under Plan NP as of March 1, 2026 |
Divigel®, Estrogel® |
| etanercept |
Brenzys®, Erelzi®, Rymti® |
| evolocumab |
Repatha™ |
| ezetimibe |
Ezetrol®, generics |
| famotidine (RPD, H2 blockers category) |
Pepcid® |
| febuxostat |
Uloric® |
| felodipine (RDP, CCB category) |
Plendil®, Renedil® |
| fentanyl patch (covered under Plan G when approved for Special Authority coverage in patients at risk of harm from the toxic illicit drug supply) |
Duragesic® |
| fentanyl tablet (Plan G) |
Fentora® |
| ferric carboxymaltose for iron deficiency anemia |
Ferinject® |
| ferric carboxymaltose for iron deficiency with heart failure |
Ferinject® |
| fidaxomicin |
Dificid® |
| filgrastim |
Grastofil®, Nivestym®, Nypozi™ |
| finasteride* |
Proscar® |
| finerenone |
Kerendia® |
| fingolimod |
generics, Gilenya® (partial benefit) |
| flash glucose monitor |
FreeStyle Libre 2®, FreeStyle Libre 3 Plus |
| fluconazole oral solids |
Diflucan® |
| flurbiprofen |
Ansaid®, Froben® |
| fluticasone furoate-umeclidinium-vilanterol |
Trelegy® Ellipta® |
| fluticasone furoate-vilanterol |
Breo® Ellipta® |
| fluticasone propionate-salmeterol |
Advair® |
| fluvastatin (RDP, statins category) |
Lescol® |
| foslevodopa/foscarbidopa |
Vyalev™ |
| formoterol |
Foradil®, Oxeze® Turbuhaler® |
| fosinopril (RDP, ACEI category) |
Monopril® |
| fremanezumab |
Ajovy® |
| gabapentin (Plan G) |
Neurontin® |
| galantamine (Plan G) |
Reminyl® |
| galcanezumab |
Emgality® |
| glatiramer acetate |
Glatect™, Mylan-Glatiramer |
| glecaprevir-pibrentasvir |
Maviret™ |
| gliclazide is a regular benefit under Plan NP as of March 1, 2026 |
Diamicron® |
| glucagon |
foreign label |
| glycopyrronium |
Seebri® Breezhaler® |
| golimumab |
Simponi® |
| goserelin |
Zoladex® |
| granisetron |
Kytril® |
| guselkumab for Crohn's disease |
Tremfya® |
| guselkumab for ulcerative colitis |
Tremfya® |
| glycerol phenylbutyrate |
Ravicti® |
| glycopyrronium-indacaterol |
Ultibro® Breezhaler® |
| hydromorphone controlled release |
Hydromorph Contin® |
| hydromorphone injection |
Hydromorphone HP 50 |
| hydroxyurea |
Hydrea® |
| hydroxyzine (Plan G)* |
Atarax® |
| icatibant |
Firazyr® |
| icosapent ethyl |
Vascepa® |
| indacaterol-glycopyrronium-mometasone furoate |
Enerzair® Breezhaler® |
| indacaterol-mometasone furoate |
Atectura® Breezhaler® |
| indapamide |
Lozide® |
| indomethacin |
Indocid® |
| infliximab for PsA, AS, PsO |
Avsola®, Inflectra™, Ixifi®, Renflexis™, Remdantry™ |
| infliximab for Crohn's disease |
Avsola®, Inflectra™, Ixifi®, Renflexis™, Remdantry™, Remsima™SC |
| infliximab for ulcerative colitis |
Avsola®, Inflectra™, Ixifi®, Renflexis™, Remdantry™â€‹, Remsima™SC |
| infliximab for rheumatoid arthritis |
Avsola®, Inflectra™, Ixifi®, Renflexis™, Remdantry™â€‹, Remsima™SC |
| insulin glargine is a regular benefit under Plan NP as of March 1, 2026 |
Basaglar®, Semglee® |
| insulin pumps |
- OmniPod Personal Diabetes Manager, Omnipod Dash Personal Diabetes Manager, Omnipod 5 Automated Insulin Delivery (AID) system
- mylife YpsoPump
- MiniMed 670G, 770G, and 780G Insulin Pump Systems
|
| interferon alfa |
Intron A® |
| interferon beta-1a |
Avonex®, Rebif® |
| interferon beta-1b |
Betaseron®, Extavia® |
| ipratropium nebules |
Atrovent® |
| ipratropium and salbutamol combination nebules |
Combivent® UDV |
| irbesartan with/without HCTZ (RDP, ARB category and LCD) |
Avapro®, Avalide® |
| iron isomaltoside |
Monoferric® |
| iron sucrose |
Venofer® |
| isavuconazole |
Cresemba® |
| itraconazole |
Sporanox® |
| ivabradine |
Lancora™ |
| ixekizumab |
Taltz™ |
| ketoconazole 2% cream |
Nizoral® |
| ketoprofen enteric-coated |
Orudis E® |
| ketoprofen SR |
Orudis® |
| lacosamide tablets |
Vimpat® |
| lactulose |
Laxilose® |
| lamivudine |
Heptovir® |
| lansoprazole (RDP, PPI category and LCD) |
Prevacid® |
| lebrikizumab |
Ebglyss™ |
| ledipasvir-sofosbuvir |
Harvoni™ |
| letermovir |
Prevymis™ |
| leuprolide acetate (Plan G) |
Lupron® |
| leuprolide acetate (extended-release) |
Eligard® |
| levetiracetam* |
Keppra® |
| levetiracetam (oral solution) |
pdp-levetiracetam |
| levodopa-carbidopa |
Duodopa® |
| linagliptin and linagliptin-metformin (Plan NP) |
Trajenta™, Jentadueto™ |
| linezolid 600 mg tablet |
Zyvoxam® |
| lisdexamfetamine (Plan G) |
Vyvanse® |
| lisinopril with or without HCTZ (RDP, ACEI category) |
Prinivil®, Zestril®, Zestoretic® |
| loperamide |
Imodium® |
| losartan* |
Cozaar®, Hyzaar® |
| lovastatin (RDP, statins category) |
Mevacor® |
| lurasidone (Plan G) |
generics |
| luspatercept |
Reblozyl® |
| maribavir |
Livtencity™ |
| mavacamten |
Camzyos™ |
| meloxicam |
Mobicox® |
| mepolizumab |
Nucala® |
| mercaptopurine |
Purinethol® |
| methotrexate pre-filled syringes |
PharmaScience |
| methylphenidate (Plan G) |
Concerta®, Foquest® |
| miconazole 2% topical |
Micatin Cream® |
| miconazole topical |
Monistat Derm Cream® |
| mirikizumab for Crohn's disease |
Omvoh® |
| mirikizumab for ulcerative colitis |
Omvoh® |
| modafinil (Plan G) |
Alertec® |
| mometasone-formoterol |
Zenhale™ |
| mometasone nasal spray |
Nasonex® |
| mycophenolate mofetil |
CellCept® |
| nabumetone |
Relafen® |
| nadroparin |
Fraxiparine® |
| naproxen enteric-coated (RDP, NSAID category) |
Naprosyn EC® |
| naproxen SR (RDP, NSAID category) |
Naprosyn® |
| natalizumab |
Tysabri® |
| netupitant-palonosetron |
Akynzeo® |
| nifedipine (RDP, CCB category) |
Adalat® |
| nintedanib |
Ofev® |
| nitisinone |
Orfadin® |
| nizatidine (RDP, H2 blocker category) |
Axid® |
| obeticholic acid |
Ocaliva® |
| ocrelizumab |
Ocrevus® |
| ocriplasmin |
Jetrea® |
| ofloxacin ophthalmic drops |
Ocuflox® |
| olanzapine (Plan G) |
Zyprexa®, Zyprexa Zydis® |
| olmesartan |
Olmetec®, Olmetec Plus® |
| omalizumab for severe allergic asthma |
Omlyclo™ |
| omalizumab for chronic idiopathic urticaria |
Omlyclo™ |
| omalizumab for chronic rhinosinusitis with nasal polyps |
Omlyclo™ |
| oseltamivir |
Tamiflu® |
| omeprazole 20 mg (RDP, PPI category and LCD) |
Losec® 20 mg |
| ondansetron |
Zofran® |
| ozanimod |
Zeposia® |
| paliperidone palmitate injection (Plan G) |
Invenga Sustenna®, Invega Trinza® |
| pamidronate |
Aredia® |
| pantoprazole magnesium (RDP, PPI category and LCD)* |
Tecta® |
| pantoprazole sodium 40 mg (RDP, PPI category and LCD) |
Pantoloc® 40 mg |
| pegfilgrastim |
Ziextenzo®, Lapelga®, Fulfila® |
| perampanel |
Fycompa™ |
| perindopril (RDP, ACEI category)* |
Coversyl® |
| pimecrolimus cream |
Elidel® Cream |
| pioglitazone (Plan NP) |
Actos® |
| pirfenidone |
Esbriet® |
| piroxicam capsule |
Feldene® |
| pramipexole |
Mirapex® |
| pravastatin (RDP, statins category) |
Pravachol® |
| propranolol hydrochloride |
Hemangiol® |
| prostaglandin compounded injection |
Prostaglandin® |
| quinapril with HCTZ (RDP, ACEI category) |
Accuretic® |
| rabeprazole (RDP, PPI category and LCD)* |
Pariet® |
| raloxifene |
Evista® |
| relugolix/estradiol/norethindrone acetate |
Myfembree® |
| rifaximin |
Zaxine® |
| riociguat |
Sandoz® riociguat |
| risedronate 30 mg |
Actonel® 30 mg |
| risperidone (Plan G) |
Okedi® |
| risperidone microspheres (Plan G) |
Risperdal Consta® |
| rituximab |
Truxima®, Riximyo® and Ruxience® |
| risankizumab for Crohn's disease |
Skyrizi® |
| risankizumab for plaque psoriasis |
Skyrizi® |
| risankizumab for ulcerative colitis |
Skyrizi® |
| rivaroxaban granules |
Xarelto® |
| rivastigmine (Plan G) |
Exelon® |
| romosozumab |
Evenity™ |
| ropinirole |
ReQuip® |
| rotigotine |
Neupro® |
| rozanolixizumab |
Rystiggo® |
| rufinamide |
Banzel® |
| ruxolitinib |
Jakavi® |
| sacubitril-valsartan |
Entresto™ |
| salbutamol nebules |
Ventolin® |
| salmeterol |
Serevent® |
| sapropterin |
Kuvan® |
| sarilumab |
Kevzara® |
| satralizumab |
Enspryng® |
| saxagliptin and saxagliptin-metformin (Plan NP) |
Onglyza®, Komboglyze™ |
| secukinumab for Ps, AS, PsA |
Cosentyx® |
| secukinumab for HS |
Cosentyx® |
| selexipag |
Uptravi® |
| selumetinib |
Koselugo™ |
| semaglutide* |
Ozempic® |
| sildenafil |
Viagra® |
| simvastatin (RDP, statins category) |
Zocor® |
| siponimod |
Mayzent® |
| sodium phenylbutyrate |
Pheburane® |
| sofosbuvir |
Sovaldi® |
| sofosbuvir-velpatasvir |
Epclusa® |
| sofosbuvir-velpatasvir-voxilaprevir |
Vosevi™ |
| solifenacin |
generics only |
| somatropin |
Genotropin®, Humatrope®, Norditriopin® Nordiflex™, Norditropin® Flexpro™, Omnitrope®, Saizen® |
| sotatercept |
Winrevair® |
| stiripentol |
Diacomit™ |
| sulindac |
Clinoril® |
| sumatriptan injection |
Imitrex® Injection |
| tacrolimus ointment |
Protopic® Ointment |
| tadalafil 20 mg |
Adcirca® |
| tazarotene topical* |
Arazlo® |
| teduglutide |
Revestive® |
| telmisartan without HCTZ (RDP, ARB category and LCD)* |
Micardis® |
| telmisartan with HCTZ (RDP, ARB category and LCD)* |
Micardis Plus® |
| telmisartan + amlodipine combination (RDP, ARB category and LCD) |
Twynsta® |
| tenofovir alafenamide |
Vemlidy® |
| tenofovir disoproxil fumarate |
Viread® |
| tenoxicam |
Mobiflex® |
| terbinafine tablets |
Lamisil® tablets |
| teriflunomide |
generics |
| testosterone cypionate* |
Depo-testosterone® |
| testosterone enanthate* |
Delatestryl® |
| tezepelumab |
Tezspire™ |
| tiaprofenic acid regular release |
Surgam® |
| ticagrelor |
Brilinta® |
| tinzaparin |
Innohep® |
| tiotropium-olodaterol |
Inspiolto® Respimat® |
| tizanidine |
Zanaflex® |
| tobramycin |
Tobi®, Tobi® Podhaler® |
| tocilizumab for giant cell arteritis |
Tyenne®, Avtozma™ |
| tocilizumab for active polyarticular juvenile idiopathic arthritis |
Tyenne®, Avtozma™ |
| tocilizumab for active systemic juvenile idiopathic arthritis |
Tyenne®, Avtozma™ |
| tocilizumab for rheumatoid arthritis |
Tyenne®â€‹, Avtozma™ |
| tocilizumab for neuromyelitis optica spectrum disorder |
Tyenne®â€‹, Avtozma™ |
| tofacitinib for ankylosing spondylitis |
generics |
| tofacitinib for psoriatic arthritis |
generics |
| tofacitinib for rheumatoid arthritis |
generics |
| tofacitinib for ulcerative colitis |
generics |
| trandolapril (RDP, ACEI category) |
Mavik® |
| treprostinil |
Remodulin® |
| tretinoin topical* |
Rejuva-A Cream®, Retin-A Cream®, Stieva-A Cream®, Vitamin A Acid Cream® |
| trientine |
Mar-Trientine, Waymade-Trientine |
| umeclidinium-vilanterol |
Anoro® Ellipta® |
| upadacitinib for Crohn's disease |
Rinvoq® |
| ustekinumab for Crohn's disease |
Otulfi®, Pyzchiva®, Steqeyma®, Wezlana™, Yestinek™ |
| ustekinumab for plaque psoriasis |
Jamteki™,Otulfi®, Pyzchiva®, Steqeyma®, Wezlana™, Yestinek™ |
| ustekinumab for psoriatic arthritis |
Jamteki™,Otulfi®, Pyzchiva®, Steqeyma®, Wezlana™, Yestinek™ |
| ustekinumab for ulcerative colitis |
Otulfi®, Pyzchiva®, Steqeyma®, Wezlana™, Yestinek™ |
| upadacitinib for atopic dermatitis |
Rinvoq® |
| valganciclovir |
Valcyte® |
| valsartan (RDP, ARB category and LCD)* |
Diovan®, Diovan HCT® |
| vancomycin oral* |
Vancocin® |
| varenicline (Plan G) |
Champix® |
| vedolizumab |
Entyvio® |
| vericiguat |
Verquvo® |
| voriconazole |
Vfend® |
| vortioxetine (Plan G) |
Trintellix™ |
| zanamivir |
Relenza® |
| zilucoplan |
Zilbrysq® |
| ziprasidone (Plan G) |
Zeldox® |
| zoledronic acid |
Aclasta™ |
| zopiclone (Plan G)* |
Imovane® |
Last updated on September 24, 2026