Ventegra Medication Policies

Disclaimer: Medication Policies are developed to help ensure safe, effective and appropriate use of selected medications. They offer a guide to coverage and are not intended to dictate to providers how to practice medicine. Refer to Plan for individual adoption of specific Medication Policies. Providers are expected to exercise their medical judgment in providing the most appropriate care for their patients.
Therapeutic Class or Brand Name Generic Drug Name
Adagen® pegademase bovine
Afinitor® everolimus
Akynzeo® netupitant/palonosetron
Aloxi® palonosetron HCL
Ampyra® dalfampridine
Androgens (all dosage forms) testosterone transdermal system Androderm®
Androgens (all dosage forms) testosterone gel Androgel®
Androgens (all dosage forms) methyltestosterone tablet Android®
Androgens (all dosage forms) testosterone topical solution Axiron®
Androgens (all dosage forms) methyltestosterone tablet Methitest®
Androgens (all dosage forms) testosterone nasal gel Natesto™
Androgens (all dosage forms) testosterone buccal Striant®
Androgens (all dosage forms) testosterone gel Testim®
Androgens (all dosage forms) estosterone pellet Testopel®
Androgens (all dosage forms) methyltestosterone capsule Testred®
Androgens (all dosage forms) testosterone gel Vogelxo™
Anticoagulants (oral) apixaban Eliquis®
Anticoagulants (oral) dabigatran Pradaxa®
Anticoagulants (oral) edoxaban Savaysa™
Anticoagulants (oral) rivaroxaban Xarelto®
Aranesp® darbepoetin
Aubagio® Teriflunomide
Baraclude® Entecavir
Bosulif® bosutinib
Brand Name Medication
Breast Cancer Risk Reduction Med for Zero Copay tamoxifen
Breast Cancer Risk Reduction Med for Zero Copay raloxifene
Breast Cancer Risk Reduction Med for Zero Copay Soltamox
Butrans® buprenorphine
Caprelsa® vandetanib
Casodex® bicalutamide
Cayston® aztreonam
Chronic Opioid Chronic Opioid
Cimzia® certolizumab
Colony Stimulating Factors sargramostim Leukine®
Colony Stimulating Factors pegfilgrastim Neulasta®
Colony Stimulating Factors filgrastim Neupogen®
Colony Stimulating Factors tbo-filgrastim Granix®
Colony Stimulating Factors (filgrastim-sndz) Zarxio®
Cosentyx® Secukinumab
Dupixent Dupilumab
Daklinza™ daclatasvir
Egrifta® tesamorelin
Emend® aprepitant
Enbrel® etanercept
Endothelin Antagonists ambrisentan Letairis®
Endothelin Antagonists macetentan Opsumit®
Endothelin Antagonists bosentan Tracleer®
Epclusa® Sofosbuvir/Velpatasvir
Erivedge® vismodegib
Erythropoietins epoetin Alfa Epogen®
Erythropoietins epoetin Alfa Procrit®
Esbriet® Pirfenidone
Exjade® Deferasirox
Forteo® Teriparatide
Gilenya® fingolimod
Gleevec® imatinib
Gleostine® lomustine
Growth Hormone - Adult
Growth Hormone - Adult somatropin Genotropin®
Growth Hormone - Adult somatropin Humatrope®
Growth Hormone - Adult somatropin Norditropin®
Growth Hormone - Adult somatropin Nutropin® / AQ
Growth Hormone - Adult somatropin Omnitrope®
Growth Hormone - Adult somatropin Saizen®
Growth Hormone - Adult somatropin Serostim®
Growth Hormone - Adult somatropin Zomacton™
Growth Hormone - Adult somatropin Zorbtive®
Growth Hormone - Children somatropin Norditropin®
Growth Hormone - Children somatropin Genotropin®
Growth Hormone - Children somatropin Humatrope®
Growth Hormone - Children somatropin Nutropin®
Growth Hormone - Children somatropin Omnitrope®
Growth Hormone - Children somatropin Saizen®
Growth Hormone - Children somatropin Serostim®
Growth Hormone - Children somatropin Zomacton™
Growth Hormone - Children somatropin Zorbtive®
Harvoni® Ledipasvir/Sofosbuvir
Hepatitis C Treatment Options adefovir
Hepsera® adefovir
Humira® adalimumab
Hycamtin® topotecan
Hydroxyprogesterone Caproate Injection Makena
Hydroxyprogesterone Caproate Injection Compounded 17P
Iclusig® ponatinib
Imfinzi™ Durvalumab
Inlyta® axitinib
Isotretinoin Products isotretinoin Amnesteem®
Isotretinoin Products isotretinoin Claravis®
Isotretinoin Products isotretinoin Myorisan™
Isotretinoin Products isotretinoin Absorica®
Isotretinoin Products isotretinoin Zenatane™
Jakafi® ruxolitinib
Keytruda® Pembrolizumab
Kineret® anakinra
Lamisil® terbinafine
Lotronex® Alosetron
Lupron Depot® and Lupron Depot-Ped® leuprolide
Lynparza™ Olaparib
Mepron® atovaquone
MS Biologics interferon beta-1a Avonex®
MS Biologics glatiramer Copaxone®
MS Biologics glatiramer Glatopa®
MS Biologics peginterferon beta-1a Plegridy™
MS Biologics interferon beta-1b Betaseron®
MS Biologics interferon beta-1b Extavia®
MS Biologics alemtuzumab Lemtrada™
MS Biologics ocrelizumab Ocrevus™
MS Biologics interferon beta-1a Rebif®
MS Biologics interferon beta-1a Zinbryta™
Nexavar® sorafenib
Non-Preferred ER Opioid Analgesics morphine/naltrexone Embeda®
Non-Preferred ER Opioid Analgesics hydromorphone Exalgo®
Non-Preferred ER Opioid Analgesics hydrocodone Hysingla® ER
Non-Preferred ER Opioid Analgesics morphine Kadian®
Non-Preferred ER Opioid Analgesics morphine MS Contin®
Non-Preferred ER Opioid Analgesics tapentadol Nucynta® ER
Non-Preferred ER Opioid Analgesics oxymorphone Opana® ER
Non-Preferred ER Opioid Analgesics oxycodone/naltrexone Troxyca® ER
Non-Preferred ER Opioid Analgesics oxycodone Xtampza™ ER
Non-Preferred ER Opioid Analgesics hydrocodone Zohydro® ER
Non-Preferred Hyptonics suvorexant Belsomra®
Non-Preferred Hyptonics ramelteon Rozerem®
Non-Preferred Hyptonics zolpidem SL Edluar®
Non-Preferred Hyptonics zolpidem SL Intermezzo®
Non-Preferred Hyptonics zolpidem oral spray ZolpiMist®
Non-Preferred Mesalamine Products mesalamine Apriso®
Non-Preferred Mesalamine Products mesalamine Canasa®
Non-Preferred Mesalamine Products mesalamine Lialda®
Non-Preferred Mesalamine Products mesalamine Pentasa®
Nucala® Mepolizumab
Nuedexta® Dextromethorphan/Quinidine
Nuvigil® armodafinil
Olysio™ simeprevir
Opdivo® Teriflunomide
Ophthalmic VEGF Inhibitors bevacizumab Avastin®
Ophthalmic VEGF Inhibitors aflibercept Eylea®
Ophthalmic VEGF Inhibitors ranibizumab Lucentis®
Ophthalmic VEGF Inhibitors pegaptanib Macugen®
Orkambi® Lumacaftor/Ivacaftor
Otezla® Apremilast
Oxandrin® oxandrolone
Parenteral Iron Therapy iron dextran INFeD®
Parenteral Iron Therapy iron sucrose Venofer®
Parenteral Iron Therapy ferumoxytol Feraheme™
Parenteral Iron Therapy sodium ferric gluconate complex in sucrose Ferrlecit®
Parenteral Iron Therapy ferric carboxymaltose Injectafer®
PCSK9 Inhibitors alirocumab Praluent®
PCSK9 Inhibitors evolocumab Repatha™
PDE-5 Inhibitors tadalafil Adcirca®
PDE-5 Inhibitors sildenafil Revatio®
Pegylated Interferons peginterferon alfa-2a Pegasys®
Pegylated Interferons peginterferon alfa-2b Pegintron®
Phenylbutyrates sodium phenylbutyrate powder
Phenylbutyrates sodium phenylbutyrate Buphenyl®
Phenylbutyrates glycerol phenylbutyrate Ravicti®
Prolia® Denosumab
Promacta® eltrombopag
Proton Pump Inhibitors rabeprazole Aciphex®
Proton Pump Inhibitors dexlansoprazole Dexilant®
Proton Pump Inhibitors esomeprazole Nexium®
Proton Pump Inhibitors lansoprazole Prevacid®
Proton Pump Inhibitors omeprazole Prilosec®
Proton Pump Inhibitors pantoprazole Protonix®
Provigil® modafinil
Pulmozyme® dornase alfa
Rayos® prednisone delayed-release
Relenza® zanamivir
Restasis® cyclosporine ophthalmic emulsion
Revlimid® lenalidomide
Ribavirin ribavirin Copegus®
Ribavirin ribavirin Moderiba™
Ribavirin ribavirin Rebetol®
Ribavirin ribavirin Ribasphere®
Rilutek® riluzole
Sabril® vigabatrin
Samsca® Tolvaptan
Saxenda® liraglutide
Sensipar® Cinacalcet
Simponi® golimumab
Smoking Deterrents Bupropion (smoking deterrent) SR (generic)
Smoking Deterrents varenicline Chantix®
Smoking Deterrents Nicotine Gum (generic)
Smoking Deterrents Nicotine Lozenge (generic)
Smoking Deterrents Nicotine Patch (generic)
Smoking Deterrents nicotine inhalation system Nicotrol®
Smoking Deterrents nicotine inhalation system Nicotrol® NS
Sovaldi® Sofosbuvir
Sprycel® dasatinib
Stivarga® regorafenib
Stribild® elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil
Suboxone® Film buprenorphine/Naloxone
Subsys® Fentanyl sublingual spray
Sutent® sunitinib
Taltz® Ixekizumab
Tamiflu® oseltamivir
Tarceva® erlotinib
Tasigna® nilotinib
Tasmar® Talcapone
Tecentriq® Atezolizumab
Tecfidera® dimethyl fumarate
Temodar® temozolomide
Technivie™ Ombitasvir, Paritaprevir, and Ritonavir
Thalomid® thalidomide
Thiola® Tiopronin
TOBI® tobramycin inhalation
Truvada® emtricitabine/tenofovir disoproxil
Tykerb® lapatinib
Valcyte® Valganciclovir
Viekira Pak™/XR™ Ombitasvir, Paritaprevir, and Ritonavir/Dasabuvir
Viread® tenofovir
Xalkori® crizotinib
Xeljanz® tofacitinib
Xeloda® capecitabine
Xenazine® tetrabenazine
Xgeva® Denosumab
Xifaxan® rifaximin
Xolair® Omalizumab
Xtandi® enzalutamide
Xyrem® sodium oxybate
Zelboraf® vemurafenib
Zepatier™ Elbasvir/Grazoprevir
Zytiga® abiraterone
Zyvox® linezolid