Medication Policies

Ventegra offers quality of care, affordability and choice.

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.

Ventegra Medication Policies

Therapeutic Class or Brand Name Generic Drug Name
Afinitor® everolimus
Akynzeo® netupitant/palonosetron
Androgens (all dosage forms) testosterone transdermal system Androderm®
Androgens (all dosage forms) testosterone gel Androgel®
Androgens (all dosage forms) testosterone undecanoate Aveed™
Androgens (all dosage forms) testosterone topical solution
Androgens (all dosage forms) testosterone cypionate injection Depo® - Testosterone
Androgens (all dosage forms) testosterone Enanthate Injection
Androgens (all dosage forms) testosterone gel Fortesta®
Androgens (all dosage forms) testosterone undecanoate oral capsules Jatenzo®
Androgens (all dosage forms) methyltestosterone tablet Methitest®
Androgens (all dosage forms) testosterone nasal gel Natesto™
Androgens (all dosage forms) testosterone gel Testim®
Androgens (all dosage forms) testosterone cypionate Testone CIK™
Androgens (all dosage forms) estosterone pellet Testopel®
Androgens (all dosage forms) Testosterone Transdermal Gel
Androgens (all dosage forms) methyltestosterone capsule
Androgens (all dosage forms) testosterone gel Vogelxo™
Androgens (all dosage forms) testosterone enanthate Xyosted™
Anticoagulants (oral) apixaban Eliquis®
Anticoagulants (oral) dabigatran Pradaxa®
Anticoagulants (oral) edoxaban Savaysa™
Anticoagulants (oral) rivaroxaban Xarelto®
Antiobesity Medications (AOM) phentermine Adipex-P
Antiobesity Medications (AOM) benzphetamine
Antiobesity Medications (AOM) naltrexone/bupropion Contrave® ER
Antiobesity Medications (AOM) diethylpropion
Antiobesity Medications (AOM) diethylpropion ER
Antiobesity Medications (AOM) phendimetrazine
Antiobesity Medications (AOM) phendimetrazine ER
Antiobesity Medications (AOM) Phentermine HCl Lomaira™
Antiobesity Medications (AOM) orlistat Orlistat
Antiobesity Medications (AOM) phentermine/topiramate extended-release Qsymia®
Antiobesity Medications (AOM) liraglutide Saxenda®
Antiobesity Medications (AOM) semaglutide Wegovy™
Antiobesity Medications (AOM) tirzepatide Zepbound™
Antiobesity Medications (AOM) orlistat Xenical®
Antivirals, Influenza oseltamivir Tamiflu®
Antivirals, Influenza Zanamivir Relenza®
Antivirals, Influenza baloxavir Xofluza™
Antiretrovirals HIV cabotegravir extended-release injectable suspension Apretude®
Antiretrovirals HIV cabotegravir extended-release injectable suspension Apretude®
Antiretrovirals HIV efavirenz/emtricitabine/tenofovir disoproxil fumarate Atripla®
Antiretrovirals HIV bictegravir/emtricitabine/tenofovir alafenamide Biktarvy®
Antiretrovirals HIV cabotegravir extended-release injectable suspension/rilpivirine extended-release injectable suspension Cabenuva™
Antiretrovirals HIV lamuvidine/tenofovir disoproxil fumarate Cimduo®
Antiretrovirals HIV emtricitabine/tenofovir alafenamide Descovy®
Antiretrovirals HIV emtricitabine Emtriva®
Antiretrovirals HIV dolutegravir/rilpivirine Juluca®
Antiretrovirals HIV elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate Stribilid®
Antiretrovirals HIV efavirenz/lamivudine/tenofovir disoproxil fumarate Symfi®, Symfi Lo®
Antiretrovirals HIV darunavir/cobicistat/emtricitabine/tenofovir alafenamide Symtuza®
Antiretrovirals HIV emtricitabine/tenofovir disoproxil Truvada®
Antiretrovirals HIV cabotegravir Vocabria™
Azacitidine Onureg®
Azacitidine Vidaza®
Besremi® Ropeginterferon alfa-2b-njft
Bosulif® bosutinib
Botulinum Toxins onabotulinumtoxinA Botox®
Botulinum Toxins abobotulinumtoxinA Dysport®
Botulinum Toxins incobotulinumtoxinA Xeomin®
BRAF-MEK Inhibitors Encorafenib Braftovi™
BRAF-MEK Inhibitors Binimetinib Mektovi®
Brand Name Medication
Breast Cancer Risk Reduction Medications for Zero Copay tamoxifen
Breast Cancer Risk Reduction Medications for Zero Copay raloxifene
Breast Cancer Risk Reduction Medications for Zero Copay Soltamox
Camzyos® Mavacamten
Caprelsa® vandetanib
Cayston® aztreonam
Chronic Constipation lubiprostone Amitiza
Chronic Constipation tenapanor Ibsrela®
Chronic Constipation linaclotide Linzess®*
Chronic Constipation lubiprostone
Chronic Constipation prucalopride Motegrity®
Chronic Constipation naloxegol Movantik®
Chronic Constipation methylnaltrexone bromide Relistor®
Chronic Constipation naldemedine Symprioic®
Chronic Constipation plecanatide Trulance®
Chronic Opioid Chronic Opioid
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim-jmdb Fulphila™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim-jmdb Fulphila™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim-pbbk Fylnetra™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) tbo-filgrastim Granix®
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) sargramostim Leukine®
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim Neulasta® / Onpro
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) filgrastim Neupogen®
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) filgrastim-aafi Nivestym™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim-apgf Nyvepria™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) filgrastim-ayow Releuko™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) eflapegrastim-xnst Rolvedon™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim-fpgk Stimufend
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim-cbqv Udenyca™
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) filgrastim-sndz Zarxio®
Colony-Stimulating Factors (CSF)/ Myeloid Growth Factor (MGF) pegfilgrastim-bmex Ziextenzo™
Continuous Glucose Monitoring (CGM) Systems Dexcom® CGMs
Continuous Glucose Monitoring (CGM) Systems Eversense®
Continuous Glucose Monitoring (CGM) Systems Freestyle Libre Products
Continuous Glucose Monitoring (CGM) Systems Guardian Connect® CGM System
Corlanor® Ivabradine
Cresemba® isavuconazonium sulfate
Dificid® fidaxomicin
Diacomit® Stiripentol
Disposable Insulin Delivery Systems Omnipod® 5
Disposable Insulin Delivery Systems Omnipod DASH®
Dupixent Dupilumab
Egrifta® tesamorelin
Endothelin Antagonists ambrisentan Letairis®
Endothelin Antagonists macetentan Opsumit®
Endothelin Antagonists bosentan Tracleer®
Epidiolex® Cannabidiol
Erivedge® vismodegib
Erythropoiesis-Stimulating Agents (ESAs) darbepoetin alfa Aranesp®
Erythropoiesis-Stimulating Agents (ESAs) epoetin Alfa Epogen®
Erythropoiesis-Stimulating Agents (ESAs) methoxy polyethylene glycol-epoetin beta Mircera®
Erythropoiesis-Stimulating Agents (ESAs) epoetin Alfa Procrit®
Erythropoiesis-Stimulating Agents (ESAs) epoetin Alfa Retacrit™
Esbriet® Pirfenidone
Fasenra® Benralizumab
Forteo® Teriparatide
Fycompa® Perampanel
Gleevec® imatinib
Gleostine® lomustine
GnRH Antagonists relugolix 40mg, estradiol 1mg, and norethindrone 0.5mg Myfembree
GnRH Antagonists Elagolix 300 mg, estradiol 1 mg, norethindrone acetate 0.5 mg Oriahnn™
GnRH Antagonists Elagolix Orilissa™
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 AQ®
Growth Hormone - Children somatropin Omnitrope®
Growth Hormone - Children somatropin Saizen®
Growth Hormone - Children somatropin Serostim®
Growth Hormone - Children lonapegsomatropin Skytrofa®
Growth Hormone - Children somatropin Zomacton™
Growth Hormone - Children somatropin Zorbtive®
Growth Hormone - Children somatropin Zorbtive®
HCV Antivirals Epclusa® Sofosbuvir/Velpatasvir
HCV Antivirals Harvoni® Ledipasvir/Sofosbuvir
HCV Antivirals Mavyret™ Glecaprevir/Pibrentasvir
HCV Antivirals Sovaldi® Sofosbuvir
HCV Antivirals Vosevi® Sofosbuvir/Velpatasvir/Voxilaprevir
HCV Antivirals Zepatier™ Elbasvir/Grazoprevir
Hereditary Angioedema Agents C1 esterase inhibitor [human] Cinryze®
Hereditary Angioedema Agents icatibant Firazyr®
Hereditary Angioedema Agents C1 esterase inhibitor [human] Haegarda®
Hereditary Angioedema Agents ecallantide Kalbitor®
Hereditary Angioedema Agents berotralstat Orladeyo®
Hereditary Angioedema Agents C1 esterase inhibitor [human] Ruconest®
Hereditary Angioedema Agents icatibant Sajazir™
Hereditary Angioedema Agents lanadelumab-flyo Takhzyro®
H.P.Acthar® Repository corticotropin injection gel
Hycamtin® topotecan
Hypercholesterolemia Agents lomitapide Juxtapid®
Hypercholesterolemia Agents bempedoic acid Nexletol®
Hypercholesterolemia Agents bempedoic acid and ezetimibe Nexlizet™
Hypercholesterolemia Agents alirocumab Praluent®
Hypercholesterolemia Agents evolocumab Repatha™
Iclusig® ponatinib
Imbruvica ibrutinib
Imfinzi™ Durvalumab
Immune Globulin Products Asceniv®
Immune Globulin Products Bivigam®
Immune Globulin Products Carimune® NF
Immune Globulin Products Cutaquig®
Immune Globulin Products Cuvitru®
Immune Globulin Products Flebogamma® DIF
Immune Globulin Products GamaSTAN® S/D
Immune Globulin Products Gammagard®
Immune Globulin Products Gammagard® S/D
Immune Globulin Products Gammaked™
Immune Globulin Products Gammaplex®
Immune Globulin Products Gamunex® -C
Immune Globulin Products Hizentra®
Immune Globulin Products HyQvia®
Immune Globulin Products Octagam®
Immune Globulin Products Panzyga®
Immune Globulin Products Privigen®
Immune Globulin Products Xembify®
Incretin Mimetics - Diabetes exenatide Byetta®
Incretin Mimetics - Diabetes exenatide Bydureon BCise®
Incretin Mimetics - Diabetes tirzepatide Mounjaro™
Incretin Mimetics - Diabetes semaglutide Ozempic®
Incretin Mimetics - Diabetes semaglutide Rybelsus®
Incretin Mimetics - Diabetes dulaglutide Trulicity®
Incretin Mimetics - Diabetes liraglutide Victoza®
Inhaled Tobramycin Products tobramycin inhalation solution Bethkis®
Inhaled Tobramycin Products tobramycin inhalation solution Kitabis® Pak
Inhaled Tobramycin Products tobramycin inhalation solution TOBI®
Inhaled Tobramycin Products tobramycin inhalation solution TOBI® Podhaler®
Inhaled Tobramycin Products Tobramycin inhalation solution (generic)
Ingrezza® Valbenazine
Inlyta® axitinib
Inqovi® Decitabine and Cedazuridine
Iron Chelating Agents deferasirox Exjade®
Iron Chelating Agents deferiprone Ferriprox
Iron Chelating Agents Deferasirox Jadenu
Jakafi® ruxolitinib
Kerendia™ Finerenone
Keytruda® Pembrolizumab
Kineret® anakinra
Lampit® Nifurtimox
Leqembi™ Lecanemab
Lupron Depot® and Lupron Depot-Ped® leuprolide
Lynparza™ Olaparib
Medical Necessity
Mekinist® Trametinib
Migraine Treatment & Prevention Erenumab-aooe Aimovig™
Migraine Treatment & Prevention fremanezumab-vfrm Ajovy™
Migraine Treatment & Prevention galcanezumab-gnlm Emgality™
Migraine Treatment & Prevention rimegepant Nurtec™
Migraine Treatment & Prevention rimegepant Nurtec™ ODT
Migraine Treatment & Prevention atogepant Qulipta™
Migraine Treatment & Prevention lasmiditan Reyvow™
Migraine Treatment & Prevention zavegepant Ubrelvy™
Migraine Treatment & Prevention ubrogepant Zavzpret™
Multiple Sclerosis Agents interferon beta-1a Avonex®
Multiple Sclerosis Agents Monomethyl Fumarate Bafiertam™
Multiple Sclerosis Agents interferon beta-1b Betaseron®
Multiple Sclerosis Agents ublituximab Briumvi®
Multiple Sclerosis Agents glatiramer Copaxone®
Multiple Sclerosis Agents interferon beta-1b Extavia®
Multiple Sclerosis Agents Fingolimod Gilenya®
Multiple Sclerosis Agents glatiramer Glatopa™
Multiple Sclerosis Agents Ofatumumab Kesimpta®
Multiple Sclerosis Agents alemtuzumab Lemtrada®
Multiple Sclerosis Agents cladribine Mavenclad®
Multiple Sclerosis Agents siponimod Mayzent®
Multiple Sclerosis Agents ocrelizumab Ocrevus™
Multiple Sclerosis Agents peginterferon beta-1a Plegridy®
Multiple Sclerosis Agents interferonbeta-1a Rebif®
Multiple Sclerosis Agents Dimethyl Fumarate Tecfidera®
Multiple Sclerosis Agents natalizumab Tysabri®
Multiple Sclerosis Agents diroximel fumarate Vumerity™
Multiple Sclerosis Agents ozanimod Zeposia®
Neupro® Rotigotine Transdermal System
Nexavar® sorafenib
Non-Preferred Mesalamine Products mesalamine Apriso®
Non-Preferred Mesalamine Products mesalamine Asacol® HD
Non-Preferred Mesalamine Products mesalamine Canasa®
Non-Preferred Mesalamine Products mesalamine Lialda®
Non-Preferred Mesalamine Products mesalamine Pentasa®
Nucala® Mepolizumab
Nuedexta® Dextromethorphan/Quinidine
Nuplazid® Pimavanserin
Ofev® Nintedanib
Opdivo® Nivolumab
Ophthalmic Immunomodulators cyclosporine 0.09% ophthalmic solution Cequa™
Ophthalmic Immunomodulators loteprednol etabonate Eysuvis™
Ophthalmic Immunomodulators cyclosporine 0.05% Ophthalmic Emulsion Restasis®
Ophthalmic Immunomodulators cyclosporine 0.1% ophthalmic emulsion Verkazia™
Ophthalmic Immunomodulators lifitegrast 5% ophthalmic solution Xiidra™
Orkambi® Lumacaftor/Ivacaftor
Oxybates sodium oxybate Lumryz®
Oxybates sodium oxybate Xyrem®
Oxybates calcium, magnesium, potassium and sodium oxybates Xywav®
PDE-5 Inhibitors tadalafil Adcirca®
PDE-5 Inhibitors sildenafil Revatio®
Pegasys® peginterferon alfa-2a
Phenylbutyrates sodium phenylbutyrate powder
Phenylbutyrates sodium phenylbutyrate Buphenyl®
Phenylbutyrates glycerol phenylbutyrate Ravicti®
Potassium Binders Sodium Zirconium cyclosilicate Lokelma®
Potassium Binders Patiromer Veltassa®
Prevymis™ Letermovir
Prolia® Denosumab
Promacta® eltrombopag
Proton Pump Inhibitors rabeprazole Aciphex®
Proton Pump Inhibitors dexlansoprazole Dexilant®
Proton Pump Inhibitors omeprazole/sodium bicarbonate Konvomep
Proton Pump Inhibitors esomeprazole Nexium®
Proton Pump Inhibitors lansoprazole Prevacid®
Proton Pump Inhibitors omeprazole Prilosec®
Proton Pump Inhibitors pantoprazole Protonix®
Proton Pump Inhibitors omeprazole/sodium bicarbonate Zegerid®
Pulmozyme® dornase alfa
Rayos® prednisone delayed-release
Recorlev® Levoketoconazole
Relyvrio® Sodium phenylbutyrate-taurursodiol
RET Kinase Inhibitor Selpercatinib Gavreto®
RET Kinase Inhibitor Pralsetinib Retevmo®
Revlimid® lenalidomide
Rozlytrek® Entrectinib
Sabril® vigabatrin
Scemblix® Asciminib
Sensipar® Cinacalcet
Sirturo® Bendaquiline
Smoking Deterrents nicotine inhalation system Nicotrol®
Smoking Deterrents nicotine inhalation system Nicotrol® NS
Smoking Deterrents Bupropion (smoking deterrent) SR (generic)
Smoking Deterrents Nicotine Gum (generic)
Smoking Deterrents Nicotine Lozenge (generic)
Smoking Deterrents Nicotine Patch (generic)
Smoking Deterrents Varenicline (generic)
Sprycel® dasatinib
Substance Use Disorder buprenorphine Brixadi Monthly / Weekly
Substance Use Disorder buprenorphine Sublocade
Substance Use Disorder naltrexone Vivitrol
Stivarga® regorafenib
Stromectol® Ivermectin
Subsys® Fentanyl sublingual spray
Sutent® sunitinib
Tafinlar® Dabrafenib
Tarceva® erlotinib
Targeted Immune Modulators (TIM) adalimumab-afbz Abrilada
Targeted Immune Modulators (TIM) tocilizumab Actemra®
Targeted Immune Modulators (TIM) Adalimumab-aacf
Targeted Immune Modulators (TIM) Adalimumab-adaz
Targeted Immune Modulators (TIM) Adalimumab-adbm
Targeted Immune Modulators (TIM) Adalimumab-fkjp
Targeted Immune Modulators (TIM) adalimumab-atto Amjevita™
Targeted Immune Modulators (TIM) tralokinumab-ldrm Adbry®
Targeted Immune Modulators (TIM) infliximab-axxq Avsola®
Targeted Immune Modulators (TIM) bimekizumab-bkzx Bimzelx
Targeted Immune Modulators (TIM) abrocitinib Cibinqo™
Targeted Immune Modulators (TIM) certolizumab pegol Cimzia®
Targeted Immune Modulators (TIM) secukinumab Cosentyx®
Targeted Immune Modulators (TIM) adalimumab-adb Cyltezo
Targeted Immune Modulators (TIM) dupilumab Dupixent®
Targeted Immune Modulators (TIM) etanercept Enbrel®
Targeted Immune Modulators (TIM) vedolizumab Entyvio®
Targeted Immune Modulators (TIM) adalimumab-bwwd/td> Hadlima
Targeted Immune Modulators (TIM) adalimumab-fkjp Hulio
Targeted Immune Modulators (TIM) adalimumab Humira®
Targeted Immune Modulators (TIM) canakinumab Hyrimoz (adalimumab-adaz)
Targeted Immune Modulators (TIM) canakinumab Idacio (adalimumab-aacf)
Targeted Immune Modulators (TIM) canakinumab Ilaris®
Targeted Immune Modulators (TIM) tildrakizumab-asmn Ilumya®
Targeted Immune Modulators (TIM) infliximab-dyyb Inflectra®
Targeted Immune Modulators (TIM) sarilumab Kevzara®
Targeted Immune Modulators (TIM) anakinra Kineret®
Targeted Immune Modulators (TIM) baricitinib Olumiant®
Targeted Immune Modulators (TIM) mirzikizumab Omvoh
Targeted Immune Modulators (TIM) ruxolitinib Opzelura™
Targeted Immune Modulators (TIM) abatacept Orencia®
Targeted Immune Modulators (TIM) apremilast Otezla®
Targeted Immune Modulators (TIM) infliximab Remicade®
Targeted Immune Modulators (TIM) infliximab-abda Renflexis®
Targeted Immune Modulators (TIM) rituximab-arrx Riabni®
Targeted Immune Modulators (TIM) upadacitinib Rinvoq®
Targeted Immune Modulators (TIM) rituximab Rituxan®
Targeted Immune Modulators (TIM) rituximab-pvvr Ruxience®
Targeted Immune Modulators (TIM) brodalumab Siliq®
Targeted Immune Modulators (TIM) golimumab Simponi® /Simponi Aria®
Targeted Immune Modulators (TIM) risankizumab Skyrizi®
Targeted Immune Modulators (TIM) deucravacitinib Sotyktu™
Targeted Immune Modulators (TIM) ustekinumab Stelara®
Targeted Immune Modulators (TIM) ixekizumab Taltz®
Targeted Immune Modulators (TIM) guselkumab Tremfya®
Targeted Immune Modulators (TIM) rituximab-abbs Truxima®
Targeted Immune Modulators (TIM) natalizumab Tysabri®
Targeted Immune Modulators (TIM) etrasimod Velsipity
Targeted Immune Modulators (TIM) tofacitinib Xeljanz® /Xeljanz XR®
Targeted Immune Modulators (TIM) adalimumab-aaty Yuflyma
Targeted Immune Modulators (TIM) adalimumab-aqvh Yusimry
Targeted Immune Modulators (TIM) ozanimod Zeposia®
Targeted Immune Modulators (TIM) roflumilast Zoryve
Targeted Immune Modulators (TIM) infliximab-dyyb Zymfentra
Tasigna® nilotinib
Tasmar® Talcapone
Tavneos® Avacopan
Tecentriq® Atezolizumab
Tepmetko® Tepotinib
Tezspire™ Tezepelumab-ekko
Thalomid® thalidomide
Thiola® Tiopronin
Tolvaptan Tolvaptan Jynarque®
Tolvaptan Tolvaptan Samsca®
Trikafta Elexacaftor/tezacaftor/Ivacaftor and Ivacaftor
Tolvaptan Tolvaptan Samsca®
Tykerb® lapatinib
Tzield™ Teplizumab-mzwv
Vemlidy® Tenofovir Alafenamide
Verquvo® Vericiguat
Verzenio® abemaciclib
Viberzi® Eluxadoline
Vijoice® alpelisib
Vonjo® Pacritinib
Votrient® Pazopanib
Wakix® Pitolisant
Xalkori® crizotinib
Xenazine® tetrabenazine
Xgeva® Denosumab
Xifaxan® rifaximin
Xolair® Omalizumab
Xpovio® selinexor
Xtandi® enzalutamide
Zelboraf® vemurafenib
Zytiga® abiraterone

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