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 | |
| Aloxi® | palonosetron HCL | |
| Ampyra® | dalfampridine | |
| 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® |
| Antivirals, Influenza | oseltamivir | Tamiflu® |
| Antivirals, Influenza | Zanamivir | Relenza® |
| Antivirals, Influenza | baloxavir | Xofluza™ |
| Atripla® | Efavirenz, Emtricitabine, Tenofovir Disoproxil Fumarate | |
| Azacitidine | Onureg® | |
| Azacitidine | Vidaza® | |
| Biktarvy | Bictegravir/Emtracitibine/Tenofovir Alfenamide | |
| 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 | |
| Botulinum Toxins | onabotulinumtoxinA | Botox® |
| Botulinum Toxins | abobotulinumtoxinA | Dysport® |
| Botulinum Toxins | incobotulinumtoxinA | Xeomin® |
| BRAF-MEK Inhibitors | Encorafenib | Braftovi™ |
| BRAF-MEK Inhibitors | Binimetinib | Mektovi® |
| Caprelsa® | vandetanib | |
| Casodex® | bicalutamide | |
| Cayston® | aztreonam | |
| CGRP Inhibitors | Erenumab-aooe | Aimovig™ |
| CGRP Inhibitors | fremanezumab-vfrm | Ajovy™ |
| CGRP Inhibitors | galcanezumab-gnlm | Emgality™ |
| CGRP Inhibitors | rimegepant | Nurtec™ |
| CGRP Inhibitors | ubrogepant | Ubrelvy™ |
| CGRP Inhibitors | eptinezumab-jjmr | Vypeti™ |
| Chronic Constipation — Idiopathic and IBS-C* | lubiprostone | Amitiza® |
| Chronic Constipation — Idiopathic and IBS-C* | linaclotide | Linzess®** |
| Chronic Constipation — Idiopathic and IBS-C* | prucalopride | Motegrity® |
| Chronic Constipation — Idiopathic and IBS-C* | plecanatide | Trulance® |
| Chronic Constipation — Idiopathic and IBS-C* | tegaserod | Zelnorm™ |
| Chronic Constipation — Opioid-Induced* | lubiprostone | Amitiza® |
| Chronic Constipation — Opioid-Induced* | prucalopride | Movantik® |
| Chronic Constipation — Opioid-Induced* | methylnaltrexone bromide | Relistor® |
| Chronic Constipation — Opioid-Induced* | naldemedine | Symprioic® |
| Chronic Opioid | Chronic Opioid | |
| Cimduo™ | Lamivudine/Tenofovir Disoproxil Fumarate | |
| Cimzia® | certolizumab | |
| Colony Stimulating Factors | pegfilgrastim-jmdb | Fulphila™ |
| Colony Stimulating Factors | tbo-filgrastim | Granix® |
| Colony Stimulating Factors | sargramostim | Leukine® |
| Colony Stimulating Factors | pegfilgrastim | Neulasta® / Onpro |
| Colony Stimulating Factors | filgrastim | Neupogen® |
| Colony Stimulating Factors | filgrastim-aafi | Nivestym™ |
| Colony Stimulating Factors | pegfilgrastim-cbqv | Udenyca™ |
| Colony Stimulating Factors | filgrastim-sndz | Zarxio® |
| Colony Stimulating Factors | pegfilgrastim-bmex | Ziextenzo™ |
| Continuous Glucose Monitoring (CGM) Systems | Dexcom® CGMs | |
| Continuous Glucose Monitoring (CGM) Systems | Eversense® | |
| Continuous Glucose Monitoring (CGM) Systems | Freestyle Libre 2 | |
| Continuous Glucose Monitoring (CGM) Systems | Freestyle Libre 14 Day | |
| Continuous Glucose Monitoring (CGM) Systems | Guardian Connect® CGM System | |
| Corlanor® | Ivabradine | |
| Cosentyx® | Secukinumab | |
| Descovy™ | Emtracitibine/Tenofovir Alfenamide | |
| Diacomit® | Stiripentol | |
| Dupixent | Dupilumab | |
| Egrifta® | tesamorelin | |
| Emend® | aprepitant | |
| Emtriva® | Emtricitabine | |
| Enbrel® | etanercept | |
| Endothelin Antagonists | ambrisentan | Letairis® |
| Endothelin Antagonists | macetentan | Opsumit® |
| Endothelin Antagonists | bosentan | Tracleer® |
| Entresto® | Sacubitril/Valsartan | |
| Epclusa® | Sofosbuvir/Velpatasvir | |
| 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 | 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 | somatropin | Zomacton™ |
| Growth Hormone - Children | somatropin | Zorbtive® |
| Harvoni® | Ledipasvir/Sofosbuvir | |
| Hepatitis C Treatment Options | ||
| H.P.Acthar® | Repository corticotropin injection gel | |
| Humira® | adalimumab | |
| Hycamtin® | topotecan | |
| Hydroxyprogesterone Caproate Injection | Makena | |
| Hydroxyprogesterone Caproate Injection | Compounded 17P | |
| Iclusig® | ponatinib | |
| IL-23 Inhibitors | Risankizumab | Skyrizi™ |
| IL-23 Inhibitors | Guselkumab | Tremfya® |
| IL-23 Inhibitors | Tildrakizumab | Ilumya™ |
| Imbruvica | ibrutinib | |
| Imfinzi™ | Durvalumab | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Asceniv® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Bivigam® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Carimune® NF | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Cutaquig® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Cuvitru® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Flebogamma® DIF | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | GamaSTAN® S/D | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Gammagard® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Gammagard® S/D | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Gammaked™ | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Gammaplex® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Gamunex®-C | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Hizentra® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | HyQvia® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Octagam® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Panzyga® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Privigen® | |
| Immune Globulin Replacement Therapy (IVIG) IV/SQ/IM | Xembify® | |
| Infliximab | infliximab-axxq | Avsola® |
| Infliximab | infliximab-dyyb | Inflectra® |
| Infliximab | infliximab | Remicade® |
| Infliximab | infliximab-abda | Renflexis® |
| Ingrezza® | Valbenazine | |
| Inlyta® | axitinib | |
| Inqovi® | Decitabine and Cedazuridine | |
| Iron Chelating Agents | deferasirox | Exjade® |
| Iron Chelating Agents | Deferasirox | Jadenu |
| Iron Chelating Agents | deferiprone | Ferriprox |
| Isotretinoin Products | isotretinoin | Amnesteem® |
| Isotretinoin Products | isotretinoin | Claravis® |
| Isotretinoin Products | isotretinoin | Myorisan™ |
| Isotretinoin Products | isotretinoin | Absorica® |
| Isotretinoin Products | isotretinoin | Zenatane™ |
| Jakafi® | ruxolitinib | |
| Janus Kinase (JAK) Inhibitors | Baricitinib | Olumiant® |
| Janus Kinase (JAK) Inhibitors | Tofacitinib | Xeljanz®, XeljanzXR® |
| Janus Kinase (JAK) Inhibitors | Upadacitinib | Rinvoq® |
| Juluca™ | Dolutegravir sodium/Rilpivirine hydrochloride | |
| Keytruda® | Pembrolizumab | |
| Kineret® | anakinra | |
| Lamisil® | terbinafine | |
| Lampit® | Nifurtimox | |
| Lotronex® | Alosetron | |
| Lupron Depot® and Lupron Depot-Ped® | leuprolide | |
| Lynparza™ | Olaparib | |
| Medical Necessity | ||
| Mavyret™ | Glecaprevir/Pibrentasvir | |
| Mekinist® | Trametinib | |
| Mepron® | atovaquone | |
| Multiple Sclerosis Agents | interferon beta-1a | Avonex® |
| Multiple Sclerosis Agents | Monomethyl Fumarate | Bafiertam™ |
| Multiple Sclerosis Agents | interferon beta-1b | Betaseron® |
| 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 | |
| Nexletol® | Bempedoic acid | |
| Nexlizet™ | Bempedoic acid/ezetimibe | |
| Non-Preferred Long-Acting Opioid Analgesics | morphine | Arymo® ER |
| Non-Preferred Long-Acting Opioid Analgesics | buprenorphine buccal film | Belbuca™ |
| Non-Preferred Long-Acting Opioid Analgesics | buprenorphine transdermal system | Butrans® |
| Non-Preferred Long-Acting Opioid Analgesics | tramadol hydrochloride | Conzip® |
| Non-Preferred Long-Acting Opioid Analgesics | morphine/naltrexone | Embeda® |
| Non-Preferred ER Opioid Analgesics | hydrocodone | Hysingla® ER |
| Non-Preferred Long-Acting Opioid Analgesics | morphine | Kadian® |
| Non-Preferred Long-Acting Opioid Analgesics | morphine | MorphaBond™ ER |
| Non-Preferred Long-Acting Opioid Analgesics | morphine | MS Contin® |
| Non-Preferred Long-Acting Opioid Analgesics | tapentadol | Nucynta® ER |
| Non-Preferred Long-Acting Opioid Analgesics | oxycodone hydrochloride | Oxycontin® |
| Non-Preferred Long-Acting Opioid Analgesics | oxycodone | Xtampza™ ER |
| Non-Preferred Long-Acting Opioid Analgesics | hydrocodone | Zohydro® ER |
| 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 | cyclosporine 0.05% Ophthalmic Emulsion | Restasis® |
| Ophthalmic Immunomodulators | lifitegrast 5% ophthalmic solution | Xiidra™ |
| Ophthalmic VEGF Inhibitors | bevacizumab | Avastin® |
| Ophthalmic VEGF Inhibitors | brolucizumab | Beovu® |
| Ophthalmic VEGF Inhibitors | aflibercept | Eylea® |
| Ophthalmic VEGF Inhibitors | ranibizumab | Lucentis® |
| Ophthalmic VEGF Inhibitors | pegaptanib | Macugen® |
| Ophthalmic VEGF Inhibitors | bevacizumab-awwb | Mvasi™ |
| Ophthalmic VEGF Inhibitors | bevacizumab-bvzr | Zirabev™ |
| Orkambi® | Lumacaftor/Ivacaftor | |
| Otezla® | Apremilast | |
| Oxandrin® | oxandrolone | |
| 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® |
| 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 | 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 | |
| RET Kinase Inhibitor | Selpercatinib | Gavreto® |
| RET Kinase Inhibitor | Pralsetinib | Retevmo® |
| Revlimid® | lenalidomide | |
| Reyvow™ | Lasmiditan | |
| Rozlytrek® | Entrectinib | |
| Sabril® | vigabatrin | |
| Samsca® | Tolvaptan | |
| Saxenda® | liraglutide | |
| Sensipar® | Cinacalcet | |
| Simponi® | golimumab | |
| Sirturo® | Bendaquiline | |
| 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 | |
| Stelara® | Ustekinumab | |
| Stivarga® | regorafenib | |
| Stribild® | elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil | |
| Stromectol® | Ivermectin | |
| Suboxone® Film | buprenorphine/Naloxone | |
| Subsys® | Fentanyl sublingual spray | |
| Sunosi® | Solriamfetol | |
| Sutent® | sunitinib | |
| Symfi, Symfi Lo | Efavirenz/Lamivudine/Tenofovir Disoproxil Fumarate | |
| Symtuza® | Darunavir-Cobisistat/Emtricitabine/Tenofovir Alafenamide | |
| Tafinlar® | Dabrafenib | |
| Taltz® | Ixekizumab | |
| Tarceva® | erlotinib | |
| Tasigna® | nilotinib | |
| Tasmar® | Talcapone | |
| Tecentriq® | Atezolizumab | |
| Temodar® | temozolomide | |
| Tepmetko® | Tepotinib | |
| Thalomid® | thalidomide | |
| Thiola® | Tiopronin | |
| TOBI® | tobramycin inhalation | Kitabis® Pak |
| TOBI® | tobramycin inhalation Solution | |
| TOBI® | tobramycin inhalation | Bethkis® |
| TOBI® | tobramycin inhalation Solution | TOBI® |
| TOBI® | tobramycin inhalation | TOBI® Podhaler® |
| Truvada® | emtricitabine/tenofovir disoproxil | |
| Tykerb® | lapatinib | |
| Ukoniq® | Umbralisib | |
| Valcyte® | Valganciclovir | |
| Valtoco® | Diazepam Nasal Spray | |
| Vemlidy® | Tenofovir Alafenamide | |
| Verquvo® | Vericiguat | |
| Verzenio® | abemaciclib | |
| Viberzi® | Eluxadoline | |
| Vimpat® | Lacosamide | |
| Vosevi® | Sofosbuvir/Velpatasvir/Voxilaprevir | |
| Votrient® | Pazopanib | |
| Xalkori® | crizotinib | |
| Xenazine® | tetrabenazine | |
| Xgeva® | Denosumab | |
| Xifaxan® | rifaximin | |
| Xolair® | Omalizumab | |
| Xpovio® | selinexor | |
| Xtandi® | enzalutamide | |
| Xyrem® | sodium oxybate | |
| Zelboraf® | vemurafenib | |
| Zepatier™ | Elbasvir/Grazoprevir | |
| Zytiga® | abiraterone | |
| Zyvox® | linezolid |
