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
Braftovi™ Encorafenib
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
BRAF-MEK Inhibitors Encorafenib Braftovi™
BRAF-MEK Inhibitors Binimetinib Mektovi®
Botulinum Toxins onabotulinumtoxinA Botox®
Botulinum Toxins abobotulinumtoxinA Dysport®
Botulinum Toxins incobotulinumtoxinA Xeomin®
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
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
Cosentyx® Secukinumab
Descovy™ Emtracitibine/Tenofovir Alfenamide
Dupixent Dupilumab
Egrifta® tesamorelin
Emend® aprepitant
Emtriva® Emtricitabine
Enbrel® etanercept
Endothelin Antagonists ambrisentan Letairis®
Endothelin Antagonists macetentan Opsumit®
Endothelin Antagonists bosentan Tracleer®
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
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
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
Sirturo® Bendaquiline
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
Stelara® Ustekinumab
Stivarga® regorafenib
Stribild® elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil
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
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

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