Skip to Main Content

Clinical & Payment Policies

Policy Title Policy Number Effective Date
Acupuncture (PDF) AR.MP.92 03/17/17
Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) AR.MP.108 04/17/17
Ambulatory Surgery Center Optimization (PDF) AR.MP.158 04/16/18
Applied Behavioral Analysis for Autism (PDF) CP.MP.104 10/19/18
Articular Cartilage Defect Repairs (PDF) CP.MP.26 10/19/18
Assistive Reproductive Technology (PDF) AR.MP.55 09/08/17
Balloon Sinus Ostial Dilation (PDF) AR.MP.119 04/18/17
Biofeedback (PDF) AR.MP.168 11/07/17
Bone-Anchored Hearing Aid (PDF) AR.MP.93 12/01/17
Carrier Screening in Pregnancy (PDF) AR.MP.83 11/07/17
Caudal or Interlaminar Epidural Steroid Injections (PDF) AR.MP.164 12/10/2018
Cell-Free Fetal DNA Testing (PDF) AR.MP.84 03/16/17
Clinical Policy Committee (PDF) AR.CPC.01 04/17/17
Clinical Policy Web Posting (PDF) AR.CPC.02 04/17/17
Clinical Trials (PDF) AR.MP.94 12/01/17
Cochlear Implant Replacements (PDF) CP.MP.14 10/19/18
Cosmetic Reconstructive Surgery (PDF) AR.MP.31 03/15/17
Dental Anesthesia (PDF) AR.MP.61 03/15/17
Disc Decompression Procedures (PDF) CP.MP.114 10/19/18
Discography (PDF) CP.MP.115 10/19/18
Durable Medical Equipment (DME) (PDF) AR.MP.107 12/10/2018
Electric Tumor Treatment Fields (PDF) AR.MP.145 09/08/17
Essure Removal (PDF) AR.MP.131
04/18/17
Experimental Policy (PDF) AR.MP.36
03/15/17
Facet Joint Interventions (PDF) AR.MP.171 12/10/2018
Fecal Incontinence Treatments (PDF) AR.MP.137
04/18/17
Ferriscan R2-MRI (PDF) AR.MP.53
03/15/17
Fetal Surgery in Utero (PDF) AR.MP.129
Retired on 12/9/18
Fetal surgery in utero for prenatally diagnosed malformations (PDF) AR.MP.129 12/10/2018
Flu and Strep Testing (PDF) AR.MP.112
04/17/17
Functional MRI (PDF) AR.MP.43
03/15/17
Gastric Electrical Stimulation (PDF) AR.MP.40
03/15/17
Gender Reassignment Surgery (PDF) AR.MP.95
04/17/17
Genetic Testing (PDF) AR.MP.89
03/16/17
Heart-Lung Transplant (PDF) CP.MP.132 10/19/18
Home Birth (PDF) AR.MP.216
04/18/17
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) AR.MP.150
12/31/17
Hospice Clinical Coverage (PDF) AR.MP.54
03/15/17
Hyperbaric Oxygen Therapy (PDF) AR.MP.27
03/15/17
Hyperemesis Gravidarum Treatment (PDF) AR.MP.34
03/15/17
Hyperhidrosis Treatments (PDF) CP.MP.62 10/19/18
Inhaled Nitric Oxide (PDF) AR.MP.87
03/16/17
Injections for Pain Management (PDF) CP.MP.118 Retired 12/18/2018
Injections for Pain Management (PDF) AR.MP.118 12/19/2018
Intensity Modulated Radiation Therapy (PDF) CP.MP.69 10/19/18
Intestinal & Multivisceral Transplant (PDF) AR.MP.58
03/15/17
Intradiscal Steroid Injections (PDF) AR.MP.167 12/10/2018
Long Term Care Placement Criteria (PDF) AR.MP.71
03/16/17
Lung Transplantation (PDF) CP.MP.57 10/19/18
Lysis of Epidural Lesions (PDF) AR.MP.116
04/18/17
Medical Necessity Criteria (PDF) AR.MP.68
03/16/17
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) CP.MP.161  10/19/18
Multiple Sleep Latency Testing (PDF) CP.MP.24 10/19/18
Neonatal Abstinence Syndrome Guidelines (PDF) AR.MP.86
03/16/17
Neonatal Sepsis Management Guidelines (PDF) AR.MP.85
03/16/17
Nerve Blocks for Pain Management (PDF) AR.MP.170 12/10/2018
NICU Apnea Bradycardia Guidelines (PDF) AR.MP.82
03/16/17
NICU Discharge Guidelines (PDF) AR.MP.81
03/16/17
Nonmyeloablative allogeneic stem cell transplant (PDF) AR.MP.141
09/08/17
OB Home Health Programs (PDF) AR.MP.91
03/17/17
Optic Nerve Decompression Surgery (PDF) AR.MP.128
04/18/17
Outpatient Testing for Drugs of Abuse (PDF) AR.MP.50 12/10/2018
Pain Management Procedures (PDF) AR.MP.63
03/16/17
Pancreas Transplantation (PDF) AR.MP.102
04/17/17
Panniculectomy (PDF) AR.MP.109
04/17/17
Pediatric Heart Transplant (PDF) AR.MP.138
04/18/17
Percutaneous LAAD Stroke Prevention (PDF) CP.MP.147 10/19/18
Posterior Nerve Stimulation for Voiding Dysfunction (PDF) AR.MP.133
04/18/17
Preventive Health and Clinical Practice Guideline Policy (PDF) CP.CPC.03 Retired on 12/9/2018
Preventive Health and Clinical Practice Guideline Policy (PDF) AR.CPC.03 12/10/2018
Radial Head Implant (PDF) AR.MP.148
12/08/17
Reduction Mammoplasty and Gynecomastia Surgery (PDF) AR.MP.51 12/10/2018
Sacroiliac Joint Fusion (PDF) AR.MP.126
04/18/17
Sacroiliac Joint Interventions for Pain Management (PDF) AR.MP.166 12/10/2018
Selective Nerve Root Blocks and Transforaminal Epidural (PDF) AR.MP.165 12/10/2018
Sickle Cell Disease Observation (PDF) AR.MP.88
03/16/17
Spinal Cord Stimulation (PDF) AR.MP.117
04/18/17
Stereotactic Body Radiation Therapy (PDF) AR.MP.22
01/17/18
Tandem Transplant (PDF) CP.MP.162 Retired on 12/9/2018
Tandem Transplant (PDF) AR.MP.162 12/10/2018
Therapy Services (PTOTST) (PDF) AR.MP.49
04/17/17
Transcatheter Closure of Patent Foramen Ovale (PFO) (PDF) CP.MP.151 10/19/18
Trigger Point Injections for Pain Management (PDF) AR.MP.169 12/10/2018
Urinary Incontinence Devices and Treatments (PDF) AR.MP.142
09/08/17
Vagus Nerve Stimulation for Epilepsy (PDF) AR.MP.12
Retired on 12/9/2018
Vagus Nerve Stimulation (PDF) AR.MP.12 12/10/2018
Ventricular Assist Devices (PDF) CP.MP.46  10/19/18
Ventriculectomy and Cardiomyoplasty (PDF) AR.MP.56
04/17/17
Zika Virus Testing (PDF) CP.MP.111 10/19/18
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 7/1/2014
Add on Code Billed Without Primary Code (PDF) CC.PP.030 10/18/2016
ADHD Assessment and Treatment (PDF) CP.MP.124 4/1/2017
Allergy Testing (PDF) CP.MP.100 8/12/2016
Ambulatory EEG (PDF) CP.MP.96 8/12/2016
Assistant Surgeon (PDF) CC.PP.029 2/7/2017
Bevacizumab (PDF) CP.PHAR.93 2/10/2017
Bilateral Procedures (PDF) CC.PP.037 2/7/2017
Bronchial Thermoplasty (PDF) CP.MP.110 4/1/2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 5/21/2018
Cerumen Removal (PDF) CC.PP.008 8/12/2016
Clean Claims (PDF) CC.PP.021 10/18/2016
CLIA Number (PDF) CC.PP.022 10/18/2016
Coding Overview (PDF) CC.PP.011 10/18/2016
Cosmetic Procedures (PDF) CC.PP.024 10/18/2016
Diagnosis of Vaginitis (PDF) CP.MP.97 4/1/2017
Digital Analysis of EEGs (PDF) CP.MP.105 2/10/2017
Distinct Procedural Modifiers (PDF) CC.PP.020 10/18/2016
DNA Analysis of Stool (PDF) CP.MP.125 6/17/2017
Duplicate Primary Code Billing (PDF) CC.PP.044 2/7/2017
E&M Medical Decision-Making (PDF) CC.PP.051 7/25/2017
EEG in Evaluation of Headache (PDF) CP.MP.155 5/21/2018
EM Bundling Edits (PDF) CC.PP.010 8/12/2016
Endometrial Ablation (EA) (PDF) CP.MP.106 Retired on 12/9/2018
Endometrial Ablation (PDF) CP.MP.106 12/10/2018
EpiFix Wound Treatment (PDF) CP.MP.140 11/1/2017
Evoked Potentials (PDF) CP.MP.134 6/17/2017
Fecal Calprotectin Assay (PDF) CP.MP.135 6/17/2017
FeNo Testing (PDF) CP.MP.103 4/1/2017
Global Maternity Billing (PDF) CC.PP.016 10/18/2016
H Pylori Testing (PDF) CP.MP.153 5/21/2018
Holter Monitors (PDF) CP.MP.113 4/1/2017
Homocysteine Testing (PDF) CP.MP.121 4/1/2017
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 10/18/2016
Inpatient Consultation (PDF) CC.PP.038 2/7/2017
Inpatient Only Procedures (PDF) MP.PP.018 10/18/2016
IV Hydration (PDF) CC.PP.012 10/18/2016
Laser Skin Treatment (PDF) CP.MP.123 4/1/2017
Leveling of Emergency Room (PDF) CC.PP.053  1/1/2019
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 11/1/2017
Maximum Units (PDF) CC.PP.007 8/12/2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 5/21/2018
Mechanical Stretch Devices (PDF) CP.MP.144 11/1/2017
Moderate Conscious Sedation (PDF) CC.PP.015 10/18/2016
Modifier -25 clinical validation (PDF) CC.PP.013 10/18/2016
Modifier -59 clinical validation (PDF) CC.PP.014 10/18/2016
Modifier DOS Validation (PDF) CC.PP.034 10/18/2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 10/18/2016
Monitored Anesthesia Care (PDF) CP.MP.151 12/15/18
Multiple CPT Code Replacement (PDF) CC.PP.033 10/18/2016
NCCI Unbundling (PDF) CC.PP.031 10/18/2016
Never Paid Events (PDF) CC.PP.017 10/18/2016
New Patient (PDF) CC.PP.036 2/7/2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  12/15/2018
Outpatient Consultation (PDF) CC.PP.039 2/7/2017
Paclitaxel (PDF) CP.PHAR.176 5/16/2016
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 10/18/2016
Place of Service Mismatch (PDF) CC.PP.063  12/15/2018
Post-Operative Visits (PDF) CC.PP.042 2/7/2017
Pre-Operative Visits (PDF) CC.PP.041 2/7/2017
Problem Oriented Visits with Preventative Services CC.PP.057 11/1/2018
Problem Oriented Visits with Surgical Procedures CC.PP.052 11/1/2018
Professional Component (PDF) CC.PP.027 10/18/2016
PROM Testing (PDF) CP.MP.149 11/8/2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 2/10/2017
Pulse Oximetry (PDF) CC.PP.025 10/18/2016
Rituximab (PDF) CP.PHAR.260 2/10/2017
Robotic Surgery (PDF) CC.PP.050 11/1/2017
Same Day Visits (PDF) CC.PP.040 2/7/2017
Status "B" Bundled Services (PDF) CC.PP.046 2/7/2017
Status P Bundled Services (PDF) CC.PP.049 6/17/2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 10/18/2016
Thyroid Testing in Pediatrics (PDF) CP.MP.154 5/21/2018
Transgender Related Services (PDF) CC.PP.047 2/22/2017
Ultrasound in Pregnancy (PDF) CP.MP.38 2/10/2017
Unbundled Professional Services (PDF) CC.PP.043 4/6/2017
Unbundled Surgical Procedures (PDF) CC.PP.045 4/6/2017
Unlisted Procedure Codes (PDF) CC.PP.009 8/12/2016
Urine Specimen Validity Testing (PDF) CC.PP.056 11/8/2017
Urodynamic Testing (PDF) CP.MP.98 8/12/2016
Vitamin D Testing in Children (PDF) CP.MP.157 5/21/2018
Wheelchair Accessories (PDF) CC.PP.502 8/12/2016
Wheelchair Seating (PDF) CP.MP.99 8/12/2016
Wireless Motility Capsule (PDF) CP.MP.143 11/1/2017
Policy Title Policy Number Effective Date
Abaloparatide (Tymlos) (PDF) AR.PHAR.345
11/07/17
Abatacept (Orencia) (PDF) AR.PHAR.241
12/08/17
AbobotulinumtoxinA (Dysport) (PDF) AR.PHAR.230
11/07/17
Acne treatment options except isotretinoin (PDF) HIM.PA.71
03/01/16
Adalimumab (Humira) (PDF) AR.PHAR.242
12/08/17
Aflibercept (Eylea) (PDF) AR.PHAR.184
07/01/16
Alemtuzumab (Lemtrada) (PDF) AR.PHAR.243
12/08/17
Alpha-1 Proteinase Inhibitors (PDF) AR.PHAR.94
07/24/15
Ambrisentan (PDF) AR.PHAR.190
07/01/16
Anakinra (Kineret) (PDF) AR.PHAR.244
12/08/17
Anzemet (PDF) HIM.PA.85
03/01/16
Apremilast (Otezla) (PDF) AR.PHAR.245
12/08/17
aprepitant (Emend) (PDF) HIM.PA.62
03/01/16
Atezolizumab (Tecentriq) (PDF) AR.PHAR.235
09/08/17
atomoxetine (Strattera) PDF) HIM.PA.66
03/01/16
Atypical antipsychotics (PDF) HIM.PA.59
03/01/16
Avelumab (Bavencio) (PDF) AR.PHAR.333
09/08/17
Axitinib (Inlyta) (PDF) AR.PHAR.100
09/08/17
Aztreonam (Cayston) (PDF) AR.PHAR.209
09/08/17
Benlysta (belimumab) (PDF) AR.PHAR.88
07/24/15
Bexarotene (Targretin) Capsules (PDF) AR.PHAR.75 11/07/17

Bosentan (PDF) AR.PHAR.191 07/01/16

Bosulif (PDF) AR.PHAR.105 03/01/16

Brand Name Override and Non-formulary Medication Policy (PDF) HIM.PA.103
03/01/16
Brigatinib (Alunbrig) (PDF) AR.PHAR.342
11/07/17
Butorphanol Nasal Spray (PDF) HIM.PA.46
03/01/16
C1 Esterase Inhibitors (PDF) AR.PHAR.202
07/01/16
Cabozantinib (Cometriq, Cabometyx) (PDF) AR.PHAR.111
09/08/17
Capecitabine (Xeloda) (PDF) AR.PHAR.60
11/07/17
Caprelsa (vandetanib) (PDF) AR.PHAR.80
07/24/15
Carglumic acid (Carbaglu) (PDF) AR.PHAR.206
09/08/17
Cerliponase alfa (Brineura) (PDF) AR.PHAR.338
11/07/17
Certolizumab (Cimzia) (PDF) AR.PHAR.247
12/08/17
Cinacalcet (Sensipar (PDF) AR.PHAR.61
09/08/17
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) AR.PHAR.385 10/19/2018
Cosyntropin (Cortrosyn) (PDF) AR.PHAR.203
09/08/17
Crizotinib (PDF) AR.PHAR.90
12/08/17
Dabrafenib (Tafinlar) (PDF) AR.PHAR.239
11/07/17
Daclatasvir (Daklinza) (PDF) AR.PHAR.274
12/08/17
Daclizumab (Zinbryta) (PDF) AR.PHAR.269
12/08/17
Dalfampridine (Ampyra) (PDF) AR.PHAR.248
12/08/17
Dalteparin (Fragmin) (PDF) AR.PHAR.225
0908/17
Darbopoetin Alfa (PDF) AR.PHAR.236
10/30/16
Dasabuvir Ombitasvir Paritaprevir Ritonavir (PDF) AR.PHAR.278
12/08/17
Dasatinib (Sprycel) (PDF) AR.PHAR.72
11/07/17
Denosumab (PDF) AR.PHAR.58
12/08/17
Desferal (deferoxamine) (PDF) AR.PHAR.146
03/01/16
Desmopressin Acetate (DDAVP Injection) (PDF) AR.PHAR.214
09/08/17
Deutetrabenazine (Austedo) (PDF) AR.PHAR.341
11/07/17
Dimethyl Fumarate (Tecfidera) (PDF) AR.PHAR.249
12/08/17
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) HIM.PA.58
03/01/16
Dornase Alfa (Pulmozyme) (PDF) AR.PHAR.212
09/08/17
Dupilumab (Dupixent) (PDF) AR.PHAR.336
09/08/17
Durvalumab (Imfinzi) (PDF) AR.PHAR.339
11/07/17
Ecallantide (Kalbitor) (PDF) AR.PHAR.177
07/01/16
Eculizumab (Soliris) (PDF) AR.PHAR.97
09/08/17
Edaravone (Radicava) (PDF) AR.PHAR.343
11/07/17
Egrifta (PDF) AR.PHAR.109
04/01/16
Elbasvir Grazoprevir (PDF) AR.PHAR.275
12/08/17
Eltrombopag (Promacta) (PDF) AR.PHAR.180
07/01/16
Enfuvirtide (PDF) AR.PHAR.41
07/24/15
Enoxaparin (Lovenox) (PDF) AR.PHAR.224
09/08/17
Epoetin alfa (PDF) AR.PHAR.237
07/01/16
Epoprostenol (PDF) AR.PHAR.192
07/01/16
Etanercept (Enbrel) (PDF) AR.PHAR.250
12/08/17
Everolimus (Afinitor, Afinitor Disperz) (PDF) AR.PHAR.63
09/08/17
Exjade (deferasirox) (PDF) AR.PHAR.145
03/01/16
ezogabine (Potiga) (PDF) HIM.PA.60
03/01/16
Factor VIII (Human, Recombinant) (PDF) AR.PHAR.215
09/08/17
Factor VIII von Willebrand Factor Complex (PDF) AR.PHAR.216
09/08/17
famciclovir (Famvir) (PDF) HIM.PA.63
03/01/16
Ferriprox (deferiprone) (PDF) AR.PHAR.147
03/01/16
Fingolimod (Gilenya) (PDF) AR.PHAR.251
12/08/17
Fondaparinux (Arixtra) (PDF) AR.PHAR.226
09/08/17
Glatiramer (Copaxone, GlatopaTM) (PDF) AR.PHAR.252
12/08/17
Glecaprevir Pibrentasvir (Mavyret) (PDF) AR.PHAR.348
12/08/17
Global Biopharm Policy (PDF) AR.PHAR.57
12/08/17
Golimumab (SimponiSimponi Aria) (PDF) AR.PHAR.253
11/07/17
guanfacine ER (INTUNIV) (PDF) HIM.PA.98
03/01/16
HIV Medications (PDF) HIM.PA.78
03/01/16
Hyaluronate derivatives (PDF) AR.PHAR.05
12/08/17
Hydroxyprogesterone Caproate (Makena) (PDF) AR.PHAR.14
03/01/16
Ibandronate sodium (PDF) AR.PHAR.189
07/01/16
Icatibant (PDF) AR.PHAR.178
07/01/16
Iloprost (PDF) AR.PHAR.193
07/01/16
Imatinib (Gleevec) (PDF) AR.PHAR.65
11/07/17
Immune Globulin Injections (PDF) AR.PHAR.103
03/01/16
Immunization Coverage (PDF) AR.PHAR.28
07/24/15
IncobotulinumtoxinA (Xeomin) (PDF) AR.PHAR.231
11/07/17
Infliximab (PDF) AR.PHAR.254
11/07/17
Inhaled Corticosteroids (PDF) HIM.PA.73
03/01/16
Inhaled Long Acting Beta Agonists and Combination Products (PDF) HIM.PA.74
03/01/16
Interferon beta-1a (Avonex, Rebif) (PDF) AR.PHAR.255

12/08/17
Interferon beta-1b (Betaseron, Extavia) (PDF) AR.PHAR.256
12/08/17
Interferon Gamma 1-b b (Actimmune) (PDF) AR.PHAR.52
09/08/17
isotretinoin (Claravis, Sotret, Amnesteem, Myorisan) (PDF) HIM.PA.50
03/01/16
Ivacaftor (Kalydeco) (PDF) AR.PHAR.210
09/08/17
Ixekizumab (Taltz) (PDF) AR.PHAR.257
12/08/17
lacosamide (Vimpat) (PDF) HIM.PA.49
03/01/16
LedipasvirSofosbuvir (Harvoni) (PDF) AR.PHAR.279
09/08/17
Lenalidomide (PDF) AR.PHAR.71
10/30/16
Long Acting Injectable Atypical Antipsychotics (PDF) HIM.PA.99
03/01/16
lubiprostone (Amitiza) (PDF) HIM.PA.79
03/01/16
Lumacaftor-Ivacaftor (Orkambi) (PDF) AR.PHAR.213
09/08/17
Macitentan (PDF) AR.PHAR.194
07/01/16
Mepolizumab (Nucala) (PDF) AR.PHAR.200
09/08/17
Midostaurin (Rydapt) (PDF) AR.PHAR.344
11/07/17
Mifepristone (Korlym) (PDF) AR.PHAR.101
09/08/17
Mitoxantrone (PDF) AR.PHAR.258
12/08/17
Naltrexone (Vivitrol) (PDF) AR.PHAR.96
07/01/16
nasal steroids (PDF) HIM.PA.93
03/01/16
Natalizumab (Tysabri) (PDF) AR.PHAR.259
11/07/17
Nilotinib (Tasigna) (PDF) AR.PHAR.76
11/07/17
Nivolumab (Opdivo) (PDF) AR.PHAR.121
09/08/17
Non-formulary and formulary contraceptives (PDF) HIM.PA.100
07/25/15
Nucynta (PDF) HIM.PA.86
03/01/16
Ocrelizumab (Ocrevus) (PDF) AR.PHAR.335
09/08/17
Ocreotide acetate (PDF) AR.PHAR.40
07/24/15
Omalizumab (Xolair) (PDF) AR.PHAR.01
11/07/17
Ombitasvir Paritaprevir Ritonavir (PDF) AR.PHAR.276
12/08/17
OnabotulinumtoxinA (Botox) (PDF) AR.PHAR.232
11/07/17
Opioid Analgesics (PDF) HIM.PA.139
01/01/18
Overactive Bladder Agents (PDF) HIM.PA.40
03/01/16
Palivizumab (Synagis ) (PDF) AR.PHAR.16
12/08/17
Paricalcitol (Generic and Zemplar) (PDF) AR.PHAR.270
12/08/17
Pegaptanib (Macugen) (PDF) AR.PHAR.185
07/01/16
Peginterferon beta-1a (Plegridy) (PDF) AR.PHAR.271
12/08/17
Pegloticase (Krystexxa) (PDF) AR.PHAR.115
06/01/13
Pertuzumab (PDF) AR.PHAR.227
10/30/16
Pomalyst (PDF) AR.PHAR.116
04/01/16
Ponatinib (PDF) AR.PHAR.112
10/30/16
Praluent (PDF) AR.PHAR.124
03/01/16
Provenge (PDF) AR.PHAR.120
04/01/16
Ramucirumab (Cyramza) (PDF) AR.PHAR.119
09/08/17
Ranibizumab (Lucentis) (PDF) AR.PHAR.186
07/01/16
rasagiline (Azilect) (PDF) HIM.PA.89
03/01/16
Repatha (PDF) AR.PHAR.123
03/01/16
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) AR.PHAR.168
09/08/17
Reslizumab (Cinqair) (PDF) AR.PHAR.223 09/08/17

Ribociclib (Kisqali) (PDF) AR.PHAR.334
09/08/17
rifaximin (Xifaxan) (PDF) HIM.PA.68
03/01/16
Rilonacept (Arcalyst) (PDF) AR.PHAR.266 11/07/17

RimabotulinumtoxinB (Myobloc) (PDF) AR.PHAR.233
11/07/17
Riociguat (PDF) AR.PHAR.195
07/01/16
Risperidone (PDF) HIM.PA.81
03/01/16
romiplostim (Nplate) (PDF) AR.PHAR.179
07/01/16
rufinamide (Banzel) (PDF) HIM.PA.90
03/01/16
Ruxolitinib (Jakafi) (PDF) AR.PHAR.98
09/08/17
Sapropterin (Kuvan) (PDF) AR.PHAR.43
09/08/17
Secukinumab (Cosentyx) (PDF) AR.PHAR.261
12/08/17
Selexipag (PDF) AR.PHAR.196
07/01/16
Sildenafil (PDF) AR.PHAR.197
07/01/16
Simeprevir (Olysio) (PDF) AR.PHAR.280
12/08/17
sodium oxybate (Xyrem) (PDF) HIM.PA.69
03/01/16
Sofosbuvir & Velpatasvir (Epclusa) (PDF) AR.PHAR.268
12/08/17
Sofosbuvir (Sovaldi) (PDF) AR.PHAR.281
09/08/17
Sofosbuvir Velpatasvir Voxilaprevir (Vosevi) (PDF) AR.PHAR.347
12/08/17
Somatropin (Recombinant Human Growth Hormone) (PDF) AR.PHAR.55
11/07/17
Sonidegib (Odomzo) (PDF) AR.PHAR.272
12/08/17
Sorafenib (PDF) AR.PHAR.69
10/30/16
Stivarga (regorafenib) (PDF) AR.PHAR.107
03/01/16
Sunitinib (PDF) AR.PHAR.73
12/08/17
Sylatron (peginterferon alfa-2b) (PDF) AR.PHAR.89
07/24/15
Synribo (omacetaxine mepesuccinate) (PDF) AR.PHAR.108
04/01/16
Tadalafil (PDF) AR.PHAR.198
07/01/16
Tarceva (PDF) AR.PHAR.74
07/24/15
Teduglutide (Gattex) (PDF) AR.PHAR.114
09/08/17
telbivudine (Tyzeka) (PDF) HIM.PA.95
03/01/16
Temozolomide (PDF) AR.PHAR.77
12/08/17
Teriflunomide (Aubagio) (PDF) AR.PHAR.262
12/08/17
Teriparatide (PDF) AR.PHAR.188
07/01/16
Thalidomide (PDF) AR.PHAR.78
10/30/16
Thyrogen (PDF) AR.PHAR.95
07/24/15
Tobramycin (PDF) AR.PHAR.211
09/08/17
Tocilizumab (Actemra) (PDF) AR.PHAR.263
11/07/17
Tofacitinib (XeljanzXeljanz XR) (PDF) AR.PHAR.267
11/07/17
Topical Immunomodulators (PDF) HIM.PA.56
03/01/16
Topical Testosterone (PDF) HIM.PA.87
03/01/16
Topotecan (PDF) AR.PHAR.64
10/30/16
Trabectedin (Yondelis) (PDF) AR.PHAR.204
09/08/17
Trametinib (Mekinist) (PDF) AR.PHAR.240
11/07/17
Treprostinil (PDF) AR.PHAR.199
07/01/16
Tykerb (lapatinib) (PDF) AR.PHAR.79
07/24/15
Ustekinumab (Stelara) (PDF) AR.PHAR.264
12/08/17
Valbenazine (Ingrezza) (PDF) AR.PHAR.340
11/07/17
Vedolizumab (Entyvio) (PDF) AR.PHAR.265
11/07/17
Verteporfin (PDF) AR.PHAR.187
07/01/16
Vismodegib (Erivedge) (PDF) AR.PHAR.273
12/08/17
Votrient (pazopanib) (PDF) AR.PHAR.81
07/24/15
Xenazine (tetrabenazine) (PDF) AR.PHAR.92
07/24/15
Xiaflex (PDF) AR.PHAR.82
07/24/15
Xtandi (enzalutamide) (PDF) AR.PHAR.106
03/01/16
Zelboraf (vemurafenib) (PDF) AR.PHAR.91
07/24/15
Zoledronic acid (PDF) AR.PHAR.59
07/01/16
Zolinza (PDF) AR.PHAR.83
07/24/15
Zytiga (abiraterone) (PDF) AR.PHAR.84
07/24/15