Clinical Payment Policies | Ambetter from Arkansas Health & Wellness

 

Clinical & Payment Policies

To easily search for a policy, use the Ctrl+F (Command+F on Mac) function on your keyboard to search by keyword, policy number or effective date.

What are Clinical Policies?

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include policies relating to evolving medical technologies and procedures as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice, including peer-reviewed medical literature, government agency/program approval status, evidence-based guidelines, positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas affected by the policy, and other available clinical information. 

All policies found in the Arkansas Health & Wellness Clinical Policy Manual apply to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Clinical Policy Manual may have either an “Arkansas Health & Wellness” or a “Centene” heading.  Arkansas Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures, or pharmaceutical treatments for which an Arkansas Health & Wellness clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual SmartSheets™ for adult and pediatric procedures, durable medical equipment, and imaging procedures by logging in to our Secure Provider Portal or calling Arkansas Health & Wellness at 1-877-617-0390 (TTY 1-877-617-0392).

Arkansas Health & Wellness may, from time to time, delegate utilization management of specific services. In such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure, or treatment that is not addressed in the Clinical Policy Manuals or InterQual criteria is payable by Arkansas Health & Wellness.

What are Payment Policies?

Healthcare claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether healthcare services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include claims processing guidelines referenced by the Centers for Medicare & Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), CPT® guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of healthcare and medical necessity, and, at times, state-specific claims reimbursement
guidance.

All policies found in the Arkansas Health & Wellness Payment Policy Manual apply with respect to Arkansas Health & Wellness members. Policies in the Arkansas Health & Wellness Payment Policy Manual may have either an “Arkansas Health & Wellness” or a “Centene” heading. Arkansas Health & Wellness may, from time-to-time, employ a vendor that applies payment policies to specific services. In such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure, or treatment that is not addressed in the Payment Policy Manual is payable by Arkansas Health & Wellness. 

Prior Authorization Requests

Beginning January 1, 2021, Ambetter from Arkansas Health & Wellness has partnered with National Imaging Associates (NIA) for prior authorization requests for the following services:

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Spinal Epidural Injections
  • Paravertebral Facet Joint Injections or Blocks
  • Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
  • Sacroiliac Joint Injections

Clinical Policies for these procedures can be found at the NIA website.

Clinical Policies for CT/CTA/CCTA, MRI, MRA, and Pet scans can also be found at the NIA website.

Policy TitlePolicy NumberEffective Date
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157November 1, 2023
Acupuncture (PDF)CP.MP.92September 1, 2023
Allergy Testing and Therapy (PDF)CP.MP.100
November 1, 2023
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108December 1, 2023
Applied Behavior Analysis (PDF)CP.BH.104June 1, 2024
Applied Behavioral Analysis Documentation Requirements (PDF)CP.BH.105May 1, 2024
Articular Cartilage Defect Repairs (PDF)CP.MP.26April 1, 2024
Assisted Reproductive Technology (PDF)CP.MP.55March 1, 2024
Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)CP.BH.124August 1, 2023
Behavioral Health Treatment Documentation Requirements (PDF)CP.BH.500November 1, 2022
Biofeedback (PDF)CP.MP.168January 1, 2024
Biofeedback for Behavioral Health Disorders (PDF)CP.BH.300May 1, 2023
Bone-Anchored Hearing Aids (PDF)AR.CP.MP.93August 1, 2023
Burn Surgery (PDF)CP.MP.186April 1, 2024
Cardiac Biomarker Testing (PDF)CP.MP.156November 1, 2023
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164September 1, 2023
Clinical Trials (PDF)CP.MP.94August 1, 2023
Cochlear Implanted Replacements (PDF)AR.CP.MP.14September 1, 2020
Concert Genetics Oncology: Algorithmic Testing (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Cancer Screening (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating
Tumor Cells (Liquid Biopsy) (PDF)
V1.2024April 1, 2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V1.2024April 1, 2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Cardiac Disorders (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Eye Disorders (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Hearing Loss (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V1.2024 June 1, 2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Kidney Disorders (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Lung Disorders (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V1.2024June 1, 2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Pharmacogenetics (PDF)V1.2024
April 1, 2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V1.2024June 1, 2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V1.2024April 1, 2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V1.2024April 1, 2024
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31December 1, 2023
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201August 1, 2023
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203October 1, 2023
Disc Decompression Procedures (PDF)CP.MP.114July 1, 2023
Discography (PDF)CP.MP.115August 1, 2023
Donor Lymphocyte Infusion (PDF)CP.MP.101June 1, 2024
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50August 1, 2023
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107March 1, 2024
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145January 1, 2024
Endometrial Ablation (PDF)CP.MP.106August 1, 2023
Experimental Technologies (PDF)CP.MP.36June 1, 2024
Facet Joint Interventions (PDF)CP.MP.171September 1, 2023
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248June 1, 2024
Fecal Incontinence Treatments (PDF)CP.MP.137December 1, 2023
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129March 1, 2024
Ferriscan R2-MRI (PDF)CP.MP.53December 1, 2023
Fertility Preservation (PDF)CP.MP.130March 1, 2024
Functional MRI (PDF)CP.MP.43April 1, 2024
Gastric Electrical Stimulation (PDF)CP.MP.40July 1, 2023
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)CP.MP.209August 1, 2023
Gender-Affirming Procedures (PDF)CP.MP.95

October 1, 2023
Heart-Lung Transplant (PDF)CP.MP.132July 1, 2023
Helicobacter Pylori Serology TestingPDF)CP.MP.153November 1, 2023
Home Births (PDF)CP.MP.136March 1, 2024
Home Ventilators (PDF)CP.MP.184August 1, 2023
Hospice Services (PDF)CP.MP.54September 1, 2023
Hyperhidrosis Treatments (PDF)CP.MP.62June 1, 2024
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180January 1, 2024
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173June 1, 2024
Implantable Loop Recorder (PDF)CP.MP.243June 1, 2024
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160June 1, 2024
Intensity-Modulated Radiotherapy (PDF)CP.MP.69October 1, 2023
Intestinal and Multivisceral Transplant (PDF)CP.MP.58July 1, 2023
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167October 1, 2023
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61December 1, 2023
Lantidra (Donislecel): Allogenic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250April 1, 2024
Liposuction for Lipedema (PDF)CP.MP.244July 1, 2023
Long Term Care Placement (PDF)CP.MP.71April 1, 2024
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139March 1, 2023
Lung Transplantation (PDF)CP.MP.57June 1, 2024
Lysis of Epidural Lesions (PDF)CP.MP.116July 1, 2023
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144April 1, 2024
Multiple Sleep Latency Testing (PDF)CP.MP.24June 1, 2023
Neonatal Abstinence Syndrome Guidelines (PDF)CP.MP.86March 1, 2024
Neonatal Sepsis Management (PDF)CP.MP.85March 1, 2024
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170June 1, 2024
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48December 1, 2023
NICU Apnea Bradycardia Guidelines (PDF)CP.MP.82March 1, 2024
NICU Discharge Guidelines (PDF)CP.MP.81March 1, 2024
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141April 1, 2023
Obstetrical Home Care Programs (PDF)CP.MP.91January 1, 2024
Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249August 1, 2023
Orthognathic Surgery (PDF)CP.MP.202 December 1, 2023
Osteogenic Stimulation (PDF)CP.MP.194October 1, 2023
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176July 1, 2023
Outpatient Oxygen Use (PDF)CP.MP.190June 1, 2024
Pancreas Transplantation (PDF)CP.MP.102April 1, 2024
Panniculectomy (PDF)CP.MP.109December 1, 2023
Pediatric Heart Transplant (PDF)CP.MP.138December 1, 2023
Pediatric Kidney Transplant (PDF)CP.MP.246June 1, 2024
Pediatric Liver Transplant (PDF)CP.MP.120July 1, 2023
Pediatric Oral Function Therapy (PDF)CP.MP.188July 1, 2023
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147July 1, 2023
Phototherapy for Neonatal Hyperbilirubinemia (PDF)CP.MP.150December 1, 2023
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49November 1, 2023
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)CP.MP.181November 1, 2023
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133October 1, 2023
Proton and Neutron Beam Therapies (PDF)CP.MP.70January 1, 2024
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51September 1, 2023
Repair of Nasal Valve Compromise (PDF)CP.MP.210July 1, 2023
Sacroiliac Joint Fusion (PDF)CP.MP.126November 1, 2023
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166October 1, 2023
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146September 1, 2023
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174January 1, 2024
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165October 1, 2023
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185September 1, 2023
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117March 1, 2024
Stereotactic Body Radiation Therapy (PDF)CP.MP.22June 1, 2024
Substance Use Disorders Treatment and Services (PDF)CP.BH.100November 1, 2022
Tandem Transplant (PDF)CP.MP.162April 1, 2024
Therapeutic Utilization of Inhaled Nitric Oxide (PDF)CP.MP.87June 1, 2023
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154November 1, 2023
Total Artificial Heart (PDF)CP.MP.127September 1, 2023
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163April 1, 2024
Transcatheter Closure of Patent Foramen Ovale (PDF)CP.MP.151January 1, 2024
Transplant Service Documentation Requirements (PDF)CP.MP.247April 1, 2024
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200August 1, 2023
Trigger Point Injections for Pain Management (PDF)CP.MP.169October 1, 2022
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142January 1, 2024
Vagus Nerve Stimulation (PDF)CP.MP.12October 1, 2022
Ventricular Assist Devices (PDF)CP.MP.46April 1, 2024
Wireless Motility Capsule (PDF)CP.MP.143November 1, 2023

Policy TitlePolicy NumberEffective Date
3-Day Payment Window (PDF)CC.PP.500July 1, 2014
Add-On Code Billed Without Primary Code (PDF)CC.PP.030October 18, 2016
Ambulatory EEG (PDF)CP.MP.96August 12, 2016
Assistant Surgeon (PDF)CC.PP.029February 7, 2017
Bilateral Procedures (PDF)CC.PP.037February 7, 2017
Bronchial Thermoplasty (PDF)CP.MP.110May 1, 2023
Cerumen Removal (PDF)CC.PP.008August 12, 2016
Clean Claims (PDF)CC.PP.021October 18, 2016
Coding Overview (PDF)CC.PP.011October 18, 2016
Cosmetic Procedures (PDF)CC.PP.024October 18, 2016
Digital EEG Spike Analysis (PDF)CP.MP.105June 1, 2024
Distinct Procedural Modifiers (PDF)CC.PP.020October 18, 2016
Duplicate Primary Code Billing (PDF)CC.PP.044February 7, 2017
EEG in the Evaluation of Headache (PDF)CP.MP.155June 1, 2024
E&M Medical Decision-Making (PDF)CC.PP.051July 25, 2017
EM Bundling Edits (PDF)CC.PP.010August 12, 2016
Evoked Potential Testing (PDF)CP.MP.134June 1, 2024
Global Maternity Billing (PDF)CC.PP.016October 18, 2016
Holter Monitors (PDF)CP.MP.113June 1, 2024
Homocysteine Testing (PDF)CP.MP.121May 1, 2023
Hospital Visit Codes Billed with Labs (PDF)CC.PP.023October 18, 2016
Inpatient Consultation (PDF)CC.PP.038February 7, 2017
Inpatient Only Procedures (PDF)MP.PP.018April 1, 2024
IV Hydration (PDF)CC.PP.012October 18, 2016
Laser Therapy for Skin Conditions (PDF)CP.MP.123June 1, 2024
Leveling of Care: Evaluation and Management Overcoding (PDF)CC.PP.066March 15, 2021
Leveling of Emergency Room (PDF)CC.PP.053 January 1, 2019
Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139May 1, 2013
Maximum Units (PDF)CC.PP.007August 12, 2016
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152June 1, 2024
Moderate Conscious Sedation (PDF)CC.PP.015October 18, 2016
Modifier -25 clinical validation (PDF)CC.PP.013October 18, 2016
Modifier -59 clinical validation (PDF)CC.PP.014October 18, 2016
Modifier DOS Validation (PDF)CC.PP.034October 18, 2016
Modifier to Procedure Code Validation (PDF)CC.PP.028October 18, 2016
Multiple CPT Code Replacement (PDF)CC.PP.033October 18, 2016
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)CC.PP.065March 15, 2021
Multiple Procedure Reduction: Ophthalmology (PDF)CC.PP.069March 15, 2021
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)CC.PP.068March 15, 2021
NCCI Unbundling (PDF)CC.PP.031October 18, 2016
Never Paid Events (PDF)CC.PP.017October 18, 2016
New Patient (PDF)CC.PP.036February 7, 2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF)CC.PP.061 March 15, 2021
Outpatient Consultation (PDF)CC.PP.039February 7, 2017
Physician’s Consultation Services (PDF)CC.PP.054September 1, 2018
Physician Visit Codes Billed with Labs (PDF)CC.PP.019October 18, 2016
Place of Service Mismatch (PDF)CC.PP.063 December 15, 2018
Post-Operative Visits (PDF)CC.PP.042February 7, 2017
Pre-Operative Visits (PDF)CC.PP.041February 7, 2017
Problem Oriented Visits with Preventative Services (PDF)CC.PP.057November 1, 2018
Problem Oriented Visits with Surgical Procedures (PDF)CC.PP.052November 1, 2018
Professional Component (PDF)CC.PP.027October 18, 2016
Pulmonary Function Testing (PDF)CP.MP.242June 1, 2024
Pulse Oximetry (PDF)CC.PP.025October 18, 2016
Renal Hemodialysis (PDF)CC.PP.067March 15, 2021
Robotic Surgery (PDF)CC.PP.050November 1, 2017
Same Day Visits (PDF)CC.PP.040February 7, 2017
Skilled Nursing Facility Leveling (PDF)CC.PP.206June 1, 2024
Status "B" Bundled Services (PDF)CC.PP.046February 7, 2017
Status P Bundled Services (PDF)CC.PP.049June 17, 2017
Supplies Billed on Same Day As Surgery (PDF)CC.PP.032October 18, 2016
Testing for Select Genitourinary Conditions (PDF)CP.MP.97June 1, 2024
Transgender Related Services (PDF)CC.PP.047February 22, 2017
Ultrasound in Pregnancy (PDF)CP.MP.38June 1, 2024
Unbundled Professional Services (PDF)CC.PP.043April 6, 2017
Unbundled Surgical Procedures (PDF)CC.PP.045April 6, 2017
Unlisted Procedure Codes (PDF)CC.PP.009August 12, 2016
Urine Specimen Validity Testing (PDF)CC.PP.056November 8, 2017
Urodynamic Testing (PDF)CP.MP.98June 1, 2024
Wheelchair Accessories (PDF)CC.PP.502August 12, 2016
Wheelchair Seating (PDF)CP.MP.99May 1, 2023

Policy TitlePolicy NumberEffective Date
Abaloparatide (Tymlos) (PDF)CP.PHAR.345February 1, 2024
Abametapir (Xeglyze) (PDF)CP.PMN.253December 1, 2023
Abatacept (Orencia)CP.PHAR.241Retire by July 1, 2024
Abatacept (Orencia)CP.PHAR.241July 1, 2024
Abemaciclib (Verzenio) (PDF)CP.PHAR.355December 1, 2023
Abiraterone (Zytiga) (PDF)CP.PHAR.84April 1, 2024
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230Retire by July 1, 2024
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230July 1, 2024
Abrocitinib (Cibinqo) (PDF)CP.PHAR.578March 1, 2024
Acalabrutinib (Calquence)CP.PHAR.366February 1, 2024
Adzynma (ADAMTS13, recombinant-krhn) (PDF)CP.PHAR.635Retire by May 1, 2024
Adzynma (ADAMTS13, recombinant-krhn) (PDF)CP.PHAR.635May 1, 2024
Acyclovir Buccal tab (Sitavig) (PDF)CP.PMN.210December 1, 2023
Adagrasib (Krazati) (PDF)CP.PHAR.605April 1, 2024
Adefovir (Hepsera) (PDF)CP.PHAR.142December 1, 2023
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)CP.PHAR.229June 1, 2024
Aducanumab (Aduhelm) (PDF)CP.PHAR.468June 1, 2024
Afamelanotide (Scenesse) (PDF)CP.PHAR.444February 1, 2024
Afatinib (Gilotrif) (PDF)CP.PHAR.298June 1, 2023
Aflibercept (Eylea) (PDF)CP.PHAR.184May 1, 2024
Agalsidase Beta (Fabrazyme) (PDF)CP.PHAR.158 July 1, 2024
Agalsidase Beta (Fabrazyme) (PDF)CP.PHAR.158 Retire by July 1, 2024
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)CP.PMN.138June 1, 2024
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)CP.PMN.138Retire to June 1, 2024
Alectinib (Alecensa) (PDF)CP.PHAR.369June 1, 2024
Alemtuzumab (Lemtrada) (PDF)CP.PHAR.243June 1, 2024
Alendronate (Binosto, Fosamax plus D) (PDF)CP.PMN.88February 1, 2024
Alglucosidase (Lumizyme) (PDF)CP.PHAR.160July 1, 2024
Alglucosidase (Lumizyme) (PDF)CP.PHAR.160Retire by July 1, 2024
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (PDF)CP.PHAR.562February 1, 2024
Allogenic processed thymus tissue-agdc (Rethymic) (PDF)CP.PHAR.563February 1, 2024
Alpelisib (Piqray) (PDF)CP.PHAR.430April 1, 2024
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)CP.PHAR.94February 1, 2024
Amantadine ER (Gocovri,Osmolex ER) (PDF)CP.PMN.89February 1, 2024
Ambrisentan (Letairis®) (PDF)CP.PHAR.190February 1, 2024
Amifampridine (Firdapse)(PDF)CP.PHAR.411April 1, 2024
Amikacin (Arikayce)(PDF) CP.PHAR.401June 1, 2024
Amisulpride (Barhemsys)(PDF)CP.PMN.236February 1, 2024
Amivantamab-vmjw (Rybrevant) (PDF)CP.PHAR.544August 1, 2023
Anifrolumab-fnia (Saphnelo) (PDF)CP.PHAR.551January 1. 2024
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)CP.PHAR.217February 1, 2024
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF)CP.PHAR.506January 1, 2024
Antithrombin III (ATryn, Thrombate III) (PDF)CP.PHAR.564February 1, 2024
Apalutamide (Erleada) (PDF)CP.PCH.45July 1, 2024
Apalutamide (Erleada) (PDF)CP.PCH.45Retire by July 1, 2024
Apomorphine (Apokyn) (PDF)CP.PHAR.488August 1, 2023
Aprepitant (Emend®) (PDF)CP.PMN.19February 1, 2024
Arimoclomol (Brand Name) (PDF)CP.PHAR.510December 1, 2023
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada)  (PDF)CP.PHAR.290February 1, 2024
Aripiprazole ODT (Abilify) (PDF)CP.PCH.37February 1, 2024
Armodafinil (Nuvigil) (PDF)CP.PMN.35June 1, 2024
Asciminib (Scemblix) (PDF)CP.PHAR.565April 1, 2024
Asenapine (Saphris) (PDF)CP.PMN.15October 1, 2023
Asfotase Alfa (Strensiq) (PDF)CP.PHAR.328December 1, 2023
Aspirin-dipyridamole (Aggrenox) (PDF)CP.PMN.20February 1, 2024
Atezolizumab (Tecentriq) (PDF)CP.PHAR.235April 1, 2024
Atidarsagene autotemcel (OTL-200) (PDF)CP.PHAR.602Pending FDA Approval
Atogepant (Qulipta) (PDF)CP.PHAR.566December 1, 2023
Avacopan (Tavneos) (PDF)CP.PHAR.515February 1, 2024
Avacincaptad pegol (Izervay) (PDF)CP.PHAR.641May 1, 2024
Avalglucosidase alfa-ngpt (Nexviazyme) (PDF)CP.PHAR.521July 1, 2024
Avalglucosidase alfa-ngpt (Nexviazyme) (PDF)CP.PHAR.521Retire by July 1, 2024
Avapritinib (Ayvakit) (PDF)CP.PHAR.454February 1, 2024
Avatrombopag (Doptelet) (PDF)CP.PHAR.130December 1, 2023
Avelumab (Bavencio) (PDF)CP.PHAR.333February 1, 2024
axicabtagene ciloleucel (Yescarta®) (PDF)CP.PHAR.362February 1, 2024
Axitinib (Inlyta) (PDF)CP.PHAR.100April 1, 2024
Azacitidine (Vidaza) (PDF)CP.PHAR.387December 1, 2023
Azelaic Acid (Finacea) (PDF)HIM.PA.119December 1, 2023
Aztreonam (Cayston) (PDF)CP.PHAR.209August 1, 2023
Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax)CP.PHAR.149December 1, 2023
Baloxavir Marboxil (Xofluza) (PDF)CP.PMN.185May 1, 2024
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (PDF)CP.PHAR.532July 1, 2023
Bardoxolone Methyl (RTA 402) (PDF)CP.PHAR.560December 1, 2023
Bedaquiline (Sirturo) (PDF)CP.PMN.212February 1, 2024
Belatacept (Nulojix®)  (PDF)CP.PHAR.201December 1, 2023
Belimumab (Benlysta) (PDF)CP.PHAR.88July 1, 2024
Belimumab (Benlysta) (PDF)CP.PHAR.88Retire by July 1, 2024
Belinostat (Beleodaq®) (PDF)CP.PHAR.311December 1, 2023
Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (PDF)CP.PMN.237April 1, 2024
Bendamustine (Bendeka®, Treanda®) (PDF)CP.PHAR.307January 1, 2024
Benralizumab (Fasenra) (PDF)CP.PHAR.373February 1, 2024
Benznidazole (PDF)CP.PMN.90February 1, 2024
Berdazimer (Zelsuvmi) (PDF)CP.PMN.293June 1, 2024
Beremagene Geperpavec (Vyjuvek) (PDF)CP.PHAR.592July 1, 2024
Beremagene Geperpavec (Vyjuvek) (PDF)CP.PHAR.592Retire by July 1, 2024
Betaine (Cystadane) (PDF)CP.PHAR.143December 1, 2023
Betibeglogene autotemcel (PDF)CP.PHAR.545August 1, 2023
evacizumab (PDF)CP.PHAR.93February 1, 2024
Bexarotene (Targretin) (PDF)CP.PHAR.75July 1, 2024
Bexarotene (Targretin) (PDF)CP.PHAR.75Retire by July 1, 2024
Bezlotoxumab (Zinplava) (PDF)CP.PHAR.300February 1, 2024
Belantamab mafodotin (Blenrep) (PDF)CP.PHAR.469June 1, 2024
Belumosudil (Rezurock) (PDF)CP.PHAR.552December 1, 2023
Belzutifan (Welireg) (PDF)CP.PHAR.553February 1, 2024
Berotralstat (Orladeyo) (PDF)HIM.PA.169January 1, 2024
Betamethasone Dipropionate Spray (Sernivo) (PDF)CP.PMN.182December 1, 2023
Bimatoprost Implant (Durysta) (PDF)CP.PHAR.486June 1, 2024
Binimetinib (Mektovi) (PDF)CP.PHAR.50Retire by July 1, 2024
Binimetinib (Mektovi) (PDF)CP.PHAR.50July 1, 2024
Biologic and Non-biologic DMARDs (PDF)HIM.PA.SP60July 1, 2024
Biologic and Non-biologic DMARDs (PDF)HIM.PA.SP60Retire by July 1, 2024
Birch Triterpenes (Filsuvez) (PDF)CP.PHAR.669July 1, 2024
Birch Triterpenes (Filsuvez) (PDF)CP.PHAR.669Retire by July 1, 2024
Blinatumomab (Blincyto) (PDF)CP.PHAR.312August 1, 2023
Bortezomib (Velcade) (PDF)CP.PHAR.410February 1, 2024
Bosentan (Tracleer®) (PDF)CP.PHAR.191February 1, 2024
Bosutinib (Bosulif) (PDF)CP.PHAR.105June 1, 2024
Brand Name Override and Non-Formulary Medications (PDF)HIM.PA.103December 1, 2023
Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.303October 2, 2023
Brexanolone (Zulresso) (PDF)CP.PHAR.417January 1, 2024
Brexpiprazole (Rexulti) (PDF)CP.PMN.68October 1, 2023
Brexucabtagene Autoleucel (Tecartus) (PDF)CP.PHAR.472April 1, 2024
Brigatinib (Alunbrig) (PDF)CP.PHAR.342July 1, 2024
Brigatinib (Alunbrig) (PDF)CP.PHAR.342Retire by July 1, 2024
Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.445 February 1, 2024
Brimonidine Tartrate (Mirvaso) (PDF)CP.PMN.192June 1, 2024
Brinzolamide/Brimonidine (Simbrinza) (PDF)HIM.PA.15December 1, 2023
Brivaracetam (Briviact) (PDF)CP.PCH.26October 2, 2023
Budesonide (Tarpeyo) (PDF)CP.PHAR.572February 1, 2024
Budesonide (Uceris) (PDF)CP.PCH.11January 1, 2024
Bulevirtide (Hepcludex) (PDF)CP.PHAR.589Pending FDA Approval
Buprenorphine implant (Probuphine) (PDF)CP.PHAR.289May 1, 2024
Bupropion/Naltrexone (Contr07e) (PDF)CP.PCH.12July 1, 2024
Bupropion/Naltrexone (Contr07e) (PDF)CP.PCH.12Retire by July 1, 2024
Burosumab-twza (Crysvita) (PDF)CP.PHAR.11August 1, 2023
Burprenorphine (Brixadi) (PDF)CP.PHAR.498Pending FDA Approval
Buprenorphine/Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)CP.PMN.81February 1, 2024
Buprenorphine (Subutex)CP.PMN.82February 1, 2024
Butorphanol Nasal Spray (PDF)HIM.PA.46June 1, 2024
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)HIM.PA.170January 1, 2024
cabazitaxel (Jevtana®) (PDF)CP.PHAR.316June 1, 2024
Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF)CP.PHAR.573February 1, 2024
Cabozantinib (Cometriq®, Cabometyx®) (PDF)CP.PHAR.111April 1, 2024
Calcifediol (Rayaldee) (PDF)CP.PMN.76 October 2, 2023
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF)CP.PMN.181December 1, 2023
Canakinumab (Ilaris) (PDF)CP.PHAR.246July  1, 2024
Canakinumab (Ilaris) (PDF)CP.PHAR.246Retire by July  1, 2024
Cannabidiol (Epidiolex) (PDF)CP.PMN.164January 1, 2024
Capecitabine (Xeloda) (PDF)CP.PHAR.60June 1, 2024
Capivasertib (Truqap) (PDF)CP.PHAR.663February 1, 2024
Caplacizumab-yhdp (Cablivi) (PDF)CP.PHAR.416June 1, 2024
Capmatinib (Tabrecta) (PDF)CP.PHAR.494August 1, 2023
Carbetocin (PDF)CP.PHAR.546Pending FDA Approval
Carbidopa-Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa) (PDF)CP.PMN.238August 1, 2023
Carfilzomib (Kyprolis®) (PDF)CP.PHAR.309January 1, 2024
Carglumic acid (Carbaglu®) (PDF)CP.PHAR.206 February 1, 2024
Cariprazine (Vraylar) (PDF)CP.PMN.91October 1, 2023
Casimersen (Amondys 45) (PDF)CP.PHAR.470April 1, 2024
Casirivimab and imdevimab (REGEN-COV) (PDF)CP.PHAR.520July 1, 2023
Celecoxib (Celebrex) (PDF)CP.PMN.122December 1, 2023
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397January 1, 2024
Cenegermin-bkbj (Oxervate)(PDF)CP.PMN.186February 1, 2024
Cenobamate (Xcopri) (PDF)CP.PMN.231February 1, 2024
Ceritinib (Zykadia) (PDF)CP.PHAR.349June 1, 2024
Cerliponase alfa (Brineura) (PDF)CP.PHAR.338October 2, 2022
Cetuximab (Erbitux®) (PDF)CP.PHAR.317January 1, 2024
Chenodiol (Chenodal) (PDF)CP.PMN.239August 1, 2023
Chlorambucil (Leukeran) (PDF)CP.PHAR.554December 1, 2023
Chloramphenicol Sodium Succinate (PDF)CP.PHAR.388August 1, 2023
Cholic Acid (Cholbam) (PDF)CP.PHAR.390December 1, 2023
Ciclopirox (Penlac) (PDF)CP.PMN.24February 1, 2024
Ciltacabtagene Autoleucel (Carvykti) (PDF)CP.PHAR.533June 1, 2024
Cinacalcet (Sensipar) (PDF)CP.PHAR.61August 1, 2023
Cipaglucosidase alfa-miglustat (AT-GAA) (PDF)CP.PHAR.567May 1, 2024
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF)CP.PMN.248December 1, 2023
Ciprofloxacin/Fluocinolone (Otovel) (PDF)CP.PMN.249December 1, 2023
Cladribine (Mavenclad) (PDF)CP.PHAR.422June 1, 2024
Clascoterone (Winlevi) (PDF)CP.PMN.257April 1, 2024
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260August 1, 2023
Clobazam (Onfi) (PDF)CP.PMN.54December 1, 2023
CNS Stimulants (PDF)CP.PMN.92February 1, 2024
Cobimetinib (Cotellic) (PDF)CP.PHAR.380Retire by July 1, 2024
Cobimetinib (Cotellic) (PDF)CP.PHAR.380July 1, 2024
Colchicine (Colcrys, Lodoco) (PDF)CP.PMN.123February 1, 2024
Colchicine (Lodoco) (PDF)CP.PHAR.640December 1, 2023
Colesevelam (Welchol) (PDF)CP.PMN.250December 1, 2023
Collagenase (Xiaflex) (PDF)CP.PHAR.82August 1, 2023
Colonoscopy Preparation Products (PDF)CP.PCH.43June 1, 2024
Compounded Medications (PDF)CP.PMN.280May 1, 2024
Concizumab (NN7415) (PDF)CP.PHAR.625June 1, 2024
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)CP.PMN.258February 1, 2024
Continuous Glucose Monitors (PDF)CP.PMN.214December 1, 2023
Copanlisib (Aliqopa®)  (PDF)CP.PHAR.357December 1, 2023
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF)CP.PHAR.385August 1, 2023
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF)HIM.PA.168July 1, 2024
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF)HIM.PA.168Retire by July 1, 2024
Cosyntropin (Cortrosyn) (PDF)CP.PHAR.203February 1, 2024
Crisaborole (Eucrisa) (PDF)CP.PMN.110June 1, 2024
Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449February 1, 2024
Crizotinib (Xalkori) (PDF)CP.PHAR.90June 1, 2024
Crovalimab (PDF)CP.PHAR.664February 1, 2024
Cyclosporine (Restasis, Cequa) (PDF)CP.PMN.48June 1, 2024
Cysteamine ophthalmic (Cystaran) (PDF)CP.PMN.130June 1, 2024
Cysteamine oral (Cystagon, Procysbi) (PDF)CP.PHAR.155   Retire by June 1, 2024
Cysteamine oral (Cystagon, Procysbi) (PDF)CP.PHAR.155   June 1, 2024
Cytomegalovirus Immune Globulin (Cytogam) (PDF)CP.PHAR.277August 1, 2023
Dabrafenib (Tafinlar) (PDF)CP.PHAR.239 July 1, 2024
Dabrafenib (Tafinlar) (PDF)CP.PHAR.239Retire by July 1, 2024
Dacomitinib (Vizimpro) (PDF)CP.PHAR.399December 1, 2023
Dalfampridine (Ampyra) (PDF)CP.PHAR.248June 1, 2024
Dalteparin (Fragmin) (PDF)CP.PHAR.225February 1, 2024
Danicopan (ALXN2040) (PDF)CP.PHAR.665February 1, 2024
Daprodustat (Jesduvroq) (PDF)CP.PHAR.628July 1, 2024
Daprodustat (Jesduvroq) (PDF)CP.PHAR.628Retire by July 1, 2024
Daptomycin (Cubicin, Cubicin RF) (PDF)CP.PHAR.351February 1, 2024
Dapsone (Aczone Gel) (PDF)CP.PCH.32April 1, 2024
Daratumumab (Darzalex) (PDF)CP.PHAR.310October 2, 2022
Darbepoetin alfa (Aranesp) (PDF)CP.PHAR.236Retire by July 1, 2024
Darbepoetin alfa (Aranesp) (PDF)CP.PHAR.236July 1, 2024
Darolutamide (Nubeqa) (PDF)CP.PHAR.435December 1, 2023
Dasabuvir-Ombitasvir-Paritaprevir-Ritonavir (Viekira Pak) (PDF)HIM.PA.SP61March 1, 2024
Dasatinib (Sprycel) (PDF)CP.PHAR.72July 1, 2024
Dasatinib (Sprycel) (PDF)CP.PHAR.72Retire by July 1, 2024
Dasiclucagon (ZP4207) (PDF)CP.PHAR.642December 1, 2023
DaxibotulinumtoxinA-lanm (Daxxify) (PDF)CP.PHAR.651May 1, 2024
Daunorubicin/cytarabine (Vyxeos®) (PDF)CP.PHAR.352December 1, 2023
Decitabine-Cedazuridine (Inqovi) (PDF)CP.PHAR.479June 1, 2024
Deferasirox (Exjade Jadenu) (PDF)CP.PHAR.145October 2, 2023
Deferoxamine (Desferal) (PDF)CP.PHAR.146October 2, 2023
Deflazacort (Emflaza) (PDF)CP.PHAR.331April 1, 2024
Degarelix acetate (Firmagon®) (PDF)CP.PHAR.170December 1, 2023
Delafloxacin (Baxdela) (PDF)CP.PMN.115August 1, 2023
Delandistrogene moxeparvovec-rokl  (Elevidys) (PDF)CP.PHAR.593 June 1, 2024
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.58February 1, 2024
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)CP.PHAR.214February 1, 2024
Deutetrabenazine (Austedo) (PDF)CP.PCH.42June 1, 2024
Dexlansoprazole (Dexilant) (PDF)HIM.PA.05December 1, 2023
Dexrazoxane (Zinecard, Totect) (PDF)CP.PHAR.418Retire by July 1, 2024
Dexrazoxane (Zinecard, Totect) (PDF)CP.PHAR.418July 1, 2024
Dextromethorphan-bupropion (Auvelity) (PDF)CP.PMN.284February 1, 2024
Dextromethorphan-Quinidine (Nuedexta) (PDF)CP.PMN.93February 1, 2024
Diazepam Nasal Spray (Valtoco)(PDF)CP.PMN.216December 1, 2023
Dichlorphenamide (Keveyis) (PDF)CP.PMN.261February 1, 2024
diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF)CP.PCH.28January 1, 2024
Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (PDF)CP.PCH.41December 1, 2023
Dimethyl fumarate (Tecfidera), diroximel fumarate, monomethyl fumarate (PDF)CP.PHAR.249June 1, 2024
Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41August 1, 2023
Dipeptidyl Peptidase-4 Inhibitors (PDF)HIM.PA.58April 1, 2024
Dolasetron (Anzemet) (PDF)CP.PMN.141August 1, 2023
Donanemab (LY300281) (PDF)CP.PHAR.594January 1, 2024
Donislecel (Lantidra) (PDF)CP.PHAR.569December 1, 2023
Dornase alfa (Pulmozyme) (PDF)CP.PHAR.212August 1, 2023
Dostarlimab-gxly (Jemperli) (PDF)CP.PHAR.540November 1, 2023
Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF)HIM.PA.147December 1, 2023
Doxycycline (Doryx, Oracea, Acticlate) (PDF)CP.PMN.79June 1, 2024
Dupilumab (Dupixent) (PDF)CP.PHAR.336July 1, 2024
Dupilumab (Dupixent) (PDF)CP.PHAR.336Retire by July 1, 2024
Durvalumab (Imfinzi) (PDF)CP.PHAR.339July 1, 2024
Durvalumab (Imfinzi) (PDF)CP.PHAR.339Retire by July 1, 2024
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF)CP.PMN.128June 1, 2024
Duvelisib (Copiktra) (PDF)CP.PHAR.400January 1, 2024
Ecallantide (Kalbitor) (PDF)CP.PHAR.177August 1, 2023
Eculizumab (Soliris) (PDF)CP.PHAR.97August 1, 2023
Edaravone (Radicava) (PDF)CP.PHAR.343June 1, 2024
Efgartigimod (ARGX-113) (PDF)CP.PHAR.555
February 1, 2024
Efinaconazole (Jublia) (PDF)CP.PMN.25February 1, 2024
Eflornithine (Iwilfin) (PDF)CP.PHAR.670March 1, 2024
Elacestrant (Orserdu) (PDF)CP.PHAR.623June 1, 2024
Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (PDF)CP.PHAR.136December 1, 2023
Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.419June 1, 2024
Elbasvir/Grazoprevir (Zepatier) (PDF)HIM.PA.SP62March 1, 2024
Eliglustat (Cerdelga) (PDF)CP.PHAR.153June 1, 2024
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF)CP.PHAR.440March 1, 2024
Elosulfase Alfa (Vimizim) (PDF)CP.PHAR.162 June 1, 2024
Elotuzumab (Empliciti) (PDF)CP.PHAR.308December 1, 2023
Elranatamab-bcmm (Elrexfio) (PDF)CP.PHAR.652May 1, 2024
Eltrombopag (Promacta®) (PDF)CP.PHAR.180April 1, 2024
Eluxadoline (Viberzi) (PDF)CP.PMN.170December 1, 2023
Elivaldogene Autotemcel (PDF)CP.PHAR.556December 1, 2023
Emapalumab-lzsg (Gamifant)(PDF)CP.PHAR.402April 1, 2024
Emicizumab-kxwh (Hemlibra) (PDF)CP.PHAR.370February 1, 2024
Emtricitabine-tenofovir alafenamide (Descovy) (PDF)CP.PMN.235June 1, 2024
Enasidenib (Idhifa) (PDF)CP.PHAR.363December 1, 2023
Encorafenib (Braftovi) (PDF)CP.PHAR.127June 1, 2024
Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41   July 1, 2021
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455February 1, 2024
Enoxaparin (Lovenox) (PDF)CP.PHAR.224February 1, 2024
Entecavir (Baraclude) (PDF)HIM.PA.08June 1, 2024
Entrectinib (Rozlytrek) (PDF)CP.PHAR.441February 1, 2024
Enzalutamide (Xtandi) (PDF)CP.PHAR.106April 1, 2024
Enzalutamide (Xtandi) (PDF)HIM.PA.164May 1, 2023
Epcoritamab-bysp (Epkinly) (PDF)CP.PHAR.634February 1, 2024
Eplontersen (AKCEA-TTR-LRx) (PDF)CP.PHAR.633JUne 1, 2024
Epoetin Alfa (Epogen® and Procrit) (PDF)CP.PHAR.237July 1, 2024
Epoetin Alfa (Epogen® and Procrit) (PDF)CP.PHAR.237Retire by July 1, 2024
Epoprostenol (PDF)CP.PHAR.192February 1, 2024
Eptinezumab-jjmr (Vyepti) (PDF)HIM.PA.SP64December 1, 2023
Erdafitinib (Balversa) (PDF)CP.PHAR.423June 1, 2024
Erenumab-aaoe (Aimovig) (PDF)HIM.PA.SP65December 1, 2023
Eribulin Mesylate (Halaven®) (PDF)CP.PHAR.318January 1, 2024
Erlotinib (Tarceva) (PDF)CP.PHAR.74June 1, 2024
Erwinia Asparaginase (Erwinaze) (PDF)CP.PHAR.301February 1, 2024
Esketamine (Spravato) (PDF)CP.PMN.199June 1, 2024
Esomeprazole-Naproxen (Vimovo) (PDF)CP.PMN.117July 1, 2024
Esomeprazole-Naproxen (Vimovo) (PDF)CP.PMN.117Retire by July 1, 2024
Estradiol (Femring) (PDF)CP.PMN.263August 1, 2023
Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379August 1, 2023
Eteplirsen  (Exondys 51) (PDF)CP.PHAR.288April 1, 2024
Etranacogene Dezaparvovec (Hemgenix) (PDF)CP.PHAR.580February 1, 2024
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF)CP.PHAR.63April 1, 2024
Evinacumab-dgnb (Evkeeza) (PDF)CP.PHAR.511March 1, 2022
Evinacumab-dgnb (Evkeeza) (PDF)HIM.PA.166April 1, 2024
Evolocumab (Repatha) (PDF)HIM.PA.156April 1, 2024
Exagamglogene autotemcel (Casgevy) (PDF)CP.PHAR.603July 1, 2024
Exagamglogene autotemcel (Casgevy) (PDF)CP.PHAR.603Retire by July 1, 2024
Factor IX (Human, Recombinant) (PDF)CP.PHAR.218June 1, 2024
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF)CP.PHAR.219February 1, 2024
Factor VIIa, Recombinant (NovoSeven® RT) (PDF)CP.PHAR.220February 1, 2024
Factor VIII (Human Recombinant) (PDF)CP.PHAR.215June 1, 2024
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF)CP.PHAR.216February 1, 2024
Factor XIII A-Subunit, Recombinant (Tretten®)CP.PHAR.222February 1, 2024
Factor XIII, Human (Corifact®) (PDF)CP.PHAR.221February 1, 2024
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.456February 1, 2024
Famotidine-Ibuprofen (Duexis) (PDF)CP.PMN.120Retire by July 1, 2024
Famotidine-Ibuprofen (Duexis) (PDF)CP.PMN.120July 1, 2024
Faricimab (Vabysmo) (PDF)CP.PHAR.581June 1, 2024
Febuxostat (Uloric) (PDF)CP.PMN.57April 1, 2024
Fecal microbiota, live-jslm (Rebyota) (PDF)CP.PHAR.613February 1, 2024
Fecal microbiota spores, live-brpk (Vowst) (PDF)CP.PHAR.632August 1, 2023
Fedratinib (Inrebic) (PDF)CP.PHAR.442December 1, 2023
Fenfluramine (Fintepla) (PDF)CP.PMN.246October 1, 2023
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)CP.PMN.127June 1, 2024
Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234May 1, 2024
Ferric Derisomaltose (Monoferric) (PDF)CP.PHAR.480June 1, 2024
Ferric gluconate (Ferrlecit®) (PDF)CP.PHAR.166July 1, 2023
Ferric Maltol (Accrufer) (PDF)CP.PMN.213December 1, 2023
Ferric Pyrophosphate Citrate (Triferic) (PDF)CP.PHAR.624June 1, 2024
Ferumoxytol (Feraheme®) (PDF)CP.PHAR.165March 1, 2024
Fezolinetant (Veozah) (PDF)CP.PMN.289 September 1, 2023
Fidanacogene Elaparvovec (PDF)CP.PHAR.643December 1, 2023
Flibanserin (Addyi) (PDF)CP.PHAR.446December 1, 2023
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF)CP.PHAR.526June 1, 2024
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF)CP.PHAR.297October 2, 2023
Finerenone (Kerendia) (PDF)CP.PMN.266December 1, 2023
Fingolimod (Gilenya) (PDF)CP.PCH.38June 1, 2024
Fluorouracil Cream (Tolak) (PDF)CP.PMN.165December 1, 2023
Fluticasone Propionate (Xhance) (PDF)CP.PMN.95August 1, 2023
Fondaparinux (Arixtra) (PDF)CP.PHAR.226February 1, 2024
Formulary Medications Without Specific Guidelines (PDF)HIM.PA.33December 1, 2023
Fosdenopterin (Nulibry) (PDF)CP.PHAR.471June 1, 2024
Fostamatinib (Tavalisse) (PDF)CP.PHAR.24April 1, 2024
Fostemsavir (Rukobia) (PDF)CP.PHAR.516February 1, 2024
Fremanezumb-vfrm (PDF)HIM.PA.SP66December 1, 2023
Fruquintinib (Fruzaqla) (PDF)CP.PHAR.666February 1, 2024
Fulvestrant (Faslodex Injection) (PDF)CP.PHAR.424August 1, 2023
Furosemide (Furoscix) (PDF)CP.PHAR.608February 1, 2024
Futibatinib (Lytgobi) (PDF)CP.PHAR.604February 1, 2024
Gabapentin ER (Gralise, Horizant) (PDF)CP.PMN.240August 1, 2023
Galcanezumab-gnlm (Emgality) (PDF)HIM.PA.SP67December 1, 2023
Galsulfase (Naglazyme) (PDF)CP.PHAR.161June 1, 2024
Ganaxolone (Ztalmy) (PDF)CP.PMN.278Retire by July 1, 2024
Ganaxolone (Ztalmy) (PDF)CP.PMN.278July 1, 2024
Garadacimab (CSL312)_PEPP (PDF)CP.PHAR.673June 1, 2024 ( Pending FDA Approval)
Gefitinib (Iressa) (PDF)CP.PHAR.68June 1, 2024
gemtuzumab ozogamicin (Mylotarg®) (PDF)CP.PHAR.358December 1, 2023
Gepirone (Exxua) (PDF)CP.PMN.292December 1, 2023
Gilteritinib (Xospata)(PDF)CP.PHAR.412February 1, 2024
Givinostat (ITF2357) (PDF)CP.PHAR.644December 1, 2023
Givosiran (Givlaari) (PDF)CP.PHAR.457April 1, 2024
Givosiran (Givlaari) (PDF)CP.PHAR.457Retire by April 1, 2024
Glasdegib (Daurismo)(PDF)CP.PHAR.413February 1, 2024
Glatiramer (Copaxone, Glatopa) (PDF)HIM.PA.SP68December 1, 2023
Glatiramer (Copaxone, Glatopa)  (PDF)CP.PHAR.252June 1, 2024
Glaucoma Agents (Omlonti, Rhopressa, Rocklatan, Vyzulta) (PDF)CP.PMN.286February 1, 2024
Glecaprevir-Pibrentasvir (PDF)HIM.PA.SP36March 1, 2024
Glofitamab-gxbm (Columvi) (PDF)CP.PHAR.636 February 1, 2024
Glucagon-Like Peptide-1 Receptor Agonists (PDF)HIM.PA.53February 1, 2024
Glycerol phenylbutyrate (Ravicti®) (PDF)CP.PHAR.207May 1, 2024
Glycerol phenylbutyrate (Ravicti®) (PDF)CP.PHAR.207Retire by May 1, 2024
Golodirsen (Vyondys 53) (PDF)CP.PHAR.453April 1, 2024
Goserelin acetate (Zoladex®) (PDF)CP.PHAR.171December 1, 2023
Granisetron (Kytril, Sancuso, Sustol) (PDF)CP.PMN.74August 1, 2023
Halcinonide (Halog) (PDF)HIM.PA.20January 1, 2024
Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate) (PDF)CP.PMN.180December 1, 2023
Halobetasol Propionate/Tazarotene (Duobrii) (PDF)CP.PMN.208August 1, 2023
Hemin (Panhematin®) (PDF)CP.PHAR.181February 1, 2024
Histrelin acetate (Vantas®, Supprelin LA®) (PDF)CP.PHAR.172July 1, 2024
Histrelin acetate (Vantas®, Supprelin LA®) (PDF)CP.PHAR.172Retire by July 1, 2024
House dust mite allergen extract (Odactra®) (PDF)CP.PMN.111 August 1, 2023
Human Growth Hormone (Somapacitan, Somatropin) (PDF)HIM.PA.161February 1, 2024
Hyaluronate Derivatives (PDF)CP.PHAR.05April 1, 2024
Hydroxyprogesterone Caproate (Makena) (PDF)CP.PHAR.14June 1, 2024
Hydroxyurea (Siklos) (PDF)CP.PMN.193June 1, 2024
ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.378June 1, 2024
Ibandronate sodium (PDF)CP.PHAR.189April 1, 2024
Ibrutinib (Imbruvica) (PDF)CP.PHAR.126February 1, 2024
Icatibant (Firazyr®) (PDF)CP.PHAR.178August 1, 2023
Icosapent ethyl (Vascepa) (PDF)CP.PMN.187February 1, 2024
Idecabtagene vicleucel (Abecma) (PDF)CP.PHAR.481June 1, 2024
Idelalisib (Zydelig) (PDF)CP.PHAR.133December 1, 2023
Idursulfase (Elaprase) (PDF)CP.PHAR.156 June 1, 2024
Iloperidone (Fanapt) (PDF)CP.PMN.32October 1, 2023
Iloprost (Ventavis®) (PDF)CP.PHAR.193February 1, 2024
Imatinib (Gleevec) (PDF)CP.PHAR.65June 1, 2024
Imiglucerase (Cerezyme) (PDF)CP.PHAR.154June 1, 2024
Immune Globulins (PDF)CP.PHAR.103June 1, 2024
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231July 1, 2024
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231Retire by July 1, 2024
Inhaled Agents for Asthma and COPD (PDF)HIM.PA.153July 1, 2024
Inhaled Agents for Asthma and COPD (PDF)HIM.PA.153Retire by July 1, 2024
Infertility and Fertility Preservation (PDF)CP.PHAR.131January 1, 2024
Inclisiran (Leqvio) (PDF)CP.PHAR.568April 1, 2024
Inebilizumab (PDF)CP.PHAR.458August 1, 2023
Infigratinib (Truseltiq) (PDF)CP.PHAR.547October 2, 2023
Inotersen (Tegsedi) (PDF)CP.PHAR.405Retire July 1, 2024
Inotersen (Tegsedi) (PDF)CP.PHAR.405July 1, 2024
inotuzumab ozogamicin (Besponsa®) (PDF)CP.PHAR.359December 1, 2023
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)CP.PHAR.534June 1, 2024
Insulin detemir (Levemir) (PDF)HIM.PA.171        January 1, 2024
Insulin glargine (Rezvoglar, Semglee, Toujeo) (PDF)HIM.PA.09 February 1, 2024
Interferon Beta-1b (Betaseron, Extavia) (PDF)CP.PHAR.255June 1, 2024
Interferon beta-1b (Betaseron, Extavia) (PDF)CP.PCH.46June 1, 2024
Interferon Gamma- 1b (Actimmune) (PDF)CP.PHAR.52February 1, 2024
Intrathecal Baclofen (Gablofen, Lioresal) (PDF)CP.PHAR.149December 1, 2023
Iobenguane I-131 (Azedra) (PDF)CP.PHAR.459February 1, 2024
Ipilimumab (Yervoy) (PDF)CP.PHAR.319June 1, 2024
Iptacopan (LNP023) (PDF)CP.PHAR.656February 1, 2024 (Previously Pending FDA Approval)
Irinotecan Liposome (Onivyde®) (PDF)CP.PHAR.304May 1, 2024
Iron sucrose (Venofer®) (PDF)CP.PHAR.167July 1, 2023
Isatuximab-irfc (Sarclisa) (PDF)CP.PHAR.482June 1, 2023
isavuconazonium (Cresemba®) (PDF)CP.PMN.154February 1, 2024
Isotretinoin (Claravis, Absorica, Absorica LD, Myorisan, Zenatane, Amnesteem) (PDF)CP.PMN.143April 1, 2024
Istradefylline (Nourianz) (PDF)CP.PMN.217February 1, 2024
Itraconazole (Sporanox, Onmel) (PDF)CP.PMN.124June 1, 2024
Itraconazole (Sporanox, Onmel) (PDF)CP.PMN.124Retire by June 1, 2024
Ivabradine (Corlanor) (PDF)CP.PMN.70February 1, 2024
Ivacaftor (Kalydeco) (PDF)CP.PHAR.210March 1, 2024
Ivermectin (Stromectol, Sklice)CP.PMN.269 August 1, 2023
Ivosidenib (Tibsovo) (PDF)CP.PHAR.137February 1, 2024
Ixazomib (Ninlaro) (PDF)CP.PHAR.302October 2, 2023
Ketorolac nasal spray (Sprix) (PDF)CP.PMN.282December 1, 2023
Lacosamide (Vimpat) (PDF)CP.PMN.155August 1, 2022
L-glutamine (Endari) (PDF)CP.PMN.116December 1, 2023
Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF)CP.PMN.251December 1, 2022
Lanadelumab-fylo (Takhzyro) (PDF)HIM.PA.172        January 1, 2024
Lanreotide (Somatuline Depot) (PDF)CP.PHAR.391January 1, 2024
lapatinib (Tykerb®) (PDF)CP.PHAR.79January 1, 2024
Laronidase (Aldurazyme) (PDF)CP.PHAR.152June 1, 2024
Larotrectinib (Vitrakvi)(PDF)CP.PHAR.414February 1, 2024
Lasmiditan (Reyvow) (PDF)CP.PMN.218April 1, 2024
Latanoprostene Bunod (Vyzulta) (PDF)CP.PMN.108May 1, 2023
Lecanemab-irmb (Leqembi) (PDF)CP.PHAR.596December 1, 2023
Ledipasvir-Sofosbuvir (Harvoni) (PDF)HIM.PA.SP3March 1, 2024
Lefamulin (Xenleta) (PDF)CP.PMN.219August 1, 2023
Lenacapavir (Sunlenca) (PDF)CP.PHAR.622June 1, 2024
Lenalidomide (Revlimid) (PDF)CP.PHAR.71July 1, 2024
Lenalidomide (Revlimid) (PDF)CP.PHAR.71Retire by July 1, 2024
Lenvatinib (Lenvima) (PDF)CP.PHAR.138January 1, 2024
Leniolisib (Joenja) (PDF)CP.PHAR.597February 1, 2024
Letermovir (Prevymis) (PDF)CP.PHAR.367February 1, 2024
Leucovorin Injection (PDF)CP.PHAR.393December 1, 2023
Levodopa Inhalation Powder (Inbrija) (PDF)CP.PMN.267December 1, 2023
Levoleucovorin (Fusilev, Khapzory) (PDF)CP.PHAR.151December 1, 2023
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF)CP.PHAR.173April 1, 2024
Levoketoconazole (Recorlev) (PDF)CP.PMN.275June 1, 2024
Levomilnacipran (Fetzima) (PDF)HIM.PA.125April 1, 2024
Lidocaine transdermal (Lidoderm®) (PDF)CP.PMN.08 August 1, 2023
Lifileucel (LN-144) (PDF)CP.PHAR.598December 1, 2023
Lifitegrast (Xiidra®) (PDF)CP.PMN.73December 1, 2023
Linaclotide (Linzess) (PDF)CP.PMN.71December 1, 2023
Lnezolid (Zyvox) (PDF)CP.PMN.27August 1, 2023
Lisocabtagene maraleucel (Breyanzi) (PDF)CP.PHAR.483July 1, 2024
Lisocabtagene maraleucel (Breyanzi) (PDF)CP.PHAR.483Retire by July 1, 2024
Lofexidine (Lucemyra) (PDF)CP.PMN.152August 1, 2023
Lomustine (Gleostine) (PDF)CP.PHAR.507December 1, 2023
Lonafarnib (Zokinvy) (PDF)CP.PHAR.499February 1, 2024
Loncastuximab tesirine-lpyl (Zynlonta) (PDF)CP.PHAR.539October 2, 2023
Lorlatinib (Lorbrena)(PDF)CP.PHAR.406June 1, 2024
Loteprednol etabonate (Eysuvis) (PDF)CP.PMN.260February 1, 2024
Lotilaner (Xdemvy) (PDF)CP.PMN.291December 1, 2023
Lovotibeglogene Autotemcel (Lovo-Cel) (PDF)CP.PHAR.627March 1, 2024
Lubiprostone (Amitiza) (PDF)CP.PMN.142December 1, 2023
Luliconazole Cream (Luzu) (PDF)CP.PMN.166February 1, 2024
Lumacaftor-Ivacaftor (Orkambi) (PDF)CP.PHAR.213March 1, 2024
Lumasiran (Oxlumo) (PDF)CP.PHAR.473July 1, 2024
Lumasiran (Oxlumo) (PDF)CP.PHAR.473Retire by July 1, 2024
Lumateperone (Caplyta) (PDF)CP.PMN.232February 1, 2024
Lurbinectedin (Zepzelca) (PDF)CP.PHAR.500October 2, 2023
Lurasidone (Latuda) (PDF)CP.PMN.50March 1, 2023
Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.450February 1, 2024
Lusutrombopag (Mulpleta)(PDF)CP.PHAR.407April 1, 2024
Lutetium Lu 177 Dotatate (Lutathera) (PDF)CP.PHAR.384August 1, 2023
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) 09.09.22.docxCP.PHAR.582June 1, 2024
Macitentan (Opsumit) (PDF)CP.PHAR.194February 1, 2024
Macitentan (Opsumit®) (PDF)CP.PCH.31March 1, 2022
Mannitol (Bronchitol) (PDF)CP.PHAR.518August 1, 2023
Maralixibat (Livmarli) (PDF)CP.PHAR.543December 1, 2023
Margetuximab-cmkb (Margenza) (PDF)CP.PHAR.522February 1, 2024
Maribavir (Livtencity) (PDF)CP.PMN.271April 1, 2024
Marstacimab (PF-06741086)_PEPP (PDF)CP.PHAR.674June 1, 2024 ( Pending FDA Approval)
Mavacamten (MYK-461) (PDF)CP.PMN.272February 1, 2024
Mecamylamine (Vecamyl) (PDF)CP.PMN.136June 1, 2024
Mecasermin (Increlex) (PDF)CP.PHAR.150August 1, 2023
Mechlorethamine Gel (Valchlor) (PDF)CP.PHAR.381October 2, 2022
Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF)CP.PMN.179December 1, 2023
Melphalan (Hepzato) (PDF)CP.PHAR.653December 1, 2023
Melphalan flufenamide (Pepaxto) (PDF)CP.PHAR.535May 1, 2024
Memantine (Namenda XR, Namzaric) (PDF)CP.PCH.30August 1, 2023
Mepolizumab (Nucala) (PDF)CP.PHAR.200February 1, 2024
Mercaptopurine (Purixan) (PDF)CP.PHAR.447June 1, 2024
Mesenchymal stem cell-NTF (NurOwn)CP.PHAR.637 September 1, 2023
Metformin ER (Glumetza, Fortamet) (PDF)CP.PMN.72February 1, 2024
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)CP.PHAR.134May 1, 2024
Methoxsalen (Uvadex) (PDF)HIM.PA.17December 1, 2023
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.238Retire by July 1, 2024
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF)CP.PHAR.238July 1, 2024
Methylnaltrexone Bromide (Relistor) (PDF)CP.PMN.169December 1, 2023
Metoclopramide (Gimoti) (PDF)CP.PMN.252December 1, 2023
Metreleptin (Myalept) (PDF)CP.PHAR.425August 1, 2023
Midazolam (Nayzilam) (PDF)CP.PMN.211August 1, 2023
Midostaurin (Rydapt) (PDF)CP.PHAR.344July 1, 2024
Midostaurin (Rydapt) (PDF)CP.PHAR.344Retire by July 1, 2024
Mifepristone (Korlym) (PDF)CP.PHAR.101February 1, 2024
Migalastat (Galafold) (PDF)CP.PHAR.394January 1, 2024
Miglustat (Zavesca) (PDF)CP.PHAR.164 June 1, 2024
Milnacipran (Savella) (PDF)CP.PMN.125June 1, 2024
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF)CP.PMN.80June 1, 2024
Minocycline micronized foam (Amzeeq) (PDF)CP.PMN.242December 1, 2022
Mirvetuximab soravtansine-gynx (Elahere) (PDF)CP.PHAR.617February 1, 2024
Mitapivat (Pyrukynd) (PDF)CP.PHAR.558December 1, 2023
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)CP.PHAR.495October 2, 2023
Mitoxantrone (Novantrone) (PDF)CP.PHAR.258July 1, 2024
Mitoxantrone (Novantrone) (PDF)CP.PHAR.258Retire by July 1, 2024
Mixed pollens allergen extract (Oralair) (PDF)CP.PMN.85August 1, 2023
Mobocertinib (Exkivity) (PDF)CP.PHAR.559March 1, 2024
Modafinil (Provigil) (PDF)CP.PMN.39June 1, 2023
Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.139December 1, 2023
Momelotinib (Ojjaara) (PDF)CP.PHAR.654December 1, 2023
Mometasone (Nasonex) (PDF)HIM.PA.93August 1, 2023
Mometasone Furoate (Sinuva) (PDF)CP.PHAR.448August 1, 2023
Montelukast oral granules (Singulair) (PDF)HIM.PA.129December 1, 2023
Mosunetuzumab-axgb (Lunsumio)  (PDF)CP.PHAR.618February 1, 2024
Motixafortide (Aphexda) (PDF)CP.PHAR.655May 1, 2024
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.398December 1, 2023
Nabumatone Double-Strength (Relafen DS) (PDF)CP.PMN.287Retire by June 1, 2024
Nabumatone Double-Strength (Relafen DS) (PDF)CP.PMN.287June 1, 2024
Nadofaragene Firadenovec (Instiladrin)(PDF)CP.PHAR.461May 1, 2024
Nafarelin acetate (Synarel®) (PDF)CP.PHAR.174July 1, 2024
Nafarelin acetate (Synarel®) (PDF)CP.PHAR.174Retire by July 1, 2024
Naldemedine (Symproic) (PDF)CP.PMN.112December 1, 2023
Nalmefene (Opvee) (PDF)CP.PHAR.638 September 1, 2023
Naloxegol (Movantik) (PDF)HIM.PA.167December 1, 2023
Naltrexone (Vivitrol) (PDF)CP.PHAR.96February 1, 2024
Naproxen oral suspension (Naprosyn) (PDF)HIM.PA.130January 1, 2024
Narsoplimab (OMS721) (PDF)CP.PHAR.527June 1, 2024
Natalizumab (Tysabri) (PDF)CP.PHAR.259May 1, 2024
Naxitamab-gqgk (Danyelza) CP.PHAR.523February 1, 2024
Necitumumab (Portrazza®) (PDF)CP.PHAR.320December 1, 2023
Nedosiran (DCR-PHXC) (PDF)CP.PHAR.619Retire by July 1, 2024
Nedosiran (DCR-PHXC) (PDF)CP.PHAR.619July 1, 2024
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF)CP.PMN.167December 1, 2023
Neratinib (Nerlynx) (PDF)CP.PHAR.365December 1, 2023
Netarsudil (Rhopressa), Netarsudil-Latanoprost (Rocklatan) (PDF)CP.PMN.118May 1, 2023
Netupitant and Palonosetron (Akynzeo) (PDF)CP.PMN.158October 2, 2023
Nifurtimox (Lampit) ^ (PDF)CP.PMN.256December 1, 2023
nilotinib (Tasigna) (PDF)CP.PHAR.76July 1, 2024
nilotinib (Tasigna) (PDF)CP.PHAR.76Retire by July 1, 2024
Nintedanib (Ofev) (PDF)CP.PHAR.285August 1, 2023
Nitisinone (Nityr, Orfadin) (PDF)CP.PHAR.132Retire by July 1, 2024
Nitisinone (Nityr, Orfadin) (PDF)CP.PHAR.132July 1, 2024
Niraparib (Zejula) (PDF)CP.PHAR.408February 1, 2024
Niraparib and Abiraterone (Akeega) (PDF)CP.PHAR.645December 1, 2023
Nirmatrelvir-Ritonavir (Paxlovid) (PDF)CP.PMN.288April 1, 2024
Nirogacestat (Ogsiveo) (PDF)CP.PHAR.671March 1, 2024
Nirsevimab (Beyfortus) (PDF)CP.PHAR.614January 1, 2024
Nitazoxanide (Alinia) (PDF)HIM.PA.152December 1, 2023
Nivolumab (Opdivo) (PDF)CP.PHAR.121  May 1, 2024
Nivolumab and Relatlimab (Opdualag) (PDF)CP.PHAR.588August 1, 2023
Non-Calcium Phosphate Binders (PDF)CP.PMN.04February 1, 2024
Non-Formulary and Formulary Contraceptives (PDF)HIM.PA.100June 1, 2024
Non-Formulary Test Strips (PDF)HIM.PA.34February 1, 2024
Nusinersen (Spinraza®) (PDF)CP.PHAR.327February 1, 2024
Obecabtagene autoleucel (AUTO1)_PEPP (PDF)CP.PHAR.675June 1, 2024  Pending FDA Approval
Obeticholic acid (Ocaliva) (PDF)CP.PHAR.287December 1, 2023
Obinutuzumab (Gazyva®) (PDF)CP.PHAR.305December 1, 2023
Ocrelizumab (Ocrevus) (PDF)CP.PHAR.335June 1, 2024
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)CP.PHAR.40April 1, 2024
Odevixibat (Bylvay) (PDF)CP.PHAR.528June 1, 2024
Odevixibat (Bylvay) (PDF)CP.PHAR.528Retire by June 1, 2024
Ofatumumab (Arzerra®) (PDF)CP.PHAR.306June 1, 2024
Off-label Policy (PDF)HIM.PA.154December 1, 2023
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)CP.PHAR.292August 1, 2023
Olanzapine-samidorphan (Lybalvi) (PDF)CP.PMN.265October 1, 2023
Olaparib (Lynparza) (PDF)CP.PHAR.360February 1, 2024
Olaratumab (Lartruvo®) (PDF)CP.PHAR.326December 1, 2023
Olipudase alfa-rpcp (Xenpozyme) 09.08.22.docxCP.PHAR.586August 1, 2023
Olutasidenib (Rezlidhia) (PDF)CP.PHAR.615February 1, 2024
Omacetaxine (Synribo) (PDF)CP.PHAR.108June 1, 2024
Omadacycline (Nuzyra)(PDF)CP.PMN.188August 1, 2023
Omalizumab (Xolair) (PDF)CP.PCH.49February 1, 2024
Omalizumab (Xolair®) (PDF)CP.PHAR.01February 1, 2024
Omaveloxolone (RTA-408) (PDF)CP.PHAR.590 June 1, 2024
Omburtamab (Omblastys) (PDF)CP.PHAR.585December 1, 2023
OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.232June 1, 2024
Onasemnogene abeparvovec (Zolgensma) (PDF)CP.PHAR.421June 1, 2024
Ondansetron (Zuplenz) (PDF)CP.PMN.45August 1, 2023
Ophthalmic Corticosteroids (PDF)HIM.PA.03December 1, 2023
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)CP.PHAR.536June 1, 2024
Opicapone (Ongentys) (PDF)CP.PMN.245August 1, 2023
Opioid Analgesics (PDF)HIM.PA.139June 1, 2024
Osilodrostat (Isturisa) (PDF)CP.PHAR.487August 1, 2023
Osimertinib (Tagrisso) (PDF)CP.PHAR.294June 1, 2024
Ospemifene (Osphena) (PDF)CP.PMN.168December 1, 2023
Overactive Bladder Agents (PDF)CP.PMN.198December 1, 2023
Oxymetazoline (Rhofade) (PDF)CP.PMN.86June 1, 2024
Ozanimod (Zeposia) (PDF)CP.PHAR.462June 1, 2024
Ozenoxacin (Xepi) (PDF)CP.PMN.119June 1, 2024
Paclitaxel, protein-bound (Abraxane) (PDF)CP.PHAR.176 July 1, 2024
Paclitaxel, protein-bound (Abraxane) (PDF)CP.PHAR.176 Retire by July 1, 2024
Pacritinib (Vonjo) (PDF)CP.PHAR.583June 1, 2024
Palbociclib (Ibrance) (PDF)HIM.PA.173March 1, 2024
Palbociclib (Ibrance) (PDF)CP.PHAR.125March 1, 2024
Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera) (PDF)CP.PHAR.291August 1, 2023
Palivizumab (Synagis) (PDF)CP.PHAR.16June 1, 2024
Palovarotene (PDF)CP.PHAR.548December 1, 2023
Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) (PDF)CP.PCH.44May 1, 2024
Panitumumab (Vectibix®) (PDF)CP.PHAR.321January 1, 2024
Panobinostat (Farydak) (PDF)CP.PHAR.382August 1, 2023
Parathyroid Hormone (Natpara) (PDF)CP.PHAR.282February 1, 2024
Paricalcitol Injection (Zemplar) (PDF)CP.PHAR.270February 1, 2024
Pasireotide (Signifor LAR®) (PDF)CP.PHAR.332December 1, 2023
Patiromer (Veltassa) (PDF)CP.PMN.205February 1, 2024
Patisiran (Onpattro) (PDF)CP.PHAR.395July 1, 2024
Patisiran (Onpattro) (PDF)CP.PHAR.395Retire by July 1, 2024
Pazopanib (Votrient) (PDF)CP.PHAR.81August 1, 2023
Peanut allergen powder (Palforzia) (PDF)CP.PMN.220August 1, 2023
Pegaptanib (Macugen) (PDF)CP.PHAR.185May 1, 2023
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF)CP.PHAR.353December 1, 2023
Pegcetacoplan (Empaveli0 (PDF)CP.PHAR.524February 1, 2024
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF)CP.PHAR.296June 1, 2024
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF)CP.PHAR.296Retire by June 1, 2024
Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF)CP.PHAR.89October 2, 2023
Peginterferon beta-1a (Plegridy) (PDF)CP.PHAR.271June 1, 2024
Pegloticase (Krystexxa) (PDF)CP.PHAR.115February 1, 2024
Pegunigalsidase Alfa (PRX-102) (PDF)CP.PHAR.512 February 1, 2024
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140December 1, 2023
Pegvisomant (Somavert) (PDF)CP.PHAR.389December 1, 2023
Pegzilarginase (AEB1102) (PDF)CP.PHAR.587Pending FDA Approval
Pembrolizumab (Keytruda®) (PDF)CP.PHAR.322May 1, 2024
Pembrolizumab (Keytruda®) (PDF)CP.PHAR.322Retire by May 1, 2024
Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.368February 1, 2024
Pemigatinib (Pemazyre) (PDF)CP.PHAR.496August 1, 2023
Penicillamine (Cuprimine) (PDF)CP.PCH.09December 1, 2023
Pentosan polysulfate sodium (Elmiron) (PDF)CP.PMN.276June 1, 2023
Perampanel (Fycompa) (PDF)CP.PMN.156October 1, 2023
Perfluorohexyloctane (Miebo) (PDF)CP.PMN.290 September 1, 2023
Pertuzumab (Perjeta) (PDF)CP.PHAR.227June 1, 2024
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF)CP.PHAR.501October 2, 2023
Pexidartinib (Turalio)(PDF)CP.PHAR.436December 1, 2023
Phendimetrazine (PDF)CP.PCH.47July 1, 2024
Phendimetrazine (PDF)CP.PCH.47Retire by July 1, 2024
Phentermine (Adipex-P, Lomaira) (PDF)CP.PCH.13July 1, 2024
Phentermine (Adipex-P, Lomaira) (PDF)CP.PCH.13Retire by July 1, 2024
Phentermine-topiramate (Qsymia) (PDF)CP.CPA.336September 1, 2022
Pilocarpine (Vuity) (PDF)CP.PMN.270February 1, 2024
Pimavanserin (Nuplazid) (PDF)CP.PMN.140August 1, 2023
Pirfenidone (Esbriet) (PDF)CP.PHAR.286August 1, 2023
Pirtobrutinib (Jaypirca) (PDF)CP.PHAR.620July  1, 2024
Pirtobrutinib (Jaypirca) (PDF)CP.PHAR.620Retire by July  1, 2024
Pitolisant (Wakix) (PDF)CP.PMN.221June 1, 2024
Plasminogen (Ryplazim) (PDF)CP.PHAR.513December 1, 2023
Plecanatide (Trulance) (PDF)CP.PMN.87April 1, 2024
Plecanatide (Trulance) (PDF)HIM.PA.158April 1, 2024
Plerixafor (Mozobil) (PDF)CP.PHAR.323April 1, 2023
Polatuzumab Vedotin-piiq (Polivy) (PDF)CP.PHAR.433October 2, 2023
Pomalidomide (Pomalyst) (PDF)CP.PHAR.116Retire by July 1, 2024
Pomalidomide (Pomalyst) (PDF)CP.PHAR.116July 1, 2024
Ponatinib (Iclusig) (PDF)CP.PHAR.112July 1, 2024
Ponatinib (Iclusig) (PDF)CP.PHAR.112Retire by July 1, 2024
Ponesimod (Ponvory) (PDF)CP.PHAR.537June 1, 2024
Potassium (Klor-Con) (PDF)HIM.PA.143February 1, 2024
Pozelimab (REGN3918) (PDF)CP.PHAR.626May 1, 2024
Prademagene Zamikeracel (EB-101) (PDF)CP.PHAR.609Pending FDA Approval
Pralatrexate (Folotyn®) (PDF)CP.PHAR.313December 1, 2023
Pralsetinib (Gavreto) (PDF)CP.PHAR.514June 1, 2023
Pramlintide (Symlin) (PDF)CP.PMN.129May 1, 2024
Prasterone (Intrarosa) (PDF)CP.PMN.99February 1, 2024
Pregabalin (Lyrica) (PDF)CP.PMN.33Retire by July 1, 2024
Pregabalin (Lyrica) (PDF)CP.PMN.33July 1, 2024
Pretomanid (PDF)CP.PMN.222February 1, 2024
Progesterone (Crinone, Endometrin, Milprosa) (PDF)CP.PMN.243October 2, 2023
Propranolol (Hemangeol) (PDF)CP.PCH.51 June 1, 2024
protein c concentrate, human (Ceprotin®) (PDF)CP.PHAR.330February 1, 2024
propranolol HCL solution (Hemangeol) (PDF)CP.PMN.58January 1, 2024
Prucalopride (Motegrity) (PDF)HIM.PA.159December 1, 2023
Pyrimethamine (Daraprim®) (PDF)CP.PMN.44 August 1, 2023
Quantity Limit Override and Dose Optimization (PDF)CP.PMN.59 December 1, 2023
Quetiapine ER (Seroquel XR) (PDF)CP.PMN.64February 1, 2024
Quinine Sulfate (Qualaquin) (PDF)CP.PMN.262July 1, 2024
Quinine Sulfate (Qualaquin) (PDF)CP.PMN.262Retire by July 1, 2024
Quizartinib (Vanflyta) (PDF)CP.PHAR.646December 1, 2023
Ramucirumab (Cyramza) (PDF)CP.PHAR.119February 1, 2024
Ranibizumab (Lucentis) (PDF)CP.PHAR.186February 1, 2024
Rasagiline (Azilect®) (PDF)HIM.PA.89August 1, 2023
Ravulizumab-cwvz (Ultomiris) (PDF)CP.PHAR.415August 1, 2023
Regorafenib (Stivarga) (PDF)CP.PHAR.107July 1, 2024
Regorafenib (Stivarga) (PDF)CP.PHAR.107Retire by July 1, 2024
Relugolix (Orgovyx) (PDF)CP.PHAR.529June 1, 2024
Remestemcel-L (Ryoncil) (PDF)CP.PHAR.474June 1, 2024
Remetirom (PDF)CP.PHAR.647December 1, 2023
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)CP.PHAR.168May 1, 2023
Repotrectinib (Augtyro) (PDF)CP.PHAR.667February 1, 2024
Respiratory Syncytial Virus Vaccine (Abrysvo) (PDF)CP.PHAR.658January 1, 2024
Reslizumab (Cinqair) (PDF)CP.PHAR.223February 1, 2024
Retifanlimab-dlwr (Zynyz) (PDF)CP.PHAR.629July 1, 2024
Retifanlimab-dlwr (Zynyz) (PDF)CP.PHAR.629Retire by July 1, 2024
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF)CP.PHAR.141December 1, 2023
Ribociclib (Kisqali, Kisqali Femara) (PDF)CP.PHAR.334December 1, 2023
Rifabutin (Mycobutin) (PDF)CP.PMN.223April 1, 2024
Rifamycin (Aemcolo) (PDF)CP.PMN.196Retire by July 1, 2024
Rifamycin (Aemcolo) (PDF)CP.PMN.196July 1, 2024
Rifaximin (Xifaxan®) (PDF)CP.PMN.47December 1, 2023
Rilonacept (Arcalyst) (PDF)CP.PHAR.266July 1, 2024
Rilonacept (Arcalyst) (PDF)CP.PHAR.266Retire by July 1, 2024
Ripretinib (Qinlock) (PDF)CP.PHAR.502October 2, 2023
RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.233June 1, 2024
Rimegepant (Nurtec ODT) (PDF)CP.PHAR.490January 1, 2024
Riociguat (Adempas®) (PDF)CP.PHAR.195February 1, 2024
Risdiplam (Evrysdi) (PDF)CP.PHAR.477February 1, 2024
Risedronate (Actonel, Atelvia) (PDF)CP.PMN.100April 1, 2024
Risperidone Long-Acting Injection (Risperdal Consta) (PDF)CP.PHAR.293May 1, 2024
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)CP.Phar.260July 1, 2024
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)CP.Phar.260Retire by July 1, 2024
Roflumilast (Daliresp, Zoryve) (PDF)CP.PMN.46March 1, 2024
Rolapitant (Varubi) (PDF)CP.PMN.102August 1, 2023
Romidepsin (Istodax®) (PDF)CP.PHAR.314December 1, 2023
Romiplostim (Nplate®) (PDF)CP.PHAR.179 April 1, 2024
Romosozumab-aqqg (Evenity) (PDF)CP.PHAR.428April 1, 2024
Ropeginterferon alfa-2b-njft (Besremi) (PDF)CP.PHAR.570July 1, 2024
Ropeginterferon alfa-2b-njft (Besremi) (PDF)CP.PHAR.570Retire by July 1, 2024
Rozanolixizumab-noli (Rystiggo) (PDF)CP.PHAR.648December 1, 2023
RP-L201 (PDF)CP.PHAR.599December 1, 2023
Rucaparib (Rubraca®) (PDF)CP.PHAR.350February 1, 2024
Rufinamide (Banzel) (PDF)CP.PMN.157October 1, 2023
Ruxolitinib (Jakafi) (PDF)CP.PHAR.98April 1, 2024
Sacituzumab Govitecan-hziy (Trodelvy) (PDF)CP.PHAR.475June 1, 2024
Sacubitril/Valsartan (Entresto) (PDF)CP.PMN.67April 1, 2024
Safinamide (Xadago) (PDF)CP.PMN.113February 1, 2024
Sapropterin (Kuvan) (PDF)CP.PHAR.43Retire by July 1, 2024
Sapropterin (Kuvan) (PDF)CP.PHAR.43July 1, 2024
Sarecycline (Seysara) (PDF)CP.PMN.189February 1, 2024
Sargramostim (Leukine) (PDF)CP.PHAR.295January 1, 2024
Satralizumab-mwge (Enspryng) (PDF)CP.PHAR.463August 1, 2023
Sebelipase Alfa (Kanuma) (PDF)CP.PHAR.159June 1, 2024
Secnidazole (Solosec) (PDF)CP.PMN.103February 1, 2024
Selexipag (Uptravi®) (PDF)CP.PHAR.196April 1, 2024
Selinexor (Xpovio) (PDF)CP.PHAR.431October 2, 2023
Selpercatinib (Retevmo) (PDF)CP.PHAR.478July 1, 2024
Selpercatinib (Retevmo) (PDF)CP.PHAR.478Retire by July 1, 2024
Selumetinib (Koselugo) (PDF)CP.PHAR.464April 1, 2024
Setmelanotide (Imcivree) (PDF)CP.PHAR.491February 1, 2024
Short ragweed pollen allergen extract (Ragwitek) (PDF)CP.PMN.83August 1, 2023
Sildenafil (Revatio®) (PDF)CP.PHAR.197February 1, 2024
Sildenafil (Viagra) (PDF)CP.PCH.07June 1, 2024
Siponimod (Mayzent) (PDF)CP.PHAR.427Jue 1, 2024
Sipuleucel-T (Provenge) (PDF)CP.PHAR.120June 1, 2024
Sirolimus Protein-Bound Particles (Fyarro), topical gel (Hyftor) (PDF)CP.PHAR.574February 1, 2024
Siltuximab (Sylvant) (PDF)CP.PHAR.329February 1, 2024
sodium oxybate (Xyrem) (PDF)CP.PMN.42June 1, 2024
Sodium-Glucose Co-Transporter 2  Inhibitors (PDF)HIM.PA.91July 1, 2024
Sodium-Glucose Co-Transporter 2  Inhibitors (PDF)HIM.PA.91Retire by July 1, 2024
Sodium Phenylbutyrate (Buphenyl) (PDF)CP.PHAR.208February 1, 2024
Sodium Phenylbutyrate-Taurursodiol (Relyvrio) 10.06.22.docxCP.PHAR.584June 1, 2024
Sodium thiosulfate (Pedmark) (PDF)CP.PHAR.610May 1, 2024
Sodium Zirconium Cyclosilicate (Lokelma) (PDF)CP.PMN.163August 1, 2023
Sofosbuvir-Velpatasvir (Epclusa)  (PDF)HIM.PA.SP1January 1, 2024
Sofosbuvir (Sovaldi) (PDF)HIM.PA.SP2March 1, 2024
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF)HIM.PA.SP63March 1, 2024
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF)HIM.PA.SP63March 1, 2024
Solriamfetol (Sunosi) (PDF)CP.PMN.209June 1, 2024
Sonidegib (Odomzo) (PDF)CP.PHAR.272June 1, 204
Sorafenib (Nexavar) (PDF)CP.PHAR.69July 1, 2024
Sorafenib (Nexavar) (PDF)CP.PHAR.69Retire by July 1, 2024
Sotatercept (ACE-011) (PDF)CP.PHAR.657Pending FDA Approval
Sotorasib (Lumakras) (PDF)CP.PHAR.549October 2, 2023
Sotrovimab (VIR-7831) (PDF)CP.PHAR.541Pending FDA Approval
Sparsentan (Filspari) (PDF)CP.PHAR.631June 1, 2024
Spesolimab-sbzo (Spevigo) (PDF)CP.PHAR.606July 1, 2024
Spesolimab-sbzo (Spevigo) (PDF)CP.PHAR.606Retire by July 1, 2024
Spinosad (Natroba) (PDF)HIM.PA.134August 1, 2023
Step Therapy Criteria (PDF)HIM.PA.109June 1, 2024
Stiripentol (Diacomit) (PDF)CP.PMN.184December 1, 2023
sunitinib (Sutent) (PDF)CP.PHAR.73June 1, 2024
sunitinib (Sutent) (PDF)CP.PHAR.73Retire by June 1, 2024
Sutimlimab-jome (Enjaymo) (PDF)CP.PHAR.503June 1, 2024
Suvorexant (Belsomra®) (PDF)CP.PMN.109December 1, 2023
Tadalafil (Adcirca®) (PDF)CP.PHAR.198February 1, 2024
Tadalafil BHP - ED (Cialis) (PDF)CP.PMN.132August 1, 2023
Tafamidis (Vyndaqel, Vyndamax) (PDF)CP.PHAR.432October 1, 2023
Tafasitamab-cxix (Monjuvi) (PDF)CP.PHAR.508December 1, 2023
Talquetamab-tgvs (Talvey) (PDF)CP.PHAR.649May 1, 2024
Talazoparib (Talzenna)(PDF)CP.PHAR.409April 1, 2024
Taliglucerase Alfa (Elelyso) (PDF)CP.PHAR.157June 1, 2024
Talimogene laherparepvec (Imlygic) (PDF)CP.PHAR.542August 1, 2023
Tapinarof (Vtama) (PDF)CP.PMN.283December 1, 2023
Tasimelteon (Hetlioz) (PDF)CP.PMN.104April 1, 2024
Tavaborole (Kerydin®) (PDF)CP.PMN.105February 1, 2024
Tazarotene (Arazlo, Fabior, Tazorac) (PDF)CP.PMN.244April 1, 2024
Tazemetostat (PDF)CP.PHAR.452February 1, 2024
Tebentafusp-tebn (Kimmtrak) (PDF)CP.PHAR.575June 1, 2024
Teclistamab-cqyv (Tecvayli) (PDF)CP.PHAR.611February 1, 2024
Tedizolid (Sivextro) (PDF)CP.PMN.62February 1, 2024
Teduglutide (Gattex) (PDF)CP.PHAR.114April 1, 2024
Tegaserod (Zelnorm) (PDF)HIM.PA.160December 1, 2023
Telotristat ethyl (Xermelo) (PDF)CP.PHAR.337June 1, 2024
Temozolomide (Temodar) (PDF)CP.PHAR.77July 1, 2024
Temozolomide (Temodar) (PDF)CP.PHAR.77Retire by July 1, 2024
Temsirolimus (Torisel®) (PDF)CP.PHAR.324December 1, 2023
Tenapanor (Ibsrela) (PDF)CP.PMN.224March 1, 2024
Tenapanor (Ibsrela, Xphozah) (PDF)HIM.PA.174        March 1, 2023
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)CP.PMN.268December 1, 2023
Teplizumab (PDF)CP.PHAR.492February 1, 2024 (Previously Pending FDA Approval)
Tepotinib (Tepmetko) (PDF)CP.PHAR.530Retire by July 1, 2024
Tepotinib (Tepmetko) (PDF)CP.PHAR.530July 1, 2024
Teprotumumab (Tepezza) (PDF)CP.PHAR.465February 1, 2024
Teriflunomide (Aubagio) (PDF)CP.PCH.40June 1, 2024
Teriparatide (Forteo®) (PDF)CP.PHAR.188April 1, 2024
Tesamorelin (Egrifta) (PDF)CP.PHAR.109August 1, 2023
Testosterone (Androderm) (PDF)HIM.PA.87January 1, 2024
Testosterone (Testopel, Jatenzo) (PDF)CP.PHAR.354December 1, 2023
Tetrabenazine (Xenazine) (PDF)CP.PHAR.92June 1, 2024
Tezacaftor-Ivacaftor (Symdeko) (PDF)CP.PHAR.377March 1, 2024
Tezepelumab (Tezspire) (PDF)CP.PHAR.576February 1, 2024
Thalidomide (Thalomid) (PDF)CP.PHAR.78July 1, 2024
Thalidomide (Thalomid) (PDF)CP.PHAR.78Retire by July 1, 2024
Thioguanine (Tabloid) (PDF)CP.PHAR.437January 1, 2024
Thyrotropin Alfa (Thyrogen) (PDF)CP.PHAR.95August 1, 2023
Timothy grass pollen allergen extract (Grastek®) (PDF)CP.PMN.84 August 1, 2023
Tiopronin Delayed-Release (Thiola EC) (PDF)CP.PCH.50June 1, 2024
Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.361April 1, 2024
Tisotumab Vedotin-tftv (Tivdak)CP.PHAR.561December 1, 2023
Tivozanib (Fotivda) (PDF)CP.PHAR.538Retire by July 1, 2024
Tivozanib (Fotivda) (PDF)CP.PHAR.538July 1, 2024
Tixagevimab-Cilgavimab (Evusheld) (PDF)CP.PHAR.571July 1, 2023
Tobramycin (PDF)CP.PHAR.211August 1, 2023
Tofersen (BIIB067) (PDF)CP.PHAR.591December 1, 2023
Tolvaptan (Jynarque) (PDF)CP.PHAR.27August 1, 2023
Topical Acne Treatment (PDF)HIM.PA.71April 1, 2024
Topotecan (Hycamtin) (PDF)CP.PHAR.64Retire by July 1, 2024
Topotecan (Hycamtin) (PDF)CP.PHAR.64July 1, 2024
Topical Immunomodulators (PDF)CP.PMN.107February 1, 2024
Topiramate ER (Qudexy XR, Trokendi XR (PDF)CP.PMN.281October 1, 2023
Toripalimab (Loqtorzi) (PDF)CP.PHAR.668February 1, 2024
Trabectedin (Yondelis) (PDF)CP.PHAR.204February 1, 2024
Tralokinumab-ldrm (Adbry) (PDF)CP.PHAR.577June 1, 2024
Trametinib (Mekinist) (PDF)CP.PHAR.240July 1, 2024
Trametinib (Mekinist) (PDF)CP.PHAR.240Retire by July 1, 2024
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)CP.PHAR.228July 1, 2024
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)CP.PHAR.228Retire by July 1, 2024
Travoprost (iDose TR) (PDF)CP.PHAR.672March 1, 2024
Tremelimumab-actl (Imjudo) (PDF)CP.PHAR.612February 1, 2024
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF)CP.PHAR.199 February 1, 2024
Triamcinolone ER Injection (Zilretta) (PDF)CP.PHAR.371February 1, 2024
Triclabendazole (Egaten) (PDF)CP.PMN.207August 1, 2023
Trientine (Syprine) (PDF)CP.PHAR.438January 1, 2024
Trifarotene (Aklief) (PDF)CP.PMN.225February 1, 2024
Trifluridine/Tipiracil (Lonsurf) (PDF)CP.PHAR.383December 1, 2023
Triheptanoin (Dojolvi) ^ (PDF)CP.PHAR.509December 1, 2023
Triptorelin pamoate (Trelstar®, Triptodur®) (PDF)CP.PHAR.175April 1, 2024
Trofinetide (Daybue) (PDF)CP.PHAR.600June 1, 2024
Troriluzole (PDF)CP.PHAR.639 September 1, 2023
Tucatinib (Tukysa) (PDF)CP.PHAR.497October 2, 2023
Ublituximab-xiiy (Briumvi)  (PDF)CP.PHAR.621June 1, 2024
Ubrogepant (Ubrelvy) (PDF)CP.PHAR.476March 1, 2022
Udenafil (PDF)CP.PHAR.557December 1, 2023
Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia)(PDF)CP.PMN.277June 1, 2024
Umbralisib (Ukoniq) (PDF)CP.PHAR.531Retire by July 1, 2024
Umbralisib (Ukoniq) (PDF)CP.PHAR.531July 1, 2024
Uridine acetate (Vistogard) (PDF)HIM.PA.SP55December 1, 2023
Valbenazine (Ingrezza) (PDF)CP.PCH.48July 1, 2024
Valbenazine (Ingrezza) (PDF)CP.PCH.48Retire by July 1, 2024
valganciclovir (Valcyte) (PDF)CP.PCH.06April 1, 2024
Valoctocogene Roxaparvovec (PDF)CP.PHAR.466April 1, 2024 (Previously Pending FDA Approval)
Valrubicin (Valstar) (PDF)CP.PHAR.439December 1, 2023
Vamorolone (Agamree) (PDF)CP.PHAR.659February 1, 2024
Vandetanib (Caprelsa®) (PDF)CP.PHAR.80February 1, 2024
Varenicline (Tyrvaya) (PDF)CP.PMN.273February 1, 2024
Velaglucerase Alfa (VPRIV) (PDF)CP.PHAR.163June 1, 2024
Velmanase Alfa-tycv (Lamzede) (PDF)CP.PHAR.601June 1, 2024
Vemurafenib (Zelboraf®) (PDF)CP.PHAR.91February 1, 2024
Venetoclax (Venclexta) (PDF)CP.PHAR.129December 1, 2023
Vestronidase alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374July 1, 2024
Vestronidase alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374Retire by July 1, 2024
Verteporfin (PDF)CP.PHAR.187February 1, 2024
Vigabatrin (Sabril) (PDF)CP.PHAR.169 October 1, 2023
Vilazodone (Viibryd) (PDF)CP.PMN.145July 1, 2021
Viloxazine (Qelbree) (PDF)CP.PMN.264June 1, 2024
Viloxazine (Qelbree) (PDF)CP.PMN.264Retire by June 1, 2024
Viltolarsen (Viltepso) (PDF)CP.PHAR.484April 1, 2024
vincristine sulfate liposome injection (Marqibo®) (PDF)CP.PHAR.315January 1, 2024
Vismodegib (Erivedge) (PDF)CP.PHAR.273July 1, 2024
Vismodegib (Erivedge) (PDF)CP.PHAR.273Retire by July 1, 2024
Vutrisiran (Amvuttra)CP.PHAR.550July 1, 2024
Vutrisiran (Amvuttra)CP.PHAR.550Retire by July 1, 2024
Voclosporin (Lupkynis) (PDF)CP.PHAR.504Retire by July 1, 2024
Voclosporin (Lupkynis) (PDF)CP.PHAR.504July 1, 2024
Vorapaxar (Zontivity) (PDF)HIM.PA.146February 1, 2024
Voretigene neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.372February 1, 2024
Vorinostat (Zolinza) (PDF)CP.PHAR.83August 1, 2023
Vortioxetine (Trintellix®) (PDF)CP.PMN.65 April 1, 2024
Vosoritide (Voxzogo) (PDF)CP.PHAR.525February 1, 2024
Voxelotor (Oxbryta) (PDF)CP.PHAR.451February 1, 2024
Zanubrutinib (Brukinsa) (PDF)CP.PHAR.467February 1, 2024
Zavegepant (Zavzpret) (PDF)CP.PHAR.630June 1, 2024
Zilucoplan (RA101495) (PDF)CP.PHAR.616February 1, 2024
Ziv-aflibercept (Zaltrap®) (PDF)CP.PHAR.325December 1, 2023
Zoledronic acid (PDF)CP.PHAR.59February 1, 2024
Zuranolone (Zurzuvae) (PDF)CP.PHAR.650June 1, 2024