Clinical Payment Policies | Ambetter from Arkansas Health & Wellness

 

Clinical & Payment 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 but are not limited to 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; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and 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 a Arkansas Health & Wellness or a “Centene” heading.  Arkansas Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Arkansas Health & Wellness clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Arkansas Health & Wellness. In addition, 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. 

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Health care 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 health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and 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), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care 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 a Arkansas Health & Wellness or a “Centene” heading.  In addition, 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. 

Ambetter Policies

Ambetter from Arkansas Health and Wellness will be partnering with National Imaging Associates beginning January 1, 2021 for prior authorization requests for the following services:

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy

Clinical Policies for these procedures can be found at www.RadMD.com

Clinical Policies for CT/CTA/CCTA, MRI, MRA and Pet Scans can also be found at the NIA website (www.RADMD.com)

Policy Title Policy Number Effective Date
Acupuncture (PDF) CP.MP.92 October 1, 2021
ADHD Assessment and Treatment (PDF) CP.MP.124 October 1, 2021
Air Ambulance (PDF) CP.MP.175 October 1, 2021
Allergy Testing (PDF) CP.MP.100 November 1, 2021
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF) CP.MP.108 January 1, 2021
Ambulatory EEG (PDF) CP.MP.96 September 1, 2021
Antithrombin III (PDF) CP.MP.179 December 1, 2020
Articular Cartilage Defect Repairs (PDF) CP.MP.26 April 1, 2021
Assisted Reproductive Technology (PDF) CP.MP.55 May 1, 2021
Applied Behavioral Analysis (PDF) CP.BH.104 August 1, 2021
Biofeedback (PDF) CP.MP.168 July 1, 2021
Bone-Anchored Hearing Aid (PDF) AR.CP.MP.93 November 1, 2021
Bronchial Thermoplasty (PDF) CP.MP.110 June 1, 2021
Burn Surgery (PDF) CP.MP.186 October 1, 2021
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 March 1, 2021
Caudal or Interlaminar Epidural Steroid Injections (PDF) CP.MP.164 November 1, 2021
Cell free DNA Testing (PDF) CP.MP.84 November 1, 2021
Clinical Trials (PDF) CP.MP.94 August 1, 2021
Cochlear Implant Replacements (PDF) AR.CP.MP.14 September 1, 2020
Cosmetic Reconstructive Surgery (PDF) CP.MP.31 January 1, 2022
Dental Anesthesia (PDF) CP.MP.61 May 1, 2021
Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF) CP.BH.201 June 1, 2021
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 December 1, 2021
Diaphragmatic/Phrenic Nerve Stimulation (PDF) CP.MP.203 May 1, 2021
Digital Analysis of EEGs (PDF) CP.MP.105 March 1, 2021
Disc Decompression Procedures (PDF) CP.MP.114 July 1, 2021
Discography (PDF) CP.MP.115 August 1, 2021
Donor Lymphocyte Infusion (PDF) CP.MP.101 December 1, 2020
Drugs of Abuse: Presumptive Testing (PDF) CP.MP.208 December 1, 2021
Durable Medical Equipment (DME) (PDF) CP.MP.107 January 1, 2022
EEG in Evaluation of Headache (PDF) CP.MP.155 July 1, 2021
Electric Tumor Treatment Fields (PDF) CP.MP.145 May 1, 2021
Electromyography and Nerve Conduction Studies (PDF) CP.MP.211 September 1, 2021
Essure Removal (PDF) CP.MP.131 December 1, 2020
Evoked Potentials (PDF) CP.MP.134 October 1, 2021
Experimental Technologies (PDF) CP.MP.36 June 1, 2021
Facet Joint Interventions (PDF) CP.MP.171 September 1, 2021
Fecal incontinence treatments (PDF) CP.MP.137 September 1, 2021
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) CP.MP.129 December 1, 2021
FeNo Testing (PDF) CP.MP.103 January 1, 2021
Ferriscan R2-MRI (PDF) CP.MP.53 December 1, 2020
Fertility Preservation (PDF) CP.MP.130 November 1, 2021
Gastric Electrical Stimulation (PDF) CP.MP.40 November 1, 2021
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) CP.MP.209 January 1, 2021 
Gender Reassignment (PDF) CP.MP.95 September 1, 2021
Genetic Testing (PDF) CP.MP.89 June 1, 2021
Heart-Lung Transplant (PDF) CP.MP.132 October 1, 2021
H Pylori Testing (PDF) CP.MP.153 December 1, 2020
Holter Monitors (PDF) CP.MP.113 June 1, 2021
Home Births (PDF) CP.MP.136 November 1, 2021
Homocysteine Testing (PDF) CP.MP.121 July 1, 2021
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) CP.MP.150 March 1, 2021
Hospice (PDF) CP.MP.54 September 1, 2021
Hyperhidrosis Treatments (PDF) CP.MP.62 March 1, 2021
Hyperemesis Gravidarum Treatment (PDF) CP.MP.34 July 1, 2021
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) CP.MP.180 January 1, 2021
Implanable Intrathecal Pain Pump (PDF) CP.MP.173 March 1, 2021
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) CP.MP.160 June 1, 2021
Inhaled Nitric Oxide (PDF) CP.MP.87 December 1, 2021
Intensity Modulated Radiotherapy (PDF) CP.MP.69 February 1, 2021
Intestinal and Multivisceral Transplant (PDF) CP.MP.58 October 1, 2021
Intradiscal Steroid Injections for Pain Management (PDF) CP.MP.167 October 1, 2021
Laser Skin Treatment (PDF) CP.MP.123 August 1, 2021
Long Term Care Placement Criteria (PDF) CP.MP.71 June 1, 2021
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 September 1, 2021
Lung Transplantation (PDF) CP.MP.57 November 1, 2021
Lysis of Epidural Lesions (PDF) CP.MP.116 July 1, 2021
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 December 1, 2020
Mechanical Stretch Devices (PDF) CP.MP.144 June 1,  2021
Neonatal Abstinence syndrome guideline (PDF) CP.MP.86 November 1, 2021
Neonatal Sepsis Management Guidelines (PDF) CP.MP.85 December 1, 2021
Neurofeedback for Behavioral Health Disorders (PDF) CP.BH.300 August 1, 2021
Nerve Blocks for Pain Management (PDF) CP.MP.170 November 1, 2021 
NICU Apnea Bradycardia Guidelines (PDF) CP.MP.82 August 1, 2021
NICU Discharge Guidelines (PDF) CP.MP.81 November 1, 2021
Non-Invasive Home Ventilator (PDF) CP.MP.184 October 1, 2021
Nonmyeloablative allogeneic stem cell transplant (PDF) CP.MP.141 April 1, 2021
OB Home Health Programs (PDF) CP.MP.91 May 1, 2021
Optic Nerve Decompression Surgery (PDF) CP.MP.128 October 1, 2021
Osteogenic Stimulation (PDF) CP.MP.194 November 1, 2021
Outpatient Cardiac Rehabilitation (PDF) CP.MP.176 July 1, 2021
Outpatient Testing for Drugs of Abuse (PDF) CP.MP.50 August 1, 2021
Oxygen Use and Concentrators (PDF) CP.MP.190 November 1, 2021
Pancreas Transplantation (PDF) CP.MP.102 October 1, 2021
Panniculectomy (PDF) CP.MP.109 August 1, 2021
Pediatric Heart Transplant (PDF) CP.MP.138 October 1, 2021
Pediatric Liver Transplant (PDF) CP.MP.120 October 1, 2021
Pediatric Oral Function Therapy (PDF) CP.MP.188 July 1, 2021
Reduction Mammoplasty and Gynecomastia Surgery (PDF) CP.MP.51 November 1, 2021
Repair of Nasal Valve Compromise (PDF) CP.MP.210 October 1, 2021
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) CP.MP.147 July 1, 2021
Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49 August 1, 2021
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) CP.MP.181 October 1, 2021
Post-Acute Care (PDF) CP.MP.213 January 1, 2021
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) CP.MP.133 October 1, 2021
PROM Testing (PDF) CP.MP.149 August 1, 2021
Proton and Neutron Beam Therapy (PDF) CP.MP.70 April 1, 2021
Radial Head Implant (PDF) CP.MP.148 July 1, 2021
Radiofrequency Ablation of Uterine Fibroids (PDF) CP.MP.187 June 1, 2021
Sacroiliac Joint Fusion (PDF) CP.MP.126 August 1, 2021
Sacroiliac Joint Interventions for Pain Management (PDF) CP.MP.166 October 1, 2021
 Sclerotherapy (PDF) CP.MP.146 October 1, 2021
Selective Dorsal Rhizotomy (PDF) CP.MP.174 May 1, 2021
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF) CP.MP.165 October 1, 2021
Skin Substitutes for Chronic Wounds (PDF) CP.MP.185 September 1, 2021
Skilled Nursing Facility Leveling (PDF) CP.MP.206 October 1, 2021
Spinal Cord Stimulation (PDF) CP.MP.117 September 1, 2021
Stereotactic Body Radiation Therapy (PDF) CP.MP.22 March 1, 2021
Tandem Transplant (PDF) CP.MP.162 October 1, 2021
Total Artificial Heart (PDF) CP.MP.127 January 1, 2021
Thymus Transplantation (PDF) CP.MP.189 August 1, 2021
Thyroid Testing in Pediatrics (PDF) CP.MP.154 December 1, 2020
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) CP.MP.163 September 1, 2021
Transcatheter Closure of Patent Foramen Ovale (PDF) CP.MP.151 January 1, 2021
Transcranial Magnetic Stimulation (PDF) CP.BH.200 June 1, 2021
Trigger Point Injections for Pain Management (PDF) CP.MP.169 October 1, 2021
Ultrasound in Pregnancy (PDF) CP.MP.38 Novembe 1, 2021
Urinary Incontinence Devices and Treatments (PDF) CP.MP.142 May 1, 2021
Urodynamic Testing (PDF) CP.MP.98 September 1, 2021
Vagus Nerve Stimulation (PDF) CP.MP.12 OCtober 1, 2021
Ventricular Assist Devices (PDF) CP.MP.46 July 1, 2021
Vitamin D Testing in Children (PDF) CP.MP.157 March 1, 2021
Wheelchair seating (PDF) CP.MP.99 September 1, 2021
Wireless Motility Capsule (PDF) CP.MP.143 March 1, 2021
Policy Title Policy Number Effective Date
3-Day Payment Window (PDF) CC.PP.500 July 1, 2014
Add on Code Billed Without Primary Code (PDF) CC.PP.030 October 18, 2016
ADHD Assessment and Treatment (PDF) CP.MP.124 May 1, 2021
Ambulatory EEG (PDF) CP.MP.96 August 12, 2016
Ambulatory Surgery Center Optimization (PDF) CP.MP.158 June 1, 2021
Assistant Surgeon (PDF) CC.PP.029 February 7, 2017
Bilateral Procedures (PDF) CC.PP.037 February 7, 2017
Bronchial Thermoplasty (PDF) CP.MP.110 April 1, 2017
Cardiac Biomarker Testing for Acute MI (PDF) CP.MP.156 March 1, 2021
Cerumen Removal (PDF) CC.PP.008 August 12, 2016
Clean Claims (PDF) CC.PP.021 October 18, 2016
Coding Overview (PDF) CC.PP.011 October 18, 2016
Cosmetic Procedures (PDF) CC.PP.024 October 18, 2016
Testing for Select Genitourinary Conditions (PDF) CP.MP.97 June 1, 2021
Digital Analysis of EEGs (PDF) CP.MP.105 March 1, 2021
Distinct Procedural Modifiers (PDF) CC.PP.020 October 18, 2016
DNA Analysis of Stool (PDF) CP.MP.125 August 1, 2021
Duplicate Primary Code Billing (PDF) CC.PP.044 February 7, 2017
E&M Medical Decision-Making (PDF) CC.PP.051 July 25, 2017
EM Bundling Edits (PDF) CC.PP.010 August 12, 2016
Endometrial Ablation (PDF) CP.MP.106 September 1, 2021
FeNo Testing (PDF) CP.MP.103 April 1, 2017
Functional MRI (PDF) CP.MP.43 November 1, 2021
Global Maternity Billing (PDF) CC.PP.016 October 18, 2016
H Pylori Testing (PDF) CP.MP.153 May 21, 2018
Holter Monitors (PDF) CP.MP.113 April 1, 2017
Homocysteine Testing (PDF) CP.MP.121 May 1, 2021
Hospice Services (PDF) CP.MP.54 September 1, 2021
Hospital Visit Codes Billed with Labs (PDF) CC.PP.023 October 18, 2016
Inpatient Consultation (PDF) CC.PP.038 February 7, 2017
Inpatient Only Procedures (PDF) MP.PP.018 October 18, 2016
IV Hydration (PDF) CC.PP.012 October 18, 2016
Leveling of Care: Evaluation and Management Overcoding (PDF) CC.PP.066 March 15, 2021
Leveling of Emergency Room (PDF) CC.PP.053  January 1, 2019
Low-Frequency Ultrasound Wound Therapy (PDF) CP.MP.139 November 1, 2017
Maximum Units (PDF) CC.PP.007 August 12, 2016
Measure Serum 1,25 Vitamin D (PDF) CP.MP.152 May 21, 2018
Moderate Conscious Sedation (PDF) CC.PP.015 October 18, 2016
Modifier -25 clinical validation (PDF) CC.PP.013 October 18, 2016
Modifier -59 clinical validation (PDF) CC.PP.014 October 18, 2016
Modifier DOS Validation (PDF) CC.PP.034 October 18, 2016
Modifier to Procedure Code Validation (PDF) CC.PP.028 October 18, 2016
Multiple CPT Code Replacement (PDF) CC.PP.033 October 18, 2016
Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF) CC.PP.065 March 15, 2021
Multiple Procedure Reduction: Ophthalmology (PDF) CC.PP.069 March 15, 2021
Multiple Procedure Payment Reduction for Therapeutic Services (PDF) CC.PP.068 March 15, 2021
Multiple Sleep Latency Testing (PDF) CP.MP.24 June 1, 2021
NCCI Unbundling (PDF) CC.PP.031 October 18, 2016
Neuromuscular Electrical Stimulation (PDF) CP.MP.48 December 1, 2021
Never Paid Events (PDF) CC.PP.017 October 18, 2016
New Patient (PDF) CC.PP.036 February 7, 2017
Non-Obstetrical Pelvic and Transabdominal Ultrasound (PDF) CC.PP.061  March 15, 2021
Outpatient Consultation (PDF) CC.PP.039 February 7, 2017
Physician’s Consultation Services (PDF) CC.PP.054 September 1, 2018
Physician Visit Codes Billed with Labs (PDF) CC.PP.019 October 18, 2016
Place of Service Mismatch (PDF) CC.PP.063  December 15, 2018
Post-Operative Visits (PDF) CC.PP.042 February 7, 2017
Pre-Operative Visits (PDF) CC.PP.041 February 7, 2017
Problem Oriented Visits with Preventative Services (PDF) CC.PP.057 November 1, 2018
Problem Oriented Visits with Surgical Procedures (PDF) CC.PP.052 November 1, 2018
Professional Component (PDF) CC.PP.027 October 18, 2016
PROM Testing (PDF) CP.MP.149 November 8, 2017
Proton and Neutron Beam Therapy (PDF) CP.MP.70 June 1, 2019
Pulse Oximetry (PDF) CC.PP.025 October 18, 2016
Renal Hemodialysis (PDF) CC.PP.067 March 15, 2021
Robotic Surgery (PDF) CC.PP.050 November 1, 2017
Same Day Visits (PDF) CC.PP.040 February 7, 2017
Status "B" Bundled Services (PDF) CC.PP.046 February 7, 2017
Status P Bundled Services (PDF) CC.PP.049 June 17, 2017
Supplies Billed on Same Day As Surgery (PDF) CC.PP.032 October 18, 2016
Thyroid Testing in Pediatrics (PDF) CP.MP.154 May 21, 2018
Transgender Related Services (PDF) CC.PP.047 February 22, 2017
Ultrasound in Pregnancy (PDF) CP.MP.38 February 10, 2017
Unbundled Professional Services (PDF) CC.PP.043 April 6, 2017
Unbundled Surgical Procedures (PDF) CC.PP.045 April 6, 2017
Unlisted Procedure Codes (PDF) CC.PP.009 August 12, 2016
Urine Specimen Validity Testing (PDF) CC.PP.056 November 8, 2017
Video Electroencephalographic (VEEG) Monitoring (PDF) CP.MP.177 November 1, 2021
Vitamin D Testing in Children (PDF) CP.MP.157 March 1, 2021
Wheelchair Accessories (PDF) CC.PP.502 August 12, 2016
Wireless Motility Capsule (PDF) CP.MP.143 March 1, 2021
Policy Title Policy Number Effective Date
Abaloparatide (Tymlos) (PDF) CP.PHAR.345 March 1, 2021
Abametapir (Xeglyze) (PDF) CP.PMN.253 December 1, 2020
Abatacept (Orencia) (PDF) CP.PHAR.241 August 1, 2021
Abemaciclib (Verzenio) (PDF) CP.PHAR.355 January 1, 2022
Abiraterone (Zytiga) (PDF) CP.PHAR.84 March 1, 2021
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 July 1, 2021
Aclidinium/Formoterol (Duaklir Pressair) (PDF) HIM.PA.151 March 1, 2021
Adefovir (Hepsera) (PDF) CP.PHAR.142 December 1, 2020
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) CP.PHAR.229 July 1, 2021
Aducanumab (Aduhelm) (PDF) CP.PHAR.468 December 1, 2021
Afamelanotide (Scenesse) (PDF) CP.PHAR.444 March 1, 2021
afatinib (Gilotrif) (PDF) CP.PHAR.298 June 1, 2021
Aflibercept (Eylea) (PDF) CP.PHAR.184 December 1, 2021
Agalsidase Beta (Fabrazyme) (PDF) CP.PHAR.158  August 1, 2021
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PMN.138 June 1, 2021
Alectinib (Alecensa) (PDF) CP.PHAR.369 June 1, 2021
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 June 1, 2021
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 March 1, 2021
Alglucosidase (Lumizyme) (PDF) CP.PHAR.160 July 1, 2021
Alpelisib (Piqray) (PDF) CP.PHAR.430 July 1, 2021
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) CP.PHAR.94 March 1, 2021
Amantadine ER (Gocovri,Osmolex ER) (PDF) CP.PMN.89 March 1, 2021
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 March 1, 2021
Amifampridine (Firdapse)(PDF) CP.PHAR.411 May 1, 2021
Amikacin (Arikayce)(PDF)  CP.PHAR.401 March 1, 2021
Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544 October 1, 2021
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) CP.PHAR.217 March 1, 2021
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) CP.PHAR.506 December 1, 2020
Apalutamide (Erleada) (PDF) CP.PHAR.376 August 1, 2021 
Apomorphine (Apokyn) (PDF) CP.PHAR.488 July 1, 2021
aprepitant (Emend®) (PDF) CP.PMN.19 March 1, 2021
Arformoterol Tartrate (Brovana) (PDF) CP.PMN.201 March 1, 2021
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada)  (PDF) CP.PHAR.290 July 1, 2021
Aripiprazole ODT (Abilify) (PDF) CP.PCH.37 March 1, 2021
armodafinil (Nuvigil) (PDF) CP.PMN.35 June 1, 2021
Asenapine (Saphris) (PDF) CP.PMN.15 March 1, 2021
Aspirin-dipyridamole (Aggrenox) (PDF) CP.PMN.20 May 1, 2021
Atezolizumab (Tecentriq) (PDF) CP.PHAR.235 March 1, 2021
Avapritinib (Ayvakit) (PDF) CP.PHAR.454 March 1, 2021
Avatrombopag (Doptelet) (PDF) CP.PHAR.130 December  1, 2020
Avelumab (Bavencio) (PDF) CP.PHAR.333 May 1, 2021
axicabtagene ciloleucel (Yescarta®) (PDF) CP.PHAR.362 June 1, 2021
Axitinib (Inlyta) (PDF) CP.PHAR.100 March 1, 2021
Azacitidine (Vidaza) (PDF) CP.PHAR.387 December 1, 2020
Azelaic Acid (Finacea) (PDF) HIM.PA.119 December 1, 2020
Aztreonam (Cayston) (PDF) CP.PHAR.209 May 1, 2021
Baricitinib (Olumiant) (PDF) CP.PHAR.135 July 1, 2021
Bedaquiline (Sirturo) (PDF) CP.PMN.212 June 1, 2021
belatacept (Nulojix®)  (PDF) CP.PHAR.201 December 1, 2020
Belimumab (Benlysta) (PDF) CP.PHAR.88 June 1, 2021
belinostat (Beleodaq®) (PDF) CP.PHAR.311 December 1, 2020
Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (PDF) CP.PMN.237 March 1, 2021
bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 December 1, 2020
Benralizumab (Fasenra) (PDF) CP.PHAR.373 March 1, 2021
Benznidazole (PDF) CP.PMN.90 March 1, 2021
Benzphetamine (Didrex, Regimex) (PDF) CP.CPA.326 July 1, 2021
Berotralstat (Orladeyo) (PDF) CP.PHAR.485 October 1, 2021
Betaine (Cystadane) (PDF) CP.PHAR.143 December 1, 2020
Betibeglogene autotemcel (PDF) CP.PHAR.545 October 1, 2021
Bevacizumab (PDF) CP.PHAR.93 August 2, 2021
Bexarotene (Targretin) (PDF) CP.PHAR.75 June 1, 2021
Bezlotoxumab (Zinplava) (PDF) CP.PHAR.300 March 1, 2021
Bimatoprost Implant (Durysta) (PDF) CP.PHAR.486 June 1, 2021
Biologic DMARDs (PDF) HIM.PA.SP60 July 1, 2021 
Binimetinib (Mektovi) (PDF) CP.PHAR.50 August 1, 2021 
Belantamab mafodotin (Blenrep) (PDF) CP.PHAR.469 June 1, 2021
Blinatumomab (Blincyto) (PDF) CP.PHAR.312 July 1, 2021
Bortezomib (Velcade) (PDF) CP.PHAR.410 March 1, 2021
Bosentan (Tracleer®) (PDF) CP.PHAR.191 March 1, 2021
Bosutinib (Bosulif) (PDF) CP.PHAR.105 July 1, 2021 
Brand Name Override and Non-Formulary Medications (PDF) HIM.PA.103 March 1, 2021
Brentuximab Vedotin (Adcetris) (PDF) CP.PHAR.303 July 1, 2021
Brexanolone (Zulresso) (PDF) CP.PHAR.417 June 1, 2021
Brexpiprazole (Rexulti) (PDF) CP.PMN.68 March 1, 2021
Brexucabtagene Autoleucel (Tecartus) (PDF) CP.PHAR.472 July 1, 2021
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 June 1, 2021
Brolucizumab-dbll (Beovu) (PDF) CP.PHAR.445  March 1, 2021
Oxymetazoline (Rhofade)(PDF) CP.PMN.86 June 1, 2021
Brimonidine Tartrate (Mirvaso) (PDF) CP.PMN.192 June 1, 2021
Brinzolamide/Brimonidine (Simbrinza) (PDF) HIM.PA.15 June 1, 2021
Brivaracetam (Briviact) (PDF) CP.PCH.26 July 1, 2021
Budesonide (Uceris) (PDF) CP.PCH.11 December 1, 2020
Budesonide-glycopyrrolate-formoterol fumarate (Breztri Aerosphere) (PDF) HIM.PA.150 December 1, 2020
buprenorphine implant (Probuphine) (PDF) CP.PHAR.289 March 1, 2021
Bupropion/Naltrexone (Contr07e) (PDF) CP.PCH.12 July 1, 2021
Burosumab-twza (Crysvita) (PDF) CP.PHAR.11 July 1, 2021
Butorphanol Nasal Spray (PDF) HIM.PA.46 June 1, 2021
C1 Esterase Inhibitors (PDF) CP.PHAR.202 October 1, 2021
cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 August 1, 2021
Cabozantinib (Cometriq®, Cabometyx®) (PDF) CP.PHAR.111 September 1, 2021
Calcifediol (Rayaldee) (PDF) CP.PMN.76  July 1, 2021
Canakinumab (Ilaris) (PDF) CP.PHAR.246 August 1, 2021 
Cannabidiol (Epidiolex) (PDF) CP.PMN.164 July 1, 2021
capecitabine (Xeloda) (PDF) CP.PHAR.60 June 1, 2021
Caplacizumab-yhdp (Cablivi) (PDF) CP.PHAR.416 June 1, 2021
Carbetocin (PDF) CP.PHAR.546 October 1, 2021
carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 June 1, 2019
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206  July 8, 2021
Casimersen (Amondys 45) (PDF) CP.PHAR.470 June 1, 2021
Celecoxib (Celebrex) (PDF) CP.PMN.122 June 1, 2021
Cemiplimab-rwlc (Libtayo) (PDF) CP.PHAR.397 June 1, 2019
Cenegermin-bkbj (Oxervate)(PDF) CP.PMN.186 March 1, 2021
Cenobamate (Xcopri) (PDF) CP.PMN.231 March 1, 2021
Ceritinib (Zykadia) (PDF) CP.PHAR.349 June 1, 2021
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 July 1, 2021
Certolizumab (Cimzia) (PDF) CP.PHAR.247 August 1, 2021 
cetuximab (Erbitux®) (PDF) CP.PHAR.317 December 1, 2020
Chlorambucil (Leukeran) (PDF) HIM.PA.SP59 December 1, 2020
Chloramphenicol Sodium Succinate (PDF) CP.PHAR.388 March 1, 2021
Cholic Acid (Cholbam) (PDF) CP.PHAR.390 March 1, 2021
Ciclopirox (Penlac) (PDF) CP.PMN.24 March 1, 2021
Cinacalcet (Sensipar) (PDF) CP.PHAR.61 July 1, 2021
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) CP.PMN.248 December 1, 2020
Ciprofloxacin/Fluocinolone (Otovel) (PDF) CP.PMN.249 December 1, 2020
Cladribine (Mavenclad) (PDF) CP.PHAR.422 June 1, 2021
Clascoterone (Winlevi) (PDF) CP.PMN.257 March 1, 2021
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 October 1, 2021 
Clobazam (Onfi) (PDF) CP.PMN.54 December 1, 2020
CNS Stimulants (PDF) CP.PMN.92 October 1, 2021
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 June 1, 2021
Colchicine (Colcrys) (PDF) CP.PMN.123 July 1, 2021
Colesevelam (Welchol) (PDF) CP.PMN.250 December 1, 2020
Collagenase (Xiaflex) (PDF) CP.PHAR.82 July 1, 2021
Colonoscopy Preparation Products (PDF) HIM.PA.04 December 1, 2020
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) CP.PMN.258 March 1, 2021
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) CP.PHAR.505 December 1, 2020
Continuous Glucose Monitors (PDF) CP.PMN.214 July 1, 2021
copanlisib (Aliqopa®)  (PDF) CP.PHAR.357 December 1, 2020
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) CP.PHAR.385 July 1, 2021
Cosyntropin (Cortrosyn) (PDF) CP.PHAR.203 March 1, 2021
Crisaborole (Eucrisa) (PDF) CP.PMN.110 June 1, 2021
Crizanlizumab-tmca (Adakveo) (PDF) CP.PHAR.449 June 1, 2021
Crizotinib (Xalkori) (PDF) CP.PHAR.90 June 1, 2021
Cyclosporine (Restasis, Cequa) (PDF) CP.PMN.48 June 1, 2021
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 June 1, 2021
Cysteamine oral (Cystagon, Procysbi) (PDF) CP.PHAR.155    July 1, 2021
Cytomegalovirus Immune Globulin (Cytogam) (PDF) CP.PHAR.277 July 1, 2021
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 August 1, 2021 
Daclatasvir (Daklinza) (PDF) HIM.PA.SP27 December 1, 2020
Dacomitinib (Vizimpro) (PDF) CP.PHAR.399 December 1, 2020
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 June 1, 2021
Deflazacort (Emflaza) (PDF) CP.PHAR.331 March 1, 2021
Dalteparin (Fragmin) (PDF) CP.PHAR.225 March 1, 2017
Daptomycin (Cubicin, Cubicin RF) (PDF) CP.PHAR.351 July 1, 2021
Dapsone (Aczone Gel) (PDF) CP.PCH.32 December 1, 2020
Daratumumab (Darzalex) (PDF) CP.PHAR.310 July 1, 2021
Darbepoetin alfa (Aranesp) (PDF) CP.PHAR.236 August 1, 2021 
Darolutamide (Nubeqa) (PDF) CP.PHAR.435 December 1, 2020
Dasabuvir-Ombitasvir-Paritaprevir-Ritonavir (Viekira Pak) (PDF) HIM.PA.sp61 July 1, 2021
Dasatinib (Sprycel) (PDF) CP.PHAR.72 June 1, 2021
daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 July 1, 2021
Decitabine-Cedazuridine (Inqovi) (PDF) CP.PHAR.479 June 1, 2021
deferasirox (Exjade Jadenu) (PDF) CP.PHAR.145 July 1, 2021
Deferoxamine (Desferal) (PDF) CP.PHAR.146 July 1, 2021
degarelix acetate (Firmagon®) (PDF) CP.PHAR.170 December 1, 2020
Delafloxacin (Baxdela) (PDF) CP.PMN.115 March 1, 2021
Denosumab (Prolia, Xgeva) (PDF) CP.PHAR.58 March 1, 2021
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) CP.PHAR.214 March 1, 2021
Deutetrabenazine (Austedo) (PDF) CP.PCH.42 July 1, 2021
Dexlansoprazole (Dexilant) (PDF) HIM.PA.05 December 1, 2020
Dexrazoxane (Zinecard, Totect) (PDF) CP.PHAR.418 June 1, 2021
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 March 1, 2021
Diazepam Nasal Spray (Valtoco)(PDF) CP.PMN.216 December 1, 2020
Dichlorphenamide (Keveyis) (PDF) CP.PMN.261 March 1, 2021
diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) CP.PCH.28 September 1, 2021
Diethylpropion (Tenuate, Tenuate Dospan) (PDF) CP.CPA.328 July 1, 2021
Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (PDF) CP.PCH.41 July 1, 2021
Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam) (PDF) CP.PHAR.41 June 1, 2021
Dipeptidyl Peptidase-4 Inhibitors (PDF) HIM.PA.58 February 1, 2020
Dolasetron (Anzemet) (PDF) CP.PMN.141 July 1, 2021
Dornase alfa (Pulmozyme) (PDF) CP.PHAR.212 May 1, 2021
Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) HIM.PA.147 December 1, 2020
Doxycycline (Doryx, Oracea, Acticlate) (PDF) CP.PMN.79 August 1, 2021 
Dupilumab (Dupixent) (PDF) CP.PHAR.336 March 1, 2021
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 August 1, 2021 
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) CP.PMN.128 June 1, 2021
Duvelisib (Copiktra) (PDF) CP.PHAR.400 December 1, 2020
Ecallantide (Kalbitor) (PDF) CP.PHAR.177 October 1, 2021
Eculizumab (Soliris) (PDF) CP.PHAR.97 May 1, 2021
Edaravone (Radicava) (PDF) CP.PHAR.343 June 7, 2021
Efinaconazole (Jublia) (PDF) CP.PMN.25 March 1, 2021
Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (PDF) CP.PHAR.136 March 1, 2021
Elapegademase-lvlr (Revcovi) (PDF) CP.PHAR.419 August 1, 2021 
Elbasvir/Grazoprevir (Zepatier) (PDF) CP.CPA.284 July 1, 2021
Eliglustat (Cerdelga) (PDF) CP.PHAR.153 July 1, 2021
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) CP.PHAR.440 March 1, 2021
Elosulfase Alfa (Vimizim) (PDF) CP.PHAR.162  June 1, 2021
Elotuzumab (Empliciti) (PDF) CP.PHAR.308 December 1, 2020
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 March 1, 2021
Eluxadoline (Viberzi) (PDF) CP.PMN.170 December 1, 2020
Emapalumab-lzsg (Gamifant)(PDF) CP.PHAR.402 May 1, 2021
Emicizumab-kxwh (Hemlibra) (PDF) CP.PHAR.370 March 1, 2021
Emtricitabine-tenofovir alafenamide (Descovy) (PDF) CP.PMN.235 June 1, 2021
Encorafenib (Braftovi) (PDF) CP.PHAR.127 July 1, 2021
Enfuvirtide (Fuzeon) (PDF) CP.PHAR.41    July 1, 2021
Enfortumab Vedotin-ejfv (Padcev) (PDF) CP.PHAR.455 October 1, 2021
Entecavir (Baraclude) (PDF) HIM.PA.08 June 1, 2021
Entrectinib (Rozlytrek) (PDF) CP.PHAR.441 October 1, 2020
Enzalutamide (Xtandi) (PDF) CP.PHAR.106 March 1, 2021
Epoetin Alfa (Epogen® and Procrit) (PDF) CP.PHAR.237 August 1, 2021 
Epoprostenol (PDF) CP.PHAR.192 March 1, 2021
Eptinezumab-jjmr (Vyepti) (PDF) HIM.PA.SP64 December 1, 2021
Erdafitinib (Balversa) (PDF) CP.PHAR.423 July 1, 2021
Erenumab-aaoe (Aimovig) (PDF) HIM.PA.SP65 December 1, 2021
eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 March 1, 2021
Erlotinib (Tarceva) (PDF) CP.PHAR.74 June 1, 2021
Erwinia Asparaginase (Erwinaze) (PDF) CP.PHAR.301 March 1, 2021
Esketamine (Spravato) (PDF) CP.PMN.199 August 1, 2021 
Esomeprazole-Naproxen (Vimovo) (PDF) CP.PMN.117 August 1, 2021 
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 July 1, 2021
Eteplirsen  (Exondys 51) (PDF) CP.PHAR.288 July 1, 2021
Etidronate (Didronel) (PDF) CP.PMN.94 March 1, 2021
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF) CP.PHAR.63 March 1, 2021
Evinacumab-dgnb (Evkeeza) (PDF) CP.PHAR.511 August 1, 2021 
Evolocumab (Repatha) (PDF) CP.PHAR.123 July 1, 2021
Factor IX (Human, Recombinant) (PDF) CP.PHAR.218 December 1, 2020
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) CP.PHAR.219 March 1, 2021
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) CP.PHAR.220 March 1, 2021
Factor VIII (Human Recombinant) (PDF) CP.PHAR.215 March 1, 2021
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) CP.PHAR.216 May 1, 2021
Factor XIII A-Subunit, Recombinant (Tretten®) CP.PHAR.222 March 1, 2021
Factor XIII, Human (Corifact®) (PDF) CP.PHAR.221 March 1, 2021
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) CP.PHAR.456 March 1, 2021
Famotidine-Ibuprofen (Duexis) (PDF) CP.PMN.120 August 1, 2021 
febuxostat (Uloric) (PDF) CP.PMN.57 March 1, 2021
Fedratinib (Inrebic) (PDF) CP.PHAR.442 Januray 1, 2021
Fenfluramine (Fintepla) (PDF) CP.PMN.246 July 1, 2021
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) CP.PMN.127 June 1, 2021
Ferric Carboxymaltose (Injectafer) (PDF) CP.PHAR.234 March 1, 2021
Ferric Derisomaltose (Monoferric) (PDF) CP.PHAR.480 August 1, 2021 
Ferric gluconate (Ferrlecit®) (PDF) CP.PHAR.166 May 1, 2021
Ferric Maltol (Accrufer) (PDF) CP.PMN.213 December 1, 2020
Ferumoxytol (Feraheme®) (PDF) CP.PHAR.165 March 1, 2021
Flibanserin (Addyi) (PDF) CP.PHAR.446 May 1, 2021
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) CP.PHAR.526 June 1, 2021
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) CP.PHAR.297 September 1, 2021
Fingolimod (Gilenya) (PDF) CP.PCH.38 June 1, 2021
Fluorouracil Cream (Tolak) (PDF) CP.PMN.165 December 1, 2020
Fluticasone Propionate (Xhance) (PDF) CP.PMN.95 March 1, 2021
Fondaparinux (Arixtra) (PDF) CP.PHAR.226 May 1, 2021
Formulary Medications Without Specific Guidelines (PDF) HIM.PA.33 March 1, 2021
Fostamatinib (Tavalisse) (PDF) CP.PHAR.24 March 1, 2021
Fostemsavir (Rukobia) (PDF) CP.PHAR.516 March 1, 2021
Fremanezumb-vfrm (PDF) HIM.PA.SP66 December 1, 2021
Fulvestrant (Faslodex Injection) (PDF) CP.PHAR.424 July 1, 2021
Galcanezumab-gnlm (Emgality) (PDF) HIM.PA.SP67 December 1, 2021
Galsulfase (Naglazyme) (PDF) CP.PHAR.161  
Gefitinib (Iressa) (PDF) CP.PHAR.68 June 1, 2021
gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 December 1, 2020
Gilteritinib (Xospata)(PDF) CP.PHAR.412 March 1, 2021
Givosiran (Givlaari) (PDF) CP.PHAR.457 March 1, 2021
Glasdegib (Daurismo)(PDF) CP.PHAR.413 March 1, 2021
Glatiramer (Copaxone, Glatopa) (PDF) HIM.PA.SP68 June 1, 2021
Glecaprevir-Pibrentasvir (PDF) HIM.PA.SP36 July 1, 2021
Glucagon-Like Peptide-1 Receptor Agonists (PDF) HIM.PA.53 October 1, 2021
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 March 1, 2021
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 August 1, 2021 
Golodirsen (Vyondys 53) (PDF) CP.PHAR.453 July 1, 2021
goserelin acetate (Zoladex®) (PDF) CP.PHAR.171 December 1, 2020
Halcinonide (Halog) (PDF) HIM.PA.20 December1, 2020
Halobetasol Propionate/Tazarotene (Duobrii) (PDF) CP.PMN.208 July 1, 2021
Hemin (Panhematin®) (PDF) CP.PHAR.181 March 1, 2021
histrelin acetate (Vantas®, Supprelin LA®) (PDF) CP.PHAR.172 December 1, 2020
House dust mite allergen extract (Odactra®) (PDF) CP.PMN.111  July 1, 2021
Human Growth Hormone (Somapacitan, Somatropin) (PDF) CP.PCH.39 March 1, 2021
Hyaluronate Derivatives (PDF) CP.PHAR.05 July 1, 2021
Hydroxyprogesterone Caproate (Makena) (PDF) CP.PHAR.14 March 1, 2021
Hydroxyurea (Siklos) (PDF) CP.PMN.193 June 1, 2021
ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 June 1, 2021
Ibandronate sodium (PDF) CP.PHAR.189 March 1, 2021
Ibrutinib (Imbruvica) (PDF) CP.PHAR.126 May 1, 2021
Icatibant (Firazyr®) (PDF) CP.PHAR.178 October 1, 2021
Icosapent ethyl (Vascepa) (PDF) CP.PMN.187 May 1, 2021
Idelalisib (Zydelig) (PDF) CP.PHAR.133 December 1, 2020
Idursulfase (Elaprase) (PDF) CP.PHAR.156  July 1, 2021
lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (PDF) CP.PMN.150 March 1, 2021
Iloperidone (Fanapt) (PDF) CP.PMN.32 March 1, 2021
Iloprost (Ventavis®) (PDF) CP.PHAR.193 March 1, 2021
Imatinib (Gleevec) (PDF) CP.PHAR.65 June 1, 2021
Imiglucerase (Cerezyme) (PDF) CP.PHAR.154  July 1, 2021
Immune Globulins (PDF) CP.PHAR.103 October 1, 2021
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 July 1, 2021
Inhaled Agents for Asthma and COPD (PDF) HIM.PA.153 October 1, 2021
Infertility and Fertility Preservation (PDF) CP.PHAR.131 March 1, 2021
Inebilizumab (PDF) CP.PHAR.458 March 1, 2021
Infigratinib (Truseltiq) (PDF) CP.PHAR.547  
Infliximab (Avsola, Inflectra, Remicade, Renflexis) (PDF) CP.PHAR.254 October 1, 2021 
Inotersen (Tegsedi) (PDF) CP.PHAR.405 March 1, 2021
inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 December 1, 2020
Interferon Beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 June 1, 2021
Insulin Degludec (Tresiba) (PDF) HIM.PA.09 March 1, 2021
interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 June 1, 2021
Interferon Gamma- 1b (Actimmune) (PDF) CP.PHAR.52 March 1, 2021
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) CP.PHAR.149 December 1, 2020
Iobenguane I-131 (Azedra) (PDF) CP.PHAR.459 March 1, 2021
Ipilimumab (Yervoy) (PDF) CP.PHAR.319 August 1, 2021 
irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 March 1, 2021
Iron sucrose (Venofer®) (PDF) CP.PHAR.167 May 1, 2021
Isatuximab-irfc (Sarclisa) (PDF) CP.PHAR.482 June 1, 2021
isavuconazonium (Cresemba®) (PDF) CP.PMN.154 June 1, 2021
Isotretinoin (PDF) CP.PMN.143 December 1, 2020
Istradefylline (Nourianz) (PDF) CP.PMN.217 March 1, 2021
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 June 1, 2021
Ivabradine (Corlanor) (PDF) CP.PMN.70 March 1, 2021
Ivacaftor (Kalydeco) (PDF) CP.PHAR.210 March 1, 2021
ivermectin (Sklice®) (PDF) HIM.PA.124  July 1, 2021
Ivosidenib (Tibsovo) (PDF) CP.PHAR.137 December 1, 2020
Ixazomib (Ninlaro) (PDF) CP.PHAR.302 July 1, 2021
Lacosamide (Vimpat) (PDF) CP.PMN.155 July 1, 2021
Lactic acid-citric acid-potassium bitartrate (Phexxi) (PDF) CP.PMN.251 December 1, 2020
Lanadelumab-fylo (Takhzyro)(PDF) CP.PHAR.396 October 1, 2021
Lanreotide (Somatuline Depot) (PDF) CP.PHAR.391 December 1, 2020
lapatinib (Tykerb®) (PDF) CP.PHAR.79 March 1, 2021
Laronidase (Aldurazyme) (PDF) CP.PHAR.152 July 1, 2021
Larotrectinib (Vitrakvi)(PDF) CP.PHAR.414 May 1, 2021
Lasmiditan (Reyvow) (PDF) CP.PMN.218 March 1, 2021
Latanoprostene Bunod (Vyzulta) (PDF) CP.PMN.108 May 1, 2021
ledipasvir sofosbuvir (Harvoni) (PDF) HIM.PA.SP3 July 1, 2021
Lefamulin (Xenleta) (PDF) CP.PMN.219 March 1, 2021
lenalidomide (Revlimid) (PDF) CP.PHAR.71 August 1, 2021 
Lenvatinib (Lenvima) (PDF) CP.PHAR.138 October 1, 2021
Letermovir (Prevymis) (PDF) CP.PHAR.367 March 1, 2021
Levoleucovorin (Fusilev, Khapzory) (PDF) CP.PHAR.151 December 1, 2020
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) CP.PHAR.173 October 1, 2021
Levalbuterol (Xopenex) (PDF) CP.PMN.07 March 1, 2021
Levomilnacipran (Fetzima) (PDF) HIM.PA.125 July 1, 2021
lidocaine transdermal (Lidoderm®) (PDF) CP.PMN.08  September 1, 2020
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 December 1, 2020
Linaclotide (Linzess) (PDF) CP.PMN.71 October 1, 2021
linezolid (Zyvox) (PDF) CP.PMN.27 March 1, 2021
Liraglutide (Saxenda) (PDF) CP.CPA.332 July 1, 2021
Phentermine-topiramate (Qsymia) (PDF) CP.CPA.336 July 1, 2021
Lisocabtagene maraleucel (Breyanzi) (PDF) CP.PHAR.483 June 1, 2021
Lofexidine (Lucemyra) (PDF) CP.PMN.152 July 1, 2021
Lomustine (Gleostine) (PDF) CP.PHAR.507 December 1, 2020
Lorcaserin (Belviq®, Belviq XR) (PDF) CP.PCH.03 July 1, 2021
Lorlatinib (Lorbrena)(PDF) CP.PHAR.406 June 1, 2021
Loteprednol etabonate (Eysuvis) (PDF) CP.PMN.260 March 1, 2021
Lubiprostone (Amitiza) (PDF) CP.PMN.142 July 1, 2021
Luliconazole Cream (Luzu) (PDF) CP.PMN.166 March 1, 2021
Lumacaftor-Ivacaftor (Orkambi) (PDF) CP.PHAR.213 March 1, 2021
Lumasiran (Oxlumo) (PDF) CP.PHAR.473 October 1, 2021
Lumateperone (Caplyta) (PDF) CP.PMN.232 March 1, 2021
Lurbinectedin (Zepzelca) (PDF) CP.PHAR.500 July 1, 2021
Lurasidone (Latuda) (PDF) CP.PMN.50 March 1, 2021
Luspatercept-aamt (Reblozyl) (PDF) CP.PHAR.450 March 1, 2021
Lusutrombopag (Mulpleta)(PDF) CP.PHAR.407 May 1, 2021
Lutetium Lu 177 Dotatate (Lutathera) (PDF) CP.PHAR.384 July 1, 2021
Macitentan (Opsumit®) (PDF) CP.PCH.31 March 1, 2021
Mannitol (Bronchitol) (PDF) CP.PHAR.518 March 1, 2021
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 June 1, 2021
Mecasermin (Increlex) (PDF) CP.PHAR.150 July 1, 2021
Mechlorethamine Gel (Valchlor) (PDF) CP.PHAR.381 July 1, 2021
Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) CP.PMN.179 December 1, 2020
Mepolizumab (Nucala) (PDF) CP.PHAR.200 March 1, 2021
Mercaptopurine (Purixan) (PDF) CP.PHAR.447 June 1, 2021
Metformin ER (Glumetza, Fortamet) (PDF) CP.PMN.72 March 1, 2021
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) CP.PHAR.134 December 1, 2020
Methoxsalen (Uvadex) (PDF) HIM.PA.17 June 1, 2019
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 July 1, 2021
Methylnaltrexone Bromide (Relistor) (PDF) CP.PMN.169 December 1, 2020
Metoclopramide (Gimoti) (PDF) CP.PMN.252 December 1, 2020
Metreleptin (Myalept) (PDF) CP.PHAR.425 July 1, 2021
Midazolam (Nayzilam) (PDF) CP.PMN.211 July 1, 2021
Midostaurin (Rydapt) (PDF) CP.PHAR.344 June 1, 2021
Mifepristone (Korlym) (PDF) CP.PHAR.101 March 1, 2021
Migalastat (Galafold) (PDF) CP.PHAR.394 December 1, 2020
Miglustat (Zavesca) (PDF) CP.PHAR.164  July 1, 2021
Milnacipran (Savella) (PDF) CP.PMN.125 June 1, 2021
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF) CP.PMN.80 June 1, 2021
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 August 1, 2021 
modafinil (Provigil) (PDF) CP.PMN.39 June 1, 2021
Mogamulizumab-kpkc (Poteligeo) (PDF) CP.PHAR.139 June 1, 2020
Mometasone (Nasonex) (PDF) HIM.PA.93 July 1, 2021
Mometasone (Asmanex) (PDF) CP.PCH.36 March 1, 2021
Mometasone Furoate (Sinuva) (PDF) CP.PHAR.448 March 1, 2021
Montelukast oral granules (Singulair) (PDF) HIM.PA.129 Dece,ber  1, 2020
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) CP.PHAR.398 December 1, 2020
nafarelin acetate (Synarel®) (PDF) CP.PHAR.174 December 1, 2020
Naltrexone (Vivitrol) (PDF) CP.PHAR.96 March 1, 2021
Naproxen oral suspension (Naprosyn) (PDF) HIM.PA.130 December 1, 2020
natalizumab (Tysabri) (PDF) HIM.PA.SP.17 June 1, 2021
Nebivolol (Bystolic) (PDF) HIM.PA.131 January 1, 2021
necitumumab (Portrazza®) (PDF) CP.PHAR.320 December 1, 2020
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) CP.PMN.167 December 1, 2020
Neratinib (Nerlynx) (PDF) CP.PHAR.365 September 1, 2020
Netarsudil (Rhopressa), Netarsudil-Latanoprost (Rocklatan) (PDF) CP.PMN.118 June 1, 2021
Netupitant and Palonosetron (Akynzeo) (PDF) CP.PMN.158 July 1, 2021
Nifurtimox (Lampit) ^ (PDF) CP.PMN.256 December 1, 2020
nilotinib (Tasigna) (PDF) CP.PHAR.76 June 1, 2021
Nintedanib (Ofev) (PDF) CP.PHAR.285 October 1, 2021
Nitisinone (Nityr, Orfadin) (PDF) CP.PHAR.132 March 1, 2021
Nivolumab (Opdivo) (PDF) CP.PHAR.121   January 1, 2022 - NEW
No Coverage Criteria (PDF) CP.PMN.255 December 1, 2020
No Coverage Criteria/Off-Label Use Policy (PDF) CP.PMN.53 September 1, 2021
Non-Formulary and Formulary Contraceptives (PDF) HIM.PA.100 June 1, 2021
Non-Formulary Test Strips (PDF) HIM.PA.34 March 1, 2021
nusinersen (Spinraza®) (PDF) CP.PHAR.327 July 1, 2021
obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 December 1, 2020
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 June 1, 2021
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) CP.PHAR.40 March 1, 2021
Odevixibat (PDF) CP.PHAR.528 October 1, 2021
ofatumumab (Arzerra®) (PDF) CP.PHAR.306 August 1, 2021 
Off-label Policy (PDF) HIM.PA.154 September 1, 2021
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) CP.PHAR.292 July 1, 2021
olaparib (Lynparza) (PDF) CP.PHAR.360 March 1, 2021
olaratumab (Lartruvo®) (PDF) CP.PHAR.326 May 1, 2021
Omacetaxine (Synribo) (PDF) CP.PHAR.108 July 1, 2021 
Omadacycline (Nuzyra)(PDF) CP.PMN.188 March 1, 2021
Omalizumab (Xolair®) (PDF) CP.PHAR.01 April 1, 2021
Omega-3-Acid Ethyl Esters (Lovaza) (PDF) CP.PMN.52 May 1, 2021
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 July 1, 2021 
Onasemnogene abeparvovec (Zolgensma) (PDF) CP.PHAR.421 June 1, 2021
Ophthalmic Corticosteroids (PDF) HIM.PA.03 December 1, 2020
Opioid Analgesics (PDF) HIM.PA.139 October 1, 2021
Orlistat (Xenical) (PDF) CP.CPA.335 July 1, 2021
Osimertinib (Tagrisso) (PDF) CP.PHAR.294 June 1, 2021
Ospemifene (Osphena) (PDF) CP.PMN.168 December 1, 2020
Overactive Bladder Agents (PDF) CP.PMN.198 June 1, 2021
Ozanimod (Zeposia) (PDF) CP.PHAR.462 June 1, 2021
Ozenoxacin (Xepi) (PDF) CP.PMN.119 June 1, 2021
Paclitaxel, protein-bound (Abraxane) (PDF) CP.PHAR.176  July 1, 2021
Palbociclib (Ibrance) (PDF) CP.PHAR.125 March 1, 2021
Paliperidone (Invega) (PDF) CP.PMN.30 July 1, 2021
Palivizumab (Synagis) (PDF) CP.PHAR.16 September 1, 2021 
Palovarotene (PDF) CP.PHAR.548 October 1, 2021
Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) (PDF) HIM.PA.155 June 1, 2021
panitumumab (Vectibix®) (PDF) CP.PHAR.321 December 1, 2020
Parathyroid Hormone (Natpara) (PDF) CP.PHAR.282 March 1, 2021
Paricalcitol Injection (Zemplar) (PDF) CP.PHAR.270 October 1, 2021
pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 December 1, 2020
Patisiran (Onpattro) (PDF) CP.PHAR.395 December 1, 2020
Pazopanib (Votrient) (PDF) CP.PHAR.81 July 1, 2021
Peanut allergen powder (Palforzia) (PDF) CP.PMN.220 March 1, 2021
Pegademase Bovine (Adagen) (PDF) CP.PHAR.392 December 1, 2020
Pegaptanib (Macugen) (PDF) CP.PHAR.185 March 1, 2021
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) CP.PHAR.353 December 1, 2020
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) CP.PHAR.296 September 1, 2021
Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF) CP.PHAR.89 July 1, 2021
peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 June 1, 2021
Pegloticase (Krystexxa) (PDF) CP.PHAR.115 May 1, 2021
Pegvaliase-pqpz (Palynziq) (PDF) CP.PHAR.140 March 1, 2021
Pegvisomant (Somavert) (PDF) CP.PHAR.389 December 1, 2020
pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 October 1, 2021
Pemetrexed (Alimta, Pemfexy) (PDF) CP.PHAR.368 May 1, 2021
Pemigatinib (Pemazyre) (PDF) CP.PHAR.496 November 1, 2021
Penicillamine (Cuprimine) (PDF) CP.PCH.09 July 1, 2021
Perampanel (Fycompa) (PDF) CP.PMN.156 July 1, 2021
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 August 1, 2021 
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) CP.PHAR.501 July 1, 2021
Pexidartinib (Turalio)(PDF) CP.PHAR.436 December 1, 2020
Phendimetrazine IR (Bontril PDM) (PDF) HIM.PA.114 August 1, 2021 
Phentermine (Adipex-P, Lomaira) (PDF) CP.PCH.13 June 1, 2021
Pirfenidone (Esbriet) (PDF) CP.PHAR.286 July 1, 2021
Pitolisant (Wakix) (PDF) CP.PMN.221 August 1, 2021 
Plerixafor (Mozobil) (PDF) CP.PHAR.323 July 1, 2021
Polatuzumab Vedotin-piiq (Polivy) (PDF) CP.PHAR.433 July 1, 2021
Pomalidomide (Pomalyst) (PDF) CP.PHAR.116 August 1, 2021
Ponatinib (Iclusig) (PDF) CP.PHAR.112 August 1, 2021 
Potassium (Klor-Con) (PDF) HIM.PA.143 March 1, 2021
pralatrexate (Folotyn®) (PDF) CP.PHAR.313 December 1, 2020
Pramlintide (Symlin) (PDF) CP.PMN.129 March 1, 2021
Prasterone (Intrarosa) (PDF) CP.PMN.99 March 1, 2021
pregabalin (Lyrica) (PDF) CP.PMN.33 June 1, 2021
Pretomanid (PDF) CP.PMN.222 June 1, 2021
protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 March 1, 2021
propranolol HCL solution (Hemangeol) (PDF) CP.PMN.58 June 1, 2021
Prucalopride (Motegrity) (PDF) CP.PMN.194 July 1, 2021
pyrimethamine (Daraprim®) (PDF) CP.PMN.44  October 1, 2021
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 March 1, 2021
Quinine Sulfate (Qualaquin) (PDF) CP.PMN.262 June 1, 2021
Ondansetron (Zuplenz) (PDF) CP.PMN.45 July 1, 2021
Ramelteon (Rozerem) (PDF) CP.PMN.173 December 1, 2020
Ramucirumab (Cyramza) (PDF) CP.PHAR.119 May 8, 2021
Ranibizumab (Lucentis) (PDF) CP.PHAR.186 March 1, 2021
rasagiline (Azilect®) (PDF) HIM.PA.89 July 1, 2021
Ravulizumab-cwvz (Ultomiris) (PDF) CP.PHAR.415 May 1, 2021
Regorafenib (Stivarga) (PDF) CP.PHAR.107 July 1, 2021
Relugolix (Orgovyx) (PDF) CP.PHAR.529 October 1, 2021
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) CP.PHAR.168 March 1, 2021
Reslizumab (Cinqair) (PDF) CP.PHAR.223 March 1, 2021
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) CP.PHAR.141 December 1, 2020
Ribociclib (Kisqali, Kisqali Femara) (PDF) CP.PHAR.334 January 1, 2022
Rifabutin (Mycobutin) (PDF) CP.PMN.223 May 1, 2021
Rifamycin (Aemcolo) (PDF) CP.PMN.196 June 1, 2021
rifaximin (Xifaxan®) (PDF) CP.PMN.47 March 1, 2021
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 August 1, 2021 
Ripretinib (Qinlock) (PDF) CP.PHAR.502 July 1, 2021
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 July 1, 2021
Riociguat (Adempas®) (PDF) CP.PHAR.195 March 1, 2021
Risdiplam (Evrysdi) (PDF) CP.PHAR.477 June 1, 2021
Risedronate (Actonel, Atelvia) (PDF) CP.PMN.100 March 1, 2021
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) CP.PHAR.293 July 1, 2021
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) CP.Phar.260 October 1,2021
Rolapitant (Varubi) (PDF) CP.PMN.102 July 1, 2021
romidepsin (Istodax®) (PDF) CP.PHAR.314 October 1, 2021
Romiplostim (Nplate®) (PDF) CP.PHAR.179  March 1, 2021
Romosozumab-aqqg (Evenity) (PDF) CP.PHAR.428 March 1, 2021
Rucaparib (Rubraca®) (PDF) CP.PHAR.350 May 1, 2021
Rufinamide (Banzel) (PDF) CP.PMN.157 July 1, 2021
Ruxolitinib (Jakafi) (PDF) CP.PHAR.98 May 1, 2021
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) CP.PHAR.475 June 1, 2021
Sacubitril/Valsartan (Entresto) (PDF) CP.PMN.67 JMarch 1, 2021
Safinamide (Xadago) (PDF) CP.PMN.113 March 1, 2021
Sapropterin (Kuvan) (PDF) CP.PHAR.43 August 1, 2021 
Sarecycline (Seysara) (PDF) CP.PMN.189 March 1, 2021
Sargramostim (Leukine) (PDF) CP.PHAR.295 July 1, 2021
Satralizumab-mwge (Enspryng) (PDF) CP.PHAR.463 May 1, 2021
Sebelipase Alfa (Kanuma) (PDF) CP.PHAR.159 July 1, 2021
Secnidazole (Solosec) (PDF) CP.PMN.103 March 1, 2021
Selexipag (Uptravi®) (PDF) CP.PHAR.196 October 1, 2021
Selinexor (Xpovio) (PDF) CP.PHAR.431 July 1, 2021
Selpercatinib (Retevmo) (PDF) CP.PHAR.478 June 1, 2021
Selumetinib (Koselugo) (PDF) CP.PHAR.464 March 1, 2021
Sildenafil (Revatio®) (PDF) CP.PHAR.197 March 1, 2021
Sildenafil (Viagra) (PDF) CP.PCH.07 July 1, 2021
Siponimod (Mayzent) (PDF) CP.PHAR.427 June 1, 2021
Sipuleucel-T (Provenge) (PDF) CP.PHAR.120 July 1, 2021
Siltuximab (Sylvant) (PDF) CP.PHAR.329 March 1, 2021
sodium oxybate (Xyrem) (PDF) CP.PMN.42 August 1, 2021 
Sodium-Glucose Co-Transporter 2  Inhibitors (PDF) HIM.PA.91 October 1, 2021
Sodium Phenylbutyrate (Buphenyl) (PDF) CP.PHAR.208 March 1, 2021
Sodium Zirconium Cyclosilicate (Lokelma) (PDF) CP.PMN.163 July 1, 2021
Sofosbuvir (Sovaldi) (PDF) HIM.PA.SP2 July 1, 2021
Sofosbuvir-Velpatasvir (Epclusa)  (PDF) HIM.PA.SP1 July 1, 2021
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF) Him.PA.SP63 July 1, 2021
Solriamfetol (Sunosi) (PDF) CP.PMN.209 June 1, 2021
Somatropin (Growth Hormone) (PDF) CP.PCH.25 March 1, 2021
Sonidegib (Odomzo) (PDF) CP.PHAR.272 August 1, 2021 
sorafenib (Nexavar) (PDF) CP.PHAR.69 August 1, 2021 
Sotorasib (Lumakras) (PDF) CP.PHAR.549 October 1, 2021
Spinosad (Natroba) (PDF) HIM.PA.134 July 1, 2021
Step Therapy (PDF) CP.CPA.83 October 1, 2021
Step Therapy Criteria (PDF) HIM.PA.109 October 1, 2021
Stiripentol (Diacomit) (PDF) CP.PMN.184 Janurary 1, 2021
sucroferric oxyhydoxide (Velphoro) (PDF) HIM.PA.SP30 March 1, 2021
sunitinib (Sutent) (PDF) CP.PHAR.73 October 1, 2021 
Suvorexant (Belsomra®) (PDF) CP.PMN.109 December 1, 2020
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 March 1, 2021
Tadalafil BHP - ED (Cialis) (PDF) CP.PMN.132 July 1, 2021
Tafamidis (Vyndaqel, Vyndamax) (PDF) CP.PHAR.432 July 1, 2021
Tafasitamab-cxix (Monjuvi) (PDF) CP.PHAR.508 December 1, 2020
Talazoparib (Talzenna)(PDF) CP.PHAR.409 March 1, 2021
Taliglucerase Alfa (Elelyso) (PDF) CP.PHAR.157 July 1, 2021
Tasimelteon (Hetlioz) (PDF) CP.PMN.104 May 1, 2021
tavaborole (Kerydin®) (PDF) CP.PMN.105 March 1, 2021
Tazarotene (Arazlo, Fabior, Tazorac) (PDF) CP.PMN.244 December 1, 2020
Tazemetostat (PDF) CP.PHAR.452 May 1, 2021
Tedizolid (Sivextro) (PDF) CP.PMN.62 March 1, 2021
Teduglutide (Gattex) (PDF) CP.PHAR.114 March 1, 2021
Tegaserod (Zelnorm) (PDF) CP.PMN.206 July 1, 2021
Telotristat ethyl (Xermelo) (PDF) CP.PHAR.337 June 1, 2021
Temozolomide (Temodar) (PDF) CP.PHAR.77 August 1, 2021
temsirolimus (Torisel®) (PDF) CP.PHAR.324 December 1, 2020
Tenapanor (Ibsrela) (PDF) CP.PMN.224 March 1, 2021
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) CP.PCH.33 December 1, 2020
Tepotinib (Tepmetko) (PDF) CP.PHAR.530 June 1, 2021
Teprotumumab (Tepezza) (PDF) CP.PHAR.465 March 1, 2021
Teriflunomide (Aubagio) (PDF) CP.PCH.40 June 1, 2021
Teriparatide (Forteo®) (PDF) CP.PHAR.188 July 1, 2021
Tesamorelin (Egrifta) (PDF) CP.PHAR.109 July 1, 2021
Testosterone (Androderm) (PDF) HIM.PA.87 December 1, 2020
Testosterone (Testopel, Jatenzo) (PDF) CP.PHAR.354 December 1, 2020
tetrabenazine (Xenazine) (PDF) CP.PHAR.92 June 1, 2021
Tezacaftor-Ivacaftor (Symdeko) (PDF) CP.PHAR.377 March 1, 2021
Thalidomide (Thalomid) (PDF) CP.PHAR.78 June 1, 2021
Thioguanine (Tabloid) (PDF) CP.PHAR.437 December 1, 2020
Thyrotropin Alfa (Thyrogen) (PDF) CP.PHAR.95 July 1, 2021
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84  July 1, 2021
Tisagenlecleucel (Kymriah) (PDF) CP.PHAR.361 July 1, 2021
Tobramycin (PDF) CP.PHAR.211 May 1, 2021
Tocilizumab (Actemra) (PDF) CP.PHAR.263 August 1, 2021 
Tolvaptan (Jynarque) (PDF) CP.PHAR.27 July 1, 2021
Topical Acne Treatment (PDF) HIM.PA.71 December 1, 2020
Topotecan (Hycamtin) (PDF) CP.PHAR.64 June 1, 2021
Topical Immunomodulators (PDF) CP.PMN.107 March 1, 2021
Toremifene (Fareston) (PDF) CP.PMN.126 August 1, 2021 
Trabectedin (Yondelis) (PDF) CP.PHAR.204 March 1, 2021
Trametinib (Mekinist) (PDF) CP.PHAR.240 August 1, 2021 
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 July 1, 2021
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) CP.PHAR.199  October 1, 2021
Triamcinolone ER Injection (Zilretta) (PDF) CP.PHAR.371 June 1, 2021
Triclabendazole (Egaten) (PDF) CP.PMN.207 July 1, 2021
Trientine (Syprine) (PDF) CP.PHAR.438 December 1, 2020
Trifarotene (Aklief) (PDF) CP.PMN.225 March 1, 2021
Trifluridine/Tipiracil (Lonsurf) (PDF) CP.PHAR.383 October 1, 2021
Triheptanoin (Dojolvi) ^ (PDF) CP.PHAR.509 December 1, 2020
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 December 1, 2020
Ubrogepant (Ubrelvy) (PDF) CP.PHAR.476 September 1, 2021
Umbralisib (Ukoniq) (PDF) CP.PHAR.531 June 1, 2021
Uridine acetate (Vistogard) (PDF) HIM.PA.SP55 December 1, 2020
Ustekinumab (Stelara) (PDF) CP.PHAR.264 August 1, 2021 
Valbenazine (Ingrezza) (PDF) CP.CPA.351 July 1, 2021
valganciclovir (Valcyte) (PDF) CP.PCH.06 March 1, 2021
Valproate Sodium for Intravenous Injection (Depacon) (PDF) CP.PHAR.429 July 1, 2021
Valrubicin (Valstar) (PDF) CP.PHAR.439 December 1, 2020
Vandetanib (Caprelsa®) (PDF) CP.PHAR.80 May 1, 2021
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 October 1, 2021 
Velaglucerase Alfa (VPRIV) (PDF) CP.PHAR.163 July 1, 2021
Vemurafenib (Zelboraf®) (PDF) CP.PHAR.91 May 1, 2021
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 June 1, 2021
Verteporfin (PDF) CP.PHAR.187 July 1, 2021
Vigabatrin (Sabril) (PDF) CP.PHAR.169  July 1, 2021
Vilazodone (Viibryd) (PDF) CP.PMN.145 July 1, 2021
Viltolarsen (Viltepso) (PDF) CP.PHAR.484 July 1, 2021
vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 December 1, 2020
Vismodegib (Erivedge) (PDF) CP.PHAR.273 August 1, 2021 
Voclosporin (Lupkynis) (PDF) CP.PHAR.504 June 1, 2021
Vorapaxar (Zontivity) (PDF) HIM.PA.146 March 1, 2021
Voretigene neparvovec-rzyl (Luxturna) (PDF) CP.PHAR.372 July 1, 2021
Vortioxetine (Trintellix®) (PDF) CP.PMN.65  July 1, 2021
Voxelotor (Oxbryta) (PDF) CP.PHAR.451 March 1, 2021
Zanubrutinib (Brukinsa) (PDF) CP.PHAR.467 July 1, 2021
ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 December 1, 2020
Zoledronic acid (PDF) CP.PHAR.59 March 1, 2021
Vorinostat (Zolinza) (PDF) CP.PHAR.83 July 1, 2021