Policy Title |
Policy Number |
Effective Date |
---|
Abaloparatide (Tymlos) (PDF) |
CP.PHAR.345 |
11/7/2017 |
Abametapir (Xeglyze) (PDF) |
CP.PMN.253 |
12/1/2020 |
Abiraterone (Zytiga) (PDF) |
CP.PHAR.84 |
7/24/2015 |
AbobotulinumtoxinA (Dysport) (PDF) |
CP.PHAR.230 |
11/1/2020 |
Aclidinium/Formoterol (Duaklir Pressair) (PDF) |
HIM.PA.151 |
3/1/2021 |
Adefovir (Hepsera) (PDF) |
CP.PHAR.142 |
6/1/2019 |
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) |
CP.PHAR.229 |
6/1/2019 |
Afamelanotide (Scenesse) (PDF) |
CP.PHAR.444 |
3/1/2020 |
afatinib (Gilotrif) (PDF) |
CP.PHAR.298 |
6/1/2019 |
Aflibercept (Eylea) (PDF) |
CP.PHAR.184 |
7/1/2016 |
Agalsidase Beta (Fabrazyme) (PDF) |
CP.PHAR.158 |
6/1/2019 |
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) |
CP.PMN.138 |
6/1/2019 |
Alemtuzumab (Lemtrada) (PDF) |
CP.PHAR.243 |
12/8/2017 |
Alendronate (Binosto, Fosamax plus D) (PDF) |
CP.PMN.88 |
6/1/2019 |
Alglucosidase Alfa (Lumizyme) (PDF) |
CP.PHAR.160 |
6/1/2019 |
Alpelisib (Piqray) (PDF) |
CP.PHAR.430 |
12/1/2019 |
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) |
CP.PHAR.94 |
7/24/2015 |
Ambrisentan (Letairis®) (PDF) |
CP.PHAR.190 |
7/1/2016 |
Amifampridine (Firdapse)(PDF) |
CP.PHAR.411 |
3/1/2019 |
Amikacin (Arikayce)(PDF) |
CP.PHAR.401 |
3/1/2019 |
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) |
CP.PHAR.217 |
12/1/2020 |
Antithrombin III (PDF) |
CP.MP.179 |
12/1/2020 |
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) |
CP.PHAR.506 |
12/1/2020 |
Apomorphine (Apokyn) (PDF) |
CP.PHAR.488 |
3/1/2020 |
aprepitant (Emend®) (PDF) |
CP.PMN.19 |
3/1/2016 |
Arformoterol Tartrate (Brovana) (PDF) |
CP.PMN.201 |
6/1/2019 |
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) |
CP.PHAR.290 |
1/1/2020 |
armodafinil (Nuvigil) (PDF) |
CP.PMN.35 |
6/1/2019 |
Asenapine (Saphris) (PDF) |
CP.PMN.15 |
6/1/2019 |
Aspirin-dipyridamole (Aggrenox) (PDF) |
CP.PMN.20 |
6/1/2019 |
Atezolizumab (Tecentriq) (PDF) |
CP.PHAR.235 |
11/1/2020 |
Avapritinib (Ayvakit) (PDF) |
CP.PHAR.454 |
3/1/2020 |
Avatrombopag (Doptelet) (PDF) |
CP.PHAR.130 |
3/1/2019 |
Avelumab (Bavencio) (PDF) |
CP.PHAR.333 |
10/1/2020 |
axicabtagene ciloleucel (Yescarta®) (PDF) |
CP.PHAR.362 |
6/1/2019 |
Axitinib (Inlyta) (PDF) |
CP.PHAR.100 |
9/8/2017 |
Azacitidine (Vidaza) (PDF) |
CP.PHAR.387 |
6/1/2019 |
Azelaic Acid (Finacea) (PDF) |
HIM.PA.119 |
6/1/2019 |
Aztreonam (Cayston) (PDF) |
CP.PHAR.209 |
9/8/2017 |
Bedaquiline (Sirturo) (PDF) |
CP.PMN.212 |
6/1/2019 |
belatacept (Nulojix®) (PDF) |
CP.PHAR.201 |
6/1/2019 |
Belimumab (Benlysta) (PDF) |
CP.PHAR.88 |
7/24/2015 |
belinostat (Beleodaq®) (PDF) |
CP.PHAR.311 |
6/1/2019 |
bendamustine (Bendeka®, Treanda®) (PDF) |
CP.PHAR.307 |
6/1/2019 |
Benralizumab (Fasenra) (PDF) |
CP.PHAR.373 |
6/1/2019 |
Benznidazole (PDF) |
CP.PMN.90 |
12/1/2020 |
Betaine (Cystadane) (PDF) |
CP.PHAR.143 |
6/1/2019 |
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) |
CP.PHAR.93 |
6/1/2020 |
Bexarotene (Targretin) (PDF) |
CP.PHAR.75 |
11/7/2017 |
Bezlotoxumab (Zinplava) (PDF) |
CP.PHAR.300 |
7/15/2019 |
Biologic DMARDs (PDF) |
HIM.PA.SP60 |
1/1/2021 |
Binimetinib (Mektovi) (PDF) |
CP.PHAR.50 |
6/1/2019 |
Belantamab mafodotin (Blenrep) (PDF) |
CP.PHAR.469 |
12/1/2020 |
Blinatumomab (Blincyto) (PDF) |
CP.PHAR.312 |
6/1/2019 |
Bortezomib (Velcade) (PDF) |
CP.PHAR.410 |
7/15/2019 |
Bosentan (Tracleer®) (PDF) |
CP.PHAR.191 |
7/1/2016 |
Bosutinib (Bosulif) (PDF) |
CP.PHAR.105 |
3/1/2016 |
Brand Name Override and Non-Formulary Medications (PDF) |
HIM.PA.103 |
3/1/2016 |
Brentuximab Vedotin (Adcetris) (PDF) |
CP.PHAR.303 |
6/1/2019 |
Brexanolone (Zulresso) (PDF) |
CP.PHAR.417 |
6/1/2019 |
Brexpiprazole (Rexulti) (PDF) |
CP.PMN.68 |
6/1/2019 |
Brexucabtagene Autoleucel (Tecartus) (PDF) |
CP.PHAR.472 |
9/1/2020 |
Brigatinib (Alunbrig) (PDF) |
CP.PHAR.342 |
7/1/2020 |
Brolucizumab-dbll (Beovu) (PDF) |
CP.PHAR.445 |
3/1/2020 |
Oxymetazoline (Rhofade)(PDF) |
CP.PMN.86 |
6/1/2019 |
Brimonidine Tartrate (Mirvaso) (PDF) |
CP.PMN.192 |
6/1/2019 |
Brinzolamide/Brimonidine (Simbrinza) (PDF) |
HIM.PA.15 |
6/1/2019 |
Brivaracetam (Briviact) (PDF) |
HIM.PA.07 |
1/1/2020 |
Budesonide (Uceris) (PDF) |
CP.PCH.11 |
6/1/2019 |
Budesonide-glycopyrrolate-formoterol fumarate (Breztri Aerosphere) (PDF) |
HIM.PA.150 |
12/1/2020 |
Budesonide Suspension (Pulmicort Respules) (PDF) |
HIM.PA.48 |
6/1/2019 |
buprenorphine implant (Probuphine) (PDF) |
CP.PHAR.289 |
6/1/2019 |
Bupropion/Naltrexone (Contrave) (PDF) |
CP.PCH.12 |
7/15/2019 |
Burosumab-twza (Crysvita) (PDF) |
CP.PHAR.11 |
6/1/2019 |
Butorphanol Nasal Spray (PDF) |
HIM.PA.46 |
3/1/2016 |
C1 Esterase Inhibitors (PDF) |
CP.PHAR.202 |
7/1/2016 |
cabazitaxel (Jevtana®) (PDF) |
CP.PHAR.316 |
6/1/2019 |
Cabozantinib (Cometriq®, Cabometyx®) (PDF) |
CP.PHAR.111 |
9/8/2017 |
Calcifediol (Rayaldee) (PDF) |
CP.PMN.76 |
9/1/2020 |
Canakinumab (Ilaris) (PDF) |
CP.PHAR.246 |
6/1/2019 |
Cannabidiol (Epidiolex) (PDF) |
CP.PMN.164 |
7/1/2019 |
capecitabine (Xeloda) (PDF) |
CP.PHAR.60 |
11/7/2017 |
Caplacizumab-yhdp (Cablivi) (PDF) |
CP.PHAR.416 |
6/1/2019 |
carfilzomib (Kyprolis®) (PDF) |
CP.PHAR.309 |
6/1/2019 |
Carglumic acid (Carbaglu®) (PDF) |
CP.PHAR.206 |
9/8/2017 |
Celecoxib (Celebrex) (PDF) |
CP.PMN.122 |
6/1/2019 |
Cemiplimab-rwlc (Libtayo) (PDF) |
CP.PHAR.397 |
6/1/2019 |
Cenegermin-bkbj (Oxervate)(PDF) |
CP.PMN.186 |
3/1/2019 |
Ceritinib (Zykadia) (PDF) |
CP.PHAR.349 |
6/1/2019 |
Cerliponase alfa (Brineura) (PDF) |
CP.PHAR.338 |
11/7/2017 |
cetuximab (Erbitux®) (PDF) |
CP.PHAR.317 |
6/1/2019 |
Chlorambucil (Leukeran) (PDF) |
HIM.PA.SP59 |
6/1/2019 |
Chloramphenicol Sodium Succinate (PDF) |
CP.PHAR.388 |
6/1/2019 |
Cholic Acid (Cholbam) (PDF) |
CP.PHAR.390 |
6/1/2019 |
Ciclesonide (Alvesco) (PDF) |
HIM.PA.65 |
6/1/2019 |
Cinacalcet (Sensipar) (PDF) |
CP.PHAR.61 |
9/8/2017 |
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) |
CP.PMN.248 |
12/1/2020 |
Ciprofloxacin/Fluocinolone (Otovel) (PDF) |
CP.PMN.249 |
12/1/2020 |
Cladribine (Mavenclad) (PDF) |
CP.PHAR.422 |
1/1/2020 |
Clinical Policy: Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) |
CP.PHAR.260 |
6/1/2019 |
Clobazam (Onfi) (PDF) |
CP.PMN.54 |
6/1/2019 |
CNS Stimulants (PDF) |
CP.PMN.92 |
3/1/2020 |
Colesevelam (Welchol) (PDF) |
CP.PMN.250 |
12/1/2020 |
Collagenase (Xiaflex) (PDF) |
CP.PHAR.82 |
7/24/2015 |
Colonoscopy Preparation Products (PDF) |
HIM.PA.04 |
6/1/2020 |
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) |
HIM.PA.140 |
6/1/2019 |
Continuous Insulin Delivery Systems (V-Go, Omnipod) (PDF) |
CP.PHAR.505 |
12/1/2020 |
Continuous Glucose Monitors (PDF) |
CP.PMN.214 |
3/1/2020 |
copanlisib (Aliqopa®) (PDF) |
CP.PHAR.357 |
6/1/2019 |
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) |
CP.PHAR.385 |
10/19/2018 |
Crisaborole (Eucrisa) (PDF) |
CP.PMN.110 |
6/1/2019 |
Crizanlizumab-tmca (Adakveo) (PDF) |
CP.PHAR.449 |
6/1/2020 |
Crizotinib (Xalkori) (PDF) |
CP.PHAR.90 |
12/8/2017 |
Cyclosporine (Restasis, Cequa) (PDF) |
CP.PMN.48 |
6/1/2019 |
Cysteamine ophthalmic (Cystaran) (PDF) |
CP.PMN.130 |
6/1/2019 |
Cysteamine oral (Cystagon, Procysbi) (PDF) |
CP.PHAR.155 |
12/1/2020 |
Cytomegalovirus Immune Globulin (Cytogam) (PDF) |
CP.PHAR.277 |
1/1/2020 |
Dabrafenib (Tafinlar) (PDF) |
CP.PHAR.239 |
11/7/2017 |
Daclatasvir (Daklinza) (PDF) |
HIM.PA.SP27 |
11/1/2020 |
Dacomitinib (Vizimpro) (PDF) |
CP.PHAR.399 |
6/1/2019 |
Dalfampridine (Ampyra) (PDF) |
CP.PHAR.248 |
12/8/2017 |
Deflazacort (Emflaza) (PDF) |
CP.PHAR.331 |
7/15/2019 |
Dalteparin (Fragmin) (PDF) |
CP.PHAR.225 |
9/8/2017 |
Daptomycin (Cubicin, Cubicin RF) (PDF) |
CP.PHAR.351 |
1/1/2020 |
Dapsone (Aczone Gel) (PDF) |
CP.PCH.32 |
12/1/2020 |
Daratumumab (Darzalex) (PDF) |
CP.PHAR.310 |
10/1/2020 |
Darbepoetin alfa (Aranesp) (PDF) |
CP.PHAR.236 |
10/30/2016 |
Darolutamide (Nubeqa) (PDF) |
CP.PHAR.435 |
12/1/2019 |
Dasabuvir-Ombitasvir-Paritaprevir-Ritonavir (Viekira Pak) (PDF) |
HIM.PA.SP61 |
11/1/2020 |
Dasatinib (Sprycel) (PDF) |
CP.PHAR.72 |
11/7/2017 |
daunorubicin/cytarabine (Vyxeos®) (PDF) |
CP.PHAR.352 |
6/1/2019 |
Decitabine-Cedazuridine (Inqovi) (PDF) |
CP.PHAR.479 |
12/1/2020 |
deferasirox (Exjade Jadenu) (PDF) |
CP.PHAR.145 |
3/1/2016 |
Deferoxamine (Desferal) (PDF) |
CP.PHAR.146 |
9/1/2020 |
degarelix acetate (Firmagon®) (PDF) |
CP.PHAR.170 |
6/1/2019 |
Delafloxacin (Baxdela) (PDF) |
CP.PMN.115 |
1/1/2020 |
Denosumab (Prolia, Xgeva) (PDF) |
CP.PHAR.58 |
12/8/2017 |
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) |
CP.PHAR.214 |
9/8/2017 |
Deutetrabenazine (Austedo) (PDF) |
CP.PHAR.341 |
11/7/2017 |
Dexlansoprazole (Dexilant) (PDF) |
HIM.PA.05 |
6/1/2020 |
Dexrazoxane (Zinecard, Totect) (PDF) |
CP.PHAR.418 |
6/1/2019 |
Diazepam Nasal Spray (Valtoco)(PDF) |
CP.PMN.216 |
12/1/2019 |
Dichlorphenamide (Keveyis) (PDF) |
CP.PCH.04 |
6/1/2019 |
diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) |
HIM.PA.123 |
6/1/2019 |
Dimethyl Fumarate (Tecfidera) (PDF) |
CP.PHAR.249 |
12/8/2017 |
Dipeptidyl Peptidase-4 Inhibitors (PDF) |
HIM.PA.58 |
3/1/2016 |
Dolasetron (Anzemet) (PDF) |
CP.PMN.141 |
3/1/2016 |
Dornase alfa (Pulmozyme) (PDF) |
CP.PHAR.212 |
9/8/2017 |
Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) |
HIM.PA.147 |
6/1/2019 |
Dupilumab (Dupixent) (PDF) |
CP.PHAR.336 |
9/8/2017 |
Durvalumab (Imfinzi) (PDF) |
CP.PHAR.339 |
11/7/2017 |
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) |
CP.PMN.128 |
3/1/2020 |
Duvelisib (Copiktra) (PDF) |
CP.PHAR.400 |
7/15/2019 |
Ecallantide (Kalbitor) (PDF) |
CP.PHAR.177 |
7/1/2016 |
Eculizumab (Soliris) (PDF) |
CP.PHAR.97 |
9/8/2017 |
Edaravone (Radicava) (PDF) |
CP.PHAR.343 |
11/7/2017 |
Efinaconazole (Jublia) (PDF) |
CP.PMN.25 |
6/1/2019 |
Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (PDF) |
CP.PHAR.136 |
3/1/2021 |
Elapegademase-lvlr (Revcovi) (PDF) |
CP.PHAR.419 |
6/1/2019 |
Elbasvir/Grazoprevir (Zepatier) (PDF) |
HIM.PA.SP62 |
11/1/2020 |
Eliglustat (Cerdelga) (PDF) |
CP.PHAR.153 |
6/1/2019 |
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) |
CP.PHAR.440 |
12/1/2019 |
Elosulfase Alfa (Vimizim) (PDF) |
CP.PHAR.162 |
6/1/2019 |
Elotuzumab (Empliciti) (PDF) |
CP.PHAR.308 |
12/1/2020 |
Eltrombopag (Promacta®) (PDF) |
CP.PHAR.180 |
7/1/2016 |
Eluxadoline (Viberzi) (PDF) |
CP.PMN.170 |
6/1/2019 |
Emapalumab-lzsg (Gamifant)(PDF) |
CP.PHAR.402 |
3/1/2019 |
Emicizumab-kxwh (Hemlibra) (PDF) |
CP.PHAR.370 |
6/1/2019 |
Emtricitabine/Tenofovir (Truvada®) (PDF) |
HIM.PA.78 |
3/1/2016 |
Encorafenib (Braftovi) (PDF) |
CP.PHAR.127 |
6/1/2019 |
Enfuvirtide (Fuzeon) (PDF) |
CP.PHAR.41 |
7/24/2015 |
Enfortumab Vedotin-ejfv (Padcev) (PDF) |
CP.PHAR.455 |
3/1/2020 |
Enoxaparin (Lovenox) (PDF) |
CP.PHAR.224 |
9/8/2017 |
Entecavir (Baraclude) (PDF) |
HIM.PA.08 |
6/1/2019 |
Entrectinib (Rozlytrek) (PDF) |
CP.PHAR.441 |
12/1/2019 |
Enzalutamide (Xtandi) (PDF) |
CP.PHAR.106 |
3/1/2016 |
Epoetin Alfa (Epogen® and Procrit) (PDF) |
CP.PHAR.237 |
2/1/2020 |
Epoprostenol (PDF) |
CP.PHAR.192 |
7/1/2016 |
Eptinezumab-jjmr (Vyepti) (PDF) |
HIM.PA.SP64 |
2/1/2021 |
Erdafitinib (Balversa) (PDF) |
CP.PHAR.423 |
1/1/2020 |
Erenumab-aaoe (Aimovig) (PDF) |
HIM.PA.SP65 |
10/1/2021 |
eribulin Mesylate (Halaven®) (PDF) |
CP.PHAR.318 |
6/1/2019 |
Erlotinib (Tarceva) (PDF) |
CP.PHAR.74 |
7/24/2015 |
Erwinia Asparaginase (Erwinaze) (PDF) |
CP.PHAR.301 |
3/1/2020 |
Esketamine (Spravato) (PDF) |
CP.PMN.199 |
6/1/2019 |
Etelcalcetide (Parsabiv) (PDF) |
CP.PHAR.379 |
6/1/2019 |
Eteplirsen (Exondys 51) (PDF) |
CP.PHAR.288 |
10/1/2020 |
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF) |
CP.PHAR.63 |
9/8/2017 |
Evolocumab (Repatha) (PDF) |
CP.PHAR.123 |
3/1/2016 |
Factor IX (Human, Recombinant) (PDF) |
CP.PHAR.218 |
12/1/2020 |
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) |
CP.PHAR.219 |
6/1/2019 |
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) |
CP.PHAR.220 |
6/1/2019 |
Factor VIII (Human Recombinant) (PDF) |
CP.PHAR.215 |
11/1/2020 |
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) |
CP.PHAR.216 |
9/8/2017 |
Factor XIII A-Subunit, Recombinant (Tretten®) |
CP.PHAR.222 |
6/1/2019 |
Factor XIII, Human (Corifact®) (PDF) |
CP.PHAR.221 |
6/1/2019 |
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) |
CP.PHAR.456 |
3/1/2020 |
febuxostat (Uloric) (PDF) |
CP.PMN.57 |
6/1/2019 |
Fedratinib (Inrebic) (PDF) |
CP.PHAR.442 |
12/1/2019 |
Fenfluramine (Fintepla) (PDF) |
CP.PMN.246 |
12/1/2020 |
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) |
CP.PMN.127 |
6/1/2019 |
Ferric Carboxymaltose (Injectafer) (PDF) |
CP.PHAR.234 |
3/1/2020 |
Ferric gluconate (Ferrlecit®) (PDF) |
CP.PHAR.166 |
3/1/2020 |
Ferric Maltol (Accrufer) (PDF) |
CP.PMN.213 |
12/1/2019 |
Ferumoxytol (Feraheme®) (PDF) |
CP.PHAR.165 |
3/1/2020 |
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) |
CP.PHAR.297 |
2/1/2021 |
Fingolimod (Gilenya) (PDF) |
CP.PHAR.251 |
12/8/2017 |
Fluorouracil Cream (Tolak) (PDF) |
CP.PMN.165 |
6/1/2019 |
Fluticasone Propionate (Xhance) (PDF) |
CP.PMN.95 |
5/1/2019 |
Fondaparinux (Arixtra) (PDF) |
CP.PHAR.226 |
9/8/2017 |
Formulary Medications Without Specific Guidelines (PDF) |
HIM.PA.33 |
6/1/2019 |
Fostamatinib (Tavalisse) (PDF) |
CP.PHAR.24 |
6/1/2019 |
Fremanezumb-vfrm (PDF) |
HIM.PA.SP66 |
2/1/2021 |
Fulvestrant (Faslodex Injection) (PDF) |
CP.PHAR.424 |
1/1/2020 |
Galcanezumab-gnlm (Emgality) (PDF) |
HIM.PA.SP67 |
10/1/2020 |
Galsulfase (Naglazyme) (PDF) |
CP.PHAR.161 |
6/1/2019 |
Gefitinib (Iressa) (PDF) |
CP.PHAR.68 |
6/1/2019 |
gemtuzumab ozogamicin (Mylotarg®) (PDF) |
CP.PHAR.358 |
6/1/2019 |
Gilteritinib (Xospata)(PDF) |
CP.PHAR.412 |
3/1/2019 |
Givosiran (Givlaari) (PDF) |
CP.PHAR.457 |
3/1/2020 |
Glasdegib (Daurismo)(PDF) |
CP.PHAR.413 |
3/1/2019 |
Glatiramer (Copaxone, Glatopa) (PDF) |
CP.PHAR.252 |
12/8/2017 |
Glecaprevir-Pibrentasvir (PDF) |
HIM.PA.SP36 |
8/1/2020 |
Glucagon-Like Peptide-1 Receptor Agonists (PDF) |
HIM.PA.53 |
6/1/2019 |
Glycerol phenylbutyrate (Ravicti®) (PDF) |
CP.PHAR.207 |
3/1/2020 |
Golodirsen (Vyondys 53) (PDF) |
CP.PHAR.453 |
3/1/2020 |
goserelin acetate (Zoladex®) (PDF) |
CP.PHAR.171 |
6/1/2019 |
Halcinonide (Halog) (PDF) |
HIM.PA.20 |
6/1/2019 |
Halobetasol Propionate/Tazarotene (Duobrii) (PDF) |
CP.PMN.208 |
9/1/2020 |
Hemin (Panhematin®) (PDF) |
CP.PHAR.181 |
3/1/2020 |
histrelin acetate (Vantas®, Supprelin LA®) (PDF) |
CP.PHAR.172 |
6/1/2019 |
House dust mite allergen extract (Odactra®) (PDF) |
CP.PMN.111 |
6/1/2019 |
Hyaluronate Derivatives (PDF) |
CP.PHAR.05 |
12/8/2017 |
Hydrocodone-chlorpheniramine (Vituz) (PDF) |
HIM.PA.141 |
6/1/2019 |
Hydroxyprogesterone Caproate (Makena) (PDF) |
CP.PHAR.14 |
3/1/2016 |
ibalizumab-uiyk (Trogarzo) (PDF) |
CP.PHAR.378 |
6/1/2019 |
Ibandronate sodium (PDF) |
CP.PHAR.189 |
7/1/2016 |
Ibrutinib (Imbruvica) (PDF) |
CP.PHAR.126 |
6/1/2019 |
Icatibant (Firazyr®) (PDF) |
CP.PHAR.178 |
7/1/2016 |
Icosapent ethyl (Vascepa) (PDF) |
CP.PMN.187 |
6/1/2019 |
Idelalisib (Zydelig) (PDF) |
CP.PHAR.133 |
6/1/2019 |
Idursulfase (Elaprase) (PDF) |
CP.PHAR.156 |
6/1/2019 |
lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (PDF) |
CP.PMN.150 |
1/1/2020 |
Iloperidone (Fanapt) (PDF) |
CP.PMN.32 |
6/1/2019 |
Iloprost (Ventavis®) (PDF) |
CP.PHAR.193 |
7/1/2016 |
Imatinib (Gleevec) (PDF) |
CP.PHAR.65 |
11/7/2017 |
Imiglucerase (Cerezyme) (PDF) |
CP.PHAR.154 |
6/1/2019 |
Immune Globulins (PDF) |
CP.PHAR.103 |
3/1/2016 |
Immunization Coverage (PDF) |
CP.PHAR.28 |
7/24/2015 |
IncobotulinumtoxinA (Xeomin) (PDF) |
CP.PHAR.231 |
3/1/2021 |
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) |
HIM.PA.102 |
6/1/2019 |
Infertility and Fertility Preservation (PDF) |
CP.PHAR.131 |
6/1/2019 |
Infliximab (Remicade, Inflectra, Renflexis) (PDF) |
CP.PHAR.254 |
1/1/2021 |
Inebilizumab (PDF) |
CP.PHAR.458 |
3/1/2020 |
Inotersen (Tegsedi) (PDF) |
CP.PHAR.405 |
3/1/2019 |
inotuzumab ozogamicin (Besponsa®) (PDF) |
CP.PHAR.359 |
10/1/2020 |
Insulin Degludec (Tresiba) (PDF) |
HIM.PA.09 |
7/15/2019 |
interferon beta-1a (Avonex, Rebif) (PDF) |
HIM.PA.SP14 |
12/8/2017 |
interferon beta-1b (Betasero, Extavia) (PDF) |
HIM.PA.SP15 |
12/8/2017 |
Interferon Gamma- 1b (Actimmune) (PDF) |
CP.PHAR.52 |
9/8/2017 |
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) |
CP.PHAR.149 |
6/1/2019 |
Iobenguane I-131 (Azedra) (PDF) |
CP.PHAR.459 |
3/1/2020 |
Ipilimumab (Yervoy) (PDF) |
CP.PHAR.319 |
6/1/2019 |
irinotecan Liposome (Onivyde®) (PDF) |
CP.PHAR.304 |
6/1/2019 |
Iron sucrose (Venofer®) (PDF) |
CP.PHAR.167 |
3/1/2020 |
isavuconazonium (Cresemba®) (PDF) |
HIM.PA.108 |
6/1/2019 |
Isotretinoin (PDF) |
CP.PMN.143 |
3/1/2016 |
Itraconazole (Sporanox, Onmel) (PDF) |
CP.PMN.124 |
6/1/2019 |
Ivacaftor (Kalydeco) (PDF) |
CP.PHAR.210 |
9/8/2017 |
ivermectin (Sklice®) (PDF) |
HIM.PA.124 |
6/1/2019 |
Ivosidenib (Tibsovo) (PDF) |
CP.PHAR.137 |
7/15/2019 |
Ixazomib (Ninlaro) (PDF) |
CP.PHAR.302 |
6/1/2019 |
Lacosamide (Vimpat) (PDF) |
CP.PMN.155 |
9/8/2017 |
Lactic acid-citric acid-potassium bitartrate (Phexxi) (PDF) |
CP.PMN.251 |
12/1/2020 |
Lanadelumab-fylo (Takhzyro)(PDF) |
CP.PHAR.396 |
3/1/2019 |
Lanreotide (Somatuline Depot) (PDF) |
CP.PHAR.391 |
6/1/2019 |
lapatinib (Tykerb®) (PDF) |
CP.PHAR.79 |
7/24/2015 |
Laronidase (Aldurazyme) (PDF) |
CP.PHAR.152 |
6/1/2019 |
Larotrectinib (Vitrakvi)(PDF) |
CP.PHAR.414 |
3/1/2019 |
ledipasvir sofosbuvir (Harvoni) (PDF) |
HIM.PA.SP3 |
11/1/2020 |
lenalidomide (Revlimid) (PDF) |
CP.PHAR.71 |
10/30/2016 |
Lenvatinib (Lenvima) (PDF) |
CP.PHAR.138 |
6/1/2019 |
Letermovir (Prevymis) (PDF) |
CP.PHAR.367 |
6/1/2019 |
Levoleucovorin (Fusilev, Khapzory) (PDF) |
CP.PHAR.151 |
12/1/2020 |
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) |
CP.PHAR.173 |
9/1/2020 |
Levalbuterol (Xopenex) (PDF) |
CP.PMN.07 |
6/1/2019 |
Levomilnacipran (Fetzima) (PDF) |
HIM.PA.125 |
6/1/2019 |
lidocaine transdermal (Lidoderm®) (PDF) |
CP.PMN.08 |
6/1/2019 |
Lifitegrast (Xiidra®) (PDF) |
CP.PMN.73 |
3/1/2020 |
Linaclotide (Linzess) (PDF) |
CP.PMN.71 |
6/1/2019 |
linezolid (Zyvox) (PDF) |
CP.PMN.27 |
6/1/2019 |
Lofexidine (Lucemyra) (PDF) |
CP.PMN.152 |
7/15/2019 |
Lomustine (Gleostine) (PDF) |
CP.PHAR.507 |
12/1/2020 |
Lorcaserin (Belviq®, Belviq XR) (PDF) |
CP.PCH.03 |
6/1/2019 |
Lorlatinib (Lorbrena)(PDF) |
CP.PHAR.406 |
3/1/2019 |
Lubiprostone (Amitiza) (PDF) |
CP.PMN.142 |
3/1/2016 |
Luliconazole Cream (Luzu) (PDF) |
CP.PMN.166 |
6/1/2019 |
Lumacaftor-Ivacaftor (Orkambi) (PDF) |
CP.PHAR.213 |
3/1/2019 |
Lurbinectedin (Zepzelca) (PDF) |
CP.PHAR.500 |
12/1/2020 |
Lurasidone (Latuda) (PDF) |
CP.PMN.50 |
6/1/2019 |
Luspatercept-aamt (Reblozyl) (PDF) |
CP.PHAR.450 |
6/1/2020 |
Lusutrombopag (Mulpleta)(PDF) |
CP.PHAR.407 |
7/1/2019 |
Lutetium Lu 177 Dotatate (Lutathera) (PDF) |
CP.PHAR.384 |
6/1/2019 |
Macitentan (Opsumit®) (PDF) |
CP.PCH.31 |
3/1/2021 |
Mecamylamine (Vecamyl) (PDF) |
CP.PMN.136 |
6/1/2019 |
Mecasermin (Increlex) (PDF) |
CP.PHAR.150 |
12/1/2020 |
Mechlorethamine Gel (Valchlor) (PDF) |
CP.PHAR.381 |
9/1/2020 |
Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) |
CP.PMN.179 |
6/1/2019 |
Mepolizumab (Nucala) (PDF) |
CP.PHAR.200 |
9/8/2017 |
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) |
CP.PHAR.134 |
7/1/2020 |
Methoxsalen (Uvadex) (PDF) |
HIM.PA.17 |
6/1/2019 |
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) |
CP.PHAR.238 |
6/1/2019 |
Methylnaltrexone Bromide (Relistor) (PDF) |
CP.PMN.169 |
6/1/2019 |
Metoclopramide (Gimoti) (PDF) |
CP.PMN.252 |
12/1/2020 |
Metreleptin (Myalept) (PDF) |
CP.PHAR.425 |
6/1/2019 |
Midazolam (Nayzilam) (PDF) |
CP.PMN.211 |
1/1/2020 |
Mifepristone (Korlym) (PDF) |
CP.PHAR.101 |
3/1/2020 |
Migalastat (Galafold) (PDF) |
CP.PHAR.394 |
7/15/2019 |
Miglustat (Zavesca) (PDF) |
CP.PHAR.164 |
6/1/2019 |
Milnacipran (Savella) (PDF) |
CP.PMN.125 |
6/1/2019 |
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF) |
CP.PMN.80 |
12/1/2020 |
Mitoxantrone (Novantrone) (PDF) |
CP.PHAR.258 |
12/8/2017 |
modafinil (Provigil) (PDF) |
CP.PMN.39 |
6/1/2019 |
Mogamulizumab-kpkc (Poteligeo) (PDF) |
CP.PHAR.139 |
6/1/2019 |
Mometasone (Nasonex) (PDF) |
HIM.PA.93 |
3/1/2016 |
Mometasone (Asmanex) (PDF) |
HIM.PA.01 |
3/1/2021 |
Mometasone Furoate (Sinuva) (PDF) |
CP.PHAR.448 |
3/1/2020 |
Montelukast oral granules (Singulair) (PDF) |
HIM.PA.129 |
6/1/2019 |
Monomethyl Fumarate (Bafiertam) (PDF) |
CP.PHAR.460 |
3/1/2/2020 |
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) |
CP.PHAR.398 |
6/1/2019 |
Moxidectin (PDF) |
CP.PMN.162 |
6/1/2019 |
nafarelin acetate (Synarel®) (PDF) |
CP.PHAR.174 |
6/1/2019 |
Naltrexone (Vivitrol) (PDF) |
CP.PHAR.96 |
11/1/2020 |
Naproxen oral suspension (Naprosyn) (PDF) |
HIM.PA.130 |
6/1/2019 |
natalizumab (Tysabri) (PDF) |
HIM.PA.SP17 |
11/7/2017 |
Nebivolol (Bystolic) (PDF) |
HIM.PA.131 |
6/1/2019 |
necitumumab (Portrazza®) (PDF) |
CP.PHAR.320 |
6/1/2019 |
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) |
CP.PMN.167 |
6/1/2019 |
Neratinib (Nerlynx) (PDF) |
CP.PHAR.365 |
9/1/2020 |
Netupitant and Palonosetron (Akynzeo) (PDF) |
CP.PMN.158 |
9/1/2020 |
Nifurtimox (Lampit) ^ (PDF) |
CP.PMN.256 |
12/1/2020 |
nilotinib (Tasigna) (PDF) |
CP.PHAR.76 |
11/7/2017 |
Nintedanib (Ofev) (PDF) |
CP.PHAR.285 |
7/15/2019 |
Nitisinone (Nityr, Orfadin) (PDF) |
CP.PHAR.132 |
6/1/2019 |
Nivolumab (Opdivo) (PDF) |
CP.PHAR.121 |
9/8/2017 |
No Coverage Criteria (PDF) |
CP.PMN.255 |
12/1/2020 |
No Coverage Criteria/Off-Label Use Policy (PDF) |
CP.PMN.53 |
6/1/2019 |
Non-Formulary and Formulary Contraceptives (PDF) |
HIM.PA.100 |
7/25/2015 |
Non-Formulary Test Strips (PDF) |
HIM.PA.34 |
6/1/2019 |
nusinersen (Spinraza®) (PDF) |
CP.PHAR.327 |
6/1/2019 |
obinutuzumab (Gazyva®) (PDF) |
CP.PHAR.305 |
6/1/2019 |
Ocrelizumab (Ocrevus) (PDF) |
CP.PHAR.335 |
6/1/2019 |
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) |
CP.PHAR.40 |
9/1/2020 |
ofatumumab (Arzerra®) (PDF) |
CP.PHAR.306 |
6/1/2019 |
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) |
CP.PHAR.292 |
1/1/2020 |
olaparib (Lynparza) (PDF) |
CP.PHAR.360 |
6/1/2019 |
olaratumab (Lartruvo®) (PDF) |
CP.PHAR.326 |
6/1/2019 |
Omacetaxine (Synribo) (PDF) |
CP.PHAR.108 |
4/1/2016 |
Omadacycline (Nuzyra)(PDF) |
CP.PMN.188 |
3/1/2019 |
Omalizumab (Xolair®) (PDF) |
CP.PHAR.01 |
11/7/2017 |
OnabotulinumtoxinA (Botox) (PDF) |
CP.PHAR.232 |
3/1/2021 |
Onasemnogene abeparvovec (Zolgensma) (PDF) |
CP.PHAR.421 |
12/1/2020 |
Ophthalmic Corticosteroids (PDF) |
HIM.PA.03 |
6/1/2020 |
Opioid Analgesics (PDF) |
HIM.PA.139 |
1/1/2018 |
Ospemifene (Osphena) (PDF) |
CP.PMN.168 |
6/1/2019 |
Overactive Bladder Agents (PDF) |
CP.PMN.198 |
7/15/2019 |
Ozanimod (Zeposia) (PDF) |
CP.PHAR.462 |
9/1/2020 |
Paclitaxel, protein-bound (Abraxane) (PDF) |
CP.PHAR.176 |
6/1/2019 |
Palbociclib (Ibrance) (PDF) |
CP.PHAR.125 |
9/1/2020 |
Paliperidone (Invega) (PDF) |
CP.PMN.30 |
6/1/2019 |
Palivizumab (Synagis) (PDF) |
CP.PHAR.16 |
12/8/2017 |
panitumumab (Vectibix®) (PDF) |
CP.PHAR.321 |
6/1/2019 |
Parathyroid Hormone (Natpara) (PDF) |
CP.PHAR.282 |
3/1/2020 |
Paricalcitol Injection (Zemplar) (PDF) |
CP.PHAR.270 |
12/8/2017 |
pasireotide (Signifor LAR®) (PDF) |
CP.PHAR.332 |
6/1/2019 |
Patisiran (Onpattro) (PDF) |
CP.PHAR.395 |
6/1/2019 |
Pazopanib (Votrient) (PDF) |
CP.PHAR.81 |
7/24/2015 |
Pegademase Bovine (Adagen) (PDF) |
CP.PHAR.392 |
6/1/2019 |
Pegaptanib (Macugen) (PDF) |
CP.PHAR.185 |
7/1/2016 |
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) |
CP.PHAR.353 |
6/1/2019 |
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) |
CP.PHAR.296 |
7/1/2020 |
Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF) |
CP.PHAR.89 |
7/24/2015 |
peginterferon beta-1a (Plegridy) (PDF) |
CP.PHAR.271 |
12/1/2020 |
Pegloticase (Krystexxa) (PDF) |
CP.PHAR.115 |
6/1/2013 |
Pegvaliase-pqpz (Palynziq) (PDF) |
CP.PHAR.140 |
7/15/2019 |
Pegvisomant (Somavert) (PDF) |
CP.PHAR.389 |
6/1/2019 |
pembrolizumab (Keytruda®) (PDF) |
CP.PHAR.322 |
1/1/2021 |
Pemetrexed (Alimta, Pemfexy) (PDF) |
CP.PHAR.368 |
10/31/2017 |
Penicillamine (Cuprimine) (PDF) |
CP.PCH.09 |
6/1/2019 |
Perampanel (Fycompa) (PDF) |
CP.PMN.156 |
6/1/2019 |
Pertuzumab (Perjeta) (PDF) |
CP.PHAR.227 |
10/30/2016 |
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) |
CP.PHAR.501 |
12/1/2020 |
Pexidartinib (Turalio)(PDF) |
CP.PHAR.436 |
12/1/2019 |
Phendimetrazine IR (Bontril PDM) (PDF) |
HIM.PA.114 |
6/1/2019 |
Phentermine (Adipex-P, Lomaira) (PDF) |
CP.PCH.13 |
7/15/2019 |
Pimecrolimus (Elidel) (PDF) |
CP.PMN.98 |
6/1/2019 |
Pirfenidone (Esbriet) (PDF) |
CP.PHAR.286 |
12/1/2020 |
Pitolisant (Wakix) (PDF) |
CP.PMN.221 |
5/1/2019 |
Plerixafor (Mozobil) (PDF) |
CP.PHAR.323 |
6/1/2019 |
Polatuzumab Vedotin-piiq (Polivy) (PDF) |
CP.PHAR.433 |
1/1/2021 |
Pomalidomide (Pomalyst) (PDF) |
CP.PHAR.116 |
4/1/2016 |
Potassium (Klor-Con) (PDF) |
HIM.PA.143 |
6/1/2019 |
pralatrexate (Folotyn®) (PDF) |
CP.PHAR.313 |
6/1/2019 |
Pramlintide (Symlin) (PDF) |
CP.PMN.129 |
6/1/2019 |
pregabalin (Lyrica) (PDF) |
CP.PMN.33 |
6/1/2019 |
protein c concentrate, human (Ceprotin®) (PDF) |
CP.PHAR.330 |
7/15/2019 |
propranolol HCL solution (Hemangeol) (PDF) |
CP.PMN.58 |
6/1/2019 |
Prucalopride (Motegrity) (PDF) |
CP.PMN.194 |
9/1/2019 |
pyrimethamine (Daraprim®) (PDF) |
CP.PMN.44 |
6/1/2019 |
Quetiapine ER (Seroquel XR) (PDF) |
CP.PMN.64 |
6/1/2019 |
Ondansetron (Zuplenz) (PDF) |
CP.PMN.45 |
3/1/2020 |
Quinine Sulfate (Qualaquin) (PDF) |
HIM.PA.144 |
6/1/2019 |
Quinine Sulfate (Qualaquin) (PDF) |
CP.PCH.10 |
6/1/2019 |
Ramelteon (Rozerem) (PDF) |
CP.PMN.173 |
6/1/2019 |
Ramucirumab (Cyramza) (PDF) |
CP.PHAR.119 |
9/8/2017 |
Ranibizumab (Lucentis) (PDF) |
CP.PHAR.186 |
11/1/2020 |
rasagiline (Azilect®) (PDF) |
HIM.PA.89 |
3/1/2016 |
Ravulizumab-cwvz (Ultomiris) (PDF) |
CP.PHAR.415 |
6/1/2019 |
Regorafenib (Stivarga) (PDF) |
CP.PHAR.107 |
3/1/2016 |
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) |
CP.PHAR.168 |
9/8/2017 |
Reslizumab (Cinqair) (PDF) |
CP.PHAR.223 |
9/8/2017 |
Revefenacin (Yupelri) (PDF) |
CP.PMN.195 |
9/1/2019 |
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) |
CP.PHAR.141 |
6/1/2019 |
Rifabutin (Mycobutin) (PDF) |
HIM.PA.12 |
6/1/2019 |
rifaximin (Xifaxan®) (PDF) |
CP.PMN.47 |
3/1/2016 |
Rilonacept (Arcalyst) (PDF) |
CP.PHAR.266 |
11/7/2017 |
Ripretinib (Qinlock) (PDF) |
CP.PHAR.502 |
12/1/2020 |
RimabotulinumtoxinB (Myobloc) (PDF) |
CP.PHAR.233 |
11/7/2017 |
Riociguat (Adempas®) (PDF) |
CP.PHAR.195 |
7/1/2016 |
Risdiplam (Evrysdi) (PDF) |
CP.PHAR.477 |
9/1/2020 |
Risedronate (Actonel, Atelvia) (PDF) |
CP.PMN.100 |
6/1/2019 |
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) |
CP.PHAR.293 |
3/1/2016 |
Rolapitant (Varubi) (PDF) |
CP.PMN.102 |
6/1/2019 |
romidepsin (Istodax®) (PDF) |
CP.PHAR.314 |
6/1/2019 |
Romiplostim (Nplate®) (PDF) |
CP.PHAR.179 |
12/1/2020 |
Romosozumab-aqqg (Evenity) (PDF) |
CP.PHAR.428 |
1/1/2020 |
Rucaparib (Rubraca®) (PDF) |
CP.PHAR.350 |
3/1/2020 |
Rufinamide (Banzel) (PDF) |
CP.PMN.157 |
3/1/2016 |
Ruxolitinib (Jakafi) (PDF) |
CP.PHAR.98 |
9/8/2017 |
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) |
CP.PHAR.475 |
9/1/2020 |
Sacubitril/Valsartan (Entresto) (PDF) |
CP.PMN.67 |
6/1/2019 |
Safinamide (Xadago) (PDF) |
CP.PMN.113 |
3/1/2020 |
Sapropterin (Kuvan) (PDF) |
CP.PHAR.43 |
9/8/2017 |
Sarecycline (Seysara) (PDF) |
CP.PMN.189 |
3/1/2020 |
Sargramostim (Leukine) (PDF) |
CP.PHAR.295 |
6/1/2019 |
Sebelipase Alfa (Kanuma) (PDF) |
CP.PHAR.159 |
6/1/2019 |
Secnidazole (Solosec) (PDF) |
CP.PMN.103 |
6/1/2019 |
Segesterone acetate/Ethinyl estradiol (Annovera) (PDF) |
CP.PMN.190 |
7/15/2019 |
Selexipag (Uptravi®) (PDF) |
CP.PHAR.196 |
3/1/2020 |
Selinexor (Xpovio) (PDF) |
CP.PHAR.431 |
1/1/2020 |
Selpercatinib (Retevmo) (PDF) |
CP.PHAR.478 |
9/1/2020 |
Sildenafil (Revatio®) (PDF) |
CP.PHAR.197 |
7/1/2016 |
Sildenafil (Viagra) (PDF) |
CP.PCH.07 |
6/1/2019 |
Siponimod (Mayzent) (PDF) |
CP.PHAR.427 |
1/1/2020 |
Sipuleucel-T (Provenge) (PDF) |
CP.PHAR.120 |
4/1/2016 |
sodium oxybate (Xyrem) (PDF) |
CP.PMN.42 |
5/1/2019 |
Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) |
HIM.PA.91 |
6/1/2019 |
Sodium Phenylbutyrate (Buphenyl) (PDF) |
CP.PHAR.208 |
3/1/2020 |
Sodium Zirconium Cyclosilicate (Lokelma) (PDF) |
CP.PMN.163 |
3/1/2020 |
Sofosbuvir (Sovaldi) (PDF) |
HIM.PA.SP2 |
11/1/2020 |
Sofosbuvir-Velpatasvir (Epclusa) (PDF) |
HIM.PA.SP1 |
8/1/2020 |
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF) |
HIM.PA.SP63 |
8/1/2020 |
Solriamfetol (Sunosi) (PDF) |
CP.PMN.209 |
1/1/2020 |
Somatropin (Growth Hormone) (PDF) |
CP.PCH.25 |
11/7/2017 |
Sonidegib (Odomzo) (PDF) |
CP.PHAR.272 |
12/8/2017 |
sorafenib (Nexavar) (PDF) |
CP.PHAR.69 |
10/30/2016 |
Spinosad (Natroba) (PDF) |
HIM.PA.134 |
6/1/2019 |
Step Therapy (PDF) |
HIM.PA.109 |
6/1/2019 |
Stiripentol (Diacomit) (PDF) |
CP.PMN.184 |
3/1/2020 |
sucroferric oxyhydoxide (Velphoro) (PDF) |
HIM.PA.SP30 |
6/1/2019 |
Sulfacetamide Sodium Sulfur (Sumadan) (PDF) |
HIM.PA.145 |
6/1/2019 |
sunitinib (Sutent) (PDF) |
CP.PHAR.73 |
12/8/2017 |
Suvorexant (Belsomra®) (PDF) |
CP.PMN.109 |
6/1/2019 |
Tadalafil (Adcirca®) (PDF) |
CP.PHAR.198 |
7/1/2016 |
Tadalafil BHP - ED (Cialis) (PDF) |
CP.PMN.132 |
6/1/2019 |
Tafamidis (Vyndaqel, Vyndamax) (PDF) |
CP.PHAR.432 |
1/1/2020 |
Tafasitamab-cxix (Monjuvi) (PDF) |
CP.PHAR.508 |
12/1/2020 |
Tafenoquine (Krintafel) (PDF) |
CP.PMN.178 |
6/1/2019 |
Talazoparib (Talzenna)(PDF) |
CP.PHAR.409 |
3/1/2019 |
Taliglucerase Alfa (Elelyso) (PDF) |
CP.PHAR.157 |
1/1/2021 |
Tasimelteon (Hetlioz) (PDF) |
CP.PMN.104 |
6/1/2019 |
tavaborole (Kerydin®) (PDF) |
CP.PMN.105 |
6/1/2019 |
Tazarotene (Arazlo, Fabior, Tazorac) (PDF) |
CP.PMN.244 |
11/1/2020 |
Tazemetostat (PDF) |
CP.PHAR.452 |
6/1/2020 |
Tedizolid (Sivextro) (PDF) |
CP.PMN.62 |
6/1/2019 |
Teduglutide (Gattex) (PDF) |
CP.PHAR.114 |
9/8/2017 |
Tegaserod (Zelnorm) (PDF) |
CP.PMN.206 |
1/1/2020 |
Temozolomide (Temodar) (PDF) |
CP.PHAR.77 |
12/8/2017 |
temsirolimus (Torisel®) (PDF) |
CP.PHAR.324 |
6/1/2019 |
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) |
CP.PCH.33 |
12/1/2020 |
Teprotumumab (Tepezza) (PDF) |
CP.PHAR.465 |
12/1/2020 |
Teriflunomide (Aubagio) (PDF) |
CP.PHAR.262 |
12/1/2020 |
Teriparatide (Forteo®) (PDF) |
CP.PHAR.188 |
7/1/2016 |
Tesamorelin (Egrifta) (PDF) |
CP.PHAR.109 |
4/1/2016 |
Testosterone (Androderm) (PDF) |
HIM.PA.87 |
3/1/2016 |
Testosterone (Testopel, Jatenzo) (PDF) |
CP.PHAR.354 |
03/01/20 |
tetrabenazine (Xenazine) (PDF) |
CP.PHAR.92 |
7/24/2015 |
Thalidomide (Thalomid) (PDF) |
CP.PHAR.78 |
10/30/2016 |
Thioguanine (Tabloid) (PDF) |
CP.PHAR.437 |
6/1/2019 |
Thyrotropin Alfa (Thyrogen) (PDF) |
CP.PHAR.95 |
7/24/2015 |
Timothy grass pollen allergen extract (Grastek®) (PDF) |
CP.PMN.84 |
6/1/2019 |
Tisagenlecleucel (Kymriah) (PDF) |
CP.PHAR.361 |
6/1/2019 |
Tobramycin (PDF) |
CP.PHAR.211 |
9/8/2017 |
Tolvaptan (Jynarque) (PDF) |
CP.PHAR.27 |
6/1/2019 |
Topical Acne Treatment (PDF) |
HIM.PA.71 |
3/1/2016 |
Topotecan (Hycamtin) (PDF) |
CP.PHAR.64 |
10/30/2016 |
Topical Immunomodulators (PDF) |
CP.PMN.107 |
7/15/2019 |
Trabectedin (Yondelis) (PDF) |
CP.PHAR.204 |
9/8/2017 |
Trametinib (Mekinist) (PDF) |
CP.PHAR.240 |
11/7/2017 |
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) |
CP.PHAR.228 |
6/1/2019 |
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) |
CP.PHAR.199 |
7/1/2016 |
Triamcinolone ER Injection (Zilretta) (PDF) |
CP.PHAR.371 |
6/1/2019 |
Triclabendazole (Egaten) (PDF) |
CP.PMN.207 |
1/1/2020 |
Trientine (Syprine) (PDF) |
CP.PHAR.438 |
6/1/2019 |
Trifarotene (Aklief) (PDF) |
CP.PMN.225 |
8/1/2020 |
Trifluridine/Tipiracil (Lonsurf) (PDF) |
CP.PHAR.383 |
9/1/2020 |
Triheptanoin (Dojolvi) ^ (PDF) |
CP.PHAR.509 |
12/1/2020 |
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) |
CP.PHAR.175 |
6/1/2019 |
Ubrogepant (Ubrelvy) (PDF) |
CP.PHAR.476 |
9/1/2020 |
Unoprostone Isopropyl (Rescula) (PDF) |
HIM.PA.11 |
6/1/2019 |
Uridine acetate (Vistogard) (PDF) |
HIM.PA.SP55 |
6/1/2019 |
valganciclovir (Valcyte) (PDF) |
CP.PCH.06 |
6/1/2019 |
Valproate Sodium for Intravenous Injection (Depacon) (PDF) |
CP.PHAR.429 |
1/1/2020 |
Valrubicin (Valstar) (PDF) |
CP.PHAR.439 |
6/1/2019 |
Vandetanib (Caprelsa®) (PDF) |
CP.PHAR.80 |
7/24/2015 |
Vedolizumab (Entyvio) (PDF) |
CP.PHAR.265 |
11/7/2017 |
Velaglucerase Alfa (VPRIV) (PDF) |
CP.PHAR.163 |
6/1/2019 |
Vemurafenib (Zelboraf®) (PDF) |
CP.PHAR.91 |
7/24/2015 |
Vestronidase alfa-vjbk (Mepsevii) (PDF) |
CP.PHAR.374 |
6/1/2019 |
Verteporfin (PDF) |
CP.PHAR.187 |
7/1/2016 |
Vigabatrin (Sabril) (PDF) |
CP.PHAR.169 |
6/1/2019 |
Vilazodone (Viibryd) (PDF) |
CP.PMN.145 |
6/1/2019 |
Viltolarsen (Viltepso) (PDF) |
CP.PHAR.484 |
9/1/2020 |
vincristine sulfate liposome injection (Marqibo®) (PDF) |
CP.PHAR.315 |
6/1/2019 |
Vismodegib (Erivedge) (PDF) |
CP.PHAR.273 |
12/8/2017 |
Vorapaxar (Zontivity) (PDF) |
HIM.PA.146 |
6/1/2019 |
Voretigene neparvovec-rzyl (Luxturna) (PDF) |
CP.PHAR.372 |
6/1/2019 |
Vortioxetine (Trintellix®) (PDF) |
CP.PMN.65 |
6/1/2019 |
Voxelotor (Oxbryta) (PDF) |
CP.PHAR.451 |
6/1/2020 |
ziv-aflibercept (Zaltrap®) (PDF) |
CP.PHAR.325 |
6/1/2019 |
Zoledronic acid (PDF) |
CP.PHAR.59 |
7/1/2016 |
Vorinostat (Zolinza) (PDF) |
CP.PHAR.83 |
7/24/2015 |