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Arizona Complete Health-Complete Care Plan | Care1st Health Plan Arizona

Pharmacy Policies

 

Policy Name Policy Number Reviewed
Abaloparatide (Tymlos) AZ.CP.PHAR.345 02/22
Acetylcholinesterase Inhibitors (Aricept, Aricept ODT, Razadyne, Razadyne ER, Exelon, Exelon Patch) AZ.CP.PHAR.1018 02/22
ADHD Medications in Children Under 6 Years Old AZ.CP.PMN.07 09/20
Agents for Insomnia AZ.CP.PMN.1016 10/21
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) AZ.CP.PHAR.94 02/22
Amisulpride (Barhemsys) AZ.CP.PMN.236 07/21
Anthelmintics (albendazole ivermectin) AZ.CP.PHAR.403 07/21
Antipsychotic Medications in Children Under 18 AZ.CP.PMN.08 07/20
Atogepart (Qulipta) AZ.CP.PHAR.566 02/22
Bevacizumab (Avastin, Mvasi, Zirabev) AZ.CP.PHAR.93 11/21
Budesonide/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) and Fluticasone/Umeclidinium/Vilanterol (Trelegy Ellipta) AZ.CP.PMN.1005 02/22
Buprenorphine (Subutex) SL tablets AZ.CP.PMN.82 02/22
Buprenorphine Implant/Injection (Probuphine, Sublocade) AZ.CP.PHAR.289 02/22
Concomitant Antidepressant AZ.CP.PMN.11 12/19
Concomitant Antipsychotic Treatment AZ.CP.PMN.10 07/20
Cytokine and CAM antagonists AZ.CP.PHAR.06 10/21
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors AZ.CP.PMN.43 02/22
Dronedarone (Multaq) AZ.CP.PMN.1024 02/20
Edoxaban (Savaysa) AZ.CP.PMN.227 02/22
Elexacaftor-Ivacaftor-Tezacaftor (Trikafta) AZ.CP.PHAR.440 02/22
Endothelin Receptor Antagonists-ETRA (Letairis, Opsumit, Tracleer) AZ.CP.PHAR.1012 02/22
Esketamine (Spravato) AZ.CP.PMN.199 04/21
Eteplirsen (Exondys 51) AZ.CP.PHAR.288 02/22
Filgrastim (Neupogen Zarxio Granix Nivestym) AZ.CP.PHAR.297 07/21
Glecaprevir/Pibrentasvir (Mavyret) and Sofosbuvir/Velpatasvir (Epclusa Approved Generic) AZ.CP.PHAR.44 11/21
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists AZ.CP.PMN.183 04/21
Hepatitis B Drugs- Entecavir (Baraclude) and Adefovir (Hepsera) AZ.CP.PMN.03 11/21
Herceptin Biosimilars Trastuzumab-Hyaluronidase AZ.CP.PHAR.228 04/21
Human Growth Hormone (Somapacitan Somatropin) AZ.CP.PHAR.517 02/22
Imatinib (Gleevec) AZ.CP.PHAR.65 04/21
Istradefylline (Nourianz) AZ.CP.PMN.217 02/22
Ivacaftor (Kalydeco) AZ.CP.PHAR.210 02/22
Lactitol (Pizensy) AZ.CP.PMN.241 08/21
LAMA/LABA Combination Inhalers AZ.CP.PMN.1021 07/20
Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) AZ.CP.PHAR.173 02/22
Long-Acting Opioid Analgesics AZ.CP.PMN.97b 02/22
Lumacaftor-Ivacaftor (Orkambi) AZ.CP.PHAR.213 02/22
Maraviroc (Selzentry) AZ.CP.PHAR.32 08/20
Melphalan (Pepaxto, Alkeran) AZ.CP.PHAR.535 08/21
Methylnaltrexone Bromide (Relistor) AZ.CP.PMN.169 10/20
Migraine Products – Monoclonal Antibodies (Aimovig, Ajovy, Emgality, Vyepti) AZ.CP.PHAR.1010 02/22
Multiple Sclerosis Drugs AZ.CP.PHAR.1020 02/22
Naldemedine (Symproic) AZ.CP.PMN.112 10/20
Naloxegol (Movantik) AZ.CP.PMN.171 10/20
No Coverage Criteria/Off-Label Use Policy AZ.CP.PMN.53 10/20
Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renvela, Renagel, Velphoro) AZ.CP.PMN.04 02/22
Non-Preferred drugs and Brand Name Override AZ.CP.PMN.16 11/21
Non-Preferred Hepatitis C Treatments AZ.CP.PHAR.400 08/21
Non-Preferred Second-Generation Antipsychotics  AZ.CP.PMN.1025 02/22
Nusinersen (Spinraza) AZ.CP.PHAR.327 02/22
Ophthalmics – Anti-inflammatory/Immunomodulators (Cequa, Restasis, Restasis Multidose, Xiidra) AZ.CP.PMN.1014 02/22
Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastin-apgf (Nyvepria) AZ.CP.PHAR.296 08/21
Phosphodiesterase-5 Inhibitors (PDE-5) (Adcirca, Alyq, Revatio) AZ.CP.PHAR.1013 02/22
Plecanatide (Trulance) AZ.CP.PMN.87 10/20
Posaconazole (Noxafil) AZ.CP.PMN.1000 09/20
Proton Pump Inhibitors AZ.CP.PMN.1002 02/21
Prucalopride (Motegrity) AZ.CP.PMN.194 10/20
Rifapentine (Priftin) AZ.CP.PMN.05 02/22
Rimegepant (Nurtec ODT) AZ.CP.PHAR.490 02/22
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) AZ.CP.PHAR.260 05/21
SABG Drug List Exception Requests AZ.CP.PMN.1009 09/19
Short-Acting Opioid Analgesics AZ.CP.PMN.97a 02/22
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors AZ.CP.PMN.14 02/22
Step Therapy AZ.CP.PST.01 02/22
Tenapanor (Ibsrela) AZ.CP.PMN.224 02/21
Teriparatide (Forteo) AZ.CP.PHAR.188 02/21
Testosterone (Injectable; Nasal; Transdermal) AZ.CP.PMN.02 04/21
Thrombopoiesis Stimulating Agents- Doptelet, Nplate, Mulpleta, Promacta, Tavalisse AZ.CP.PHAR.1019 02/22
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) AZ.CP.PHAR.211 02/22
Treprostinil (Orenitram, Remodulin, Tyvaso) AZ.CP.PHAR.199 08/21
Trintellix and Viibryd AZ.CP.PMN.20 07/21
Vancomycin Oral (Vancocin) AZ.CP.PMN.166 02/21
VMAT2 inhibitors (Ingrezza Austedo Xenazine) AZ.CP.PHAR.340 02/22
Voriconazole (Vfend) AZ.CP.PMN.1003 11/20
Weight Loss Medications AZ.CP.PMN.1004 07/20

 

Medicaid (Arizona Complete Health-Complete Care Plan, Care1st Health Plan Arizona)


Medicaid and Marketplace (Ambetter)

POLICY TITLE POLICY NUMBER Last Review Date
Abaloparatide (Tymlos®) (PDF) CP.PMN.164 08/21
Abatacept (Orencia) (PDF) CP.PHAR.241 02/21
Abemaciclib (Verzenio) (PDF) CP.PHAR.355 11/21
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 02/21
Acalabrutinib (Calquence®) (PDF) CP.PHAR.366 02/21
Acitretin (Soriatane®) (PDF) CP.PMN.40 08/21
Actimmune (PDF) CP.PHAR.52 02/21
Afatinib (Gilotrif) (PDF) CP.PHAR.298 05/21
Afinitor (PDF) CP.PHAR.63 02/21
Aflibercept (Eylea®) (PDF) CP.PHAR.184 02/21
Aldurazyme (PDF) CP.PHAR.152 05/21
Alectinib (Alecensa) (PDF) CP.PHAR.369 05/21
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 02/21
Alosetron (Lotronex) (PDF) CP.PMN.153 02/21
Amantadine ER (Gocovri) (PDF) CP.PMN.89 02/21
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 02/21
Anakinra (Kineret) (PDF) CP.PHAR.244 02/21
Apalutamide (Erleada) (PDF) CP.PHAR.376 02/22
Apremilast (Otezla) (PDF) CP.PHAR.245 11/21
Aprepitant (Emend®) (PDF) CP.PMN.19 02/21
Aralast, Glassia, Prolastin-C, Zemaira (PDF) CP.PHAR.94 02/21
Armodafinil (Nuvigil) (PDF) CP.PMN.35 02/22
Asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 11/20
Aspirin dipyridamole (Aggrenox®) (PDF) CP.PMN.20 02/21
Atezolizumab (Tecentrip®) (PDF) CP.PHAR.235 02/21
Avelumab (Bacencio®) (PDF) CP.PHAR.333 02/21
Aztreonam (Cayston®) (PDF) CP.PHAR.209 02/21
Becaplermin (Regranex®) (PDF) CP.PMN.21 02/21
Belatacept (Nulojix®) (PDF) CP.PHAR.201 11/20
Belinostat (Beleodaq®) (PDF) CP.PHAR.311 11/20
Benralizumab (Fasenra) (PDF) CP.PHAR.373 02/21
Benznidazole (PDF) CP.PMN.90 02/21
Bezlotoxumab (Zinplava®) (PDF) CP.PHAR.300 02/21
Bosentan (Tracleer®) (PDF) CP.PHAR.191 02/21
Bosulif (PDF) CP.PHAR.105 05/21
Brand Name Override (PDF) CP.PMN.22 02/21
Brentuximab Vedotin (Adcetris®) (PDF) CP.PHAR.303 08/21
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 05/21
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 02/21
Cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 05/21
Calcifediol (Rayaldee®) (PDF) CP.PMN.76 08/21
Canakinumab (Ilaris) (PDF) CP.PHAR.246 05/21
Caprelsa (PDF) CP.PHAR.80 02/21
Carbamazepine ER (Equetro) (PDF) CP.PMN.137 05/20
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 02/21
Celecoxib (Celebrex) (PDF) CP.PMN.122 02/22
Cerdelga (PDF) CP.PHAR.153 05/21
Cerezyme (PDF) CP.PHAR.154 05/21
Ceritinib (Zykadia) (PDF) CP.PHAR.349 05/21
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 08/21
Certolizumab (Cimzia) (PDF) CP.PHAR.247 02/21
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 11/21
Ciclopirox (Penlac®) (PDF) CP.PMN.24 02/21
Clobazam (Onfi) (PDF) CP.PMN.54 11/21
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 05/21
Colchicine (Colcrys) (PDF) CP.PMN.123 02/21
Copanlisib (Aliqopa®) (PDF) CP.PHAR.357 11/21
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 02/21
Crisaborole (Eucrisa) (PDF) CP.PMN.110 05/21
Crysvita (PDF) CP.PHAR.11 08/21
Cyramza (PDF) CP.PHAR.119 02/21
Cystagon, Procysbi (PDF) CP.PHAR.155 05/21
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 05/21
Cytomegalovirus Immune Globulin (CytoGam) (PDF) CP.PHAR.277 08/21
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 05/21
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 02/02
Daratumumab (Darzalex®) (PDF) CP.PHAR.310 08/21
Daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 11/21
Deflazacort (Emflaza®) (PDF) CP.PHAR.331 02/21
Delafloxacin (Baxdela) (PDF) CP.PMN.115 02/21
Desferal (PDF) CP.PHAR.146 08/21
Desmopressin acetate (DDAVP Injection®, Stimate®) (PDF) CP.PHAR.214 02/21
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 05/21
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 02/21
Dolasetron (Anzemet) (PDF) CP.PMN.141 02/21
Dornase alfa (Pulmozyme®) (PDF) CP.PHAR.212 02/21
Dose Optimization (PDF)Doxycycline (Acticlate, Doryx, Oracea) (PDF) CP.PMN.13 11/21
Dronabinol (Marinol, Syndros) (PDF) CP.PMN.159 02/21
Droxidopa (Northera®) (PDF) CP.PMN.17 11/21
Dupilumab (Dupixent®) (PDF) CP.PHAR.336 02/21
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 05/21
Dutasteride (Avodart) and dutasteride/tamsulosin (Jalyn) (PDF) CP.PMN.128 02/22
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 02/21
Efinaconazole (Jublia®) (PDF) CP.PMN.25 02/21
Egrifta (PDF) CP.PHAR.109 08/21
Elaprase (PDF) CP.PHAR.156 05/21
Elelyso (PDF) CP.PHAR.157 11/21
Elotuzumab (Empliciti®) (PDF) CP.PHAR.308 11/21
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 02/21
Emicizumab-kxwh (Hemlibra®) (PDF) CP.PHAR.370 02/21
Enasidenib (Idhifa®) (PDF) CP.PHAR.363 11/21
Epidiolex (PDF) CP.PMN.164 08/21
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 02/21
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 11/21
Erwina asparaginase (Erwinaze®) (PDF) CP.PHAR.301 02/21
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 08/21
Eteplirsen (Exondys 51®) (PDF) CP.PHAR.288 02/21
Etidronate (Didronel) (PDF) CP.PMN.94 02/21
POLICY TITLE POLICY NUMBER Last Review Date
Febuxostat (Uloric) (PDF) CP.PMN.57 02/21
Feraheme (PDF) CP.PHAR.165 02/21
Ferric carboxymaltose (Injectafer®) (PDF) CP.PHAR.234 02/21
Ferriprox (PDF) CP.PHAR.147 08/21
Ferrlecit (PDF) CP.PHAR.166 02/21
Firmagon (PDF) CP.PHAR.170 11/21
Fluticasone propionate (Xhance) (PDF) CP.PMN.95 02/21
Fusilev (PDF) CP.PHAR.151 11/21
Fuzeon (PDF) CP.PHAR.41 08/21
Gablofen (PDF) CP.PHAR.149 11/21
Gattex (PDF) CP.PHAR.114 02/21
Gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 11/21
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 02/21
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 02/21
Granisetron (Sancuso®) (PDF) CP.PMN.74 02/21
H.P. Acthar Gel (PDF) CP.PHAR.168 02/21
Hemin (Panhematin®) (PDF) CP.PHAR.181 02/21
House dust mite allergen extract (Odactra®) (PDF) CP.PMN.111 02/22
Hycamtin (PDF) CP.PHAR.64 05/21
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 05/21
Ibandronate Oral (Boniva) (PDF) CP.PMN.96 02/21
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 02/21
Ibrance (PDF) CP.PHAR.125 11/21
Ibuprofen and Famotidine (Duexis) (PDF) CP.PMN.120 05/21
Icatibant (Firazyr®) (PDF) CP.PHAR.178 02/21
Iclusig (PDF) CP.PHAR.112 05/21
Iloprost (Ventavis®) (PDF) CP.PHAR.193 02/21
Imbruvica (PDF) CP.PHAR.126 02/21
Immunization Coverage (PDF) CP.PHAR.28 08/21
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 05/21
Increlex (PDF) CP.PHAR.150 08/21
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 02/21
Inlyta (PDF) CP.PHAR.100 02/21
Inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 11/21
Ipilimumab (Yervoy®) (PDF) CP.PHAR.319 02/21
Iressa (PDF) CP.PHAR.68 05/21
Irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 11/21
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 05/21
Isotretinoin (PDF) CP.PMN.143 11/21
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 05/21
Ivabradine (Corlanor) (PDF) CP.PMN.70 02/21
Ivacaftor (Kalydeco®) (PDF) CP.PHAR.210 02/21
Ixazomib (Ninlaro®) (PDF) CP.PHAR.302 08/21
Jadenu (PDF) CP.PHAR.145 08/21
Jynarque (PDF) CP.PHAR.27 08/21
Kanuma (PDF) CP.PHAR.159 05/21
Korlym (PDF) CP.PHAR.101 02/21
Krystexxa (PDF) CP.PHAR.115 02/21
Kuvan (PDF) CP.PHAR.43 02/21
Lacosamide (Vimpat) (PDF) CP.PMN.155 08/21
Latanoprostene bunod (Vyzulta®) (PDF) CP.PMN.108 02/21
Lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (PDF) CP.PMN.150 02/21
Letermovir (Prevymis®) (PDF) CP.PHAR.367 02/21
L-glutamine (Endari) (PDF) CP.PMN.116 11/21
Lidocaine transdermal (Lidoderm®) (PDF) CP.PMN.08 08/21
Linaclotide (Linzess®) (PDF) CP.PMN.71 11/20
Linezolid (Zyvox) (PDF) CP.PMN.27 02/21
Lomitapide (Juxtapid®) (PDF) CP.PHAR.283 02/21
Lubiprostone (Amitiza) (PDF) CP.PMN.142 11/21
Lumacaftor-ivacaftor (Orkambi®) (PDF) CP.PHAR.213 02/21
Lumizyme (PDF) CP.PHAR.160 05/20
Lutetium Lu 177 dotatate (Lutathera) (PDF) CP.PHAR.384 08/21
Macitentan (Opsumit®) (PDF) CP.PHAR.194 02/21
Makena (PDF) CP.PHAR.14 02/21
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/21
Mechlorethamine (Valchlor) (PDF) CP.PHAR.381 08/21
Mepolizumab (Nucala) (PDF) CP.PHAR.200 02/21
Metformin hcl (Glumetza) (PDF) CP.PMN.72 02/21
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 05/21
Midostaurin (Rydapt) (PDF) CP.PHAR.344 05/21
Milnacipran (Savella) (PDF) CP.PMN.125 05/21
Minocycline (Solodyn) (PDF) CP.PMN.80 05/21
Mipomersen (Kynamro®) (PDF) CP.PHAR.284 02/21
Mixed pollens allergen extract (Oralair®) (PDF) CP.PMN.85 08/21
Modafinil (Provigil) (PDF) CP.PMN.39 05/21
Nabilone (Cesamet) (PDF) CP.PMN.160 02/21
Naglazyme (PDF) CP.PHAR.161 05/21
Naloxone (Evzio) (PDF) CP.PMN.139 08/21
Naproxen and esomeprazole magnesium (Vimovo) (PDF) CP.PMN.117 05/21
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 11/21
Neratinib (Nerlynx®) (PDF) CP.PHAR.365 11/21
Netarsudil (Rhopressa) (PDF) CP.PMN.118 05/21
Nexavar (PDF) CP.PHAR.69 05/21
Nintedanib (Ofev®) (PDF) CP.PHAR.285 08/21
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Obeticholic acid (Ocaliva®) (PDF) CP.PHAR.287 08/21
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 11/21
Ofatumumab (Arzerra®) (PDF) CP.PHAR.306 02/21
Olaparib (Lynparza) (PDF) CP.PHAR.360 02/21
Olaratumab (Lartruvo®) (PDF) CP.PHAR.326 02/21
Omega-3-acid ethyl esters (Lovaza®) (PDF) CP.PMN.52 02/21
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 05/21
Ondansetron (Zuplenz) (PDF) CP.PMN.45 02/21
Opdivo (PDF) CP.PHAR.121 02/21
Osimertinib (Tagrisso®) (PDF) CP.PHAR.294 05/21
Ozenoxacin (Xepi) (PDF) CP.PMN.119 05/21
Paclitaxel, protein bound (Abraxane) (PDF) CP.PHAR.176 05/21
Panitumumab (Vectibix®) (PDF) CP.PHAR.321 11/21
Panobinostat (Farydak) (PDF) CP.PHAR.382 08/21
Parathyroid hormone (Natpara) (PDF) CP.PHAR.282 02/21
Paricalcitol (Zemplar) (PDF) CP.PHAR.270 08/21
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 11/21
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 02/21
Pegaspargase (Oncaspar®) (PDF) CP.PHAR.353 11/21
Pegfilgrastim (Neulasta®) (PDF) CP.PHAR.296 02/21
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 08/21
Pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 08/21
Pemetrexed (Alimta®) (PDF) CP.PHAR.368 02/21
Perampanel (Fycompa) (PDF) CP.PMN.156 08/21
Perixafor (Mozobil®) (PDF) CP.PHAR.323 08/21
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 05/21
Pimavanserin (Nuplazid) (PDF) CP.PMN.140 08/21
Pirfenidone (Esbriet®) (PDF) CP.PHAR.286 08/21
Plecanatide (Trulance) (PDF) CP.PMN.87 11/21
Pomalyst (PDF) CP.PHAR.116 05/21
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 11/21
Praluent (PDF) CP.PHAR.124 02/21
Pramlintide (Symlin) (PDF) CP.PMN.129 02/21
Prasterone (Intrarosa) (PDF)Pregabalin (Lyrica) (PDF) CP.PMN.99 02/21
Prolia, Xgeva (PDF) CP.PHAR.58 02/21
Propranolol HCL solution (Hemangeol) (PDF) CP.PMN.58 05/21
Protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 02/21
Pyrimethamine (Daraprim®) (PDF) CP.PMN.44 08/21
QL of Diabetic Test Strips not receiving insulin (PDF) CP.PMN.151 02/21
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 02/21
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 02/21
Ranolazine (Ranexa®) (PDF) CP.PMN.34 02/21
Repatha (PDF) CP.PHAR.123 02/21
Reslizumab (Cinqair®) (PDF) CP.PHAR.223 02/21
Revlimid (PDF) CP.PHAR.71 05/21
Ribociclib (Kisqali®), ribociclib (Kisqali Femara®) (PDF) CP.PHAR.334 11/21
Rifapentine (Priftin®) (PDF) CP.PMN.05 02/21
Rifaximin (Xifaxan®) (PDF) CP.PMN.47 11/21
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 08/21
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 05/21
Riociguat (Adempas®) (PDF) CP.PHAR.195 02/21
Risedronate (Actonel®, Atelvia®) (PDF) CP.PMN.100 02/21
Rituximab (Rituxan), Rituximab and hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 02/21
Rivastigmine (Exelon®) (PDF) CP.PHAR.101 02/21
Roflumilast (Daliresp®) (PDF) CP.PMN.46 08/21
Rolapitant (Varubi®) (PDF) CP.PMN.102 02/21
Romidepsin (Istodax®) (PDF) CP.PHAR.314 11/21
Romiplostim (Nplate®) (PDF) CP.PHAR.179 02/21
Rucaparib (Rucaparib®) (PDF) CP.PHAR.350 02/21
Rufinamide (Banzel) (PDF) CP.PMN.157 08/21
Sabril (PDF) CP.PHAR.169 08/21
Sacubitril-valsartan (Entresto) (PDF) CP.PMN.67 02/21
Safinamide (Xadago) (PDF) CP.PMN.113 02/21
Sandostatin (PDF) CP.PHAR.40 02/21
Sargramostim (Leukine®) (PDF) CP.PHAR.295 08/21
Sarilumab (Kevzara) (PDF) CP.PHAR.346 02/21
Secnidazole (Solosec®) (PDF) CP.PMN.103 02/21
Selexipag (Uptravi®) (PDF) CP.PHAR.196 02/21
Sensipar (PDF) CP.PHAR.61 08/21
Short ragweed pollen allergen extract (Ragwitek®) (PDF) CP.PMN.83 08/21
Sildenafil (Revatio®) (PDF) CP.PHAR.197 02/21
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 02/21
Sodium oxybate (Xyrem) (PDF) CP.PMN.42 05/21
Sodium phenylbutyrate (Buphenyl®) (PDF) CP.PHAR.208 02/21
Soliris (PDF) CP.PHAR.97 02/21
Sonidegib (Odomzo) (PDF) CP.PHAR.272 05/21
Sprycel (PDF) CP.PHAR.72 05/21
Step Therapy (PDF) CP.PST.01 02/21
Stivarga (PDF) CP.PHAR.107 05/21
Sutent (PDF) CP.PHAR.73 05/21
Sylatron (PDF) CP.PHAR.89 08/21
Synribo (PDF) CP.PHAR.108 05/21
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 02/21
Tarceva (PDF) CP.PHAR.74 05/21
Targretin (PDF) CP.PHAR.75 05/21
Tasigna (PDF) CP.PHAR.76 05/21
Tasimelteon (Hetlioz®) (PDF) CP.PMN.104 02/21
Tavaborole (Kerydin®) (PDF) CP.PMN.105 02/21
Tavalisse (PDF) CP.PHAR.24 02/21
Tedizolid (Sivextro®) (PDF) CP.PMN.62 02/21
Telotristat ethyl (Xermelo) (PDF) CP.PHAR.337 05/21
Temodar (PDF) CP.PHAR.77 05/21
Temsirolimus (Torisel®) (PDF) CP.PHAR.324 11/21
Tezacaftor/iv acafter; ivacaftor (Symdeko) (PDF) CP.PHAR.377 02/21
Thalomid (PDF) CP.PHAR.78 08/21
Thyrogen (PDF) CP.PHAR.95 08/21
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 08/21
Tocilizumab (Actemra) (PDF) CP.PHAR.263 02/21
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) CP.PHAR.267 02/21
Topical Immunomodulators (PDF) CP.PMN.107 02/21
Toremifene (Fareston) (PDF) CP.PMN.126 05/21
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 02/21
Trametinib (Mekinist) (PDF) CP.PHAR.240 05/21
Trifluridine_Tipiracil (Lonsurf) (PDF) CP.PHAR.383 08/21
Tykerb (PDF) CP.PHAR.79 11/21
Venofer (PDF) CP.PHAR.167 02/21
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 02/21
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 05/21
Vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 11/21
Vismodegib (Erivedge) (PDF) CP.PHAR.273 05/21
Voretigene neparvovec-rzyl (Luxturna®) (PDF) CP.PHAR.372 02/21
Votrient (PDF) CP.PHAR.81 08/21
VPRIV (PDF) CP.PHAR.163 11/21
Xalkori (PDF) CP.PHAR.90 05/21
Xeloda (PDF) CP.PHAR.60 05/21
Xolair (PDF) CP.PHAR.01 02/21
Xtandi (PDF) CP.PHAR.106 02/21
Zelboraf (PDF) CP.PHAR.91 02/21
Ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 11/21
Zoladex (PDF) CP.PHAR.171 11/21
Zolinza (PDF) CP.PHAR.83 08/21
Zytiga (PDF) CP.PHAR.84 02/21

 

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