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Pharmacy

Arizona Complete Health is committed to providing appropriate, high-quality, and cost-effective drug therapy to all Arizona Complete Health members.

Arizona Complete Health covers prescription medications and certain over-the-counter medications with a written order from an Arizona Complete Health provider. The pharmacy program does not cover all medications. Some medications may require prior authorization and some may have limitations. Other medically necessary pharmacy services are covered as well.

Finding your medication(s) on the Drug Lists

  • You can search by the drug name.
  • The lists include drugs that are generally covered

Arizona Complete Health-Complete Care Plan has three approved drug lists (formularies); Integrated, Behavioral and Crisis. You can view the drug lists using the following links:

Prescription Prior Authorization Requests

To submit a prior authorization electronically, use CoverMyMeds with Envolve Pharmacy Solutions.

Pharmacy Prior Authorization Fax Form (PDF)

Oncology Prior Authorization Requests

Pre-approval Process

The requesting physician must complete an authorization request using one of the following methods:

  • Logging into the NCH Provider Web Portal: https://my.newcenturyhealth.com
  • Calling 1-877-624-8601 (Monday – Friday 5 a.m. to 5 p.m. PST)
  • Faxing the authorization form to 1-877-624-8602

Please note:

Inpatient requests for chemotherapy should continue to be submitted via the Arizona Complete Health’s Secure Provider Portal.

Pharmacy dispensed chemotherapeutic and supportive agents that were previously submitted to Envolve Pharmacy Solutions or CoverMyMeds should be submitted directly to NCH.

Ambetter from Arizona Complete Health pharmacy information is available using the following link:
Ambetter from Arizona Complete Health Pharmacy

Pharmacy Policies for Medicaid and Ambetter

POLICY TITLE POLICY NUMBER LAST REVIEW DATE
Adalimumab (Humira) (PDF) AZ.CP.PHAR.25 9/18
ADHD Medications in Children Under 6 years Old (PDF) AZ.CP.PHAR.10.11.7 09/18
Agents for Insomnia (PDF) AZ.CP.PMN.1016 04/20
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) AZ.CP.PHAR.94 08/20
Amisulpride (Barhemsys) (PDF) AZ.CP.PMN.236 07/20
Anthelmintics (PDF) AZ.CP.PHAR.403 09/18
Antipsychotic Medications in Children Under 6 years Old (PDF) AZ.CP.PMN.08 08/20
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) AZ.CP.PHAR.93 08/20
Brexpiprazole(Rexulti) (PDF) AZ.CP.PMN.68 08/20
Buprenorphine (Probuphine, Sublocade) (PDF) AZ.CP.PMN.82 07/20
Cariprazine (Vraylar) (PDF) AZ.CP.PMN.91 01/20
Concomitant Antidepressant Treatment (PDF) AZ.CP.PHAR.10.11.11 07/18
Concomitant Antipsychotic Treatment (PDF) AZ.CP.PMN.10 07/20
Cytokine and CAM Antagonists (PDF) AZ.CP.PHAR.06 07/20
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) AZ.CP.PMN.43 04/20
Esketamine (Spravato) (PDF) AZ.CP.PMN.199 07/20
Endothelin Receptor Antagonists-ETRA (Letairis, Opsumit, Tracleer) (PDF) AZ.CP.PHAR.1012 01/20
Etanercept (Enbrel) (PDF) AZ.CP.PHAR.18 09/18
Extended Release Opioid Analgesics (PDF) AZ.CP.PHAR.97b 02/20
Fabrazyme (PDF) AZ.CP.PHAR.03 08/18
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbofilgrastim (Granix), Filgrastim-aafi (Nivestym) (PDF) AZ.CP.PHAR.297 08/20
Fluticasone/Umeclidinium/Vilanterol (Trelegy Ellipta) (PDF) AZ.CP.PMN.146 07/20
Glecaprevir/Pibrentasvir (Mavyret) and Sofosbuvir/Velpatasvir (Epclusa Approved Generic) (PDF) AZ.CP.PHAR.44 08/18
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) AZ.CP.PMN.183 07/20
Hepatitis B Drugs (PDF) AZ.CP.PMN.03 08/20
Iloperidone (Fanapt) (PDF) AZ.CP.PMN.32 01/20
Immediate Release Opioid Analgesics (PDF) AZ.CP.PHAR.97a 02/20
Lactitol (Pizensy) (PDF) AZ.CP.PMN.241 08/20
LAMA/LABA Combination Inhalers (PDF) AZ.CP.PMN.1021 0720
Maraviroc (Selzentry) (PDF) AZ.CP.PHAR.32 08/20
Memantine/Donepezil (Namenda, Namzaric) (PDF) AZ.CP.PHAR.29 09/18
Migraine Products - Monoclonal Antibodies - (Aimovig, Ajovy, Emgality) (PDF) AZ.CP.PHAR.1010 04/20
Multiple Sclerosis Drugs (PDF) AZ.CP.PHAR.1020 07/20
Namenda (PDF) AZ.CP.PHAR.29  
No Coverage Criteria-Off-Label Use- Brand Name Request (PDF) AZ.CP.PMN.53 08/20
Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renvela, Renagel, Velphoro) (PDF) AZ.CP.PMN.04 01/20
Non-Preferred Agents for Insomnia (PDF) AZ.CP.PHAR.10.11.23 07/18
Non Preferred Drugs and Brand Name Override (PDF) AZ.CP.PMN.16 10/19
Non-Preferred Hepatitis C Treatments (PDF) AZ.CP.PHAR.400 07/20
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) AZ.CP.PHAR.292 07/20
Ophthalmics – Anti-inflammatory/Immunomodulators (PDF) AZ.CP.PMN.1014 04/20
Paliperidone (Invega) (PDF) AZ.CP.PMN.30 01/20
Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (PDF) AZ.CP.PHAR.296 07/20
Phosphodiesterase-5 inhibitors (PDE-5) (Adcirca, Revatio) (PDF) AZ.CP.PHAR.1013 08/20
Polyserotonergic Antidepressants Vortioxetine (Trintellix) and or Vilazodone (Viibryd) (PDF) AZ.CP.PMN.20 07/20
Posaconazole (Noxafil) (PDF) AZ.CP.PHAR.30 09/18
Proton Pump Inhibitors (PDF) AZ.CP.PMN.1002 08/20
Rituximab(Rituxan), Rituximab-pvvr(Ruxience), Rituximab-abbs(Truxima) Rituximab-Hyaluronidase(Rituxan Hycela) (PDF) AZ.CP.PHAR.260 07/20
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) AZ.CP.PMN.14 07/20
Sodium Oxybate (Xyrem) (PDF) AZ.CP.PMN.42 08/20
Somatropin (Norditropin, Genotropin) (PDF) AZ.CP.PHAR.55 07/20
Tadalafil (Cialis) (PDF) AZ.CP.PHAR.42 09/18
Testosterone (PDF) AZ.CP.PMN.02 08/20
Thrombopoiesis Stimulating Agents (PDF) AZ.CP.PHAR.1019 07/20
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) AZ.CP.PHAR.199 01/20
VMAT2 inhibitors (Ingrezza, Austedo, Xenazine) (PDF) AZ.CP.PHAR.340 04/20
Voriconazole (Vfend) (PDF) AZ.CP.PHAR.39 09/18
Weight Loss (PDF) AZ.CP.PMN.1004 07/20
POLICY TITLE POLICY NUMBER Last Review Date
Abaloparatide (Tymlos®) (PDF) CP.PMN.164 11/20
Abatacept (Orencia) (PDF) CP.PHAR.241 02/21
Abemaciclib (Verzenio) (PDF) CP.PHAR.355 11/20
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 02/21
Acalabrutinib (Calquence®) (PDF) CP.PHAR.366 02/21
Acitretin (Soriatane®) (PDF) CP.PMN.40 08/20
Actimmune (PDF) CP.PHAR.52 02/21
Afatinib (Gilotrif) (PDF) CP.PHAR.298 05/20
Afinitor (PDF) CP.PHAR.63 02/21
Aflibercept (Eylea®) (PDF) CP.PHAR.184 02/21
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PHAR.138 05/20
Aldurazyme (PDF) CP.PHAR.152 05/20
Alectinib (Alecensa) (PDF) CP.PHAR.369 05/20
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/20
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 05/20
Apremilast (Otezla) (PDF) CP.PHAR.245 05/20
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 11/20
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
Avastin (PDF) CP.PHAR.93 11/20
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
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 11/18
Benralizumab (Fasenra) (PDF) CP.PHAR.373 02/21
Benznidazole (PDF) CP.PMN.90 02/21
Betrixaban (Bevyxxa) (PDF) CP.PMN.114 11/19
Bevacizumab-awwb (Mvasi®) (PDF) CP.PHAR.356 11/17
Bezlotoxumab (Zinplava®) (PDF) CP.PHAR.300 02/21
Bosentan (Tracleer®) (PDF) CP.PHAR.191 02/21
Bosulif (PDF) CP.PHAR.105 05/20
Braftovi (PDF) CP.PHAR.127 08/18
Brand Name Override (PDF) CP.PMN.22 02/21
Brentuximab Vedotin (Adcetris®) (PDF) CP.PHAR.303 08/20
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 05/20
Brodalumab (Siliq) (PDF) CP.PHAR.375 05/20
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 02/21
Cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 05/20
Calcifediol (Rayaldee®) (PDF) CP.PMN.76 08/20
Canakinumab (Ilaris) (PDF) CP.PHAR.246 11/20
Caprelsa (PDF) CP.PHAR.80 02/21
Carbamazepine ER (Equetro) (PDF) CP.PMN.137 05/20
Carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 11/18
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 02/21
Celecoxib (Celebrex) (PDF) CP.PMN.122 05/20
Cerdelga (PDF) CP.PHAR.153 05/20
Cerezyme (PDF) CP.PHAR.154 05/20
Ceritinib (Zykadia) (PDF) CP.PHAR.349 05/20
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 08/20
Certolizumab (Cimzia) (PDF) CP.PHAR.247 02/21
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 11/20
Ciclopirox (Penlac®) (PDF) CP.PMN.24 02/21
Clobazam (Onfi) (PDF) CP.PMN.54 11/20
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 05/20
Colchicine (Colcrys) (PDF) CP.PMN.123 02/21
Copanlisib (Aliqopa®) (PDF) CP.PHAR.357 11/20
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 02/21
Crestor (PDF) CP.PST.20 11/17
Crisaborole (Eucrisa) (PDF) CP.PMN.110 05/20
Crysvita (PDF) CP.PHAR.11 11/20
Cyclosporine (Restasis) (PDF) CP.PMN.48 05/20
Cyramza (PDF) CP.PHAR.119 02/21
Cystagon, Procysbi (PDF) CP.PHAR.155 05/20
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 05/20
Cytomegalovirus Immune Globulin (CytoGam) (PDF) CP.PHAR.277 08/20
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 05/20
Daclizumab (Zinbryta) (PDF) CP.PHAR.269 05/18
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 05/20
Daratumumab (Darzalex®) (PDF) CP.PHAR.310 08/20
Daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 11/20
Deflazacort (Emflaza®) (PDF) CP.PHAR.331 02/21
Delafloxacin (Baxdela) (PDF) CP.PMN.115 02/21
Desferal (PDF) CP.PHAR.146 08/20
Desmopressin acetate (DDAVP Injection®, Stimate®) (PDF) CP.PHAR.214 02/21
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 08/20
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 02/21
Dimethyl fumarate (Tecfidera) (PDF) CP.PHAR.249 08/20
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 11/20
Dronabinol (Marinol, Syndros) (PDF) CP.PMN.159 02/21
Droxidopa (Northera®) (PDF) CP.PMN.17 11/20
Dupilumab (Dupixent®) (PDF) CP.PHAR.336 02/21
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 05/20
Dutasteride (Avodart) and dutasteride/tamsulosin (Jalyn) (PDF) CP.PMN.128 05/20
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 02/21
Efinaconazole (Jublia®) (PDF) CP.PMN.25 02/21
Egrifta (PDF) CP.PHAR.109 08/20
Elaprase (PDF) CP.PHAR.156 05/20
Elelyso (PDF) CP.PHAR.157 05/20
Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped (PDF) CP.PHAR.173 08/20
Elotuzumab (Empliciti®) (PDF) CP.PHAR.308 11/20
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 02/21
Emicizumab-kxwh (Hemlibra®) (PDF) CP.PHAR.370 02/21
Enasidenib (Idhifa®) (PDF) CP.PHAR.363 11/20
Epidiolex (PDF) CP.PMN.164 11/20
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 02/21
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 11/20
Erwina asparaginase (Erwinaze®) (PDF) CP.PHAR.301 02/21
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 08/20
Eteplirsen (Exondys 51®) (PDF) CP.PHAR.288 02/21
Etidronate (Didronel) (PDF) CP.PMN.94 02/21
Exemestane Step Therapy (PDF) CP.PST.05 11/17
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 08/20
Ferrlecit (PDF) CP.PHAR.166 02/21
Fingolimod (Gilenya) (PDF) CP.PHAR.251 08/20
Firmagon (PDF) CP.PHAR.170 11/20
Fluticasone propionate (Xhance) (PDF) CP.PMN.95 02/21
Fusilev (PDF) CP.PHAR.151 11/20
Fuzeon (PDF) CP.PHAR.41 08/20
Gablofen (PDF) CP.PHAR.149 11/20
Gattex (PDF) CP.PHAR.114 02/21
Gefitinib (Iressa®) (PDF) CP.PHAR.299 11/17
Gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 11/20
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/20
Gleevec (PDF) CP.PHAR.65 11/20
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
Guselkumab (Tremfya) (PDF) CP.PHAR.364 11/20
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 08/20
Hycamtin (PDF) CP.PHAR.64 05/20
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 05/20
Ibandronate Oral (Boniva) (PDF) CP.PMN.96 02/21
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 02/21
Ibrance (PDF) CP.PHAR.125 11/20
Ibuprofen and Famotidine (Duexis) (PDF) CP.PMN.120 05/20
Icatibant (Firazyr®) (PDF) CP.PHAR.178 02/21
Iclusig (PDF) CP.PHAR.112 05/20
Iloprost (Ventavis®) (PDF) CP.PHAR.193 02/21
Imbruvica (PDF) CP.PHAR.126 02/21
Immunization Coverage (PDF) CP.PHAR.28 08/20
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 05/20
Increlex (PDF) CP.PHAR.150 08/20
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 02/21
Inlyta (PDF) CP.PHAR.100 02/21
Inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 11/20
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 08/20
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 08/20
Ipilimumab (Yervoy®) (PDF) CP.PHAR.319 02/21
Iressa (PDF) CP.PHAR.68 05/20
Irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 11/20
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 05/20
Isotretinoin (PDF) CP.PMN.143 11/20
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 08/20
Ivabradine (Corlanor) (PDF) CP.PMN.70 02/21
Ivacaftor (Kalydeco®) (PDF) CP.PHAR.210 02/21
Ixazomib (Ninlaro®) (PDF) CP.PHAR.302 08/20
Ixekizumab (Taltz) (PDF) CP.PHAR.257 11/20
Jadenu (PDF) CP.PHAR.145 08/20
Jakafi (PDF) CP.PHAR.98 02/18
Jynarque (PDF) CP.PHAR.27 08/20
Kanuma (PDF) CP.PHAR.159 05/20
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 08/20
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 11/20
Lidocaine transdermal (Lidoderm®) (PDF) CP.PMN.08 08/20
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 11/20
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 11/20
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 08/20
Macitentan (Opsumit®) (PDF) CP.PHAR.194 02/21
Makena (PDF) CP.PHAR.14 02/21
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/20
Mechlorethamine (Valchlor) (PDF) CP.PHAR.381 08/20
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 05/20
Midostaurin (Rydapt) (PDF) CP.PHAR.344 05/20
Milnacipran (Savella) (PDF) CP.PMN.125 05/20
Minocycline (Solodyn) (PDF) CP.PMN.80 11/20
Mipomersen (Kynamro®) (PDF) CP.PHAR.284 02/21
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 08/20
Mixed pollens allergen extract (Oralair®) (PDF) CP.PMN.85 08/20
Modafinil (Provigil) (PDF) CP.PMN.39 11/20
Nabilone (Cesamet) (PDF) CP.PMN.160 02/21
Naglazyme (PDF) CP.PHAR.174 11/20
Naldemedine (Symproic) (PDF) CP.PMN.112 11/20
Naloxone (Evzio) (PDF) CP.PMN.139 08/20
Naproxen and esomeprazole magnesium (Vimovo) (PDF) CP.PMN.117 05/20
Natalizumab (Tysabri) (PDF) CP.PHAR.259 08/20
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 11/20
Neratinib (Nerlynx®) (PDF) CP.PHAR.365 11/20
Netarsudil (Rhopressa) (PDF) CP.PMN.118 05/20
Nexavar (PDF) CP.PHAR.69 05/20
Nintedanib (Ofev®) (PDF) CP.PHAR.259 08/20
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Obeticholic acid (Ocaliva®) (PDF) CP.PHAR.01  
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 11/20
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 08/20
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 11/20
Ondansetron (Zuplenz) (PDF) CP.PMN.45 02/21
Opdivo (PDF) CP.PHAR.121 02/21
Osimertinib (Tagrisso®) (PDF) CP.PHAR.294 05/20
Oxymetazoline (Rhofade) (PDF) CP.PMN.86 05/18
Ozenoxacin (Xepi) (PDF) CP.PMN.119 05/20
Paclitaxel, protein bound (Abraxane) (PDF) CP.PHAR.176 05/20
Panitumumab (Vectibix®) (PDF) CP.PHAR.321 11/20
Panobinostat (Farydak) (PDF) CP.PHAR.382 08/20
Parathyroid hormone (Natpara) (PDF) CP.PHAR.282 02/21
Paricalcitol (Zemplar) (PDF) CP.PHAR.270 08/20
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 11/20
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 02/21
Pegaspargase (Oncaspar®) (PDF) CP.PHAR.353 11/20
Pegfilgrastim (Neulasta®) (PDF) CP.PHAR.296 02/21
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 08/20
Pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 08/20
Pemetrexed (Alimta®) (PDF) CP.PHAR.368 02/21
Perampanel (Fycompa) (PDF) CP.PMN.156 08/20
Perixafor (Mozobil®) (PDF) CP.PHAR.323 08/20
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 05/20
Pimavanserin (Nuplazid) (PDF) CP.PMN.140 08/20
Pirfenidone (Esbriet®) (PDF) CP.PHAR.286 08/20
Plecanatide (Trulance) (PDF) CP.PMN.87 11/20
Pomalyst (PDF) CP.PHAR.116 0820
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 11/20
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 05/20
Protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 02/21
Pyrimethamine (Daraprim®) (PDF) CP.PMN.44 08/20
QL of Diabetic Test Strips not receiving insulin (PDF) CP.PMN.151 02/21
Quantity Limit Overrides (PDF) CP.PMN.59 11/18
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 11/20
Ribociclib (Kisqali®), ribociclib (Kisqali Femara®) (PDF) CP.PHAR.334 11/20
Rifapentine (Priftin®) (PDF) CP.PMN.05 02/21
Rifaximin (Xifaxan®) (PDF) CP.PMN.47 11/20
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 05/20
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 05/20
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 08/20
Rolapitant (Varubi®) (PDF) CP.PMN.102 02/21
Romidepsin (Istodax®) (PDF) CP.PHAR.314 11/20
Romiplostim (Nplate®) (PDF) CP.PHAR.179 02/21
Rucaparib (Rucaparib®) (PDF) CP.PHAR.350 02/21
Rufinamide (Banzel) (PDF) CP.PMN.157 08/20
Sabril (PDF) CP.PHAR.169 08/20
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 08/20
Sarilumab (Kevzara) (PDF) CP.PHAR.346 02/21
Secnidazole (Solosec®) (PDF) CP.PMN.103 02/21
Secukinumab (Cosentyx) (PDF) CP.PHAR.261 11/20
Selexipag (Uptravi®) (PDF) CP.PHAR.196 02/21
Sensipar (PDF) CP.PHAR.61 08/20
Short ragweed pollen allergen extract (Ragwitek®) (PDF) CP.PMN.83 08/20
Sildenafil (Revatio®) (PDF) CP.PHAR.197 02/21
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 02/21
Sodium oxybate (Xyrem) (PDF) CP.PMN.42 11/20
Sodium phenylbutyrate (Buphenyl®) (PDF) CP.PHAR.208 02/21
Soliris (PDF) CP.PHAR.97 02/21
Sonidegib (Odomzo) (PDF) CP.PHAR.272 05/20
Sprycel (PDF) CP.PHAR.72 05/20
Step Therapy (PDF) CP.PST.01 02/21
Stivarga (PDF) CP.PHAR.107 05/20
Sutent (PDF) CP.PHAR.73 05/20
Suvorexant (Belsomra®) (PDF) CP.PMN.109 11/20
Sylatron (PDF) CP.PHAR.89 05/20
Synribo (PDF) CP.PHAR.108 05/20
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 02/21
Tarceva (PDF) CP.PHAR.74 05/20
Targretin (PDF) CP.PHAR.75 05/20
Tasigna (PDF) CP.PHAR.76 05/20
Tasimelteon (Hetlioz®) (PDF) CP.PMN.104 02/21
Tavaborole (Kerydin®) (PDF) CP.PMN.105 02/21
Tavalisse (PDF) CP.PHAR.24 02/21
Tazarotene (Tazorac®) (PDF) CP.PMN.75 11/19
Tedizolid (Sivextro®) (PDF) CP.PMN.62 02/21
Telotristat ethyl (Xermelo) (PDF) CP.PHAR.337 05/20
Temodar (PDF) CP.PHAR.77 05/20
Temsirolimus (Torisel®) (PDF) CP.PHAR.324 11/20
Teriflunomide (Aubagio) (PDF) CP.PHAR.262 08/20
Tezacaftor/iv acafter; ivacaftor (Symdeko) (PDF) CP.PHAR.377 02/21
Thalomid (PDF) CP.PHAR.78 11/20
Thyrogen (PDF) CP.PHAR.95 08/20
Tildrakizumab-asmn (Ilumya) (PDF) CP.PHAR.386 05/20
Tiludronate (Skelid®) (PDF) CP.PMN.106 03/18
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 08/20
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 05/20
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 02/21
Trametinib (Mekinist) (PDF) CP.PHAR.240 05/20
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 05/20
Trifluridine_Tipiracil (Lonsurf) (PDF) CP.PHAR.383 08/20
Triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/20
Tykerb (PDF) CP.PHAR.79 11/20
Vantas, Supprelin LA (PDF) CP.PHAR.172 11/20
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 05/20
Venofer (PDF) CP.PHAR.167 02/21
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 02/21
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 05/20
Vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 11/20
Vismodegib (Erivedge) (PDF) CP.PHAR.273 05/20
Voretigene neparvovec-rzyl (Luxturna®) (PDF) CP.PHAR.372 02/21
Votrient (PDF) CP.PHAR.81 08/20
VPRIV (PDF) CP.PHAR.163 05/20
Xalkori (PDF) CP.PHAR.90 05/20
Xeloda (PDF) CP.PHAR.60 05/20
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 11/20
Zoladex (PDF) CP.PHAR.171 11/20
Zolinza (PDF) CP.PHAR.83 08/20
Zytiga (PDF) CP.PHAR.84 02/21