POLICY TITLE |
POLICY NUMBER |
EFFECTIVE DATE |
---|
Abaloparatide (Tymlos) (PDF) |
CP.PHAR.345 |
07/01/2017 |
abatacept (Orencia) (PDF) |
CP.PHAR.241 |
08/01/2016 |
Abiraterone (Zytiga) (PDF) |
CP.PHAR.84 |
10/01/2011 |
Abiraterone (Zytiga, Yonsa) (PDF) |
CP.PHAR.84 |
10/01/2011 |
AbobotulinumtoxinA (Dysport) (PDF) |
CP.PHAR.230 |
07/01/2016 |
Adalimumab (Humira) (PDF) |
CP.PHAR.242 |
08/01/2016 |
Adefovir (Hepsera) (PDF) |
CP.PHAR.142 |
08/28/2018 |
Aducanumab (PDF) |
CP.PHAR.468 |
06/01/2020 |
Afatinib (Gilotrif) (PDF) |
CP.PHAR.298 |
01/01/2017 |
Aflibercept (Eylea®) (PDF) |
CP.PHAR.184 |
03/01/2016 |
Agalsidase Beta (Fabrazyme) (PDF) |
CP.PHAR.158 |
02/01/2016 |
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) |
CP.PMN.138 |
03/13/2018 |
Age Limit for Tazarotene (Tazorac, Arazlo) (PDF) |
CP.PMN.75 |
11/09/2017 |
Alectinib (Alecensa) (PDF) |
CP.PHAR.369 |
11/16/2016 |
Alemtuzumab (Lemtrada) (PDF) |
CP.PHAR.243 |
08/01/2016 |
Alendronate (Binosto, Fosamax plus D) (PDF) |
CP.PMN.88 |
03/01/2018 |
Alglucosidase Alfa (Lumizyme) (PDF) |
CP.PHAR.160 |
02/01/2016 |
Alirocumab (Praluent) (PDF) |
CP.PHAR.124 |
10/01/2015 |
Alpelisib (Piqray) (PDF) |
CP.PHAR.430 |
09/01/2019 |
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) |
CP.PHAR.94 |
03/01/2012 |
Ambrisentan (Letairis®) (PDF) |
CP.PHAR.190 |
03/01/2016 |
Amifampridine (Firdapse, Ruzurgi) (PDF) |
CP.PHAR.411 |
01/22/2019 |
Amikacin (Arikayce) (PDF) |
CP.PHAR.401 |
11/13/2018 |
Anakinra (Kineret) (PDF) |
CP.PHAR.244 |
08/01/2016 |
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) |
CP.PHAR.217 |
05/01/2016 |
Apalutamide (Erleada) (PDF) |
CP.PHAR.376 |
06/01/2018 |
Apremilast (Otezla) (PDF) |
CP.PHAR.245 |
08/01/2016 |
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) |
CP.PMN.19 |
11/30/2016 |
Arformoterol Tartrate (Brovana) (PDF) |
CP.PMN.201 |
09/01/2019 |
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) |
CP.PHAR.290 |
12/01/2016 |
Armodafinil (Nuvigil) (PDF) |
CP.PMN.35 |
08/01/2009 |
Asenapine (Saphris, Secuado) (PDF) |
CP.PMN.15 |
12/01/2014 |
asfotase alfa (Strensiq®) (PDF) |
CP.PHAR.328 |
03/01/2017 |
Aspirin-dipyridamole (Aggrenox) (PDF) |
CP.PMN.20 |
09/01/2006 |
Atezolizumab (Tecentriq®) (PDF) |
CP.PHAR.235 |
06/01/2016 |
Avapritinib (Ayvakit) (PDF) |
CP.PHAR.454 |
03/01/2020 |
Avatrombopag (Doptelet) (PDF) |
CP.PHAR.130 |
07/17/2018 |
Avelumab (Bavencio®) (PDF) |
CP.PHAR.333 |
05/01/2017 |
Axicabtagene Ciloleucel (Yescarta) (PDF) |
CP.PHAR.362 |
10/31/2017 |
Axitinib (Inlyta®) (PDF) |
CP.PHAR.100 |
05/01/2012 |
Azacitidine (Vidaza) (PDF) |
CP.PHAR.387 |
08/28/2017 |
Aztreonam (Cayston®) (PDF) |
CP.PHAR.209 |
05/01/2016 |
Baclofen (Gablofen, Lioresal, Ozobax) (PDF) |
CP.PHAR.149 |
11/09/2017 |
Baloxavir Marboxil (Xofluza) (PDF) |
CP.PMN.185 |
10/30/2018 |
Bedaquiline (Sirturo) (PDF) |
CP.PMN.212 |
12/01/2019 |
belatacept (Nulojix®) (PDF) |
CP.PHAR.201 |
11/09/2017 |
Belantamab Mafodotin (PDF) |
CP.PHAR.469 |
06/01/2020 |
Belimumab (Benlysta) (PDF) |
CP.PHAR.88 |
10/01/2011 |
belinostat (Beleodaq®) (PDF) |
CP.PHAR.311 |
02/01/2017 |
Bendamustine (Bendeka®, Treanda®) (PDF) |
CP.PHAR.307 |
02/01/2017 |
Benralizumab (Fasenra) (PDF) |
CP.PHAR.373 |
01/16/2018 |
Benznidazole (PDF) |
CP.PMN.90 |
10/17/2017 |
Berotralstat (PDF) |
CP.PHAR.485 |
06/01/2020 |
Betaine (Cystadane) (PDF) |
CP.PHAR.143 |
08/28/2018 |
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) |
CP.PHAR.93 |
11/01/2011 |
Bexarotene (Targretin) (PDF) |
CP.PHAR.75 |
09/01/2011 |
Bezlotoxumab (Zinplava) (PDF) |
CP.PHAR.300 |
11/16/2016 |
Bimatoprost Implant (Durysta) (PDF) |
CP.PHAR.486 |
06/01/2020 |
Binimetinib (Mektovi) (PDF) |
CP.PHAR.50 |
07/24/2018 |
Blinatumomab (Blincyto) (PDF) |
CP.PHAR.312 |
02/01/2017 |
Bortezomib (Velcade) (PDF) |
CP.PHAR.410 |
12/11/2018 |
Bosentan (Tracleer®) (PDF) |
CP.PHAR.191 |
03/01/2016 |
Bosutinib (Bosulif) (PDF) |
CP.PHAR.105 |
10/01/2012 |
Brentuximab Vedotin (Adcetris) (PDF) |
CP.PHAR.303 |
02/01/2017 |
Brexanolone (Zulresso) (PDF) |
CP.PHAR.417 |
04/16/2019 |
Brexpiprazole (Rexulti) (PDF) |
CP.PMN.68 |
11/05/2015 |
Brexucabtagene Autoleucel (Tecartus) (PDF)
|
CP.PHAR.472 |
06/01/2020 |
Brigatinib (Alunbrig) (PDF) |
CP.PHAR.342 |
07/17/2017 |
Brimonidine Tartrate (Mirvaso) (PDF) |
CP.PMN.192 |
11/16/2016 |
Brivaracetam (Briviact) (PDF) |
HIM.PA.07 |
09/01/2019 |
Brolucizumab-dbll (Beovu) (PDF) |
CP.PHAR.445 |
03/01/2020 |
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) |
CP.PHAR.289 |
11/16/2016 |
Buprenorphine implant (Probuphine) (PDF) |
CP.PHAR.289 |
11/16/2016 |
Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) |
CP.PMN.81 |
09/01/2017 |
Buprenorphine (Subutex) (PDF) |
CP.PMN.82 |
09/01/2017 |
Burosumab-twza (Crysvita)(PDF) |
CP.PHAR.11 |
05/08/2018 |
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) |
CP.PHAR.202 |
03/01/2016 |
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) |
CP.PHAR.202 |
03/01/2016 |
cabazitaxel (Jevtana® (PDF) |
CP.PHAR.316 |
02/01/2017 |
Cabozantinib (Cometriq®, Cabometyx®) (PDF) |
CP.PHAR.111 |
06/01/2013 |
Cannabidiol (Epidiolex) (PDF) |
CP.PMN.164 |
07/17/2018 |
Canakinumab (Ilaris) (PDF) |
CP.PHAR.246 |
08/01/2016 |
capecitabine (Xeloda) (PDF) |
CP.PHAR.60 |
05/01/2011 |
Caplacizumab-yhdp (Cablivi) (PDF) |
CP.PHAR.416 |
03/12/2019 |
carfilzomib (Kyprolis®) (PDF) |
CP.PHAR.309 |
02/01/2017 |
Carglumic acid (Carbaglu®) (PDF) |
CP.PHAR.206 |
05/01/2016 |
Casimersen (PDF) |
CP.PHAR.470 |
06/01/2020 |
Cedazuridine/Decitabine (ASTX-727) (PDF) |
CP.PHAR.479 |
06/01/2020 |
Celecoxib (Celebrex, Elyxyb) (PDF) |
CP.PMN.122 |
01/01/2007 |
Cenegermin-bkbj (Oxervate) (PDF) |
CP.PMN.186 |
10/09/2018 |
Cenobamate (Xcopri) (PDF) |
CP.PMN.231 |
03/01/2020 |
Cemiplimab-rwlc (Libtayo) (PDF) |
CP.PHAR.397 |
10/16/2018 |
Ceritinib (Zykadia) (PDF) |
CP.PHAR.349 |
07/01/2017 |
Cerliponase alfa (Brineura) (PDF) |
CP.PHAR.338 |
07/01/2017 |
Certolizumab (Cimzia) (PDF) |
CP.PHAR.247 |
08/01/2016 |
Cetuximab (Erbitux®) (PDF) |
CP.PHAR.317 |
02/01/2017 |
Chloramphenicol Sodium Succinate (PDF) |
CP.PHAR.388 |
12/01/2018 |
Cholic Acid (Cholbam) (PDF) |
CP.PHAR.390 |
12/01/2018 |
Cinacalcet (Sensipar) (PDF) |
CP.PHAR.61 |
05/01/2011 |
Cladribine (Mavenclad) (PDF) |
CP.PHAR.422 |
09/01/2019 |
Clobazam (Onfi) (PDF) |
CP.PMN.54 |
11/1/2012 |
CNS Stimulants (PDF) |
CP.PMN.92 |
03/01/2018 |
Cobimetinib (Cotellic) (PDF) |
CP.PHAR.380 |
11/16/2016 |
Collagenase (Xiaflex) (PDF) |
CP.PHAR.82 |
10/01/2011 |
Continuous Glucose Monitors (PDF) |
CP.PMN.214 |
12/01/2019 |
copanlisib (Aliqopa®) (PDF) |
CP.PHAR.357 |
10/17/2017 |
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) |
CP.PHAR.385 |
05/29/2018 |
Cosyntropin (Cortrosyn®) (PDF) |
CP.PHAR.203 |
04/01/2016 |
Crisaborole (Eucrisa) (PDF) |
CP.PMN.110 |
02/21/2017 |
Crizanlizumab-tmca (Adakveo) (PDF) |
CP.PHAR.449 |
03/01/2020 |
Crizotinib (Xalkori) (PDF) |
CP.PHAR.90 |
11/01/2011 |
Cyclosporine (Cequa, Restasis) (PDF) |
CP.PMN.48 |
05/01/2012 |
Cysteamine ophthalmic (Cystaran) (PDF) |
CP.PMN.130 |
08/01/2017 |
Cysteamine oral (Cystagon, Procysbi) (PDF) |
CP.PHAR.155 |
02/01/2016 |
Cytomegalovirus Immune Globulin (Cytogam)(PDF) |
CP.PHAR.277 |
09/01/2018 |
Dabrafenib (Tafinlar) (PDF) |
CP.PHAR.239 |
11/16/2016 |
Daclatasvir (Daklinza) (PDF) |
CP.PHAR.278 |
09/01/2016 |
Daclizumab (Zinbryta) (PDF) |
CP.PHAR.269 |
08/01/2016 |
Dacomitinib (Vizimpro) (PDF) |
CP.PHAR.399 |
10/16/2018 |
Dalfampridine (Ampyra) (PDF) |
CP.PHAR.248 |
08/01/2016 |
Dalteparin (Fragmin) (PDF) |
CP.PHAR.225 |
05/01/2016 |
Daptomycin (Cubicin, Cubicin RF) (PDF) |
CP.PHAR.351 |
11/30/2017 |
Daratumumab (Darzalex) (PDF) |
CP.PHAR.310 |
07/01/2017 |
Darbepoetin Alfa (Aranesp) (PDF) |
CP.PHAR.236 |
06/01/2016 |
Darolutamide (Nubeqa) (PDF)
|
CP.PHAR.435 |
12/01/2019 |
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR, Viekira Pak) (PDF) |
CP.PHAR.278 |
09/01/2016 |
Dasatinib (Sprycel) (PDF) |
CP.PHAR.72 |
06/01/2012 |
daunorubicin/cytarabine (Vyxeos®) (PDF) |
CP.PHAR.352 |
12/01/2017 |
Deferasirox (Exjade Jadenu) (PDF) |
CP.PHAR.145 |
11/01/2015 |
Deferiprone (Ferriprox) (PDF) |
CP.PHAR.147 |
11/01/2015 |
Deferoxamine (Desferal) (PDF) |
CP.PHAR.146 |
11/01/2015 |
Deflazacort (Emflaza) (PDF) |
CP.PHAR.331 |
03/01/2017 |
Degarelix acetate (Firmagon®) (PDF) |
CP.PHAR.170 |
11/09/2017 |
Denosumab (Prolia, Xgeva) (PDF) |
CP.PHAR.58 |
03/01/2011 |
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) |
CP.PHAR.214 |
05/01/2016 |
Deutetrabenazine (Austedo) (PDF) |
CP.PHAR.341 |
06/13/2017 |
Dexrazoxane (Zinecard, Totect) (PDF) |
CP.PHAR.418 |
03/19/2019 |
Dextromethorphan-Quinidine (Nuedexta) (PDF) |
CP.PMN.93 |
03/01/2018 |
Diazepam Nasal Spray (Valtoco) (PDF) |
CP.PMN.216 |
12/01/2019 |
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF) |
CP.PHAR.249 |
08/01/2016 |
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) |
CP.PMN.03 |
09/19/2018 |
Dolasetron (Anzemet) (PDF) |
CP.PMN.141 |
09/01/2006 |
Dornase alfa (Pulmozyme) (PDF) |
CP.PHAR.212 |
05/01/2016 |
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) |
CP.PMN.79 |
05/01/2017 |
droxidopa (Northera®) (PDF) |
CP.PMN.17 |
11/09/2017 |
Dupilumab (Dupixent) (PDF) |
CP.PHAR.336 |
05/01/2017 |
Durvalumab (Imfinzi) (PDF) |
CP.PHAR.339 |
07/01/2017 |
Duvelisib (Copiktra) (PDF) |
CP.PHAR.400 |
10/16/2018 |
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF) |
CP.PMN.234 |
06/01/2020 |
Ecallantide (Kalbitor®) (PDF) |
CP.PHAR.177 |
03/01/2016 |
Eculizumab (Soliris®) (PDF) |
CP.PHAR.97 |
03/01/2012 |
Edaravone (Radicava) (PDF) |
CP.PHAR.343 |
07/01/2017 |
Efinaconazole (Jublia) (PDF) |
CP.PMN.25 |
08/01/2016 |
Elagolix (Orilissa) (PDF) |
CP.PHAR.136 |
08/28/2018 |
Elapegademase-lvlr (Revcovi) (PDF) |
CP.PHAR.419 |
04/23/2019 |
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) |
CP.PHAR.440 |
12/01/2019 |
Eliglustat (Cerdelga) (PDF) |
CP.PHAR.153 |
02/01/2016 |
Elosulfase Alfa (Vimizim) (PDF) |
CP.PHAR.162 |
02/01/2016 |
Elotuzumab (Empliciti®) |
CP.PHAR.308 |
02/01/2017 |
Eltrombopag (Promacta®) (PDF) |
CP.PHAR.180 |
03/01/2016 |
Emapalumab-lzsg (Gamifant) (PDF) |
CP.PHAR.402 |
12/11/2018 |
Emicizumab-kxwh (Hemlibra) (PDF) |
CP.PHAR.370 |
03/01/2018 |
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF) |
CP.PMN.235 |
06/01/2020 |
Enasidenib (Idhifa) (PDF) |
CP.PHAR.363 |
09/05/2017 |
Encorafenib (Braftovi) (PDF) |
CP.PHAR.127 |
07/24/2018 |
Enfortumab Vedotin-ejfv (Padcev) (PDF) |
CP.PHAR.455 |
03/01/2020 |
Enfuvirtide (Fuzeon) (PDF) |
CP.PHAR.41 |
06/01/2010 |
Enoxaparin (Lovenox) (PDF) |
CP.PHAR.224 |
05/01/2016 |
Entrectinib (Rozlytrek) (PDF) |
CP.PHAR.441 |
12/01/2019 |
Enzalutamide (Xtandi) (PDF) |
CP.PHAR.106 |
10/01/2012 |
Epoetin Alfa (Epogen® and Procrit) (PDF) |
CP.PHAR.237 |
06/01/2016 |
Epoprostenol (Flolan®), Veletri®) (PDF) |
CP.PHAR.192 |
03/01/2016 |
Erdafitinib (Balversa)(PDF) |
CP.PHAR.423 |
09/01/2019 |
Erenumab-aaoe (Aimovig) (PDF) |
CP.PHAR.128 |
07/10/2018 |
Eribulin Mesylate (Halaven®) (PDF) |
CP.PHAR.318 |
03/01/2017 |
Erlotinib (Tarceva) (PDF) |
CP.PHAR.74 |
09/01/2011 |
Erwinia Asparaginase (Erwinaze) (PDF) |
CP.PHAR.301 |
02/01/2017 |
Esketamine (Spravato) (PDF) |
CP.PMN.199 |
03/12/2019 |
Etanercept (Enbrel) (PDF) |
CP.PHAR.250 |
08/01/2016 |
Etelcalcetide (Parsabiv) (PDF) |
CP.PHAR.379 |
03/20/2018 |
Eteplirsen (Exondys 51) (PDF) |
CP.PHAR.288 |
12/01/2016 |
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) |
CP.PHAR.63 |
06/01/2011 |
Evolocumab (Repatha) (PDF) |
CP.PHAR.123 |
10/01/2015 |
Factor IX (Human, Recombinant) (PDF) |
CP.PHAR.218 |
05/01/2016 |
Factor IX Complex, Human (Profilnine) (PDF) |
CP.PHAR.219 |
05/01/2016 |
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) |
CP.PHAR.219 |
05/01/2016 |
Factor VIII (Human Recombinant) (PDF) |
CP.PHAR.215 |
05/01/2016 |
Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) |
CP.PHAR.216 |
05/01/2016 |
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) |
CP.PHAR.220 |
05/01/2016 |
Factor XIII A-Subunit, Recombinant (Tretten®) (PDF) |
CP.PHAR.222 |
05/01/2016 |
Factor XIII, Human (Corifact®) (PDF) |
CP.PHAR.221 |
05/01/2016 |
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) |
CP.PHAR.456 |
03/01/2020 |
Febuxostat (Uloric) (PDF) |
CP.PMN.57 |
08/01/2013 |
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) |
CP.PMN.127 |
06/01/2015 |
Ferric Carboxymaltose (Injectafer) (PDF) |
CP.PHAR.234 |
06/01/2016 |
Ferric Derisomaltose (Monoferric) (PDF) |
CP.PHAR.280 |
06/01/2020 |
Ferric gluconate (Ferrlecit®) (PDF) |
CP.PHAR.166 |
3/1/2016 |
Ferumoxytol (Feraheme®) (PDF) |
CP.PHAR.165 |
3/1/2016 |
Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF) |
CP.PHAR.297 |
12/01/2016 |
Fingolimod (Gilenya) (PDF) |
CP.PHAR.251 |
08/01/2016 |
Fondaparinux (Arixtra) (PDF) |
CP.PHAR.226 |
05/01/2016 |
Fosdenopterin (PDF) |
CP.PHAR.471 |
06/01/2020 |
Fostamatinib (Tavalisse) (PDF) |
CP.PHAR.24 |
06/05/2018 |
Fluorouracil Cream (Tolak(PDF) |
CP.PMN.165 |
12/1/2018 |
Fluticasone Propionate (Xhance) (PDF) |
CP.PMN.95 |
10/24/2017 |
Fluticasone/Vilanterol (Breo Ellipta) (PDF) |
CP.PMN.229 |
03/01/2020 |
Fremanezumab-vfrm (Ajovy) (PDF) |
CP.PHAR.403 |
10/30/2018 |
Fulvestrant (Faslodex Injection)(PDF) |
CP.PHAR.424 |
09/01/2019 |
Galcanezumab-gnlm (Emgality) (PDF) |
CP.PHAR.404 |
11/13/2018 |
Galsulfase (Naglazyme) (PDF) |
CP.PHAR.161 |
02/01/2016 |
Gefitinib (Iressa) (PDF) |
CP.PHAR.68 |
11/16/2016 |
gemtuzumab ozogamicin (Mylotarg®) (PDF) |
C.PHAR.358 |
10/03/2017 |
Gilteritinib (Xospata) (PDF) |
CP.PHAR.412 |
01/15/2019 |
Givosiran (Givlaari) (PDF) |
CP.PHAR.457 |
03/01/2020 |
Glasdegib (Daurismo) (PDF) |
CP.PHAR.413 |
01/08/2019 |
Glatiramer (Copaxone, Glatopa) (PDF) |
CP.PHAR.252 |
08/01/2016 |
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) |
CP.PMN.183 |
09/19/2018 |
Glycerol phenylbutyrate (Ravicti®) (PDF) |
CP.PHAR.207 |
05/01/2016 |
Golimumab (Simponi, Simponi Aria) (PDF) |
CP.PHAR.253 |
07/01/2016 |
Golodirsen (Vyondys 53) (PDF) |
CP.PHAR.453 |
03/01/2020 |
goserelin acetate (Zoladex®) (PDF) |
CP.PHAR.171 |
11/09/2017 |
Granisetron (Kytril, Sancuso, Sustol) (PDF) |
CP.PMN.74 |
11/01/2016 |
Hemin (Panhematin®) (PDF) |
CP.PHAR.181 |
02/01/2016 |
histrelin acetate (Vantas®, Supprelin LA®) (PDF) |
CP.PHAR.172 |
11/09/2017 |
Hyaluronate Derivatives (PDF) |
CP.PHAR.05 |
10/01/2008 |
Hydroxyprogesterone Caproate (Makena/compound) |
CP.PHAR.14 |
11/20/2017 |
Hydroxyurea (Siklos) (PDF) |
CP.PMN.193 |
02/19/2019 |
Ibalizumab-uiyk (Trogarzo) (PDF) |
CP.PHAR.378 |
04/17/2018 |
Ibandronate sodium (Boniva®) (PDF) |
CP.PHAR.189 |
11/15/2017 |
Ibrutinib (Imbruvica) (PDF) |
CP.PHAR.126 |
10/01/2015 |
Ibuprofen/Famotidine (Duexis) (PDF) |
CP.PMN.120 |
06/01/2018 |
Icatibant (Firazyr) (PDF) |
CP.PHAR.178 |
03/01/2016 |
Icosapent ethyl (Vascepa) (PDF) |
CP.PMN.187 |
11/20/2018 |
Idecabtagene Vicleucel (BB2121) (PDF) |
CP.PHAR.481 |
06/01/2020 |
Idelalisib (Zydelig) (PDF) |
CP.PHAR.133 |
12/01/2018 |
Idursulfase (Elaprase) (PDF) |
CP.PHAR.156 |
02/01/2016 |
Iloperidone (Fanapt) (PDF) |
CP.PMN.32 |
12/01/2014 |
Iloprost (Ventavis®) (PDF) |
CP.PHAR.193 |
03/01/2016 |
Imatinib (Gleevec) (PDF) |
CP.PHAR.65 |
06/01/2011 |
Imiglucerase (Cerezyme) (PDF) |
CP.PHAR.154 |
02/01/2016 |
Immune Globulins (PDF) |
CP.PHAR.103 |
08/01/2012 |
IncobotulinumtoxinA (Xeomin) (PDF) |
CP.PHAR.231 |
07/01/2016 |
Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF) |
HIM.PA.102 |
09/01/2018 |
Inebilizumab (PDF) |
CP.PHAR.458 |
03/01/2020 |
Infertility and Fertility Preservation (PDF) |
CP.PHAR.131 |
11/16/2016 |
Infliximab (Remicade, Inflectra, Renflexis) (PDF) |
CP.PHAR.254 |
07/01/2016 |
Inotersen (Tegsedi) (PDF) |
CP.PHAR.405 |
11/20/2018 |
inotuzumab ozogamicin (Besponsa®) (PDF) |
CP.PHAR.359 |
09/26/2017 |
Insulin Infusion Pump (Omnipod, Omnipod DASH) (PDF) |
CP.PHAR.420 |
04/23/2019 |
Interferon beta-1a (Avonex, Rebif) (PDF) |
CP.PHAR.255 |
08/01/2016 |
Interferon beta-1b (Betaseron, Extavia) (PDF) |
CP.PHAR.256 |
08/01/2016 |
Interferon Gamma- 1b (Actimmune) (PDF) |
CP.PHAR.52 |
06/01/2010 |
Itraconazole (Sporanox, Onmel, Tolsura) (PDF) |
CP.PMN.124 |
11/01/2006 |
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) |
CP.PHAR.149 |
11/09/2017 |
Iobenguane I-131 (Azedra) (PDF) |
CP.PHAR.459 |
03/01/2020 |
Ipilimumab (Yervoy) (PDF) |
CP.PHAR.319 |
04/17/2018 |
irinotecan Liposome (Onivyde®) (PDF) |
CP.PHAR.304 |
02/01/2017 |
Iron sucrose (Venofer®) (PDF) |
CP.PHAR.167 |
03/01/2016 |
Isatuximab-irfc (Sarclisa)(PDF) |
CP.PHAR.482 |
06/01/2020 |
Isavuconazonium (Cresemba) (PDF) |
CP.PMN.154 |
11/16/2016 |
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) |
CP.PMN.143 |
12/01/2014 |
Istradefylline (Nourianz) (PDF) |
CP.PMN.217 |
03/01/2020 |
Ivabradine (Corlanor) (PDF) |
CP.PMN.70 |
11/01/2015 |
Ivacaftor (Kalydeco) (PDF) |
CP.PHAR.210 |
05/01/2016 |
Ivosidenib (Tibsovo) (PDF)
|
CP.PHAR.137 |
08/21/2018 |
Ixazomib (Ninlaro) (PDF) |
CP.PHAR.302 |
02/01/2017 |
Ixekizumab (Taltz) (PDF) |
CP.PHAR.257 |
08/01/2016 |
Lacosamide (Vimpat) (PDF) |
CP.PMN.155 |
12/01/2014 |
Lanadelumab-fylo (Takhzyro) (PDF) |
CP.PHAR.396 |
09/25/2018 |
Lanreotide (Somatuline Depot) (PDF) |
CP.PHAR.391 |
08/28/2018 |
lapatinib (Tykerb®) (PDF) |
CP.PHAR.79 |
11/09/2017 |
Laronidase (Aldurazyme) (PDF) |
CP.PHAR.152 |
02/01/2016 |
Larotrectinib (Vitrakvi) (PDF) |
CP.PHAR.414 |
01/15/2018 |
Lasmiditan (Reyvow) (PDF) |
CP.PMN.218 |
03/01/2020 |
Ledipasvir/Sofosbuvir (Harvoni) (PDF) |
CP.PHAR.279 |
09/01/2016 |
Lefamulin (Xenleta) (PDF) |
CP.PMN.219 |
03/01/2020 |
Lemborexant (Dayvigo)(PDF) |
CP.PMN.233 |
06/01/2020 |
Lenalidomide (Revlimid) (PDF) |
CP.PHAR.71 |
07/01/2011 |
Lenvatinib (Lenvima) (PDF) |
CP.PHAR.138 |
12/01/2018 |
Letermovir (Prevymis) (PDF) |
CP.PHAR.367 |
03/01/2018 |
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) |
CP.PHAR.173 |
11/09/2017 |
Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF) |
CP.PMN.07 |
09/01/2006 |
Levoleucovorin (Fusilev®) (PDF) |
CP.PHAR.151 |
11/09/2017 |
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) |
CP.PMN.08 |
09/01/2006 |
Linaclotide (Linzess) (PDF) |
CP.PMN.71 |
11/01/2015 |
Linezolid (Zyvox) (PDF) |
CP.PMN.27 |
09/01/2016 |
Lifitegrast (Xiidra®) (PDF) |
CP.PMN.73 |
11/09/2017 |
Lisocabtagene Maraleucel (JCAR017) (PDF) |
CP.PHAR.483 |
06/01/2020 |
Lofexidine (Lucemyra) (PDF) |
CP.PMN.152 |
08/01/2018 |
Lomitapide (Juxtapid) (PDF) |
CP.PHAR.283 |
10/01/2016 |
Lorlatinib (Lorbrena) (PDF) |
CP.PHAR.406 |
12/11/2018 |
Lubiprostone (Amitiza) (PDF) |
CP.PMN.142 |
12/01/2014 |
Luliconazole Cream (Luzu) (PDF) |
CP.PMN.166 |
08/28/2018 |
Lumacaftor-Ivacaftor (Orkambi) (PDF) |
CP.PHAR.213 |
05/01/2016 |
Lumasiran (ALN-GO1) (PDF) |
CP.PHAR.473 |
06/01/2020 |
Lumateperone (Caplyta) (PDF) |
CP.PMN.232 |
03/01/2020 |
Lurasidone (Latuda) (PDF) |
CP.PMN.50 |
12/01/2014 |
Luspatercept-aamt (Reblozyl) (PDF) |
CP.PHAR.450 |
03/01/2020 |
Lusutrombopag (Mulpleta) (PDF) |
CP.PHAR.407 |
09/18/2018 |
Lutetium Lu 177 Dotatate (Lutathera)(PDF) |
CP.PHAR.384 |
05/22/2018 |
Macitentan (Opsumit®) (PDF) |
CP.PHAR.194 |
03/01/2016 |
Mecasermin (Increlex) (PDF) |
CP.PHAR.150 |
03/01/2011 |
Mecamylamine (Vecamyl) (PDF) |
CP.PMN.136 |
05/01/2017 |
Megestrol Acetate (Megace ES) (PDF) |
CP.PMN.179 |
12/01/2018 |
Mepolizumab (Nucala) (PDF) |
CP.PHAR.200 |
04/01/2016 |
Metformin ER (Fortamet, Glumetza) (PDF) |
CP.PMN.72 |
11/01/2015 |
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) |
CP.PHAR.134 |
12/01/2018 |
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) |
CP.PHAR.238 |
06/01/2016 |
Methylnaltrexone Bromide (Relistor) (PDF) |
CP.PMN.169 |
12/01/2018 |
Metreleptin (Myalept) (PDF) |
CP.PHAR.425 |
09/01/2019 |
Midazolam (Nayzilam) (PDF) |
CP.PMN.211 |
09/01/2019 |
Midostaurin (Rydapt) (PDF) |
CP.PHAR.344 |
06/01/2017 |
Mifepristone (Korlym) (PDF) |
CP.PHAR.101 |
05/01/2012 |
Migalastat (Galafold) (PDF) |
CP.PHAR.394 |
09/11/2018 |
Miglustat (Zavesca) (PDF) |
CP.PHAR.164 |
02/01/2016 |
Milnacipran (Savella) (PDF) |
CP.PMN.125 |
08/01/2012 |
Mipomersen (Kynamro) (PDF) |
CP.PHAR.284 |
10/01/2016 |
Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF) |
CP.PMN.80 |
05/01/2017 |
Mitoxantrone (Novantrone) (PDF) |
CP.PHAR.258 |
08/01/2016 |
Modafinil (Provigil) (PDF) |
CP.PMN.39 |
05/01/2008 |
Mogamulizumab-kpkc (Poteligeo) (PDF) |
CP.PHAR.139 |
09/04/2018 |
Mometasone/Formoterol (Dulera) (PDF) |
CP.PMN.230 |
03/01/2020 |
Mometasone Furoate (Sinuva) (PDF) |
CP.PHAR.448 |
03/01/2020 |
Monomethyl Fumarate (Bafiertam) (PDF) |
CP.PHAR.460 |
03/01/2020 |
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) |
CP.PHAR.398 |
10/16/2018 |
Nadofaragene Firadenovec (Instiladrin) (PDF) |
CP.PHAR.461 |
03/01/2020 |
nafarelin acetate (Synarel®) (PDF) |
CP.PHAR.174 |
11/09/2017 |
Naproxen/Esomeprazole (Vimovo) (PDF) |
CP.PMN.117 |
06/01/2018 |
Natalizumab (Tysabri) (PDF) |
CP.PHAR.259 |
07/01/2016 |
Necitumumab (Portrazza®) (PDF) |
CP.PHAR.320 |
03/01/2017 |
Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF) |
CP.PMN.167 |
08/28/2018 |
Neratinib (Nerlynx) (PDF) |
CP.PHAR.365 |
09/05/2017 |
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF) |
CP.PMN.118 |
02/13/2018 |
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) |
CP.PMN.158 |
09/01/2006 |
nilotinib (Tasigna) (PDF) |
CP.PHAR.76 |
09/01/2011 |
Nintedanib (Ofev) (PDF) |
CP.PHAR.285 |
10/01/2016 |
Nitisinone (Nityr, Orfadin) (PDF) |
CP.PHAR.132 |
08/28/2018 |
Nivolumab (Opdivo) (PDF) |
CP.PHAR.121 |
07/01/2015 |
No Coverage Criteria/Off-Label Use Policy (PDF) |
CP.PMN.53 |
09/12/2017 |
Nusinersen (Spinraza®)(PDF) |
CP.PHAR.327 |
11/28/2017 |
Obeticholic (Ocaliva) (PDF) |
CP.PHAR.287 |
11/01/2016 |
Obinutuzumab (Gazyva®) (PDF) |
CP.PHAR.305 |
02/01/2017 |
Ocrelizumab (Ocrevus) (PDF) |
CP.PHAR.335 |
04/01/2017 |
Octreotide (Sandostatin, Sandostatin LAR) (PDF) |
CP.PHAR.40 |
03/01/2010 |
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF) |
CP.PHAR.40 |
03/01/2010 |
ofatumumab (Arzerra®) (PDF) |
CP.PHAR.306 |
02/01/2017 |
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) |
CP.PHAR.292 |
12/01/2016 |
Olaparib (Lynparza) (PDF) |
CP.PHAR.360 |
10/03/2017 |
olaratumab (Lartruvo®) (PDF) |
CP.PHAR.326 |
03/01/2017 |
Omadacycline (Nuzyra) (PDF) |
CP.PMN.188 |
11/20/2018 |
Omacetaxine (Synribo) (PDF) |
CP.PHAR.108 |
04/01/2013 |
Omalizumab (Xolair®) (PDF) |
CP.PHAR.01 |
10/1/2008 |
OnabotulinumtoxinA (Botox) (PDF) |
CP.PHAR.232 |
07/01/2016 |
Onasemnogene Abeparvovec (Zolgensma) (PDF) |
CP.PHAR.421 |
06/07/2019 |
Ondansetron (Zuplenz) (PDF) |
CP.PMN.45 |
09/01/2006 |
Osimertinib (Tagrisso) (PDF) |
CP.PHAR.294 |
12/01/2016 |
Ospemifene (Osphena) (PDF) |
CP.PMN.168 |
08/28/2018 |
Overactive Bladder Agents (PDF) |
CP.PMN.198 |
05/01/2016 |
Ozanimod (PDF) |
CP.PHAR.462 |
03/01/2020 |
Ozenoxacin (Xepi) (PDF) |
CP.PMN.119 |
01/30/2018 |
Paclitaxel, Protein-Bound (Abraxane) (PDF) |
CP.PHAR.176 |
07/01/2015 |
Palbociclib (Ibrance®) (PDF) |
CP.PHAR.125 |
10/01/2015 |
Palivizumab (Synagis) (PDF) |
CP.PHAR.16 |
08/01/2009 |
panitumumab (Vectibix®) (PDF) |
CP.PHAR.321 |
03/01/2017 |
Parathyroid Hormone (Natpara) (PDF) |
CP.PHAR.282 |
11/16/2016 |
Paricalcitol Injection (Zemplar) (PDF) |
CP.PHAR.270 |
08/01/2016 |
Pasireotide (Signifor LAR®) (PDF) |
CP.PHAR.332 |
03/01/2017 |
Patisiran (Onpattro) (PDF) |
CP.PHAR.395 |
09/11/2018 |
Pazopanib (Votrient) (PDF) |
CP.PHAR.81 |
10/01/2011 |
Peanut Allergen Powder-dnfp (Palforzia) (PDF) |
CP.PMN.220 |
03/01/2020 |
Pegademase Bovine (Adagen) (PDF) |
CP.PHAR.392 |
08/28/2018 |
Pegaptanib (Macugen®) (PDF) |
CP.PHAR.185 |
03/01/2016 |
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) |
CP.PHAR.353 |
09/05/2017 |
Pegfilgrastim (Neulasta) (PDF) |
CP.PHAR.296 |
12/01/2016 |
peginterferon alfa-2b (PegIntron, Sylatron®) (PDF) |
CP.PHAR.89 |
10/01/2011 |
Peginterferon beta-1a (Plegridy) (PDF) |
CP.PHAR.271 |
08/01/2016 |
Pegloticase (Krystexxa®) (PDF) |
CP.PHAR.115 |
6/1/2013 |
Pegvaliase-pqpz (Palynziq) (PDF) |
CP.PHAR.140 |
07/31/2018 |
Pegvisomant (Somavert) (PDF) |
CP.PHAR.389 |
12/01/2018 |
Pemetrexed (Alimta, Pemfexy) (PDF) |
CP.PHAR.368 |
10/31/2017 |
pembrolizumab (Keytruda®) (PDF) |
CP.PHAR.322 |
03/01/2017 |
Perampanel (Fycompa) (PDF) |
CP.PMN.156 |
11/16/2016 |
Pertuzumab (Perjeta) (PDF) |
CP.PHAR.227 |
06/01/2016 |
Pexidartinib (Turalio) (PDF) |
CP.PHAR.436 |
12/01/2019 |
Pitolisant (Wakix) (PDF) |
CP.PMN.221 |
03/01/2020 |
Plerixafor (Mozobil) (PDF) |
CP.PHAR.323 |
03/01/2017 |
Polatuzumab Vedotin-piiq (Polivy) (PDF) |
CP.PHAR.433 |
09/01/2019 |
Pomalidomide (Pomalyst) (PDF) |
CO.PHAR.116 |
07/01/2013 |
Ponatinib (Iclusig) (PDF) |
CO.PHAR.112 |
06/01/2013 |
Pralatrexate (Folotyn®) (PDF) |
CP.PHAR.313 |
02/01/2017 |
Pramlintide (Symlin) (PDF) |
CP.PMN.129 |
06/01/2018 |
Pregabalin (Lyrica, Lyrica CR) (PDF) |
CP.PMN.33 |
01/01/2007 |
Pretomanid (PDF) |
CP.PMN.222 |
03/01/2020 |
Protein C Concentrate, Human (Ceprotin) (PDF) |
CP.PHAR.330 |
03/01/2017 |
Propranolol HCl Oral Solution (Hemangeol) (PDF) |
CP.PMN.58 |
05/01/2014 |
Prucalopride (Motegrity) (PDF) |
CP.PMN.194 |
01/29/2019 |
pyrimethamine (Daraprim®) (PDF) |
CP.PMN.44 |
11/01/2015 |
Quetiapine ER (Seroquel XR) (PDF) |
CP.PMN.64 |
12/01/2014 |
Ramucirumab (Cyramza®) (PDF) |
CP.PHAR.119 |
05/01/2015 |
Ranibizumab (Lucentis®) (PDF) |
CP.PHAR.186 |
03/01/2016 |
Regorafenib (Stivarga) (PDF) |
CP.PHAR.107 |
12/01/2012 |
Remestemcel-L (Prochymal) (PDF) |
CP.PHAR.474 |
06/01/2020 |
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) |
CP.PHAR.168 |
03/01/2016 |
Request for Medically Necessary Drug Not on the PDL (PDF) |
CP.PMN.16 |
11/09/2017 |
Reslizumab (Cinqair) (PDF) |
CP.PHAR.223 |
05/01/2016 |
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) |
CP.PHAR.141 |
11/16/2016 |
Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF) |
CP.PMN.223 |
03/01/2020 |
Rifamycin (Aemcolo) (PDF) |
CP.PMN.196 |
01/08/2019 |
rifaximin (Xifaxan®)(PDF) |
CP.PMN.47 |
11/01/2011 |
Rilonacept (Arcalyst) (PDF) |
CP.PHAR.266 |
11/16/2016 |
RimabotulinumtoxinB (Myobloc) (PDF) |
CP.PHAR.233 |
07/01/2016 |
Riociguat (Adempas®) (PDF) |
CP.PHAR.195 |
03/01/2016 |
Risdiplam (PDF) |
CP.PHAR.477 |
06/01/2020 |
Risedronate (Actonel, Atelvia) (PDF) |
CP.PMN.100 |
03/01/2018 |
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) |
CP.PHAR.293 |
12/01/2016 |
Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF) |
CP.PHAR.260 |
07/01/2016 |
Rolapitant (Varubi) (PDF) |
CP.PMN.102 |
02/01/2017 |
romidepsin (Istodax®) (PDF) |
CP.PHAR.314 |
01/01/2017 |
Romiplostim (Nplate®) (PDF) |
CP.PHAR.179 |
03/01/2016 |
Rucaparib (Rubraca®) (PDF) |
CP.PHAR.350 |
09/01/2017 |
Rufinamide (Banzel) (PDF) |
CP.PMN.157 |
12/01/2014 |
Sacubitril/Valsartan (Entresto) (PDF) |
CP.PMN.67 |
11/01/2015 |
Sacitizumab Govitecan (PDF) |
CP.PHAR.475 |
06/01/2020 |
Safinamide (Xadago) (PDF) |
CP.PMN.113 |
07/01/2017 |
Sapropterin Dihydrochloride (Kuvan) (PDF) |
CP.PHAR.43 |
02/01/2010 |
Sarecycline (Seysara) (PDF) |
CP.PMN.189 |
11/13/2018 |
Sargramostim (Leukine) (PDF) |
CP.PHAR.295 |
12/01/2016 |
Satralizumab (PDF) |
CP.PHAR.463 |
03/01/2020 |
Sebelipase Alfa (Kanuma) (PDF) |
CP.PHAR.159 |
02/01/2016 |
Secnidazole (Solosec) (PDF) |
CP.PMN.103 |
10/24/2017 |
Selexipag (Uptravi®) (PDF) |
CP.PHAR.196 |
03/01/2016 |
Selinexor (Xpovio) (PDF) |
CP.PHAR.431 |
09/01/2019 |
Selpercatinib (LOXO-292) (PDF) |
CP.PHAR.478 |
06/01/2020 |
Selumetinib (Koselugo) (PDF) |
CP.PHAR.464 |
03/01/2020 |
Sildenafil (Revatio®) (PDF) |
CP.PHAR.197 |
03/01/2016 |
Siltuximab (Sylvant®) (PDF) |
CP.PHAR.329 |
03/01/2017 |
Simeprevir (Olysio) (PDF) |
CP.PHAR.280 |
09/01/2016 |
Siponimod (Mayzent) (PDF) |
CP.PHAR.427 |
09/01/2019 |
Sipuleucel-T (Provenge) (PDF) |
CP.PHAR.120 |
06/01/2015 |
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) |
CP.PMN.14 |
09/18/2018 |
sodium oxybate (Xyrem) (PDF) |
CP.PMN.42 |
05/01/2011 |
Sodium Phenylbutyrate (Buphenyl) (PDF) |
CP.PHAR.208 |
05/01/2016 |
Sofosbuvir (Sovaldi) (PDF) |
CP.PHAR.281 |
09/01/2016 |
Solriamfetol (Sunosi) (PDF) |
CP.PMN.209 |
09/01/2019 |
Somatropin (Growth Hormone) (PDF) |
CP.PHAR.55 |
03/01/2011 |
Sonidegib (Odomzo) (PDF) |
CP.PHAR.272 |
05/01/2012 |
sorafenib (Nexavar) (PDF) |
CP.PHAR.69 |
07/01/2011 |
Step Therapy (PDF) |
CP.PST.01 |
12/28/2017 |
Stiripentol (Diacomit) (PDF) |
CP.PMN.184 |
09/25/2018 |
sunitinib (Sutent) (PDF) |
CP.PHAR.73 |
09/01/2011 |
Suvorexant (Belsomra®) (PDF) |
CP.PMN.109 |
02/01/2017 |
Tadalafil (Adcirca®) (PDF) |
CP.PHAR.198 |
03/01/2016 |
Tadalafil BHP - ED (Cialis) (PDF) |
CP.PMN.132 |
06/01/2018 |
Tafamidis (Vyndaqel, Vyndamax) (PDF) |
CP.PHAR.432 |
09/01/2019 |
Talazoparib (Talzenna) (PDF) |
CP.PHAR.409 |
11/27/2018 |
Taliglucerase Alfa (Elelyso) (PDF) |
CP.PHAR.157 |
02/01/2016 |
Tasimelteon (Hetlioz) (PDF) |
CP.PMN.104 |
02/01/2017 |
Tavaborole (Kerydin) (PDF) |
CP.PMN.105 |
03/01/2018 |
Tazemetostat (Tazverik) (PDF) |
CP.PHAR.452 |
03/01/2020 |
Tedizolid (Sivextro) (PDF) |
CP.PMN.62 |
03/01/2015 |
Teduglutide (Gattex) (PDF) |
CP.PHAR.114 |
05/01/2013 |
Tegaserod (Zelnorm) (PDF) |
CP.PMN.206 |
09/01/2019 |
Telotristat Ethyl (Xermelo) (PDF) |
CP.PHAR.337 |
06/01/2017 |
Temozolomide (Temodar) (PDF) |
CP.PHAR.77 |
09/01/2011 |
temsirolimus (Torisel®) (PDF) |
CP.PHAR.324 |
03/01/2017 |
Tenapanor (Ibsrela) (PDF) |
CP.PMN.224 |
03/01/2020 |
Teprotumumab (Tepezza) (PDF) |
CP.PHAR.465 |
01/21/2020 |
Teriflunomide (Aubagio) (PDF) |
CP.PHAR.262 |
08/01/2016 |
Teriparatide (Forteo®) (PDF) |
CP.PHAR.188 |
11/15/2017 |
Tesamorelin (Egrifta) (PDF) |
CP.PHAR.109 |
03/01/2014 |
Testosterone (Testopel, Jatenzo) (PDF) |
CP.PHAR.354 |
08/01/2017 |
tetrabenazine (Xenazine) (PDF) |
CP.PHAR.92 |
12/01/2011 |
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) |
CP.PHAR.377 |
04/03/2018 |
Thalidomide (Thalomid) (PDF) |
CP.PHAR.78 |
09/01/2011 |
Thioguanine (Tabloid) (PDF) |
CP.PHAR.437 |
12/01/2019 |
Thyrotropin Alfa (Thyrogen) (PDF) |
CP.PHAR.95 |
03/01/2012 |
Timothy grass pollen allergen extract (Grastek®) (PDF) |
CP.PMN.84 |
08/31/2017 |
Tisagenlecleucel (Kymriah) (PDF) |
CP.PHAR.361 |
09/26/2017 |
Tobramycin (Bethkis®, Kitabis Pak®, TOBI®, TOBI Podhaler®) (PDF) |
CP.PHAR.211 |
05/01/2016 |
Tocilizumab (Actemra) (PDF) |
CP.PHAR.263 |
07/01/2016 |
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) |
CP.PHAR.267 |
01/30/2018 |
Tolvaptan (Jynarque) (PDF) |
CP.PHAR.27 |
06/05/2018 |
Topical Immunomodulators (PDF) |
CP.PMN.107 |
09/01/2006 |
Topotecan (Hycamtin)(PDF) |
CP.PHAR.64 |
06/01/2011 |
Trabectedin (Yondelis®) (PDF) |
CP.PHAR.204 |
05/01/2016 |
Trametinib (Mekinist) (PDF) |
CP.PHAR.240 |
07/01/2016 |
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) |
CP.PHAR.228 |
06/01/2016 |
Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF) |
CP.PHAR.199 |
03/01/2016 |
Triamcinolone ER Injection (Zilretta) (PDF) |
CP.PHAR.371 |
03/01/2018 |
Trientine (Syprine) (PDF) |
CP.PHAR.438 |
12/01/2019 |
triptorelin pamoate (Trelstar®, Triptodur®) (PDF) |
CP.PHAR.175 |
11/09/2017 |
Ubrogepant (Ubrelvy) (PDF) |
CP.PHAR.475 |
06/01/2020 |
Upadacitinib (Rinvoq) (PDF) |
CP.PHAR.443 |
12/01/2019 |
Ustekinumab (Stelara) (PDF) |
CP.PHAR.264 |
08/01/2016 |
Valoctocogene Roxaparvovec (PDF) |
CP.PHAR.466 |
03/01/2020 |
Valproate Sodium for Intravenous Injection (Depacon) (PDF) |
CP.PHAR.429 |
09/01/2019 |
Valrubicin (Valstar) (PDF) |
CP.PHAR.439 |
12/01/2019 |
Vandetanib (Caprelsa®) (PDF) |
CP.PHAR.80 |
10/01/2011 |
Vedolizumab (Entyvio) (PDF) |
CP.PHAR.265 |
07/01/2016 |
Velaglucerase Alfa (VPRIV) (PDF) |
CP.PHAR.163 |
02/01/2016 |
Vemurafenib (Zelboraf®) (PDF) |
CP.PHAR.91 |
11/01/2011 |
Verteporfin (Visudyne®) (PDF) |
CP.PHAR.187 |
03/01/2016 |
Vestronidase alfa-vjbk (Mepsevii) (PDF) |
CP.PHAR.374 |
01/19/2018 |
Vigabatrin (Sabril) (PDF) |
CP.PHAR.169 |
02/01/2016 |
Vilazodone (Viibryd) (PDF) |
CP.PMN.145 |
08/01/2012 |
Viltolarsen (PDF) |
CP.PHAR.484 |
06/01/2020 |
vincristine sulfate liposome injection (Marqibo®) (PDF) |
CP.PHAR.315 |
02/01/2017 |
Vismodegib (Erivedge) (PDF) |
CP.PHAR.273 |
08/01/2016 |
Voretigene neparvovec-rzyl (Luxturna) (PDF) |
CP.PHAR.372 |
03/01/2018 |
Vorinostat (Zolinza) (PDF) |
CP.PHAR.83 |
12/01/2012 |
Vortioxetine (Trintellix®) (PDF) |
CP.PMN.65 |
05/31/2017 |
Voxelotor (Oxbryta) (PDF) |
CP.PHAR.451 |
03/01/2020 |
Zanubrutinib (Brukinsa) (PDF) |
CP.PHAR.467 |
03/01/2020 |
ziv-aflibercept (Zaltrap®) (PDF) |
CP.PHAR.325 |
03/01/2017 |
Zoledronic acid (Reclast, Zometa) (PDF) |
CP.PHAR.59 |
03/01/2011 |