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Texas Clinical Payment Policies | Ambetter from Superior HealthPlan
Clinical & Payment Policies
Ambetter Clinical and Payment Polices
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (CP.MP.108) (PDF)
- Antithrombin III (Thrombate III, Atryn) (CP.MP.179) (PDF)
- Applied Behavioral Analysis for Autism (CP.MP.104) (PDF)
- Bariatric Surgery (CP.MP.37 ) - Effective 10/01/2020 (PDF)
- Bone-anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty - Effective 1/15/2017 (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Carrier Screening in Pregnancy (CP.MP.83) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections for Pain Management (CP.MP.164) (PDF)
- Cell-free Fetal DNA Testing (CP.MP.84) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) - Effective 10/01/2020 (PDF)
- Dental Anesthesia (CP.MP.61) (PDF)
- DNA Analysis of Stool - Effective 5/1/2017 (CP.MP.125) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (Optune) (CP.MP.145) - Effective 10/01/2020 (PDF)
- Essure Removal (CP.MP.131) (PDF)
- Facet Joint Interventions for Pain Management (CP.MP.171) (PDF)
- Facet Joint Interventions for Pain Management (CP.MP.171) - Effective 10/01/2020 (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) - Effective 10/01/2020 (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fixed Wing Air Transportation (CP.MP.175) - Effective 07/15/2020 (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Genetic and Pharmacogenetic Testing (CP.MP.89) - Effective 10/01/2020 (PDF)
- Heart-Lung Transplant (CP.MP.132) - Effective 10/01/2020 (PDF)
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperemesis Gravidarum Treatment (CP.MP.34) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Intrathecal Pain Pump (CP.MP.173) (PDF)
- Inhaled Nitric Oxide (CP.MP.87) - Effective 07/15/2020 (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) - Effective 10/01/2020 (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- Lung Transplantation (CP.MP.57) - Effective 10/01/2020 (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Mechanical Stretching Devices for Joint Stiffness (CP.MP.144)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management Guidelines (CP.MP.85) (PDF)
- Neonatal Sepsis Management Guidelines - Effective 10/01/2020 (CP.MP.85) (PDF)
- Nerve Blocks for Pain Management (CP.MP.170) (PDF)
- Non-Invasive Home Ventilator (CP.MP.184) - Effective 10/01/2020 (PDF)
- Non-myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Health Care Programs (CP.MP.91) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Testing for Drugs of Abuse (CP.MP.50) - Effective 10/01/2020 (PDF)
- Pancreas Transplantation (CP.MP.102) - Effective 10/01/2020 (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) - Effective 10/01/2020 (PDF)
- Pediatric Liver Transplant (CP.MP.120) - Effective 10/01/2020 (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Private Duty Nursing (TX.CP.MP.520) (PDF)
- Proton and Neutron Beam Therapy - Effective 8/15/2016 (CP.MP.70) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery - Effective 10/01/2020 (CP.MP.51) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy for Varicose Veins (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay - Effective 9/15/2020 (CP.MP.182) (PDF)
- Sickle Cell Disease Observation (CP.MP.88) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) - Effective 10/01/2020 (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Therapy Services (PT/OT/ST) (CP.MP.49) (PDF)
- Thymus Transplantation (CP.MP.189) - Effective 10/01/2020 (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventriculectomy and Cardiomyoplasty (CP.MP.56) (PDF)
- Wheelchair Seating - Effective 8/12/2016 (CP.MP.99) (PDF)
Ambetter Pharmacy Policies
- Abaloparatide (Tymlos) (CP.PHAR.345) - Effective 3/19/2019 (PDF)
- Abatacept (Orencia) (CP.PHAR.241) - Effective 6/1/2016 (PDF)
- Abiraterone (Zytiga, Yonsa) (CP.PHAR.84) - Effective 10/1/2011 (PDF)
- AbobotulinumtoxinA (Dysport) (CP.PHAR.230) - Effective 7/1/2016 (PDF)
- Aclidinium/Formoterol (Duaklir Pressair) (CP.PCH.23) - Effective 3/1/2020 (PDF)
- Adalimumab (Humira), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-adaz (Hyrimoz) (CP.PHAR.242) - Effective 8/1/2016 (PDF)
- Adefovir (Hepsera) (CP.PHAR.142) - Effective 8/28/2018 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) (CP.PHAR.229) - Effective 6/1/2016 (PDF)
- Afamelanotide (Scenesse) (CP.PHAR.444) - Effective 3/21/2020 (PDF)
- Afatinib (Gilotrif) (CP.PHAR.298) - Effective 1/1/2017 (PDF)
- Aflibercept (Eylea) (CP.PHAR.184) - Effective 3/1/2016 (PDF)
- Agalsidase Beta (Fabrazyme) (CP.PHAR.158) - Effective 2/1/2016 (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (CP.PMN.138) - Effective 3/13/2018 (PDF)
- Alectinib (Alecensa) (CP.PHAR.369) - Effective 11/16/2016 (PDF)
- Alemtuzumab (Lemtrada) (CP.PHAR.243) - Effective 8/1/2016 (PDF)
- Alendronate (Binosto, Fosamax Plus D) (CP.PMN.88) - Effective 3/1/2018 (PDF)
- Alglucosidase Alfa (Lumizyme) (CP.PHAR.160) - Effective 2/1/2016 (PDF)
- Alpelisib (Piqray) (CP.PHAR.430) - Effective 7/9/2019 (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) - Effective 3/1/2012 (CP.PHAR.94) (PDF)
- Ambrisentan (Letairis) (CP.PHAR.190) - Effective 3/1/2016 (PDF)
- Amifampridine (Firdapse, Ruzurgi) (CP.PHAR.411) - Effective 1/22/2019 (PDF)
- Amikacin (Arikayce) - Effective 11/13/2018 (CP.PHAR.401) (PDF)
- Anakinra (Kineret) - Effective 8/1/2016 (CP.PHAR.244) (PDF)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) (CP.PHAR.217) - Effective 5/1/2016 (PDF)
- Antithymocyte Globulin (Thymoglobulin, Atgam) (HIM.PA.16) - Effective 9/4/2018 (PDF)
- Apalutamide (Erleada) - Effective 6/1/2018 (CP.PHAR.376)
- Apomorphine (Apokyn) (CP.PCH.14) - Effective 11/16/2016 (PDF)
- Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (CP.PMN.19) - Effective 11/1/2006 (PDF)
- Arformoterol tartrate (Brovana) (CP.PMN.201) - Effective 9/1/2018 (PDF)
- Aripiprazole LA injections (Abilify Maintena Aristada Aristada Initio) (CP.PHAR.290) - Effective 12/1/2016 (PDF)
- Armodafinil (Nuvigil) (CP.PMN.35) - Effective 8/1/2009 (PDF)
- Asenapine (Saphris, Secuado) (CP.PMN.15) - Effective 12/1/2014 (PDF)
- Asfotase Alfa (Strensiq) (CP.PHAR.328) - Effective 3/1/2017 (PDF)
- Aspirin/Dipyridamole (Aggrenox) (CP.PMN.20) - Effective 9/1/2006 (PDF)
- Atezolizumab (Tecentriq®) (CP.PHAR.235) - Effective 6/1/2016 (PDF)
- Avapritinib (Ayvakit) (CP.PHAR.454) - Effective 3/1/2020 (PDF)
- Avatrombopag (Doptelet) (CP.PHAR.130) - Effective 7/7/2018 (PDF)
- Avelumab (Bavencio) (CP.PHAR.333) - Effective 5/1/2017 (PDF)
- Axicabtagene Ciloleucel (Yescarta) (CP.PHAR.362) - Effective 12/1/2017 (PDF)
- Axitinib (Inlyta) (CP.PHAR.100) - Effective 5/1/2012 (PDF)
- Azacitidine (Vidaza) (CP.PHAR.387) - Effective 8/28/2018 (PDF)
- Azelaic Acid (Finacea Topical Gel) (HIM.PA.119) - Effective 12/1/2017 (PDF)
- Aztreonam (Cayston) (CP.PHAR.209) - Effective 5/1/2016 (PDF)
- Baclofen (Gablofen, Lioresal, Ozobax) (CP.PHAR.149) - Effective 12/1/2015 (PDF)
- Baricitinib (Olumiant) (CP.PHAR.135) - Effective 7/24/2018 (PDF)
- Bedaquiline (Sirturo) (CP.PMN.212) - Effective 9/4/2018 (PDF)
- Belatacept (Nulojix) (CP.PHAR.201) - Effective 3/1/2016 (PDF)
- Belimumab (Benlysta) (CP.PHAR.88) - Effective 10/1/2011 (PDF)
- Belinostat (Beleodaq) (CP.PHAR.311) - Effective 2/1/2017 (PDF)
- Bendamustine (Bendeka, Treanda) (CP.PHAR.307) - Effective 2/1/2017 (PDF)
- Benralizumab (Fasenra) (CP.PHAR.373) - Effective 6/1/2018 (PDF)
- Benznidazole (CP.PMN.90) - Effective 3/1/2018 (PDF)
- Betaine (Cystadane) (CP.PHAR.143) - Effective 8/28/2018 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (CP.PHAR.93) - Effective 12/1/2011 (PDF)
- Bexarotene (Targretin Capsules, Gel) (CP.PHAR.75) - Effective 9/1/2011 (PDF)
- Bezlotoxumab (Zinplava) (CP.PHAR.300) - Effective 11/16/2016 (PDF)
- Bimatoprost Implant (Durysta) - Effective 6/1/2020 (CP.PHAR.486)
- Binimetinib (Mektovi) (CP.PHAR.50) - Effective 9/1/2018 (PDF)
- Biologic DMARDs (HIM.PA.SP60) - Effective 1/1/2020 (PDF)
- Blinatumomab (Blincyto) (CP.PHAR.312) - Effective 2/1/2017 (PDF)
- Bortezomib (Velcade) (CP.PHAR.410) - Effective 12/11/2018 (PDF)
- Bosentan (Tracleer) (CP.PHAR.191) - Effective 3/1/2016 (PDF)
- Bosutinib (Bosulif) (CP.PHAR.105) - Effective 10/1/2012 (PDF)
- Brand Name Override and Non-Formulary Medications (HIM.PA.103) - Effective 12/1/2014 (PDF)
- Bremelanotide (Vyleesi) (CP.PHAR.434) - Effective 8/7/2019 (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) - Effective 2/1/2017 (PDF)
- Brexanolone (Zulresso) (CP.PHAR.417) - Effective 6/1/2019 (PDF)
- Brexpiprazole (Rexulti) (CP.PMN.68) - Effective 12/1/2015 (PDF)
- Brigatinib (Alunbrig) (CP.PHAR.342) - Effective 7/7/2017 (PDF)
- Brimonidine Tartrate (Mirvaso) (CP.PMN.192) - Effective 11/16/2016 (PDF)
- Brinzolamide/Brimonidine (Simbrinza) (HIM.PA.15) - Effective 9/4/2018 (PDF)
- Brivaracetam (Briviact) (HIM.PA.07) - Effective 5/1/2019 (PDF)
- Brodalumab (Siliq) (CP.PHAR.375) - Effective 6/1/2018 (PDF)
- Brolucizumab-dbll (Beovu) (CP.PHAR.445) - Effective 3/1/2020 (PDF)
- Budesonide (Pulmicort Respules) (HIM.PA.48) - Effective 9/1/2018 (PDF)
- Budesonide (Uceris) (CP.PCH.11) (PDF)
- Buprenorphine (Subutex) (CP.PMN.82) - Effective 9/1/2017 (PDF)
- Buprenorphine Implant/Injection (Probuphine/Sublocade) (CP.PHAR.289) - Effective 12/1/2016 (PDF)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (HIM.PA.35) - Effective 2/1/2017 (PDF)
- Bupropion/Naltrexone (Contrave) (CP.PCH.12) - Effective 5/1/2017 (PDF)
- Burosumab-twza (Crysvita) (CP.PHAR.11) - Effective 5/8/2018 (PDF)
- Butorphanol Nasal Spray (HIM.PA.46) - Effective 12/1/2014 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (CP.PHAR.202) - Effective 3/1/2016 (PDF)
- Cabazitaxel (Jevtana) (CP.PHAR.316) - Effective 3/1/2017 (PDF)
- Cabozantinib (Cabometyx, Cometriq) (CP.PHAR.111) - Effective 6/1/2013 (PDF)
- Canakinumab (Ilaris) (CP.PHAR.246) - Effective 8/1/2016 (PDF)
- Cannabidiol (Epidiolex) (CP.PMN.164) - Effective 7/17/2018 (PDF)
- Capecitabeine (Xeloda) (CP.PHAR.60) - Effective 5/1/2011 (PDF)
- Caplacizumab-yhdp (Cablivi) (CP.PHAR.416) - Effective 3/12/2019 (PDF)
- Carfilzomib (Kyprolis) (CP.PHAR.309) - Effective 2/1/2017 (PDF)
- Carglumic Acid (Carbaglu) (CP.PHAR.206) - Effective 5/1/2016 (PDF)
- Celecoxib (Celebrex, Elyxyb) (CP.PMN.122) - Effective 1/1/2007 (PDF)
- Cemiplimab-rwlc (Libtayo) (CP.PHAR.397) - Effective 10/16/2018 (PDF)
- Cenegermin-bkbj (Oxervate) (CP.PMN.186) - Effective 3/1/2019 (PDF)
- Cenobamate (Xcopri) (CP.PMN.231) - Effective 3/1/2020 (PDF)
- Ceritinib (Zykadia) (CP.PHAR.349) - Effective 7/1/2017 (PDF)
- Cerliponase alfa (Brineura) (CP.PHAR.338) - Effective 7/1/2017 (PDF)
- Certolizumab (Cimzia) (CP.PHAR.247) - Effective 8/1/2016 (PDF)
- Cetuximab (Erbitux) (CP.PHAR.317) - Effective 2/1/2017 (PDF)
- Chlorambucil (Leukeran) (HIM.PA.SP59) - Effective 8/28/2018 (PDF)
- Chloramphenicol Sodium Succinate (CP.PHAR.388) - Effective 12/1/2018 (PDF)
- Cholic Acid (Cholbam) (CP.PHAR.390) - Effective 12/1/2018 (PDF)
- Ciclesonide (Alvesco) (HIM.PA.65) - Effective 9/1/2018 (PDF)
- Cinacalcet (Sensipar) (CP.PHAR.61) - Effective 5/1/2011 (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) (HIM.PA.120) - Effective 12/1/2017 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) (HIM.PA.14) - Effective 9/4/2018 (PDF)
- Cladribine (Mavenclad) (CP.PHAR.422) - Effective 9/1/2019 (PDF)
- Clindamycin (Evoclin) (HIM.PA.21) - Effective 8/28/2018 (PDF)
- Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (HIM.PA.31) - Effective 12/1/2018 (PDF)
- Clobazam (Onfi, Sympazan) (CP.PMN.54) - Effective 11/1/2012 (PDF)
- CNS Stimulants (CP.PMN.92) - Effective 3/1/2018 (PDF)
- Cobimetinib (Cotellic) (CP.PHAR.380) - Effective 11/16/2016 (PDF)
- Colesevelam (WelChol) (HIM.PA.121) - Effective 12/1/2017 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) (CP.PHAR.82) - Effective 10/1/2011 (PDF)
- Colonoscopy Preparation Products (HIM.PA.04) - Effective 1/1/2020 (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) (HIM.PA.140) - Effective 10/24/2017 (PDF)
- Continuous Glucose Monitors (CP.PMN.214) - Effective 9/3/2019 (PDF)
- Copanlisib (Aliqopa) (CP.PHAR.357) - Effective 10/17/2017 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (CP.PHAR.385) - Effective 5/29/2018 (PDF)
- Cosyntropin (Cortrosyn) (CP.PHAR.203) - Effective 4/1/2016 (PDF)
- Crisaborole (Eucrisa) (CP.PMN.110) - Effective 2/21/2017 (PDF)
- Crizanlizumab-tmca (Adakveo) (CP.PHAR.449) - Effective 3/1/2020 (PDF)
- Crizotinib (Xalkori) (CP.PHAR.90) - Effective 11/1/2011 (PDF)
- Cyclosprine (Cequa, Restasis) (CP.PMN.48) - Effective 5/1/2012 (PDF)
- Cysteamine ophthalmic (Cystaran) (CP.PMN.130) - Effective 8/1/2017 (PDF)
- Cysteamine oral (Cystagon, Procysbi) (CP.PHAR.155) - Effective 2/1/2016 (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) (CP.PHAR.277) - Effective 9/1/2018 (PDF)
- Dabrafenib (Tafinlar) (CP.PHAR.239) - Effective 11/16/2016 (PDF)
- Daclatasvir (Daklinza) (CP.PCH.15) - Effective 1/1/2020 (PDF)
- Dacomitinib (Vizimpro) (CP.PHAR.399) - Effective 10/16/2018 (PDF)
- Dalfampridine (Ampyra) (CP.PHAR.248) - Effective 8/1/2016 (PDF)
- Dalteparin (Fragmin) (CP.PHAR.225) - Effective 5/1/2016 (PDF)
- Daptomycin (Cubicin, Cubicin RF) (CP.PHAR.351) - Effective 11/1/2017 (PDF)
- Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) (CP.PHAR.310) - Effective 7/1/2017 (PDF)
- Darbepoetin Alfa (Aranesp) (CP.PHAR.236) - Effective 7/1/2016 (PDF)
- Darolutamide (Nubeqa) (CP.PHAR.435) - Effective 9/3/2019 (PDF)
- Dasatinib (Sprycel) (CP.PHAR.72) - Effective 6/1/2012 (PDF)
- Daunorubicin-cytarabine (Vyxeos) (CP.PHAR.352) - Effective 12/1/2017 (PDF)
- Deferasirox (Exjade/Jadenu) (CP.PHAR.145) - Effective 11/1/2015 (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) - Effective 11/1/2015 (PDF)
- Deflazacort (Emflaza) (CP.PHAR.331) - Effective 4/1/2017 (PDF)
- Degarelix Acetate (Firmagon) (CP.PHAR.170) - Effective 10/1/2016 (PDF)
- Delafloxacin (Baxdela) (CP.PMN.115) - Effective 12/1/2017 (PDF)
- Denosumab (Prolia, Xgeva) (CP.PHAR.58) - Effective 3/1/2011 (PDF)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (CP.PHAR.214) - Effective 5/1/2016 (PDF)
- Deutetrabenazine (Austedo) (CP.PHAR.341) - Effective 6/13/2017 (PDF)
- Dexlansoprazole (Dexilant) (HIM.PA.05) - Effective 1/1/2020 (PDF)
- Dexrazoxane (Zinecard, Totect) (CP.PHAR.418) - Effective 3/19/2019 (PDF)
- Dextromethorphan-Quinidine (Nuedexta) (CP.PMN.93) - Effective 12/5/2017 (PDF)
- Diazepam Nasal Spray (Valtoco) (CP.PMN.216) - Effective 12/1/2019 (PDF)
- Dichlorphenamide (Keveyis) (CP.PCH.04) - Effective 11/16/2016 (PDF)
- Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (CP.PHAR.249) - Effective 9/1/2016 (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (HIM.PA.58) - Effective 3/1/2018 (PDF)
- Dolasetron (Anzemet) (CP.PMN.141) - Effective 9/1/2006 (PDF)
- Dornase Alfa (Pulmozyme) (CP.PHAR.212) - Effective 5/1/2016 (PDF)
- Doxepin (Silenor, Prudoxin, Zonalon) (HIM.PA.147) - Effective 11/17/2017 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (CP.PMN.79) - Effective 6/1/2017 (PDF)
- Dupilumab (Dupixent) (CP.PHAR.336) - Effective 6/1/2017 (PDF)
- Durvalumab (Imfinzi) (CP.PHAR.339) - Effective 7/1/2017 (PDF)
- Duvelisib (Copiktra) (CP.PHAR.400) - Effective 10/16/2018 (PDF)
- Ecallantide (Kalbitor) (CP.PHAR.177) - Effective 3/1/2016 (PDF)
- Eculizumab (Soliris) (CP.PHAR.97) - Effective 3/1/2012 (PDF)
- Edaravone (Radicava) (CP.PHAR.343) - Effective 7/1/2017 (PDF)
- Efinaconazole (Jublia) (CP.PMN.25) - Effective 8/1/2016 (PDF)
- Elagolix (Orilissa) (CP.PHAR.136) - Effective 8/28/2018 (PDF)
- Elapegademase-lvlr (Revcovi) (CP.PHAR.419) - Effective 4/23/2019 (PDF)
- Elbasvir/Grazoprevir (Zepatier) (CP.PCH.16) - Effective 1/1/2020 (PDF)
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (CP.PHAR.440) - Effective 12/1/2019 (PDF)
- Eliglustat (Cerdelga) (CP.PHAR.153) - Effective 2/1/2016 (PDF)
- Elosulfase Alfa (Vimizim) (CP.PHAR.162) - Effective 2/1/2016 (PDF)
- Elotuzumab (Empliciti) (CP.PHAR.308) - Effective 2/1/2017 (PDF)
- Eltrombopag (Promacta) (CP.PHAR.180) - Effective 3/1/2016 (PDF)
- Emapalumab-lzsg (Gamifant) (CP.PHAR.402) - Effective 12/11/2018 (PDF)
- Emicizumab-kxwh (Hemlibra) (CP.PHAR.370) - Effective 3/1/2018 (PDF)
- Enasidenib (Idhifa) (CP.PHAR.363) - Effective 9/5/2017 (PDF)
- Encorafenib (Braftovi) (CP.PHAR.127) - Effective 9/1/2018 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) (CP.PHAR.455) - Effective 3/1/2020 (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) - Effective 6/1/2010 (PDF)
- Entecavir (Baraclude) (HIM.PA.08) - Effective 6/1/2019 (PDF)
- Entrectinib (Rozlytrek) (CP.PHAR.441) - Effective 12/1/2019 (PDF)
- Enzalutamide (Xtandi) (CP.PHAR.106) - Effective 10/1/2012 (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (CP.PHAR.237) - Effective 6/1/2016 (PDF)
- Epoprostenol (Flolan, Veletri) (CP.PHAR.192) - Effective 3/1/2016 (PDF)
- Erdafitinib (Balversa) (CP.PHAR.423) - Effective 5/7/2019 (PDF)
- Erenumab-aaoe (Aimovig) (CP.PHAR.128) - Effective 7/10/2018 (PDF)
- Eribulin Mesylate (Halaven) (CP.PHAR.318) - Effective 3/1/2017 (PDF)
- Erlotinib (Tarceva) (CP.PHAR.74) - Effective 9/1/2011 (PDF)
- Erwinia Asparaginase (Erwinaze) (CP.PHAR.301) - Effective 2/1/2017 (PDF)
- Esketamine (Spravato) (CP.PMN.199) - Effective 3/12/2019 (PDF)
- Etanercept (Enbrel) (CP.PHAR.250) - Effective 8/1/2016 (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) - Effective 3/20/2018 (PDF)
- Eteplirsen (Exondys 51) (CP.PHAR.288) - Effective 1/1/2017 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) (CP.PHAR.63) - Effective 6/1/2011 (PDF)
- Evolocumab (Repatha) (CP.PHAR.123) - Effective 10/1/2015 (PDF)
- Factor IX (Human, Recombinant) (CP.PHAR.218) - Effective 5/1/2016 (PDF)
- Factor IX Complex, Human (Profilnine) (CP.PHAR.219) - Effective 5/1/2016 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (CP.PHAR.220) (PDF) - Effective 5/1/2016 (PDF)
- Factor VIII (Human, Recombinant) (CP.PHAR.215) - Effective 6/1/2016 (PDF)
- Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (CP.PHAR.216) - Effective 5/1/2016 (PDF)
- Factor XIII A-Subunit, Recombinant (Tretten) (CP.PHAR.222) - Effective 5/1/2016 (PDF)
- Factor XIII, Human (Corifact) (CP.PHAR.221) - Effective 5/1/2016 (PDF)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CP.PHAR.456) - Effective 3/1/2020 (PDF)
- Febuxostat (Uloric) (CP.PMN.57) - Effective 8/1/2013 (PDF)
- Fedratinib (Inrebic) (CP.PHAR.442) - Effective 12/1/2019 (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (CP.PMN.127) - Effective 6/1/2015 (PDF)
- Ferric Carboxymaltose (Injectafer) (CP.PHAR.234) - Effective 6/1/2016 (PDF)
- Ferric Derisomaltose (Monoferric) (CP.PHAR.480) - Effective 6/1/2020 (PDF)
- Ferric Gluconate (Ferrlecit) (CP.PHAR.166) - Effective 3/1/2016 (PDF)
- Ferric Maltol (Accrufer) (CP.PMN.213) - Effective 9/3/2019 (PDF)
- Ferumoxytol (Feraheme) (CP.PHAR.165) - Effective 3/1/2016 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) (CP.PHAR.297) - Effective 12/1/2016 (PDF)
- Fingolimod (Gilenya) (CP.PHAR.251) - Effective 9/1/2016 (PDF)
- Fluorouracil Cream (Tolak) (CP.PMN.165) - Effective 12/1/2018 (PDF)
- Fluticasone Propionate (Xhance) (CP.PMN.95) - Effective 3/1/2018 (PDF)
- Fondaparinux (Arixtra) (CP.PHAR.226) - Effective 5/1/2016 (PDF)
- Formulary Medications without Specific Guidelines (HIM.PA.33) - Effective 5/1/2016 (PDF)
- Fostamatinib (Tavalisse) (CP.PHAR.24) - Effective 6/5/2018 (PDF)
- Fremanezumab-vfrm (Ajovy) (CP.PCH.17) - Effective 3/1/2020 (PDF)
- Fulvestrant (Faslodex Injection) (CP.PHAR.424) - Effective 5/14/2019 (PDF)
- Galcanezumab-gnlm (Emgality) (CP.PCH.24) - Effective 1/1/2020 (PDF)
- Galsulfase (Naglazyme) (CP.PHAR.161) - Effective 2/1/2016 (PDF)
- Gefitinib (Iressa) (CP.PHAR.68) - Effective 11/16/2016 (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) (CP.PHAR.358) - Effective 10/3/2017 (PDF)
- Gilteritinib (Xospata) (CP.PHAR.412) - Effective 1/15/2019 (PDF)
- Givosiran (Givlaari) (CP.PHAR.457) - Effective 3/1/2020 (PDF)
- Glasdegib (Daurismo) (CP.PHAR.413) - Effective 1/8/2019 (PDF)
- Glatiramer Acetate (Copaxone, Glatopa) (CP.PHAR.252) - Effective 9/1/2016 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) (HIM.PA.SP36) - Effective 8/31/2019 (PDF)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (CP.PMN.183) - Effective 9/19/2018 (PDF)
- Glycerol Phenylbutyrate (Ravicti) (CP.PHAR.207) - Effective 5/1/2016 (PDF)
- Golimumab (Simponi, Simponi Aria) (CP.PHAR.253) - Effective 7/1/2016 (PDF)
- Golodirsen (Vyondys 53) (CP.PHAR.453) - Effective 3/1/2020 (PDF)
- Goserelin Acetate (Zoladex) (CP.PHAR.171) - Effective 10/1/2016 (PDF)
- Granisetron (Kytril, Sancuso, Sustol) (CP.PMN.74) - Effective 11/1/2016 (PDF)
- Guselkumab (Tremfya) (CP.PHAR.364) - Effective 8/29/2017 (PDF)
- Halcinonide (Halog) (HIM.PA.20) - Effective 8/28/2018 (PDF)
- Hemin (Panhematin) (CP.PHAR.181) - Effective 2/1/2016 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) (CP.PHAR.172) - Effective 10/1/2016 (PDF)
- Hyaluronate Derivatives (CP.PHAR.05) - Effective 10/1/2018 (PDF)
- Hydroxyurea (Siklos) (CP.PMN.193) - Effective 2/19/2019 (PDF)
- Ibalizumab-uiyk (Trogarzo) (CP.PHAR.378) - Effective 6/1/2018 (PDF)
- Ibandronate Injection (Boniva) (CP.PHAR.189) - Effective 11/15/2017 (PDF)
- Ibrutinib (Imbruvica) (CP.PHAR.126) - Effective 10/1/2015 (PDF)
- Ibuprofen/Famotidine (Duexis) (CP.PMN.120) - Effective 6/1/2018 (PDF)
- Icatibant (Firazyr) (CP.PHAR.178) - Effective 3/1/2016 (PDF)
- Icosapent Ethyl (Vascepa) (CP.PMN.187) - Effective 3/1/2019 (PDF)
- Idelalisib (Zydelig) (CP.PHAR.133) - Effective 12/1/2018 (PDF)
- Idursulfase (Elaprase) (CP.PHAR.156) - Effective 2/1/2016 (PDF)
- Iloperidone (Fanapt) (CP.PMN.32) - Effective 9/1/2015 (PDF)
- Iloprost (Ventavis) (CP.PHAR.193) - Effective 3/1/2016 (PDF)
- Imatinib (Gleevec) (CP.PHAR.65) - Effective 6/1/2011 (PDF)
- Imiglucerase (Cerezyme) (CP.PHAR.154) - Effective 2/1/2016 (PDF)
- Immune Globulins (CP.PHAR.103) - Effective 8/1/2012 (PDF)
- IncobotulinumtoxinA (Xeomin) (CP.PHAR.231) - Effective 7/1/2016 (PDF)
- Indacaterol (Arcapta Neohaler) (CP.PMN.203) - Effective 9/1/2018 (PDF)
- Indacaterol-Glycopyrrolate (Utibron Neohaler) (HIM.PA.102) - Effective 9/1/2018 (PDF)
- Infertility and Fertility Preservation (CP.PHAR.131) - Effective 11/16/2016 (PDF)
- Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) (CP.PHAR.254) - Effective 7/1/2016 (PDF)
- Inotersen (Tegsedi) (CP.PHAR.405) - Effective 11/20/2018 (PDF)
- Inotuzumab Ozogamicin (Besponsa) (CP.PHAR.359) - Effective 9/26/2017 (PDF)
- Insulin Degludec (Tresiba) (HIM.PA.09) - Effective 3/1/2019 (PDF)
- Insulin Infusion Pump (Omnipod, Omnipod DASH) (CP.PHAR.420) - Effective 4/23/2019 (PDF)
- Interferon Beta-1a (Avonex, Rebif) (CP.PHAR.255) - Effective 9/1/2016 (PDF)
- Interferon Beta-1b (Betaseron, Extavia) (CP.PHAR.256) - Effective 8/1/2016 (PDF)
- Interferon Gamma-1b (Actimmune) (CP.PHAR.52) - Effective 6/1/2010 (PDF)
- Iobenguane I-131 (Azedra) (CP.PHAR.459) - Effective 3/1/2020 (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) - Effective 4/17/2018 (PDF)
- Irinotecan Liposome (Onivyde) (CP.PHAR.304) - Effective 2/1/2017 (PDF)
- Isavuconazonium (Cresemba) (CP.PMN.154) - Effective 11/16/2016 (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (CP.PMN.143) - Effective 12/1/2014 (PDF)
- Istradefylline (Nourianz) (CP.PMN.217) - Effective 3/1/2020 (PDF)
- Itraconazole (Sporanox, Onmel, Tolsura) (CP.PMN.124) - Effective 11/1/2006 (PDF)
- Ivabradine (Corlanor) (CP.PMN.70) - Effective 11/1/2015 (PDF)
- Ivacaftor (Kalydeco) (CP.PHAR.210) - Effective 5/1/2016 (PDF)
- Ivermectin (Sklice) (HIM.PA.124) - Effective 12/1/2017 (PDF)
- Ivosidenib (Tibsovo) (CP.PHAR.137) - Effective 8/21/2018 (PDF)
- Ixazomib (Ninlaro) (CP.PHAR.302) - Effective 2/1/2017 (PDF)
- Lanadelumab-fylo (Takhzyro) (CP.PHAR.396) - Effective 9/25/2018 (PDF)
- Lanreotide (Somatuline Depot) (CP.PHAR.391) - Effective 8/14/2018 (PDF)
- Lapatinib (Tykerb) (CP.PHAR.79) - Effective 10/1/2011 (PDF)
- Laronidase (Aldurazyme) (CP.PHAR.152) - Effective 2/1/2016 (PDF)
- Larotrectinib (Vitrakvi) (CP.PHAR.414) - Effective 1/15/2018 (PDF)
- Lasmiditan (Reyvow) (CP.PMN.218) - Effective 3/1/2020 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) (CP.PCH.19) - Effective 11/1/2016 (PDF)
- Lefamulin (Xenleta) (CP.PMN.219) - Effective 3/1/2020 (PDF)
- Lemborexant (Dayvigo) (CP.PMN.233) - Effective 6/1/2020 (PDF)
- Lenalidomide (Revlimid) (CP.PHAR.71) - Effective 7/1/2011 (PDF)
- Lenvatinib (Lenvima) (CP.PHAR.138) - Effective 12/1/2018 (PDF)
- Lesinurad (Zurampic), Duzallo (CP.PMN.150) - Effective 11/16/2016 (PDF)
- Letermovir (Prevymis) (CP.PHAR.367) - Effective 3/1/2018 (PDF)
- Leucovorin Injection (CP.PHAR.393) - Effective 12/1/2018 (PDF)
- Leuprolide Acetate (CP.PHAR.173) - Effective 10/1/2016 (PDF)
- Levalbuterol (Xopenex HFA/Inhalation Solution) (CP.PMN.07) - Effective 9/1/2006 (PDF)
- Levoleucovorin (Fusilev) (CP.PHAR.151) - Effective 2/1/2016 (PDF)
- Levomilnacipran (Fetzima) (HIM.PA.125) - Effective 12/1/2017 (PDF)
- Lidocaine Transdermal (Lidoderm, ZTlido) (CP.PMN.08) - Effective 9/1/2006 (PDF)
- Lifitegrast (Xiidra) (CP.PMN.73) - Effective 11/1/2016 (PDF)
- Linaclotide (Linzess) (CP.PMN.71) - Effective 11/1/2015 (PDF)
- Linezolid (Zyvox) (CP.PMN.27) - Effective 9/1/2006 (PDF)
- Lofexidine (Lucemyra) (CP.PMN.152) - Effective 7/31/2018 (PDF)
- Lomustine (Gleostine) (HIM.PA.19) - Effective 8/28/2018 (PDF)
- Lorcaserin (Belviq, Belviq XR) (CP.PCH.03) - Effective 5/1/2017 (PDF)
- Lorlatinib (Lorbrena) (CP.PHAR.406) - Effective 12/11/2018 (PDF)
- Lubiprostone (Amitiza) (CP.PMN.142) - Effective 12/1/2014 (PDF)
- Luliconazole Cream (Luzu) (CP.PMN.166) - Effective 8/28/2018 (PDF)
- Lumacaftor-Ivacaftor (Orkambi) (CP.PHAR.213) - Effective 5/1/2016 (PDF)
- Lumateperone (Caplyta) (CP.PMN.232) - Effective 3/1/2020 (PDF)
- Lurasidone (Latuda) (CP.PMN.50) - Effective 9/1/2015 (PDF)
- Luspatercept-aamt (Reblozyl) (CP.PHAR.450) - Effective 3/1/2020 (PDF)
- Lusutrombopag (Mulpleta) (CP.PHAR.407) - Effective 9/18/2018 (PDF)
- Lutetium Lu 177 Dotatate (Lutathera) (CP.PHAR.384) - Effective 5/22/2018 (PDF)
- Mecamylamine (Vecamyl) (CP.PMN.136) - Effective 6/1/2017 (PDF)
- Mecasermin (Increlex) (CP.PHAR.150) - Effective 3/1/2011 (PDF)
- Mecitentan (Opsumit) (CP.PCH.31) - Effective 3/1/2016 (PDF)
- Megestrol Acetate (Megace ES) (CP.PMN.179) - Effective 12/1/2018 (PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) - Effective 5/1/2016 (PDF)
- Mesalamine (Apriso) (HIM.PA.42) - Effective 9/4/2018 (PDF)
- Metformin ER (Fortamet, Glumetza) (CP.PMN.72) - Effective 12/1/2015 (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep) (CP.PHAR.134) - Effective 12/1/2018 (PDF)
- Methoxsalen (Uvadex) (HIM.PA.17) - Effective 9/4/2018 (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera) (CP.PHAR.238) - Effective 7/1/2016 (PDF)
- Methylnaltrexone Bromide (Relistor) (CP.PMN.169) - Effective 12/1/2018 (PDF)
- Metreleptin (Myalept) (CP.PHAR.425) - Effective 11/16/2016 (PDF)
- Midazolam (Nayzilam) (CP.PMN.211) - Effective 6/25/2019 (PDF)
- Midostaurin (Rydapt) (CP.PHAR.344) - Effective 6/1/2017 (PDF)
- Mifepristone (Korlym) (CP.PHAR.101) - Effective 5/1/2012 (PDF)
- Migalastat (Galafold) (CP.PHAR.394) - Effective 9/11/2018 (PDF)
- Miglustat (Zavesca) (CP.PHAR.164) - Effective 2/1/2016 (PDF)
- Milnacipran (Savella) (CP.PMN.125) - Effective 8/1/2012 (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (CP.PMN.80) - Effective 6/1/2017 (PDF)
- Mitoxantrone (Novantrone) (CP.PHAR.258) - Effective 8/1/2016 (PDF)
- Modafinil (Provigil) (CP.PMN.39) - Effective 5/1/2008 (PDF)
- Mogamulizumab-kpkc (Poteligeo) (CP.PHAR.139) - Effective 9/4/2018 (PDF)
- Mometasone (Nasonex) (HIM.PA.93) - Effective 12/1/2014 (PDF)
- Mometasone Furoate (Sinuva) (CP.PHAR.448) - Effective 3/1/2020 (PDF)
- Montelukast Oral Granules (Singulair) (HIM.PA.129) - Effective 12/1/2017 (PDF)
- Moxetumomab Pasudotox-tdfk (Lumoxiti) (CP.PHAR.398) - Effective 10/16/2018 (PDF)
- Nafarelin Acetate (Synarel) (CP.PHAR.174) - Effective 10/1/2016 (PDF)
- Naloxone (Evzio) (CP.PMN.139) - Effective 11/16/2016 (PDF)
- Naltrexone (Vivitrol) (CP.PHAR.96) - Effective 3/1/2012 (PDF)
- Naproxen Oral Suspension (Naprosyn) (HIM.PA.130) - Effective 12/1/2017 (PDF)
- Naproxen/Esomeprazole (Vimovo) (CP.PMN.117) - Effective 6/1/2018 (PDF)
- Natalizumab (Tysabri) (CP.PHAR.259) - Effective 8/1/2016 (PDF)
- Nebivolol (Bystolic) (HIM.PA.131) - Effective 12/1/2017 (PDF)
- Necitumumab (Portrazza) (CP.PHAR.320) - Effective 3/1/2017 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (CP.PMN.167) - Effective 8/28/2018 (PDF)
- Neratinib (Nerlynx) (CP.PHAR.365) - Effective 12/1/2017 (PDF)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (CP.PMN.118) - Effective 2/13/2018 (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (CP.PMN.158) - Effective 9/1/2006 (PDF)
- Nilotinib (Tasigna) (CP.PHAR.76) - Effective 9/1/2011 (PDF)
- Nintedanib (Ofev) (CP.PHAR.285) - Effective 11/1/2016 (PDF)
- Nitisinone (Nityr, Orfadin) (CP.PHAR.132) - Effective 8/28/2018 (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) - Effective 8/1/2015 (PDF)
- No Coverage Criteria/Off-Label Use (CP.PMN.53) - Effective 9/12/2017 (PDF)
- Non-Formulary and Formulary Contraceptives (HIM.PA.100) - Effective 5/1/2015 (PDF)
- Non-Formulary Test Strips (HIM.PA.34) - Effective 2/1/2016 (PDF)
- Nusinersen (Spinraza) (CP.PHAR.327) - Effective 3/1/2017 (PDF)
- Obeticholic Aacid (Ocaliva) (CP.PHAR.287) - Effective 11/1/2016 (PDF)
- Obinutuzumab (Gazyva) (CP.PHAR.305) - Effective 2/1/2017 (PDF)
- Ocrelizumab (Ocrevus) (CP.PHAR.335) - Effective 5/1/2017 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (CP.PHAR.40) - Effective 3/1/2010 (PDF)
- Ofatumumab (Arzerra) (CP.PHAR.306) - Effective 2/1/2017 (PDF)
- Olanzapine LA Injection (Zyprexa Relprevv) (CP.PHAR.292) - Effective 12/1/2016 (PDF)
- Olaparib (Lynparza) (CP.PHAR.360) - Effective 10/3/2017 (PDF)
- Olaratumab (Lartruvo) (CP.PHAR.326) - Effective 3/1/2017 (PDF)
- Omadacycline (Nuzyra) (CP.PMN.188) - Effective 3/1/2019 (PDF)
- Omalizumab (Xolair) (CP.PHAR.01) - Effective 10/1/2008 (PDF)
- Omecetaxine (Synribo) (CP.PHAR.108) - Effective 1/0/1900 (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) - Effective 7/1/2016 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) (CP.PHAR.421) - Effective 6/7/2019 (PDF)
- Ondansetron (Zuplenz) (CP.PMN.45) - Effective 9/1/2006 (PDF)
- Ophthalmic Corticosteroids (HIM.PA.03) - Effective 1/1/2020 (PDF)
- Opioid Analgesics* (HIM.PA.139) - Effective 8/1/2018 (PDF)
- Osimertinib (Tagrisso) (CP.PHAR.294) - Effective 12/1/2016 (PDF)
- Ospemifene (Osphena) (CP.PMN.168) - Effective 8/28/2018 (PDF)
- Overactive Bladder Agents (CP.PMN.198) - Effective 5/1/2016 (PDF)
- Ozenoxacin (Xepi) (CP.PMN.119) - Effective 6/1/2018 (PDF)
- Paclitaxel, Protein-Bound (Abraxane) (CP.PHAR.176) - Effective 7/1/2015 (PDF)
- Palbociclib (Ibrance) (CP.PHAR.125) - Effective 10/1/2015 (PDF)
- Paliperidone Long-Acting Injections (Invega Sustenna, Invega Trinza) (CP.PHAR.291) - Effective 12/1/2016 (PDF)
- Palivizumab (Synagis) (CP.PHAR.16) - Effective 8/1/2009 (PDF)
- Panitumumab (Vectibix) (CP.PHAR.321) - Effective 3/1/2017 (PDF)
- Parathyroid Hormone (Natpara) (CP.PHAR.282) - Effective 11/16/2016 (PDF)
- Paricalcitol Injection (Zemplar) (CP.PHAR.270) - Effective 8/1/2016 (PDF)
- Pasireotide (Signifor, Signifor LAR) (CP.PHAR.332) - Effective 3/1/2017 (PDF)
- Patisiran (Onpattro) (CP.PHAR.395) - Effective 9/11/2018 (PDF)
- Pazopanib (Votrient) (CP.PHAR.81) - Effective 10/1/2011 (PDF)
- Peanut Allergen Powder-dnfp (Palforzia) (CP.PMN.220) - Effective 3/1/2020 (PDF)
- Pegademase Bovine (Adagen) (CP.PHAR.392) - Effective 8/28/2018 (PDF)
- Pegaptanib (Macugen) (CP.PHAR.185) - Effective 3/1/2016 (PDF)
- Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (CP.PHAR.353) - Effective 9/5/2017 (PDF)
- Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo) (CP.PHAR.296) - Effective 12/1/2016 (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (CP.PHAR.89) - Effective 10/1/2011 (PDF)
- Peginterferon Beta-1a (Plegridy) (CP.PHAR.271) - Effective 8/1/2016 (PDF)
- Pegloticase (Krystexxa) (CP.PHAR.115) - Effective 6/1/2013 (PDF)
- Pegvaliase-pqpz (Palynziq) (CP.PHAR.140) - Effective 7/31/2018 (PDF)
- Pegvisomant (Somavert) (CP.PHAR.389) - Effective 12/1/2018 (PDF)
- Pembrolizumab (Keytruda) (CP.PHAR.322) - Effective 3/1/2017 (PDF)
- Pemetrexed (Alimta, Pemfexy) (CP.PHAR.368) - Effective 10/31/2017 (PDF)
- Penicillamine (Cuprimine) (CP.PCH.09) - Effective 12/1/2018 (PDF)
- Perampanel (Fycompa) (CP.PMN.156) - Effective 11/16/2016 (PDF)
- Pertuzumab (Perjeta) (CP.PHAR.227) - Effective 6/1/2016 (PDF)
- Pexidartinib (Turalio) (CP.PHAR.436) - Effective 9/3/2019 (PDF)
- Phendimetrazine IR (Bontril PDM) (HIM.PA.114) - Effective 6/1/2017 (PDF)
- Phentermine (Adipex-P, Lomaira) (CP.PCH.13) - Effective 5/1/2017 (PDF)
- Pitolisant (Wakix) (CP.PMN.221) - Effective 3/1/2020 (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) - Effective 3/1/2017 (PDF)
- Polatuzumab Vedotin-piiq (Polivy) (CP.PHAR.433) - Effective 7/9/2019 (PDF)
- Pomalidomide (Pomalyst) (CP.PHAR.116) - Effective 7/1/2013 (PDF)
- Ponatinib (Iclusig) (CP.PHAR.112) - Effective 6/1/2013 (PDF)
- Potassium Chloride for Oral Solution (Klor-Con Powder) (HIM.PA.143) - Effective 10/31/2017 (PDF)
- Pralatrexate (Folotyn) (CP.PHAR.313) - Effective 2/1/2017 (PDF)
- Pramlintide (Symlin) (CP.PMN.129) - Effective 6/1/2018 (PDF)
- Pregabalin (Lyrica, Lyrica CR) (CP.PMN.33) - Effective 1/1/2007 (PDF)
- Pretomanid (CP.PMN.222) - Effective 3/1/2020 (PDF)
- Propranolol HCl Oral Solution (Hemangeol) (CP.PMN.58) - Effective 5/1/2014 (PDF)
- Protein C Concentrate, Human (Ceprotin) (CP.PHAR.330) - Effective 3/1/2017 (PDF)
- Prucalopride (Motegrity) (CP.PMN.194) - Effective 1/29/2019 (PDF)
- Pyrimethamine (Darapim) (CP.PMN.44) - Effective 11/1/2015 (PDF)
- Quetiapine Extended-Release (Seroquel XR) (CP.PMN.64) - Effective 9/1/2015 (PDF)
- Quinine (Qualaquin) (CP.PCH.10) - Effective 12/1/2018 (PDF)
- Ramucirumab (Cyramza) (CP.PHAR.119) - Effective 6/1/2015 (PDF)
- Ranibizumab (Lucentis) (CP.PHAR.186) - Effective 3/1/2016 (PDF)
- Rasagiline (Azilect) (HIM.PA.89) - Effective 12/1/2014 (PDF)
- Ravulizumab-cwvz (Ultomiris) (CP.PHAR.415) - Effective 6/1/2019 (PDF)
- Regorafenib (Stivarga) (CP.PHAR.107) - Effective 12/1/2012 (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel) (CP.PHAR.168) - Effective 3/1/2016 (PDF)
- Reslizumab (Cinqair) (CP.PHAR.223) - Effective 6/1/2016 (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (CP.PHAR.141) - Effective 11/16/2016 (PDF)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (CP.PMN.223) - Effective 3/1/2020 (PDF)
- Rifamycin (Aemcolo) (CP.PMN.196) - Effective 6/1/2019 (PDF)
- Rifaximin (Xifaxan) (CP.PMN.47) - Effective 11/1/2011 (PDF)
- Rilonacept (Arcalyst) (CP.PHAR.266) - Effective 11/16/2016 (PDF)
- RimabotulinumtoxinB (Myobloc) (CP.PHAR.233) - Effective 7/1/2016 (PDF)
- Riociguat (Adempas) (CP.PHAR.195) - Effective 3/1/2016 (PDF)
- Risankizumab-rzaa (Skyrizi) (CP.PHAR.426) - Effective 6/4/2019 (PDF)
- Risedronate (Actonel, Atelvia) (CP.PMN.100) - Effective 3/1/2018 (PDF)
- Risperidone LA Injection (Risperdal Consta, Perseris) (CP.PHAR.293) - Effective 12/1/2016Risankizumab-rzaa (Skyrizi) (CP.PHAR.426) - Effective 6/4/2019 (PDF)
- Rituximab (Rituxan), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (CP.PHAR.260) - Effective 7/1/2016 (PDF)
- Rolapitant (Varubi) (CP.PMN.102) - Effective 2/1/2017 (PDF)
- Romidepsin (Istodax) (CP.PHAR.314) - Effective 1/1/2017 (PDF)
- Romiplostim (Nplate) (CP.PHAR.179) - Effective 3/1/2016 (PDF)
- Romosozumab-aqqg (Evenity) (CP.PHAR.428) - Effective 5/21/2019 (PDF)
- Rucaparib (Rubraca) (CP.PHAR.350) - Effective 9/1/2017 (PDF)
- Rufinamide (Banzel) (CP.PMN.157) - Effective 12/1/2014 (PDF)
- Ruxolitinib (Jakafi) (CP.PHAR.98) - Effective 3/1/2012 (PDF)
- Sacubitril/Valsartan (Entresto) (CP.PMN.67) - Effective 11/1/2015 (PDF)
- Safinamide (Xadago) (CP.PMN.113) - Effective 7/1/2017 (PDF)
- Sapropterin Dihydrochloride (Kuvan) (CP.PHAR.43) - Effective 2/1/2010 (PDF)
- Sarecycline (Seysara) (CP.PMN.189) - Effective 3/1/2019 (PDF)
- Sargramostim (Leukine) (CP.PHAR.295) - Effective 12/1/2016 (PDF)
- Sarilumab (Kevzara) (CP.PHAR.346) - Effective 7/28/2017 (PDF)
- Sebelipase Alfa (Kanuma) (CP.PHAR.159) - Effective 2/1/2016 (PDF)
- Secnidazole (Solosec) (CP.PMN.103) - Effective 3/1/2018 (PDF)
- Secukinumab (Cosentyx) (CP.PHAR.261) - Effective 8/1/2016 (PDF)
- Selexipag (Uptravi®) (CP.PHAR.196) - Effective 3/1/2016 (PDF)
- Selinexor (Xpovio) (CP.PHAR.431) - Effective 7/16/2019 (PDF)
- Selumetinib (Koselugo) (CP.PHAR.464) - Effective 4/10/2020 (PDF)
- Semaglutide (Rybelsus) (HIM.PA.02) - Effective 3/1/2020 (PDF)
- Sildenafil (Revatio) (CP.PHAR.197) - Effective 3/1/2016 (PDF)
- Sildenafil for ED (Viagra) (CP.PCH.07) - Effective 6/1/2018 (PDF)
- Siltuximab (Sylvant) (CP.PHAR.329) - Effective 3/1/2017 (PDF)
- Siponimod (Mayzent) (CP.PHAR.427) - Effective 9/1/2019 (PDF)
- Sipuleucel-T (Provenge) (CP.PHAR.120) - Effective 7/1/2015 (PDF)
- Sodium Oxybate (Xyrem) (CP.PMN.42) - Effective 5/1/2011 (PDF)
- Sodium phenylbutyrate (Buphenyl) (CP.PHAR.208) - Effective 5/1/2016 (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (HIM.PA.91) - Effective 1/1/2015 (PDF)
- Sofosbuvir (Sovaldi) (CP.PCH.20) - Effective 11/1/2016 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) (HIM.PA.SP1) - Effective 8/31/2016 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (HIM.PA.SP63) - Effective 8/1/2020 (PDF)
- Solriamfetol (Sunosi) (CP.PMN.209) - Effective 5/7/2019 (PDF)
- Somatropin (Human Growth Hormone) (CP.PCH.25) - Effective 1/1/2020 (PDF)
- Sonidegib (Odomzo) (CP.PHAR.272) - Effective 5/1/2012 (PDF)
- Sorafenib (Nexavar) (CP.PHAR.69) - Effective 7/1/2011 (PDF)
- Spinosad (Natroba) (HIM.PA.134) - Effective 12/1/2017 (PDF)
- Step Therapy (HIM.PA.109) - Effective 8/1/2017 (PDF)
- Stiripentol (Diacomit) (CP.PMN.184) - Effective 9/25/2018 (PDF)
- Sucroferric Oxyhydroxide (Velphoro) (HIM.PA.SP30) - Effective 5/1/2017 (PDF)
- Sunitinib (Sutent) (CP.PHAR.73) - Effective 9/1/2011 (PDF)
- Suvorexant (Belsomra) (CP.PMN.109) - Effective 2/1/2017 (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (CP.PMN.85) - Effective 11/16/2016 (PDF)
- Tadalafil (Adcirca, Alyq) (CP.PHAR.198) - Effective 3/1/2016 (PDF)
- Tadalafil BPH - ED (Cialis) (CP.PMN.132) - Effective 6/1/2018 (PDF)
- Tafamidis (Vyndaqel, Vyndamax) (CP.PHAR.432) - Effective 9/1/2019 (PDF)
- Talazoparib (Talzenna) (CP.PHAR.409) - Effective 11/27/2018 (PDF)
- Taliglucerase Alfa (Elelyso) (CP.PHAR.157) - Effective 2/1/2016 (PDF)
- Tasimelteon (Hetlioz) (CP.PMN.104) - Effective 3/1/2017 (PDF)
- Tavaborole (Kerydin) (CP.PMN.105) - Effective 3/1/2018 (PDF)
- Tazemetostat (Tazverik) (CP.PHAR.452) - Effective 3/1/2020 (PDF)
- Tedizolid (Sivextro) (CP.PMN.62) - Effective 3/1/2015 (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) - Effective 5/1/2013 (PDF)
- Telotristat Ethyl (Xermelo) (CP.PHAR.337) - Effective 6/1/2017 (PDF)
- Temozolomide (Temodar) (CP.PHAR.77) - Effective 9/1/2011 (PDF)
- Temsirolimus (Torisel) (CP.PHAR.324) - Effective 3/1/2017 (PDF)
- Tenapanor (Ibsrela) (CP.PMN.224) - Effective 3/1/2020 (PDF)
- Teprotumumab (Tepezza) (CP.PHAR.465) - Effective 1/21/2020 (PDF)
- Teriflunomide (Aubagio) (CP.PHAR.262) - Effective 8/1/2016 (PDF)
- Teriparatide (Forteo) (CP.PHAR.188) - Effective 11/15/2017 (PDF)
- Tesamorelin (Egrifta) (CP.PHAR.109) - Effective 3/1/2014 (PDF)
- Testosterone (Androderm) (HIM.PA.87) - Effective 12/1/2014 (PDF)
- Testosterone (Testopel) (CP.PHAR.354) - Effective 8/1/2017 (PDF)
- Tetrabenazine (Xenazine) (CP.PHAR.92) - Effective 12/1/2011 (PDF)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (CP.PHAR.377) - Effective 4/3/2018 (PDF)
- Thalidomide (Thalomid) (CP.PHAR.78) - Effective 9/1/2011 (PDF)
- Thioguanine (Tabloid) (CP.PHAR.437) - Effective 9/4/2018 (PDF)
- Thyrotropin alfa (Thyrogen) (CP.PHAR.95) - Effective 3/1/2012 (PDF)
- Tildrakizumab-asmn (Ilumya) (CP.PHAR.386) - Effective 5/1/2018 (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) (CP.PMN.84) - Effective 11/16/2016 (PDF)
- Tisagenlecleucel (Kymriah) (CP.PHAR.361) - Effective 12/1/2017 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (CP.PHAR.211) - Effective 5/1/2016 (PDF)
- Tocilizumab (Actemra) (CP.PHAR.263) - Effective 7/1/2016 (PDF)
- Tofacitinib (Xeljanz, Xeljanz XR) (CP.PHAR.267) - Effective 1/30/2018 (PDF)
- Tolvaptan (Jynarque, Samsca) (CP.PHAR.27) - Effective 6/5/2018 (PDF)
- Topical Acne Treatment (HIM.PA.71) - Effective 12/1/2014 (PDF)
- Topical Diclofenac (Solaraze, Flector) (HIM.PA.123) - Effective 12/1/2017 (PDF)
- Topical Immunomodulators (CP.PMN.107) - Effective 9/1/2006 (PDF)
- Topotecan (Hycamtin) (CP.PHAR.64) - Effective 6/1/2011 (PDF)
- Trabectedin (Yondelis) (CP.PHAR.204) - Effective 5/1/2016 (PDF)
- Trametinib (Mekinist) (CP.PHAR.240) - Effective 7/1/2016 (PDF)
- Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase (CP.PHAR.228) - Effective 6/1/2016 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (CP.PHAR.199) - Effective 3/1/2016 (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) - Effective 12/11/2018 (PDF)
- Triclabendazole (Egaten) (CP.PMN.207) - Effective 4/2/2019 (PDF)
- Trientine (Syprine) (CP.PHAR.438) - Effective 12/1/2018 (PDF)
- Trifarotene (Aklief) (CP.PMN.225) - Effective 3/1/2020 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur) (CP.PHAR.175) - Effective 10/1/2016 (PDF)
- Ubrogepant (Ubrelvy) (CP.PHAR.476) - Effective 6/1/2020 (PDF)
- Umeclidinium/Vilanterol (Anoro Ellipta) (HIM.PA.106) - Effective 9/1/2018 (PDF)
- Unoprostone Isopropyl (Rescula) (HIM.PA.11) - Effective 9/4/2018 (PDF)
- Uridine triacetate (Vistogard) (HIM.PA.SP55) - Effective 12/1/2017 (PDF)
- Ustekinumab (Stelara) (CP.PHAR.264) - Effective 8/1/2016 (PDF)
- Valganciclovir (Valcyte) (CP.PCH.06) - Effective 12/1/2017 (PDF)
- Valproate (Depacon) (CP.PHAR.429) - Effective 6/4/2019 (PDF)
- Valrubicin (Valstar) (CP.PHAR.439) - Effective 9/4/2018 (PDF)
- Vandetanib (Caprelsa) (CP.PHAR.80) - Effective 10/1/2011 (PDF)
- Vedolizumab (Entyvio) (CP.PHAR.265) - Effective 7/1/2016 (PDF)
- Velaglucerase Alfa (VPRIV) (CP.PHAR.163) - Effective 2/1/2016 (PDF)
- Vemurafenib (Zelboraf) (CP.PHAR.91) - Effective 11/1/2011 (PDF)
- Verteporfin (Visudyne) (CP.PHAR.187) - Effective 3/1/2016 (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (CP.PHAR.374) - Effective 1/9/2018 (PDF)
- Vigabatrin (Sabril) (CP.PHAR.169) - Effective 2/1/2016 (PDF)
- Vilazodone (Viibryd) (CP.PMN.145) - Effective 8/1/2012 (PDF)
- Vincristine Liposome (Marqibo) (CP.PHAR.315) - Effective 2/1/2017 (PDF)
- Vismodegib (Erivedge) (CP.PHAR.273) - Effective 8/1/2016 (PDF)
- Vorapaxar (Zontivity) (HIM.PA.146) - Effective 10/31/2017 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) (CP.PHAR.372) - Effective 3/1/2018 (PDF)
- Vorinostat (Zolinza) (CP.PHAR.83) - Effective 12/1/2012 (PDF)
- Vortioxetine (Trintellix) (CP.PMN.65) - Effective 5/1/2015 (PDF)
- Voxelotor (Oxbryta) (CP.PHAR.451) - Effective 3/1/2020 (PDF)
- Zanubrutinib (Brukinsa) (CP.PHAR.467) - Effective 3/1/2020 (PDF)
- Ziv-aflibercept (Zaltrap) (CP.PHAR.325) - Effective 3/1/2017 (PDF)
- Zoledronic Acid (Reclast, Zometa) (CP.PHAR.59) - Effective 3/1/2011 (PDF)