Policy Title | Policy Number | Effective Date |
---|
Abaloparatide (Tymlos) (PDF) | CP.PHAR.345 | February 1, 2024 |
Abametapir (Xeglyze) (PDF) | CP.PMN.253 | December 1, 2023 |
Abatacept (Orencia) | CP.PHAR.241 | July 1, 2024 |
Abemaciclib (Verzenio) (PDF) | CP.PHAR.355 | December 1, 2023 |
Abiraterone (Zytiga) (PDF) | CP.PHAR.84 | April 1, 2024 |
AbobotulinumtoxinA (Dysport) (PDF) | CP.PHAR.230 | July 1, 2024 |
Abrocitinib (Cibinqo) (PDF) | CP.PHAR.578 | September 1, 2024 |
Acalabrutinib (Calquence) | CP.PHAR.366 | February 1, 2024 |
Acyclovir Buccal tab (Sitavig) (PDF) | CP.PMN.210 | December 1, 2023 |
Adagrasib (Krazati) (PDF) | CP.PHAR.605 | September 1, 2024 |
ADAMTS13, recombinant-krhn (Adzynma) (PDF) | CP.PHAR.635 | August 1, 2024 |
Adefovir (Hepsera) (PDF) | CP.PHAR.142 | December 1, 2023 |
Ado-Trastuzumab Emtansine (Kadcyla) (PDF) | CP.PHAR.229 | June 1, 2024 |
Aducanumab (Aduhelm) (PDF) | CP.PHAR.468 | June 1, 2024 |
Afamelanotide (Scenesse) (PDF) | CP.PHAR.444 | February 1, 2024 |
Afatinib (Gilotrif) (PDF) | CP.PHAR.298 | June 1, 2023 |
Aflibercept (Eylea) (PDF) | CP.PHAR.184 | September 1, 2024 |
Agalsidase Beta (Fabrazyme) (PDF) | CP.PHAR.158 | July 1, 2024 |
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) | CP.PMN.138 | June 1, 2024 |
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) | CP.PMN.138 | Retire to June 1, 2024 |
Alectinib (Alecensa) (PDF) | CP.PHAR.369 | August 1, 2024 |
Alemtuzumab (Lemtrada) (PDF) | CP.PHAR.243 | June 1, 2024 |
Alendronate (Binosto, Fosamax plus D) (PDF) | CP.PMN.88 | February 1, 2024 |
Alglucosidase (Lumizyme) (PDF) | CP.PHAR.160 | July 1, 2024 |
Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft) (PDF) | CP.PHAR.562 | February 1, 2024 |
Allogenic processed thymus tissue-agdc (Rethymic) (PDF) | CP.PHAR.563 | February 1, 2024 |
Alpelisib (Piqray) (PDF) | CP.PHAR.430 | September 1, 2024 |
Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF) | CP.PHAR.94 | February 1, 2024 |
Amantadine ER (Gocovri,Osmolex ER) (PDF) | CP.PMN.89 | February 1, 2024 |
Ambrisentan (Letairis®) (PDF) | CP.PHAR.190 | February 1, 2024 |
Amifampridine (Firdapse)(PDF) | CP.PHAR.411 | April 1, 2024 |
Amikacin (Arikayce)(PDF) | CP.PHAR.401 | September 1, 2024 |
Amisulpride (Barhemsys)(PDF) | CP.PMN.236 | October 1, 2024 |
Amisulpride (Barhemsys)(PDF) | CP.PMN.236 | Retire by October 1, 2024 |
Amivantamab-vmjw (Rybrevant) (PDF) | CP.PHAR.544 | September 1, 2024 |
Anifrolumab-fnia (Saphnelo) (PDF) | CP.PHAR.551 | January 1. 2024 |
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) | CP.PHAR.217 | February 1, 2024 |
Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF) | CP.PHAR.506 | January 1, 2024 |
Antithrombin III (ATryn, Thrombate III) (PDF) | CP.PHAR.564 | February 1, 2024 |
Apalutamide (Erleada) (PDF) | CP.PCH.45 | July 1, 2024 |
Apomorphine (Apokyn) (PDF) | CP.PHAR.488 | September 1, 2024 |
Aprepitant (Emend®) (PDF) | CP.PMN.19 | September 1, 2024 |
Aprocitentan (Tryvio) (PDF) | CP.PHAR.676 | June 1, 2024 |
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF) | CP.PHAR.290 | September 1, 2024 |
Aripiprazole ODT (Abilify) (PDF) | CP.PCH.37 | September 1, 2024 |
Armodafinil (Nuvigil) (PDF) | CP.PMN.35 | June 1, 2024 |
Asciminib (Scemblix) (PDF) | CP.PHAR.565 | October 1, 2024 |
Asenapine (Saphris) (PDF) | CP.PMN.15 | September 1, 2024 |
Asfotase Alfa (Strensiq) (PDF) | CP.PHAR.328 | September 1, 2024 |
Aspirin-dipyridamole (Aggrenox) (PDF) | CP.PMN.20 | February 1, 2024 |
Atezolizumab (Tecentriq) (PDF) | CP.PHAR.235 | April 1, 2024 |
Atidarsagene autotemcel (OTL-200) (PDF) | CP.PHAR.602 | September 1, 2024 |
Atogepant (Qulipta) (PDF) | CP.PHAR.566 | December 1, 2023 |
Avacopan (Tavneos) (PDF) | CP.PHAR.515 | February 1, 2024 |
Avacincaptad pegol (Izervay) (PDF) | CP.PHAR.641 | May 1, 2024 |
Avalglucosidase alfa-ngpt (Nexviazyme) (PDF) | CP.PHAR.521 | July 1, 2024 |
Avapritinib (Ayvakit) (PDF) | CP.PHAR.454 | February 1, 2024 |
Avatrombopag (Doptelet) (PDF) | CP.PHAR.130 | December 1, 2023 |
Avelumab (Bavencio) (PDF) | CP.PHAR.333 | February 1, 2024 |
axicabtagene ciloleucel (Yescarta®) (PDF) | CP.PHAR.362 | February 1, 2024 |
Axitinib (Inlyta) (PDF) | CP.PHAR.100 | April 1, 2024 |
Azacitidine (Vidaza) (PDF) | CP.PHAR.387 | December 1, 2023 |
Azelaic Acid (Finacea) (PDF) | HIM.PA.119 | December 1, 2023 |
Aztreonam (Cayston) (PDF) | CP.PHAR.209 | September 1, 2024 |
Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) | CP.PHAR.149 | December 1, 2023 |
Baloxavir Marboxil (Xofluza) (PDF) | CP.PMN.185 | May 1, 2024 |
Bamlanivimab-etesevimab (LY-CoV555-LY-CoV016) (PDF) | CP.PHAR.532 | July 1, 2023 |
Bardoxolone Methyl (RTA 402) (PDF) | CP.PHAR.560 | December 1, 2023 |
Bedaquiline (Sirturo) (PDF) | CP.PMN.212 | September 1, 2024 |
Belatacept (Nulojix®) (PDF) | CP.PHAR.201 | December 1, 2023 |
Belimumab (Benlysta) (PDF) | CP.PHAR.88 | October 1, 2024 |
Belinostat (Beleodaq®) (PDF) | CP.PHAR.311 | December 1, 2023 |
Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet) (PDF) | CP.PMN.237 | September 1, 2024 |
Bendamustine (Bendeka®, Treanda®) (PDF) | CP.PHAR.307 | January 1, 2024 |
Benralizumab (Fasenra) (PDF) | CP.PHAR.373 | July 1, 2024 |
Benznidazole (PDF) | CP.PMN.90 | February 1, 2024 |
Berdazimer (Zelsuvmi) (PDF) | CP.PMN.293 | June 1, 2024 |
Beremagene Geperpavec (Vyjuvek) (PDF) | CP.PHAR.592 | September 1, 2024 |
Betaine (Cystadane) (PDF) | CP.PHAR.143 | December 1, 2024 |
Betaine (Cystadane) (PDF) | CP.PHAR.143 | Retire by December 1, 2024 |
Betibeglogene autotemcel (PDF) | CP.PHAR.545 | October 1, 2024 |
Betibeglogene autotemcel (PDF) | CP.PHAR.545 | Retire by October 1, 2024 |
Bevacizumab (Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev) (PDF) | CP.PHAR.93 | August 1, 2024 |
Bexarotene (Targretin) (PDF) | CP.PHAR.75 | July 1, 2024 |
Bezlotoxumab (Zinplava) (PDF) | CP.PHAR.300 | February 1, 2024 |
Belantamab mafodotin (Blenrep) (PDF) | CP.PHAR.469 | June 1, 2024 |
Belumosudil (Rezurock) (PDF) | CP.PHAR.552 | December 1, 2023 |
Belzutifan (Welireg) (PDF) | CP.PHAR.553 | February 1, 2024 |
Berotralstat (Orladeyo) (PDF) | HIM.PA.169 | September 1, 2024 |
Betamethasone Dipropionate Spray (Sernivo) (PDF) | CP.PMN.182 | December 1, 2023 |
Bimatoprost Implant (Durysta) (PDF) | CP.PHAR.486 | June 1, 2024 |
Binimetinib (Mektovi) (PDF) | CP.PHAR.50 | July 1, 2024 |
Biologic and Non-biologic DMARDs (PDF) | HIM.PA.SP60 | November 1, 2024 |
Biologic and Non-biologic DMARDs (PDF) | HIM.PA.SP60 | Retire by November 1, 2024 |
Birch Triterpenes (Filsuvez) (PDF) | CP.PHAR.669 | July 1, 2024 |
Blinatumomab (Blincyto) (PDF) | CP.PHAR.312 | November 1, 2024 |
Blinatumomab (Blincyto) (PDF) | CP.PHAR.312 | Retire by November 1, 2024 |
Bortezomib (Velcade) (PDF) | CP.PHAR.410 | February 1, 2024 |
Bosentan (Tracleer®) (PDF) | CP.PHAR.191 | February 1, 2024 |
Bosutinib (Bosulif) (PDF) | CP.PHAR.105 | August 1, 2024 |
Brand Name Override and Non-Formulary Medications (PDF) | HIM.PA.103 | August 1, 2024 |
Brentuximab Vedotin (Adcetris) (PDF) | CP.PHAR.303 | October 1, 2024 |
Brentuximab Vedotin (Adcetris) (PDF) | CP.PHAR.303 | Retire by October 1, 2024 |
Brexanolone (Zulresso) (PDF) | CP.PHAR.417 | June 1, 2024 |
Brexpiprazole (Rexulti) (PDF) | CP.PMN.68 | September 1, 2024 |
Brexucabtagene Autoleucel (Tecartus) (PDF) | CP.PHAR.472 | April 1, 2024 |
Brigatinib (Alunbrig) (PDF) | CP.PHAR.342 | July 1, 2024 |
Brolucizumab-dbll (Beovu) (PDF) | CP.PHAR.445 | February 1, 2024 |
Brimonidine Tartrate (Mirvaso) (PDF) | CP.PMN.192 | June 1, 2024 |
Brinzolamide/Brimonidine (Simbrinza) (PDF) | HIM.PA.15 | December 1, 2023 |
Brivaracetam (Briviact) (PDF) | CP.PCH.26 | September 1, 2024 |
Budesonide (Eohilia, Uceris) (PDF) | CP.PMN.294 | June 1, 2024 |
Budesonide (Tarpeyo) (PDF) | CP.PHAR.572 | September 1, 2024 |
Buprenorphine (Sublocade, Brixaldi) (PDF) | CP.PHAR.289 | August 1, 2024 |
Bupropion/Naltrexone (Contr07e) (PDF) | CP.PCH.12 | July 1, 2024 |
Burosumab-twza (Crysvita) (PDF) | CP.PHAR.11 | October 1, 2024 |
Burosumab-twza (Crysvita) (PDF) | CP.PHAR.11 | Retire by October 1, 2024 |
Burprenorphine (Brixadi) (PDF) | CP.PHAR.498 | Pending FDA Approval |
Buprenorphine/Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) | CP.PMN.81 | August 1, 2024 |
Buprenorphine (Subutex) | CP.PMN.82 | August 1, 2024 |
Butorphanol Nasal Spray (PDF) | HIM.PA.46 | June 1, 2024 |
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) | HIM.PA.170 | September 1, 2024 |
cabazitaxel (Jevtana®) (PDF) | CP.PHAR.316 | June 1, 2024 |
Cabotegravir, Cabotegravir-Rilpivirine (Apretude Cabenuva) (PDF) | CP.PHAR.573 | October 1, 2024 |
Cabozantinib (Cometriq®, Cabometyx®) (PDF) | CP.PHAR.111 | April 1, 2024 |
Calcifediol (Rayaldee) (PDF) | CP.PMN.76 | September 1, 2024 |
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) | CP.PMN.181 | December 1, 2023 |
Canakinumab (Ilaris) (PDF) | CP.PHAR.246 | July 1, 2024 |
Cannabidiol (Epidiolex) (PDF) | CP.PMN.164 | September 1, 2024 |
Capecitabine (Xeloda) (PDF) | CP.PHAR.60 | June 1, 2024 |
Capivasertib (Truqap) (PDF) | CP.PHAR.663 | February 1, 2024 |
Caplacizumab-yhdp (Cablivi) (PDF) | CP.PHAR.416 | June 1, 2024 |
Capmatinib (Tabrecta) (PDF) | CP.PHAR.494 | September 1, 2024 |
Carbetocin (PDF) | CP.PHAR.546 | Pending FDA Approval |
Carbidopa-Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa) (PDF) | CP.PMN.238 | September 1, 2024 |
Carfilzomib (Kyprolis®) (PDF) | CP.PHAR.309 | January 1, 2024 |
Carglumic acid (Carbaglu®) (PDF) | CP.PHAR.206 | February 1, 2024 |
Cariprazine (Vraylar) (PDF) | CP.PMN.91 | October 1, 2024 |
Cariprazine (Vraylar) (PDF) | CP.PMN.91 | Retire by October 1, 2024 |
Casimersen (Amondys 45) (PDF) | CP.PHAR.470 | April 1, 2024 |
Casirivimab and imdevimab (REGEN-COV) (PDF) | CP.PHAR.520 | July 1, 2023 |
Celecoxib (Celebrex) (PDF) | CP.PMN.122 | December 1, 2023 |
Cemiplimab-rwlc (Libtayo) (PDF) | CP.PHAR.397 | January 1, 2024 |
Cenegermin-bkbj (Oxervate)(PDF) | CP.PMN.186 | February 1, 2024 |
Cenobamate (Xcopri) (PDF) | CP.PMN.231 | February 1, 2024 |
Ceritinib (Zykadia) (PDF) | CP.PHAR.349 | June 1, 2024 |
Cerliponase alfa (Brineura) (PDF) | CP.PHAR.338 | October 1, 2024 |
Cetuximab (Erbitux®) (PDF) | CP.PHAR.317 | January 1, 2024 |
Chenodiol (Chenodal) (PDF) | CP.PMN.239 | September 1, 2024 |
Chlorambucil (Leukeran) (PDF) | CP.PHAR.554 | December 1, 2023 |
Chloramphenicol Sodium Succinate (PDF) | CP.PHAR.388 | September 1, 2024 |
Cholic Acid (Cholbam) (PDF) | CP.PHAR.390 | December 1, 2023 |
Ciclopirox (Penlac) (PDF) | CP.PMN.24 | February 1, 2024 |
Ciltacabtagene Autoleucel (Carvykti) (PDF) | CP.PHAR.533 | August 1, 2024 |
Cinacalcet (Sensipar) (PDF) | CP.PHAR.61 | October 1, 2024 |
Cinacalcet (Sensipar) (PDF) | CP.PHAR.61 | Retire by October 1, 2024 |
Cipaglucosidase alfa-miglustat (AT-GAA) (PDF) | CP.PHAR.567 | May 1, 2024 |
Ciprofloxacin-Dexamethasone (Ciprodex) (PDF) | CP.PMN.248 | December 1, 2023 |
Ciprofloxacin/Fluocinolone (Otovel) (PDF) | CP.PMN.249 | December 1, 2023 |
Cladribine (Mavenclad) (PDF) | CP.PHAR.422 | June 1, 2024 |
Clascoterone (Winlevi) (PDF) | CP.PMN.257 | April 1, 2024 |
Clobazam (Onfi) (PDF) | CP.PMN.54 | December 1, 2023 |
CNS Stimulants (PDF) | CP.PMN.92 | February 1, 2024 |
Cobimetinib (Cotellic) (PDF) | CP.PHAR.380 | July 1, 2024 |
Colchicine (Colcrys, Lodoco) (PDF) | CP.PMN.123 | September 1, 2024 |
Colesevelam (Welchol) (PDF) | CP.PMN.250 | December 1, 2023 |
Collagenase (Xiaflex) (PDF) | CP.PHAR.82 | September 1, 2024 |
Colonoscopy Preparation Products (PDF) | CP.PCH.43 | June 1, 2024 |
Compounded Medications (PDF) | CP.PMN.280 | September 1, 2024 |
Concizumab (NN7415) (PDF) | CP.PHAR.625 | June 1, 2024 |
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) | CP.PMN.258 | February 1, 2024 |
Continuous Glucose Monitors (PDF) | CP.PMN.214 | December 1, 2023 |
Copanlisib (Aliqopa®) (PDF) | CP.PHAR.357 | December 1, 2023 |
Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF) | CP.PHAR.385 | September 1, 2024 |
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) (PDF) | HIM.PA.168 | July 1, 2024 |
Cosyntropin (Cortrosyn) (PDF) | CP.PHAR.203 | February 1, 2024 |
Crisaborole (Eucrisa) (PDF) | CP.PMN.110 | June 1, 2024 |
Crizanlizumab-tmca (Adakveo) (PDF) | CP.PHAR.449 | February 1, 2024 |
Crizotinib (Xalkori) (PDF) | CP.PHAR.90 | June 1, 2024 |
Crovalimab (PDF) | CP.PHAR.664 | October 1, 2024 |
Cyclosporine (Restasis, Cequa) (PDF) | CP.PMN.48 | June 1, 2024 |
Cysteamine ophthalmic (Cystaran) (PDF) | CP.PMN.130 | June 1, 2024 |
Cysteamine oral (Cystagon, Procysbi) (PDF) | CP.PHAR.155 | June 1, 2024 |
Cytomegalovirus Immune Globulin (Cytogam) (PDF) | CP.PHAR.277 | September 1, 2024 |
Dabrafenib (Tafinlar) (PDF) | CP.PHAR.239 | July 1, 2024 |
Dacomitinib (Vizimpro) (PDF) | CP.PHAR.399 | December 1, 2023 |
Dalfampridine (Ampyra) (PDF) | CP.PHAR.248 | June 1, 2024 |
Dalteparin (Fragmin) (PDF) | CP.PHAR.225 | February 1, 2024 |
Danicopan (ALXN2040) (PDF) | CP.PHAR.665 | October 1, 2024 |
Daprodustat (Jesduvroq) (PDF) | CP.PHAR.628 | August 1, 2024 |
Daptomycin (Cubicin, Cubicin RF) (PDF) | CP.PHAR.351 | September 1, 2024 |
Dapsone (Aczone Gel) (PDF) | CP.PCH.32 | April 1, 2024 |
Daratumumab (Darzalex) (PDF) | CP.PHAR.310 | September 1, 2024 |
Darbepoetin alfa (Aranesp) (PDF) | CP.PHAR.236 | August 1, 2024 |
Darolutamide (Nubeqa) (PDF) | CP.PHAR.435 | December 1, 2023 |
Dasabuvir-Ombitasvir-Paritaprevir-Ritonavir (Viekira Pak) (PDF) | HIM.PA.SP61 | September 1, 2024 |
Dasatinib (Sprycel) (PDF) | CP.PHAR.72 | August 1, 2024 |
Dasiclucagon (ZP4207) (PDF) | CP.PHAR.642 | December 1, 2023 |
DaxibotulinumtoxinA-lanm (Daxxify) (PDF) | CP.PHAR.651 | May 1, 2024 |
Daunorubicin/cytarabine (Vyxeos®) (PDF) | CP.PHAR.352 | December 1, 2023 |
Decitabine-Cedazuridine (Inqovi) (PDF) | CP.PHAR.479 | August 1, 2024 |
Deferasirox (Exjade Jadenu) (PDF) | CP.PHAR.145 | September 1, 2024 |
Deferoxamine (Desferal) (PDF) | CP.PHAR.146 | September 1, 2024 |
Deflazacort (Emflaza) (PDF) | CP.PHAR.331 | October 1, 2024 |
Deflazacort (Emflaza) (PDF) | CP.PHAR.331 | Retire by October 1, 2024 |
Degarelix acetate (Firmagon®) (PDF) | CP.PHAR.170 | December 1, 2023 |
Delafloxacin (Baxdela) (PDF) | CP.PMN.115 | September 1, 2024 |
Delandistrogene moxeparvovec-rokl (Elevidys) (PDF) | CP.PHAR.593 | November 1, 2024 |
Delandistrogene moxeparvovec-rokl (Elevidys) (PDF) | CP.PHAR.593 | Retire by November 1, 2024 |
Denosumab (Prolia, Xgeva) (PDF) | CP.PHAR.58 | August 1, 2024 |
Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF) | CP.PHAR.214 | February 1, 2024 |
Deutetrabenazine (Austedo) (PDF) | CP.PCH.42 | September 1, 2024 |
Dexrazoxane (Zinecard, Totect) (PDF) | CP.PHAR.418 | July 1, 2024 |
Dextromethorphan-bupropion (Auvelity) (PDF) | CP.PMN.284 | October 1, 2024 |
Dextromethorphan-bupropion (Auvelity) (PDF) | CP.PMN.284 | Retire by October 1, 2024 |
Dextromethorphan-Quinidine (Nuedexta) (PDF) | CP.PMN.93 | February 1, 2024 |
Diazepam Nasal Spray (Valtoco)(PDF) | CP.PMN.216 | July 1, 2024 |
Dichlorphenamide (Keveyis) (PDF) | CP.PMN.261 | February 1, 2024 |
diclofenac sodium topical gel (Solaraze, Voltaren®) (PDF) | CP.PCH.28 | January 1, 2024 |
Dimethyl fumarate (Tecfidera), diroximel fumarate, monomethyl fumarate (PDF) | CP.PHAR.249 | June 1, 2024 |
Enfuvirtide (Fuzeon) (PDF) | CP.PHAR.41 | September 1, 2024 |
Dipeptidyl Peptidase-4 Inhibitors (PDF) | HIM.PA.58 | October 1, 2024 |
Dolasetron (Anzemet) (PDF) | CP.PMN.141 | September 1, 2024 |
Donanemab (LY300281) (PDF) | CP.PHAR.594 | November 1, 2024 |
Donanemab (LY300281) (PDF) | CP.PHAR.594 | Retire by November 1, 2024 |
Donislecel (Lantidra) (PDF) | CP.PHAR.569 | December 1, 2023 |
Dornase alfa (Pulmozyme) (PDF) | CP.PHAR.212 | September 1, 2024 |
Dostarlimab-gxly (Jemperli) (PDF) | CP.PHAR.540 | September 1, 2024 |
Doxepin Hydrochloride Cream (Prudoxin, Zonalon) (PDF) | HIM.PA.147 | December 1, 2023 |
Doxycycline (Doryx, Oracea, Acticlate) (PDF) | CP.PMN.79 | June 1, 2024 |
Dupilumab (Dupixent) (PDF) | CP.PHAR.336 | July 1, 2024 |
Durvalumab (Imfinzi) (PDF) | CP.PHAR.339 | September 1, 2024 |
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) | CP.PMN.128 | June 1, 2024 |
Duvelisib (Copiktra) (PDF) | CP.PHAR.400 | January 1, 2024 |
Ecallantide (Kalbitor) (PDF) | CP.PHAR.177 | September 1, 2024 |
Eculizumab (Soliris) (PDF) | CP.PHAR.97 | October 1, 2024 |
Eculizumab (Soliris) (PDF) | CP.PHAR.97 | Retire by October 1, 2024 |
Edaravone (Radicava) (PDF) | CP.PHAR.343 | June 1, 2024 |
Efgartigimod (ARGX-113) (PDF) | CP.PHAR.555
| February 1, 2024 |
Efinaconazole (Jublia) (PDF) | CP.PMN.25 | February 1, 2024 |
Eflornithine (Iwilfin) (PDF) | CP.PHAR.670 | March 1, 2024 |
Elacestrant (Orserdu) (PDF) | CP.PHAR.623 | June 1, 2024 |
Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) (PDF) | CP.PHAR.136 | December 1, 2023 |
Elapegademase-lvlr (Revcovi) (PDF) | CP.PHAR.419 | June 1, 2024 |
Elbasvir/Grazoprevir (Zepatier) (PDF) | HIM.PA.SP62 | September 1, 2024 |
Elafibranor (Iqirvo) (PDF) | CP.PHAR.688 | September 1, 2024 |
Eliglustat (Cerdelga) (PDF) | CP.PHAR.153 | June 1, 2024 |
Elexacaftor-ivacaftor-tezacaftor (Trikafta) (PDF) | CP.PHAR.440 | September 1, 2024 |
Elosulfase Alfa (Vimizim) (PDF) | CP.PHAR.162 | June 1, 2024 |
Elotuzumab (Empliciti) (PDF) | CP.PHAR.308 | December 1, 2023 |
Elranatamab-bcmm (Elrexfio) (PDF) | CP.PHAR.652 | May 1, 2024 |
Eltrombopag (Promacta®) (PDF) | CP.PHAR.180 | April 1, 2024 |
Eluxadoline (Viberzi) (PDF) | CP.PMN.170 | December 1, 2023 |
Elivaldogene Autotemcel (PDF) | CP.PHAR.556 | December 1, 2023 |
Emapalumab-lzsg (Gamifant)(PDF) | CP.PHAR.402 | April 1, 2024 |
Emicizumab-kxwh (Hemlibra) (PDF) | CP.PHAR.370 | June 1, 2024 |
Emtricitabine-tenofovir alafenamide (Descovy) (PDF) | CP.PMN.235 | August 1, 2024 |
Enasidenib (Idhifa) (PDF) | CP.PHAR.363 | December 1, 2023 |
Encorafenib (Braftovi) (PDF) | CP.PHAR.127 | June 1, 2024 |
Enfuvirtide (Fuzeon) (PDF) | CP.PHAR.41 | July 1, 2021 |
Enfortumab Vedotin-ejfv (Padcev) (PDF) | CP.PHAR.455 | February 1, 2024 |
Enoxaparin (Lovenox) (PDF) | CP.PHAR.224 | February 1, 2024 |
Entecavir (Baraclude) (PDF) | HIM.PA.08 | June 1, 2024 |
Entrectinib (Rozlytrek) (PDF) | CP.PHAR.441 | February 1, 2024 |
Enzalutamide (Xtandi) (PDF) | CP.PHAR.106 | April 1, 2024 |
Enzalutamide (Xtandi) (PDF) | HIM.PA.164 | May 1, 2023 |
Epcoritamab-bysp (Epkinly) (PDF) | CP.PHAR.634 | September 1, 2024 |
Eplontersen (AKCEA-TTR-LRx) (PDF) | CP.PHAR.633 | September 1, 2024 |
Epoetin Alfa (Epogen® and Procrit) (PDF) | CP.PHAR.237 | August 1, 2024 |
Epoprostenol (PDF) | CP.PHAR.192 | February 1, 2024 |
Eptinezumab-jjmr (Vyepti) (PDF) | HIM.PA.SP64 | December 1, 2023 |
Erdafitinib (Balversa) (PDF) | CP.PHAR.423 | September 1, 2024 |
Erenumab-aaoe (Aimovig) (PDF) | HIM.PA.SP65 | December 1, 2023 |
Eribulin Mesylate (Halaven®) (PDF) | CP.PHAR.318 | January 1, 2024 |
Erlotinib (Tarceva) (PDF) | CP.PHAR.74 | June 1, 2024 |
Erwinia Asparaginase (Erwinaze) (PDF) | CP.PHAR.301 | February 1, 2024 |
Esketamine (Spravato) (PDF) | CP.PMN.199 | October 1, 2024 |
Esketamine (Spravato) (PDF) | CP.PMN.199 | Retire by October 1, 2024 |
Esomeprazole-Naproxen (Vimovo) (PDF) | CP.PMN.117 | July 1, 2024 |
Estradiol Vaginal Ring (Femring) (PDF) | CP.PMN.263 | September 1, 2024 |
Etelcalcetide (Parsabiv) (PDF) | CP.PHAR.379 | September 1, 2024 |
Eteplirsen (Exondys 51) (PDF) | CP.PHAR.288 | April 1, 2024 |
Etranacogene Dezaparvovec (Hemgenix) (PDF) | CP.PHAR.580 | February 1, 2024 |
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF) | CP.PHAR.63 | April 1, 2024 |
Evinacumab-dgnb (Evkeeza) (PDF) | CP.PHAR.511 | March 1, 2022 |
Evinacumab-dgnb (Evkeeza) (PDF) | HIM.PA.166 | April 1, 2024 |
Evolocumab (Repatha) (PDF) | HIM.PA.156 | July 1, 2024 |
Exagamglogene autotemcel (Casgevy) (PDF) | CP.PHAR.603 | July 1, 2024 |
Factor IX (Human, Recombinant) (PDF) | CP.PHAR.218 | June 1, 2024 |
Factor IX Complex Human (Bebulin®, Profilnine®) (PDF) | CP.PHAR.219 | June 1, 2024 |
Factor VIIa, Recombinant (NovoSeven® RT) (PDF) | CP.PHAR.220 | September 1, 2024 |
Factor VIII (Human Recombinant) (PDF) | CP.PHAR.215 | June 1, 2024 |
Factor VIII/von Willebrand Factor Complex (Human - Alphanate®, Humate-P®, Wilate®) (PDF) | CP.PHAR.216 | June 1, 2024 |
Factor XIII A-Subunit, Recombinant (Tretten®) | CP.PHAR.222 | February 1, 2024 |
Factor XIII, Human (Corifact®) (PDF) | CP.PHAR.221 | February 1, 2024 |
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF) | CP.PHAR.456 | August 1, 2024 |
Famotidine-Ibuprofen (Duexis) (PDF) | CP.PMN.120 | July 1, 2024 |
Faricimab (Vabysmo) (PDF) | CP.PHAR.581 | October 1, 2024 |
Febuxostat (Uloric) (PDF) | CP.PMN.57 | April 1, 2024 |
Fecal microbiota, live-jslm (Rebyota) (PDF) | CP.PHAR.613 | February 1, 2024 |
Fecal microbiota spores, live-brpk (Vowst) (PDF) | CP.PHAR.632 | September 1, 2024 |
Fedratinib (Inrebic) (PDF) | CP.PHAR.442 | December 1, 2023 |
Fenfluramine (Fintepla) (PDF) | CP.PMN.246 | September 1, 2024 |
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) | CP.PMN.127 | August 1, 2024 |
Ferric Carboxymaltose (Injectafer) (PDF) | CP.PHAR.234 | September 1, 2024 |
Ferric Derisomaltose (Monoferric) (PDF) | CP.PHAR.480 | November 1, 2024 |
Ferric Derisomaltose (Monoferric) (PDF) | CP.PHAR.480 | Retire by November 1, 2024 |
Ferric gluconate (Ferrlecit®) (PDF) | CP.PHAR.166 | July 1, 2023 |
Ferric Maltol (Accrufer) (PDF) | CP.PMN.213 | December 1, 2023 |
Ferric Pyrophosphate Citrate (Triferic) (PDF) | CP.PHAR.624 | June 1, 2024 |
Ferumoxytol (Feraheme®) (PDF) | CP.PHAR.165 | September 1, 2024 |
Fezolinetant (Veozah) (PDF) | CP.PMN.289 | September 1, 2024 |
Fidanacogene Elaparvovec (PDF) | CP.PHAR.643 | October 1, 2024 |
Flibanserin (Addyi) (PDF) | CP.PHAR.446 | December 1, 2023 |
Fibrinogen concentrate (human) (Fibryga, RiaSTAP) (PDF) | CP.PHAR.526 | June 1, 2024 |
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) | CP.PHAR.297 | October 1, 2024 |
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (PDF) | CP.PHAR.297 | Retire by October 1, 2024 |
Finerenone (Kerendia) (PDF) | CP.PMN.266 | December 1, 2023 |
Fingolimod (Gilenya) (PDF) | CP.PCH.38 | June 1, 2024 |
Fluorouracil Cream (Tolak) (PDF) | CP.PMN.165 | December 1, 2023 |
Fluticasone Propionate (Xhance) (PDF) | CP.PMN.95 | September 1, 2024 |
Fondaparinux (Arixtra) (PDF) | CP.PHAR.226 | February 1, 2024 |
Formulary Medications Without Specific Guidelines (PDF) | HIM.PA.33 | August 1, 2024 |
Fosdenopterin (Nulibry) (PDF) | CP.PHAR.471 | June 1, 2024 |
Fostamatinib (Tavalisse) (PDF) | CP.PHAR.24 | April 1, 2024 |
Fostemsavir (Rukobia) (PDF) | CP.PHAR.516 | August 1, 2024 |
Fremanezumb-vfrm (PDF) | HIM.PA.SP66 | December 1, 2023 |
Fruquintinib (Fruzaqla) (PDF) | CP.PHAR.666 | February 1, 2024 |
Fulvestrant (Faslodex Injection) (PDF) | CP.PHAR.424 | October 1, 2024 |
Fulvestrant (Faslodex Injection) (PDF) | CP.PHAR.424 | Retire by October 1, 2024 |
Furosemide (Furoscix) (PDF) | CP.PHAR.608 | February 1, 2024 |
Futibatinib (Lytgobi) (PDF) | CP.PHAR.604 | February 1, 2024 |
Gabapentin ER (Gralise, Horizant) (PDF) | CP.PMN.240 | September 1, 2024 |
Galcanezumab-gnlm (Emgality) (PDF) | HIM.PA.SP67 | December 1, 2023 |
Galsulfase (Naglazyme) (PDF) | CP.PHAR.161 | June 1, 2024 |
Ganaxolone (Ztalmy) (PDF) | CP.PMN.278 | July 1, 2024 |
Garadacimab (CSL312)_PEPP (PDF) | CP.PHAR.673 | June 1, 2024 ( Pending FDA Approval) |
Gefitinib (Iressa) (PDF) | CP.PHAR.68 | June 1, 2024 |
gemtuzumab ozogamicin (Mylotarg®) (PDF) | CP.PHAR.358 | December 1, 2023 |
Gepirone (Exxua) (PDF) | CP.PMN.292 | October 1, 2024 |
Gepirone (Exxua) (PDF) | CP.PMN.292 | Retire by October 1, 2024 |
Gilteritinib (Xospata)(PDF) | CP.PHAR.412 | February 1, 2024 |
Givinostat (ITF2357) (PDF) | CP.PHAR.644 | October 1, 2024 |
Givosiran (Givlaari) (PDF) | CP.PHAR.457 | April 1, 2024 |
Glasdegib (Daurismo)(PDF) | CP.PHAR.413 | February 1, 2024 |
Glatiramer (Copaxone, Glatopa) (PDF) | CP.PHAR.252 | June 1, 2024 |
Glaucoma Agents (Omlonti, Rhopressa, Rocklatan, Vyzulta) (PDF) | CP.PMN.286 | February 1, 2024 |
Glecaprevir-Pibrentasvir (PDF) | HIM.PA.SP36 | September 1, 2024 |
Glofitamab-gxbm (Columvi) (PDF) | CP.PHAR.636 | September 1, 2024 |
Glucagon-Like Peptide-1 Receptor Agonists (PDF) | HIM.PA.53 | February 1, 2024 |
Glycerol phenylbutyrate (Ravicti®) (PDF) | CP.PHAR.207 | May 1, 2024 |
Goserelin acetate (Zoladex®) (PDF) | CP.PHAR.171 | December 1, 2023 |
Granisetron (Kytril, Sancuso, Sustol) (PDF) | CP.PMN.74 | September 1, 2024 |
Halcinonide (Halog) (PDF) | HIM.PA.20 | January 1, 2024 |
Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate) (PDF) | CP.PMN.180 | December 1, 2023 |
Halobetasol Propionate/Tazarotene (Duobrii) (PDF) | CP.PMN.208 | September 1, 2024 |
Hemin (Panhematin®) (PDF) | CP.PHAR.181 | February 1, 2024 |
Histrelin acetate (Vantas®, Supprelin LA®) (PDF) | CP.PHAR.172 | July 1, 2024 |
House dust mite allergen extract (Odactra®) (PDF) | CP.PMN.111 | September 1, 2024 |
Human Growth Hormone (Somapacitan, Somatropin) (PDF) | HIM.PA.161 | September 1, 2024 |
Hyaluronate Derivatives (PDF) | CP.PHAR.05 | August 1, 2024 |
Hydroxyprogesterone Caproate (Makena) (PDF) | CP.PHAR.14 | June 1, 2024 |
Hydroxyurea (Siklos) (PDF) | CP.PMN.193 | August 1, 2024 |
ibalizumab-uiyk (Trogarzo) (PDF) | CP.PHAR.378 | August 1, 2024 |
Ibandronate sodium (PDF) | CP.PHAR.189 | April 1, 2024 |
Ibrutinib (Imbruvica) (PDF) | CP.PHAR.126 | February 1, 2024 |
Icatibant (Firazyr®) (PDF) | CP.PHAR.178 | September 1, 2024 |
Icosapent ethyl (Vascepa) (PDF) | CP.PMN.187 | February 1, 2024 |
Idecabtagene vicleucel (Abecma) (PDF) | CP.PHAR.481 | August 1, 2024 |
Idelalisib (Zydelig) (PDF) | CP.PHAR.133 | December 1, 2023 |
Idursulfase (Elaprase) (PDF) | CP.PHAR.156 | June 1, 2024 |
Iloperidone (Fanapt) (PDF) | CP.PMN.32 | September 1, 2024 |
Iloprost (Ventavis®) (PDF) | CP.PHAR.193 | February 1, 2024 |
Imatinib (Gleevec) (PDF) | CP.PHAR.65 | June 1, 2024 |
Imetelstat (Rytelo) (PDF) | CP.PHAR.690 | September 1, 2024 |
Imiglucerase (Cerezyme) (PDF) | CP.PHAR.154 | June 1, 2024 |
Immune Globulins (PDF) | CP.PHAR.103 | September 1, 2024 |
IncobotulinumtoxinA (Xeomin) (PDF) | CP.PHAR.231 | October 1, 2024 |
Inhaled Agents for Asthma and COPD (PDF) | HIM.PA.153 | July 1, 2024 |
Infertility and Fertility Preservation (PDF) | CP.PHAR.131 | January 1, 2024 |
Inclisiran (Leqvio) (PDF) | CP.PHAR.568 | April 1, 2024 |
Inebilizumab (PDF) | CP.PHAR.458 | October 1, 2024 |
Inebilizumab (PDF) | CP.PHAR.458 | Retire by October 1, 2024 |
Infigratinib (Truseltiq) (PDF) | CP.PHAR.547 | September 1, 2024 |
Inotersen (Tegsedi) (PDF) | CP.PHAR.405 | Retire July 1, 2024 |
Inotersen (Tegsedi) (PDF) | CP.PHAR.405 | July 1, 2024 |
inotuzumab ozogamicin (Besponsa®) (PDF) | CP.PHAR.359 | October 1, 2024 |
inotuzumab ozogamicin (Besponsa®) (PDF) | CP.PHAR.359 | Retire by October 1, 2024 |
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) | CP.PHAR.534 | November 1, 2024 |
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) | CP.PHAR.534 | Retire by November 1, 2024 |
Insulin detemir (Levemir) (PDF) | HIM.PA.171 | January 1, 2024 |
Insulin glargine (Rezvoglar, Semglee, Toujeo) (PDF) | HIM.PA.09 | February 1, 2024 |
Interferon Beta-1b (Betaseron, Extavia) (PDF) | CP.PHAR.255 | June 1, 2024 |
Interferon beta-1b (Betaseron, Extavia) (PDF) | CP.PCH.46 | June 1, 2024 |
Interferon Gamma- 1b (Actimmune) (PDF) | CP.PHAR.52 | February 1, 2024 |
Intrathecal Baclofen (Gablofen, Lioresal) (PDF) | CP.PHAR.149 | December 1, 2023 |
Iobenguane I-131 (Azedra) (PDF) | CP.PHAR.459 | February 1, 2024 |
Ipilimumab (Yervoy) (PDF) | CP.PHAR.319 | June 1, 2024 |
Iptacopan (LNP023) (PDF) | CP.PHAR.656 | October 1, 2024 |
Iptacopan (LNP023) (PDF) | CP.PHAR.656 | Retire by October 1, 2024 |
Irinotecan Liposome (Onivyde®) (PDF) | CP.PHAR.304 | May 1, 2024 |
Iron sucrose (Venofer®) (PDF) | CP.PHAR.167 | July 1, 2023 |
Isatuximab-irfc (Sarclisa) (PDF) | CP.PHAR.482 | June 1, 2023 |
isavuconazonium (Cresemba®) (PDF) | CP.PMN.154 | February 1, 2024 |
Isotretinoin (Claravis, Absorica, Absorica LD, Myorisan, Zenatane, Amnesteem) (PDF) | CP.PMN.143 | September 1, 2024 |
Istradefylline (Nourianz) (PDF) | CP.PMN.217 | February 1, 2024 |
Itraconazole (Sporanox, Onmel) (PDF) | CP.PMN.124 | June 1, 2024 |
Ivabradine (Corlanor) (PDF) | CP.PMN.70 | February 1, 2024 |
Ivacaftor (Kalydeco) (PDF) | CP.PHAR.210 | September 1, 2024 |
Ivermectin (Stromectol, Sklice) | CP.PMN.269 | October 1, 2024 |
Ivermectin (Stromectol, Sklice) | CP.PMN.269 | Retire by October 1, 2024 |
Ivosidenib (Tibsovo) (PDF) | CP.PHAR.137 | February 1, 2024 |
Ixazomib (Ninlaro) (PDF) | CP.PHAR.302 | September 1, 2024 |
Ketamine (Ketalar) (PDF) | CP.PMN.296 | September 1, 2024 |
Ketorolac nasal spray (Sprix) (PDF) | CP.PMN.282 | December 1, 2023 |
Lacosamide (Vimpat) (PDF) | CP.PMN.155 | August 1, 2022 |
L-glutamine (Endari) (PDF) | CP.PMN.116 | December 1, 2023 |
Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) (PDF) | CP.PMN.251 | December 1, 2022 |
Lanadelumab-fylo (Takhzyro) (PDF) | HIM.PA.172 | September 1, 2024 |
Lanreotide (Somatuline Depot) (PDF) | CP.PHAR.391 | August 1, 2024 |
lapatinib (Tykerb®) (PDF) | CP.PHAR.79 | January 1, 2024 |
Laronidase (Aldurazyme) (PDF) | CP.PHAR.152 | June 1, 2024 |
Larotrectinib (Vitrakvi)(PDF) | CP.PHAR.414 | August 1, 2024 |
Lasmiditan (Reyvow) (PDF) | CP.PMN.218 | April 1, 2024 |
Latanoprostene Bunod (Vyzulta) (PDF) | CP.PMN.108 | May 1, 2023 |
Lecanemab-irmb (Leqembi) (PDF) | CP.PHAR.596 | December 1, 2023 |
Ledipasvir-Sofosbuvir (Harvoni) (PDF) | HIM.PA.SP3 | September 1, 2024 |
Lefamulin (Xenleta) (PDF) | CP.PMN.219 | September 1, 2024 |
Lenacapavir (Sunlenca) (PDF) | CP.PHAR.622 | August 1, 2024 |
Lenalidomide (Revlimid) (PDF) | CP.PHAR.71 | July 1, 2024 |
Lenvatinib (Lenvima) (PDF) | CP.PHAR.138 | January 1, 2024 |
Leniolisib (Joenja) (PDF) | CP.PHAR.597 | February 1, 2024 |
Letermovir (Prevymis) (PDF) | CP.PHAR.367 | February 1, 2024 |
Leucovorin Injection (PDF) | CP.PHAR.393 | December 1, 2023 |
Levodopa Inhalation Powder (Inbrija) (PDF) | CP.PMN.267 | December 1, 2023 |
Levoleucovorin (Fusilev, Khapzory) (PDF) | CP.PHAR.151 | December 1, 2023 |
leuprolide acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (PDF) | CP.PHAR.173 | April 1, 2024 |
Levoketoconazole (Recorlev) (PDF) | CP.PMN.275 | June 1, 2024 |
Levomilnacipran (Fetzima) (PDF) | HIM.PA.125 | October 1, 2024 |
Levomilnacipran (Fetzima) (PDF) | HIM.PA.125 | Retire by October 1, 2024 |
Lidocaine transdermal (Lidoderm®) (PDF) | CP.PMN.08 | October 1, 2024 |
Lidocaine transdermal (Lidoderm®) (PDF) | CP.PMN.08 | Retire by October 1, 2024 |
Lifileucel (LN-144) (PDF) | CP.PHAR.598 | June 1, 2024 |
Lifitegrast (Xiidra®) (PDF) | CP.PMN.73 | December 1, 2023 |
Linaclotide (Linzess) (PDF) | CP.PMN.71 | December 1, 2023 |
Linezolid (Zyvox) (PDF) | CP.PMN.27 | October 1, 2024 |
Linezolid (Zyvox) (PDF) | CP.PMN.27 | Retire by October 1, 2024 |
Lisocabtagene maraleucel (Breyanzi) (PDF) | CP.PHAR.483 | August 1, 2024 |
Lofexidine (Lucemyra) (PDF) | CP.PMN.152 | September 1, 2024 |
Lomustine (Gleostine) (PDF) | CP.PHAR.507 | December 1, 2023 |
Lonafarnib (Zokinvy) (PDF) | CP.PHAR.499 | February 1, 2024 |
Loncastuximab tesirine-lpyl (Zynlonta) (PDF) | CP.PHAR.539 | September 1, 2024 |
Lorlatinib (Lorbrena)(PDF) | CP.PHAR.406 | June 1, 2024 |
Loteprednol etabonate (Eysuvis) (PDF) | CP.PMN.260 | February 1, 2024 |
Lotilaner (Xdemvy) (PDF) | CP.PMN.291 | December 1, 2023 |
Lovotibeglogene Autotemcel (Lovo-Cel) (PDF) | CP.PHAR.627 | August 1, 2024 |
Lubiprostone (Amitiza) (PDF) | CP.PMN.142 | December 1, 2023 |
Luliconazole Cream (Luzu) (PDF) | CP.PMN.166 | February 1, 2024 |
Lumacaftor-Ivacaftor (Orkambi) (PDF) | CP.PHAR.213 | September 1, 2024 |
Lumasiran (Oxlumo) (PDF) | CP.PHAR.473 | August 1, 2024 |
Lumateperone (Caplyta) (PDF) | CP.PMN.232 | September 1, 2024 |
Lurbinectedin (Zepzelca) (PDF) | CP.PHAR.500 | September 1, 2024 |
Lurasidone (Latuda) (PDF) | CP.PMN.50 | March 1, 2023 |
Luspatercept-aamt (Reblozyl) (PDF) | CP.PHAR.450 | December 1, 2024 |
Luspatercept-aamt (Reblozyl) (PDF) | CP.PHAR.450 | Retire by December 1, 2024 |
Lusutrombopag (Mulpleta)(PDF) | CP.PHAR.407 | April 1, 2024 |
Lutetium Lu 177 Dotatate (Lutathera) (PDF) | CP.PHAR.384 | September 1, 2024 |
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) 09.09.22.docx | CP.PHAR.582 | June 1, 2024 |
Macitentan (Opsumit) (PDF) | CP.PHAR.194 | February 1, 2024 |
Macitentan (Opsumit®) (PDF) | CP.PCH.31 | March 1, 2022 |
Mannitol (Bronchitol) (PDF) | CP.PHAR.518 | September 1, 2024 |
Maralixibat (Livmarli) (PDF) | CP.PHAR.543 | October 1, 2024 |
Maralixibat (Livmarli) (PDF) | CP.PHAR.543 | Retire by October 1, 2024 |
Margetuximab-cmkb (Margenza) (PDF) | CP.PHAR.522 | February 1, 2024 |
Maribavir (Livtencity) (PDF) | CP.PMN.271 | April 1, 2024 |
Marstacimab (PF-06741086)_PEPP (PDF) | CP.PHAR.674 | June 1, 2024 ( Pending FDA Approval) |
Mavacamten (MYK-461) (PDF) | CP.PMN.272 | September 1, 2024 |
Mavorixafor (Xolremdi) | CP.PHAR.679 | July 1, 2024 |
Mecamylamine (Vecamyl) (PDF) | CP.PMN.136 | June 1, 2024 |
Mecasermin (Increlex) (PDF) | CP.PHAR.150 | October 1, 2024 |
Mecasermin (Increlex) (PDF) | CP.PHAR.150 | Retire by October 1, 2024 |
Mechlorethamine Gel (Valchlor) (PDF) | CP.PHAR.381 | September 1, 2024 |
Megestrol Acetate 125 mg/mL Oral Suspension (Megace ES) (PDF) | CP.PMN.179 | December 1, 2023 |
Melphalan (Hepzato) (PDF) | CP.PHAR.653 | December 1, 2023 |
Melphalan flufenamide (Pepaxto) (PDF) | CP.PHAR.535 | May 1, 2024 |
Memantine (Namenda XR, Namzaric) (PDF) | CP.PCH.30 | September 1, 2024 |
Mepolizumab (Nucala) (PDF) | CP.PHAR.200 | February 1, 2024 |
Mercaptopurine (Purixan) (PDF) | CP.PHAR.447 | August 1, 2024 |
Metformin ER (Glumetza, Fortamet) (PDF) | CP.PMN.72 | February 1, 2024 |
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) | CP.PHAR.134 | August 1, 2024 |
Methoxsalen (Uvadex) (PDF) | HIM.PA.17 | December 1, 2023 |
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) | CP.PHAR.238 | August 1, 2024 |
Methylnaltrexone Bromide (Relistor) (PDF) | CP.PMN.169 | December 1, 2023 |
Metoclopramide (Gimoti) (PDF) | CP.PMN.252 | December 1, 2023 |
Metreleptin (Myalept) (PDF) | CP.PHAR.425 | September 1, 2024 |
Midazolam (Nayzilam) (PDF) | CP.PMN.211 | September 1, 2024 |
Midostaurin (Rydapt) (PDF) | CP.PHAR.344 | July 1, 2024 |
Mifepristone (Korlym) (PDF) | CP.PHAR.101 | February 1, 2024 |
Migalastat (Galafold) (PDF) | CP.PHAR.394 | January 1, 2024 |
Miglustat (Zavesca) (PDF) | CP.PHAR.164 | June 1, 2024 |
Milnacipran (Savella) (PDF) | CP.PMN.125 | October 1, 2024 |
Milnacipran (Savella) (PDF) | CP.PMN.125 | Retire by October 1, 2024 |
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF) | CP.PMN.80 | June 1, 2024 |
Minocycline micronized foam (Amzeeq) (PDF) | CP.PMN.242 | December 1, 2022 |
Mirvetuximab soravtansine-gynx (Elahere) (PDF) | CP.PHAR.617 | July 1, 2024 |
Mitapivat (Pyrukynd) (PDF) | CP.PHAR.558 | December 1, 2023 |
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) | CP.PHAR.495 | September 1, 2024 |
Mitoxantrone (Novantrone) (PDF) | CP.PHAR.258 | July 1, 2024 |
Mixed pollens allergen extract (Oralair) (PDF) | CP.PMN.85 | September 1, 2024 |
Mobocertinib (Exkivity) (PDF) | CP.PHAR.559 | March 1, 2024 |
Modafinil (Provigil) (PDF) | CP.PMN.39 | June 1, 2023 |
Mogamulizumab-kpkc (Poteligeo) (PDF) | CP.PHAR.139 | December 1, 2023 |
Momelotinib (Ojjaara) (PDF) | CP.PHAR.654 | December 1, 2023 |
Mometasone (Nasonex) (PDF) | HIM.PA.93 | October 1, 2024 |
Mometasone (Nasonex) (PDF) | HIM.PA.93 | Retire by October 1, 2024 |
Mometasone Furoate (Sinuva) (PDF) | CP.PHAR.448 | September 1, 2024 |
Montelukast oral granules (Singulair) (PDF) | HIM.PA.129 | December 1, 2023 |
Mosunetuzumab-axgb (Lunsumio) (PDF) | CP.PHAR.618 | February 1, 2024 |
Motixafortide (Aphexda) (PDF) | CP.PHAR.655 | May 1, 2024 |
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) | CP.PHAR.398 | December 1, 2023 |
Nabumatone Double-Strength (Relafen DS) (PDF) | CP.PMN.287 | June 1, 2024 |
Nadofaragene Firadenovec (Instiladrin)(PDF) | CP.PHAR.461 | May 1, 2024 |
Nafarelin acetate (Synarel®) (PDF) | CP.PHAR.174 | July 1, 2024 |
Naldemedine (Symproic) (PDF) | CP.PMN.112 | December 1, 2023 |
Nalmefene (Opvee) (PDF) | CP.PHAR.638 | September 1, 2024 |
Naloxegol (Movantik) (PDF) | HIM.PA.167 | December 1, 2023 |
Naltrexone (Vivitrol) (PDF) | CP.PHAR.96 | August 1, 2024 |
Naproxen oral suspension (Naprosyn) (PDF) | HIM.PA.130 | January 1, 2024 |
Narsoplimab (OMS721) (PDF) | CP.PHAR.527 | June 1, 2024 |
Natalizumab (Tysabri) (PDF) | CP.PHAR.259 | September 1, 2024 |
Naxitamab-gqgk (Danyelza) | CP.PHAR.523 | February 1, 2024 |
Necitumumab (Portrazza®) (PDF) | CP.PHAR.320 | December 1, 2023 |
Nedosiran (DCR-PHXC) (PDF) | CP.PHAR.619 | August 1, 2024 |
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) | CP.PMN.167 | December 1, 2023 |
Neratinib (Nerlynx) (PDF) | CP.PHAR.365 | December 1, 2023 |
Netarsudil (Rhopressa), Netarsudil-Latanoprost (Rocklatan) (PDF) | CP.PMN.118 | May 1, 2023 |
Netupitant and Palonosetron (Akynzeo) (PDF) | CP.PMN.158 | September 1, 2024 |
Nifurtimox (Lampit) ^ (PDF) | CP.PMN.256 | December 1, 2023 |
nilotinib (Tasigna) (PDF) | CP.PHAR.76 | July 1, 2024 |
Nintedanib (Ofev) (PDF) | CP.PHAR.285 | September 1, 2024 |
Nitisinone (Nityr, Orfadin) (PDF) | CP.PHAR.132 | July 1, 2024 |
Niraparib (Zejula) (PDF) | CP.PHAR.408 | February 1, 2024 |
Niraparib and Abiraterone (Akeega) (PDF) | CP.PHAR.645 | December 1, 2023 |
Nirmatrelvir-Ritonavir (Paxlovid) (PDF) | CP.PMN.288 | September 1, 2024 |
Nirogacestat (Ogsiveo) (PDF) | CP.PHAR.671 | July 1, 2024 |
Nirsevimab (Beyfortus) (PDF) | CP.PHAR.614 | September 1, 2024 |
Nitazoxanide (Alinia) (PDF) | HIM.PA.152 | December 1, 2023 |
Nivolumab (Opdivo) (PDF) | CP.PHAR.121 | August 1, 2024 |
Nivolumab and Relatlimab (Opdualag) (PDF) | CP.PHAR.588 | September 1, 2023 |
Nogapendekin alfa inbakicept-pmln (Anktiva) (PDF) | CP.PHAR.684 | September 1, 2024 |
Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) (PDF) | CP.PMN.04 | October 1, 2024 |
Non-Formulary and Formulary Contraceptives (PDF) | HIM.PA.100 | June 1, 2024 |
Non-Formulary Test Strips (PDF) | HIM.PA.34 | February 1, 2024 |
Nusinersen (Spinraza®) (PDF) | CP.PHAR.327 | February 1, 2024 |
Obecabtagene autoleucel (AUTO1)_PEPP (PDF) | CP.PHAR.675 | June 1, 2024 Pending FDA Approval |
Obeticholic acid (Ocaliva) (PDF) | CP.PHAR.287 | September 1, 2024 |
Obinutuzumab (Gazyva®) (PDF) | CP.PHAR.305 | December 1, 2023 |
Ocrelizumab (Ocrevus) (PDF) | CP.PHAR.335 | June 1, 2024 |
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) | CP.PHAR.40 | September 1, 2024 |
Odevixibat (Bylvay) (PDF) | CP.PHAR.528 | June 1, 2024 |
Ofatumumab (Arzerra®) (PDF) | CP.PHAR.306 | June 1, 2024 |
Off-label Policy (PDF) | HIM.PA.154 | August 1, 2024 |
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) | CP.PHAR.292 | September 1, 2024 |
Olanzapine-samidorphan (Lybalvi) (PDF) | CP.PMN.265 | September 1, 2024 |
Olaparib (Lynparza) (PDF) | CP.PHAR.360 | February 1, 2024 |
Olaratumab (Lartruvo®) (PDF) | CP.PHAR.326 | December 1, 2023 |
Olipudase alfa-rpcp (Xenpozyme) 09.08.22.docx | CP.PHAR.586 | September 1, 2024 |
Olutasidenib (Rezlidhia) (PDF) | CP.PHAR.615 | February 1, 2024 |
Omacetaxine (Synribo) (PDF) | CP.PHAR.108 | June 1, 2024 |
Omadacycline (Nuzyra)(PDF) | CP.PMN.188 | September 1, 2024 |
Omalizumab (Xolair) (PDF) | CP.PCH.49 | August 1, 2024 |
Omalizumab (Xolair®) (PDF) | CP.PHAR.01 | August 1, 2024 |
Omaveloxolone (RTA-408) (PDF) | CP.PHAR.590 | June 1, 2024 |
Omburtamab (Omblastys) (PDF) | CP.PHAR.585 | December 1, 2023 |
OnabotulinumtoxinA (Botox) (PDF) | CP.PHAR.232 | July 1, 2024 |
Onasemnogene abeparvovec (Zolgensma) (PDF) | CP.PHAR.421 | September 1, 2024 |
Ondansetron (Zuplenz) (PDF) | CP.PMN.45 | August 1, 2024 |
Ophthalmic Corticosteroids (PDF) | HIM.PA.03 | December 1, 2023 |
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) | CP.PHAR.536 | June 1, 2024 |
Opicapone (Ongentys) (PDF) | CP.PMN.245 | September 1, 2024 |
Opioid Analgesics (PDF) | HIM.PA.139 | June 1, 2024 |
Osilodrostat (Isturisa) (PDF) | CP.PHAR.487 | September 1, 2024 |
Osimertinib (Tagrisso) (PDF) | CP.PHAR.294 | June 1, 2024 |
Ospemifene (Osphena) (PDF) | CP.PMN.168 | December 1, 2023 |
Overactive Bladder Agents (PDF) | CP.PMN.198 | December 1, 2023 |
Oxymetazoline (Rhofade) (PDF) | CP.PMN.86 | June 1, 2024 |
Ozanimod (Zeposia) (PDF) | CP.PHAR.462 | September 1, 2024 |
Ozenoxacin (Xepi) (PDF) | CP.PMN.119 | June 1, 2024 |
Paclitaxel, protein-bound (Abraxane) (PDF) | CP.PHAR.176 | July 1, 2024 |
Pacritinib (Vonjo) (PDF) | CP.PHAR.583 | June 1, 2024 |
Palbociclib (Ibrance) (PDF) | HIM.PA.173 | March 1, 2024 |
Paliperidone inj (Invega Sustenna, Invega Trinza, Invega Hafyera) (PDF) | CP.PHAR.291 | September 1, 2024 |
Palivizumab (Synagis) (PDF) | CP.PHAR.16 | June 1, 2024 |
Palovarotene (PDF) | CP.PHAR.548 | September 1, 2024 |
Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) (PDF) | CP.PCH.44 | May 1, 2024 |
Panitumumab (Vectibix®) (PDF) | CP.PHAR.321 | January 1, 2024 |
Panobinostat (Farydak) (PDF) | CP.PHAR.382 | September 1, 2024 |
Parathyroid Hormone (Natpara) (PDF) | CP.PHAR.282 | February 1, 2024 |
Paricalcitol Injection (Zemplar) (PDF) | CP.PHAR.270 | September 1, 2024 |
Pasireotide (Signifor LAR®) (PDF) | CP.PHAR.332 | September 1, 2024 |
Patiromer (Veltassa) (PDF) | CP.PMN.205 | September 1, 2024 |
Patisiran (Onpattro) (PDF) | CP.PHAR.395 | July 1, 2024 |
Pazopanib (Votrient) (PDF) | CP.PHAR.81 | September 1, 2024 |
Peanut allergen powder (Palforzia) (PDF) | CP.PMN.220 | September 1, 2024 |
Pegaptanib (Macugen) (PDF) | CP.PHAR.185 | May 1, 2023 |
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF) | CP.PHAR.353 | December 1, 2023 |
Pegcetacoplan (Empaveli0 (PDF) | CP.PHAR.524 | October 1, 2024 |
Pegcetacoplan (Empaveli0 (PDF) | CP.PHAR.524 | Retire by October 1, 2024 |
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) | CP.PHAR.296 | October 1, 2024 |
Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) (PDF) | CP.PHAR.296 | Retire by October 1, 2024 |
Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF) | CP.PHAR.89 | September 1, 2024 |
Peginterferon beta-1a (Plegridy) (PDF) | CP.PHAR.271 | June 1, 2024 |
Pegloticase (Krystexxa) (PDF) | CP.PHAR.115 | February 1, 2024 |
Pegunigalsidase Alfa (PRX-102) (PDF) | CP.PHAR.512 | September 1, 2024 |
Pegvaliase-pqpz (Palynziq) (PDF) | CP.PHAR.140 | December 1, 2023 |
Pegvisomant (Somavert) (PDF) | CP.PHAR.389 | September 1, 2024 |
Pembrolizumab (Keytruda®) (PDF) | CP.PHAR.322 | November 1, 2024 |
Pembrolizumab (Keytruda®) (PDF) | CP.PHAR.322 | Retire by November 1, 2024 |
Pemigatinib (Pemazyre) (PDF) | CP.PHAR.496 | September 1, 2024 |
Penicillamine (Cuprimine) (PDF) | CP.PCH.09 | December 1, 2023 |
Pentosan polysulfate sodium (Elmiron) (PDF) | CP.PMN.276 | June 1, 2023 |
Perampanel (Fycompa) (PDF) | CP.PMN.156 | September 1, 2024 |
Perfluorohexyloctane (Miebo) (PDF) | CP.PMN.290 | September 1, 2024 |
Pertuzumab (Perjeta) (PDF) | CP.PHAR.227 | June 1, 2024 |
Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) (PDF) | CP.PHAR.501 | September 1, 2024 |
Pexidartinib (Turalio)(PDF) | CP.PHAR.436 | December 1, 2023 |
Phendimetrazine (PDF) | CP.PCH.47 | July 1, 2024 |
Phentermine (Adipex-P, Lomaira) (PDF) | CP.PCH.13 | July 1, 2024 |
Phentermine-topiramate (Qsymia) (PDF) | CP.CPA.336 | September 1, 2022 |
Pilocarpine (Vuity) (PDF) | CP.PMN.270 | February 1, 2024 |
Pimavanserin (Nuplazid) (PDF) | CP.PMN.140 | September 1, 2024 |
Pirfenidone (Esbriet) (PDF) | CP.PHAR.286 | September 1, 2024 |
Pirtobrutinib (Jaypirca) (PDF) | CP.PHAR.620 | July 1, 2024 |
Pitolisant (Wakix) (PDF) | CP.PMN.221 | September 1, 2024 |
Plasminogen (Ryplazim) (PDF) | CP.PHAR.513 | December 1, 2023 |
Plecanatide (Trulance) (PDF) | CP.PMN.87 | April 1, 2024 |
Plerixafor (Mozobil) (PDF) | CP.PHAR.323 | October 1, 2024 |
Plerixafor (Mozobil) (PDF) | CP.PHAR.323 | Retire by October 1, 2024 |
Polatuzumab Vedotin-piiq (Polivy) (PDF) | CP.PHAR.433 | September 1, 2024 |
Pomalidomide (Pomalyst) (PDF) | CP.PHAR.116 | July 1, 2024 |
Ponatinib (Iclusig) (PDF) | CP.PHAR.112 | August 1, 2024 |
Ponesimod (Ponvory) (PDF) | CP.PHAR.537 | June 1, 2024 |
Potassium (Klor-Con) (PDF) | HIM.PA.143 | February 1, 2024 |
Pozelimab (REGN3918) (PDF) | CP.PHAR.626 | May 1, 2024 |
Prademagene Zamikeracel (EB-101) (PDF) | CP.PHAR.609 | Pending FDA Approval |
Pralatrexate (Folotyn®) (PDF) | CP.PHAR.313 | December 1, 2023 |
Pralsetinib (Gavreto) (PDF) | CP.PHAR.514 | June 1, 2023 |
Pramlintide (Symlin) (PDF) | CP.PMN.129 | May 1, 2024 |
Prasterone (Intrarosa) (PDF) | CP.PMN.99 | February 1, 2024 |
Pregabalin (Lyrica) (PDF) | CP.PMN.33 | July 1, 2024 |
Pretomanid (PDF) | CP.PMN.222 | February 1, 2024 |
Progesterone (Crinone, Endometrin, Milprosa) (PDF) | CP.PMN.243 | September 1, 2024 |
Propranolol (Hemangeol) (PDF) | CP.PCH.51 | June 1, 2024 |
protein c concentrate, human (Ceprotin®) (PDF) | CP.PHAR.330 | February 1, 2024 |
propranolol HCL solution (Hemangeol) (PDF) | CP.PMN.58 | January 1, 2024 |
Prucalopride (Motegrity) (PDF) | HIM.PA.159 | December 1, 2023 |
Pyrimethamine (Daraprim®) (PDF) | CP.PMN.44 | September 1, 2024 |
Quantity Limit Override and Dose Optimization (PDF) | CP.PMN.59 | August 1, 2024 |
Quetiapine ER (Seroquel XR) (PDF) | CP.PMN.64 | October 1, 2024 |
Quetiapine ER (Seroquel XR) (PDF) | CP.PMN.64 | Retire by October 1, 2024 |
Quinine Sulfate (Qualaquin) (PDF) | CP.PMN.262 | July 1, 2024 |
Quizartinib (Vanflyta) (PDF) | CP.PHAR.646 | December 1, 2023 |
Ramucirumab (Cyramza) (PDF) | CP.PHAR.119 | February 1, 2024 |
Ranibizumab (Lucentis) (PDF) | CP.PHAR.186 | February 1, 2024 |
Rasagiline (Azilect®) (PDF) | HIM.PA.89 | September 1, 2024 |
Ravulizumab-cwvz (Ultomiris) (PDF) | CP.PHAR.415 | October 1, 2024 |
Ravulizumab-cwvz (Ultomiris) (PDF) | CP.PHAR.415 | Retire by October 1, 2024 |
Regorafenib (Stivarga) (PDF) | CP.PHAR.107 | July 1, 2024 |
Relugolix (Orgovyx) (PDF) | CP.PHAR.529 | June 1, 2024 |
Remestemcel-L (Ryoncil) (PDF) | CP.PHAR.474 | June 1, 2024 |
Remetirom (PDF) | CP.PHAR.647 | AUgust 1, 2024 |
Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) | CP.PHAR.168 | May 1, 2023 |
Repotrectinib (Augtyro) (PDF) | CP.PHAR.667 | September 1, 2024 |
Respiratory Syncytial Virus Vaccine (Abrysvo) (PDF) | CP.PHAR.658 | January 1, 2024 |
Reslizumab (Cinqair) (PDF) | CP.PHAR.223 | February 1, 2024 |
Retifanlimab-dlwr (Zynyz) (PDF) | CP.PHAR.629 | July 1, 2024 |
Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF) | CP.PHAR.141 | December 1, 2023 |
Ribociclib (Kisqali, Kisqali Femara) (PDF) | CP.PHAR.334 | December 1, 2023 |
Rifabutin (Mycobutin) (PDF) | CP.PMN.223 | April 1, 2024 |
Rifamycin (Aemcolo) (PDF) | CP.PMN.196 | July 1, 2024 |
Rifaximin (Xifaxan®) (PDF) | CP.PMN.47 | December 1, 2023 |
Rilonacept (Arcalyst) (PDF) | CP.PHAR.266 | July 1, 2024 |
Ripretinib (Qinlock) (PDF) | CP.PHAR.502 | September 1, 2024 |
RimabotulinumtoxinB (Myobloc) (PDF) | CP.PHAR.233 | June 1, 2024 |
Rimegepant (Nurtec ODT) (PDF) | CP.PHAR.490 | January 1, 2024 |
Riociguat (Adempas®) (PDF) | CP.PHAR.195 | February 1, 2024 |
Risdiplam (Evrysdi) (PDF) | CP.PHAR.477 | February 1, 2024 |
Risedronate (Actonel, Atelvia) (PDF) | CP.PMN.100 | April 1, 2024 |
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) | CP.PHAR.293 | October 1, 2024 |
Risperidone Long-Acting Injection (Risperdal Consta) (PDF) | CP.PHAR.293 | Retire by October 1, 2024 |
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) | CP.PHAR.260 | August 1, 2024 |
Roflumilast (Daliresp, Zoryve) (PDF) | CP.PMN.46 | September 1, 2024 |
Rolapitant (Varubi) (PDF) | CP.PMN.102 | September 1, 2024 |
Romidepsin (Istodax®) (PDF) | CP.PHAR.314 | December 1, 2023 |
Romiplostim (Nplate®) (PDF) | CP.PHAR.179 | April 1, 2024 |
Romosozumab-aqqg (Evenity) (PDF) | CP.PHAR.428 | April 1, 2024 |
Ropeginterferon alfa-2b-njft (Besremi) (PDF) | CP.PHAR.570 | July 1, 2024 |
Rozanolixizumab-noli (Rystiggo) (PDF) | CP.PHAR.648 | December 1, 2023 |
RP-L201 (PDF) | CP.PHAR.599 | December 1, 2023 |
Rucaparib (Rubraca®) (PDF) | CP.PHAR.350 | February 1, 2024 |
Rufinamide (Banzel) (PDF) | CP.PMN.157 | September 1, 2024 |
Ruxolitinib (Jakafi) (PDF) | CP.PHAR.98 | September 1, 2024 |
Sacituzumab Govitecan-hziy (Trodelvy) (PDF) | CP.PHAR.475 | June 1, 2024 |
Sacubitril/Valsartan (Entresto) (PDF) | CP.PCH.52 | September 1, 2024 |
Safinamide (Xadago) (PDF) | CP.PMN.113 | February 1, 2024 |
Sapropterin (Kuvan) (PDF) | CP.PHAR.43 | July 1, 2024 |
Sarecycline (Seysara) (PDF) | CP.PMN.189 | February 1, 2024 |
Sargramostim (Leukine) (PDF) | CP.PHAR.295 | October 1, 2024 |
Sargramostim (Leukine) (PDF) | CP.PHAR.295 | Retire by October 1, 2024 |
Satralizumab-mwge (Enspryng) (PDF) | CP.PHAR.463 | October 1, 2024 |
Satralizumab-mwge (Enspryng) (PDF) | CP.PHAR.463 | Retire by October 1, 2024 |
Sebelipase Alfa (Kanuma) (PDF) | CP.PHAR.159 | June 1, 2024 |
Secnidazole (Solosec) (PDF) | CP.PMN.103 | February 1, 2024 |
Selexipag (Uptravi®) (PDF) | CP.PHAR.196 | April 1, 2024 |
Selinexor (Xpovio) (PDF) | CP.PHAR.431 | September 1, 2024 |
Selpercatinib (Retevmo) (PDF) | CP.PHAR.478 | November 1, 2024 |
Selpercatinib (Retevmo) (PDF) | CP.PHAR.478 | Retire by November 1, 2024 |
Selumetinib (Koselugo) (PDF) | CP.PHAR.464 | April 1, 2024 |
Semaglutide (Wegovy) (PDF) | CP.PMN.295 | September 1, 2024 |
Setmelanotide (Imcivree) (PDF) | CP.PHAR.491 | February 1, 2024 |
Short ragweed pollen allergen extract (Ragwitek) (PDF) | CP.PMN.83 | September 1, 2024 |
Sildenafil (Revatio®) (PDF) | CP.PHAR.197 | February 1, 2024 |
Sildenafil (Viagra) (PDF) | CP.PCH.07 | June 1, 2024 |
Siponimod (Mayzent) (PDF) | CP.PHAR.427 | Jue 1, 2024 |
Sipuleucel-T (Provenge) (PDF) | CP.PHAR.120 | June 1, 2024 |
Sirolimus Protein-Bound Particles (Fyarro), topical gel (Hyftor) (PDF) | CP.PHAR.574 | February 1, 2024 |
Siltuximab (Sylvant) (PDF) | CP.PHAR.329 | February 1, 2024 |
Sodium Oxybate (Xyrem, Lumryz) and Calcium Magnesium Potassium Sodium Oxybate (Xywav) (PDF) | CP.PMN.42 | November 1, 2024 |
Sodium Oxybate (Xyrem, Lumryz) and Calcium Magnesium Potassium Sodium Oxybate (Xywav) (PDF) | CP.PMN.42 | Retire by November 1, 2024 |
Sodium-Glucose Co-Transporter 2 Inhibitors (PDF) | HIM.PA.91 | September 1, 2024 |
Sodium Phenylbutyrate (Buphenyl) (PDF) | CP.PHAR.208 | February 1, 2024 |
Sodium Phenylbutyrate-Taurursodiol (Relyvrio) 10.06.22.docx | CP.PHAR.584 | August 1, 2024 |
Sodium thiosulfate (Pedmark) (PDF) | CP.PHAR.610 | May 1, 2024 |
Sodium Zirconium Cyclosilicate (Lokelma) (PDF) | CP.PMN.163 | September 1, 2024 |
Sofosbuvir-Velpatasvir (Epclusa) (PDF) | HIM.PA.SP1 | September 1, 2024 |
Sofosbuvir (Sovaldi) (PDF) | HIM.PA.SP2 | September 1, 2024 |
Sofosbuvir-Vepatasvir-Voxilaprevir (Vosevi) (PDF) | HIM.PA.SP63 | September 1, 2024 |
Solriamfetol (Sunosi) (PDF) | CP.PMN.209 | June 1, 2024 |
Sonidegib (Odomzo) (PDF) | CP.PHAR.272 | June 1, 204 |
Sorafenib (Nexavar) (PDF) | CP.PHAR.69 | July 1, 2024 |
Sotatercept (ACE-011) (PDF) | CP.PHAR.657 | September 1, 2024 |
Sotorasib (Lumakras) (PDF) | CP.PHAR.549 | September 1, 2024 |
Sotrovimab (VIR-7831) (PDF) | CP.PHAR.541 | Pending FDA Approval |
Sparsentan (Filspari) (PDF) | CP.PHAR.631 | June 1, 2024 |
Spesolimab-sbzo (Spevigo) (PDF) | CP.PHAR.606 | August 1, 2024 |
Spinosad (Natroba) (PDF) | HIM.PA.134 | September 1, 2024 |
Step Therapy Criteria (PDF) | HIM.PA.109 | October 1, 2024 |
Step Therapy Criteria (PDF) | HIM.PA.109 | Retire by October 1, 2024 |
Stiripentol (Diacomit) (PDF) | CP.PMN.184 | December 1, 2023 |
sunitinib (Sutent) (PDF) | CP.PHAR.73 | June 1, 2024 |
Sutimlimab-jome (Enjaymo) (PDF) | CP.PHAR.503 | June 1, 2024 |
Suvorexant (Belsomra®) (PDF) | CP.PMN.109 | December 1, 2023 |
Tadalafil (Adcirca®) (PDF) | CP.PHAR.198 | February 1, 2024 |
Tadalafil BHP - ED (Cialis) (PDF) | CP.PMN.132 | September 1, 2024 |
Tafamidis (Vyndaqel, Vyndamax) (PDF) | CP.PHAR.432 | September 1, 2024 |
Tafasitamab-cxix (Monjuvi) (PDF) | CP.PHAR.508 | December 1, 2023 |
Talquetamab-tgvs (Talvey) (PDF) | CP.PHAR.649 | May 1, 2024 |
Talazoparib (Talzenna)(PDF) | CP.PHAR.409 | June 1, 2024 |
Taliglucerase Alfa (Elelyso) (PDF) | CP.PHAR.157 | June 1, 2024 |
Talimogene laherparepvec (Imlygic) (PDF) | CP.PHAR.542 | September 1, 2024 |
Tapinarof (Vtama) (PDF) | CP.PMN.283 | December 1, 2023 |
Tarlatamab-dlle (Imdelltra) (PDF) | CP.PHAR.685 | September 1, 2024 |
Tasimelteon (Hetlioz) (PDF) | CP.PMN.104 | October 1, 2024 |
Tavaborole (Kerydin®) (PDF) | CP.PMN.105 | February 1, 2024 |
Tazarotene (Arazlo, Fabior, Tazorac) (PDF) | CP.PMN.244 | April 1, 2024 |
Tazemetostat (PDF) | CP.PHAR.452 | February 1, 2024 |
Tebentafusp-tebn (Kimmtrak) (PDF) | CP.PHAR.575 | June 1, 2024 |
Teclistamab-cqyv (Tecvayli) (PDF) | CP.PHAR.611 | February 1, 2024 |
Tedizolid (Sivextro) (PDF) | CP.PMN.62 | September 1, 2024 |
Teduglutide (Gattex) (PDF) | CP.PHAR.114 | April 1, 2024 |
Tegaserod (Zelnorm) (PDF) | HIM.PA.160 | December 1, 2023 |
Telotristat ethyl (Xermelo) (PDF) | CP.PHAR.337 | June 1, 2024 |
Temozolomide (Temodar) (PDF) | CP.PHAR.77 | July 1, 2024 |
Temsirolimus (Torisel®) (PDF) | CP.PHAR.324 | December 1, 2023 |
Tenapanor (Ibsrela) (PDF) | CP.PMN.224 | March 1, 2024 |
Tenapanor (Ibsrela, Xphozah) (PDF) | HIM.PA.174 | March 1, 2023 |
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) | CP.PMN.268 | July 1, 2024 |
Teplizumab (PDF) | CP.PHAR.492 | February 1, 2024 (Previously Pending FDA Approval) |
Tepotinib (Tepmetko) (PDF) | CP.PHAR.530 | July 1, 2024 |
Teprotumumab (Tepezza) (PDF) | CP.PHAR.465 | February 1, 2024 |
Teriflunomide (Aubagio) (PDF) | CP.PCH.40 | June 1, 2024 |
Teriparatide (Forteo®) (PDF) | CP.PHAR.188 | April 1, 2024 |
Tesamorelin (Egrifta) (PDF) | CP.PHAR.109 | October 1, 2024 |
Tesamorelin (Egrifta) (PDF) | CP.PHAR.109 | Retire by October 1, 2024 |
Testosterone (Androderm) (PDF) | HIM.PA.87 | January 1, 2024 |
Testosterone (Testopel, Jatenzo) (PDF) | CP.PHAR.354 | December 1, 2023 |
Tetrabenazine (Xenazine) (PDF) | CP.PHAR.92 | June 1, 2024 |
Tezacaftor-Ivacaftor (Symdeko) (PDF) | CP.PHAR.377 | September 1, 2024 |
Tezepelumab (Tezspire) (PDF) | CP.PHAR.576 | February 1, 2024 |
Thalidomide (Thalomid) (PDF) | CP.PHAR.78 | July 1, 2024 |
Thioguanine (Tabloid) (PDF) | CP.PHAR.437 | January 1, 2024 |
Thyrotropin Alfa (Thyrogen) (PDF) | CP.PHAR.95 | September 1, 2024 |
Timothy grass pollen allergen extract (Grastek®) (PDF) | CP.PMN.84 | September 1, 2024 |
Tiopronin Delayed-Release (Thiola EC) (PDF) | CP.PCH.50 | June 1, 2024 |
Tisagenlecleucel (Kymriah) (PDF) | CP.PHAR.361 | April 1, 2024 |
Tislelizumab-jsgr (Tevimbra) (PDF) | CP.PHAR.686 | September 1, 2024 |
Tisotumab Vedotin-tftv (Tivdak) | CP.PHAR.561 | August 1, 2024 |
Tivozanib (Fotivda) (PDF) | CP.PHAR.538 | July 1, 2024 |
Tixagevimab-Cilgavimab (Evusheld) (PDF) | CP.PHAR.571 | July 1, 2023 |
Tobramycin (PDF) | CP.PHAR.211 | September 1, 2024 |
Tocilizumab
(Actemra), Tocilizumab-bavi (Tofidence), Tocilizumab-aazg (Tyenne) | CP.PHAR.263 | July 1, 2024 |
Tofersen (BIIB067) (PDF) | CP.PHAR.591 | December 1, 2023 |
Tolvaptan (Jynarque) (PDF) | CP.PHAR.27 | October 1, 2024 |
Tolvaptan (Jynarque) (PDF) | CP.PHAR.27 | Retire by October 1, 2024 |
Topical Acne Treatment (PDF) | HIM.PA.71 | September 1, 2024 |
Topotecan (Hycamtin) (PDF) | CP.PHAR.64 | July 1, 2024 |
Topical Immunomodulators (PDF) | CP.PMN.107 | February 1, 2024 |
Topiramate ER (Qudexy XR, Trokendi XR (PDF) | CP.PMN.281 | October 1, 2024 |
Topiramate ER (Qudexy XR, Trokendi XR (PDF) | CP.PMN.281 | Retire by October 1, 2024 |
Toripalimab (Loqtorzi) (PDF) | CP.PHAR.668 | September 1, 2024 |
Tovorafenib (Ojemda) (PDF) | CP.PHAR.687 | September 1, 2024 |
Trabectedin (Yondelis) (PDF) | CP.PHAR.204 | February 1, 2024 |
Tralokinumab-ldrm (Adbry) (PDF) | CP.PHAR.577 | November 1, 2024 |
Tralokinumab-ldrm (Adbry) (PDF) | CP.PHAR.577 | Retire by November 1, 2024 |
Trametinib (Mekinist) (PDF) | CP.PHAR.240 | July 1, 2024 |
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) | CP.PHAR.228 | August 1, 2024 |
Travoprost (iDose TR) (PDF) | CP.PHAR.672 | August 1, 2024 |
Tremelimumab-actl (Imjudo) (PDF) | CP.PHAR.612 | Retire by December 1, 2024 |
Tremelimumab-actl (Imjudo) (PDF) | CP.PHAR.612 | December 1, 2024 |
Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (PDF) | CP.PHAR.199 | February 1, 2024 |
Triamcinolone ER Injection (Zilretta) (PDF) | CP.PHAR.371 | September 1, 2024 |
Triclabendazole (Egaten) (PDF) | CP.PMN.207 | September 1, 2024 |
Trientine (Syprine) (PDF) | CP.PHAR.438 | January 1, 2024 |
Trifarotene (Aklief) (PDF) | CP.PMN.225 | February 1, 2024 |
Trifluridine/Tipiracil (Lonsurf) (PDF) | CP.PHAR.383 | September 1, 2024 |
Triheptanoin (Dojolvi) ^ (PDF) | CP.PHAR.509 | December 1, 2023 |
Triptorelin pamoate (Trelstar®, Triptodur®) (PDF) | CP.PHAR.175 | April 1, 2024 |
Trofinetide (Daybue) (PDF) | CP.PHAR.600 | June 1, 2024 |
Tucatinib (Tukysa) (PDF) | CP.PHAR.497 | October 1, 2024 |
Tucatinib (Tukysa) (PDF) | CP.PHAR.497 | Retire by October 1, 2024 |
Ublituximab-xiiy (Briumvi) (PDF) | CP.PHAR.621 | June 1, 2024 |
Ubrogepant (Ubrelvy) (PDF) | CP.PHAR.476 | March 1, 2022 |
Udenafil (PDF) | CP.PHAR.557 | December 1, 2023 |
Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia)(PDF) | CP.PMN.277 | June 1, 2024 |
Umbralisib (Ukoniq) (PDF) | CP.PHAR.531 | July 1, 2024 |
Uridine acetate (Vistogard) (PDF) | HIM.PA.SP55 | December 1, 2023 |
Vadadustat (Vafseo) (PDF) | CP.PHAR.677 | August 1, 2024 |
Valbenazine (Ingrezza) (PDF) | CP.PCH.48 | August 1, 2024 |
valganciclovir (Valcyte) (PDF) | CP.PCH.06 | April 1, 2024 |
Valoctocogene Roxaparvovec (PDF) | CP.PHAR.466 | April 1, 2024 (Previously Pending FDA Approval) |
Valrubicin (Valstar) (PDF) | CP.PHAR.439 | December 1, 2023 |
Vamorolone (Agamree) (PDF) | CP.PHAR.659 | February 1, 2024 |
Vandetanib (Caprelsa®) (PDF) | CP.PHAR.80 | February 1, 2024 |
Varenicline (Tyrvaya) (PDF) | CP.PMN.273 | February 1, 2024 |
Velaglucerase Alfa (VPRIV) (PDF) | CP.PHAR.163 | June 1, 2024 |
Velmanase Alfa-tycv (Lamzede) (PDF) | CP.PHAR.601 | June 1, 2024 |
Vemurafenib (Zelboraf®) (PDF) | CP.PHAR.91 | February 1, 2024 |
Venetoclax (Venclexta) (PDF) | CP.PHAR.129 | December 1, 2023 |
Vestronidase alfa-vjbk (Mepsevii) (PDF) | CP.PHAR.374 | July 1, 2024 |
Verteporfin (PDF) | CP.PHAR.187 | February 1, 2024 |
Vigabatrin (Sabril) (PDF) | CP.PHAR.169 | September 1, 2024 |
Vilazodone (Viibryd) (PDF) | CP.PMN.145 | July 1, 2021 |
Viloxazine (Qelbree) (PDF) | CP.PMN.264 | June 1, 2024 |
Viltolarsen (Viltepso) (PDF) | CP.PHAR.484 | April 1, 2024 |
Vincristine Liposome (Marqibo®) (PDF) | CP.PHAR.315 | August 1, 2024 |
Vismodegib (Erivedge) (PDF) | CP.PHAR.273 | July 1, 2024 |
Vutrisiran (Amvuttra) | CP.PHAR.550 | July 1, 2024 |
Voclosporin (Lupkynis) (PDF) | CP.PHAR.504 | July 1, 2024 |
Vorapaxar (Zontivity) (PDF) | HIM.PA.146 | February 1, 2024 |
Voretigene neparvovec-rzyl (Luxturna) (PDF) | CP.PHAR.372 | February 1, 2024 |
Vorinostat (Zolinza) (PDF) | CP.PHAR.83 | September 1, 2024 |
Vortioxetine (Trintellix®) (PDF) | CP.PMN.65 | October 1, 2024 |
Vortioxetine (Trintellix®) (PDF) | CP.PMN.65 | Retire by October 1, 2024 |
Vosoritide (Voxzogo) (PDF) | CP.PHAR.525 | February 1, 2024 |
Voxelotor (Oxbryta) (PDF) | CP.PHAR.451 | February 1, 2024 |
Zanubrutinib (Brukinsa) (PDF) | CP.PHAR.467 | August 1, 2024 |
Zavegepant (Zavzpret) (PDF) | CP.PHAR.630 | June 1, 2024 |
Zilucoplan (RA101495) (PDF) | CP.PHAR.616 | February 1, 2024 |
Ziv-aflibercept (Zaltrap®) (PDF) | CP.PHAR.325 | December 1, 2023 |
Zoledronic acid (PDF) | CP.PHAR.59 | February 1, 2024 |
Zuranolone (Zurzuvae) (PDF) | CP.PHAR.650 | June 1, 2024 |