Pharmacy Resources for Providers | Ambetter of Illinois

 

Pharmacy

  

We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all Ambetter Health members. Use our Preferred Drug List to find more information on the drugs that Ambetter Health covers.

PA Forms

Other PA Forms

Drug Approval Criteria

Pharmacy Policy List

A-G
H-P
Q-Z
Abaloparatide (Tymlos) (PDF)Halcinonide (Halog) (PDF)Quetiapine Extended-Release (Seroquel XR)
Abemaciclib (Verzenio) (PDF)Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF)Quinine Sulfate(Qualaquin) (PDF)
Abiraterone (Zytiga, Yonsa) (PDF)Halobetasol Propionate/Tazarotene (Duobrii) (PDF)Ramucirumab (Cyramza) (PDF)
AbobotulinumtoxinA (Dysport) (PDF)Hemin (Panhematin) (PDF)Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF)
Abrocitinib(Cibinqo) (PDF)Histrelin Acetate (Vantas, Supprelin LA) (PDF)Rasagiline (Azilect) (PDF)
Acyclovir Buccal Tablet (Sitavig) (PDF)Human Growth Hormone (Somapacitan, Somatropin) (PDF)Ravulizumab-cwvz (Ultomiris) (PDF)
Adefovir (Hepsera) (PDF)Hyaluronate Derivatives (PDF)Regorafenib (Stivarga) (PDF)
Ado-TrastuzumabEmtansine (Kadcyla) (PDF)Hydroxyurea(Siklos) (PDF)Relugolix (Orgovyx),Relugolix/Estradiol/Norethinedrone (Myfembree) (PDF)
Aducanumab-avwa(Aduhelm) (PDF)Ibalizumab-uiyk (Trogarzo) (PDF)Reslizumab (Cinqair) (PDF)
Afamelanotide (Scenesse) (PDF)
Ibandronate Injection (Boniva) (PDF)Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF)
Afatinib (Gilotrif) (PDF)Ibrutinib (Imbruvica) (PDF)Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF)
Aflibercept (Eylea) (PDF)Ibuprofen/Famotidine(Duexis) (PDF)Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)
Agalsidase Beta (Fabrazyme) (PDF)Idecabtagene Vicleucel(Abecma) (PDF)Rifabutin (Mycobutin) (PDF)
Alectinib (Alecensa) (PDF)Idelalisib (Zydelig) (PDF)Rifamycin(Aemcolo) (PDF)
Alemtuzumab (Lemtrada) (PDF)Idursulfase (Elaprase) (PDF)Rifaximin (Xifaxan) (PDF)
Alendronate (Binosto, Fosamax Plus D) (PDF)Iloperidone (Fanapt) (PDF)Rilonacept (Arcalyst) (PDF)
Alglucosidase Alfa (Lumizyme) (PDF)Iloprost (Ventavis (PDF)RimabotulinumtoxinB (Myobloc) (PDF)
Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF)Imatinib (Gleevec) (PDF)Rimegepant (Nurtec ODT) (PDF)
Allogenic Processed Thymus Tissue-agdc(Rethymic) (PDF)Imiglucerase (Cerezyme) (PDF)Riociguat (Adempas) (PDF)
Alpelisib (Piqray) (PDF)Immune Globulins (PDF)Ripretinib(Qinlock) (PDF)
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)Inclisiran (Leqvio) (PDF)Risdiplam(Evrysdi) (PDF)
Amantadine ER (Gocovri, Osmolex ER) (PDF)IncobotulinumtoxinA (Xeomin) (PDF)Risedronate (Actonel, Atelvia) (PDF)
Amikacin (Arikayce) (PDF)Inebilizumab-cdon(Uplizna) (PDF)Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF)
Amisulpride (Barhemsys) (PDF)Infertility and Fertility Preservation (PDF)Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)
Amivantamab-vmjw(Rybrevant) (PDF)Infigratinib (Truseltiq) (PDF)Rolapitant (Varubi) (PDF)
Anifrolumab-fnia(Saphnelo) (PDF)InhaledAgents for Asthma and COPD (PDF)Romidepsin (Istodax) (PDF)
Anti-Inhibitor Coagulant Complex,Human (Feiba) (PDF)Inotersen (Tegsedi) (PDF)Romiplostim (Nplate) (PDF)
Antithrombin III(ATryn, Thrombate III) (PDF)Inotuzumab Ozogamicin (Besponsa) (PDF)Romosozumab-aqqg (Evenity) (PDF)
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)Ropeginterferon Alfa-2b-njft(BESREMi) (PDF)
Apomorphine (Apokyn, Kynmobi) (PDF)Insulin Glargine (Rezvoglar, Semglee, Toujeo) (PDF)Rucaparib (Rubraca) (PDF)
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (PDF)Interferon Beta-1a (Avonex, Rebif) (PDF)Rufinamide (Banzel) (PDF)
Aripiprazole Orally Disintegrating Tablet (PDF)Interferon Beta-1b (Betaseron, Extavia) (PDF)Ruxolitinib (Jakafi, Opzelura) (PDF)
Asciminib (Scemblix) (PDF)Interferon Gamma-1b (Actimmune) (PDF)Sacituzumab Govitecan-hziy (Trodelvy) (PDF)
Asenapine (Saphris, Secuado) (PDF)Ipilimumab (Yervoy) (PDF)Sacubitril/Valsartan (Entresto) (PDF)
Asfotase Alfa (Strensiq) (PDF) Irinotecan Liposome (Onivyde) (PDF)Safinamide (Xadago) (PDF)
Aspirin/Dipyridamole (Aggrenox) (PDF)Iron Sucrose(Venofer) (PDF)Sapropterin Dihydrochloride (Kuvan) (PDF)
Atezolizumab (Tecentriq) (PDF)Isatuximab-irfc (Sarclisa) (PDF)Sarecycline (Seysara) (PDF)
Atogepant (Qulipta) (PDF)Isavuconazonium (Cresemba) (PDF)Sargramostim (Leukine) (PDF)
Avacopan (Tavneos) (PDF)Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)Satralizumab-mwge(Enspryng) (PDF)
Avalglucosidase Alfa-ngpt(Nexviazyme) (PDF)Itraconazole (Sporanox, Tolsura) (PDF)Sebelipase Alfa (Kanuma) (PDF)
Avapritinib (Ayvakit) (PDF)Ivabradine (Corlanor) (PDF)Secnidazole (Solosec) (PDF)
Avatrombopag (Doptelet) (PDF)
Ivacaftor (Kalydeco) (PDF)Selexipag (Uptravi) (PDF)
Avelumab (Bavencio) (PDF)
Ivermectin (Stromectol, Sklice) (PDF)Selinexor (Xpovio) (PDF)
Axicabtagene Ciloleucel(Yescarta) (PDF)
Ivosidenib (Tibsovo) (PDF)Selpercatinib (Retevmo) (PDF)
Axitinib (Inlyta) (PDF)
Ixazomib (Ninlaro) (PDF)Selumetinib (Koselugo) (PDF)
Azacitidine (Onureg, Vidaza) (PDF)Lacosamide(Vimpat) (PDF)Setmelanotide (Imcivree) (PDF)
Azelaic Acid (Finacea Topical Gel/Foam) (PDF)Lactitol(Pizensy) (PDF)Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF)
Aztreonam (Cayston) (PDF)Lanadelumab-fylo (Takhzyro) (PDF)Sildenafil for ED (Viagra) (PDF)
Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF)Lanreotide (Somatuline Depot) (PDF)Siltuximab (Sylvant) (PDF)
 Lapatinib (Tykerb) (PDF)Siponimod (Mayzent) (PDF)
Bedaquiline(Sirturo) (PDF)Laronidase (Aldurazyme) (PDF)Sirolimus Protein-Bound Particles(Fyarro), Topical Gel (Hyftor) (PDF)
Belantamab Mafodotin-blmf(Blenrep) (PDF)Larotrectinib (Vitrakvi) (PDF)Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (PDF)
Belatacept (Nulojix) (PDF) Latanoprostene Bunod (Vyzulta) (PDF)Sodium Phenylbutyrate (Buphenyl) (PDF)
Belimumab (Benlysta) (PDF)Ledipasvir/Sofosbuvir (Harvoni) (PDF)Sodium Zirconium Cyclosilicate (Lokelma) (PDF)
Belinostat (Beleodaq) (PDF)Lefamulin (Xenleta) (PDF)Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)
Belumosudil (Rezurock) (PDF)Lenalidomide (Revlimid) (PDF)Sofosbuvir (Sovaldi) (PDF)
Belzutifan(Welireg) (PDF)Lenvatinib (Lenvima) (PDF)Sofosbuvir/Velpatasvir ( Epclusa (PDF)
Bempedoic Acid(Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF)Letermovir (Prevymis) (PDF)Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)
Bendamustine (Belrapzo, Bendeka, Treanda) )(PDF)Leucovorin Injection (PDF)Solriamfetol(Sunosi) (PDF)
Benralizumab (Fasenra) (PDF)Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi (PDF)Sonidegib (Odomzo) (PDF)
Benznidazole (PDF)LevodopaInhalation Powder (Inbrija) (PDF)Sorafenib (Nexavar) (PDF)
Betaine (Cystadane) (PDF)Levoketoconazole(Recorlev) (PDF)Sotorasib(Lumakras) (PDF)
Betamethasone Dipropionate Spray (Sernivo) (PDF)Levoleucovorin (Fusilev, Khapzory) (PDF) 
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF) Spinosad (Natroba) (PDF)
Bexarotene (TargretinCapsules, Gel) (PDF)L-glutamine (Endari) (PDF)Sunitinib (Sutent) (PDF)
Bezlotoxumab (Zinplava) (PDF)Lifitegrast (Xiidra) (PDF)Suvorexant (Belsomra) (PDF)
Bimatoprost Implant (Durysta) (PDF)Linaclotide (Linzess) (PDF)Tadalafil BPH -ED (Cialis) (PDF)
Binimetinib(Mektovi) (PDF)Linezolid (Zyvox) (PDF)Tafamidis (Vyndaqel, Vyndamax) (PDF)
Biologic and Non-biologic DMARDs (PDF)Lisocabtagene Maraleucel(Breyanzi) (PDF)Tafasitamab-cxix (Monjuvi) (PDF)
Blinatumomab (Blincyto) (PDF)Lomustine (Gleostine) (PDF)Talazoparib (Talzenna) (PDF)
Bortezomib(Velcade) (PDF)Lonafarnib (Zokinvy) (PDF)Taliglucerase Alfa (Elelyso) (PDF)
Bosutinib (Bosulif) (PDF)Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)Talimogene laherepvec (Imlygic) (PDF)
Brand Name Override and Non-Formulary Medications (PDF)Lorlatinib(Lorbrena) (PDF)Tasimelteon (Hetlioz, Hetlioz LQ) (PDF)
Brentuximab Vedotin (Adcetris) (PDF)Loteprednol etabonate(Eysuvis) (PDF)Tavaborole(Kerydin) (PDF)
Brexanolone (Zulresso) (PDF)LuliconazoleCream(Luzu) (PDF)Tazarotene (Arazlo, Fabior, Tazorac) (PDF)
Brexpiprazole (Rexulti) (PDF)Lumacaftor/Ivacaftor (Orkambi) (PDF)Tazemetostat(Tazverik) (PDF)
Brexucabtagene Autoleucel(Tecartus) (PDF)Lumasiran(Oxlumo) (PDF)Tebentafusp-tebn(Kimmtrak) (PDF)
Brigatinib (Alunbrig) (PDF)Lumateperone (Caplyta) (PDF)Tedizolid (Sivextro) (PDF)
Brimonidine Tartrate ( Mirvaso) (PDF)Lurasidone (Latuda) (PDF)Teduglutide (Gattex) (PDF)
Brinzolamide/Brimonidine (Simbrinza) (PDF)Lurbinectedin(Zepzelca) (PDF)Tegaserod (Zelnorm) (PDF)
Brivaracetam (Briviact) (PDF)Luspatercept-aamt (Reblozyl) (PDF)Telotristat Ethyl (Xermelo) (PDF)
Brolucizumab-dbll(Beovu) (PDF)Lusutrombopag (Mulpleta) (PDF)Temozolomide (Temodar) (PDF)
Budesonide (Tarpeyo) (PDF)
Lutetium Lu 177 vipivotide tetraxetan(Pluvicto) (PDF)Temsirolimus (Torisel) (PDF)
Budesonide (Uceris) (PDF)Macitentan (Opsumit) (PDF)Tenapanor(Ibsrela) (PDF)
Buprenorphine (Subutex) (PDF)Mannitol(Bronchitol) (PDF)Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)
Buprenorphine/Naloxone (Bunavail, Cassipa,Suboxone, Zubsolv) (PDF)Maralixibat(Livmarli) (PDF)Tepotinib(Tepmetko) (PDF)
Bupropion/Naltrexone (Contrave) (PDF)Margetuximab-cmkb(Margenza) (PDF)Teprotumumab(Tepezza) (PDF)
Burosumab-twza(Crysvita) (PDF)Maribavir (Livtencity) (PDF)Teriflunomide (Aubagio) (PDF)
Butorphanol Nasal Spray (PDF)Mecasermin (Increlex) (PDF)Teriparatide (Forteo) (PDF)
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)Mechlorethamine Gel (Valchlor) (PDF)Tesamorelin (Egrifta SV) (PDF)
Cabazitaxel(Jevtana) (PDF)Melphalan flufenamide(Pepaxto) (PDF)Testosterone(Androderm) (PDF)
Cabotegravir (Apretude), Cabotegravir/Rilpivirine(Cabenuva) (PDF)Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF)Testosterone(Testopel, Jatenzo, Tlando) (PDF)
Cabozantinib (Cabometyx, Cometriq) (PDF)Mepolizumab (Nucala) (PDF)Tetrabenazine (Xenazine) (PDF)
Calcifediol (Rayaldee) (PDF)Mercaptopurine (Purixan) (PDF)Tezacaftor/Ivacaftor; Ivacaftor(Symdeko) (PDF)
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF)Metformin ER (Fortamet, Glumetza) (PDF)Tezepelumab-ekko(Tezspire) (PDF)
Camzyos (mavacamten) (PDF)Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)Thalidomide (Thalomid) (PDF)
Canakinumab (Ilaris) (PDF)Methoxsalen (Uvadex) (PDF)Thioguanine(Tabloid) (PDF)
Cannabidiol (Epidiolex) (PDF)Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)Thyrotropin Alfa (Thyrogen) (PDF)
Capecitabine (Xeloda)Methylnaltrexone Bromide (Relistor) (PDF)Timothy Grass Pollen Allergen Extract (Grastek) (PDF)
Caplacizumab-yhdp (Cablivi)Metoclopramide(Gimoti) (PDF)Tisagenlecleucel (Kymriah) (PDF)
Capmatinib(Tabrecta) (PDF)Metreleptin (Myalept) (PDF)Tisotumab vedotin-tftv(Tivdak (PDF)
Carbidopa/Levodopa ER Capsules (Rytary),Enteral Suspension (Duopa), IRTablets (Dhivy) (PDF)Midazolam(Nayzilam) (PDF)Tivozanib (Fotivda) (PDF)
Carfilzomib (Kyprolis) (PDF)Midostaurin (Rydapt) (PDF)Topical Acne Treatment (PDF)
Carglumic Acid (Carbaglu) (PDF)Mifepristone (Korlym (PDF)Topical Immunomodulators (PDF)
Casimersen (Amondys 45) (PDF)Migalastat (Galafold) (PDF)Topotecan (Hycamtin) (PDF)
Casirivimab and Imdevimab(REGEN-COV) (PDF)Miglustat (Zavesca) (PDF)Trabectedin (Yondelis) (PDF)
Celecoxib (Celebrex, Elyxyb) (PDF)Milnacipran (Savella) (PDF)Tralokinumab-ldrm (Adbry) (PDF)
Cemiplimab-rwlc(Libtayo) (PDF)Minocycline ER (Solodyn, Ximino, Minolira),Microspheres (Arestin), Foam (Zilxi) (PDF)Trametinib (Mekinist) (PDF)
Cenegermin-bkbj (Oxervate) (PDF)Mitapivat (Pyrukynd) (PDF)Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)
Cenobamate (Xcopri) (PDF)Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
Ceritinib(Zykadia) (PDF)Mitoxantrone (PDF)Triamcinolone ER Injection (Zilretta) (PDF)
Cerliponase Alfa ( Brineura) (PDF)Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF)Triclabendazole (Egaten) (PDF)
Cetuximab (Erbitux) (PDF)Mobocertinib(Exkivity) (PDF)Trientine (Syprine) (PDF)
Chenodiol (Chenodal) (PDF)Modafinil (Provigil) (PDF)Trifluridine/Tipiracil (Lonsurf) (PDF)
Chlorambucil (Leukeran) (PDF)Mogamulizumab-kpkc (Poteligeo) (PDF)Triheptanoin(Dojolvi) (PDF)
Chloramphenicol Sodium Succinate (PDF)Mometasone (Nasonex) (PDF)Triptorelin Pamoate (Trelstar, Triptodur) (PDF)
Cholic Acid (Cholbam) (PDF)
Mometasone Furoate(Sinuva) (PDF)Tucatinib (Tukysa) (PDF)
Ciclopirox(Penlac) (PDF)Montelukast Oral Granules (Singulair) (PDF)Ubrogepant (Ubrelvy) (PDF)
Cinacalcet (Sensipar) (PDF)Nafarelin Acetate (Synarel) (PDF)Ulcer Therapy Combinations (PDF)
Ciprofloxacin/Fluocinolone(Otovel) (PDF)Naltrexone (Vivitrol) (PDF)Umbralisib (Ukoniq) (PDF)
Ciprofloxacin/Dexamethasone (Ciprodex) (PDF)Naproxen/Esomeprazole(Vimovo) (PDF)UridineTriacetate (Vistogard) (PDF)
Cladribine (Mavenclad) (PDF)Naproxen Oral Suspension(Naprosyn) (PDF)Valganciclovir (Valcyte) (PDF)
Clascoterone(Winlevi) (PDF)Natalizumab (Tysabri) (PDF)Valproate Sodium for Intravenous Injection (Depacon) (PDF)
Clobazam (Onfi, Sympazan) (PDF)Naxitamab-gqgk(Danyelza) (PDF)Valrubicin (Valstar) (PDF)
CNS Stimulants (PDF)Necitumumab (Portrazza) (PDF)Vandetanib (Caprelsa) (PDF)
Cobimetinib (Cotellic) (PDF)Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF)Varenicline (Tyrvaya) (PDF)
Colchicine (Colcrys) (PDF)Netarsudil(Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF)Velaglucerase Alfa (VPRIV) (PDF)
Colesevelam (Welchol) (PDF)Nifurtimox (Lampit) (PDF)Vemurafenib(Zelboraf) (PDF)
Collagenase Clostridium Histolyticum(Xiaflex) (PDF)Nilotinib (Tasigna) (PDF)Venetoclax (Venclexta) (PDF)
Compounded Medications (PDF)Nintedanib (Ofev) (PDF)Verteporfin (Visudyne) (PDF)
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)Niraparib (Zejula) (PDF)Vestronidase alfa-vjbk (Mepsevii) (PDF)
Continuous Glucose Monitors (PDF)Nitazoxanide (Alinia) (PDF)Vigabatrin (Sabril) (PDF)
Copanlisib (Aliqopa) (PDF)Nitisinone(Nityr, Orfadin) (PDF)Vilazodone (Viibryd) (PDF)
Corticosteroids for Ophthalmic Injection(Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)Nivolumab (Opdivo) (PDF)Viloxazine(Qelbree) (PDF)
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF)Non-Calcium Phosphate Binders (PDF)Viltolarsen (Viltepso) (PDF)
Cosyntropin (Cortrosyn) (PDF)Non-Formulary Test Strips (PDF)Vincristine Sulfate Liposome Injection (Marqibo) (PDF)
Crisaborole (Eucrisa) (PDF)Nusinersen (Spinraza) (PDF)Vismodegib (Erivedge) (PDF)
Crizanlizumab-tmca (Adakveo) (PDF)Obeticholic Acid (Ocaliva) (PDF)Voclosporin (Lupkynis) (PDF)
Crizotinib (Xalkori) (PDF)Obinutuzumab (Gazyva) (PDF)Vorapaxar (Zontivity) (PDF)
Cyclosporine (Cequa,Restasis, Verkazia) (PDF)Ocrelizumab (Ocrevus) (PDF)Voretigene Neparvovec-rzyl (Luxturna) (PDF)
Cysteamineophthalmic(Cystaran, Cystadrops) (PDF)Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)Vorinostat (Zolinza) (PDF)
Cysteamine oral (Cystagon, Procysbi) (PDF)Odevixibat (Bylvay) (PDF)Vortioxetine (Trintellix) (PDF)
Cytomegalovirus Immune Globulin (CytoGam) (PDF)Ofatumumab (Arzerra, Kesimpta) (PDF)Vosoritide (Voxzogo) (PDF)
Dabrafenib (Tafinlar) (PDF)Off-Label Drug Use (PDF)Voxelotor(Oxbryta) (PDF)
Dacomitinib (Vizimpro) (PDF)Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)Zanubrutinib (Brukinsa) (PDF)
Dalfampridine (Ampyra) (PDF)Olanzapine/Samidorphan (Lybalvi) (PDF)Ziv-aflibercept (Zaltrap) (PDF)
Dalteparin (Fragmin) (PDF)Olaparib (Lynparza) (PDF)Zoledronic Acid (Reclast, Zometa) (PDF)
Dapsone (Aczone Gel) (PDF)Olaratumab (Lartruvo) (PDF) 
Daptomycin(Cubicin, Cubicin RF) (PDF)Omacetaxine (Synribo) (PDF) 
Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF)Omadacycline (Nuzyra) (PDF) 
Darbepoetin Alfa (Aranesp) (PDF)Omacetaxine (Synribo) (PDF) 
Darolutamide(Nubeqa) (PDF)OnabotulinumtoxinA (Botox) (PDF) 
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF)Onasemnogene Abeparvovec (Zolgensma) (PDF) 
Dasatinib (Sprycel) (PDF)Ophthalmic Corticosteroids (PDF) 
Daunorubicin/Cytarabine (Vyxeos) (PDF)Opioid Analgesicss* (PDF) 
Decitabine/Cedazuridine (Inqovi) (PDF)Osilodrostat (Isturisa) (PDF) 
Deferasirox (Exjade, Jadenu) (PDF)Osimertinib (Tagrisso) (PDF) 
Deferiprone (Ferriprox) (PDF)Ospemifene(Osphena) (PDF) 
Deferoxamine (Desferal) (PDF)Overactive Bladder Agents (PDF) 
Deflazacort (Emflaza) (PDF)Oxymetazoline (Rhofade, Upneeq) (PDF) 
Degarelix Acetate (Firmagon) (PDF)Ozenoxacin (Xepi) (PDF) 
Delafloxacin (Baxdela) (PDF)Paclitaxel, Protein-Bound (Abraxane) (PDF) 
Denosumab (Prolia, Xgeva) (PDF)Pacritinib(Vonjo) (PDF) 
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)Palbociclib (Ibrance) (PDF) 
Deutetrabenazine (Austedo) (PDF)Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF) 
Dexlansoprazole(Dexilant) (PDF)Palivizumab (Synagis) (PDF) 
Dexrazoxane(Totect) (PDF)Pancrelipase(Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) 
Dexrazoxane(Zinecard, Totect) (PDF)Panitumumab (Vectibix) (PDF) 
Dextromethorphan-Quinidine (Nuedexta) (PDF)Panobinostat (Farydak) (PDF) 
DiazepamNasal Spray (Valtoco) (PDF)Parathyroid Hormone (Natpara) (PDF) 
Dichlorphenamide (Keveyis) (PDF)Paricalcitol Injection (Zemplar) (PDF) 
Diclofenac (Cambia, Flector,Licart,Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF)Pasireotide (Signifor, Signifor LAR) (PDF) 
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (PDF)Patiromer (Veltassa) (PDF) 
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)Patisiran(Onpattro) (PDF) 
Dolasetron (Anzemet) (PDF)Pazopanib (Votrient) (PDF) 
Dornase Alfa (Pulmozyme) (PDF)Peanut Allergen Powder-dnfp (Palforzia) (PDF) 
Dostarlimab-gxly(Jemperli) (PDF)Pegaspargase (Oncaspar), Calaspargase Pegol-mknl(Asparlas) (PDF) 
DoxycyclineHyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)Pegcetacoplan (Empaveli) (PDF) 
Dupilumab (Dupixent) (PDF)Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF) 
Durvalumab (Imfinzi) (PDF)Pegloticase (Krystexxa) (PDF) 
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF)Pegvaliase-pqpz(Palynziq) (PDF) 
Duvelisib (Copiktra) (PDF)Pegvisomant (Somavert) (PDF) 
Eculizumab (Soliris) (PDF)Pembrolizumab (Keytruda) (PDF) 
Edaravone (Radicava) (PDF)Pemetrexed (Alimta, Pemfexy) (PDF) 
EfgartigimodAlfa-fcab(Vyvgart) (PDF)Pemigatinib(Pemazyre) (PDF) 
Efinaconazole (Jublia) (PDF)Penicillamine (Cuprimine) (PDF) 
Elagolix(Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (PDF)Perampanel(Fycompa) (PDF) 
Elapegademase-lvlr(Revcovi) (PDF)Pertuzumab (Perjeta) (PDF) 
Elbasvir/Grazoprevir (Zepatier) (PDF)Pertuzumab/Trastuzumab/Hyaluronidase-zzxf(Phesgo) (PDF) 
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor(Trikafta) (PDF)Pexidartinib (Turalio) (PDF) 
Eliglustat (Cerdelga) (PDF)
Phendimetrazine (PDF) 
Elosulfase Alfa (Vimizim) (PDF)Phentermine (Adipex-P, Lomaira) (PDF) 
Elotuzumab (Empliciti) (PDF)Pilocarpine(Vuity) (PDF) 
Eltrombopag (Promacta) (PDF)Pimavanserin (Nuplazid) (PDF) 
Eluxadoline (Viberzi) (PDF)Pirfenidone (Esbriet) (PDF) 
Emapalumab-lzsg(Gamifant) (PDF)Plasminogen, human-tvmh(Ryplazim) (PDF) 
Emicizumab-kxwh(Hemlibra) (PDF)Plecanatide (Trulance) (PDF) 
Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF)Plerixafor (Mozobil) (PDF) 
Enasidenib (Idhifa) (PDF)Polatuzumab Vedotin-piiq (Polivy) (PDF) 
Encorafenib (Braftovi) (PDF)Pomalidomide (Pomalyst) (PDF) 
Enfortumab Vedotin-ejfv (Padcev) (PDF)Ponatinib (Iclusig) (PDF) 
Enfuvirtide (Fuzeon) (PDF)Ponesimod(Ponvory) (PDF) 
Entecavir (Baraclude) (PDF)PotassiumChloridefor Oral Solution (Klor-ConPowder) (PDF) 
Entrectinib (Rozlytrek) (PDF)Pralatrexate (Folotyn) (PDF) 
Enzalutamide (Xtandi) (PDF)Pramlintide (Symlin) (PDF) 
Epoetin Alfa(Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF)Prasterone (Intrarosa) (PDF) 
Eptinezumab-jjmr(Vyepti) (PDF)Pregabalin (Lyrica, Lyrica CR) (PDF) 
Erdafitinib (Balversa) (PDF)Pretomanid (PDF) 
Erenumab-aaoe (Aimovig) (PDF)Progesterone (Crinone, Endometrin, Milprosa) (PDF) 
Eribulin Mesylate (Halaven) (PDF)Propranolol HCl Oral Solution (Hemangeol) (PDF) 
Erlotinib (Tarceva) (PDF)Protein C Concentrate, Human (Ceprotin) (PDF) 
Erwinia Asparaginase (Erwinaze, Rylaze) (PDF)Prucalopride (Motegrity) (PDF) 
Esketamine (Spravato) (PDF)Pyrimethamine (Daraprim) (PDF) 
Estradiol Vaginal Ring (Femring) (PDF)  
Etelcalcetide(Parsabiv) (PDF)  
Eteplirsen (Exondys 51) (PDF)  
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)  
Evinacumab-dgnb(Evkeeza) (PDF)  
Evolocumab (Repatha) (PDF)  
Factor IX Complex, Human (Profilnine) (PDF)  
Factor IX (Human, Recombinant) (PDF)  
Factor VIIa, Recombinant(NovoSeven RT, SevenFact) (PDF)  
Factor VIII (Human, Recombinant) (PDF)  
Factor VIII/von Willebrand Factor Complex (Human –Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (PDF)  
Factor XIII, Human(Corifact) (PDF)  
Factor XIII A-Subunit, Recombinant (Tretten) (PDF)  
Fam-Trastuzumab Deruxtecan-nxki(Enhertu) (PDF)  
Faricimab-svoa(Vabysmo) (PDF)  
Febuxostat (Uloric) (PDF)  
Fedratinib(Inrebic) (PDF)  
Fenfluramine(Fintepla) (PDF)  
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)  
Ferric Carboxymaltose (Injectafer) (PDF)  
Ferric Derisomaltose (Monoferric) (PDF)  
Ferric Gluconate(Ferrlecit) (PDF)  
Ferric Maltol (Accrufer) (PDF)  
Ferumoxytol (Feraheme) (PDF)  
Fibrinogen Concentrate [Human](Fibryga, RiaSTAP) (PDF)  
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko) (PDF)  
Finerenone(Kerendia) (PDF)  
Fingolimod (Gilenya, Tascenso ODT) (PDF)  
Flibanserin (Addyi) (PDF)  
Fluorouracil Cream (Tolak) (PDF)  
Fluticasone Propionate (Xhance) (PDF)  
Fondaparinux (Arixtra) (PDF)  
Fosdenopterin (Nulibry) (PDF)  
Fostamatinib (Tavalisse) (PDF)  
Fostemsavir(Rukobia) (PDF)  
Fremanezumab-vfrm(Ajovy) (PDF)  
Fulvestrant (Faslodex Injection) (PDF)  
Gabapentin ER (Gralise, Horizant) (PDF)  
Galcanezumab-gnlm (Emgality) (PDF)  
Galsulfase (Naglazyme) (PDF)  
Ganaxolone(Ztalmy) (PDF)  
Gefitinib (Iressa) (PDF)  
Gemtuzumab Ozogamicin(Mylotarg) (PDF)  
Gilteritinib(Xospata) (PDF)  
Givosiran (Givlaari) (PDF)  
Glasdegib (Daurismo) (PDF)  
Glatiramer Acetate (Copaxone, Glatopa) (PDF)  
Glecaprevir/Pibrentasvir (Mavyret) (PDF)  
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)  
Glycerol Phenylbutyrate (Ravicti) (PDF)  
Golodirsen (Vyondys 53) (PDF)  
Goserelin Acetate (Zoladex) (PDF)  
Granisetron (Sancuso, Sustol) (PDF)  
   

Future Policies