¿ERES UN MIEMBRO NUEVO? REALIZA TU PRIMER PAGO PARA ASEGURAR LA COBERTURA.
Políticas clínicas y de pago
Clinical Policies
- 25-hydroxyvitamin D Testing in Children and Adolescents (CP.MP.157) (PDF)
- Acupuncture (CP.MP.92) (PDF)
- ADHD (CP.BH.124) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allergy Testing (CP.MP.100) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (CP.MP.108) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Applied Behavior Analysis Documentation Requirements (CP.BH.105) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Behavioral Health Treatment Documentation Requirements (HIM.CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Bronchial Thermoplasty (CP.MP.110) (PDF)
- Burn Surgery (CP.MP.186) (PDF)
- Cardiac Biomarker (CP.MP.156) (PDF)
- Caudal or Interlaminar Epidural Steroid Injection (CP.MP.164) (PDF)
- CG Aortopathies Connective Tissue (V2.2024) (PDF)
- CG Cardiac Disorders (V2.2024) (PDF)
- CG Dermatologic Conditions (V2.2024) (PDF)
- CG Epilepsy Neurodegenerative and Neuromuscular Disorders (V2.2024) (PDF)
- CG Exome Genome Sequencing (V2.2024) (PDF)
- CG Eye Disorders (V2.2024) (PDF)
- CG Gastroenterologic Disorders Non-Cancerous (V2.2024) (PDF)
- CG General Approach to Genetic and Molecular Testing (V2.2024) (PDF)
- CG Hearing Loss (V2.2024) (PDF)
- CG Hematologic Conditions Non-Cancerous (V2.2024) (PDF)
- CG Hereditary Cancer Susceptibility (V2.2024) (PDF)
- CG Immune, Autoimmune, and Rheumatoid Disorders (V2.2024) (PDF)
- CG Kidney Disorders (V2.2024) (PDF)
- CG Lung Disorders (V2.2024) (PDF)
- CG Metabolic, Endocrine and Mitochondrial Disorders (V2.2024) (PDF)
- CG Multisystem Inherited Disorders, ID and Developmental Delay (V2.2024) (PDF)
- CG Non-invasive Prenatal Screening (V2.2024) (PDF)
- CG Oncology Algorithmic Testing (V2.2024) (PDF)
- CG Oncology Cancer Screening (V2.2024) (PDF)
- CG Oncology Circ Tumor DNA Tumor Cells Liquid Biopsy (V2.2024) (PDF)
- CG Oncology Cytogenetic Testing (V2.2024) (PDF)
- CG Oncology Molecular Analysis of Solid Tumor and Hem Malignancies (V2.2024) (PDF)
- CG Pharmacogenetics (V2.2024) (PDF)
- CG Preimplantation Genetic Testing (V2.2024) (PDF)
- CG Prenatal and Preconception Carrier Screening (V2.2024) (PDF)
- CG Prenatal Dx of Amnio CVS or PUBS and Pregnancy Loss (V2.2024) (PDF)
- CG Skeletal Dysplasia and Rare Bone Disorders (V2.2024) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Cosmetic and Reconstructive (CP.MP.31) (PDF)
- CPG Grid (CPG Grid) (PDF)
- Deep TMS for OCD (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Digital Electroencephalography Spike Analysis (CP.MP.105) (PDF)
- Disc Decompression (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Drugs of Abuse: Definitive Drug Testing (CP.MP.50) (PDF)
- Durable Medical Equipment (DME) (CP.MP.107) (PDF)
- Electric Tumor Treating Fields (CP.MP.145) (PDF)
- Electroencephalography in the Evaluation of Headache (CP.MP.155) (PDF)
- Endometrial Ablation (CP.MP.106) (PDF)
- Evoked Potentials (CP.MP.134 ) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility Based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- GI Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- H. Pylori Serology Testing (CP.MP.153) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Holter Monitors (CP.MP.113) (PDF)
- Home Birth (CP.MP.136) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Homocysteine Testing (CP.MP.121) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement Criteria (CP.MP.71) (PDF)
- Low-frequency Ultrasound and Noncontact Wound Therapy (CP.MP.139) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF)
- Mechanical Stretching Devices (CP.MP.144) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170) (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES (CP.MP.48) (PDF)
- NICU Apnea Bradycardia (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Non-Myeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- OB Home Health Programs (CP.MP.91) (PDF)
- Omisirge (omidubicel) (CP.MP.249) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Oxygen Use and Concentrators ( Title change to Outpatient Oxygen Use) (CP.MP.190) (PDF)
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138 ) (PDF)
- Pediatric Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Pulmonary Function Testing (CP.MP.242) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Respiratory PCR Testing (CP.MP.181) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Disorders (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Injections (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skilled Nursing Facility Leveling (CC.PP.206) (PDF)
- Skin Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Thyroid Hormones and Insulin Testing in Pediatrics (CP.MP.154) (PDF)
- TMS for Treatment Resistant MDD (CP.BH.200) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Ultrasound in Pregnancy (CP.MP.38) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Urodynamic Testing (CP.MP.98) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
- Wheelchair Seating (CP.MP.99) (PDF)
- Wireless Motility Capsule (CP.MP.143) (PDF)
- Abaloparatide (Tymlos) CP.PHAR.345 (PDF)
- Abemaciclib (Verzenio) CP.PHAR.355 (PDF)
- Abiraterone (Zytiga, Yonsa) CP.PHAR.84 (PDF)
- AbobotulinumtoxinA (Dysport) CP.PHAR.230 (PDF)
- Abrocitinib (Cibinqo) CP.PHAR.578 (PDF)
- Acyclovir Buccal Tablet (Sitavig) CP.PMN.210 (PDF)
- Adagrasib (Krazati) CP.PHAR.605 (PDF)
- Adefovir (Hepsera) CP.PHAR.142 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) CP.PHAR.229 (PDF)
- Aducanumab-avwa (Aduhelm) CP.PHAR.468 (PDF)
- Afamelanotide (Scenesse) CP.PHAR.444 (PDF)
- Afatinib (Gilotrif) CP.PHAR.298 (PDF)
- Aflibercept (Eylea) CP.PHAR.184 (PDF)
- Agalsidase Beta (Fabrazyme) CP.PHAR.158 (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) CP.PMN.138 (PDF)
- Alectinib (Alecensa) CP.PHAR.369 (PDF)
- Alemtuzumab (Lemtrada) CP.PHAR.243 (PDF)
- Alendronate (Binosto, Fosamax Plus D) CP.PMN.88 (PDF)
- Alglucosidase Alfa (Lumizyme) CP.PHAR.160 (PDF)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) CP.PHAR.562 (PDF)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) CP.PHAR.563 (PDF)
- Alpelisib (Piqray) CP.PHAR.430 (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) CP.PHAR.94 (PDF)
- Amantadine ER (Gocovri, Osmolex ER) CP.PMN.89 (PDF)
- Ambrisentan (Letairis) CP.PHAR.190 (PDF)
- Amifampridine (Firdapse, Ruzurgi) CP.PHAR.411 (PDF)
- Amikacin (Arikayce) CP.PHAR.401 (PDF)
- Amisulpride (Barhemsys) CP.PMN.236 (PDF)
- Amivantamab-vmjw (Rybrevant) CP.PHAR.544 (PDF)
- Anifrolumab-fnia (Saphnelo) CP.PHAR.551 (PDF)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) CP.PHAR.217 (PDF)
- Antithrombin III (ATryn, Thrombate III) CP.PHAR.564 (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) CP.PHAR.506 (PDF)
- Apalutamide (Erleada) CP.PCH.45 (PDF)
- Apomorphine (Apokyn, Kynmobi) CP.PHAR.488 (PDF)
- Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) CP.PMN.19 (PDF)
- Aprocitentan (Tryvio) CP.PHAR.676 (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) CP.PHAR.290 (PDF)
- Aripiprazole Orally Disintegrating Tablet CP.PCH.37 (PDF)
- Armodafinil (Nuvigil) CP.PMN.35 (PDF)
- Asciminib (Scemblix) CP.PHAR.565 (PDF)
- Asenapine (Saphris, Secuado) CP.PMN.15 (PDF)
- Asfotase Alfa (Strensiq) CP.PHAR.328 (PDF)
- Aspirin/Dipyridamole (Aggrenox) CP.PMN.20 (PDF)
- Atezolizumab (Tecentriq) CP.PHAR.235 (PDF)
- Avalglucosidase Alfa-ngpt (Nexviazyme) CP.PHAR.521 (PDF)
- Avapritinib (Ayvakit) CP.PHAR.454 (PDF)
- Avatrombopag (Doptelet) CP.PHAR.130 (PDF)
- Avelumab (Bavencio) CP.PHAR.333 (PDF)
- Axatilimab-csfr (Niktimvo) CP.PHAR.691 (PDF)
- Axicabtagene Ciloleucel (Yescarta) CP.PHAR.362 (PDF)
- Axitinib (Inlyta) CP.PHAR.100 (PDF)
- Azacitidine (Onureg, Vidaza) CP.PHAR.387 (PDF)
- Azelaic Acid (Finacea Topical Gel) HIM.PA.119 (PDF)
- Aztreonam (Cayston) CP.PHAR.209 (PDF)
- Baclofen (Gablofen, Lioresal, Ozobax) CP.PHAR.149 (PDF)
- Baloxavir Marboxil (Xofluza) CP.PMN.185 (PDF)
- Bamlanivimab + Etesevimab (LY-CoV555 + LY-CoV016) CP.PHAR.532 (PDF)
- Bedaquiline (Sirturo) CP.PMN.212 (PDF)
- Belantamab Mafodotin (Blenrep) CP.PHAR.469 (PDF)
- Belatacept (Nulojix) CP.PHAR.201 (PDF)
- Belimumab (Benlysta) CP.PHAR.88 (PDF)
- Belinostat (Beleodaq) CP.PHAR.311 (PDF)
- Belumosudil (Rezurock) CP.PHAR.552 (PDF)
- Belzutifan (Welireg) CP.PHAR.553 (PDF)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) CP.PMN.237 (PDF)
- Bendamustine (Belrapzo, Bendeka, Treanda) CP.PHAR.307 (PDF)
- Benralizumab (Fasenra) CP.PHAR.373 (PDF)
- Benznidazole CP.PMN.90 (PDF)
- Berdazimer (Zelsuvmi) CP.PMN.293 (PDF)
- Berotralstat (Orladeyo) CP.PHAR.485 (PDF)
- Betaine (Cystadane) CP.PHAR.143 (PDF)
- Betamethasone Dipropionate Spray (Sernivo) CP.PMN.182 (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) CP.PHAR.93 (PDF)
- Bexarotene (Targretin Capsules, Gel) CP.PHAR.75 (PDF)
- Bezlotoxumab (Zinplava) CP.PHAR.300 (PDF)
- Bimatoprost Implant (Durysta) CP.PHAR.486 (PDF)
- Binimetinib (Mektovi) CP.PHAR.50 (PDF)
- Biologic DMARDs HIM.PA.SP60 (PDF)
- Birch Triterpenes (Filsuvez) CP.PHAR.669 (PDF)
- Blinatumomab (Blincyto) CP.PHAR.312 (PDF)
- Bortezomib (Velcade) CP.PHAR.410 (PDF)
- Bosentan (Tracleer) CP.PHAR.191 (PDF)
- Bosutinib (Bosulif) CP.PHAR.105 (PDF)
- Brand Name Override and Non-Formulary Medications HIM.PA.103 (PDF)
- Brentuximab Vedotin (Adcetris) CP.PHAR.303 (PDF)
- Brexanolone (Zulresso) CP.PHAR.417 (PDF)
- Brexpiprazole (Rexulti) CP.PMN.68 (PDF)
- Brexucabtagene Autoleucel (Tecartus) CP.PHAR.472 (PDF)
- Brigatinib (Alunbrig) CP.PHAR.342 (PDF)
- Brimonidine Tartrate (Mirvaso) CP.PMN.192 (PDF)
- Brinzolamide/Brimonidine (Simbrinza) HIM.PA.15 (PDF)
- Brivaracetam (Briviact) CP.PMN.297 (PDF)
- Brolucizumab-dbll (Beovu) CP.PHAR.445 (PDF)
- Budesonide (Eohilia, Uceris) CP.PMN.294 (PDF)
- Budesonide (Tarpeyo) CP.PHAR.572 (PDF)
- Buprenorphine (Subutex) CP.PMN.82 (PDF)
- Buprenorphine Implant/Injection (Probuphine , Sublocade) CP.PHAR.289 (PDF)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) CP.PMN.81 (PDF)
- Bupropion/Naltrexone (Contrave) CP.PCH.12 (PDF)
- Burosumab-twza (Crysvita) CP.PHAR.11 (PDF)
- Butorphanol Nasal Spray HIM.PA.46 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) CP.PHAR.202 (PDF)
- Cabazitaxel (Jevtana) CP.PHAR.316 (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) CP.PHAR.573 (PDF)
- Cabozantinib (Cabometyx, Cometriq) CP.PHAR.111 (PDF)
- Calcifediol (Rayaldee) CP.PMN.76 (PDF)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) CP.PMN.181 (PDF)
- Canakinumab (Ilaris) CP.PHAR.246 (PDF)
- Cannabidiol (Epidiolex) CP.PMN.164 (PDF)
- Capecitabine (Xeloda) CP.PHAR.60 (PDF)
- Capivasertib (Truqap) CP.PHAR.663 (PDF)
- Caplacizumab-yhdp (Cablivi) CP.PHAR.416 (PDF)
- Capmatinib (Tabrecta) CP.PHAR.494 (PDF)
- Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa) CP.PMN.238 (PDF)
- Carfilzomib (Kyprolis) CP.PHAR.309 (PDF)
- Carglumic Acid (Carbaglu) CP.PHAR.206 (PDF)
- Casimersen (Amondys 45) CP.PHAR.470 (PDF)
- Casirivimab and Imdevimab (REGEN-COV) CP.PHAR.520 (PDF)
- Celecoxib (Celebrex, Elyxyb) CP.PMN.122 (PDF)
- Cemiplimab-rwlc (Libtayo) CP.PHAR.397 (PDF)
- Cenegermin-bkbj (Oxervate) CP.PMN.186 (PDF)
- Cenobamate (Xcopri) CP.PMN.231 (PDF)
- Ceritinib (Zykadia) CP.PHAR.349 (PDF)
- Cerliponase alfa (Brineura) CP.PHAR.338 (PDF)
- Cetuximab (Erbitux) CP.PHAR.317 (PDF)
- Chenodiol (Chenodal) CP.PMN.239 (PDF)
- Chlorambucil (Leukeran) CP.PHAR.554 (PDF)
- Chloramphenicol Sodium Succinate CP.PHAR.388 (PDF)
- Cholic Acid (Cholbam) CP.PHAR.390 (PDF)
- Ciclopirox (Penlac) CP.PMN.24 (PDF)
- Cinacalcet (Sensipar) CP.PHAR.61 (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) CP.PMN.248 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) CP.PMN.249 (PDF)
- Cladribine (Mavenclad) CP.PHAR.422 (PDF)
- Clascoterone (Winlevi) CP.PMN.257 (PDF)
- Clobazam (Onfi, Sympazan) CP.PMN.54 (PDF)
- CNS Stimulants CP.PMN.92 (PDF)
- Cobimetinib (Cotellic) CP.PHAR.380 (PDF)
- Colchicine (Colcrys) CP.PMN.123 (PDF)
- Colesevelam (Welchol) CP.PMN.250 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) CP.PHAR.82 (PDF)
- Colonoscopy Preparation Products CP.PCH.43 (PDF)
- Compounded Medications CP.PMN.280 (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) CP.PMN.258 (PDF)
- Continuous Glucose Monitors CP.PMN.214 (PDF)
- Copanlisib (Aliqopa) CP.PHAR.357 (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) CP.PHAR.385 (PDF)
- Cosyntropin (Cortrosyn) CP.PHAR.203 (PDF)
- Crisaborole (Eucrisa) CP.PMN.110 (PDF)
- Crizanlizumab-tmca (Adakveo) CP.PHAR.449 (PDF)
- Crizotinib (Xalkori) CP.PHAR.90 (PDF)
- Cyclosporine (Cequa, Restasis, Verkazia) CP.PMN.48 (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops) CP.PMN.130 (PDF)
- Cysteamine oral (Cystagon, Procysbi) CP.PHAR.155 (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) CP.PHAR.277 (PDF)
- Dabrafenib (Tafinlar) CP.PHAR.239 (PDF)
- Daclatasvir (Daklinza) HIM.PA.SP27 (PDF)
- Dacomitinib (Vizimpro) CP.PHAR.399 (PDF)
- Daprodustat (Jesduvroq) CP.PHAR.628 (PDF)
- Dalfampridine (Ampyra) CP.PHAR.248 (PDF)
- Dalteparin (Fragmin) CP.PHAR.225 (PDF)
- Dapsone (Aczone Gel) CP.PCH.32 (PDF)
- Daptomycin (Cubicin, Cubicin RF) CP.PHAR.351 (PDF)
- Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) CP.PHAR.310 (PDF)
- Darbepoetin Alfa (Aranesp) CP.PHAR.236 (PDF)
- Darolutamide (Nubeqa) CP.PHAR.435 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) HIM.PA.SP61 (PDF)
- Dasatinib (Sprycel) CP.PHAR.72 (PDF)
- Daunorubicin/Cytarabine (Vyxeos) CP.PHAR.352 (PDF)
- Decitabine/Cedazuridine (Inqovi) CP.PHAR.479 (PDF)
- Deferasirox (Exjade, Jadenu) CP.PHAR.145 (PDF)
- Deferoxamine (Desferal) CP.PHAR.146 (PDF)
- Deflazacort (Emflaza) CP.PHAR.331 (PDF)
- Degarelix Acetate (Firmagon) CP.PHAR.170 (PDF)
- Delafloxacin (Baxdela) CP.PMN.115 (PDF)
- Denileukin Diftitox-cxdl (Lymphir) CP.PHAR.693 (PDF)
- Denosumab (Prolia, Xgeva) CP.PHAR.58 (PDF)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) CP.PHAR.214 (PDF)
- Deutetrabenazine (Austedo) CP.PCH.42 (PDF)
- Dexrazoxane (Zinecard, Totect) CP.PHAR.418 (PDF)
- Dextromethorphan/Bupropion (Auvelity) CP.PMN.284 (PDF)
- Dextromethorphan-Quinidine (Nuedexta) CP.PMN.93 (PDF)
- Diazepam Nasal Spray (Valtoco) CP.PMN.216 (PDF)
- Dichlorphenamide (Keveyis) CP.PMN.261 (PDF)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) CP.PCH.28 (PDF)
- Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) CP.PCH.41 (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors HIM.PA.58 (PDF)
- Dolasetron (Anzemet) CP.PMN.141 (PDF)
- Dornase Alfa (Pulmozyme) CP.PHAR.212 (PDF)
- Dostarlimab-gxly (Jemperli) CP.PHAR.540 (PDF)
- Doxepin (Silenor, Prudoxin, Zonalon) HIM.PA.147 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) CP.PMN.79 (PDF)
- Dupilumab (Dupixent) HIM.PA.SP69 (PDF)
- Durvalumab (Imfinzi) CP.PHAR.339 (PDF)
- Duvelisib (Copiktra) CP.PHAR.400 (PDF)
- Ecallantide (Kalbitor) CP.PHAR.177 (PDF)
- Eculizumab (Soliris) CP.PHAR.97 (PDF)
- Edaravone (Radicava) CP.PHAR.343 (PDF)
- Efinaconazole (Jublia) CP.PMN.25 (PDF)
- Eflornithine (Iwilfin) CP.PHAR.670 (PDF)
- Elacestrant (Orserdu) CP.PHAR.623 (PDF)
- Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) CP.PHAR.136 (PDF)
- Elapegademase-lvlr (Revcovi) CP.PHAR.419 (PDF)
- Elbasvir/Grazoprevir (Zepatier) HIM.PA.SP62 (PDF)
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) CP.PHAR.440 (PDF)
- Eliglustat (Cerdelga) CP.PHAR.153 (PDF)
- Elosulfase Alfa (Vimizim) CP.PHAR.162 (PDF)
- Elotuzumab (Empliciti) CP.PHAR.308 (PDF)
- Eltrombopag (Promacta) CP.PHAR.180 (PDF)
- Eluxadoline (Viberzi) CP.PMN.170 (PDF)
- Emapalumab-lzsg (Gamifant) CP.PHAR.402 (PDF)
- Emicizumab-kxwh (Hemlibra) CP.PHAR.370 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy) CP.PMN.235 (PDF)
- Enasidenib (Idhifa) CP.PHAR.363 (PDF)
- Encorafenib (Braftovi) CP.PHAR.127 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) CP.PHAR.455 (PDF)
- Enfuvirtide (Fuzeon) CP.PHAR.41 (PDF)
- Enoxaparin (Lovenox) CP.PHAR.224 (PDF)
- Entecavir (Baraclude) HIM.PA.08 (PDF)
- Entrectinib (Rozlytrek) CP.PHAR.441 (PDF)
- Epcoritamab-bysp (Epkinly) CP.PHAR.634 (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) CP.PHAR.237 (PDF)
- Epoprostenol (Flolan, Veletri) CP.PHAR.192 (PDF)
- Eptinezumab-jjmr (Vyepti) HIM.PA.SP64 (PDF)
- Erdafitinib (Balversa) CP.PHAR.423 (PDF)
- Erenumab-aaoe (Aimovig) HIM.PA.SP65 (PDF)
- Eribulin Mesylate (Halaven) CP.PHAR.318 (PDF)
- Erlotinib (Tarceva) CP.PHAR.74 (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) CP.PHAR.301 (PDF)
- Esketamine (Spravato) CP.PMN.199 (PDF)
- Estradiol Vaginal Ring (Femring) CP.PMN.263 (PDF)
- Etelcalcetide (Parsabiv) CP.PHAR.379 (PDF)
- Eteplirsen (Exondys 51) CP.PHAR.288 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) CP.PHAR.63 (PDF)
- Evinacumab-dgnb (Evkeeza) HIM.PA.166 (PDF)
- Evolocumab (Repatha) HIM.PA.156 (PDF)
- Factor IX (Human, Recombinant) CP.PHAR.218 (PDF)
- Factor IX Complex, Human (Profilnine) CP.PHAR.219 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) CP.PHAR.220 (PDF)
- Factor VIII (Human, Recombinant) CP.PHAR.215 (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) CP.PHAR.216 (PDF)
- Factor XIII A-Subunit, Recombinant (Tretten) CP.PHAR.222 (PDF)
- Factor XIII, Human (Corifact) CP.PHAR.221 (PDF)
- Fam-Trastuzumab Deruxtecan-nxki (Enhertu) CP.PHAR.456 (PDF)
- Faricimab-svoa (Vabysmo) CP.PHAR.581 (PDF)
- Febuxostat (Uloric) CP.PMN.57 (PDF)
- Fecal Microbiota, Live-jslm (Rebyota) CP.PHAR.613 (PDF)
- Fecal Microbiota Spores, Live-brpk (Vowst) CP.PHAR.632 (PDF)
- Fedratinib (Inrebic) CP.PHAR.442 (PDF)
- Fenfluramine (Fintepla) CP.PMN.246 (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) CP.PMN.127 (PDF)
- Ferric Carboxymaltose (Injectafer) CP.PHAR.234 (PDF)
- Ferric Derisomaltose (Monoferric) CP.PHAR.480 (PDF)
- Ferric Gluconate (Ferrlecit) CP.PHAR.166 (PDF)
- Ferric Maltol (Accrufer) CP.PMN.213 (PDF)
- Ferric Pyrophosphate (Triferic, Triferic Avnu) CP.PHAR.624 (PDF)
- Ferumoxytol (Feraheme) CP.PHAR.165 (PDF)
- Fezolinetant (Veozah) CP.PMN.289 (PDF)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) CP.PHAR.526 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) CP.PHAR.297 (PDF)
- Finerenone (Kerendia) CP.PMN.266 (PDF)
- Fingolimod (Gilenya) CP.PCH.38 (PDF)
- Flibanserin (Addyi) CP.PHAR.446 (PDF)
- Fluorouracil Cream (Tolak) CP.PMN.165 (PDF)
- Fluticasone Propionate (Xhance) CP.PMN.95 (PDF)
- Fondaparinux (Arixtra) CP.PHAR.226 (PDF)
- Formulary Medications Without Specific Guidelines HIM.PA.33 (PDF)
- Fosdenopterin (Nulibry) CP.PHAR.471 (PDF)
- Fostamatinib (Tavalisse) CP.PHAR.24 (PDF)
- Fremanezumab-vfrm (Ajovy) HIM.PA.SP66 (PDF)
- Fruquintinib (Fruzaqla) CP.PHAR.666 (PDF)
- Fulvestrant (Faslodex Injection) CP.PHAR.424 (PDF)
- Furosemide (Furoscix) CP.PHAR.608 (PDF)
- Futibatinib (Lytgobi) CP.PHAR.604 (PDF)
- Gabapentin ER (Gralise, Horizant) CP.PMN.240 (PDF)
- Galcanezumab-gnlm (Emgality) HIM.PA.SP67 (PDF)
- Galsulfase (Naglazyme) CP.PHAR.161 (PDF)
- Ganaxolone (Ztalmy) CP.PMN.278 (PDF)
- Gefitinib (Iressa) CP.PHAR.68 (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) CP.PHAR.358 (PDF)
- Gilteritinib (Xospata) CP.PHAR.412 (PDF)
- Givosiran (Givlaari) CP.PHAR.457 (PDF)
- Glasdegib (Daurismo) CP.PHAR.413 (PDF)
- Glatiramer Acetate (Copaxone, Glatopa) HIM.PA.SP68 (PDF)
- Glaucoma Agents CP.PMN.286 (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) HIM.PA.SP36 (PDF)
- Glofitamab-gxbm (Columvi) CP.PHAR.636 (PDF)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists HIM.PA.53 (PDF)
- Glycerol Phenylbutyrate (Ravicti) CP.PHAR.207 (PDF)
- Golodirsen (Vyondys 53) CP.PHAR.453 (PDF)
- Goserelin Acetate (Zoladex) CP.PHAR.171 (PDF)
- Halcinonide (Halog) HIM.PA.20 (PDF)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) CP.PMN.180 (PDF)
- Halobetasol Propionate/Tazarotene (Duobrii) CP.PMN.208 (PDF)
- Hemin (Panhematin) CP.PHAR.181 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) CP.PHAR.172 (PDF)
- House dust mite allergen extract (Odactra) CP.PMN.111 (PDF)
- Human Growth Hormone (Somapacitan, Somatropin) HIM.PA.161 (PDF)
- Hyaluronate Derivatives CP.PHAR.05 (PDF)
- Hydroxyurea (Siklos) CP.PMN.193 (PDF)
- Ibalizumab-uiyk (Trogarzo) CP.PHAR.378 (PDF)
- Ibandronate Injection (Boniva) CP.PHAR.189 (PDF)
- Ibrutinib (Imbruvica) CP.PHAR.126 (PDF)
- Ibuprofen/Famotidine (Duexis) CP.PMN.120 (PDF)
- Icatibant (Firazyr) CP.PHAR.178 (PDF)
- Icosapent Ethyl (Vascepa) CP.PMN.187 (PDF)
- Idecabtagene Vicleucel (Abecma) CP.PHAR.481 (PDF)
- Idelalisib (Zydelig) CP.PHAR.133 (PDF)
- Idursulfase (Elaprase) CP.PHAR.156 (PDF)
- Iloperidone (Fanapt) CP.PMN.32 (PDF)
- Iloprost (Ventavis) CP.PHAR.193 (PDF)
- Imatinib (Gleevec) CP.PHAR.65 (PDF)
- Imiglucerase (Cerezyme) CP.PHAR.154 (PDF)
- Immune Globulins CP.PHAR.103 (PDF)
- Inavolisib (Itovebi) CP.PHAR.702 (PDF)
- IncobotulinumtoxinA (Xeomin) CP.PHAR.231 (PDF)
- Inclisiran (Leqvio) CP.PHAR.568 (PDF)
- Inebilizumab-cdon (Uplizna) CP.PHAR.458 (PDF)
- Infertility and Fertility Preservation CP.PHAR.131 (PDF)
- Infigratinib (Truseltiq) CP.PHAR.547 (PDF)
- Inhaled Agents for Asthma and COPD HIM.PA.153 (PDF)
- Inotersen (Tegsedi) CP.PHAR.405 (PDF)
- Inotuzumab Ozogamicin (Besponsa) CP.PHAR.359 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) CP.PHAR.534 (PDF)
- Insulin Glargine (Semglee, Toujeo) HIM.PA.09 (PDF)
- Interferon Beta-1a (Avonex, Rebif) CP.PHAR.255 (PDF)
- Interferon Beta-1b (Betaseron, Extavia) CP.PCH.46 (PDF)
- Interferon Gamma- 1b (Actimmune) CP.PHAR.52 (PDF)
- Iobenguane I-131 (Azedra) CP.PHAR.459 (PDF)
- Ipilimumab (Yervoy) CP.PHAR.319 (PDF)
- Irinotecan Liposome (Onivyde) CP.PHAR.304 (PDF)
- Iron Sucrose (Venofer) CP.PHAR.167 (PDF)
- Isatuximab-irfc (Sarclisa) CP.PHAR.482 (PDF)
- Isavuconazonium (Cresemba) CP.PMN.154 (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) CP.PMN.143 (PDF)
- Istradefylline (Nourianz) CP.PMN.217 (PDF)
- Itraconazole (Sporanox, Tolsura) CP.PMN.124 (PDF)
- Ivabradine (Corlanor) CP.PMN.70 (PDF)
- Ivacaftor (Kalydeco) CP.PHAR.210 (PDF)
- Ivermectin (Stromectol, Sklice) CP.PMN.269 (PDF)
- Ivosidenib (Tibsovo) CP.PHAR.137 (PDF)
- Ixazomib (Ninlaro) CP.PHAR.302 (PDF)
- lacosamide (Vimpat) CP.PMN.155 (PDF)
- Lanadelumab-fylo (Takhzyro) CP.PHAR.396 (PDF)
- Lanreotide (Somatuline Depot) CP.PHAR.391 (PDF)
- Lapatinib (Tykerb) CP.PHAR.79 (PDF)
- Laronidase (Aldurazyme) CP.PHAR.152 (PDF)
- Larotrectinib (Vitrakvi) CP.PHAR.414 (PDF)
- Lasmiditan (Reyvow) CP.PMN.218 (PDF)
- Lazertinib (Lazcluze) CP.PHAR.695 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) HIM.PA.SP3 (PDF)
- Lefamulin (Xenleta) CP.PMN.219 (PDF)
- Lenacapavir (Sunlenca) CP.PHAR.622 (PDF)
- Lenalidomide (Revlimid) CP.PHAR.71 (PDF)
- Lenvatinib (Lenvima) CP.PHAR.138 (PDF)
- Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) CP.PMN.150 (PDF)
- Letermovir (Prevymis) CP.PHAR.367 (PDF)
- Leucovorin Injection CP.PHAR.393 (PDF)
- Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) CP.PCH.53 (PDF)
- Levodopa Inhalation Powder (Inbrija) CP.PMN.267 (PDF)
- Levoketoconazole (Recorlev) CP.PMN.275 (PDF)
- Levoleucovorin (Fusilev, Khapzory) CP.PHAR.151 (PDF)
- Levomilnacipran (Fetzima) HIM.PA.125 (PDF)
- L-glutamine (Endari) CP.PMN.116 (PDF)
- Lidocaine transdermal (Lidoderm, ZTlido) CP.PMN.08 (PDF)
- Lifitegrast (Xiidra) CP.PMN.73 (PDF)
- Linaclotide (Linzess) CP.PMN.71 (PDF)
- Linezolid (Zyvox) CP.PMN.27 (PDF)
- Lisocabtagene Maraleucel (Breyanzi) CP.PHAR.483 (PDF)
- Lofexidine (Lucemyra) CP.PMN.152 (PDF)
- Lomustine (Gleostine) CP.PHAR.507 (PDF)
- Lonafarnib (Zokinvy) CP.PHAR.499 (PDF)
- Loncastuximab Tesirine-lpyl (Zynlonta) CP.PHAR.539 (PDF)
- Lorlatinib (Lorbrena) CP.PHAR.406 (PDF)
- Loteprednol etabonate (Eysuvis) CP.PMN.260 (PDF)
- Lubiprostone (Amitiza) CP.PMN.142 (PDF)
- Luliconazole Cream (Luzu) CP.PMN.166 (PDF)
- Lumacaftor/Ivacaftor (Orkambi) CP.PHAR.213 (PDF)
- Lumasiran (Oxlumo) CP.PHAR.473 (PDF)
- Lumateperone (Caplyta) CP.PMN.232 (PDF)
- Lurasidone (Latuda) CP.PMN.50 (PDF)
- Lurbinectedin (Zepzelca) CP.PHAR.500 (PDF)
- Luspatercept-aamt (Reblozyl) CP.PHAR.450 (PDF)
- Lusutrombopag (Mulpleta) CP.PHAR.407 (PDF)
- Lutetium Lu 177 dotatate (Lutathera) CP.PHAR.384 (PDF)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) CP.PHAR.582 (PDF)
- Macitentan (Opsumit) CP.PCH.31 (PDF)
- Maralixibat (Livmarli) CP.PHAR.543 (PDF)
- Margetuximab-cmkb (Margenza) CP.PHAR.522 (PDF)
- Maribavir (Livtencity) CP.PMN.271 (PDF)
- Mavacamten (MYK-461) CP.PMN.272 (PDF)
- Mecamylamine (Vecamyl) CP.PMN.136 (PDF)
- Mecasermin (Increlex) CP.PHAR.150 (PDF)
- Mechlorethamine Gel (Valchlor) CP.PHAR.381 (PDF)
- Megestrol Acetate (Megace ES) CP.PMN.179 (PDF)
- Melphalan flufenamide (Pepaxto) CP.PHAR.535 (PDF)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) CP.PCH.30 (PDF)
- Mepolizumab (Nucala) CP.PHAR.200 (PDF)
- Mercaptopurine (Purixan) CP.PHAR.447 (PDF)
- Metformin ER (Fortamet, Glumetza) CP.PMN.72 (PDF)
- Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) CP.PHAR.134 (PDF)
- Methoxsalen (Uvadex) HIM.PA.17 (PDF)
- Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) CP.PHAR.238 (PDF)
- Methylnaltrexone Bromide (Relistor) CP.PMN.169 (PDF)
- Metoclopramide (Gimoti) CP.PMN.252 (PDF)
- Metreleptin (Myalept) CP.PHAR.425 (PDF)
- Midazolam (Nayzilam) CP.PMN.211 (PDF)
- Midostaurin (Rydapt) CP.PHAR.344 (PDF)
- Mifepristone (Korlym) CP.PHAR.101 (PDF)
- Migalastat (Galafold) CP.PHAR.394 (PDF)
- Miglustat (Zavesca) CP.PHAR.164 (PDF)
- Milnacipran (Savella) CP.PMN.125 (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) CP.PMN.80 (PDF)
- Mirvetuximab soravatansine-gynx (Elahere) CP.PHAR.617 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) CP.PHAR.495 (PDF)
- Mitoxantrone (Novantrone) CP.PHAR.258 (PDF)
- Mobocertinib (Exkivity) CP.PHAR.559 (PDF)
- Modafinil (Provigil) CP.PMN.39 (PDF)
- Mogamulizumab-kpkc (Poteligeo) CP.PHAR.139 (PDF)
- Mometasone (Nasonex) HIM.PA.93 (PDF)
- Mometasone Furoate (Sinuva) CP.PHAR.448 (PDF)
- Mosunetuzumab-axgb (Lunsumio) CP.PHAR.618 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti) CP.PHAR.398 (PDF)
- Nabumetone Double-Strength (Relafen DS) CP.PMN.287 (PDF)
- Nafarelin Acetate (Synarel) CP.PHAR.174 (PDF)
- Nalmefene (Opvee) CP.PHAR.638 (PDF)
- Naltrexone (Vivitrol) CP.PHAR.96 (PDF)
- Naloxegol (Movantik) HIM.PA.167 (PDF)
- Naproxen Oral Suspension (Naprosyn) HIM.PA.130 (PDF)
- Naproxen/Esomeprazole (Vimovo) CP.PMN.117 (PDF)
- Naxitamab-gqgk (Danyelza) CP.PHAR.523 (PDF)
- Necitumumab (Portrazza) CP.PHAR.320 (PDF)
- Nemolizumab-ilto (Nemluvio) CP.PHAR.703 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) CP.PMN.167 (PDF)
- Neratinib (Nerlynx) CP.PHAR.365 (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) CP.PMN.158 (PDF)
- Nifurtimox (Lampit) CP.PMN.256 (PDF)
- Nilotinib (Tasigna) CP.PHAR.76 (PDF)
- Nintedanib (Ofev) CP.PHAR.285 (PDF)
- Niraparib (Zejula) CP.PHAR.408 (PDF)
- Nirmatrelvir and Ritonavir (Paxlovid) CP.PMN.288 (PDF)
- Nirogacestat (Ogsiveo) CP.PHAR.671 (PDF)
- Nitazoxanide (Alinia) HIM.PA.152 (PDF)
- Nitisinone (Nityr, Orfadin) CP.PHAR.132 (PDF)
- Nivolumab and Relatlimab-rmbw (Opdualag) CP.PHAR.588 (PDF)
- Nivolumab (Opdivo) CP.PHAR.121 (PDF)
- No Coverage Criteria CP.PMN.255 (PDF)
- Non-Formulary and Formulary Contraceptives HIM.PA.100 (PDF)
- Non-Formulary Test Strips HIM.PA.34 (PDF)
- Nusinersen (Spinraza) CP.PHAR.327 (PDF)
- Obeticholic Acid (Ocaliva) CP.PHAR.287 (PDF)
- Obinutuzumab (Gazyva) CP.PHAR.305 (PDF)
- Ocrelizumab (Ocrevus) CP.PHAR.335 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) CP.PHAR.40 (PDF)
- Odevixibat (Bylvay) CP.PHAR.528 (PDF)
- Ofatumumab (Arzerra, Kesimpta) CP.PHAR.306 (PDF)
- Off-Label Drug Use HIM.PA.154 (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) CP.PHAR.292 (PDF)
- Olanzapine/Samidorphan (Lybalvi) CP.PMN.265 (PDF)
- Olaparib (Lynparza) CP.PHAR.360 (PDF)
- Olaratumab (Lartruvo) CP.PHAR.326 (PDF)
- Olutasidenib (Rezlidhia) CP.PHAR.615 (PDF)
- Omacetaxine (Synribo) CP.PHAR.108 (PDF)
- Omadacycline (Nuzyra) CP.PMN.188 (PDF)
- Omalizumab (Xolair) CP.PCH.49 (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza) CP.PMN.52 (PDF)
- OnabotulinumtoxinA (Botox) CP.PHAR.232 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) CP.PHAR.421 (PDF)
- Ondansetron (Zuplenz) CP.PMN.45 (PDF)
- Ophthalmic Corticosteroids HIM.PA.03 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) CP.PHAR.536 (PDF)
- Opicapone (Ongentys) CP.PMN.245 (PDF)
- Opioid Analgesics HIM.PA.139 (PDF)
- Osilodrostat (Isturisa) CP.PHAR.487 (PDF)
- Osimertinib (Tagrisso) CP.PHAR.294 (PDF)
- Ospemifene (Osphena) CP.PMN.168 (PDF)
- Overactive Bladder Agents CP.PMN.198 (PDF)
- Oxymetazoline (Rhofade, Upneeq) CP.PMN.86 (PDF)
- Ozanimod (Zeposia) CP.PHAR.462 (PDF)
- Ozenoxacin (Xepi) CP.PMN.119 (PDF)
- Paclitaxel, Protein-Bound (Abraxane) CP.PHAR.176 (PDF)
- Pacritinib (Vonjo) CP.PHAR.583 (PDF)
- Palbociclib (Ibrance) CP.PHAR.125 (PDF)
- Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) CP.PHAR.291 (PDF)
- Palivizumab (Synagis) CP.PHAR.16 (PDF)
- Palopegteriparatide (Yorvipath) CP.PHAR.696 (PDF)
- Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) CP.PCH.44 (PDF)
- Panitumumab (Vectibix) CP.PHAR.321 (PDF)
- Panobinostat (Farydak) CP.PHAR.382 (PDF)
- Parathyroid Hormone (Natpara) CP.PHAR.282 (PDF)
- Paricalcitol Injection (Zemplar) CP.PHAR.270 (PDF)
- Pasireotide (Signifor, Signifor LAR) CP.PHAR.332 (PDF)
- Patiromer (Veltassa) CP.PMN.205 (PDF)
- Patisiran (Onpattro) CP.PHAR.395 (PDF)
- Pazopanib (Votrient) CP.PHAR.81 (PDF)
- Peanut Allergen Powder-dnfp (Palforzia) CP.PMN.220 (PDF)
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) CP.PHAR.353 (PDF)
- Pegcetacoplan (Empaveli) CP.PHAR.524 (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastim-apgf (Nyvepria) CP.PHAR.296 (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) CP.PHAR.89 (PDF)
- Peginterferon Beta-1a (Plegridy) CP.PHAR.271 (PDF)
- Pegloticase (Krystexxa) CP.PHAR.115 (PDF)
- Pegvaliase-pqpz (Palynziq) CP.PHAR.140 (PDF)
- Pegvisomant (Somavert) CP.PHAR.389 (PDF)
- Pembrolizumab (Keytruda) CP.PHAR.322 (PDF)
- Pemetrexed (Alimta, Pemfexy) CP.PHAR.368 (PDF)
- Pemigatinib (Pemazyre) CP.PHAR.496 (PDF)
- Penicillamine (Cuprimine) CP.PCH.09 (PDF)
- Perampanel (Fycompa) CP.PMN.156 (PDF)
- Perfluorohexyloctane (Miebo) CP.PMN.290 (PDF)
- Pertuzumab (Perjeta) CP.PHAR.227 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) CP.PHAR.501 (PDF)
- Pexidartinib (Turalio) CP.PHAR.436 (PDF)
- Phendimetrazine CP.PCH.47 (PDF)
- Phentermine (Adipex-P, Lomaira) CP.PCH.13 (PDF)
- Pilocarpine CP.PMN.270 (PDF)
- Pimavanserin (Nuplazid) CP.PMN.140 (PDF)
- Pirfenidone (Esbriet) CP.PHAR.286 (PDF)
- Pirtobrutinib (Jaypirca) CP.PHAR.620 (PDF)
- Pitolisant (Wakix) CP.PMN.221 (PDF)
- Plasminogen, human-tvmh (Ryplazim) CP.PHAR.513 (PDF)
- Plerixafor (Mozobil) CP.PHAR.323 (PDF)
- Polatuzumab Vedotin-piiq (Polivy) CP.PHAR.433 (PDF)
- Pomalidomide (Pomalyst) CP.PHAR.116 (PDF)
- Ponatinib (Iclusig) CP.PHAR.112 (PDF)
- Ponesimod (Ponvory) CP.PHAR.537 (PDF)
- Potassium Chloride for Oral Solution (Klor-Con Powder) HIM.PA.143 (PDF)
- Pralatrexate (Folotyn) CP.PHAR.313 (PDF)
- Pramlintide (Symlin) CP.PMN.129 (PDF)
- Prasterone (Intrarosa) CP.PMN.99 (PDF)
- Pregabalin (Lyrica, Lyrica CR) CP.PMN.33 (PDF)
- Pretomanid CP.PMN.222 (PDF)
- Progesterone (Crinone, Endometrin, Milprosa) CP.PMN.243 (PDF)
- Propranolol HCl Oral Solution (Hemangeol) CP.PCH.51 (PDF)
- Protein C Concentrate, Human (Ceprotin) CP.PHAR.330 (PDF)
- Prucalopride (Motegrity) HIM.PA.159 (PDF)
- Pyrimethamine (Daraprim) CP.PMN.44 (PDF)
- Quetiapine Extended-Release (Seroquel XR) CP.PMN.64 (PDF)
- Quinine Sulfate (Qualaquin) CP.PMN.262 (PDF)
- Ramucirumab (Cyramza) CP.PHAR.119 (PDF)
- Ranibizumab (Lucentis) CP.PHAR.186 (PDF)
- Rasagiline (Azilect) HIM.PA.89 (PDF)
- Ravulizumab-cwvz (Ultomiris) CP.PHAR.415 (PDF)
- Regorafenib (Stivarga) CP.PHAR.107 (PDF)
- Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) CP.PHAR.529 (PDF)
- Remestemcel-L (Ryoncil) CP.PHAR.474 (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel) CP.PHAR.168 (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) HIM.PA.168 (PDF)
- Repotrectinib (Augtyro) CP.PHAR.667 (PDF)
- Reslizumab (Cinqair) CP.PHAR.223 (PDF)
- Retifanlimab-dlwr (Zynyz) CP.PHAR.629 (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) CP.PHAR.141 (PDF)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) CP.PHAR.334 (PDF)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) CP.PMN.223 (PDF)
- Rifamycin (Aemcolo) CP.PMN.196 (PDF)
- Rifaximin (Xifaxan) CP.PMN.47 (PDF)
- Rilonacept (Arcalyst) CP.PHAR.266 (PDF)
- RimabotulinumtoxinB (Myobloc) CP.PHAR.233 (PDF)
- Rimegepant (Nurtec ODT) CP.PHAR.490 (PDF)
- Riociguat (Adempas) CP.PHAR.195 (PDF)
- Ripretinib (Qinlock) CP.PHAR.502 (PDF)
- Risdiplam (Evrysdi) CP.PHAR.477 (PDF)
- Risedronate (Actonel, Atelvia) CP.PMN.100 (PDF)
- Risperidone Long-Acting Injection (Perseris, Risperdal Consta) CP.PHAR.293 (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) CP.PHAR.260 (PDF)
- Rolapitant (Varubi) CP.PMN.102 (PDF)
- Romidepsin (Istodax) CP.PHAR.314 (PDF)
- Romiplostim (Nplate) CP.PHAR.179 (PDF)
- Romosozumab-aqqg (Evenity) CP.PHAR.428 (PDF)
- Ropeginterferon Alfa-2b-njft (BESREMi) CP.PHAR.570 (PDF)
- Rucaparib (Rubraca) CP.PHAR.350 (PDF)
- Rufinamide (Banzel) CP.PMN.157 (PDF)
- Rukobia (fostemsavir) CP.PHAR.516 (PDF)
- Ruxolitinib (Jakafi, Opzelura) CP.PHAR.98 (PDF)
- Sacituzumab Govitecan-hziy (Trodelvy) CP.PHAR.475 (PDF)
- Sacubitril/Valsartan (Entresto) CP.PMN.67 (PDF)
- Safinamide (Xadago) CP.PMN.113 (PDF)
- Sapropterin Dihydrochloride (Kuvan) CP.PHAR.43 (PDF)
- Sarecycline (Seysara) CP.PMN.189 (PDF)
- Sargramostim (Leukine) CP.PHAR.295 (PDF)
- Satralizumab-mwge (Enspryng) CP.PHAR.463 (PDF)
- Sebelipase Alfa (Kanuma) CP.PHAR.159 (PDF)
- Secnidazole (Solosec) CP.PMN.103 (PDF)
- Seladelpar (Livdelzi) CP.PHAR.698 (PDF)
- Selexipag (Uptravi) CP.PHAR.196 (PDF)
- Selinexor (Xpovio) CP.PHAR.431 (PDF)
- Selpercatinib (Retevmo) CP.PHAR.478 (PDF)
- Selumetinib (Koselugo) CP.PHAR.464 (PDF)
- Semaglutide (Wegovy) CP.PMN.295 (PDF)
- Setmelanotide (Imcivree) CP.PHAR.491 (PDF)
- Short ragweed pollen allergen extract (Ragwitek) CP.PMN.83 (PDF)
- Sildenafil (Revatio) CP.PHAR.197 (PDF)
- Sildenafil for ED (Viagra) CP.PCH.07 (PDF)
- Siltuximab (Sylvant) CP.PHAR.329 (PDF)
- Siponimod (Mayzent) CP.PHAR.427 (PDF)
- Sirolimus Protein-Bound Particles (Fyarro) CP.PHAR.574 (PDF)
- Sodium thiosulfate (Pedmark) CP.PHAR.610 (PDF)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) CP.PMN.42 (PDF)
- Sodium Phenylbutyrate (Buphenyl) CP.PHAR.208 (PDF)
- Sodium zirconium cyclosilicate (Lokelma) CP.PMN.163 (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors HIM.PA.91 (PDF)
- Sofosbuvir (Sovaldi) HIM.PA.SP2 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) HIM.PA.SP1 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) HIM.PA.SP63 (PDF)
- Solriamfetol (Sunosi) CP.PMN.209 (PDF)
- Sonidegib (Odomzo) CP.PHAR.272 (PDF)
- Sorafenib (Nexavar) CP.PHAR.69 (PDF)
- Sotorasib (Lumakras) CP.PHAR.549 (PDF)
- Sparsentan (Filspari) CP.PHAR.631 (PDF)
- Spesolimab-sbzo (Spevigo) CP.PHAR.606 (PDF)
- Spinosad (Natroba) HIM.PA.134 (PDF)
- Step Therapy HIM.PA.109 (PDF)
- Stiripentol (Diacomit) CP.PMN.184 (PDF)
- Sunitinib (Sutent) CP.PHAR.73 (PDF)
- Sutimlimab CP.PHAR.503 (PDF)
- Suvorexant (Belsomra) CP.PMN.109 (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) CP.PMN.85 (PDF)
- Tadalafil (Adcirca, Alyq) CP.PHAR.198 (PDF)
- Tadalafil BHP - ED (Cialis) CP.PMN.132 (PDF)
- Tafamidis (Vyndaqel, Vyndamax) CP.PHAR.432 (PDF)
- Tafasitamab-cxix (Monjuvi) CP.PHAR.508 (PDF)
- Talazoparib (Talzenna) CP.PHAR.409 (PDF)
- Taliglucerase Alfa (Elelyso) HIM.PA.162 (PDF)
- Talimogene laherepvec (Imlygic) CP.PHAR.542 (PDF)
- Tasimelteon (Hetlioz, Hetlioz LQ) CP.PMN.104 (PDF)
- Tavaborole (Kerydin) CP.PMN.105 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) CP.PMN.244 (PDF)
- Tazemetostat (Tazverik) CP.PHAR.452 (PDF)
- Tebentafusp-tebn (Kimmtrak) CP.PHAR.575 (NEW)
- Teclistamab-cqyv (Tecvayli) CP.PHAR.611 (PDF)
- Tedizolid (Sivextro) CP.PMN.62 (PDF)
- Teduglutide (Gattex) CP.PHAR.114 (PDF)
- Telotristat Ethyl (Xermelo) CP.PHAR.337 (PDF)
- Temozolomide (Temodar) CP.PHAR.77 (PDF)
- Temsirolimus (Torisel) CP.PHAR.324 (PDF)
- Tenapanor (Ibsrela) CP.PMN.224 (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) CP.PMN.268 (PDF)
- Tepotinib (Tepmetko) CP.PHAR.530 (PDF)
- Teprotumumab (Tepezza) CP.PHAR.465 (PDF)
- Teriflunomide (Aubagio) CP.PCH.40 (PDF)
- Teriparatide (Forteo) CP.PHAR.188 (PDF)
- Tesamorelin (Egrifta SV) CP.PHAR.109 (PDF)
- Testosterone (Androderm) HIM.PA.87 (PDF)
- Testosterone (Testopel, Jatenzo) CP.PHAR.354 (PDF)
- Tetrabenazine (Xenazine) CP.PHAR.92 (PDF)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) CP.PHAR.377 (PDF)
- Tezepelumab-ekko (Tezspire) CP.PHAR.576 (PDF)
- Thalidomide (Thalomid) CP.PHAR.78 (PDF)
- Thioguanine (Tabloid) CP.PHAR.437 (PDF)
- Thyrotropin alfa (Thyrogen) CP.PHAR.95 (PDF)
- Timothy grass pollen allergen extract (Grastek) CP.PMN.84 (PDF)
- Tiopronin Delayed-Release (Thiola EC) CP.PCH.50 (PDF)
- Tisagenlecleucel (Kymriah) CP.PHAR.361 (PDF)
- Tisotumab vedotin-tftv (Tivdak) CP.PHAR.561 (PDF)
- Tivozanib (Fotivda) CP.PHAR.538 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) CP.PHAR.211 (PDF)
- Tolvaptan (Jynarque, Samsca) CP.PHAR.27 (PDF)
- Topical Acne Treatment HIM.PA.71 (PDF)
- Topical Immunomodulators CP.PMN.107 (PDF)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) CP.PMN.281 (PDF)
- Topotecan (Hycamtin) CP.PHAR.64 (PDF)
- Toripalimab-tpzi (Loqtorzi) CP.PHAR.668 (PDF)
- Trabectedin (Yondelis) CP.PHAR.204 (PDF)
- Tralokinumab-ldrm (Adbry) CP.PHAR.577 (PDF)
- Trametinib (Mekinist) CP.PHAR.240 (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase CP.PHAR.228 (PDF)
- Travoprost Implant (iDose TR) CP.PHAR.672 (PDF)
- Tremelimumab-actl (Imjudo) CP.PHAR.612 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) CP.PHAR.199 (PDF)
- Triamcinolone ER Injection (Zilretta) CP.PHAR.371 (PDF)
- Triclabendazole (Egaten) CP.PMN.207 (PDF)
- Trientine (Syprine) CP.PHAR.438 (PDF)
- Trifarotene (Aklief) CP.PMN.225 (PDF)
- Trifluridine/Tipiracil (Lonsurf) CP.PHAR.383 (PDF)
- Triheptanoin (Dojolvi) CP.PHAR.509 (PDF)
- Triptorelin Pamoate (Trelstar, Triptodur) CP.PHAR.175 (PDF)
- Tucatinib (Tukysa) CP.PHAR.497 (PDF)
- Ublituximab-xiiy (Briumvi) CP.PHAR.621 (PDF)
- Ubrogepant (Ubrelvy) CP.PHAR.476 (PDF)
- Ulcer Therapy Combinations CP.PMN.277 (PDF)
- Umbralisib (Ukoniq) CP.PHAR.531 (PDF)
- Uridine Triacetate (Vistogard) HIM.PA.SP55 (PDF)
- Vadadustat (Vafseo) CP.PHAR.677 (PDF)
- Valbenazine (Ingrezza) CP.PCH.48 (PDF)
- Valganciclovir (Valcyte) CP.PCH.06 (PDF)
- Valoctocogene Roxaparvovec CP.PHAR.466 (PDF)
- Valrubicin (Valstar) CP.PHAR.439 (PDF)
- Vamorolone (Agamree) CP.PHAR.659 (PDF)
- Vandetanib (Caprelsa) CP.PHAR.80 (PDF)
- Varenicline (Tyrvaya) CP.PMN.273 (PDF)
- Velaglucerase Alfa (VPRIV) HIM.PA.163 (PDF)
- Vemurafenib (Zelboraf) CP.PHAR.91 (PDF)
- Venetoclax (Venclexta) CP.PHAR.129 (PDF)
- Verteporfin (Visudyne) CP.PHAR.187 (PDF)
- Vestronidase alfa-vjbk (Mepsevii) CP.PHAR.374 (PDF)
- Vigabatrin (Sabril) CP.PHAR.169 (PDF)
- Vilazodone (Viibryd) CP.PMN.145 (PDF)
- Viltolarsen (Viltepso) CP.PHAR.484 (PDF)
- Vismodegib (Erivedge) CP.PHAR.273 (PDF)
- Voclosporin (Lupkynis) CP.PHAR.504 (PDF)
- Vorapaxar (Zontivity) HIM.PA.146 (PDF)
- Vorasidenib (Voranigo) CP.PHAR.699 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) CP.PHAR.372 (PDF)
- Vorinostat (Zolinza) CP.PHAR.83 (PDF)
- Vortioxetine (Trintellix) CP.PMN.65 (PDF)
- Voxelotor (Oxbryta) CP.PHAR.451 (PDF)
- Zanubrutinib (Brukinsa) CP.PHAR.467 (PDF)
- Zavegepant (Zavzpret) CP.PHAR.630 (PDF)
- Ziv-aflibercept (Zaltrap) CP.PHAR.325 (PDF)
- Zoledronic Acid (Reclast, Zometa) CP.PHAR.59 (PDF)
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- CC.PP.050 Robotic Surgery (PDF)
- CC.PP.052 Problem-Oriented Visits with Surgical Procedures (PDF)
- CC.PP.053 Non-Emergent ER Services (fka Leveling of ER Services) (PDF)
- CC.PP.054 Physician's Consultation Services (PDF)
- CC.PP.056 Urine Specimen Validity Testing (PDF)
- CC.PP.057 Problem-Oriented Visits with Preventative Visits (PDF)
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- CC.PP.065 Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
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