| A |
|
|
|
| Abaloparatide - (IP0329) |
PDF |
220kB |
04/01/2024 |
| Abatacept Intravenous - (IP0232) |
PDF |
308kB |
06/01/2024 |
| Abatacept Subcutaneous - (IP0231) |
PDF |
270kB |
06/01/2024 |
| Abilify Mycite - (IP0534) |
PDF |
185kB |
02/01/2023 |
| Abrocitinib - (IP0404) |
PDF |
352kB |
04/01/2023 |
| Acyclovir 5% Ointment for Individual and Family Plans - (IP0498) |
PDF |
184kB |
01/01/2023 |
| Adalimumab - (IP0245) |
PDF |
296kB |
06/01/2024 |
| Aducanumab - (IP0200) |
PDF |
210kB |
01/15/2024 |
Advantage Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
491kB |
07/01/2024 |
| Afamelanotide - (IP0159) |
PDF |
183kB |
08/01/2023 |
| Aflibercept - (IP0540) |
PDF |
238kB |
11/01/2023 |
| Afrezza® - (IP0533) |
PDF |
178kB |
02/01/2023 |
| Agalsidase - (IP0406) |
PDF |
211kB |
09/15/2023 |
| Albendazole for Individual and Family Plans - (IP0462) |
PDF |
209kB |
01/01/2023 |
| Aldesleukin for Non-Oncology Uses - (IP0407) |
PDF |
183kB |
05/01/2023 |
| Alemtuzumab - (IP0213) |
PDF |
224kB |
03/01/2024 |
| Alglucosidase Alfa - (IP0440) |
PDF |
209kB |
09/15/2023 |
| Alirocumab - (IP0250) |
PDF |
308kB |
05/15/2024 |
| Alosetron - (IP0012) |
PDF |
171kB |
04/01/2024 |
| Alpelisib - (IP0481) |
PDF |
213kB |
10/01/2023 |
| Alpha1-Proteinase Inhibitors - (IP0387) |
PDF |
231kB |
04/01/2024 |
| Amantadine Extended-Release - (IP0403) |
PDF |
214kB |
01/15/2024 |
| Amifampridine - (IP0290) |
PDF |
227kB |
01/15/2024 |
| Amikacin Liposome - (IP0383) |
PDF |
244kB |
02/15/2024 |
| Aminocaproic Acid for Individual and Family Plans - (IP0463) |
PDF |
175kB |
01/01/2023 |
| Amlodipine Oral Solution - (IP0484) |
PDF |
208kB |
10/01/2023 |
| Amyloidosis - Tafamidis Products - (IP0149) |
PDF |
188kB |
04/01/2024 |
| Amyloidosis – Wainua - (IP0628) |
PDF |
185kB |
07/01/2024 |
| Anakinra - (IP0243) |
PDF |
265kB |
06/01/2024 |
| Angiotensin Receptor Blockers - (IP0362) |
PDF |
113kB |
01/01/2023 |
| Antibiotics (inhaled) – Cayston - (IP0485) |
PDF |
152kB |
07/01/2024 |
| Antibiotics (Inhaled) – TOBI Podhaler - (IP0499) |
PDF |
156kB |
06/15/2024 |
| Antibiotics (Inhaled) – Tobramycin Inhalation Solution - (IP0094) |
PDF |
206kB |
07/01/2024 |
| Antibiotics – Linezolid (Zyvox), Sivextro - (IP0372) |
PDF |
217kB |
07/01/2024 |
| Anticoagulants – Dabigatran - (IP0033) |
PDF |
277kB |
05/01/2024 |
| Anticoagulants – Savaysa - (IP0034) |
PDF |
135kB |
06/01/2024 |
| Anticonvulsant Medications - (IP0031) |
PDF |
233kB |
03/15/2024 |
| Antiemetic Therapy - (1705) |
PDF |
222kB |
07/15/2022 |
| Antihemophilic Factor (Recombinant) - (IP0564) |
PDF |
189kB |
02/15/2024 |
| Antihyperglycemic Therapy (Non-Insulin) - (P0098) |
PDF |
358kB |
07/19/2024 |
| Antimalarial Therapy - (P0101) |
PDF |
83kB |
07/01/2022 |
| Antiseizure Medications – Diacomit - (IP0409) |
PDF |
245kB |
06/15/2024 |
| Antiseizure Medications - Epidiolex - (IP0410) |
PDF |
230kB |
05/15/2024 |
| Antiseizure Medications – Valtoco - (IP0105) |
PDF |
147kB |
06/01/2024 |
| Antitussives - (IP0586) |
PDF |
196kB |
01/15/2024 |
| Apixaban - (IP0030) |
PDF |
246kB |
06/15/2023 |
| Apremilast - (IP0226) |
PDF |
261kB |
07/15/2024 |
| Attention Deficit Hyperactivity Disorder (ADHD) Stimulants - (IP0477) |
PDF |
491kB |
04/01/2024 |
| Attention Deficit Hyperactivity Disorder (ADHD) Stimulants for Individual and Family Plans - (IP0584) |
PDF |
202kB |
04/01/2024 |
| Attention Deficit Hyperactivity Disorder Non-Stimulant Medications - (IP0217) |
PDF |
228kB |
11/01/2023 |
| Avacincaptad Intravitreal Injection - (IP0581) |
PDF |
181kB |
01/15/2024 |
| Avalglucosidase - (IP0279) |
PDF |
227kB |
01/15/2024 |
| Avatrombopag - (IP0152) |
PDF |
207kB |
10/01/2023 |
| Avonex (interferon beta-1b) - (IP0254) |
PDF |
193kB |
01/01/2024 |
| Azathioprine - (IP0337) |
PDF |
172kB |
12/15/2023 |
| B |
|
|
|
| Baricitinib - (IP0225) |
PDF |
270kB |
06/01/2024 |
| Becaplermin - (IP0495) |
PDF |
176kB |
12/01/2022 |
| Belatacept -(IP0219) |
PDF |
227kB |
01/15/2024 |
| Belimumab Intravenous - (IP0429) |
PDF |
233kB |
01/15/2024 |
| Belimumab Subcutaneous - (IP0430) |
PDF |
227kB |
01/15/2024 |
| Belumosudil - (IP0313) |
PDF |
196kB |
01/15/2024 |
| Bempedoic Acid/Ezetimibe - (IP0249) |
PDF |
246kB |
05/01/2024 |
| Bempedoic Acid - (IP0248) |
PDF |
257kB |
05/01/2024 |
| Benralizumab - (IP0421) |
PDF |
283kB |
08/01/2023 |
| Beremagene geperpavec-svdt - (IP0572) |
PDF |
249kB |
04/15/2024 |
| Beta Blockers - (IP0461) |
PDF |
91kB |
01/01/2023 |
| Betaine (Cystadane) for Individual and Family Plans - (IP0465) |
PDF |
227kB |
01/01/2024 |
| Bleomycin Sulfate - (IP0458) |
PDF |
91kB |
08/15/2022 |
| Bone Modifiers – Xgeva - (IP0332) |
PDF |
202kB |
06/15/2024 |
| Botulinum Therapy - (1106) |
PDF |
497kB |
03/01/2023 |
| Bowel Agents – Opioid-Induced Constipation - (IP0401) |
PDF |
169kB |
05/01/2024 |
| Brands with Bioequivalent Generics - (IP0011) |
PDF |
184kB |
07/15/2024 |
| Bremelanotide - (IP0117) |
PDF |
199kB |
06/15/2023 |
| Brexanolone - (IP0270) |
PDF |
203kB |
11/15/2023 |
| Brexucabtagene autoleucel - (IP0199) |
PDF |
233kB |
01/15/2024 |
| Brodalumab - (IP0246) |
PDF |
237kB |
06/01/2024 |
| Brolucizumab - (IP0541) |
PDF |
211kB |
04/01/2023 |
| Bupropion Extended-Release Products - (IP0058) |
PDF |
190kB |
09/01/2023 |
| Burosumab - (IP0285) |
PDF |
588kB |
12/01/2023 |
| Butalbital Combination Products - (IP0025) |
PDF |
193kB |
10/01/2023 |
| C |
|
|
|
| Carglumic Acid - (IP0438) |
PDF |
194kB |
01/01/2024 |
| Casimersen - (IP0137) |
PDF |
183kB |
07/01/2023 |
| Cenegermin Ophthalmic Solution - (IP0302) |
PDF |
182kB |
06/15/2024 |
| Cerliponase Alfa - (IP0175) |
PDF |
116kB |
08/01/2022 |
| Certolizumab - (IP0244) |
PDF |
271kB |
06/01/2024 |
| Chelating Agents – Iron Chelators (Oral) - (IP0271) |
PDF |
291kB |
05/15/2024 |
| Chenodiol - (IP0203) |
PDF |
180kB |
01/15/2024 |
| Cholic Acid - (IP0289) |
PDF |
189kB |
01/15/2024 |
| Cinacalcet for Individual and Family Plans - (IP0464) |
PDF |
146kB |
06/15/2024 |
| Cipaglucosidase alfa-atga - (IP0591) |
PDF |
204kB |
03/15/2024 |
| Ciprofloxacin-fluocinolone for Individual and Family Plans - (IP0468) |
PDF |
179kB |
01/01/2023 |
| Citalopram 30mg Oral Capsules - (IP0416) |
PDF |
206B |
04/01/2024 |
| Cladribine - (IP0261) |
PDF |
190kB |
01/01/2024 |
| Clobazam - (IP0106) |
PDF |
212kB |
03/01/2024 |
| Clomiphene - (IP0492) |
PDF |
166kB |
12/01/2022 |
| Clonidine Extended-Release - (IP0456) |
PDF |
161kB |
11/15/2022 |
| Clotting Factors and Antithrombin - (8007) |
PDF |
438kB |
06/15/2024 |
| Colchicine Oral Solution - (IP0268) |
PDF |
170kB |
11/01/2023 |
| Collagenase Clostridium Histolyticum - (IP0143) |
PDF |
191kB |
02/01/2024 |
| Collagenase for Individual and Family Plans - (IP0470) |
PDF |
171kB |
01/01/2023 |
| Complement Inhibitors – Empaveli- (IP0194) |
PDF |
162kB |
05/01/2024 |
| Complement Inhibitors – Fabhalta - (IP0614) |
PDF |
156kB |
06/01/2024 |
| Complement Inhibitors – Zilbrysq - (IP0622) |
PDF |
183kB |
07/01/2024 |
| Compounded Medications - (IP0251) |
PDF |
277kB |
11/01/2023 |
| Contraceptives - (IP0036) |
PDF |
200kB |
10/15/2023 |
| Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers - (IP0022) |
PDF |
298kB |
01/01/2024 |
| COVID-19 Drug and Biologic Therapeutics - (2016) |
PDF |
466kB |
06/15/2024 |
| Crizanlizumab-tmca - (IP0120) |
PDF |
204kB |
06/01/2023 |
| Cushing’s – Korlym - (IP0092) |
PDF |
164kB |
07/01/2024 |
| Cushing’s – Recorlev - (IP0389) |
PDF |
157kB |
06/01/2024 |
| Cyanocobalamin Nasal Spray - (IP0170) |
PDF |
128kB |
04/01/2024 |
| Cyclosporine Ophthalmic Products - (IP0026) |
PDF |
215kB |
03/15/2024 |
| Cysteamine Bitartrate Delayed-Release - (IP0046) |
PDF |
210kB |
08/01/2023 |
| Cysteamine Bitartrate for Individual and Family Plans - (IP0466) |
PDF |
205kB |
08/01/2023 |
| Cystic Fibrosis – Bronchitol - (IP0126) |
PDF |
176kB |
06/01/2024 |
| Cystic Fibrosis - Kalydeco - (IP0431) |
PDF |
235kB |
07/15/2024 |
| Cystic Fibrosis - Trikafta - (IP0434) |
PDF |
222kB |
07/15/2024 |
| D |
|
|
|
| Dalfampridine - (IP0024) |
PDF |
203kB |
02/15/2024 |
| Darbepoetin alfa - (IP0293) |
PDF |
226kB |
01/15/2024 |
| DaxibotulinumtoxinA-lanm - (IP0588) |
PDF |
184kB |
01/15/2024 |
| Delafloxacin - (IP0373) |
PDF |
175kB |
01/15/2024 |
| Denosumab (Prolia®) - (IP0331) |
PDF |
226kB |
02/01/2024 |
| Dermatology – Filsuvez - (IP0635) |
PDF |
189kB |
07/15/2024 |
| Desmopressin Nasal Spray - (IP0132) |
PDF |
209kB |
03/15/2024 |
| Desmopressin Products – Nocdurna - (IP0127) |
PDF |
220B |
06/15/2024 |
| Deucravacitinib - (IP0538) |
PDF |
229kB |
06/01/2024 |
| Deutetrabenazine - (IP0079) |
PDF |
191kB |
10/15/2023 |
| Dextromethorphan/quinidine (Nuedexta) for Individual and Family Plans - (IP0324) |
PDF |
188kB |
03/15/2024 |
| Dichlorphenamide - (IP0204) |
PDF |
185kB |
01/01/2024 |
| Difelikefalin - (IP0436) |
PDF |
118kB |
09/01/2022 |
| Dimercaprol and Edetate Calcium Disodium - (IP0138) |
PDF |
247kB |
10/01/2023 |
| Dimethyl fumarate - (IP0266) |
PDF |
200kB |
02/15/2024 |
| Diroximel fumarate - (IP0253) |
PDF |
293kB |
01/01/2024 |
| Donepezil - (IP0502) |
PDF |
150kB |
12/01/2022 |
| Dornase Alfa - (IP0483) |
PDF |
190kB |
10/15/2023 |
| Drug and Biologic Medical Necessity (Injectables) - medical benefits - (2027) |
PDF |
728kB |
07/01/2024 |
| Drug and Biologic Medical Necessity (Non-Injectables) – Medical Benefits - (2028) |
PDF |
286kB |
09/01/2023 |
| Dupilumab - (IP0453) |
PDF |
287kB |
04/15/2024 |
| E |
|
|
|
| Eculizumab - (IP0549) |
PDF |
247kB |
07/01/2024 |
| Edaravone - (IP0176) |
PDF |
263kB |
10/01/2023 |
| Efgartigimod Intravenous - (IP0376) |
PDF |
225kB |
02/15/2024 |
| Efgartigimod Subcutaneous Injection - (IP0574) |
PDF |
243kB |
02/15/2024 |
| Eflapegrastim - (IP0526) |
PDF |
208kB |
01/01/2024 |
| Elagolix - (IP0196) |
PDF |
177kB |
10/01/2023 |
| Elapegademase-lvlr - (IP0399) |
PDF |
122kB |
04/15/2024 |
| Eliglustat - (IP0441) |
PDF |
195kB |
11/01/2023 |
| Elosulfase Alfa - (IP0442) |
PDF |
199kB |
09/15/2023 |
| Emicizumab-kxwh - (IP0121) |
PDF |
256kB |
10/15/2023 |
| Entadfi (finasteride and tadalafil) - (IP0519) |
PDF |
176kB |
03/15/2024 |
| Enzyme Replacement Therapy - Lamzede - (IP0563) |
PDF |
232kB |
07/01/2024 |
| Epinephrine Injection (Self-Administered) - (IP0385) |
PDF |
208kB |
08/01/2023 |
| Epoetin Alpha Products - (IP0296) |
PDF |
279kB |
11/15/2023 |
| Erectile Dysfunction – Alprostadil Products for Individual and Family Plans - (IP0425) |
PDF |
106kB |
05/01/2024 |
| Erectile Dysfunction - Stendra - (IP0100) |
PDF |
884kB |
05/01/2024 |
| Erectile Dysfunction – Vardenafil - (IP0099) |
PDF |
190kB |
05/01/2024 |
| Esketamine - (IP0220) |
PDF |
259kB |
05/15/2024 |
| Estrogen – Transdermal - (IP0590) |
PDF |
181kB |
01/15/2024 |
| Etanercept - (IP0241) |
PDF |
295kB |
02/15/2024 |
| Etelcalcetide - (1812) |
PDF |
72kB |
12/01/2020 |
| Eteplirsen - (IP0135) |
PDF |
197kB |
09/01/2023 |
| Everolimus for Non-Oncology Uses - (IP0408) |
PDF |
155kB |
07/01/2024 |
| Evinacumab - (IP0128) |
PDF |
277kB |
06/15/2023 |
| Evolocumab - (IP0195) |
PDF |
306kB |
05/15/2024 |
| F |
|
|
|
| Faricimab - (IP0542) |
PDF |
209kB |
03/15/2024 |
| Fenfluramine - (IP0042) |
PDF |
268kB |
09/01/2023 |
| Fenofibrates - (IP0339) |
PDF |
184kB |
01/15/2024 |
| Fentanyl Transmucosal Products - (IP0381) |
PDF |
198kB |
03/15/2024 |
| Fertility Injectables - (1012) |
|
384kB |
08/01/2023 |
| Filgrastim - (IP0528) |
PDF |
294kB |
02/01/2024 |
| Finerenone - (IP0314) |
PDF |
219kB |
01/15/2024 |
| Fingolimod - (IP0259) |
PDF |
220kB |
02/15/2024 |
| Fish Oil Triglycerides - (IP0191) |
PDF |
181kB |
02/01/2023 |
| Fosdenopterin - (IP0142) |
PDF |
102kB |
08/15/2022 |
| Fostamatinib - (IP0154) |
PDF |
201kB |
10/01/2023 |
| Fostemsavir - (IP0083) |
PDF |
191kB |
11/01/2023 |
| Furosemide On-Body Infusor - (IP0551) |
PDF |
170kB |
05/01/2023 |
| G |
|
|
|
| Gabapentin Extended-Release - (IP0317) |
PDF |
206kB |
04/01/2024 |
| Galsulfase - (IP0443) |
PDF |
190kB |
09/15/2023 |
| Gamifant -(IP0113) |
PDF |
142kB |
05/01/2024 |
| Ganaxolone - (IP0508) |
PDF |
200kB |
11/15/2023 |
| Gaucher Disease – Substrate Reduction Therapy – Miglustat - (IP0446) |
PDF |
147kB |
07/01/2024 |
| Givosiran - (IP0118) |
PDF |
208kB |
01/15/2024 |
| Glatiramer - (IP0257) |
PDF |
225kB |
01/01/2024 |
| Glecaprevir/Pibrentasvir - (IP0187) |
PDF |
270kB |
06/01/2024 |
| Glucagon Products - (IP0039) |
PDF |
188kB |
03/15/2024 |
| Glucose Test Strips - (IP0272) |
PDF |
184kB |
03/15/2024 |
| Glycopyrrolate - (IP0388) |
PDF |
180kB |
01/15/2024 |
| Golimumab Subcutaneous - (IP0237) |
PDF |
261kB |
06/01/2024 |
| Golodirsen - (IP0136) |
PDF |
186kB |
06/01/2023 |
| Gonadotropin-Releasing Hormone (GnRH) Antagonists for Infertility Use - (IP0333) |
PDF |
254kB |
01/01/2024 |
| Gonadotropin-Releasing Hormone Agonists – Central Precocious Puberty - Leuprolide - (IP0108) |
PDF |
137kB |
05/01/2024 |
| Gonadotropin-Releasing Hormone Agonists – Central Precocious Puberty – Triptodur - (IP0134) |
PDF |
140kB |
05/01/2024 |
| Gonadotropin-Releasing Hormone Agonists – Implants for Non-Oncology Indications - (IP0620) |
PDF |
221kB |
06/01/2024 |
| Gonadotropin-Releasing Hormone Agonists – Injectable Long-Acting Products for Non-Oncology and Non-infertility Indications - (IP0109) |
PDF |
224kB |
06/15/2024 |
| Grass Pollen Sublingual Products - (IP0515) |
PDF |
184kB |
03/01/2024 |
| Growth Disorders – Ngenla - (IP0577) |
PDF |
183kB |
03/15/2024 |
| Growth Disorders – Skytrofa - (IP0375) |
PDF |
183kB |
03/15/2024 |
| Guselkumab - (IP0234) |
PDF |
236kB |
01/01/2024 |
| H |
|
|
|
| H. Pylori Infection Products - (IP0009) |
PDF |
123kB |
11/15/2022 |
| Hematology – Adzynma - (IP0606) |
PDF |
144kB |
05/01/2024 |
| Hematology – Cablivi - (IP0161) |
PDF |
180kB |
06/15/2024 |
| Hematology – Ceprotin - (IP0342) |
PDF |
152kB |
05/01/2024 |
| Hematology – Coagadex - (IP0554) |
PDF |
158kB |
05/01/2024 |
| Hematology - Corifact - (IP0552) |
PDF |
225kB |
05/01/2024 |
| Hematology – Enjaymo - (IP0405) |
PDF |
146kB |
05/01/2024 |
| Hematology - Fibrinogen Products - (IP0357) |
PDF |
180kB |
05/01/2024 |
| Hematology – Gene Therapy - Casgevy for Sickle Cell Disease - (IP0615) |
PDF |
231kB |
05/01/2024 |
| Hematology – Gene Therapy – Lyfgenia - (IP0617) |
PDF |
243kB |
05/01/2024 |
| Hematology – Gene Therapy - Zynteglo - (IP0486) |
PDF |
265kB |
07/01/2024 |
| Hematology – Reblozyl for Non-Oncology Uses - (IP0115) |
PDF |
221kB |
07/01/2024 |
| Hematology – Ryplazim - (IP0382) |
PDF |
161kB |
05/01/2024 |
| Hematology - Tretten - (IP0553) |
PDF |
206kB |
05/01/2024 |
| Hematology - Vonvendi - (IP0555) |
PDF |
188kB |
05/01/2024 |
| Hemophilia – Eptacog Products - Sevenfact - (IP0355) |
PDF |
191kB |
05/01/2024 |
| Hemophilia – Factor IX Products - (IP0623) |
PDF |
157kB |
06/15/2024 |
| Hemophilia - FEIBA - (IP0354) |
PDF |
190kB |
05/15/2024 |
| Hemophilia - Gene Therapy - Beqvez - (IP0648) |
PDF |
183kB |
06/27/2024 |
| Hemophilia – Gene Therapy – Hemgenix - (IP0535) |
PDF |
206kB |
06/06/2024 |
| Hepatitis C – Sovaldi - (IP0157) |
PDF |
177kB |
06/01/2024 |
| Hepatitis C –Zepatier - (IP0158) |
PDF |
185kB |
06/01/2024 |
| Hepatology – Rezdiffra - (IP0642) |
PDF |
199kB |
07/15/2024 |
| Hereditary Angioedema - Berotralstat - (IP0096) |
PDF |
201kB |
01/15/2024 |
| Hereditary Angioedema – C1 Esterase Inhibitors (IV) - (IP0315) |
PDF |
271kB |
01/15/2024 |
| Hereditary Angioedema – C1 Esterase Inhibitors (SC) - (IP0316) |
PDF |
205kB |
01/15/2024 |
| Hereditary Angioedema - Ecallantide - (IP0336) |
PDF |
211kB |
01/15/2024 |
| Hereditary Angioedema – Icatibant - (IP0335) |
PDF |
215kB |
01/15/2024 |
| Hereditary Angioedema – Lanadelumab-flyo - (IP0334) |
PDF |
206kB |
01/15/2024 |
| HIV Products - (P0050) |
PDF |
338kB |
05/01/2024 |
| HIV Products for Individual and Family Plans - (IP0090) |
PDF |
211kB |
05/01/2024 |
| HMG-CoA Reductase Inhibitors (Statins) and Combination Products - (IP0064) |
PDF |
214kB |
02/01/2024 |
| Human Chorionic Gonadotropin (hCG) for Non-Fertility Use - (IP0327) |
PDF |
208kB |
02/15/2024 |
| Human Immunodeficiency Virus – Cabenuva - (IP0123) |
PDF |
253kB |
06/01/2024 |
| Human Immunodeficiency Virus – Sunlenca - (IP0546) |
PDF |
234kB |
07/15/2024 |
| Hydroxyprogesterone Caproate - (IP0370) |
PDF |
169kB |
03/15/2024 |
| Hydroxyurea Tablet - (IP0325) |
PDF |
206kB |
01/15/2024 |
| Hypoactive Sexual Desire Disorder – Addyi - (IP0116) |
PDF |
146kB |
07/15/2024 |
| I |
|
|
|
| Ibalizumab-uiyk - (IP0171) |
PDF |
233kB |
05/15/2024 |
| Ibrexfungerp - (IP0301) |
PDF |
184kB |
01/15/2024 |
| Ibrutinib for Non-Oncology Indications - (IP0320) |
PDF |
211kB |
11/01/2022 |
| Idursulfase - (IP0444) |
PDF |
191klB |
09/15/2023 |
| Imiglucerase - (IP0162) |
PDF |
249kB |
10/01/2023 |
| Immune Globulin - (5026) |
PDF |
626kB |
06/01/2024 |
| Inclisiran - (IP0380) |
PDF |
274kB |
01/15/2024 |
| Inebilizumab - (IP0062) |
PDF |
207kB |
07/01/2024 |
| Infectious Disease – Ivermectin Tablets - (IP0300) |
PDF |
184kB |
06/01/2024 |
| Infectious Disease – Livtencity - (IP0394) |
PDF |
163kB |
07/01/2024 |
| Infectious Disease – Prevymis for Individual and Family Plans - (IP0426) |
PDF |
120kB |
04/01/2024 |
| Infectious Disease – Pyrimethamine - (IP0348) |
PDF |
166kB |
06/15/2024 |
| Infectious Disease – Sirturo - (IP0494) |
PDF |
174kB |
07/01/2024 |
| Inflammatory Conditions - Bimzelx - (IP0603) |
PDF |
187kB |
06/01/2024 |
| Inflammatory Conditions – Cosentyx Intravenous - (IP0643) |
PDF |
243kB |
07/01/2024 |
| Inflammatory Conditions – Cosentyx Subcutaneous - (IP0223) |
PDF |
237kB |
07/15/2024 |
| Inflammatory Conditions - Entyvio Subcutaneous - (IP0599) |
PDF |
178kB |
04/15/2024 |
| Inflammatory Conditions – Entyvio Subcutaneous for Total Savings and Individual and Family Plans - (IP0613) |
PDF |
189kB |
06/01/2024 |
| Inflammatory Conditions – Ilaris - (IP0235) |
PDF |
264kB |
07/01/2024 |
| Inflammatory Conditions – Omvoh Intravenous - (IP0601) |
PDF |
190kB |
06/01/2024 |
| Inflammatory Conditions – Omvoh Subcutaneous - (IP0602) |
PDF |
190kB |
06/01/2024 |
| Inflammatory Conditions – Simponi Aria - (IP0238) |
PDF |
236kB |
05/01/2024 |
| Inflammatory Conditions – Spevigo Intravenous - (IP0501) |
PDF |
207kB |
07/15/2024 |
| Inflammatory Conditions – Velsipity - (IP0605) |
PDF |
168kB |
06/01/2024 |
| Infliximab - (IP0242) |
PDF |
265kB |
03/15/2024 |
| Inotersen - (IP0417) |
PDF |
180kB |
04/01/2024 |
| Insulin Glargine - (P0023) |
PDF |
207kB |
01/01/2024 |
| Insulins (Rapid-Acting) - (IP0065) |
PDF |
184kB |
04/19/2023 |
| Interferon beta-1b - (IP0256) |
PDF |
201kB |
01/01/2024 |
| Interferon Gamma-1b for Non-Oncology Uses - (IP0201) |
PDF |
191kB |
10/01/2023 |
| Interferon Therapy - (1315) |
PDF |
191kB |
02/01/2022 |
| Intraarticular Hyaluronic Acid Derivatives - (IP0322) |
PDF |
286kB |
01/15/2024 |
| Intravenous Iron Replacement Therapy - (IP0222) |
PDF |
301kB |
02/01/2023 |
| Isavuconazonium (Oral)- (IP0305) |
PDF |
186kB |
11/01/2023 |
| Isotretinoin Low Dose - (IP0193) |
PDF |
204kB |
05/01/2023 |
| Itraconazole (Tolsura) - (IP0275) |
PDF |
175kB |
10/15/2023 |
| Ivabradine - (IP0286) |
PDF |
242kB |
11/15/2023 |
| Ixekizumab - (IP0224) |
PDF |
256kB |
07/15/2024 |
| J |
|
|
|
| Jakafi (ruxolitinib) for Non-Oncology Indications - (IP0318) |
PDF |
208kB |
01/15/2024 |
| L |
|
|
|
| Lanreotide for Non-Oncology Uses - (IP0323) |
PDF |
190kB |
12/01/2023 |
| Laronidase - (IP0445) |
pdf |
94kB |
11/01/2022 |
| Lasmiditan - (IP0114) |
PDF |
192kB |
11/01/2023 |
| Ledipasvir/Sofosbuvir - (IP0186) |
PDF |
316kB |
06/01/2024 |
Legacy Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
470kB |
06/01/2024 |
| Leniolisib - (IP0568) |
PDF |
193kB |
10/01/2023 |
| Lisocabtagene maraleucel - (IP0130) |
PDF |
214kB |
01/15/2023 |
| Lodoco (colchicine capsule) - (IP0595) |
PDF |
211kB |
03/01/2024 |
| Lomitapide - (IP0221) |
PDF |
230kB |
10/01/2023 |
| Long-Acting Muscarinic Antagonist (LAMA)/Long-Acting Beta2-Agonist (LABA) Combination Inhalers - (IP0020) |
PDF |
184kB |
01/01/2024 |
| Long-Acting Muscarinic Antagonists (Nebulized) - (IP0089) |
PDF |
216kB |
11/01/2023 |
| Lorazepam Extended-Release - (IP0364) |
PDF |
171kB |
01/15/2024 |
| Lumacaftor/Ivacaftor - (IP0432) |
PDF |
283kB |
07/15/2024 |
| Lupus – Lupkynis - (IP0122) |
PDF |
193kB |
06/15/2024 |
| Lupus – Saphnelo - (IP0280) |
PDF |
237kB |
07/01/2024 |
| Lusutrombopag - (IP0156) |
PDF |
171kB |
10/01/2023 |
| Lybalvi - (IP0368) |
PDF |
136kB |
04/15/2024 |
| LymePak - (IP0352) |
PDF |
159kB |
04/01/2024 |
| M |
|
|
|
| Maralixibat - (IP0341) |
PDF |
234kB |
06/15/2024 |
| Mavacamten - (IP0480) |
PDF |
235kB |
10/15/2023 |
| Mecasermin - (IP0310) |
PDF |
220kB |
06/01/2023 |
| Medication Administration Site of Care - (1605) |
PDF |
151kB |
03/15/2024 |
| Mepolizumab - (IP0422) |
PDF |
247kB |
05/15/2024 |
| Metabolic Disorders – Cysteamine Ophthalmic Solution - (IP0082) |
PDF |
135kB |
07/15/2024 |
| Metabolic Disorders – Phenylbutyrate Products - (IP0169) |
PDF |
152kB |
04/01/2024 |
| Metabolic Disorders – Primary Hyperoxaluria Medications – Rivfloza - (IP0629) |
PDF |
197kB |
06/01/2024 |
| Metabolic Disorders – Primary Hyperoxaluria – Oxlumo - (IP0095) |
PDF |
240kB |
05/01/2024 |
| Metabolic Products – Nitisinone Products - (IP0146) |
PDF |
164kB |
05/15/2024 |
| Methotrexate for Injection - (IP0411) |
PDF |
182kB |
04/01/2024 |
| Methoxy polyethylene glycol-epoetin beta - (IP0297) |
PDF |
240kB |
12/15/2023 |
| Metoclopramide Nasal Spray - (IP0085) |
PDF |
204kB |
05/01/2023 |
| Metreleptin - (IP0340) |
PDF |
207kB |
09/15/2023 |
| Metyrosine - (IP0450) |
PDF |
71kB |
02/15/2024 |
| Midazolam Nasal Spray - (IP0338) |
PDF |
196kB |
03/15/2024 |
| Migalastat - (IP0400) |
PDF |
227kB |
02/15/2024 |
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Aimovig - (IP0503) |
PDF |
200kB |
07/15/2024 |
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Ajovy - (IP0504) |
PDF |
223kB |
07/15/2024 |
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Emgality - (IP0505) |
PDF |
181kB |
07/15/2024 |
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Vyepti - (IP0506) |
PDF |
202kB |
07/15/2024 |
| Migraine – Nurtec ODT - (IP0147) |
PDF |
206kB |
07/15/2024 |
| Migraine – Qulipta - (IP0377) |
PDF |
174kB |
07/15/2024 |
| Migraine Treatment - (IP0029) |
PDF |
239kB |
04/01/2023 |
| Migraine – Ubrelvy - (IP0148) |
PDF |
180kB |
06/01/2024 |
| Miltefosine - (IP0210) |
PDF |
203kB |
09/01/2023 |
| Mitapivat - (IP0451) |
PDF |
201kB |
09/01/2023 |
| Monomethyl fumarate - (IP0255) |
PDF |
193kB |
01/01/2024 |
| Motixafortide - (IP0597) |
PDF |
187kB |
03/15/2024 |
| Multiple Sclerosis - Ocrevus - (IP0212) |
PDF |
184kB |
03/01/2024 |
| Muscular Dystrophy – Agamree - (IP0624) |
PDF |
157kB |
07/15/2024 |
| Muscular Dystrophy – Deflazacort - (IP0131) |
PDF |
137kB |
06/01/2024 |
| Mycapssa - (IP0491) |
PDF |
180kB |
01/15/2024 |
| Myfembree - (IP0205) |
PDF |
181kB |
10/01/2023 |
| N |
|
|
|
| Nadofaragene firadenovec-vncg - (IP0579) |
PDF |
210kB |
09/15/2023 |
| Nafarelin Acetate - (IP0415) |
PDF |
215kB |
01/01/2024 |
| Nasal Steroids and Nasal Steroid/Antihistamine Combinations - (IP0274) |
PDF |
235kB |
10/15/2023 |
| Natalizumab - (IP0215) |
PDF |
302kB |
03/01/2024 |
| Nembutal [pentobarbital] injection - (IP0557) |
PDF |
174kB |
05/01/2023 |
| Nephrology – Filspari- (IP0565) |
PDF |
216kB |
06/01/2024 |
| Nephrology − Jesduvroq - (IP0604) |
PDF |
133kB |
03/15/2024 |
| Nephrology – Tarpeyo - (IP0413) |
PDF |
179kB |
06/01/2024 |
| Nephrology – Xphozah - (IP0608) |
PDF |
154kB |
05/01/2024 |
| Neurology – Gene Therapy - Skysona - (IP0529) |
PDF |
199kB |
05/01/2024 |
| Neurology - Leqembi (lecanemab) - (IP0547) |
PDF |
279kB |
01/15/2024 |
| Neurology – Riluzole Products - (IP0258) |
PDF |
177kB |
06/01/2024 |
| Nintedanib - (IP0312) |
PDF |
242kB |
11/15/2023 |
| Nitazoxanide for Individual and Family Plans - (IP0467) |
PDF |
213kB |
01/01/2023 |
| Nonsteroidal Anti-inflammatory Drugs - (IP0457) |
PDF |
262kB |
06/15/2024 |
| Northera - (IP0110) |
PDF |
148kB |
07/15/2024 |
| NovoSeven RT - (IP0356) |
PDF |
202kB |
02/15/2024 |
| Nusinersen - (IP0182) |
PDF |
212kB |
02/15/2024 |
| O |
|
|
|
| Obeticholic Acid - (IP0304) |
PDF |
210kB |
01/15/2024 |
| Octreotide IR (Non-Oncology Indications) - (IP0490) |
PDF |
190kB |
10/15/2023 |
| Odactra - (IP0516) |
PDF |
214kB |
03/01/2024 |
| Odevixibat - (IP0363) |
PDF |
231kB |
12/15/2023 |
| Ofatumumab - (IP0260) |
PDF |
150kB |
03/01/2024 |
| Olipudase alfa-rpcp - (IP0500) |
PDF |
282kB |
03/15/2024 |
| Omadacycline - (IP0379) |
PDF |
185kB |
01/15/2024 |
| Omalizumab - (IP0487) |
PDF |
318kB |
02/15/2024 |
| Omaveloxolone - (IP0566) |
PDF |
206kB |
10/15/2023 |
| Ombitasvir/Paritaprevir/Ritonavir and Dasabuvir - (IP0189) |
PDF |
226kB |
01/01/2024 |
| Omega-3 Fatty Acid Products - (IP0051) |
PDF |
250kB |
01/01/2024 |
| Onasemnogene Abeparvovec-xioi - (IP0185) |
PDF |
234kB |
04/15/2024 |
| Oncology (Injectable) – Amtagvi - (IP0625) |
PDF |
185kB |
06/01/2024 |
| Oncology (Injectable) – Cosela - (IP0150) |
PDF |
178kB |
07/15/2024 |
| Oncology (Injectable – CAR-T) – Abecma - (IP0168) |
PDF |
193kB |
07/01/2024 |
| Oncology (Injectable – CAR-T) - Carvykti - (IP0414) |
PDF |
171kB |
06/15/2024 |
| Oncology (Injectable – CAR-T) – Kymriah - (IP0197) |
PDF |
230kB |
07/01/2024 |
| Oncology (Injectable – CAR-T) – Yescarta - (IP0198) |
PDF |
151kB |
04/01/2024 |
| Oncology Medications - (1403) |
PDF |
416kB |
07/01/2024 |
| Opfolda (miglustat) capsule - (IP0598) |
PDF |
203kB |
03/15/2024 |
| Ophthalmic Prostaglandin Analogs - (IP0027) |
PDF |
244kB |
02/01/2024 |
| Ophthalmology – Dry Eye Disease – Xiidra for Individual and Family Plans - (IP0644) |
PDF |
147kB |
07/15/2024 |
| Ophthalmology – Gene Therapy – Luxturna - (IP0160) |
PDF |
182kB |
07/15/2024 |
| Ophthalmology – Syfovre - (IP0559) |
PDF |
190kB |
06/01/2024 |
| Ophthalmology – Tepezza - (IP0129) |
PDF |
217kB |
05/15/2024 |
| Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Ranibizumab Products - (IP0543) |
PDF |
185kB |
05/01/2024 |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors – Susvimo - (IP0349) |
PDF |
161kB |
05/15/2024 |
| Ophthalmology – Verkazia - (IP0439) |
PDF |
182kB |
06/01/2024 |
| Ophthamology - iDose TR - (IP0619) |
PDF |
184kB |
06/01/2024 |
| Ophthmology - Durysta - (IP0218) |
PDF |
211kB |
06/01/2024 |
| Opioid Therapy - Employer Group Benefit Plans - (IP0561) |
PDF |
292kB |
05/15/2024 |
| Opioid Therapy - Individual and Family Plans - (IP0562) |
PDF |
293kB |
05/15/2024 |
| Oral Antihistamines - (IP0190) |
PDF |
201kB |
09/01/2023 |
| Oriahnn - (IP0087) |
PDF |
199kB |
10/01/2023 |
| Osilodrostat - (IP0044) |
PDF |
209kB |
12/01/2023 |
| Oteseconazole - (IP0513) |
PDF |
172kB |
03/01/2024 |
| Otic Antibiotics - (IP0366) |
PDF |
168kB |
12/15/2023 |
| Oxandrolone - (IP0496) |
PDF |
188kB |
12/01/2022 |
| Oxybate - (IP0103) |
PDF |
256kB |
04/01/2024 |
| Oxymetazoline Ophthalmic Solution - (IP0088) |
PDF |
200kB |
03/15/2024 |
| Ozanimod - (IP0214) |
PDF |
268kB |
06/01/2024 |
| P |
|
|
|
| Palivizumab - (IP0321) |
PDF |
263kB |
01/15/2024 |
| Palovarotene - (IP0596) |
PDF |
211kB |
02/15/2024 |
| Pancrelipase - (IP0002) |
PDF |
182kB |
04/01/2024 |
| Parathyroid Hormone - (IP0177) |
PDF |
200kB |
09/01/2023 |
| Parkinson’s Disease – Apomorphine Subcutaneous - (IP0530) |
PDF |
191kB |
06/15/2024 |
| Parkinson’s Disease – Carbidopa - (IP0523) |
PDF |
164kB |
07/01/2024 |
| Parkinson’s Disease – Duopa- (IP0303) |
PDF |
199kB |
07/15/2024 |
| Parkinson’s Disease – Inbrija - (IP0522) |
PDF |
202kB |
07/01/2024 |
| Parkinson’s Disease – Nourianz - (IP0524) |
PDF |
168kB |
07/01/2024 |
| Parkinson’s Disease – Nuplazid - (IP0145) |
PDF |
183kB |
07/01/2024 |
| Parkinson’s Disease – Ongentys - (IP0532) |
PDF |
167kB |
07/01/2024 |
| Paromomycin - (IP0520) |
PDF |
170kB |
01/15/2023 |
| Pasireotide - (IP0482) |
PDF |
7205kB |
01/15/2024 |
| Pasireotide Long-Acting - (IP0165) |
PDF |
215kB |
12/01/2023 |
| Patisiran - (IP0418) |
PDF |
184kB |
04/01/2024 |
| Peanut (Arachis hypogaea) Allergen Powder-dnfp - (IP0141) |
PDF |
211kB |
08/01/2023 |
| Pegfilgrastim - (IP0070) |
PDF |
244kB |
01/01/2024 |
| Peginterferon - (IP0263) |
PDF |
193kB |
01/01/2024 |
| Pegloticase - (IP0269) |
PDF |
207kB |
01/15/2024 |
| Pegunigalsidase Alfa - (IP0570) |
PDF |
208kB |
03/01/2024 |
| Pegvaliase-pqpz - (IP0294) |
PDF |
218kB |
01/15/2024 |
| Pegvisomant - (IP0291) |
PDF |
172kB |
01/15/2024 |
| Penicillamine - (IP0277) |
PDF |
216kB |
03/15/2024 |
| Pen Needles - (IP0569) |
PDF |
175kB |
05/15/2024 |
Performance Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
470kB |
06/01/2024 |
| Pharmacy Prior Authorization - (1407) |
PDF |
291kB |
07/15/2024 |
| Pilocarpine 1.25% Ophthalmic - (IP0343) |
PDF |
136kB |
04/15/2024 |
| Pirfenidone - (IP0311) |
PDF |
248kB |
01/15/2024 |
| Pitolisant - (IP0292) |
PDF |
209kB |
11/15/2023 |
| Plerixafor - (IP0139) |
PDF |
307kB |
08/15/2023 |
| Ponesimod - (IP0264) |
PDF |
193kB |
01/01/2024 |
| Posaconazole PowderMix for Delayed-Release Oral Suspension for Individual and Family Plans - (IP0536) |
PDF |
218kB |
11/01/2023 |
| Pregabalin Extended-Release - (IP0183) |
PDF |
217kB |
08/01/2023 |
| Prenatal Vitamins - (IP0035) |
PDF |
197kB |
09/15/2023 |
| Pretomanid - (IP0384) |
PDF |
175kB |
04/01/2024 |
| Progesterone (Endometrin) for Individual and Family Plans - (IP0091) |
PDF |
182kB |
11/01/2023 |
| Progesterone – Employer Group Plans - (IP0548) |
PDF |
198kB |
11/01/2023 |
| Proton Pump Inhibitors - (IP0061) |
PDF |
166kB |
05/01/2024 |
| Prucalopride - (IP0017) |
PDF |
205kB |
02/01/2024 |
| Psychiatry – Zurzuvae - (IP0607) |
PDF |
153kB |
05/15/2024 |
| Pulmonary Arterial Hypertension – Adempas – (IP0600) |
PDF |
161kB |
06/01/2024 |
| Pulmonary Arterial Hypertension –Orenitram - (IP0616) |
PDF |
161kB |
06/01/2024 |
| Pulmonary Arterial Hypertension – Phosphodiesterase Type 5 Inhibitors - (IP0626) |
PDF |
191kB |
06/01/2024 |
| Pulmonary Arterial Hypertension – Uptravi - (IP0627) |
PDF |
182kB |
06/01/2024 |
| Pulmonary Hypertension (PH) Therapy - (6121) |
PDF |
438kB |
06/01/2024 |
| Pulmonary – Roflumilast for Individual and Family Plans - (IP0609) |
PDF |
167kB |
05/01/2024 |
| Purified Cortrophin Gel - (IP0374) |
PDF |
192kB |
10/01/2023 |
| Pyridostigmine - (IP0544) |
PDF |
170kB |
04/01/2023 |
| Q |
|
|
|
| Qbrexza - (IP0074) |
PDF |
148kB |
07/01/2024 |
| Quantity Limitations - (1201) |
PDF |
255kB |
06/01/2024 |
| Quazepam for Individual and Family Plans - (IP0469) |
PDF |
209kB |
01/01/2023 |
| R |
|
|
|
| Ragwitek - (IP0518) |
PDF |
178kB |
03/01/2024 |
| Ranolazine - (IP0507) |
PDF |
173kB |
12/15/2022 |
| Ravulizumab-cwvz Intravenous - (IP0550) |
PDF |
276kB |
06/15/2024 |
| Rebif (interferon beta-1a) - (IP0265) |
PDF |
193kB |
01/01/2024 |
| Rebyota - (IP0556) |
PDF |
244kB |
05/01/2023 |
| Repository Corticotropin - (IP0178) |
PDF |
229kB |
10/01/2023 |
| Reslizumab - (IP0423) |
PDF |
293kB |
01/01/2024 |
| Rifaximin for Individual and Family Plans - IP0473) |
PDF |
238kB |
06/01/2023 |
| Rilonacept - (IP0437) |
PDF |
150kB |
08/15/2022 |
| RimabotulinumtoxinB - (IP0509) |
PDF |
192kB |
02/15/2023 |
| Risankizumab Intravenous - (IP0476) |
PDF |
233kB |
01/01/2024 |
| Risankizumab Subcutaneous- (IP0247) |
PDF |
249kB |
02/15/2024 |
| Risdiplam - (IP0063) |
PDF |
226kB |
11/01/2023 |
| Ritlecitinib - (IP0589) |
PDF |
246kB |
01/01/2024 |
| Rituximab for Non-Oncology Indications - (IP0319) |
PDF |
356kB |
01/15/2024 |
| Rivaroxaban - (IP0032) |
PDF |
297kB |
06/01/2023 |
| Roflumilast - (IP0527) |
PDF |
226kVB |
04/15/2024 |
| Romiplostim - (IP0155) |
PDF |
237kB |
10/01/2023 |
| Romosozumab - (IP0179) |
PDF |
208kB |
11/01/2023 |
| Rozanolixizumab - (IP0575) |
PDF |
230kB |
02/15/2024 |
| Rufinamide - (IP0048) |
PDF |
209kB |
03/15/2024 |
| S |
|
|
|
| Sacrosidase - (IP0447) |
PDF |
180kB |
09/15/2023 |
| Sandostatin LAR Depot (Non-Oncology Indications) - (IP0489) |
PDF |
222kB |
12/01/2023 |
| Sapropterin - (IP0295) |
PDF |
229kB |
02/15/2024 |
| Sarecycline - (IP0093) |
PDF |
214kB |
04/01/2023 |
| Sarilumab - (IP0233) |
PDF |
242kB |
06/01/2024 |
| Satralizumab-mwge - (IP0078) |
PDF |
203kB |
07/01/2024 |
| Sebelipase Alfa - (IP0448) |
PDF |
216kB |
09/15/2023 |
| Secukinumab Intravenous for Employer Plans - (IP0594) |
PDF |
289kB |
07/01/2024 |
| Sedative Hypnotic Medications - (IP0023) |
PDF |
249kB |
02/15/2024 |
| Selegiline - (IP0525) |
PDF |
202kB |
04/01/2024 |
| Selumetinib - (IP0038) |
PDF |
209kB |
01/15/2023 |
| Sertraline 150mg, 200mg Oral Capsules - (IP0328) |
PDF |
211kB |
01/15/2024 |
| Setmelanotide for Employer Group Plans - (IP0104) |
PDF |
229kB |
07/01/2023 |
| Short-Acting Beta2-Agonist Inhalers - (IP0040) |
PDF |
214kB |
05/15/2023 |
| Sickle Cell Disease – Endari for Individual and Family Plans - (IP0475) |
PDF |
174kB |
07/15/2024 |
| Sildenafil (Viagra) - (IP0098) |
PDF |
217kB |
02/15/2024 |
| Siponimod - (IP0262) |
PDF |
194kB |
01/01/2024 |
| Sirolimus - (IP0511) |
PDF |
201kB |
10/15/2023 |
| Skeletal Muscle Relaxants - (IP0211) |
PDF |
211kB |
02/01/2024 |
| Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors and SGLT-2 / Metformin Combinations - (IP0592) |
PDF |
264kB |
04/01/2024 |
| Sodium thiosulfate - (IP0512) |
PDF |
200kB |
04/01/2024 |
| Sofosbuvir/Velpatasvir/Voxilaprevir - (IP0188) |
PDF |
232kB |
06/01/2024 |
| Sofosbuvir/Velpatasvir - (IP0184) |
PDF |
250kB |
06/01/2024 |
| Solriamfetol - (IP0102) |
PDF |
209kB |
11/15/2023 |
| Somapacitan - (IP0576) |
PDF |
275kB |
01/01/2024 |
| Somatropin - (IP0452) |
PDF |
108kB |
01/01/2024 |
Standard Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
470kB |
06/01/2024 |
| Step Therapy Individual and Family Plan - (1603) |
PDF |
195kB |
04/15/2024 |
| Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) |
PDF |
263kB |
06/01/2024 |
| Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) |
PDF |
240kB |
05/01/2024 |
| Step Therapy – Value/Advantage Prescription Drug Lists (Employer Group Plans) - (1802) |
PDF |
230kB |
05/01/2024 |
| Sutimlimab - (IP0405) |
PDF |
218kB |
06/01/2023 |
| T |
|
|
|
| Tadalafil (Cialis®) for Employer Group Plans - (IP0097) |
PDF |
218kB |
02/15/2024 |
| Tadalafil (Cialis®) for Individual and Family Plans - (IP0101) |
PDF |
195kB |
02/15/2024 |
| Taliglucerase - (IP0163) |
PDF |
215kB |
10/01/2023 |
| Tapinarof - (IP0497) |
PDF |
210kB |
04/01/2024 |
| Tascenso ODT - (IP0514) |
PDF |
222kB |
11/15/2023 |
| Tasimelteon - (IP0428) |
PDF |
247kB |
05/15/2024 |
| Teduglutide - (IP0288) |
PDF |
200kB |
01/15/2024 |
| Tegaserod - (IP0019) |
PDF |
204kB |
02/01/2024 |
| Tenapanor - (IP0455) |
PDF |
204kB |
02/01/2024 |
| Teplizumab-mzwv - (IP0537) |
PDF |
173kB |
04/15/2024 |
| Teriflunomide - (IP0252) |
PDF |
219kB |
02/15/2024 |
| Teriflunomide for Individual and Family Plans - (IP0560) |
PDF |
223kB |
02/15/2024 |
| Teriparatide - (IP0330) |
PDF |
268kB |
02/15/2024 |
| Tesamorelin - (IP0209) |
PDF |
208kB |
01/15/2024 |
| Testosterone (Oral, Topical, and Nasal) - (IP0350) |
PDF |
212kB |
03/01/2024 |
| Testosterone Therapy (Injectables and Implantable Pellets) - (IP0351) |
PDF |
237kB |
02/15/2024 |
| Tetrabenazine - (IP0208) |
PDF |
231kB |
10/15/2023 |
| Tetracycline Antibiotics - (IP0396) |
PDF |
266kB |
06/01/2024 |
| Tezacaftor/Ivacaftor -(IP0433) |
PDF |
434kB |
08/01/2023 |
| Tezepelumab-ekko - (IP0412) |
PDF |
221kB |
02/01/2024 |
| Thalidomide Non-Oncology Uses - (IP0493) |
PDF |
201kB |
12/01/2022 |
| Thalitone - (IP0365) |
PDF |
171kB |
04/01/2024 |
| Thrombocytopenia – Eltrombopag Products - (IP0153) |
PDF |
223kB |
07/15/2024 |
| Thyroid Hormone Supplements - (IP0060) |
PDF |
249kB |
05/01/2023 |
| Tildrakizumab - (IP0236) |
PDF |
282kB |
06/01/2024 |
| Tiopronin - (IP0202) |
PDF |
230kB |
04/01/2024 |
| Tizanidine - (IP0392) |
PDF |
111kB |
04/15/2024 |
| Tobramycin/loteprednol etabonate (Zylet) Ophthalmic Suspension for Individual and Family Plans - (IP0474) |
PDF |
171kB |
01/01/2023 |
| Tocilizumab Intravenous - (IP0228) |
PDF |
365kB |
07/15/2024 |
| Tocilizumab Subcutaneous - (IP0227) |
PDF |
266kB |
06/01/2024 |
| Tofacitinib - (IP0230) |
PDF |
277kB |
06/01/2024 |
| Tolfersen - (IP0567) |
PDF |
222kB |
11/15/2023 |
| Tolvaptan (Jynarque®) - (IP0287) |
PDF |
194kB |
11/01/2023 |
| Tolvaptan for Individual and Family Plans - (IP0471) |
PDF |
206kB |
10/15/2023 |
| Topical Acne – Non-Retinoid Products - (IP0166) |
PDF |
237kB |
05/01/2024 |
| Topical Acne – Winlevi - (IP0173) |
PDF |
127kB |
06/01/2024 |
| Topical Adapalene Products - (IP0181) |
PDF |
121kB |
01/15/2024 |
| Topical Alpha Adrenergic Agonists - (IP0284) |
PDF |
172kB |
01/01/2024 |
| Topical Antifungals - (IP0273) |
PDF |
221kB |
04/01/2024 |
| Topical Antivirals - (IP0276) |
PDF |
195kB |
11/01/2023 |
| Topical Azelaic Acid Products - (IP0172) |
PDF |
155kB |
05/01/2024 |
| Topical Corticosteroids - (IP0281) |
PDF |
210kB |
11/01/2023 |
| Topical Diclofenac Sodium 3% Gel - (IP0282) |
PDF |
206kB |
02/15/2024 |
| Topical Doxepin Products - (IP0207) |
PDF |
195kB |
11/01/2023 |
| Topical Medications for Actinic Keratosis - (IP0367) |
PDF |
221kB |
12/01/2023 |
| Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - (IP0021) |
PDF |
206kB |
01/01/2024 |
| Topical Rosacea Products - (IP0003) |
PDF |
225kB |
06/01/2024 |
| Topical Ruxolitinib - (IP0369) |
PDF |
269kB |
02/15/2024 |
| Topical Tazarotene Products - (IP0174) |
PDF |
208kB |
02/15/2024 |
| Topical Tretinoin Products - (IP0167) |
PDF |
234kB |
12/15/2023 |
| Topical Trifarotene - (IP0180) |
PDF |
217kB |
06/01/2023 |
| Topical Vitamin D Analogs - (IP0361) |
PDF |
215kB |
03/15/2024 |
Total Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
491kB |
07/01/2024 |
| Tralokinumab - (IP0386) |
PDF |
222kB |
02/15/2024 |
| Triamcinolone acetonide extended-release injection - (IP0140) |
PDF |
205kB |
10/15/2023 |
| Triamcinolone Acetonide Ophthalmic - (IP0371) |
PDF |
106kB |
03/01/2022 |
| Trientine Hydrochloride - (IP0278) |
PDF |
236kB |
02/15/2024 |
| Triheptanoin - (IP0084) |
PDF |
182kB |
10/15/2023 |
| Trofinetide - (IP0578) |
PDF |
193kB |
11/01/2023 |
| U |
|
|
|
| Ublituximab - (IP0545) |
PDF |
203kB |
01/01/2024 |
| Unassigned Drug or Biologic Code Medical Precertification - (1701) |
PDF |
320kB |
07/01/2024 |
| Upadacitinib - (IP0229) |
PDF |
293kB |
07/15/2024 |
| Uridine triacetate - (IP0307) |
PDF |
173kB |
01/15/2023 |
| Ursodiol - (IP0299) |
PDF |
176kB |
04/01/2024 |
| Ustekinumab Intravenous - (IP0240) |
PDF |
282kB |
01/01/2024 |
| Ustekinumab Subcutaneous - (IP0239) |
PDF |
259kB |
01/01/2024 |
| V |
|
|
|
| Vaginal Estrogen Products and Ospemifin - (IP0216) |
PDF |
212kB |
11/15/2023 |
| Valbenazine - (IP0080) |
PDF |
190kB |
12/01/2023 |
| Valoctocogene roxaparvovec-rvox - (IP0580) |
PDF |
226kB |
10/01/2023 |
Value Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
491kB |
07/01/2024 |
| Vasculitis – Tavneos - (IP0398) |
PDF |
192kB |
06/15/2024 |
| Vedolizumab Intravenous - (IP0326) |
PDF |
212kB |
03/01/2024 |
| Velaglucerase - (IP0164) |
PDF |
205kB |
10/01/2023 |
| Veregen - (IP0393) |
PDF |
194kB |
06/01/2024 |
| Vericiguat - (IP0125) |
PDF |
199kB |
01/01/2024 |
| Vestronidase Alfa-vjbk - (IP0449) |
PDF |
209kB |
09/15/2023 |
| Vigabatrin - (IP0049) |
PDF |
235kB |
05/15/2024 |
| Viltolarsen - (IP0066) |
PDF |
190kB |
01/15/2024 |
| Vocabria - (IP0124) |
PDF |
248kB |
09/15/2023 |
| Voriconazole (Oral) - (IP0306) |
PDF |
212kB |
11/01/2023 |
| Vosoritide - (IP0402) |
PDF |
221kB |
03/01/2024 |
| Voxelotor - (IP0119) |
PDF |
216kB |
04/01/2023 |
| Vutrisiran - (IP0478) |
PDF |
203kB |
04/01/2024 |
| W |
|
|
|
| Weight Loss – Glucagon-Like Peptide-1 Agonists - (IP0206) |
PDF |
317kB |
07/15/2024 |
| Weight Loss Medications - (IP0420) |
PDF |
244kB |
11/15/2022 |
| Z |
|
|
|
| Zokinvy - (IP0107) |
PDF |
206kB |
06/01/2024 |