Drug Policy A-Z Index (Commercial and Medicare Advantage**see main Index for Medicare Advantage Coverage Policy Development and Application)

Document Title Document Type Document Size Effective Date
A
Abaloparatide - (IP0329) PDF 218kB 01/15/2024
Abatacept Intravenous - (IP0232) PDF 314kB 02/01/2024
Abatacept Subcutaneous - (IP0231) PDF 275kB 02/01/2024
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 301kB 02/01/2024
Aducanumab - (IP0200) PDF 210kB 01/15/2024
Advantage Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 467kB 02/15/2024
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 256kB 10/01/2023
Alosetron - (IP0012) PDF 171kB 04/15/2023
Alpelisib - (IP0481) PDF 213kB 10/01/2023
Alpha1-Proteinase Inhibitors - (IP0387) PDF 221kB 05/01/2023
Alprostadil for Individual and Family Plans (IFP) - (IP0425) PDF 184kB 04/15/2023
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 117kB 11/01/2022
Anakinra - (IP0243) PDF 265kB 02/01/2024
Angiotensin Receptor Blockers - (IP0362) PDF 113kB 01/01/2023
Anifrolumab - (IP0280) PDF 223kB 02/15/2024
Anticonvulsant Medications - (IP0031) PDF 195kB 02/15/2023
Antiemetic Therapy - (1705) PDF 222kB 07/15/2022
Antihemophilic Factor (Recombinant) - (IP0564) PDF 189kB 02/15/2024
Antihyperglycemic Therapy (Non-Insulin) - (P0098) PDF 431kB 01/01/2024
Antimalarial Therapy - (P0101) PDF 83kB 07/01/2022
Antitussives - (IP0586) PDF 196kB 01/15/2024
Apixaban - (IP0030) PDF 246kB 06/15/2023
Apomorphine (Apokyn) - (IP0530) PDF 207kB 12/01/2023
Atogepant - (IP0377) PDF 209kB 09/01/2023
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants - (IP0477) PDF 485kB 01/15/2024
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants for Individual and Family Plans - (IP0584) PDF 239kB 02/15/2024
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications - (IP0217) PDF 228kB 11/01/2023
Avacincaptad Intravitreal Injection - (IP0581) PDF 181kB 01/15/2024
Avacopan - (IP0398) PDF 186kB 06/15/2023
Avalglucosidase - (IP0279) PDF 227kB 01/15/2024
Avanafil - (IP0100) PDF 170kB 04/15/2023
Avatrombopag - (IP0152) PDF 207kB 10/01/2023
Avonex (interferon beta-1b) - (IP0254) PDF 193kB 01/01/2024
Axicabtagene ciloleucel - (IP0198) PDF 106kB 08/01/2022
Azathioprine - (IP0337) PDF 172kB 12/15/2023
Aztreonam Inhalation Solution - (IP0485)

PDF 204kB 09/01/2023
B
Baricitinib - (IP0225) PDF 270kB 02/01/2024
Becaplermin - (IP0495) PDF 176kB 12/01/2022
Bedaquiline - (IP0494) PDF 198kB 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 12/15/2023
Bempedoic Acid - (IP0248) PDF 257kB 12/15/2023
Benralizumab - (IP0421) PDF 283kB 08/01/2023
Beremagene geperpavec-svdt - (IP0572) PDF 225kB 11/01/2023
Beta Blockers - (IP0461) PDF 91kB 01/01/2023
Betaine (Cystadane) for Individual and Family Plans - (IP0465) PDF 227kB 01/01/2024
Betibeglogene Autotemcel - (IP0486) PDF 274kB 02/01/2023
Bexagliflozin - (IP0592) PDF 226kB 02/01/2024
Bimatoprost Ophthalmic Implant - (IP0218) PDF 208kB 11/01/2023
Bleomycin Sulfate - (IP0458) PDF 91kB 08/15/2022
Botulinum Therapy - (1106) PDF 497kB 03/01/2023
Brands with Bioequivalent Generics - (IP0011) PDF 338kB 11/01/2023
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 235kB 02/01/2024
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
Cabotegravir-Rilpivirine - (IP0123) PDF 220kB 08/01/2023
Canakinumab - (IP0235) PDF 312kB 12/15/2023
Cannabidiol - (IP0410) PDF 220kB 07/01/2022
Caplacizumab-yhdp - (IP0161) PDF 184kB 07/01/2023
Carbidopa - (IP0523) PDF 173kB 02/01/2023
Carbidopa and Levodopa Enteral Suspension - (IP0303) PDF 244kB 02/01/2023
Carglumic Acid - (IP0438) PDF 194kB 01/01/2024
Casimersen - (IP0137) PDF 183kB 07/01/2023
Cenegermin Ophthalmic Solution - (IP0302) PDF 181kB 10/15/2023
Cerliponase Alfa - (IP0175) PDF 116kB 08/01/2022
Certolizumab - (IP0244) PDF 278kB 02/01/2024
Chenodiol - (IP0203) PDF 180kB 01/15/2024
Cholic Acid - (IP0289) PDF 189kB 01/15/2024
Ciltacabtagene autoleucel - (IP0414) PDF 233kB 02/15/2024
Cinacalcet for Individual and Family Plans - (IP0464) PDF 208kB 08/01/2023
Cipaglucosidase alfa-atga - (IP0591) PDF 202kB 01/15/2024
Ciprofloxacin-fluocinolone for Individual and Family Plans - (IP0468) PDF 179kB 01/01/2023
Citalopram 30mg Oral Capsules - (IP0416) PDF 95kB 05/01/2022
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 507kB 05/01/2023
Coagulation Factor X - (IP0554) PDF 186kB 05/01/2023
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
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 593kB 01/15/2024
Crizanlizumab-tmca - (IP0120) PDF 204kB 06/01/2023
Cyanocobalamin Nasal Spray - (IP0170) PDF 188kB 09/01/2023
Cyclosporine Ophthalmic Products - (IP0026) PDF 213kB 01/15/2024
Cysteamine Bitartrate Delayed-Release - (IP0046) PDF 210kB 08/01/2023
Cysteamine Bitartrate for Individual and Family Plans - (IP0466) PDF 205kB 08/01/2023
Cysteamine Ophthalmic Solution - (IP0082)

PDF 171kB 08/01/2023
D
Dabigatran - (IP0033) PDF 277kB 01/01/2024
Dalfampridine - (IP0024) PDF 203kB 02/15/2024
Darbepoetin alfa - (IP0293) PDF 226kB 01/15/2024
DaxibotulinumtoxinA-lanm - (IP0588) PDF 184kB 01/15/2024
Deflazacort - (IP0131) PDF 205kB 02/01/2023
Delafloxacin - (IP0373) PDF 175kB 01/15/2024
Denosumab (Prolia®) - (IP0331) PDF 226kB 02/01/2024
Denosumab (Xgeva) - (IP0332) PDF 191kB 08/15/2023
Desmopressin Nasal Spray - (IP0132) PDF 125kB 02/01/2022
Desmopressin Sublingual Tablets - (IP0127) PDF 203kB 07/01/2023
Deucravacitinib - (IP0538) PDF 232kB 01/15/2024
Deutetrabenazine - (IP0079) PDF 191kB 10/15/2023
Dextromethorphan/quinidine (Nuedexta) for Individual and Family Plans - (IP0324) PDF 188kB 01/15/2023
Diazepam Nasal Spray - (IP0105) PDF 196kB 06/01/2023
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
Droxidopa - (IP0110) PDF 213kB 06/01/2023
Drug and Biologic Medical Necessity (Injectables) - medical benefits - (2027) PDF 726kB 04/15/2023
Drug and Biologic Medical Necessity (Non-Injectables) – Medical Benefits - (2028) PDF 286kB 09/01/2023
Dupilumab - (IP0453)

PDF 268kB 08/01/2023
E
Eculizumab - (IP0549) PDF 221kB 09/15/2023
Edaravone - (IP0176) PDF 263kB 10/01/2023
Edoxaban - (IP0034) PDF 135kB 05/15/2022
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 183kB 05/01/2023
Elexacaftor/Tezacaftor/Ivacaftor - (IP0434) PDF 429kB 07/01/2023
Eliglustat - (IP0441) PDF 195kB 11/01/2023
Elivaldogene autotemcel - (IP0529) PDF 195kB 02/01/2023
Elosulfase Alfa - (IP0442) PDF 199kB 09/15/2023
Eltrombopag - (IP0153) PDF 131kB 09/01/2022
Emapalumab-lzsg -(IP0113) PDF 218kB 08/01/2023
Emicizumab-kxwh - (IP0121) PDF 256kB 10/15/2023
Entadfi (finasteride and tadalafil) - (IP0519) PDF 175kB 01/15/2023
Epinephrine Injection (Self-Administered) - (IP0385) PDF 208kB 08/01/2023
Epoetin Alpha Products - (IP0296) PDF 279kB 11/15/2023
Eptinezumab - (IP0506) PDF 226kB 11/01/2023
Erenumab - (IP0503) PDF 203kB 11/01/2023
Esketamine - (IP0220) PDF 265kB 10/01/2023
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
Etranacogene dezaparvovec - (IP0535) PDF 253kB 04/01/2023
Everolimus (Afinitor, Afinitor Disperz) for Non-Oncology Uses - (IP0408) PDF 132kB 10/01/2022
Evinacumab - (IP0128) PDF 277kB 06/15/2023
Evolocumab - (IP0195)

PDF 1307kB 10/01/2023
F
Factor XIII (Plasma-Derived) - (IP0552) PDF 209kB 05/01/2023
Factor XIII A-Subunit (Recombinant) - (IP0553) PDF 206kB 05/01/2023
Faricimab - (IP0542) PDF 200kB 02/15/2024
FEIBA - (IP0354) PDF 180kB 05/01/2023
Fenfluramine - (IP0042) PDF 268kB 09/01/2023
Fenofibrates - (IP0339) PDF 184kB 01/15/2024
Fentanyl Transmucosal Products - (IP0381) PDF 197kB 06/01/2023
Fertility Injectables - (1012) PDF 384kB 08/01/2023
Fibrinogen Products - (IP0357) PDF 180kB 05/01/2023
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
Flibanserin - (IP0116) PDF 181kB 06/15/2023
Fosdenopterin - (IP0142) PDF 102kB 08/15/2022
Fostamatinib - (IP0154) PDF 201kB 10/01/2023
Fostemsavir - (IP0083) PDF 191kB 11/01/2023
Fremanezumab - (IP0504) PDF 203kB 11/01/2023
Furosemide On-Body Infusor - (IP0551)

PDF 170kB 05/01/2023
G
Gabapentin Extended-Release - (IP0317) PDF 207kB 02/15/2024
Galcanezumab - (IP0505) PDF 212kB 11/01/2023
Galsulfase - (IP0443) PDF 190kB 09/15/2023
Ganaxolone - (IP0508) PDF 200kB 11/15/2023
Givosiran - (IP0118) PDF 208kB 01/15/2024
Glatiramer - (IP0257) PDF 225kB 01/01/2024
Glecaprevir/Pibrentasvir - (IP0187) PDF 271kB 01/01/2024
Glucagon Products - (IP0039) PDF 274kB 02/01/2022
Glucose Test Strips - (IP0272) PDF 185kB 03/15/2023
Glycopyrrolate - (IP0388) PDF 180kB 01/15/2024
Glycopyrronium Topical Cloth - (IP0074) PDF 202kB 06/01/2023
Golimumab Intravenous - (IP0238) PDF 272kB 04/01/2023
Golimumab Subcutaneous - (IP0237) PDF 266kB 02/01/2024
Golodirsen - (IP0136) PDF 186kB 06/01/2023
Gonadotropin-Releasing Hormone (GnRH) Antagonists for Infertility Use - (IP0333) PDF 254kB 01/01/2024
Goserelin Acetate Subcutaneous Implant - (IP0353) PDF 239kB 08/01/2023
Grass Pollen Sublingual Products - (IP0515) PDF 184kB 03/01/2024
Grazoprevir/Elbasvir - (IP0158) PDF 229kB 01/01/2024
Guselkumab - (IP0234)

PDF 236kB 01/01/2024
H
H. Pylori Infection Products - (IP0009) PDF 123kB 11/15/2022
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
Histrelin Acetate Subcutaneous Implant - (IP0133) PDF 212kB 04/01/2023
HIV Products - (P0050) PDF 319kB 11/01/2023
HIV Products for Individual and Family Plans - (IP0090) PDF 94kB 08/15/2022
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
Hydroxyprogesterone Caproate - (IP0370) PDF 178kB 04/11/2023
Hydroxyurea Tablet - (IP0325)

PDF 206kB 01/15/2024
I
Ibalizumab-uiyk - (IP0171) PDF 211kB 09/01/2023
Ibrexfungerp - (IP0301) PDF 184kB 01/15/2024
Ibrutinib for Non-Oncology Indications - (IP0320) PDF 211kB 11/01/2022
Idecabtagene vicleucel - (IP0168) PDF 229kB 02/15/2024
Idursulfase - (IP0444) PDF 191kB 09/15/2023
Imiglucerase - (IP0162) PDF 249kB 10/01/2023
Immune Globulin - (5026) PDF 626kB 03/01/2024
Inclisiran - (IP0380) PDF 274kB 01/15/2024
Inebilizumab - (IP0062) PDF 181kB 01/15/2024
Inflammatory Conditions - Bimzelx - (IP0603) PDF 190kB 03/01/2024
Inflammatory Conditions – Cosentyx Subcutaneous - (IP0223) PDF 242kB 02/02/2024
Infliximab - (IP0242) PDF 409kB 04/01/2023
Inotersen - (IP0417) PDF 112kB 11/01/2022
Insulin Glargine - (P0023) PDF 207kB 01/01/2024
Insulins (Rapid-Acting) - (IP0065) PDF 184kB 01/01/2024
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
Iron Chelating Agents (oral) - (IP0271) PDF 308kB 11/01/2023
Isavuconazonium (Oral)- (IP0305) PDF 186kB 11/01/2023
Isotretinoin Low Dose - (IP0193) PDF 204kB 05/01/2023
Istradefylline - (IP0524) PDF 202kB 02/01/2023
Itraconazole (Tolsura) - (IP0275) PDF 175kB 10/15/2023
Ivabradine - (IP0286) PDF 242kB 11/15/2023
Ivacaftor (Kalydeco®) - (IP0431) PDF 429kB 07/01/2023
Ivermectin - (IP0300) PDF 201kB 12/15/2023
Ixekizumab - (IP0224)

PDF 258kB 02/01/2024
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 296kB 01/01/2024
Legacy Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 447kB 02/15/2024
Lenacapavir - (IP0546) PDF 187kB 06/15/2023
Leniolisib - (IP0568) PDF 193kB 10/01/2023
Letermovir Tablets (Prevymis) for Individual and Family Plans (IFP) - (IP0426) PDF 60kB 08/01/2022
Leuprolide - Central Precocious Puberty - (IP0108) PDF 218kB 08/01/2023
Leuprolide – Long Acting - (IP0109) PDF 222kB 08/01/2023
Levodopa Inhalation Powder - (IP0522) PDF 201kB 02/01/2023
Levoketoconazole - (IP0389) PDF 213kB 07/01/2023
L-glutamine Oral Powder for Individual and Family Plans - (IP0475) PDF 205kB 01/01/2023
Lisocabtagene maraleucel - (IP0130) PDF 214kB 01/15/2023
Lodoco (colchicine capsule) - (IP0595) PDF 211kB 03/01/2024
Lomitapide - (IP0221) PDF 230kB 10/01/2023
Lonafarnib - (IP0107) PDF 234kB 06/01/2023
Lonapegsomatropin - (IP0375) PDF 255kB 01/01/2024
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 449kB 12/01/2023
Lumasiran - (IP0095) PDF 224kB 03/15/2023
Luspatercept for Non-Oncology Uses - (IP0115) PDF 225kB 04/15/2023
Lusutrombopag - (IP0156) PDF 171kB 10/01/2023
Lybalvi - (IP0368) PDF 128kB 02/15/2022
LymePak - (IP0352)

PDF 130kB 01/01/2022
M
Mannitol - (IP0126) PDF 204kB 08/01/2023
Maralixibat - (IP0341) PDF 200kB 06/01/2023
Maribavir - (IP0394) PDF 201kB 05/01/2023
Mavacamten - (IP0480) PDF 235kB 10/15/2023
Mecasermin - (IP0310) PDF 220kB 06/01/2023
Medication Administration Site of Care - (1605) PDF 191kB 08/15/2023
Mepolizumab - (IP0422) PDF 296kB 08/01/2023
Methotrexate for Injection - (IP0411) PDF 180kB 07/01/2023
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 197kB 02/15/2023
Mifepristone (Korlym®) - (IP0092) PDF 186kB 01/15/2024
Migalastat - (IP0400) PDF 227kB 02/15/2024
Miglustat - (IP0446) PDF 205kB 01/15/2024
Migraine Treatment - (IP0029) PDF 239kB 04/01/2023
Miltefosine - (IP0210) PDF 203kB 09/01/2023
Mitapivat - (IP0451) PDF 201kB 09/01/2023
Monomethyl fumarate - (IP0255) PDF 193kB 01/01/2024
Multiple Sclerosis - Ocrevus - (IP0212) PDF 184kB 03/01/2024
Muscular Dystrophy – Gene Therapy – Elevidys (delandistrogene moxeparvovec-rokl) intravenous infusion - (IP0571) PDF 239kB 01/15/2024
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
Neurology - Leqembi (lecanemab) - (IP0547) PDF 279kB 01/15/2024
Nintedanib - (IP0312) PDF 242kB 11/15/2023
Nitazoxanide for Individual and Family Plans - (IP0467) PDF 213kB 01/01/2023
Nitisinone - (IP0146) PDF 182kB 08/01/2023
Nonsteroidal Anti-inflammatory Drugs - (IP0457) PDF 138kB 10/01/2022
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 - (IP0500) PDF 212kB 04/01/2023
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 222kB 05/01/2023
Oncology Medications - (1403) PDF 397kB 02/15/2024
Ophthalmic Prostaglandin Analogs - (IP0027) PDF 244kB 02/01/2024
Opicapone - (IP0532) PDF 202kB 10/15/2023
Opioid Induced Constipation Therapy - (IP0401) PDF 185kB 05/01/2023
Opioid Therapy - Employer Group Benefit Plans - (IP0561) PDF 292kB 01/01/2024
Opioid Therapy - Individual and Family Plans - (IP0562) PDF 293kB 01/01/2024
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
Oxazolidinone Antibiotics - (IP0372) PDF 253kB 02/15/2023
Oxybate - (IP0103) PDF 256kB 11/15/2023
Oxymetazoline Ophthalmic Solution - (IP0088) PDF 205kB 02/01/2023
Ozanimod - (IP0214)

PDF 270kB 02/01/2024
P
Palivizumab - (IP0321) PDF 263kB 01/15/2024
Palovarotene - (IP0596) PDF 211kB 02/15/2024
Pancrelipase - (IP0002) PDF 182kB 12/15/2023
Parathyroid Hormone - (IP0177) PDF 200kB 09/01/2023
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 187kB 05/01/2023
Peanut (Arachis hypogaea) Allergen Powder-dnfp - (IP0141) PDF 211kB 08/01/2023
Pegcetacoplan Intravitreal Injection - (IP0559) PDF 205kB 06/01/2023
Pegcetacoplan Subcutaneous Injection- (IP0194) PDF 192kB 11/01/2023
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 219kB 01/01/2023
Pen Needles - (IP0569) PDF 175kB 01/01/2024
Perfluorohexyloctane Ophthalmic Solution - (IP0583) PDF 181kB 12/15/2023
Performance Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 447kB 02/15/2024
Pharmacy Prior Authorization - (1407) PDF 204kB 02/15/2024
Phenylbutyrate - (IP0169) PDF 228kB 11/15/2023
Pilocarpine 1.25% Ophthalmic - (IP0343) PDF 90kB 05/01/2022
Pimavanserin - (IP0145) PDF 170kB 02/01/2023
Pirfenidone - (IP0311) PDF 248kB 01/15/2024
Pitolisant - (IP0292) PDF 209kB 11/15/2023
Plasmiogen - (IP0382) PDF 212kB 06/01/2023
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 174kB 05/01/2023
Progesterone (Endometrin) for Individual and Family Plans - (IP0091) PDF 182kB 11/01/2023
Progesterone – Employer Group Plans - (IP0548) PDF 198kB 11/01/2023
Protein C Concentrate - (IP0342) PDF 179kB 05/01/2023
Proton Pump Inhibitors - (IP0061) PDF 248kB 06/01/2023
Prucalopride - (IP0017) PDF 205kB 02/01/2024
Pulmonary Hypertension (PH) Therapy - (6121) PDF 482kB 01/01/2024
Purified Cortrophin Gel - (IP0374) PDF 192kB 10/01/2023
Pyridostigmine - (IP0544) PDF 170kB 04/01/2023
Pyrimethamin - (IP0348)

PDF 191kB 05/01/2023
Q
Quantity Limitations - (1201) PDF 252kB 02/01/2024
Quazepam for Individual and Family Plans - (IP0469)

PDF 209kB 01/01/2023
R
Ragwitek - (IP0518) PDF 178kB 03/01/2024
Ranibizumab - (IP0543) PDF 219kB 04/01/2023
Ranibizumab Ocular Implant - (IP0349) PDF 170kB 04/01/2023
Ranolazine - (IP0507) PDF 173kB 12/15/2022
Ravulizumab-cwvz Intravenous - (IP0550) PDF 243kB 09/15/2023
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
Riluzole - (IP0258) PDF 186kB 03/01/2024
RimabotulinumtoxinB - (IP0509) PDF 192kB 02/15/2023
Rimegepant - (IP0147) PDF 218kB 04/15/2023
Risankizumab Intravenous - (IP0476) PDF 233kB 01/01/2023
Risankizumab Subcutaneous- (IP0247) PDF 249kB 02/15/2023
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 207kB 12/15/2023
Romiplostim - (IP0155) PDF 237kB 10/01/2023
Romosozumab - (IP0179) PDF 208kB 11/01/2023
Rozanolixizumab - (IP0575) PDF 230kB 02/15/2024
Rufinamide - (IP0048)

PDF 216kB 04/01/2023
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 241kB 02/01/2024
Satralizumab - (IP0078) PDF 203kB 02/01/2023
Sebelipase Alfa - (IP0448) PDF 216kB 09/15/2023
Secukinumab Intravenous - (IP0594) PDF 268kB 02/01/2024
Sedative Hypnotic Medications - (IP0023) PDF 249kB 02/15/2024
Selegiline - (IP0525) PDF 202kB 02/01/2023
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
Sevenfact - (IP0355) PDF 209kB 05/01/2023
Short-Acting Beta2-Agonist Inhalers - (IP0040) PDF 214kB 05/15/2023
Sildenafil (Viagra) - (IP0098) PDF 217kB 02/15/2024
Sinecatechins - (IP0393) PDF 194kB 05/15/2023
Siponimod - (IP0262) PDF 194kB 01/01/2024
Sirolimus - (IP0511) PDF 201kB 10/15/2023
Skeletal Muscle Relaxants - (IP0211) PDF 211kB 02/01/2024
Sodium Phenylbutyrate and Taurursodiol Powder - (IP0539) PDF 216kB 04/01/2023
Sodium thiosulfate (Pedmark) - (IP0512) PDF 300kB 12/01/2022
Sofosbuvir/Velpatasvir/Voxilaprevir - (IP0188) PDF 211kB 01/15/2024
Sofosbuvir/Velpatasvir - (IP0184) PDF 251kB 01/01/2024
Sofosbuvir - (IP0157) PDF 256kB 02/15/2023
Solriamfetol - (IP0102) PDF 209kB 11/15/2023
Somapacitan - (IP0576) PDF 275kB 01/01/2024
Somatrogon - (IP0577) PDF 254kB 01/01/2024
Somatropin - (IP0452) PDF 108kB 01/01/2024
Sparsentan - (IP0565) PDF 216kB 08/01/2023
Spesolimab - (IP0501) PDF 195kB 02/15/2024
Standard Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 447kB 02/15/2024
Step Therapy Individual and Family Plan - (1603) PDF 198kB 01/01/2024
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) PDF 279KB 01/01/2024
Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) PDF 258kB 01/01/2024
Step Therapy – Value/Advantage Prescription Drug Lists (Employer Group Plans) - (1802) PDF 255kB 10/01/2023
Stiripentol - (IP0409) PDF 120kB 11/01/2022
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 191kB 12/01/2022
Tarpeyo - (IP0413) PDF 238kB 06/01/2023
Tascenso ODT - (IP0514) PDF 222kB 11/15/2023
Tasimelteon - (IP0428) PDF 245kB 01/01/2024
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 215kB 07/01/2023
Teprotumumab - (IP0129) PDF 212kB 08/01/2023
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 269kB 11/01/2023
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 122kB 02/01/2022
Thyroid Hormone Supplements - (IP0060) PDF 249kB 05/01/2023
Tildrakizumab - (IP0236) PDF 282kB 02/01/2024
Tiopronin - (IP0202) PDF 228kB 04/01/2023
Tisagenlecleucel - (IP197) PDF 280kB 02/01/2024
Tizanidine - (IP0392) PDF 62kB 07/01/2022
Tobramycin/loteprednol etabonate (Zylet) Ophthalmic Suspension for Individual and Family Plans - (IP0474) PDF 171kB 01/01/2023
Tobramycin Inhalation Powder - (IP0499) PDF 204kB 09/01/2023
Tobramycin Inhalation Solution - (IP0094) PDF 270kB 09/01/2023
Tocilizumab Intravenous - (IP0228) PDF 192kB 09/01/2022
Tocilizumab Subcutaneous - (IP0227) PDF 266kB 02/01/2024
Tofacitinib - (IP0230) PDF 283kB 02/01/2024
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 242kB 03/01/2024
Topical Adapalene Products - (IP0181) PDF 121kB 01/15/2024
Topical Alpha Adrenergic Agonists - (IP0284) PDF 172kB 01/01/2024
Topical Antifungals - (IP0273) PDF 227kB 06/15/2023
Topical Antivirals - (IP0276) PDF 195kB 11/01/2023
Topical Azelaic Acid Products - (IP0172) PDF 84kB 08/01/2022
Topical Clascoterone - (IP0173) PDF 193kB 06/01/2023
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 277kB 08/01/2023
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 - (IP0461) PDF 217kB 01/15/2024
Total Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 467kB 02/15/2024
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
Trilaciclib Injection - (IP0150) PDF 72kB 07/01/2022
Triptorelin Pamoate - (IP0134) PDF 187kB 06/01/2023
Trofinetide - (IP0578)

PDF 193kB 11/01/2023
U
Ublituximab - (IP0545) PDF 203kB 01/01/2024
Ubrogepant - (IP0148) PDF 205kB 08/01/2023
Unassigned Drug or Biologic Code Medical Precertification - (1701) PDF 320kB 02/01/2024
Upadacitinib - (IP0229) PDF 292kB 02/01/2024
Uridine triacetate - (IP0307) PDF 173kB 01/15/2023
Ursodiol - (IP0299) PDF 70kB 10/15/2021
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 467kB 02/15/2024
Vardenafil - (IP0099) PDF 213kB 04/15/2023
Varenicline Nasal Solution - (IP0395) PDF 176kB 01/15/2024
Vedolizumab Intravenous - (IP0326) PDF 212kB 03/01/2024
Velaglucerase - (IP0164) PDF 205kB 10/01/2023
Velmanase - (IP0563) PDF 231kB 07/01/2023
Vericiguat - (IP0125) PDF 199kB 01/01/2024
Verkazia - (IP0439) PDF 202kB 08/01/2023
Vestronidase Alfa-vjbk - (IP0449) PDF 209kB 09/15/2023
Vigabatrin - (IP0049) PDF 235kB 11/01/2023
Viltolarsen - (IP0066) PDF 190kB 01/15/2024
Vocabria - (IP0124) PDF 248kB 09/15/2023
Volcosporin - (IP0122) PDF 227kB 01/15/2024
Von Willebrand Factor (Recombinant) - (IP0555) PDF 217kB 05/01/2023
Voretigene Neparvovec - (IP0160) PDF 203kB 07/01/2023
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 206kB 01/15/2024
W
Weight Loss – Liraglutide (Saxendra®) - (IP0206) PDF 240kB 02/15/2024
Weight Loss Medications - (IP0420) PDF 244kB 11/15/2022
Weight Loss – Semaglutide (Wegovy™) - (IP0521) PDF 239kB 02/15/2024
Weight Loss – Tirzepatide (Zepbound™) - (IP0593)

PDF 236kB 12/15/2023