A |
|
|
|
Abaloparatide - (IP0329) |
PDF |
220kB |
04/01/2024 |
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 |
04/15/2024 |
Aducanumab - (IP0200) |
PDF |
210kB |
01/15/2024 |
Advantage Prescription Drug List - (1602)* *Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
491kB |
04/15/2024 |
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 |
04/01/2024 |
Alpelisib - (IP0481) |
PDF |
213kB |
10/01/2023 |
Alpha1-Proteinase Inhibitors - (IP0387) |
PDF |
231kB |
04/01/2024 |
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 |
188kB |
04/01/2024 |
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 |
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 |
04/01/2024 |
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 |
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 |
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 |
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 |
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 |
Betibeglogene Autotemcel - (IP0486) |
PDF |
274kB |
02/01/2023 |
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 |
310kB |
03/15/2024 |
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 |
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 |
174kB |
03/15/2024 |
Carbidopa and Levodopa Enteral Suspension - (IP0303) |
PDF |
234kB |
03/15/2024 |
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 |
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 |
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 |
Complement Inhibitors – Fabhalta - (IP0614) |
PDF |
156kB |
04/01/2024 |
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 |
593kB |
01/15/2024 |
Crizanlizumab-tmca - (IP0120) |
PDF |
204kB |
06/01/2023 |
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 |
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 |
209kB |
03/15/2024 |
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 |
03/15/2024 |
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 |
287kB |
04/15/2024 |
E |
|
|
|
Eculizumab - (IP0549) |
PDF |
223kB |
04/15/2024 |
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 |
122kB |
04/15/2024 |
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 |
176kB |
03/15/2024 |
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 |
209kB |
03/15/2024 |
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 |
198kB |
03/15/2024 |
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 |
206kB |
04/01/2024 |
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 |
188kB |
03/15/2024 |
Glucose Test Strips - (IP0272) |
PDF |
184kB |
03/15/2024 |
Glycopyrrolate - (IP0388) |
PDF |
180kB |
01/15/2024 |
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 |
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 |
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 |
338kB |
04/01/2024 |
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 |
169kB |
03/15/2024 |
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 |
Infectious Disease – Prevymis for Individual and Family Plans - (IP0426) |
PDF |
120kB |
04/01/2024 |
Inflammatory Conditions - Bimzelx - (IP0603) |
PDF |
190kB |
03/01/2024 |
Inflammatory Conditions – Cosentyx Subcutaneous - (IP0223) |
PDF |
242kB |
02/02/2024 |
Inflammatory Conditions-Entyvio Subcutaneous - (IP0599) |
PDF |
178kB |
04/15/2024 |
Inflammatory Conditions – Entyvio Subcutaneous for Total Savings and Individual and Family Plans - (IP0613) |
PDF |
186kB |
04/15/2024 |
Inflammatory Conditions – Omvoh Subcutaneous - (IP0602) |
PDF |
207kB |
04/15/2024 |
Inflammatory Conditions – Velsipity - (IP0605) |
PDF |
170kB |
04/15/2024 |
Infliximab - (IP0242) |
PDF |
365kB |
03/15/2024 |
Inotersen - (IP0417) |
PDF |
180kB |
04/01/2024 |
Insulin Glargine - (P0023) |
PDF |
207kB |
01/01/2024 |
Insulins (Rapid-Acting) - (IP0065) |
PDF |
184kB |
04/19/2024 |
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 |
201kB |
04/01/2024 |
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 |
473kB |
04/15/2024 |
Lenacapavir - (IP0546) |
PDF |
187kB |
06/15/2023 |
Leniolisib - (IP0568) |
PDF |
193kB |
10/01/2023 |
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 |
03/15/2024 |
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 |
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 |
136kB |
04/15/2024 |
LymePak - (IP0352) |
PDF |
159kB |
04/01/2024 |
M |
|
|
|
Mannitol - (IP0126) |
PDF |
204kB |
08/01/2023 |
Maralixibat - (IP0341) |
PDF |
199kB |
04/01/2024 |
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 |
151kB |
03/15/2024 |
Mepolizumab - (IP0422) |
PDF |
296kB |
08/01/2023 |
Metabolic Disorders – Phenylbutyrate Products - (IP0169) |
PDF |
152kB |
04/01/2024 |
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 |
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 |
Motixafortide - (IP0597) |
PDF |
187kB |
03/15/2024 |
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 |
Nephrology − Jesduvroq - (IP0604) |
PDF |
133kB |
03/15/2024 |
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 |
258kB |
03/15/2024 |
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 – CAR-T) – Yescarta - (IP0198) |
PDF |
151kB |
04/01/2024 |
Oncology Medications - (1403) |
PDF |
397kB |
02/15/2024 |
Opfolda (miglustat) capsule - (IP0598) |
PDF |
203kB |
03/15/2024 |
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 |
04/01/2024 |
Oxymetazoline Ophthalmic Solution - (IP0088) |
PDF |
200kB |
03/15/2024 |
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 |
04/01/2024 |
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 |
184kB |
04/01/2024 |
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 |
216kB |
03/15/2024 |
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 |
473kB |
04/15/2024 |
Pharmacy Prior Authorization - (1407) |
PDF |
204kB |
02/15/2024 |
Pilocarpine 1.25% Ophthalmic - (IP0343) |
PDF |
136kB |
04/15/2024 |
Pimavanserin - (IP0145) |
PDF |
169kB |
04/01/2024 |
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 |
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 |
Protein C Concentrate - (IP0342) |
PDF |
179kB |
05/01/2023 |
Proton Pump Inhibitors - (IP0061) |
PDF |
166kB |
04/15/2024 |
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 |
|
|
|
Qbrexza - (IP0074) |
PDF |
131kB |
04/01/2024 |
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 |
04/15/2024 |
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 |
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 |
226kB |
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 |
241kB |
02/01/2024 |
Satralizumab-mwge - (IP0078) |
PDF |
178kB |
03/15/2024 |
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 |
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 |
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 Glucose Co-Transporter-2 (SGLT-2) Inhibitors and SGLT-2 / Metformin Combinations - (IP0592) |
PDF |
264kB |
04/01/2024 |
Sodium Phenylbutyrate and Taurursodiol Powder - (IP0539) |
PDF |
216kB |
04/01/2023 |
Sodium thiosulfate - (IP0512) |
PDF |
200kB |
04/01/2024 |
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 |
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 |
473kB |
04/15/2024 |
Step Therapy Individual and Family Plan - (1603) |
PDF |
195kB |
04/15/2024 |
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) |
PDF |
279KB |
03/15/2024 |
Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) |
PDF |
258kB |
04/01/2024 |
Step Therapy – Value/Advantage Prescription Drug Lists (Employer Group Plans) - (1802) |
PDF |
246kB |
04/01/2024 |
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 |
210kB |
04/01/2024 |
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 |
173kB |
04/15/2024 |
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 |
171kB |
04/01/2024 |
Thyroid Hormone Supplements - (IP0060) |
PDF |
249kB |
05/01/2023 |
Tildrakizumab - (IP0236) |
PDF |
282kB |
02/01/2024 |
Tiopronin - (IP0202) |
PDF |
230kB |
04/01/2024 |
Tisagenlecleucel - (IP197) |
PDF |
280kB |
02/01/2024 |
Tizanidine - (IP0392) |
PDF |
111kB |
04/15/2024 |
Tobramycin/loteprednol etabonate (Zylet) Ophthalmic Suspension for Individual and Family Plans - (IP0474) |
PDF |
171kB |
01/01/2023 |
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 |
237kB |
03/15/2024 |
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 |
84kB |
08/01/2022 |
Topical Clascoterone - (IP0173) |
PDF |
126kB |
04/15/2024 |
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 |
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 - (IP0361) |
PDF |
215kB |
03/15/2024 |
Total Prescription Drug List - (1602)* *Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review |
PDF |
491kB |
04/15/2024 |
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 |
176kB |
04/01/2024 |
Ustekinumab Intravenous - (IP0240) |
PDF |
282kB |
01/01/2024 |
Ustekinumab Subcutaneous - (IP0239) |
PDF |
259kB |
01/01/2024 |
V |
|
|
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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 |
04/15/2024 |
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 |
203kB |
04/01/2024 |
W |
|
|
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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 |