| A |
|
|
|
| Abilify Mycite - (IP0534) |
PDF |
185kB |
|
| Adrenal Hyperplasia – Crenessity - (IP0726) |
PDF |
136kB |
|
| Aflibercept - (IP0540) |
PDF |
271kB |
|
| Albendazole for Individual and Family Plans - (IP0462) |
PDF |
168kB |
|
| Allergen Immunotherapy – Grass Pollen Sublingual Products - (IP0515) |
PDF |
151kB |
|
| Allergen Immunotherapy – Odactra - (IP0516) |
PDF |
162kB |
|
| Allergen Immunotherapy – Palforzia - (IP0141) |
PDF |
211kB |
|
| Allergen Immunotherapy – Ragwitek - (IP0518) |
PDF |
152kB |
|
| Alosetron - (IP0012) |
PDF |
171kB |
|
| Alpha1-Proteinase Inhibitor Products - (IP0387) |
PDF |
229kB |
|
| Alzheimer’s Disease – Amyloid Beta-Directed Antibodies – Kisunla - (IP0697) |
PDF |
185kB |
|
| Amantadine Extended-Release - (IP0403) |
PDF |
221kB |
|
| Amifampridine Products - (IP0290) |
PDF |
169kB |
|
| Aminocaproic Acid for Individual and Family Plans - (IP0463) |
PDF |
175kB |
|
| Amyloidosis - Attruby - (IP0728) |
PDF |
170kB |
|
| Amyloidosis – Onpattro - (IP0418) |
PDF |
208kB |
|
| Amyloidosis - Tafamidis Products - (IP0149) |
PDF |
178kB |
|
| Amyloidosis – Wainua - (IP0628) |
PDF |
195kB |
|
| Antibiotics (Inhaled) – Arikayce - (IP0383) |
PDF |
199kB |
|
| Antibiotics (inhaled) – Cayston - (IP0485) |
PDF |
175kB |
|
| Antibiotics (Inhaled) – TOBI Podhaler - (IP0499) |
PDF |
161kB |
|
| Antibiotics (Inhaled) – Tobramycin Inhalation Solution - (IP0094) |
PDF |
212kB |
|
| Antibiotics – Linezolid (Zyvox), Sivextro - (IP0372) |
PDF |
234kB |
|
| Antibiotics – Xifaxan for Individual and Family Plans - (IP0473) |
PDF |
189kB |
|
| Anticoagulants – Dabigatran - (IP0033) |
PDF |
196kB |
|
| Anticoagulants – Savaysa - (IP0034) |
PDF |
206kB |
|
| Antiemetic Therapy - (1705) |
PDF |
254kB |
|
| Antifungals – Cresemba (Oral) - (IP0305) |
PDF |
204kB |
|
| Antifungals – Posaconazole (Oral) for Individual and Family Plans - (IP0536) |
PDF |
189kB |
|
| Antifungals – Tolsura - (IP0275) |
PDF |
172kB |
|
| Antifungals – Voriconazole (Oral) - (IP0306) |
PDF |
189kB |
|
| Antiseizure Medications - (IP0031) |
PDF |
227kB |
|
| Antiseizure Medications – Clobazam Products - (IP0106) |
PDF |
252kB |
|
| Antiseizure Medications – Diacomit - (IP0409) |
PDF |
204kB |
|
| Antiseizure Medications - Epidiolex - (IP0410) |
PDF |
214kB |
|
| Antiseizure Medications – Fintepla - (IP0042) |
PDF |
247kB |
|
| Antiseizure Medications – Nayzilam - (IP0338) |
PDF |
209kB |
|
| Antiseizure Medications – Rufinamide - (IP0048) |
PDF |
187kB |
|
| Antiseizure Medications – Valtoco - (IP0105) |
PDF |
151kB |
|
| Antiseizure Medications - Ztalmy - (IP0508) |
PDF |
166kB |
|
| Antiseizure Medication – Vigabatrin - (IP0049) |
PDF |
181kB |
|
| Antitussives - (IP0586) |
PDF |
196kB |
|
| Attention Deficit Hyperactivity Disorder (ADHD) Stimulants for Employer Group Plans - (IP0477) |
PDF |
506kB |
|
| Attention Deficit Hyperactivity Disorder (ADHD) Stimulants for Individual and Family Plans - (IP0584) |
PDF |
221kB |
|
| Attention Deficit Hyperactivity Disorder Non-Stimulant Medications - (IP0217) |
PDF |
234kB |
|
| Azathioprine - (IP0337) |
PDF |
172kB |
|
| B |
|
|
|
| Barth Syndrome – Forzinity for Individual and Family Plans - (IP0786) |
PDF |
152kB |
|
| Belumosudil - (IP0313) |
PDF |
211kB |
|
| Benign Prostatic Hyperplasia – Entadfi - (IP0519) |
PDF |
168kB |
|
| Bleomycin Sulfate - (IP0458) |
PDF |
91kB |
|
| Bone Modifiers – Denosumab Products (Prolia) - (IP0331) |
PDF |
273kB |
|
| Bone Modifiers – Denosumab Products (Xgeva) - (IP0332) |
PDF |
272kB |
|
| Bone Modifiers - Evenity - (IP0179) |
PDF |
181kB |
|
| Bone Modifiers – Teriparatide Products - (IP0330) |
PDF |
218kB |
|
| Bone Modifiers - Tymlos - (IP0329) |
PDF |
166kB |
|
| Botulinum Toxins – Botox - (IP0637) |
PDF |
275kB |
|
| Botulinum Toxins – Daxxify - (IP0588) |
PDF |
210kB |
|
| Botulinum Toxins – Dysport - (IP0638) |
PDF |
210kB |
|
| Botulinum Toxins – Myobloc - (IP0509) |
PDF |
173kB |
|
| Botulinum Toxins – Xeomin - (IP0639) |
PDF |
209kB |
|
| Bowel Agents – Opioid-Induced Constipation - (IP0401) |
PDF |
179kB |
|
| Brands with Bioequivalent Generics - (IP0011) |
PDF |
248kB |
|
| Bruton's Tyrosine Kinase Inhibitor - Rhapsido - (IP0771) |
PDF |
159kB |
|
| Butalbital Combination Products - (IP0025) |
PDF |
193kB |
|
| C |
|
|
|
| Cardiology – Camzyos - (IP0480) |
PDF |
185kB |
|
| Cardiology – Cardamyst for Individual and Family Plans - (IP0783) |
PDF |
163kB |
|
| Cardiology – Ivabradine - (IP0286) |
PDF |
214kB |
|
| Cardiology – Lodoco - (IP0595) |
PDF |
255kB |
|
| Cardiology – Tryvio - (IP0713) |
PDF |
159kB |
|
| Carglumic Acid - (IP0438) |
PDF |
244kB |
|
| Chelating Agents – Iron Chelators (Oral) - (IP0271) |
PDF |
291kB |
|
| Chelating Agents – Trientine Products - (IP0278) |
PDF |
266kB |
|
| Chemoprotective Agent – Pedmark - (IP0512) |
PDF |
210kB |
|
| Chenodiol Products - (IP0203) |
PDF |
150kB |
|
| Cholbam - (IP0289) |
PDF |
156kB |
|
| Cinacalcet for Individual and Family Plans - (IP0464) |
PDF |
153kB |
|
| Ciprofloxacin-fluocinolone for Individual and Family Plans - (IP0468) |
PDF |
179kB |
|
| Citalopram 30mg Oral Capsules - (IP0416) |
PDF |
206B |
|
| Clomiphene - (IP0492) |
PDF |
166kB |
|
| Clotting Factors and Antithrombin - (8007) |
PDF |
242kB |
|
| Collagenase for Individual and Family Plans - (IP0470) |
PDF |
171kB |
|
| Colony Stimulating Factors – Filgrastim- (IP0528) |
PDF |
258kB |
|
| Colony Stimulating Factors – Pegfilgrastim - (IP0070) |
PDF |
238kB |
|
| Colony Stimulating Factors – Rolvedon - (IP0526) |
PDF |
219kB |
|
| Colony Stimulating Factors – Ryzneuta - (IP0745) |
PDF |
249kB |
|
| Complement Inhibitors – Eculizumab Products - (IP0549) |
PDF |
285kB |
|
| Complement Inhibitors – Empaveli- (IP0194) |
PDF |
205kB |
|
| Complement Inhibitors – Fabhalta - (IP0614) |
PDF |
206kB |
|
| Complement Inhibitors – PiaSky - (IP0694) |
PDF |
231kB |
|
| Complement Inhibitors – Ultomiris - (IP0550) |
PDF |
285kB |
|
| Complement Inhibitors - Veopoz - (IP0587) |
PDF |
218kB |
|
| Complement Inhibitors – Voydeya - (IP0647) |
PDF |
166kB |
|
| Complement Inhibitors – Zilbrysq - (IP0622) |
PDF |
173kB |
|
| Complement System Disorders – WHIM Syndrome – Xolremdi - (IP0654) |
PDF |
161kB |
|
| Compounded Medications - (IP0251) |
PDF |
251kB |
|
| Contraceptives - (IP0036) |
PDF |
222kB |
|
| Contraceptives - Phexx - (IP0729) |
PDF |
160kB |
|
| Corticosteroids (Intraarticular) – Zilretta - (IP0140) |
PDF |
206kB |
|
| COVID-19 Drug and Biologic Therapeutics - (2016) |
PDF |
377kB |
|
| Crysvita - (IP0285) |
PDF |
290kB |
|
| Cushing’s Isturisa - (IP0044) |
PDF |
188kB |
|
| Cushing’s – Mifepristone - (IP0092) |
PDF |
185kB |
|
| Cushing’s – Recorlev - (IP0389) |
PDF |
160kB |
|
| Cushing’s – Signifor - (IP0482) |
PDF |
183kB |
|
| Cyanocobalamin Nasal Spray - (IP0170) |
PDF |
128kB |
|
| Cystic Fibrosis – Bronchitol - (IP0126) |
PDF |
189kB |
|
| Cystic Fibrosis – Pulmozyme - (IP0483) |
PDF |
184kB |
|
| Cystic Fibrosis Transmembrane Conductance Regulator – Alyftrek - (IP0723) |
PDF |
226kB |
|
| Cystic Fibrosis Transmembrane Conductance Regulator – Kalydeco - (IP0431) |
PDF |
243kB |
|
| Cystic Fibrosis Transmembrane Conductance Regulator – Orkambi - (IP0432) |
PDF |
207kB |
|
| Cystic Fibrosis Transmembrane Conductance Regulator – Symdeko -(IP0433) |
PDF |
254kB |
|
| Cystic Fibrosis Transmembrane Conductance Regulator – Trikafta - (IP0434) |
PDF |
273kB |
|
| D |
|
|
|
| Delafloxacin - (IP0373) |
PDF |
175kB |
|
| Dermatology – Anzupgo - (IP0759) |
PDF |
172kB |
|
| Dermatology – Anzupgo Drug Quantity Management Policy – Per Days - (DQM015) |
PDF |
174kB |
|
| Dermatology – Filsuvez - (IP0635) |
PDF |
197kB |
|
| Dermatology – Gene Therapy – Vyjuvek - (IP0572) |
PDF |
225kB |
|
| Dermatology – Gene Therapy – Zevaskyn - (IP0747) |
PDF |
204kB |
|
| Dermatology – Hyftor - (IP0511) |
PDF |
242kB |
|
| Dermatology – Opzelura - (IP0369) |
PDF |
237kB |
|
| Dermatology – Vtama Drug Quantity Management Policy – Per Days - (DQM024) |
PDF |
151kB |
|
| Desmopressin Nasal Spray - (IP0132) |
PDF |
228kB |
|
| Desmopressin Products – Nocdurna - (IP0127) |
PDF |
170kB |
|
| Diabetes – Diabetic Supplies - (IP0272) |
PDF |
189kB |
|
| Diabetes – Glucagon-Like Peptide-1 Agonists for Employer Plans: Standard/Performance, Value/Advantage, Legacy, Total Savings Prescription Drug Lists - (IP0701) |
PDF |
195kB |
|
| Diabetes – Glucagon-Like Peptide-1 Agonists for Individual and Family Plans - (IP0702) |
PDF |
191kB |
|
| Diabetes – Symlin for Individual and Family Plans - (IP0698) |
PDF |
160kB |
|
| Diabetes - Tzield - (IP0537) |
PDF |
271kB |
|
| Dichlorphenamide - (IP0204) |
PDF |
217kB |
|
| Difelikefalin - (IP0436) |
PDF |
239kB |
|
| Dimercaprol and Edetate Calcium Disodium - (IP0138) |
PDF |
247kB |
|
| Diuretic – Enbumyst - (IP0784) |
PDF |
161kB |
|
| Dronabinol Products - (IP0719) |
PDF |
172kB |
|
| Droxidopa - (IP0110) |
PDF |
160kB |
|
| Drugs Requiring Medical Necessity Review for Employer Plans - (1602) |
PDF |
175kB |
|
| E |
|
|
|
| Eliglustat - (IP0441) |
PDF |
228kB |
|
| Enspryng - (IP0078) |
PDF |
196kB |
|
| Enzyme Replacement Therapy – Aldurazyme - (IP0445) |
pdf |
190kB |
|
| Enzyme Replacement Therapy – Elaprase - (IP0444) |
PDF |
170kB |
|
| Enzyme Replacement Therapy – Elfabrio - (IP0570) |
PDF |
158kB |
|
| Enzyme Replacement Therapy – Fabrazyme - (IP0406) |
PDF |
213kB |
|
| Enzyme Replacement Therapy – Kanuma - (IP0448) |
PDF |
163kB |
|
| Enzyme Replacement Therapy - Lamzede - (IP0563) |
PDF |
200kB |
|
| Enzyme Replacement Therapy – Mepsevii - (IP0449) |
PDF |
169kB |
|
| Enzyme Replacement Therapy – Naglazyme - (IP0443) |
PDF |
143kB |
|
| Enzyme Replacement Therapy – Revcovi - (IP0399) |
PDF |
147kB |
|
| Enzyme Replacement Therapy - Strensiq - (IP0308) |
PDF |
172kB |
|
| Enzyme Replacement Therapy – Sucraid - (IP0447) |
PDF |
143kB |
|
| Enzyme Replacement Therapy – Vimizim - (IP0442) |
PDF |
166kB |
|
| Enzyme Replacement Therapy-Xenpozyme - (IP0500) |
PDF |
263kB |
|
| Erectile Dysfunction – Alprostadil Products for Individual and Family Plans - (IP0425) |
PDF |
209kB |
|
| Erectile Dysfunction – Avanafil - (IP0100) |
PDF |
116kB |
|
| Erectile Dysfunction – Vardenafil - (IP0099) |
PDF |
183kB |
|
| Erythropoiesis-Stimulating Agents – Aranesp - (IP0293) |
PDF |
256kB |
|
| Erythropoiesis-Stimulating Agents – Epoetin Alfa Products - (IP0296) |
PDF |
259kB |
|
| Erythropoiesis-Stimulating Agents – Mircera - (IP0297) |
PDF |
218kB |
|
| F |
|
|
|
| Fabry Disease – Galafold - (IP0400) |
PDF |
161kB |
|
| Familial Chylomicronemia Syndrome – Tryngolza - (IP0733) |
PDF |
175kB |
|
| Fenofibrates - (IP0339) |
PDF |
184kB |
|
| Fentanyl Transmucosal Products - (IP0381) |
PDF |
149kB |
|
| Fertility Injectables - (1012) |
PDF |
360kB |
|
| Fish Oil Triglycerides - (IP0191) |
PDF |
181kB |
|
| G |
|
|
|
| Gamifant -(IP0113) |
PDF |
173kB |
|
| Gastroenterology – Eohilia - (IP0630) |
PDF |
175kB |
|
| Gastroenterology - Gattex - (IP0288) |
PDF |
159kB |
|
| Gaucher Disease – Enzyme Replacement Therapy – Cerezyme - (IP0162) |
PDF |
184kB |
|
| Gaucher Disease – Enzyme Replacement Therapy – Elelyso - (IP0163) |
PDF |
195kB |
|
| Gaucher Disease – Enzyme Replacement Therapy – Vpriv - (IP0164) |
PDF |
184kB |
|
| Gaucher Disease – Substrate Reduction Therapy – Miglustat - (IP0446) |
PDF |
170kB |
|
| Glycopyrrolate - (IP0388) |
PDF |
180kB |
|
| Gonadotropin-Releasing Hormone Agonists – Central Precocious Puberty - (IP0768) |
PDF |
199kB |
|
| Gonadotropin-Releasing Hormone Agonists – Implants for Non-Oncology Indications - (IP0620) |
PDF |
210kB |
|
| Gonadotropin-Releasing Hormone Agonists – Lupron Depot - (IP0109) |
PDF |
283kB |
|
| Gonadotropin-Releasing Hormone Agonist – Synarel - (IP0415) |
PDF |
217kB |
|
| Gonadotropin-Releasing Hormone Antagonists – Myfembree - (IP0205) |
PDF |
222kB |
|
| Gonadotropin-Releasing Hormone Antagonists – Oriahnn - (IP0087) |
PDF |
157kB |
|
| Gonadotropin-Releasing Hormone Antagonists – Orilissa - (IP0196) |
PDF |
143kB |
|
| Gout – Krystexxa - (IP0269) |
PDF |
208kB |
|
| Graft-Versus-Host Disease – Niktimvo - (IP0722) |
PDF |
182kB |
|
| Graft-Versus-Host Disease - Ryoncil - (IP0732) |
PDF |
184kB |
|
| Growth Disorders – Increlex - (IP0310) |
PDF |
200kB |
|
| Growth Disorders – Ngenla - (IP0577) |
PDF |
230kB |
|
| Growth Disorders – Skytrofa - (IP0375) |
PDF |
304kB |
|
| Growth Disorders – Voxzogo - (IP0402) |
PDF |
204kB |
|
| H |
|
|
|
| Hematology – Adzynma - (IP0606) |
PDF |
145kB |
|
| Hematology - Aphexda - (IP0597) |
PDF |
236kB |
|
| Hematology – Cablivi - (IP0161) |
PDF |
191kB |
|
| Hematology – Ceprotin - (IP0342) |
PDF |
193kB |
|
| Hematology – Coagadex - (IP0554) |
PDF |
157kB |
|
| Hematology - Corifact - (IP0552) |
PDF |
190kB |
|
| Hematology – Enjaymo - (IP0405) |
PDF |
147kB |
|
| Hematology - Fibrinogen Products - (IP0357) |
PDF |
168kB |
|
| Hematology – Gene Therapy - Casgevy - (IP0615) |
PDF |
326kB |
|
| Hematology – Gene Therapy – Lyfgenia - (IP0617) |
PDF |
255kB |
|
| Hematology – Gene Therapy - Zynteglo - (IP0486) |
PDF |
268kB |
|
| Hematology – Plerixafor - (IP0139) |
PDF |
245kB |
|
| Hematology- Pyrukind - (IP0451) |
PDF |
189kB |
|
| Hematology – Reblozyl - (IP0115) |
PDF |
243kB |
|
| Hematology – Ryplazim - (IP0382) |
PDF |
194kB |
|
| Hematology – Rytelo - (IP0693) |
PDF |
185kB |
|
| Hematology - Tretten - (IP0553) |
PDF |
174kB |
|
| Hematology - Vonvendi - (IP0555) |
PDF |
201kB |
|
| Hemophilia – Altuviiio - (IP0564) |
PDF |
202kB |
|
| Hemophilia – Eptacog Products – NovoSeven RT - (IP0356) |
PDF |
203kB |
|
| Hemophilia – Eptacog Products - Sevenfact - (IP0355) |
PDF |
176kB |
|
| Hemophilia – Factor IX Products - (IP0623) |
PDF |
211kB |
|
| Hemophilia – Factor VIII Products - (IP0618) |
PDF |
220kB |
|
| Hemophilia - FEIBA - (IP0354) |
PDF |
195kB |
|
| Hemophilia - Gene Therapy - Beqvez - (IP0648) |
PDF |
191kB |
|
| Hemophilia – Gene Therapy – Hemgenix - (IP0535) |
PDF |
245kB |
|
| Hemophilia – Gene Therapy – Roctavian - (IP0580) |
PDF |
214kB |
|
| Hemophilia – Non-Factor Routine Prophylaxis Products – Alhemo - (IP0730) |
PDF |
183kB |
|
| Hemophilia – Non-Factor Routine Prophylaxis Products – Hemlibra- (IP0121) |
PDF |
223kB |
|
| Hemophilia – Non-Factor Routine Prophylaxis Products – Hympavzi - (IP0731) |
PDF |
204kB |
|
| Hemophilia – Non-Factor Routine Prophylaxis Products – Qfitlia - (IP0742) |
PDF |
218kB |
|
| Hepatitis C – Epclusa Prior Authorization Policy - (IP0184) |
PDF |
242kB |
|
| Hepatitis C – Harvoni Prior Authorization Policy - (IP0735) |
PDF |
246kB |
|
| Hepatitis C – Hepatitis C Virus Direct-Acting Antivirals Preferred Specialty Management Policy for Employer Plans - (PSM025) |
PDF |
285kB |
|
| Hepatitis C – Hepatitis C Virus Direct-Acting Antivirals Preferred Specialty Management Policy for Individual and Family Plans - (PSM026) |
PDF |
272kB |
|
| Hepatitis C – Mavyret Prior Authorization for Preferred Specialty Management Policy - (IP0737) |
PDF |
273kB |
|
| Hepatitis C – Sovaldi Prior Authorization Policy - (IP0157) |
PDF |
191kB |
|
| Hepatitis C – Vosevi Prior Authorization Policy - (IP0736) |
PDF |
312kB |
|
| Hepatitis C – Zepatier Prior Authorization Policy- (IP0158) |
PDF |
221kB |
|
| Hepatology – Bylvay - (IP0363) |
PDF |
229kB |
|
| Hepatology – Givlaari - (IP0118) |
PDF |
191kB |
|
| Hepatology – Iqirvo - (IP0710) |
PDF |
164kB |
|
| Hepatology – Livdelzi - (IP0711) |
PDF |
166kB |
|
| Hepatology – Livmarli - (IP0341) |
PDF |
205kB |
|
| Hepatology – Metabolic Dysfunction-Associated Steatohepatitis – Wegovy Benefit Exclusion Overrides Policy for Individual and Family Plans - (IP0781) |
PDF |
228kB |
|
| Hepatology – Ocaliva - (IP0304) |
PDF |
186kB |
|
| Hepatology – Rezdiffra - (IP0642) |
PDF |
209kB |
|
| Hereditary Angioedema - Andembry - (IP0755) |
PDF |
195kB |
|
| Hereditary Angioedema – C1 Esterase Inhibitors (Intravenous) - (IP0315) |
PDF |
255kB |
|
| Hereditary Angioedema – C1 Esterase Inhibitors (Subcutaneous) - (IP0316) |
PDF |
209kB |
|
| Hereditary Angioedema - Dawnzera - (IP0761) |
PDF |
235kB |
|
| Hereditary Angioedema - Ekterly - (IP0756) |
PDF |
190kB |
|
| Hereditary Angioedema – Icatibant - (IP0335) |
PDF |
230kB |
|
| Hereditary Angioedema – Kalbitor - (IP0336) |
PDF |
210kB |
|
| Hereditary Angioedema – Orladeyo - (IP0096) |
PDF |
245kB |
|
| Hereditary Angioedema – Takhzyro - (IP0334) |
PDF |
231kB |
|
| HIV Products - (P0050) |
PDF |
339kB |
|
| HIV Products for Individual and Family Plans - (IP0090) |
PDF |
207kB |
|
| HMG-CoA Reductase Inhibitors (Statins) and Combination Products - (IP0064) |
PDF |
214kB |
|
| Homozygous Familial Hypercholesterolemia – Evkeeza - (IP0128) |
PDF |
207kB |
|
| Homozygous Familial Hypercholesterolemia – Juxtapid - (IP0221) |
PDF |
201kB |
|
| Human Chorionic Gonadotropin (hCG) for Non-Fertility Use - (IP0327) |
PDF |
208kB |
|
| Human Immunodeficiency Virus – Cabenuva - (IP0123) |
PDF |
253kB |
|
| Human Immunodeficiency Virus – Rukobia - (IP0083) |
PDF |
211kB |
|
| Human Immunodeficiency Virus – Sunlenca - (IP0546) |
PDF |
244kB |
|
| Human Immunodeficiency Virus - Trogarzo - (IP0171) |
PDF |
242kB |
|
| Hyaluronic Acid Derivatives (Intraarticular) - (IP0322) |
PDF |
364kB |
|
| Hydroxyprogesterone Caproate - (IP0370) |
PDF |
169kB |
|
| Hyperhidrosis – Qbrexza - (IP0074) |
PDF |
160kB |
|
| Hyperhidrosis – Sofdra - (IP0703) |
PDF |
153kB |
|
| Hyperlipidemia – Nexletol - (IP0248) |
PDF |
238kB |
|
| Hyperlipidemia – Nexlizet - (IP0249) |
PDF |
277kB |
|
| Hyperlipidemia – Omega-3 Fatty Acid Products - (IP0051) |
PDF |
221kB |
|
| Hypoactive Sexual Desire Disorder – Addyi - (IP0116) |
PDF |
147kB |
|
| Hypoactive Sexual Desire Disorder – Vyleesi - (IP0117) |
PDF |
142kB |
|
| Hypoparathyroidism – Natpara - (IP0177) |
PDF |
159kB |
|
| Hypoparathyroidism - Yorvipath - (IP0712) |
PDF |
173kB |
|
| I |
|
|
|
| Ibrexfungerp - (IP0301) |
PDF |
184kB |
|
| Idiopathic Pulmonary Fibrosis and Related Lung Disease – Pirfenidone - (IP0311) |
PDF |
196kB |
|
| Immune Disorder - Joenja - (IP0568) |
PDF |
202kB |
|
| Immune Globulin - (5026) |
PDF |
472kB |
|
| Immunologicals – Adbry Prior Authorization Policy - (IP0653) |
PDF |
205kB |
|
| Immunologicals – Cinqair - (IP0423) |
PDF |
238kB |
|
| Immunologicals – Dupixent - (IP0453) |
PDF |
218kB |
|
| Immunologicals – Ebglyss - (IP0708) |
PDF |
185kB |
|
| Immunologicals – Fasenra - (IP0421) |
PDF |
204kB |
|
| Immunologicals – Nemluvio - (IP0714) |
PDF |
186kB |
|
| Immunologicals – Nucala - (IP0422) |
PDF |
291kB |
|
| Immunologicals – Tezspire - (IP0412) |
PDF |
261kB |
|
| Immunologicals – Xolair - (IP0487) |
PDF |
292kB |
|
| Infectious Disease – Impavido - (IP0210) |
PDF |
168kB |
|
| Infectious Disease – Ivermectin Tablets - (IP0300) |
PDF |
199kB |
|
| Infectious Disease – Livtencity - (IP0394) |
PDF |
172kB |
|
| Infectious Disease – Livtencity Drug Quantity Management Policy - (DQM016) |
PDF |
218kB |
|
| Infectious Disease – Pretomanid - (IP0384) |
PDF |
206kB |
|
| Infectious Disease – Prevymis for Individual and Family Plans - (IP0426) |
PDF |
121kB |
|
| Infectious Disease – Pyrimethamine - (IP0348) |
PDF |
196kB |
|
| Infectious Disease – Sirturo - (IP0494) |
PDF |
165kB |
|
| Infertility-Gondadotropin-Releasing Hormone (GnRH) Antagonists - (IP0333) |
PDF |
178kB |
|
| Inflammatory Conditions – Adalimumab Products Drug Quantity Management Policy – Per Days - (DQM005) |
PDF |
292kB |
|
| Inflammatory Conditions – Adalimumab Products Preferred Specialty Management Policy: Standard/Performance, Value/Advantage, Total Savings Drug List Plans - (PSM013) |
PDF |
209kB |
|
| Inflammatory Conditions – Adalimumab Products Preferred Specialty Management Policy for Individual and Family Plans - (PSM014) |
PDF |
206kB |
|
| Inflammatory Conditions – Adalimumab Products Preferred Specialty Management Policy for Legacy Drug List Plans - (PSM003) |
PDF |
237kB |
|
| Inflammatory Conditions – Adalimumab Products Prior Authorization Policy - (IP0652) |
PDF |
307kB |
|
| Inflammatory Conditions – Arcalyst - (IP0437) |
PDF |
258kB |
|
| Inflammatory Conditions – Bimzelx Prior Authorization Policy - (IP0658) |
PDF |
234kB |
|
| Inflammatory Conditions – Cibinqo Prior Authorization Policy - (IP0677) |
PDF |
237kB |
|
| Inflammatory Conditions – Cimzia DQM – Per Days - (DQM018) |
PDF |
217kB |
|
| Inflammatory Conditions – Cimzia Prior Authorization Policy - (IP0672) |
PDF |
331kB |
|
| Inflammatory Conditions – Cosentyx Intravenous Preferred Specialty Management Policy for Employer Plans: Standard/Performance, Value/Advantage, Total Savings Prescription Drug Lists Plans - (PSM009) |
PDF |
225kB |
|
| Inflammatory Conditions – Cosentyx Intravenous Preferred Specialty Management Policy for Legacy Prescription Drug Lists Plans - (PSM016) |
PDF |
190kB |
|
| Inflammatory Conditions – Cosentyx Intravenous Prior Authorization Policy - (IP0683) |
PDF |
271kB |
|
| Inflammatory Conditions – Cosentyx Subcutaneous Drug Quantity Management Policy – Per Days - (DQM002) |
PDF |
185kB |
|
| Inflammatory Conditions – Cosentyx Subcutaneous Prior Authorization Policy - (IP0678) |
PDF |
275kB |
|
| Inflammatory Conditions – Entyvio Intravenous Prior Authorization Policy - (IP0674) |
PDF |
273kB |
|
| Inflammatory Conditions – Entyvio Subcutaneous Drug Quantity Management Policy – Per Days - (DQM006) |
PDF |
163kB |
|
| Inflammatory Conditions – Entyvio Subcutaneous Prior Authorization Policy - (IP0675) |
PDF |
273kB |
|
| Inflammatory Conditions – Etanercept Products Prior Authorization Policy - (IP0673) |
PDF |
293kB |
|
| Inflammatory Conditions – Ilaris Prior Authorization Policy - (IP0235) |
PDF |
274kB |
|
| Inflammatory Conditions – Ilumya Prior Authorization Policy - (IP0659) |
PDF |
250kB |
|
| Inflammatory Conditions – Infliximab Intravenous Products Preferred Specialty Management Policy - (PSM005) |
PDF |
160kB |
|
| Inflammatory Conditions – Infliximab Intravenous Products Prior Authorization Policy - (IP0660) |
PDF |
432kB |
|
| Inflammatory Conditions – Kevzara Prior Authorization Policy - (IP0679) |
PDF |
213kB |
|
| Inflammatory Conditions – Kineret Drug Quantity Management Policy – Per Days - (DQM008) |
PDF |
193kB |
|
| Inflammatory Conditions – Kineret Prior Authorization Policy - (IP0661) |
PDF |
321kB |
|
| Inflammatory Conditions – Leqselvi Prior Authorization Policy - (IP0751) |
PDF |
192kB |
|
| Inflammatory Conditions – Litfulo Prior Authorization Policy - (IP0680) |
PDF |
186kB |
|
| Inflammatory Conditions – Olumiant DQM – Per Days - (DQM019) |
PDF |
163kB |
|
| Inflammatory Conditions – Olumiant Prior Authorization Policy - (IP0681) |
PDF |
256kB |
|
| Inflammatory Conditions – Omvoh Intravenous Preferred Specialty Management Policy for Individual and Family Plan Prescription Drug Lists - (PSM011) |
PDF |
231kB |
|
| Inflammatory Conditions – Omvoh Intravenous Preferred Specialty Management Policy For Legacy Prescription Drug - (PSM019) |
PDF |
221kB |
|
| Inflammatory Conditions – Omvoh Intravenous Prior Authorization Policy - (IP0662) |
PDF |
270kB |
|
| Inflammatory Conditions – Omvoh Subcutaneous Prior Authorization Policy - (IP0663) |
PDF |
199kB |
|
| Inflammatory Conditions – Orencia Intravenous Preferred Specialty Management Policy for Employer Plans: Standard/Performance, Value/Advantage, Total Savings Prescription Drug Lists - (PSM006) |
PDF |
282kB |
|
| Inflammatory Conditions – Orencia Intravenous Preferred Specialty Management Policy for Individual and Family Plans - (PSM010) |
PDF |
280kB |
|
| Inflammatory Conditions – Orencia Intravenous Preferred Specialty Management Policy for Legacy Prescription Drug Lists - (PSM018) |
PDF |
283kB |
|
| Inflammatory Conditions – Orencia Intravenous Prior Authorization Policy - (IP0664) |
PDF |
284kB |
|
| Inflammatory Conditions – Orencia Subcutaneous Prior Authorization Policy - (IP0665) |
PDF |
226kB |
|
| Inflammatory Conditions – Otezla/Otezla XR Prior Authorization Policy - (IP0666) |
PDF |
245kB |
|
| Inflammatory Conditions Preferred Specialty Management Policy for Employer Plans: Legacy Prescription Drug Lists - (PSM017) |
PDF |
849kB |
|
| Inflammatory Conditions Preferred Specialty Management Policy for Employer Plans: Standard/Performance, Value/Advantage, Total Savings Prescription Drug Lists - (PSM001) |
PDF |
824kB |
|
| Inflammatory Conditions Preferred Specialty Management Policy for Individual and Family Plans - (PSM002) |
PDF |
832kB |
|
| Inflammatory Conditions – Rinvoq/Rinvoq LQ Prior Authorization Policy - (IP0682) |
PDF |
268kB |
|
| Inflammatory Conditions – Rinvoq Drug Quantity Management Policy – Per Days - (DQM021) |
PDF |
223kB |
|
| Inflammatory Conditions – Siliq Prior Authorization Policy - (IP0685) |
PDF |
232kB |
|
| Inflammatory Conditions – Simponi Aria Prior Authorization Policy - (IP0668) |
PDF |
239kB |
|
| Inflammatory Conditions – Simponi Subcutaneous Prior Authorization Policy - (IP0667) |
PDF |
231kB |
|
| Inflammatory Conditions – Skyrizi Intravenous Prior Authorization Policy - (IP0669) |
PDF |
241kB |
|
| Inflammatory Conditions – Skyrizi Subcutaneous Prior Authorization Policy - (IP0670) |
PDF |
251kB |
|
| Inflammatory Conditions – Sotyktu Prior Authorization Policy - (IP0671) |
PDF |
219kB |
|
| Inflammatory Conditions – Spevigo Intravenous Prior Authorization Policy - (IP0501) |
PDF |
219kB |
|
| Inflammatory Conditions – Spevigo Subcutaneous Prior Authorization Policy - (IP0649) |
PDF |
199kB |
|
| Inflammatory Conditions – Taltz Prior Authorization Policy - (IP0688) |
PDF |
209kB |
|
| Inflammatory Conditions – Tocilizumab Intravenous Products Preferred Specialty Management Policy - (PSM012) |
PDF |
164kB |
|
| Inflammatory Conditions – Tocilizumab Intravenous Products Prior Authorization Policy - (IP0656) |
PDF |
373kB |
|
| Inflammatory Conditions – Tocilizumab Subcutaneous Products Prior Authorization Policy - (IP0657) |
PDF |
278kB |
|
| Inflammatory Conditions – Tremfya Intravenous Prior Authorization Policy - (IP0704) |
PDF |
212kB |
|
| Inflammatory Conditions – Tremfya Prior Authorization Policy - (IP0689) |
PDF |
240kB |
|
| Inflammatory Conditions – Tremfya Subcutaneous Drug Quantity Management Policy – Per Days - (DQM012) |
PDF |
184kB |
|
| Inflammatory Conditions – Ustekinumab Intravenous Prior Authorization Policy - (IP0686) |
PDF |
269kB |
|
| Inflammatory Conditions – Ustekinumab Intravenous Products Preferred Specialty Management Policy - (PSM024) |
PDF |
161kB |
|
| Inflammatory Conditions – Ustekinumab Subcutaneous Drug Quantity Management Policy – Per Days - (DQM001) |
PDF |
244kB |
|
| Inflammatory Conditions – Ustekinumab Subcutaneous Prior Authorization Policy - (IP0687) |
PDF |
274kB |
|
| Inflammatory Conditions – Ustekinumab Subcutaneous Products Preferred Specialty Management Policy for Individual and Family Plans - (PSM023) |
PDF |
205kB |
|
| Inflammatory Conditions – Ustekinumab Subcutaneous Products Preferred Specialty Management Policy for Legacy Drug List Plans - (PSM022) |
PDF |
207kB |
|
| Inflammatory Conditions – Ustekinumab Subcutaneous Products Preferred Specialty Management Policy for Standard/Performance, Value/Advantage, and Total Savings Prescription Drug Lists - (PSM021) |
PDF |
186kB |
|
| Inflammatory Conditions – Velsipity Prior Authorization Policy - (IP0691) |
PDF |
197kB |
|
| Inflammatory Conditions – Xeljanz/Xeljanz XR Prior Authorization Policy - (IP0692) |
PDF |
254kB |
|
| Inflammatory Conditions – Zymfentra Drug Quantity Management Policy – Per Days - (DQM007) |
PDF |
188kB |
|
| Inflammatory Conditions - Zymfentra Prior Authorization Policy - (IP0646) |
PDF |
205kB |
|
| Injectable - CD20-Directed Antibody – Gazyva for Non-Oncology Uses - (IP0770) |
PDF |
217kB |
|
| Inpefa - (IP0582) |
PDF |
219kB |
|
| Interferon – Actimmune - (IP0201) |
PDF |
151kB |
|
| Interferon Therapy - (1315) |
PDF |
191kB |
|
| Iron Replacement - Feraheme - (IP0750) |
PDF |
252kB |
|
| Iron Replacement - Injectafer - (IP0748) |
PDF |
202kB |
|
| Iron Replacement – Monoferric - (IP0749) |
PDF |
210kB |
|
| L |
|
|
|
| Lidocaine Patch Products - (IP0709) |
PDF |
204kB |
|
| Lipodystrophy – Egrifta - (IP0209) |
PDF |
212kB |
|
| Lipodystrophy – Myalept - (IP0340) |
PDF |
194kB |
|
| Lofexidine for Individual and Family Plans - (IP0696) |
PDF |
142kB |
|
| Lorazepam Extended-Release - (IP0364) |
PDF |
171kB |
|
| Lupus – Benlysta Intravenous - (IP0429) |
PDF |
195kB |
|
| Lupus - Benlysta Subcutaneous - (IP0430) |
PDF |
197kB |
|
| Lupus – Lupkynis - (IP0122) |
PDF |
197kB |
|
| Lupus - Saphnelo - (IP0280) |
PDF |
238kB |
|
| LymePak - (IP0352) |
PDF |
167kB |
|
| M |
|
|
|
| Medication Administration Site of Care - (1605) |
PDF |
151kB |
|
| Metabolic Disorders – Betaine Anhydrous for Individual and Family Plans - (IP0465) |
PDF |
188kB |
|
| Metabolic Disorders – Cysteamine (Oral) Products for Employer Plans - (IP0046) |
PDF |
176kB |
|
| Metabolic Disorders – Cysteamine (oral) Products for Individual and Family Plans - (IP0466) |
PDF |
214kB |
|
| Metabolic Disorders – Cysteamine Ophthalmic Solution - (IP0082) |
PDF |
139kB |
|
| Metabolic Disorders – Dojolvi - (IP0084) |
PDF |
172kB |
|
| Metabolic Disorders - Imcivree - (IP0104) |
PDF |
222kB |
|
| Metabolic Disorders – Nulibry - (IP0142) |
PDF |
148kB |
|
| Metabolic Disorders – Phenylbutyrate Products - (IP0169) |
PDF |
198kB |
|
| Metabolic Disorders – Primary Hyperoxaluria Medications – Rivfloza - (IP0629) |
PDF |
221kB |
|
| Metabolic Disorders – Primary Hyperoxaluria – Oxlumo - (IP0095) |
PDF |
198kB |
|
| Metabolic Disorders - Tiopronin - (IP0202) |
PDF |
195kB |
|
| Metabolic Disorders – Xuriden - (IP0307) |
PDF |
215kB |
|
| Metabolic Products – Nitisinone Products - (IP0146) |
PDF |
206kB |
|
| Methotrexate Injection Step Therapy Standard / Performance Drug List Plans - (ST0001) |
PDF |
139kB |
|
| Metoclopramide Nasal Spray - (IP0085) |
PDF |
170kB |
|
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Aimovig - (IP0503) |
PDF |
179kB |
|
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Ajovy - (IP0504) |
PDF |
245kB |
|
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Emgality - (IP0505) |
PDF |
209kB |
|
| Migraine – Calcitonin Gene-Related Peptide Inhibitors – Vyepti - (IP0506) |
PDF |
208kB |
|
| Migraine – Elyxyb - (IP0640) |
PDF |
163kB |
|
| Migraine – Nurtec ODT - (IP0147) |
PDF |
213kB |
|
| Migraine – Qulipta - (IP0377) |
PDF |
174kB |
|
| Migraine - Reyvow - (IP0114) |
PDF |
197kB |
|
| Migraine Treatment - (IP0029) |
PDF |
246kB |
|
| Migraine – Ubrelvy - (IP0148) |
PDF |
168kB |
|
| Migraine – Zavzpret - (IP0573) |
PDF |
201kB |
|
| Multiple Sclerosis (Injectable) – Glatiramer - (IP0257) |
PDF |
186kB |
|
| Multiple Sclerosis (Injectable – Beta Interferon) – Betaseron - (IP0256) |
PDF |
175kB |
|
| Multiple Sclerosis (Injectable – Beta Interferon) – Plegridy - (IP0263) |
PDF |
195kB |
|
| Multiple Sclerosis (Injectable – CD20-Directed Cytolytic Antibody) – Briumvi - (IP0545) |
PDF |
200kB |
|
| Multiple Sclerosis (Injectable – CD20-Directed Cytolytic Antibody) – Kesimpta- (IP0260) |
PDF |
176kB |
|
| Multiple Sclerosis (Injectable – CD20-Directed Cytolytic Antibody) – Ocrevus - (IP0212) |
PDF |
205kB |
|
| Multiple Sclerosis (Injectable – CD20-Directed Cytolytic Antibody) – Ocrevus Zunovo - (IP0705) |
PDF |
235kB |
|
| Multiple Sclerosis (Injectable – Other) – Lemtrada - (IP0213) |
PDF |
220kB |
|
| Multiple Sclerosis (Oral – Fumarate) – Vumerity - (IP0253) |
PDF |
177kB |
|
| Multiple Sclerosis (Oral – Other) – Mavenclad - (IP0261) |
PDF |
181kB |
|
| Multiple Sclerosis (Oral - Other)– Teriflunomide for Employer Plans: Standard/ Performance, Value/Advantage, Legacy, Total Savings Prescription Drug Lists - (IP0252) |
PDF |
175kB |
|
| Multiple Sclerosis (Oral – Other) - Teriflunomide for Individual and Family Plans - (IP0560) |
PDF |
175kB |
|
| Multiple Sclerosis (Oral – Sphingosine 1-Phosphate Receptor Modulator) – Fingolimod - (IP0259) |
PDF |
191kB |
|
| Multiple Sclerosis (Oral – Sphingosine 1-Phosphate Receptor Modulator) – Mayzent - (IP0262) |
PDF |
178kB |
|
| Multiple Sclerosis – (Oral – Sphingosine 1-Phosphate Receptor Modulator) – Ponvory - (IP0264) |
PDF |
199kB |
|
| Multiple Sclerosis (Oral – Sphingosine 1-Phosphate Receptor Modulator) – Tascenso ODT - (IP0514) |
PDF |
202kB |
|
| Multiple Sclerosis and Crohn’s Disease (Injectable – Other) – Natalizumab Products Prior Authorization Policy - (IP0690) |
PDF |
252kB |
|
| Multiple Sclerosis and Ulcerative Colitis (Oral – Sphingosine 1-Phosphate Receptor Modulator) – Zeposia Prior Authorization Policy - (IP0655) |
PDF |
214kB |
|
| Multiple Sclerosis and Ulcerative Colitis – Zeposia Preferred Specialty Management Policy: Standard/Performance, Value/Advantage, Total Savings Prescription Drug List Plans - (PSM015) |
PDF |
201kB |
|
| Multiple Sclerosis and Ulcerative Colitis – Zeposia Preferred Specialty Management Policy for Individual and Family Plans - (PSM008) |
PDF |
199kB |
|
| Multiple Sclerosis and Ulcerative Colitis – Zeposia Preferred Specialty Management Policy for Legacy Prescription Drug List Plans - (PSM004) |
PDF |
211kB |
|
| Multiple Sclerosis – Avonex - (IP0254) |
PDF |
156kB |
|
| Multiple Sclerosis – Bafiertam - (IP0255) |
PDF |
195kB |
|
| Multiple Sclerosis – Dalfampridine - (IP0024) |
PDF |
158kB |
|
| Multiple Sclerosis – Dimethyl fumarate - (IP0266) |
PDF |
185kB |
|
| Multiple Sclerosis – Rebif - (IP0265) |
PDF |
174kB |
|
| Muscular Dystrophy – Agamree - (IP0624) |
PDF |
170kB |
|
| Muscular Dystrophy – Amondys 45 - (IP0137) |
PDF |
173kB |
|
| Muscular Dystrophy – Deflazacort - (IP0131) |
PDF |
191kB |
|
| Muscular Dystrophy – Duvyzat - (IP0651) |
PDF |
163kB |
|
| Muscular Dystrophy – Exondys 51 - (IP0135) |
PDF |
174kB |
|
| Muscular Dystrophy – Gene Therapy – Elevidys - (IP0571) |
PDF |
242kB |
|
| Muscular Dystrophy – Viltepso - (IP0066) |
PDF |
226kB |
|
| Muscular Dystrophy – Vyondys 53 - (IP0136) |
PDF |
186kB |
|
| N |
|
|
|
| Nephrology – Filspari- (IP0565) |
PDF |
198kB |
|
| Nephrology − Jesduvroq - (IP0604) |
PDF |
200kB |
|
| Nephrology – Tarpeyo - (IP0413) |
PDF |
209kB |
|
| Nephrology – Vafseo -(IP0706) |
PDF |
178kB |
|
| Nephrology – Vanrafia - (IP0740) |
PDF |
170kB |
|
| Nephrology – Xphozah - (IP0608) |
PDF |
158kB |
|
| Neurology - Aduhelm - (IP0200) |
PDF |
189kB |
|
| Neurology – Brineura - (IP0175) |
PDF |
175kB |
|
| Neurology – Daybue - (IP0578) |
PDF |
171kB |
|
| Neurology –Edaravone Products - (IP0176) |
PDF |
250kB |
|
| Neurology – Gene Therapy – Kebilidi - (IP0725) |
PDF |
200kB |
|
| Neurology – Gene Therapy – Lenmeldy - (IP0695) |
PDF |
226kB |
|
| Neurology – Gene Therapy - Skysona - (IP0529) |
PDF |
228kB |
|
| Neurology – Imaavy - (IP0743) |
PDF |
216kB |
|
| Neurology – Leqembi - (IP0547) |
PDF |
250kB |
|
| Neurology – Lyrica CR - (IP0183) |
PDF |
228kB |
|
| Neurology – Oxybate Products - (IP0103) |
PDF |
265kB |
|
| Neurology – Qalsody - (IP0567) |
PDF |
162kB |
|
| Neurology – Riluzole Products - (IP0258) |
PDF |
180kB |
|
| Neurology – Rystiggo - (IP0575) |
PDF |
206kB |
|
| Neurology - Skyclarys - (IP0566) |
PDF |
185kB |
|
| Neurology – Vyvgart Hytrulo - (IP0574) |
PDF |
231kB |
|
| Neurology – Vyvgart Intravenous - (IP0376) |
PDF |
208kB |
|
| Niemann-Pick disease type C – Aqneursa - (IP0715) |
PDF |
201kB |
|
| Niemann-Pick disease type C – Miplyffa - (IP0716) |
PDF |
244kB |
|
| Nitazoxanide for Individual and Family Plans - (IP0467) |
PDF |
213kB |
|
| Nonsteroidal Anti-inflammatory Drugs - (IP0457) |
PDF |
263kB |
|
| Non-Steroidal Mineralocorticoid Receptor Antagonist – Kerendia - (IP0314) |
PDF |
252kB |
|
| Nuedexta for Individual and Family Plans - (IP0324) |
PDF |
205kB |
|
| O |
|
|
|
| Omadacycline - (IP0379) |
PDF |
185kB |
|
| Oncology (Injectable) – Amtagvi - (IP0625) |
PDF |
185kB |
|
| Oncology (Injectable) – Cosela - (IP0150) |
PDF |
168kB |
|
| Oncology (Injectable) – Proleukin - (IP0407) |
PDF |
210kB |
|
| Oncology (Injectable – CAR-T) – Abecma - (IP0168) |
PDF |
234kB |
|
| Oncology (Injectable – CAR-T) – Aucatzyl - (IP0734) |
PDF |
178kB |
|
| Oncology (Injectable – CAR-T) – Breyanzi - (IP0130) |
PDF |
237kB |
|
| Oncology (Injectable – CAR-T) - Carvykti - (IP0414) |
PDF |
179kB |
|
| Oncology (Injectable – CAR-T) – Kymriah - (IP0197) |
PDF |
324kB |
|
| Oncology (Injectable – CAR-T) – Tecartus - (IP0199) |
PDF |
195kB |
|
| Oncology (Injectable – CAR-T) – Yescarta - (IP0198) |
PDF |
198kB |
|
| Oncology (Injectable – T-Cell Immunotherapy – MAGE-A4) – Tecelra - (IP0699) |
PDF |
182kB |
|
| Oncology (Other) - Adstiladrin - (IP0579) |
PDF |
192kB |
|
| Oncology – Everolimus Products - (IP0408) |
PDF |
234kB |
|
| Oncology - Imbruvica for Non-Oncology Uses - (IP0320) |
PDF |
210kB |
|
| Oncology – Jakafi - (IP0318) |
PDF |
268kB |
|
| Oncology Medications - (1403) |
PDF |
582kB |
|
| Oncology – Thalomid - (IP0493) |
PDF |
262kB |
|
| Ophthalmic – Glaucoma – Prostaglandins - (IP0027) |
PDF |
193kB |
|
| Ophthalmology – Dry Eye Disease Cyclosporine Ophthalmic Products - (IP0026) |
PDF |
181kB |
|
| Ophthalmology – Dry Eye Disease – Eysuvis for Individual and Family Plans - (IP0720) |
PDF |
141kB |
|
| Ophthalmology – Dry Eye Disease – Lacrisert for Individual and Family Plans - (IP0721) |
PDF |
138kB |
|
| Ophthalmology - Gene Therapy - Encelto - (IP0744) |
PDF |
161kB |
|
| Ophthalmology – Gene Therapy – Luxturna - (IP0160) |
PDF |
197kB |
|
| Ophthalmology – Izervay - (IP0581) |
PDF |
169kB |
|
| Ophthalmology – Oxervate - (IP0302) |
PDF |
175kB |
|
| Ophthalmology – Syfovre - (IP0559) |
PDF |
184kB |
|
| Ophthalmology - Tepezza - (IP0129) |
PDF |
212kB |
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| Ophthalmology – Upneeq - (IP0088) |
PDF |
150kB |
|
| Ophthalmology - Vascular Endothelial Growth Factor Inhbitors - Vabysmo - (IP0542) |
PDF |
188kB |
|
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu - (IP0541) |
PDF |
226kB |
|
| Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Ranibizumab Products - (IP0543) |
PDF |
225kB |
|
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors – Susvimo - (IP0349) |
PDF |
199kB |
|
| Ophthalmology – Verkazia - (IP0439) |
PDF |
182kB |
|
| Ophthalmology - Vizz - (IP0763) |
PDF |
137kB |
|
| Ophthalmology – Xipere - (IP0371) |
PDF |
228kB |
|
| Ophthamology - iDose TR - (IP0619) |
PDF |
184kB |
|
| Ophthmology - Durysta - (IP0218) |
PDF |
203kB |
|
| Opioid Therapy - Employer Group Benefit Plans - (IP0561) |
PDF |
304kB |
|
| Opioid Therapy - Individual and Family Plans - (IP0562) |
PDF |
297kB |
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| Oteseconazole - (IP0513) |
PDF |
247kB |
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| Oxandrolone - (IP0496) |
PDF |
188kB |
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| P |
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| Pain – Journavx Drug Quantity Management Policy – Per Days - (DQM004) |
PDF |
172kB |
|
| Papillomatosis-Gene Therapy-Papzimeos - (IP0765) |
PDF |
193kB |
|
| Parkinson's Disease - Onapgo - (IP0746) |
PDF |
211kB |
|
| Parkinson’s Disease – Apomorphine Subcutaneous (Apokyn) - (IP0530) |
PDF |
201kB |
|
| Parkinson’s Disease – Carbidopa - (IP0523) |
PDF |
163kB |
|
| Parkinson’s Disease – Duopa- (IP0303) |
PDF |
205kB |
|
| Parkinson’s Disease – Inbrija - (IP0522) |
PDF |
122kB |
|
| Parkinson’s Disease – Nourianz - (IP0524) |
PDF |
171kB |
|
| Parkinson’s Disease – Nuplazid - (IP0145) |
PDF |
164kB |
|
| Parkinson’s Disease – Ongentys - (IP0532) |
PDF |
168kB |
|
| Parkinson’s Disease – Vyalev - (IP0717) |
PDF |
209kB |
|
| Parkinson’s Disease – Zelapar - (IP0525) |
PDF |
208kB |
|
| Paromomycin - (IP0520) |
PDF |
170kB |
|
| Pegvisomant - (IP0291) |
PDF |
180kB |
|
| Penicillamine - (IP0277) |
PDF |
245kB |
|
| Pharmacy and Medical Prior Authorization - (1407) |
PDF |
219kB |
|
| Phenylketonuria – Palynziq - (IP0294) |
PDF |
245kB |
|
| Phenylketonuria – Sapropterin - (IP0295) |
PDF |
216kB |
|
| Phenylketonuria – Sephience - (IP0764) |
PDF |
183kB |
|
| Pheochromocytoma – Metyrosine and Phenoxybenzamine (Oral) - (IP0450) |
PDF |
235kB |
|
| Pilocarpine 1.25% Ophthalmic - (IP0343) |
PDF |
138kB |
|
| Pompe Disease – Enzyme Replacement Therapy – Lumizyme - (IP0440) |
PDF |
179kB |
|
| Pompe Disease – Enzyme Replacement Therapy – Nexviazyme - (IP0279) |
PDF |
161kB |
|
| Pompe Disease – Enzyme Replacement Therapy – Pombiliti - (IP0591) |
PDF |
162kB |
|
| Pompe Disease – Enzyme Stabilization Therapy – Opfolda - (IP0598) |
PDF |
183kB |
|
| Prader-Willi Syndrome – Vykat XR - (IP0741) |
PDF |
163kB |
|
| Prenatal Vitamins - (IP0035) |
PDF |
197kB |
|
| Progesterone (Vaginal) for Individual and Family Plans - (IP0091) |
PDF |
145kB |
|
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Praluent - (IP0250) |
PDF |
292kB |
|
| Proprotein Convertase Subtilisin Kexin Type 9 Related Products – Leqvio - (IP0380) |
PDF |
300kB |
|
| Psychiatry – Novel Psychotropics Drug Quantity Management Policy – Per Days - (DQM022) |
PDF |
261kB |
|
| Psychiatry – Spravato - (IP0220) |
PDF |
243kB |
|
| Psychiatry - Zulresso - (IP0270) |
PDF |
196kB |
|
| Psychiatry – Zurzuvae - (IP0607) |
PDF |
158kB |
|
| Pulmonary - Antifibrotics Jascayd for Individual and Family Plans - (IP0772) |
PDF |
175kB |
|
| Pulmonary – Antifibrotics – Ofev - (IP0312) |
PDF |
229kB |
|
| Pulmonary Arterial Hypertension – Adempas – (IP0600) |
PDF |
187kB |
|
| Pulmonary Arterial Hypertension and Related Lung Disease – Inhaled Prostacyclin Products - (IP0753) |
PDF |
202kB |
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| Pulmonary Arterial Hypertension - Endothelian Receptor Antagonists - (IP0631) |
PDF |
221kB |
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| Pulmonary Arterial Hypertension – Epoprostenol Products - (IP0762) |
PDF |
209kB |
|
| Pulmonary Arterial Hypertension –Orenitram - (IP0616) |
PDF |
191kB |
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| Pulmonary Arterial Hypertension – Phosphodiesterase Type 5 Inhibitors - (IP0626) |
PDF |
195kB |
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| Pulmonary Arterial Hypertension – Treprostinil Injection Prior Authorization Policy - (IP0757) |
PDF |
239kB |
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| Pulmonary Arterial Hypertension – Uptravi - (IP0627) |
PDF |
191kB |
|
| Pulmonary Arterial Hypertension – Winrevair - (IP0645) |
PDF |
170kB |
|
| Pulmonary – Brinsupri for Employer Plans - (IP0775) |
PDF |
183kB |
|
| Pulmonary-Brinsupri for Individual and Family Plans - (IP0758) |
PDF |
181kB |
|
| Pulmonary – Roflumilast - (IP0609) |
PDF |
180kB |
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| Q |
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| Qlosi - (IP0738) |
PDF |
137kB |
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| Quantity Limitations - (1201) |
PDF |
234kB |
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| Quazepam for Individual and Family Plans - (IP0469) |
PDF |
209kB |
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| R |
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| Rebyota - (IP0556) |
PDF |
229kB |
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| Regranex - (IP0495) |
PDF |
192kB |
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| Repository Corticotropin – Acthar Gel - (IP0178) |
PDF |
179kB |
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| Repository Corticotropin - Cortrophin Gel - (IP0374) |
PDF |
170kB |
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| Rituximab Intravenous Products for Non-Oncology Indications - (IP0319) |
PDF |
490kB |
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| S |
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| Scenesse - (IP0159) |
PDF |
163kB |
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| Short-Acting Beta2-Agonist Inhalers - (IP0040) |
PDF |
214kB |
|
| Sickle Cell Disease – Adakveo - (IP0120) |
PDF |
168kB |
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| Sickle Cell Disease - L-glutamine for Individual and Family Plans - (IP0475) |
PDF |
157kB |
|
| Sickle Cell Disease – Oxbryta - (IP0119) |
PDF |
178kB |
|
| Sildenafil (Viagra) - (IP0098) |
PDF |
245kB |
|
| Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors and SGLT-2 / Metformin Combinations - (IP0592) |
PDF |
279kB |
|
| Sohonos - (IP0596) |
PDF |
168kB |
|
| Somapacitan - (IP0576) |
PDF |
312kB |
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| Somatostatin Analogs – Lanreotide Products - (IP0323) |
PDF |
222kB |
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| Somatostatin Analogs – Mycapssa- (IP0491) |
PDF |
164kB |
|
| Somatostatin Analogs – Octreotide Immediate-Release Products - (IP0490) |
PDF |
266kB |
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| Somatostatin Analogs – Octreotide Long-Acting Products - (IP0489) |
PDF |
326kB |
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| Somatostatin Analogs – Signifor LAR - (IP0165) |
PDF |
237kB |
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| Somatostatin Receptor Agonist – Palsonify for Individual and Family Plans - (IP0769) |
PDF |
181kB |
|
| Somatropin - (IP0452) |
PDF |
356kB |
|
| Spinal Muscular Atrophy – Evrysdi - (IP0063) |
PDF |
179kB |
|
| Spinal Muscular Atrophy – Gene Therapy – Itvisma - (IP0790) |
PDF |
221kB |
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| Spinal Muscular Atrophy – Gene Therapy – Zolgensma - (IP0185) |
PDF |
253kB |
|
| Spinal Muscular Atrophy – Spinraza - (IP0182) |
PDF |
244kB |
|
| Step Therapy Individual and Family Plan - (1603) |
PDF |
203kB |
|
| Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) |
PDF |
280kB |
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| Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) |
PDF |
272kB |
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| Step Therapy – Value/Advantage Prescription Drug Lists (Employer Group Plans) - (1802) |
PDF |
240kB |
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| Synagis - (IP0321) |
PDF |
251kB |
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| T |
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| Tadalafil (Cialis®) for Employer Group Plans - (IP0097) |
PDF |
234kB |
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| Tadalafil (Cialis®) for Individual and Family Plans - (IP0101) |
PDF |
223kB |
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| Tasimelteon Products - (IP0428) |
PDF |
243kB |
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| Tegaserod - (IP0019) |
PDF |
204kB |
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| Tenapanor - (IP0455) |
PDF |
204kB |
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| Testosterone (Injectable) Products - (IP0351) |
PDF |
225kB |
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| Testosterone (Oral, Topical, and Nasal) Products - (IP0350) |
PDF |
204kB |
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| Testosterone – Undecatrex - (IP0724) |
PDF |
156kB |
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| Tetracycline Antibiotics - (IP0396) |
PDF |
265kB |
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| Thrombocytopenia – Doptelet - (IP0152) |
PDF |
171kB |
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| Thrombocytopenia – Eltrombopag Products - (IP0153) |
PDF |
249kB |
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| Thrombocytopenia – Mulpleta - (IP0156) |
PDF |
163kB |
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| Thrombocytopenia – Nplate - (IP0155) |
PDF |
241kB |
|
| Thrombocytopenia – Tavalisse - (IP0154) |
PDF |
182kB |
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| Thrombocytopenia – Wayrilz - (IP0774) |
PDF |
185kB |
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| Tizanidine - (IP0392) |
PDF |
111kB |
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| Tobramycin/loteprednol etabonate (Zylet) Ophthalmic Suspension for Individual and Family Plans - (IP0474) |
PDF |
171kB |
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| Tolvaptan Products – Tolvaptan (Jynarque) - (IP0287) |
PDF |
164kB |
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| Tolvaptan Products - Tolvaptan (Samsca) for Individual and Family Plans - (IP0471) |
PDF |
172kB |
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| Topical Acne – Non-Retinoid Products - (IP0166) |
PDF |
241kB |
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| Topical Acne – Winlevi - (IP0173) |
PDF |
181kB |
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| Topical Acyclovir Products - (IP0752) |
PDF |
208kB |
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| Topical Agents for Atopic Dermatitis Step Therapy Policy for Employer Plans - (ST005) |
PDF |
157kB |
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| Topical Alpha Adrenergic Agonists - (IP0284) |
PDF |
163kB |
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| Topical Alpha Adrenergic Agonists for Rosacea - Rhofade - (IP0785) |
PDF |
145kB |
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| Topical Corticosteroids-Hydrocortisone Butyrate Drug Quantity Management Policy-Per Days - (DQM011) |
PDF |
292kB |
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| Topical Corticosteroids-Hydrocortisone Butyrate Drug Quantity Management Policy-Per Days - (DQM013) |
PDF |
142kB |
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| Topical Diclofenac Sodium 3% Gel - (IP0282) |
PDF |
221kB |
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| Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - (IP0021) |
PDF |
206kB |
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| Topical Retinoids – Aklief - (IP0180) |
PDF |
175kB |
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| Topical Tazarotene Products - (IP0174) |
PDF |
261kB |
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| Topical Vitamin D Analogs - (IP0361) |
PDF |
215kB |
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| Transplantation – Grafapex - (IP0727) |
PDF |
190kB |
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| Transplantation – Nulojix - (IP0219) |
PDF |
236kB |
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| Transplantation - Yartemlea - (IP0789) |
PDF |
208kB |
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| U |
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| Unassigned Drug Code Outpatient Medical Precertification - (1701) |
PDF |
194kB |
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| Uplizna - (IP0062) |
PDF |
262kB |
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| Ursodiol - (IP0299) |
PDF |
176kB |
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| V |
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| Vasculitis – Tavneos - (IP0398) |
PDF |
162kB |
|
| Vecamyl for Individual and Family Plans - (IP0650) |
PDF |
160kB |
|
| Veregen - (IP393) |
PDF |
154kB |
|
| Vericiguat - (IP0125) |
PDF |
199kB |
|
| Vesicular Monoamine Transporter Inhibitors – Austedo - (IP0079) |
PDF |
160kB |
|
| Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza Products - (IP0080) |
PDF |
176kB |
|
| Vesicular Monoamine Transporter Type 2 Inhibitors – Tetrabenazine - (IP0208) |
PDF |
166kB |
|
| Vijoice - (IP0481) |
PDF |
171kB |
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| W |
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| Wakefulness-Promoting Agents – Armodafinil, Modafinil - (IP0075) |
PDF |
285kB |
|
| Wakefulness-Promoting Agents – Sunosi - (IP0102) |
PDF |
213kB |
|
| Wakefulness-Promoting Agents – Wakix - (IP0292) |
PDF |
244kB |
|
| Weight Loss – Appetite Suppressants and Orlistat - (IP0420) |
PDF |
293kB |
|
| Weight Loss – Glucagon-Like Peptide-1 Agonists BMI ≥ 30 - (IP0206) |
PDF |
445kB |
|
| Weight Loss – Glucagon-Like Peptide-1 Agonists BMI ≥ 32 - (IP0621) |
PDF |
422kB |
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| Weight Loss – Glucagon-Like Peptide-1 Agonists BMI ≥ 35 - (IP0739) |
PDF |
405kB |
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| X |
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| Xiaflex - (IP0143) |
PDF |
194kB |
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| Z |
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| Zokinvy - (IP0107) |
PDF |
193kB |
|
| Zontivity for Individual and Family Plan - (IP0707) |
PDF |
161kB |
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