Pharmacy (Drugs & Biologics) A-Z Index

Document Title Document Type Document Size Effective Date
A
Abatacept Intravenous - (M0006) PDF 153kB 01/01/2020
Abilify Mycite - (P0086) PDF 66kB 06/01/2020
Advantage Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 282kB 01/01/2020
Afamelanotide - (2014) PDF 122kB 06/01/2020
Afrezza® - (1506) PDF 78kB 07/01/2020
Alemtuzumab - (2001) PDF 84kB 05/08/2020
Alpha1-Proteinase Inhibitors - (4037) PDF 209kB 05/01/2020
Amifampridine - (P0074) PDF 69kB 08/01/2019
Amikacin liposome - (P0093) PDF 75kB 08/01/2019
Amyloidosis Agents – Tafamidis Products - (2008) PDF 81kB 06/15/2020
Anticonvulsant Medications - (P0048) PDF 286kB 10/01/2019
Antiemetic Therapy - (1705) PDF 237kB 12/01/2019
Antifungals, Topical - (P0046) PDF 113kB 01/01/2020
Antihyperglycemic Therapy (Non-Insulin) - (P0098) PDF 287kB 07/01/2020
Antimalarial Therapy - (P0101) PDF 105kB 01/01/2020
Antiparkinson Agents - (P0006) PDF 90kB 09/01/2019
Antitussives - (P0083) PDF 116kB 09/01/2019
Antivirals, Topical - (P0051) PDF 81kB 03/01/2020
Attention Deficit Hyperactivity Disorder (ADHD) Stimulants - (P0047) PDF 303kB 01/01/2020
Avatrombopag - (P0079)

PDF 73kB 05/01/2020
B
Barbiturates - (P0095) PDF 72kB 01/01/2020
Belimumab - (1114) PDF 111kB 12/01/2019
Benralizumab, Mepolizumab and Reslizumab - (1608) PDF 169kB 01/01/2020
Beta-Blockers - (P0060) PDF 75kB 02/01/2020
Botulinum Therapy - (1106) PDF 323kB 07/01/2020
Brexanolone - (1905) PDF 119kB 10/01/2019
Budesonide (Uceris®) - (P0084) PDF 76kB 07/01/2019
Burosumab-twza - (M0002) PDF 297kB 07/01/2020
Butalbital Combination Products - (P0066)

PDF 115kB 05/01/2020
C
Calcitonin Gene-Related Peptide (CGRP) Inhibitors - (1813) PDF 110kB 07/01/2020
Calcitonin Gene-Related Peptide (CGRP) Inhibitors – Acute Migraine Treatment - (2011) PDF 99kB 07/01/2020
Calcitonin Gene-Related Peptide (CGRP) Inhibitors – Preventative Migraine Treatment for Individual and Family Plans - (2020) PDF 104kB 07/01/2020
Canakinumab - (1110) PDF 128kB 06/01/2019
Cannabidiol - (1814) PDF 79kB 12/01/2019
Caplacizumab-yhdp - (1906) PDF 76kB 06/01/2020
Carbidopa and levodopa enteral suspension - (1606) PDF 80kB 07/01/2019
Carglumic acid - (P0112) ---- future effective policy PDF 71kB 08/01/2020
Cenegermin - (P0073) PDF 70kB 08/01/2019
Cerliponase Alfa - (1807) PDF 76kB 02/01/2020
Chimeric Antigen Receptor T-Cell (CAR-T) and Advanced Cellular / Immune Effector Cell Therapy - (1808) PDF 123kB 10/01/2019
Cholic Acid - (P0009) PDF 108kB 05/01/2020
Clobazam Oral Film - (P0085) PDF 85kB 06/01/2020
Clotting Factors and Antithrombin - (8007) PDF 436kB 06/01/2020
Colchicine - (P0119) PDF 69kB 03/17/2020
Collagenase clostridium histolyticum - (1021) PDF 121kB 09/01/2019
Complement Inhibitors - (1103) PDF 176kB 01/01/2020
Compounded Medications - (1406) PDF 137kB 06/15/2020
COVID-19 Drug and Biologic Therapeutics - (2016) PDF 148kB 06/18/2020
Crizanlizumab-tmca - (2007) PDF 110kB 06/01/2020
Cyanocobalamin Nasal Spray - (P0097) PDF 67kB 01/01/2020
Cysteamine bitartrate delayed release - (P0116) ---- future effective policy PDF 76kB 08/01/2020
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators - (1207)

PDF 227kB 06/01/2019
D
Dalfampridine - (P0004) PDF 68kB 09/01/2019
Deflazacort - (1708) PDF 139kB 11/01/2019
Delafloxacin - (P0045) PDF 70kB 09/01/2019
Denosumab - (1212) PDF 165kB 02/01/2020
Deutetrabenazine - (P0008) PDF 76kB 09/01/2019
Diazepam Nasal Spray - (2012) PDF 104kB 07/15/2020
Dimercaprol and Edetate Calcium Disodium - (6019) PDF 124kB 03/01/2020
Dose Optimization - (1804) PDF 112kB 05/01/2019
Dupilumab - (1810)

PDF 153kB 08/01/2019
E
Edaravone - (1806) PDF 126kB 12/01/2019
Elagolix - (P0065) PDF 73kB 04/01/2020
Eltrombopag - (9003) PDF 100kB 05/01/2020
Emapalumab-lzsg - (M0012) PDF 110kB 08/01/2019
Enzyme Related Therapies - (1319) PDF 238kB 11/01/2019
Epinephrine - (P0003) PDF 72kB 03/01/2020
Erythropoiesis Stimulating Agents (ESA) - (5016) PDF 177kB 05/01/2020
Esketamine - (M0010) PDF 112kB 07/01/2020
Etelcalcetide - (1812) PDF 72kB 12/01/2019
Eteplirsen - (1702)

PDF 73kB 07/01/2020
F
Filgrastim - (1611) PDF 125kB 02/01/2020
Fish Oil Triglycerides - (M0013) PDF 70kB 02/01/2020
Flibanserin - (P0002) PDF 75kB 05/01/2020
Fostamatinib - (P0081)

PDF 72kB 05/01/2020
G
Gabapentin - (P0043) PDF 88kB 12/01/2019
Givosiran - (2009) PDF 103kB 06/15/2020
Glycerol phenylbutyrate - (P0113) ---- future effective policy PDF 76kB 08/01/2020
Glycopyrronium topical cloth - (P0063) PDF 68kB 07/01/2019
Golimumab Intravenous - (M0007) PDF 133kB 01/01/2020
Golodirsen - (2005)

PDF 77kB 05/15/2020
H
Hepatitis C Therapy - (1316) PDF 378kB 01/01/2020
Hereditary Angioedema (HAE) Therapy - (1019) PDF 170kB 07/01/2020
Hereditary Transthyretin Amyloidosis Agents - (1901) PDF 110kB 06/01/2020
Histrelin Acetate Subcutaneous Implant - (8008) PDF 80kB 05/01/2020
HIV Products - (P0050) PDF 158kB 05/01/2020
HMG-CoA Reductase Inhibitors (Statins) - (P0013) PDF 161kB 02/01/2020
Human Chorionic Gonadotropin (hCG) for Non-fertility - (1815) PDF 118kB 05/01/2020
Hydroxyprogesterone Caproate Injection - (1108) PDF 71kB 08/01/2019
Hydroxyurea Tablet - (P0052)

PDF 66kB 03/01/2020
I
Ibalizumab-uiyk - (M0001) PDF 70kB 06/01/2020
Idiopathic Pulmonary Fibrosis and Related Lung Disease Therapy - (1505) PDF 171kB 06/01/2020
Immune Globulin - (5026) PDF 447kB 01/01/2020
Immunomodulators - Oral and Subcutaneous (Employer Group Benefit Plans) - (1805) PDF 467kB 03/01/2020
Immunomodulators – Oral and Subcutaneous (Individual and Family Plans) - (1903) PDF 445kB 03/01/2020
Infertility Injectables - (1012) PDF 248kB 10/01/2019
Infliximab - (M0003) PDF 245kB 01/01/2020
Inhaled Antibiotic Therapy - (P0102) PDF 127kB 01/01/2020
Insulin glargine - (P0023) PDF 73kB 07/01/2020
Interferon gamma 1b - (P0001) PDF 80kB 05/01/2020
Interferon Therapy - (1315) PDF 121kB 04/01/2019
Iron Chelating Agents - (P0090) PDF 162kB 06/01/2020
Isavuconazonium - (P0011) PDF 69kB 05/01/2019
Ivabradine - (P0010)

PDF 108kB 10/01/2019
L
Lanreotide for Non-Oncology Indications - (9005) PDF 113kB 06/01/2020
Lomitapide Mesylate - (1507) PDF 135kB 12/01/2019
Luspatercept - (2006) PDF 120kB 06/15/2020
Lusutrombopag - (P0080)

PDF 97kB 05/01/2020
M
Mecasermin - (6107) PDF 117kB 06/01/2019
Medication Administration Site of Care - (1605) PDF 101kB 05/15/2020
Midazolam Nasal Spray - (P0108) PDF 64kB 03/10/2020
Mifepristone (Korlym®)- (P0021) PDF 68kB 12/01/2019
Migraine Treatment - (P0058) PDF 210kB 11/01/2019
Miltefosine - (P0019) PDF 99kB 02/01/2020
Modafinil / Armodafinil for Employer Group Plans - (2019) PDF 156kB 07/01/2020
Modafinil / Armodafinil for Individual and Family Plans - (1501) PDF 110kB 07/01/2020
Multiple Sclerosis Therapy – Oral and Subcutaneous - (1402)

PDF 185kB 05/08/2020
N
Nafarelin acetate - (P0082) PDF 170kB 07/01/2019
Naloxone - (P0017) PDF 45kB 05/01/2019
Natalizumab for Crohn's Disease - (M0008) PDF 132kB 01/01/2020
Natalizumab for Multiple Sclerosis - (2002) PDF 104kB 05/08/2020
Nebulized Solutions for COPD - (P0053) PDF 90kB 09/01/2019
Nitrofurantoin Suspension - (P0059) PDF 76kB 02/01/2020
Nonsteroidal Anti-inflammatory Drugs - (P0057) PDF 148kB 05/01/2020
Nusinersen - (1707)

PDF 139kB 11/01/2019
O
Obeticholic acid - (1610) PDF 92kB 11/01/2019
Ocrelizumab - (2003) PDF 78kB 05/08/2020
Ocriplasmin - (1310) PDF 88kB 08/01/2019
Octreotide - (5015) PDF 105kB 07/01/2019
Omalizumab - (4026) PDF 185kB 05/01/2020
Omega-3 Fatty Acids - (P0099) PDF 111kB 03/01/2020
Onasemnogene Abeparvovec-xioi (Zolgensma®) - (1904) PDF 122kB 03/01/2020
Oncology Medications - (1403) PDF 272kB 07/01/2020
Ophthalmic Prostaglandin Analogs - (P0088) PDF 73kB 06/01/2020
Opioid Induced Constipation - (P0091) PDF 106kB 08/01/2019
Opioid Therapy - (1704) PDF 166kB 03/01/2020
Oral Antihistamines - (P0087) PDF 95kB 07/01/2019
Oral Phosphodiesterase-5 (PDE5) Inhibitors - (7003) PDF 145kB 08/01/2019
Oxazolidinone Antibiotics - (1123) PDF 111kB 06/01/2019
Oxymetholone - (P0005) PDF 65kB 02/01/2020
Ozanimod - (2022)

PDF 79kB 07/01/2020
P
Palivizumab - (5012) PDF 96kB 09/01/2019
Parathyroid Hormone Analogs (Osteoporosis) - (P0025) PDF 116kB 01/01/2020
PCSK9 Inhibitors - (1509) PDF 237kB 01/01/2020
Peanut (arachis hypogaea) allergen powder-dnfp - (2004) PDF 94kB 04/01/2020
Pegfilgrastim - (1320) PDF 88kB 03/01/2020
Pegloticase - (1107) PDF 107kB 10/01/2019
Pegvaliase-pqpz - (P0055) PDF 102kB 11/01/2019
Penicillamine and trientine hydrochloride - (1703) PDF 142kB 06/01/2020
Performance Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 262kB 01/01/2020
Pharmacy Prior Authorization - (1407) PDF 290kB 02/01/2020
Pitolisant - (P0111) PDF 96kB 03/25/2020
Plerixafor - (9008) PDF 97kB 06/01/2020
Pregabalin - (P0078) PDF 106kB 01/01/2020
Progesterone - (P0015) PDF 64kB 12/01/2019
Protein C Concentrate - (1604) PDF 78kB 06/01/2019
Proton Pump Inhibitors - (P0122) PDF 127kB 07/15/2020
Pulmonary Hypertension (PH) Therapy - (6121) PDF 260kB 08/01/2019
Pyridostigmine - (P0107) PDF 65kB 01/27/2020
Pyrimethamine - (P0012)

PDF 72kB 07/01/2020
Q
Quantity Limitations - (1201)

PDF 248kB 01/01/2020
R
Repository Corticotropin - (8001) PDF 117kB 03/01/2020
Rilonacept - (P0007) PDF 95kB 05/01/2020
Rituximab for Non-Oncology Indications - (5108) PDF 215kB 05/01/2020
Romiplostim - (9002) PDF 121kB 05/01/2020
Routine Immunizations - (9001)

PDF 110kB 04/01/2020
S
Sacubitril/valsartan - (P0016) PDF 93kB 03/01/2020
Sapropterin - (P0022) PDF 103kB 11/01/2019
Sarecycline - (P0092) PDF 72kB 01/01/2020
Selumetinib - (2017) PDF 89kB 07/01/2020
Skeletal Muscle Relaxants - (P0071) PDF 80kB 05/01/2020
Sodium Oxybate - (P0075) PDF 133kB 07/01/2019
Solriamfetol - (P0106) PDF 105kB 01/06/2020
Somatropin - (4012) PDF 221kB 07/01/2020
Standard Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 262kB 01/01/2020
Step Therapy - (1109) PDF 156kB 01/15/2020
Step Therapy Individual and Family Plan - (1603) PDF 84kB 01/01/2020
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) PDF 167kB 07/01/2020
Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) PDF 135kB 07/01/2020
Step Therapy – Value/Advantage Prescription Drug Lists (Employer Group Plans) - (1802) PDF 124kB 07/01/2020
Sublingual Allergen Immunotherapy - (1902)

PDF 141kB 05/01/2020
T
Tasimelteon - (P0018) PDF 109kB 03/01/2020
Teduglutide - (1318) PDF 49kB 08/01/2019
Teprotumumab - (2010) PDF 106kB 06/01/2020
Tesamorelin - (1112) PDF 91kB 03/01/2020
Testosterone Therapy (Injectables and Implantable Pellets) - (1503) PDF 102kB 06/15/2020
Testosterone Therapy (Oral, Nasal, and Topicals) - (2013) PDF 114kB 06/15/2020
Tetrabenazine - (P0117) PDF 84kB 07/01/2020
Tetracycline Antibiotics - (P0100) PDF 83kB 01/01/2020
Tocilizumab Intravenous - (M0004) PDF 143kB 01/01/2020
Tolvaptan (Jynarque®) - (P0056) PDF 102kB 01/01/2020
Topical Acne - (P0049) PDF 139kB 06/01/2020
Topical Alpha Adrenergic Agonists - (1401) PDF 85kB 11/01/2019
Topical Doxepin - (P0054) PDF 75kB 10/01/2019
Topical Vitamin D Analogs - (P0077) PDF 80kB 07/01/2020
Transmucosal Fentanyl - (1018) PDF 156kB 07/01/2020
Triamcinolone acetonide extended-release injection - (1811) PDF 76kB 07/01/2020
Triclabendazole - (P0105) PDF 71kB 12/01/2019
Triptorelin pamoate - (M0009)

PDF 75kB 05/01/2020
U
Unassigned Drug or Biologic Code Medical Precertification - (1701) PDF 88kB 01/01/2020
Uridine triacetate - (P0115) ---- future effective policy

PDF 85kB 08/01/2020
V
Valbenazine - (P0020) PDF 67kB 09/01/2019
Value Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 282kB 01/01/2020
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use - (1206) PDF 146kB 11/01/2019
Vedolizumab - (M0005) PDF 133kB 01/01/2020
Viscosupplementation for Osteoarthritis - (1405) PDF 177kB 07/01/2019
Voretigene neparvovec - (1809) PDF 78kB 06/01/2019
Voriconazole - (4004) PDF 82kB 06/01/2020
Voxelotor - (P0120)

PDF 69kB 06/01/2020
W
Weight Loss Medications - (P0104)

PDF 165kB 03/15/2020
Z
Zolpidem - (P0069)

PDF 118kB 05/01/2020