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

Document Title Document Type Document Size Effective Date
A
Abaloparatide - (IP0329) PDF 220kB 04/01/2024
Abatacept Intravenous - (IP0232) PDF 308kB 06/01/2024
Abatacept Subcutaneous - (IP0231) PDF 270kB 06/01/2024
Abilify Mycite - (IP0534) PDF 185kB 02/01/2023
Abrocitinib - (IP0404) PDF 352kB 04/01/2023
Acyclovir 5% Ointment for Individual and Family Plans - (IP0498) PDF 184kB 01/01/2023
Adalimumab - (IP0245) PDF 296kB 06/01/2024
Aducanumab - (IP0200) PDF 210kB 01/15/2024
Advantage Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 491kB 07/01/2024
Afamelanotide - (IP0159) PDF 183kB 08/01/2023
Aflibercept - (IP0540) PDF 238kB 11/01/2023
Afrezza® - (IP0533) PDF 178kB 02/01/2023
Agalsidase - (IP0406) PDF 211kB 09/15/2023
Albendazole for Individual and Family Plans - (IP0462) PDF 209kB 01/01/2023
Aldesleukin for Non-Oncology Uses - (IP0407) PDF 183kB 05/01/2023
Alemtuzumab - (IP0213) PDF 224kB 03/01/2024
Alglucosidase Alfa - (IP0440) PDF 209kB 09/15/2023
Alirocumab - (IP0250) PDF 308kB 05/15/2024
Alosetron - (IP0012) PDF 171kB 04/01/2024
Alpelisib - (IP0481) PDF 213kB 10/01/2023
Alpha1-Proteinase Inhibitors - (IP0387) PDF 231kB 04/01/2024
Amantadine Extended-Release - (IP0403) PDF 214kB 01/15/2024
Amifampridine - (IP0290) PDF 227kB 01/15/2024
Amikacin Liposome - (IP0383) PDF 244kB 02/15/2024
Aminocaproic Acid for Individual and Family Plans - (IP0463) PDF 175kB 01/01/2023
Amlodipine Oral Solution - (IP0484) PDF 208kB 10/01/2023
Amyloidosis - Tafamidis Products - (IP0149) PDF 188kB 04/01/2024
Amyloidosis – Wainua - (IP0628) PDF 185kB 07/01/2024
Anakinra - (IP0243) PDF 265kB 06/01/2024
Angiotensin Receptor Blockers - (IP0362) PDF 113kB 01/01/2023
Antibiotics (inhaled) – Cayston - (IP0485) PDF 152kB 07/01/2024
Antibiotics (Inhaled) – TOBI Podhaler - (IP0499) PDF 156kB 06/15/2024
Antibiotics (Inhaled) – Tobramycin Inhalation Solution - (IP0094) PDF 206kB 07/01/2024
Antibiotics – Linezolid (Zyvox), Sivextro - (IP0372) PDF 217kB 07/01/2024
Anticoagulants – Dabigatran - (IP0033) PDF 277kB 05/01/2024
Anticoagulants – Savaysa - (IP0034) PDF 135kB 06/01/2024
Anticonvulsant Medications - (IP0031) PDF 233kB 03/15/2024
Antiemetic Therapy - (1705) PDF 222kB 07/15/2022
Antihemophilic Factor (Recombinant) - (IP0564) PDF 189kB 02/15/2024
Antihyperglycemic Therapy (Non-Insulin) - (P0098) PDF 358kB 04/01/2024
Antimalarial Therapy - (P0101) PDF 83kB 07/01/2022
Antiseizure Medications – Diacomit - (IP0409) PDF 245kB 06/15/2024
Antiseizure Medications - Epidiolex - (IP0410) PDF 230kB 05/15/2024
Antiseizure Medications – Valtoco - (IP0105) PDF 147kB 06/01/2024
Antitussives - (IP0586) PDF 196kB 01/15/2024
Apixaban - (IP0030) PDF 246kB 06/15/2023
Apremilast - (IP0226) PDF 260kB 01/01/2024
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
Avalglucosidase - (IP0279) PDF 227kB 01/15/2024
Avatrombopag - (IP0152) PDF 207kB 10/01/2023
Avonex (interferon beta-1b) - (IP0254) PDF 193kB 01/01/2024
Azathioprine - (IP0337)

PDF 172kB 12/15/2023
B
Baricitinib - (IP0225) PDF 270kB 06/01/2024
Becaplermin - (IP0495) PDF 176kB 12/01/2022
Belatacept -(IP0219) PDF 227kB 01/15/2024
Belimumab Intravenous - (IP0429) PDF 233kB 01/15/2024
Belimumab Subcutaneous - (IP0430) PDF 227kB 01/15/2024
Belumosudil - (IP0313) PDF 196kB 01/15/2024
Bempedoic Acid/Ezetimibe - (IP0249) PDF 246kB 05/01/2024
Bempedoic Acid - (IP0248) PDF 257kB 05/01/2024
Benralizumab - (IP0421) PDF 283kB 08/01/2023
Beremagene geperpavec-svdt - (IP0572) PDF 249kB 04/15/2024
Beta Blockers - (IP0461) PDF 91kB 01/01/2023
Betaine (Cystadane) for Individual and Family Plans - (IP0465) PDF 227kB 01/01/2024
Bleomycin Sulfate - (IP0458) PDF 91kB 08/15/2022
Bone Modifiers – Xgeva - (IP0332) PDF 202kB 06/15/2024
Botulinum Therapy - (1106) PDF 497kB 03/01/2023
Bowel Agents – Opioid-Induced Constipation - (IP0401) PDF 169kB 05/01/2024
Brands with Bioequivalent Generics - (IP0011) PDF 310kB 06/01/2024
Bremelanotide - (IP0117) PDF 199kB 06/15/2023
Brexanolone - (IP0270) PDF 203kB 11/15/2023
Brexucabtagene autoleucel - (IP0199) PDF 233kB 01/15/2024
Brodalumab - (IP0246) PDF 237kB 06/01/2024
Brolucizumab - (IP0541) PDF 211kB 04/01/2023
Bupropion Extended-Release Products - (IP0058) PDF 190kB 09/01/2023
Burosumab - (IP0285) PDF 588kB 12/01/2023
Butalbital Combination Products - (IP0025)

PDF 193kB 10/01/2023
C
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 182kB 06/15/2024
Cerliponase Alfa - (IP0175) PDF 116kB 08/01/2022
Certolizumab - (IP0244) PDF 271kB 06/01/2024
Chelating Agents – Iron Chelators (Oral) - (IP0271) PDF 291kB 05/15/2024
Chenodiol - (IP0203) PDF 180kB 01/15/2024
Cholic Acid - (IP0289) PDF 189kB 01/15/2024
Cinacalcet for Individual and Family Plans - (IP0464) PDF 146kB 06/15/2024
Cipaglucosidase alfa-atga - (IP0591) PDF 204kB 03/15/2024
Ciprofloxacin-fluocinolone for Individual and Family Plans - (IP0468) PDF 179kB 01/01/2023
Citalopram 30mg Oral Capsules - (IP0416) PDF 206B 04/01/2024
Cladribine - (IP0261) PDF 190kB 01/01/2024
Clobazam - (IP0106) PDF 212kB 03/01/2024
Clomiphene - (IP0492) PDF 166kB 12/01/2022
Clonidine Extended-Release - (IP0456) PDF 161kB 11/15/2022
Clotting Factors and Antithrombin - (8007) PDF 438kB 06/15/2024
Colchicine Oral Solution - (IP0268) PDF 170kB 11/01/2023
Collagenase Clostridium Histolyticum - (IP0143) PDF 191kB 02/01/2024
Collagenase for Individual and Family Plans - (IP0470) PDF 171kB 01/01/2023
Complement Inhibitors – Empaveli- (IP0194) PDF 162kB 05/01/2024
Complement Inhibitors – Fabhalta - (IP0614) PDF 156kB 06/01/2024
Complement Inhibitors – Zilbrysq - (IP0622) PDF 183kB 07/01/2024
Compounded Medications - (IP0251) PDF 277kB 11/01/2023
Contraceptives - (IP0036) PDF 200kB 10/15/2023
Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers - (IP0022) PDF 298kB 01/01/2024
COVID-19 Drug and Biologic Therapeutics - (2016) PDF 466kB 06/15/2024
Crizanlizumab-tmca - (IP0120) PDF 204kB 06/01/2023
Cushing’s – Korlym - (IP0092) PDF 164kB 07/01/2024
Cushing’s – Recorlev - (IP0389) PDF 157kB 06/01/2024
Cyanocobalamin Nasal Spray - (IP0170) PDF 128kB 04/01/2024
Cyclosporine Ophthalmic Products - (IP0026) PDF 215kB 03/15/2024
Cysteamine Bitartrate Delayed-Release - (IP0046) PDF 210kB 08/01/2023
Cysteamine Bitartrate for Individual and Family Plans - (IP0466) PDF 205kB 08/01/2023
Cysteamine Ophthalmic Solution - (IP0082) PDF 171kB 08/01/2023
Cystic Fibrosis – Bronchitol - (IP0126)

PDF 176kB 06/01/2024
D
Dalfampridine - (IP0024) PDF 203kB 02/15/2024
Darbepoetin alfa - (IP0293) PDF 226kB 01/15/2024
DaxibotulinumtoxinA-lanm - (IP0588) PDF 184kB 01/15/2024
Delafloxacin - (IP0373) PDF 175kB 01/15/2024
Denosumab (Prolia®) - (IP0331) PDF 226kB 02/01/2024
Desmopressin Nasal Spray - (IP0132) PDF 209kB 03/15/2024
Desmopressin Products – Nocdurna - (IP0127) PDF 220B 06/15/2024
Deucravacitinib - (IP0538) PDF 229kB 06/01/2024
Deutetrabenazine - (IP0079) PDF 191kB 10/15/2023
Dextromethorphan/quinidine (Nuedexta) for Individual and Family Plans - (IP0324) PDF 188kB 03/15/2024
Dichlorphenamide - (IP0204) PDF 185kB 01/01/2024
Difelikefalin - (IP0436) PDF 118kB 09/01/2022
Dimercaprol and Edetate Calcium Disodium - (IP0138) PDF 247kB 10/01/2023
Dimethyl fumarate - (IP0266) PDF 200kB 02/15/2024
Diroximel fumarate - (IP0253) PDF 293kB 01/01/2024
Donepezil - (IP0502) PDF 150kB 12/01/2022
Dornase Alfa - (IP0483) PDF 190kB 10/15/2023
Droxidopa - (IP0110) PDF 213kB 06/01/2023
Drug and Biologic Medical Necessity (Injectables) - medical benefits - (2027) PDF 728kB 07/01/2024
Drug and Biologic Medical Necessity (Non-Injectables) – Medical Benefits - (2028) PDF 286kB 09/01/2023
Dupilumab - (IP0453)

PDF 287kB 04/15/2024
E
Eculizumab - (IP0549) PDF 247kB 07/01/2024
Edaravone - (IP0176) PDF 263kB 10/01/2023
Efgartigimod Intravenous - (IP0376) PDF 225kB 02/15/2024
Efgartigimod Subcutaneous Injection - (IP0574) PDF 243kB 02/15/2024
Eflapegrastim - (IP0526) PDF 208kB 01/01/2024
Elagolix - (IP0196) PDF 177kB 10/01/2023
Elapegademase-lvlr - (IP0399) PDF 122kB 04/15/2024
Elexacaftor/Tezacaftor/Ivacaftor - (IP0434) PDF 429kB 07/01/2023
Eliglustat - (IP0441) PDF 195kB 11/01/2023
Elosulfase Alfa - (IP0442) PDF 199kB 09/15/2023
Eltrombopag - (IP0153) PDF 131kB 09/01/2022
Emicizumab-kxwh - (IP0121) PDF 256kB 10/15/2023
Entadfi (finasteride and tadalafil) - (IP0519) PDF 176kB 03/15/2024
Enzyme Replacement Therapy - Lamzede - (IP0563) PDF 232kB 07/01/2024
Epinephrine Injection (Self-Administered) - (IP0385) PDF 208kB 08/01/2023
Epoetin Alpha Products - (IP0296) PDF 279kB 11/15/2023
Eptinezumab - (IP0506) PDF 226kB 11/01/2023
Erectile Dysfunction – Alprostadil Products for Individual and Family Plans - (IP0425) PDF 106kB 05/01/2024
Erectile Dysfunction - Stendra - (IP0100) PDF 884kB 05/01/2024
Erectile Dysfunction – Vardenafil - (IP0099) PDF 190kB 05/01/2024
Erenumab - (IP0503) PDF 203kB 11/01/2023
Esketamine - (IP0220) PDF 259kB 05/15/2024
Estrogen – Transdermal - (IP0590) PDF 181kB 01/15/2024
Etanercept - (IP0241) PDF 295kB 02/15/2024
Etelcalcetide - (1812) PDF 72kB 12/01/2020
Eteplirsen - (IP0135) PDF 197kB 09/01/2023
Everolimus for Non-Oncology Uses - (IP0408) PDF 155kB 07/01/2024
Evinacumab - (IP0128) PDF 277kB 06/15/2023
Evolocumab - (IP0195)

PDF 306kB 05/15/2024
F
Faricimab - (IP0542) PDF 209kB 03/15/2024
Fenfluramine - (IP0042) PDF 268kB 09/01/2023
Fenofibrates - (IP0339) PDF 184kB 01/15/2024
Fentanyl Transmucosal Products - (IP0381) PDF 198kB 03/15/2024
Fertility Injectables - (1012) 384kB 08/01/2023
Filgrastim - (IP0528) PDF 294kB 02/01/2024
Finerenone - (IP0314) PDF 219kB 01/15/2024
Fingolimod - (IP0259) PDF 220kB 02/15/2024
Fish Oil Triglycerides - (IP0191) PDF 181kB 02/01/2023
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
Gamifant -(IP0113) PDF 142kB 05/01/2024
Ganaxolone - (IP0508) PDF 200kB 11/15/2023
Gaucher Disease – Substrate Reduction Therapy – Miglustat - (IP0446) PDF 147kB 07/01/2024
Givosiran - (IP0118) PDF 208kB 01/15/2024
Glatiramer - (IP0257) PDF 225kB 01/01/2024
Glecaprevir/Pibrentasvir - (IP0187) PDF 270kB 06/01/2024
Glucagon Products - (IP0039) PDF 188kB 03/15/2024
Glucose Test Strips - (IP0272) PDF 184kB 03/15/2024
Glycopyrrolate - (IP0388) PDF 180kB 01/15/2024
Golimumab Subcutaneous - (IP0237) PDF 261kB 06/01/2024
Golodirsen - (IP0136) PDF 186kB 06/01/2023
Gonadotropin-Releasing Hormone (GnRH) Antagonists for Infertility Use - (IP0333) PDF 254kB 01/01/2024
Gonadotropin-Releasing Hormone Agonists – Central Precocious Puberty - Leuprolide - (IP0108) PDF 137kB 05/01/2024
Gonadotropin-Releasing Hormone Agonists – Central Precocious Puberty – Triptodur - (IP0134) PDF 140kB 05/01/2024
Gonadotropin-Releasing Hormone Agonists – Implants for Non-Oncology Indications - (IP0620) PDF 221kB 06/01/2024
Gonadotropin-Releasing Hormone Agonists – Injectable Long-Acting Products for Non-Oncology and Non-infertility Indications - (IP0109) PDF 224kB 06/15/2024
Grass Pollen Sublingual Products - (IP0515) PDF 184kB 03/01/2024
Growth Disorders – Ngenla - (IP0577) PDF 183kB 03/15/2024
Growth Disorders – Skytrofa - (IP0375) PDF 183kB 03/15/2024
Guselkumab - (IP0234)

PDF 236kB 01/01/2024
H
H. Pylori Infection Products - (IP0009) PDF 123kB 11/15/2022
Hematology – Adzynma - (IP0606) PDF 144kB 05/01/2024
Hematology – Cablivi - (IP0161) PDF 180kB 06/15/2024
Hematology – Ceprotin - (IP0342) PDF 152kB 05/01/2024
Hematology – Coagadex - (IP0554) PDF 158kB 05/01/2024
Hematology - Corifact - (IP0552) PDF 225kB 05/01/2024
Hematology – Enjaymo - (IP0405) PDF 146kB 05/01/2024
Hematology - Fibrinogen Products - (IP0357) PDF 180kB 05/01/2024
Hematology – Gene Therapy - Casgevy for Sickle Cell Disease - (IP0615) PDF 231kB 05/01/2024
Hematology – Gene Therapy – Lyfgenia - (IP0617) PDF 243kB 05/01/2024
Hematology – Gene Therapy - Zynteglo - (IP0486) PDF 265kB 07/01/2024
Hematology – Reblozyl for Non-Oncology Uses - (IP0115) PDF 221kB 07/01/2024
Hematology – Ryplazim - (IP0382) PDF 161kB 05/01/2024
Hematology - Tretten - (IP0553) PDF 206kB 05/01/2024
Hematology - Vonvendi - (IP0555) PDF 188kB 05/01/2024
Hemophilia – Eptacog Products - Sevenfact - (IP0355) PDF 191kB 05/01/2024
Hemophilia – Factor IX Products - (IP0623) PDF 157kB 06/15/2024
Hemophilia - FEIBA - (IP0354) PDF 190kB 05/15/2024
Hemophilia - Gene Therapy - Beqvez - (IP0648) PDF 183kB 06/27/2024
Hemophilia – Gene Therapy – Hemgenix - (IP0535) PDF 206kB 06/06/2024
Hepatitis C – Sovaldi - (IP0157) PDF 177kB 06/01/2024
Hepatitis C –Zepatier - (IP0158) PDF 185kB 06/01/2024
Hereditary Angioedema - Berotralstat - (IP0096) PDF 201kB 01/15/2024
Hereditary Angioedema – C1 Esterase Inhibitors (IV) - (IP0315) PDF 271kB 01/15/2024
Hereditary Angioedema – C1 Esterase Inhibitors (SC) - (IP0316) PDF 205kB 01/15/2024
Hereditary Angioedema - Ecallantide - (IP0336) PDF 211kB 01/15/2024
Hereditary Angioedema – Icatibant - (IP0335) PDF 215kB 01/15/2024
Hereditary Angioedema – Lanadelumab-flyo - (IP0334) PDF 206kB 01/15/2024
HIV Products - (P0050) PDF 338kB 05/01/2024
HIV Products for Individual and Family Plans - (IP0090) PDF 211kB 05/01/2024
HMG-CoA Reductase Inhibitors (Statins) and Combination Products - (IP0064) PDF 214kB 02/01/2024
Human Chorionic Gonadotropin (hCG) for Non-Fertility Use - (IP0327) PDF 208kB 02/15/2024
Human Immunodeficiency Virus – Cabenuva - (IP0123) PDF 253kB 06/01/2024
Hydroxyprogesterone Caproate - (IP0370) PDF 169kB 03/15/2024
Hydroxyurea Tablet - (IP0325)

PDF 206kB 01/15/2024
I
Ibalizumab-uiyk - (IP0171) PDF 233kB 05/15/2024
Ibrexfungerp - (IP0301) PDF 184kB 01/15/2024
Ibrutinib for Non-Oncology Indications - (IP0320) PDF 211kB 11/01/2022
Idursulfase - (IP0444) PDF 191klB 09/15/2023
Imiglucerase - (IP0162) PDF 249kB 10/01/2023
Immune Globulin - (5026) PDF 626kB 06/01/2024
Inclisiran - (IP0380) PDF 274kB 01/15/2024
Inebilizumab - (IP0062) PDF 207kB 07/01/2024
Infectious Disease – Ivermectin Tablets - (IP0300) PDF 184kB 06/01/2024
Infectious Disease – Livtencity - (IP0394) PDF 163kB 07/01/2024
Infectious Disease – Prevymis for Individual and Family Plans - (IP0426) PDF 120kB 04/01/2024
Infectious Disease – Pyrimethamine - (IP0348) PDF 166kB 06/15/2024
Infectious Disease – Sirturo - (IP0494) PDF 174kB 07/01/2024
Inflammatory Conditions - Bimzelx - (IP0603) PDF 187kB 06/01/2024
Inflammatory Conditions – Cosentyx Intravenous - (IP0643) PDF 243kB 07/01/2024
Inflammatory Conditions – Cosentyx Subcutaneous - (IP0223) PDF 236kB 06/01/2024
Inflammatory Conditions - Entyvio Subcutaneous - (IP0599) PDF 178kB 04/15/2024
Inflammatory Conditions – Entyvio Subcutaneous for Total Savings and Individual and Family Plans - (IP0613) PDF 189kB 06/01/2024
Inflammatory Conditions – Ilaris - (IP0235) PDF 264kB 07/01/2024
Inflammatory Conditions – Omvoh Intravenous - (IP0601) PDF 190kB 06/01/2024
Inflammatory Conditions – Omvoh Subcutaneous - (IP0602) PDF 190kB 06/01/2024
Inflammatory Conditions – Simponi Aria - (IP0238) PDF 236kB 05/01/2024
Inflammatory Conditions – Velsipity - (IP0605) PDF 168kB 06/01/2024
Infliximab - (IP0242) PDF 265kB 03/15/2024
Inotersen - (IP0417) PDF 180kB 04/01/2024
Insulin Glargine - (P0023) PDF 207kB 01/01/2024
Insulins (Rapid-Acting) - (IP0065) PDF 184kB 04/19/2023
Interferon beta-1b - (IP0256) PDF 201kB 01/01/2024
Interferon Gamma-1b for Non-Oncology Uses - (IP0201) PDF 191kB 10/01/2023
Interferon Therapy - (1315) PDF 191kB 02/01/2022
Intraarticular Hyaluronic Acid Derivatives - (IP0322) PDF 286kB 01/15/2024
Intravenous Iron Replacement Therapy - (IP0222) PDF 301kB 02/01/2023
Isavuconazonium (Oral)- (IP0305) PDF 186kB 11/01/2023
Isotretinoin Low Dose - (IP0193) PDF 204kB 05/01/2023
Itraconazole (Tolsura) - (IP0275) PDF 175kB 10/15/2023
Ivabradine - (IP0286) PDF 242kB 11/15/2023
Ivacaftor (Kalydeco®) - (IP0431) PDF 429kB 07/01/2023
Ixekizumab - (IP0224)

PDF 258kB 06/01/2024
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 316kB 06/01/2024
Legacy Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 470kB 06/01/2024
Lenacapavir - (IP0546) PDF 187kB 06/15/2023
Leniolisib - (IP0568) PDF 193kB 10/01/2023
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
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
Lupus – Lupkynis - (IP0122) PDF 193kB 06/15/2024
Lupus – Saphnelo - (IP0280) PDF 237kB 07/01/2024
Lusutrombopag - (IP0156) PDF 171kB 10/01/2023
Lybalvi - (IP0368) PDF 136kB 04/15/2024
LymePak - (IP0352)

PDF 159kB 04/01/2024
M
Maralixibat - (IP0341) PDF 234kB 06/15/2024
Mavacamten - (IP0480) PDF 235kB 10/15/2023
Mecasermin - (IP0310) PDF 220kB 06/01/2023
Medication Administration Site of Care - (1605) PDF 151kB 03/15/2024
Mepolizumab - (IP0422) PDF 247kB 05/15/2024
Metabolic Disorders – Phenylbutyrate Products - (IP0169) PDF 152kB 04/01/2024
Metabolic Disorders – Primary Hyperoxaluria Medications – Rivfloza - (IP0629) PDF 197kB 06/01/2024
Metabolic Disorders – Primary Hyperoxaluria – Oxlumo - (IP0095) PDF 240kB 05/01/2024
Metabolic Products – Nitisinone Products - (IP0146) PDF 164kB 05/15/2024
Methotrexate for Injection - (IP0411) PDF 182kB 04/01/2024
Methoxy polyethylene glycol-epoetin beta - (IP0297) PDF 240kB 12/15/2023
Metoclopramide Nasal Spray - (IP0085) PDF 204kB 05/01/2023
Metreleptin - (IP0340) PDF 207kB 09/15/2023
Metyrosine - (IP0450) PDF 71kB 02/15/2024
Midazolam Nasal Spray - (IP0338) PDF 196kB 03/15/2024
Migalastat - (IP0400) PDF 227kB 02/15/2024
Migraine – Nurtec ODT - (IP0147) PDF 231kB 06/01/2024
Migraine Treatment - (IP0029) PDF 239kB 04/01/2023
Migraine – Ubrelvy - (IP0148) PDF 180kB 06/01/2024
Miltefosine - (IP0210) PDF 203kB 09/01/2023
Mitapivat - (IP0451) PDF 201kB 09/01/2023
Monomethyl fumarate - (IP0255) PDF 193kB 01/01/2024
Motixafortide - (IP0597) PDF 187kB 03/15/2024
Multiple Sclerosis - Ocrevus - (IP0212) PDF 184kB 03/01/2024
Muscular Dystrophy – Deflazacort - (IP0131) PDF 137kB 06/01/2024
Mycapssa - (IP0491) PDF 180kB 01/15/2024
Myfembree - (IP0205)

PDF 181kB 10/01/2023
N
Nadofaragene firadenovec-vncg - (IP0579) PDF 210kB 09/15/2023
Nafarelin Acetate - (IP0415) PDF 215kB 01/01/2024
Nasal Steroids and Nasal Steroid/Antihistamine Combinations - (IP0274) PDF 235kB 10/15/2023
Natalizumab - (IP0215) PDF 302kB 03/01/2024
Nembutal [pentobarbital] injection - (IP0557) PDF 174kB 05/01/2023
Nephrology – Filspari- (IP0565) PDF 216kB 06/01/2024
Nephrology − Jesduvroq - (IP0604) PDF 133kB 03/15/2024
Nephrology – Tarpeyo - (IP0413) PDF 179kB 06/01/2024
Nephrology – Xphozah - (IP0608) PDF 154kB 05/01/2024
Neurology – Gene Therapy - Skysona - (IP0529) PDF 199kB 05/01/2024
Neurology - Leqembi (lecanemab) - (IP0547) PDF 279kB 01/15/2024
Neurology – Riluzole Products - (IP0258) PDF 177kB 06/01/2024
Nintedanib - (IP0312) PDF 242kB 11/15/2023
Nitazoxanide for Individual and Family Plans - (IP0467) PDF 213kB 01/01/2023
Nonsteroidal Anti-inflammatory Drugs - (IP0457) PDF 262kB 06/15/2024
NovoSeven RT - (IP0356) PDF 202kB 02/15/2024
Nusinersen - (IP0182)

PDF 212kB 02/15/2024
O
Obeticholic Acid - (IP0304) PDF 210kB 01/15/2024
Octreotide IR (Non-Oncology Indications) - (IP0490) PDF 190kB 10/15/2023
Odactra - (IP0516) PDF 214kB 03/01/2024
Odevixibat - (IP0363) PDF 231kB 12/15/2023
Ofatumumab - (IP0260) PDF 150kB 03/01/2024
Olipudase alfa-rpcp - (IP0500) PDF 282kB 03/15/2024
Omadacycline - (IP0379) PDF 185kB 01/15/2024
Omalizumab - (IP0487) PDF 318kB 02/15/2024
Omaveloxolone - (IP0566) PDF 206kB 10/15/2023
Ombitasvir/Paritaprevir/Ritonavir and Dasabuvir - (IP0189) PDF 226kB 01/01/2024
Omega-3 Fatty Acid Products - (IP0051) PDF 250kB 01/01/2024
Onasemnogene Abeparvovec-xioi - (IP0185) PDF 234kB 04/15/2024
Oncology (Injectable) – Amtagvi - (IP0625) PDF 185kB 06/01/2024
Oncology (Injectable – CAR-T) – Abecma - (IP0168) PDF 193kB 07/01/2024
Oncology (Injectable – CAR-T) - Carvykti - (IP0414) PDF 171kB 06/15/2024
Oncology (Injectable – CAR-T) – Kymriah - (IP0197) PDF 230kB 07/01/2024
Oncology (Injectable – CAR-T) – Yescarta - (IP0198) PDF 151kB 04/01/2024
Oncology Medications - (1403) PDF 416kB 07/01/2024
Opfolda (miglustat) capsule - (IP0598) PDF 203kB 03/15/2024
Ophthalmic Prostaglandin Analogs - (IP0027) PDF 244kB 02/01/2024
Ophthalmology – Syfovre - (IP0559) PDF 190kB 06/01/2024
Ophthalmology – Tepezza - (IP0129) PDF 217kB 05/15/2024
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Ranibizumab Products - (IP0543) PDF 185kB 05/01/2024
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors – Susvimo - (IP0349) PDF 161kB 05/15/2024
Ophthalmology – Verkazia - (IP0439) PDF 182kB 06/01/2024
Ophthamology - iDose TR - (IP0619) PDF 184kB 06/01/2024
Ophthmology - Durysta - (IP0218) PDF 211kB 06/01/2024
Opioid Therapy - Employer Group Benefit Plans - (IP0561) PDF 292kB 05/15/2024
Opioid Therapy - Individual and Family Plans - (IP0562) PDF 293kB 05/15/2024
Oral Antihistamines - (IP0190) PDF 201kB 09/01/2023
Oriahnn - (IP0087) PDF 199kB 10/01/2023
Osilodrostat - (IP0044) PDF 209kB 12/01/2023
Oteseconazole - (IP0513) PDF 172kB 03/01/2024
Otic Antibiotics - (IP0366) PDF 168kB 12/15/2023
Oxandrolone - (IP0496) PDF 188kB 12/01/2022
Oxybate - (IP0103) PDF 256kB 04/01/2024
Oxymetazoline Ophthalmic Solution - (IP0088) PDF 200kB 03/15/2024
Ozanimod - (IP0214)

PDF 267kB 06/01/2024
P
Palivizumab - (IP0321) PDF 263kB 01/15/2024
Palovarotene - (IP0596) PDF 211kB 02/15/2024
Pancrelipase - (IP0002) PDF 182kB 04/01/2024
Parathyroid Hormone - (IP0177) PDF 200kB 09/01/2023
Parkinson’s Disease – Apomorphine Subcutaneous - (IP0530) PDF 191kB 06/15/2024
Parkinson’s Disease – Carbidopa - (IP0523) PDF 164kB 07/01/2024
Parkinson’s Disease – Inbrija - (IP0522) PDF 202kB 07/01/2024
Parkinson’s Disease – Nourianz - (IP0524) PDF 168kB 07/01/2024
Parkinson’s Disease – Nuplazid - (IP0145) PDF 183kB 07/01/2024
Parkinson’s Disease – Ongentys - (IP0532) PDF 167kB 07/01/2024
Paromomycin - (IP0520) PDF 170kB 01/15/2023
Pasireotide - (IP0482) PDF 7205kB 01/15/2024
Pasireotide Long-Acting - (IP0165) PDF 215kB 12/01/2023
Patisiran - (IP0418) PDF 184kB 04/01/2024
Peanut (Arachis hypogaea) Allergen Powder-dnfp - (IP0141) PDF 211kB 08/01/2023
Pegfilgrastim - (IP0070) PDF 244kB 01/01/2024
Peginterferon - (IP0263) PDF 193kB 01/01/2024
Pegloticase - (IP0269) PDF 207kB 01/15/2024
Pegunigalsidase Alfa - (IP0570) PDF 208kB 03/01/2024
Pegvaliase-pqpz - (IP0294) PDF 218kB 01/15/2024
Pegvisomant - (IP0291) PDF 172kB 01/15/2024
Penicillamine - (IP0277) PDF 216kB 03/15/2024
Pen Needles - (IP0569) PDF 175kB 05/15/2024
Performance Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 470kB 06/01/2024
Pharmacy Prior Authorization - (1407) PDF 263kB 06/01/2024
Pilocarpine 1.25% Ophthalmic - (IP0343) PDF 136kB 04/15/2024
Pirfenidone - (IP0311) PDF 248kB 01/15/2024
Pitolisant - (IP0292) PDF 209kB 11/15/2023
Plerixafor - (IP0139) PDF 307kB 08/15/2023
Ponesimod - (IP0264) PDF 193kB 01/01/2024
Posaconazole PowderMix for Delayed-Release Oral Suspension for Individual and Family Plans - (IP0536) PDF 218kB 11/01/2023
Pregabalin Extended-Release - (IP0183) PDF 217kB 08/01/2023
Prenatal Vitamins - (IP0035) PDF 197kB 09/15/2023
Pretomanid - (IP0384) PDF 175kB 04/01/2024
Progesterone (Endometrin) for Individual and Family Plans - (IP0091) PDF 182kB 11/01/2023
Progesterone – Employer Group Plans - (IP0548) PDF 198kB 11/01/2023
Proton Pump Inhibitors - (IP0061) PDF 166kB 05/01/2024
Prucalopride - (IP0017) PDF 205kB 02/01/2024
Psychiatry – Zurzuvae - (IP0607) PDF 153kB 05/15/2024
Pulmonary Arterial Hypertension – Adempas – (IP0600) PDF 161kB 06/01/2024
Pulmonary Arterial Hypertension –Orenitram - (IP0616) PDF 161kB 06/01/2024
Pulmonary Arterial Hypertension – Phosphodiesterase Type 5 Inhibitors - (IP0626) PDF 191kB 06/01/2024
Pulmonary Arterial Hypertension – Uptravi - (IP0627) PDF 182kB 06/01/2024
Pulmonary Hypertension (PH) Therapy - (6121) PDF 438kB 06/01/2024
Pulmonary – Roflumilast for Individual and Family Plans - (IP0609) PDF 167kB 05/01/2024
Purified Cortrophin Gel - (IP0374) PDF 192kB 10/01/2023
Pyridostigmine - (IP0544)

PDF 170kB 04/01/2023
Q
Qbrexza - (IP0074) PDF 148kB 07/01/2024
Quantity Limitations - (1201) PDF 255kB 06/01/2024
Quazepam for Individual and Family Plans - (IP0469)

PDF 209kB 01/01/2023
R
Ragwitek - (IP0518) PDF 178kB 03/01/2024
Ranolazine - (IP0507) PDF 173kB 12/15/2022
Ravulizumab-cwvz Intravenous - (IP0550) PDF 276kB 06/15/2024
Rebif (interferon beta-1a) - (IP0265) PDF 193kB 01/01/2024
Rebyota - (IP0556) PDF 244kB 05/01/2023
Repository Corticotropin - (IP0178) PDF 229kB 10/01/2023
Reslizumab - (IP0423) PDF 293kB 01/01/2024
Rifaximin for Individual and Family Plans - IP0473) PDF 238kB 06/01/2023
Rilonacept - (IP0437) PDF 150kB 08/15/2022
RimabotulinumtoxinB - (IP0509) PDF 192kB 02/15/2023
Risankizumab Intravenous - (IP0476) PDF 233kB 01/01/2024
Risankizumab Subcutaneous- (IP0247) PDF 249kB 02/15/2024
Risdiplam - (IP0063) PDF 226kB 11/01/2023
Ritlecitinib - (IP0589) PDF 246kB 01/01/2024
Rituximab for Non-Oncology Indications - (IP0319) PDF 356kB 01/15/2024
Rivaroxaban - (IP0032) PDF 297kB 06/01/2023
Roflumilast - (IP0527) PDF 226kVB 04/15/2024
Romiplostim - (IP0155) PDF 237kB 10/01/2023
Romosozumab - (IP0179) PDF 208kB 11/01/2023
Rozanolixizumab - (IP0575) PDF 230kB 02/15/2024
Rufinamide - (IP0048)

PDF 209kB 03/15/2024
S
Sacrosidase - (IP0447) PDF 180kB 09/15/2023
Sandostatin LAR Depot (Non-Oncology Indications) - (IP0489) PDF 222kB 12/01/2023
Sapropterin - (IP0295) PDF 229kB 02/15/2024
Sarecycline - (IP0093) PDF 214kB 04/01/2023
Sarilumab - (IP0233) PDF 242kB 06/01/2024
Satralizumab-mwge - (IP0078) PDF 203kB 07/01/2024
Sebelipase Alfa - (IP0448) PDF 216kB 09/15/2023
Secukinumab Intravenous for Employer Plans - (IP0594) PDF 289kB 07/01/2024
Sedative Hypnotic Medications - (IP0023) PDF 249kB 02/15/2024
Selegiline - (IP0525) PDF 202kB 04/01/2024
Selumetinib - (IP0038) PDF 209kB 01/15/2023
Sertraline 150mg, 200mg Oral Capsules - (IP0328) PDF 211kB 01/15/2024
Setmelanotide for Employer Group Plans - (IP0104) PDF 229kB 07/01/2023
Short-Acting Beta2-Agonist Inhalers - (IP0040) PDF 214kB 05/15/2023
Sildenafil (Viagra) - (IP0098) PDF 217kB 02/15/2024
Siponimod - (IP0262) PDF 194kB 01/01/2024
Sirolimus - (IP0511) PDF 201kB 10/15/2023
Skeletal Muscle Relaxants - (IP0211) PDF 211kB 02/01/2024
Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors and SGLT-2 / Metformin Combinations - (IP0592) PDF 264kB 04/01/2024
Sodium thiosulfate - (IP0512) PDF 200kB 04/01/2024
Sofosbuvir/Velpatasvir/Voxilaprevir - (IP0188) PDF 232kB 06/01/2024
Sofosbuvir/Velpatasvir - (IP0184) PDF 250kB 06/01/2024
Solriamfetol - (IP0102) PDF 209kB 11/15/2023
Somapacitan - (IP0576) PDF 275kB 01/01/2024
Somatropin - (IP0452) PDF 108kB 01/01/2024
Spesolimab - (IP0501) PDF 195kB 02/15/2024
Standard Prescription Drug List - (1601)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 470kB 06/01/2024
Step Therapy Individual and Family Plan - (1603) PDF 195kB 04/15/2024
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) PDF 263kB 06/01/2024
Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) PDF 240kB 05/01/2024
Step Therapy – Value/Advantage Prescription Drug Lists (Employer Group Plans) - (1802) PDF 230kB 05/01/2024
Sutimlimab - (IP0405)

PDF 218kB 06/01/2023
T
Tadalafil (Cialis®) for Employer Group Plans - (IP0097) PDF 218kB 02/15/2024
Tadalafil (Cialis®) for Individual and Family Plans - (IP0101) PDF 195kB 02/15/2024
Taliglucerase - (IP0163) PDF 215kB 10/01/2023
Tapinarof - (IP0497) PDF 210kB 04/01/2024
Tascenso ODT - (IP0514) PDF 222kB 11/15/2023
Tasimelteon - (IP0428) PDF 247kB 05/15/2024
Teduglutide - (IP0288) PDF 200kB 01/15/2024
Tegaserod - (IP0019) PDF 204kB 02/01/2024
Tenapanor - (IP0455) PDF 204kB 02/01/2024
Teplizumab-mzwv - (IP0537) PDF 173kB 04/15/2024
Teriflunomide - (IP0252) PDF 219kB 02/15/2024
Teriflunomide for Individual and Family Plans - (IP0560) PDF 223kB 02/15/2024
Teriparatide - (IP0330) PDF 268kB 02/15/2024
Tesamorelin - (IP0209) PDF 208kB 01/15/2024
Testosterone (Oral, Topical, and Nasal) - (IP0350) PDF 212kB 03/01/2024
Testosterone Therapy (Injectables and Implantable Pellets) - (IP0351) PDF 237kB 02/15/2024
Tetrabenazine - (IP0208) PDF 231kB 10/15/2023
Tetracycline Antibiotics - (IP0396) PDF 266kB 06/01/2024
Tezacaftor/Ivacaftor -(IP0433) PDF 434kB 08/01/2023
Tezepelumab-ekko - (IP0412) PDF 221kB 02/01/2024
Thalidomide Non-Oncology Uses - (IP0493) PDF 201kB 12/01/2022
Thalitone - (IP0365) PDF 171kB 04/01/2024
Thyroid Hormone Supplements - (IP0060) PDF 249kB 05/01/2023
Tildrakizumab - (IP0236) PDF 282kB 06/01/2024
Tiopronin - (IP0202) PDF 230kB 04/01/2024
Tizanidine - (IP0392) PDF 111kB 04/15/2024
Tobramycin/loteprednol etabonate (Zylet) Ophthalmic Suspension for Individual and Family Plans - (IP0474) PDF 171kB 01/01/2023
Tocilizumab Intravenous - (IP0228) PDF 192kB 09/01/2022
Tocilizumab Subcutaneous - (IP0227) PDF 266kB 06/01/2024
Tofacitinib - (IP0230) PDF 277kB 06/01/2024
Tolfersen - (IP0567) PDF 222kB 11/15/2023
Tolvaptan (Jynarque®) - (IP0287) PDF 194kB 11/01/2023
Tolvaptan for Individual and Family Plans - (IP0471) PDF 206kB 10/15/2023
Topical Acne – Non-Retinoid Products - (IP0166) PDF 237kB 05/01/2024
Topical Acne – Winlevi - (IP0173) PDF 127kB 06/01/2024
Topical Adapalene Products - (IP0181) PDF 121kB 01/15/2024
Topical Alpha Adrenergic Agonists - (IP0284) PDF 172kB 01/01/2024
Topical Antifungals - (IP0273) PDF 221kB 04/01/2024
Topical Antivirals - (IP0276) PDF 195kB 11/01/2023
Topical Azelaic Acid Products - (IP0172) PDF 155kB 05/01/2024
Topical Corticosteroids - (IP0281) PDF 210kB 11/01/2023
Topical Diclofenac Sodium 3% Gel - (IP0282) PDF 206kB 02/15/2024
Topical Doxepin Products - (IP0207) PDF 195kB 11/01/2023
Topical Medications for Actinic Keratosis - (IP0367) PDF 221kB 12/01/2023
Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - (IP0021) PDF 206kB 01/01/2024
Topical Rosacea Products - (IP0003) PDF 225kB 06/01/2024
Topical Ruxolitinib - (IP0369) PDF 269kB 02/15/2024
Topical Tazarotene Products - (IP0174) PDF 208kB 02/15/2024
Topical Tretinoin Products - (IP0167) PDF 234kB 12/15/2023
Topical Trifarotene - (IP0180) PDF 217kB 06/01/2023
Topical Vitamin D Analogs - (IP0361) PDF 215kB 03/15/2024
Total Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 491kB 07/01/2024
Tralokinumab - (IP0386) PDF 222kB 02/15/2024
Triamcinolone acetonide extended-release injection - (IP0140) PDF 205kB 10/15/2023
Triamcinolone Acetonide Ophthalmic - (IP0371) PDF 106kB 03/01/2022
Trientine Hydrochloride - (IP0278) PDF 236kB 02/15/2024
Triheptanoin - (IP0084) PDF 182kB 10/15/2023
Trilaciclib Injection - (IP0150) PDF 72kB 07/01/2022
Trofinetide - (IP0578)

PDF 193kB 11/01/2023
U
Ublituximab - (IP0545) PDF 203kB 01/01/2024
Unassigned Drug or Biologic Code Medical Precertification - (1701) PDF 320kB 07/01/2024
Upadacitinib - (IP0229) PDF 285kB 06/01/2024
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
Vaginal Estrogen Products and Ospemifin - (IP0216) PDF 212kB 11/15/2023
Valbenazine - (IP0080) PDF 190kB 12/01/2023
Valoctocogene roxaparvovec-rvox - (IP0580) PDF 226kB 10/01/2023
Value Prescription Drug List - (1602)*
*Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review
PDF 491kB 07/01/2024
Vasculitis – Tavneos - (IP0398) PDF 192kB 06/15/2024
Vedolizumab Intravenous - (IP0326) PDF 212kB 03/01/2024
Velaglucerase - (IP0164) PDF 205kB 10/01/2023
Veregen - (IP0393) PDF 194kB 06/01/2024
Vericiguat - (IP0125) PDF 199kB 01/01/2024
Vestronidase Alfa-vjbk - (IP0449) PDF 209kB 09/15/2023
Vigabatrin - (IP0049) PDF 235kB 05/15/2024
Viltolarsen - (IP0066) PDF 190kB 01/15/2024
Vocabria - (IP0124) PDF 248kB 09/15/2023
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
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
Z
Zokinvy - (IP0107)

PDF 206kB 06/01/2024