Clinical Payment Policies | Ambetter from Western Sky Community Care

 

Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Ambetter from Western Sky Community Care Clinical Policy Manual apply to Ambetter from Western Sky Community Care members. Policies in the Ambetter from Western Sky Community Care Clinical Policy Manual may have either a Ambetter from Western Sky Community Care or a “Centene” heading. Ambetter from Western Sky Community Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from Western Sky Community Care clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Ambetter from Western Sky Community Care. In addition, Ambetter from Western Sky Community Care may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Ambetter from Western Sky Community Care.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

 

Policy Number

Policy Title

Effective Date of Revision

CP.MP.15725-hydroxyvitamin D Testing in Children and Adolescents (PDF)9/30/2023
CP.MP.92Acupuncture (PDF)7/31/2023
CPG GridAdopted Clinical Practice and Preventive Health Guidelines (PDF)7/31/2023
CP.MP.124ADHD Assessment and Treatment (PDF)2/28/2022
CP.MP.100Allergy Testing and Therapy (PDF)9/30/2023
CP.MP.108Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (PDF)10/31/2023
CP.MP.175Air Ambulance (PDF)6/30/2023
CP.MP.158Ambulatory Surgery Center Optimization (PDF)6/30/2023
CP.MP.55Assisted Reproductive Technology (PDF)10/31/2022
CP.MP.168Biofeedback (PDF)11/30/2022
CP.MP.93Bone-Anchored Hearing Aid (PDF)6/30/2023
CP.MP.110Bronchial Thermoplasty (PDF)5/31/2022
CP.MP.186Burn Surgery (PDF)11/30/2022
CP.MP.156Cardiac Biomarker Testing (PDF)9/30/2023
CP.MP.164Caudal or Interlaminar Epidural Steroid Injections (PDF)7/31/2023
CP.MP.94Clinical Trials (PDF)6/30/2023
CP.MP.14Cochlear Implant Replacements (PDF)7/31/2023
CP.MP.31Cosmetic and Reconstructive Procedures (PDF)10/31/2023
CP.MP.203Diaphragmatic/Phrenic Nerve Stimulation (PDF)8/31/2023
CP.MP.105Digital EEG Spike Analysis (PDF)  9/30/2023
CP.MP.114Disc Decompression (PDF)5/31/2023
CP.MP.115Discography (PDF)6/30/2023
CP.MP.101Donor Lymphocyte Infusion (PDF)10/31/2023
CP.MP.50Drugs of Abuse: Definitive Testing (PDF)6/30/2023
CP.MP.107Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)10/31/2023
CP.MP.155EEG in the Evaluation of Headache (PDF)9/30/2023
CP.MP.145Electric Tumor Treating Fields (PDF)11/30/2022
CP.MP.106Endometrial Ablation (PDF)9/30/2022
CP.MP.134Evoked Potential Testing (PDF)9/30/2023
CP.MP.171Facet Joint Interventions (PDF)7/31/2023
CP.MP.248Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)8/31/2023
CP.MP.137Fecal Incontinence Treatments (PDF)7/31/2023
CP.MP.129Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)7/31/2023
CP.MP.53Ferriscan R2-MRI (PDF)10/31/2023
CP.MP.130Fertility Preservation (PDF)5/31/2023
CP.MP.209Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)11/30/2022
CP.MP.95Gender-Affirming Procedures (PDF)8/31/2023
CP.MP.153Helicobacter Pylori Serology Testing (PDF)9/30/2023
CP.MP.113Holter Monitors (PDF)9/30/2023
CP.MP.184Home Ventilators (PDF)6/30/2023
CP.MP.121Homocysteine Testing (PDF)3/31/2022
CP.MP.54Hospice Services (PDF)7/31/2023
CP.MP.58Intestinal and Multivisceral Transplant (PDF)5/31/2023
CP.MP.69Intensity- Modulated Radiotherapy (PDF)8/31/2023
CP.MP.167Intradiscal Steroid Injections for Pain Management (PDF)8/31/2023
CP.MP.180Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)11/30/2022
CP.MP.61IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)10/31/2023
CP.MP.250Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)8/31/2023
CP.MP.123Laser Therapy for Skin Conditions (PDF)3/1/2023
CP.MP.244Liposuction for Lipedema (PDF)5/31/2023
CP.MP.139Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)3/31/2022
CP.MP.57Lung Transplantation (PDF)8/31/2023
CP.MP.116Lysis of Epidural Lesions (PDF)5/31/2023
CP.MP.152Measurement of Serum 1,25-dihydroxyvitamin D (PDF)9/30/2023
CP.MP.144Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)11/30/2022
CP.MP.170Nerve Blocks and Neurolysis for Pain Management (PDF)8/31/2023
CP.MP.48Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)7/31/2023
CP.MP.91Obstetrical Home Care Programs (PDF)12/31/2022
CP.MP.249Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)6/30/2023
CP.MP.202Orthognathic Surgery (PDF)10/1/2023
CP.MP.194Osteogenic Stimulation (PDF)8/31/2023
CP.MP.176Outpatient Cardiac Rehabilitation (PDF)5/31/2023
CP.MP.102Pancreas Transplantation (PDF)8/31/2023
CP.MP.109Panniculectomy (PDF)10/31/2023
CP.MP.138Pediatric Heart Transplant (PDF)10/31/2023
CP.MP.246Pediatric Kidney Transplant (PDF)8/31/2023
CP.MP.188Pediatric Oral Function Therapy (PDF)5/31/2023
CP.MP.147Percutaneous Left Atrial Appendage Closure for Stroke Prevention (PDF)5/31/2023
CP.MP.49Physical, Occupational, and Speech Therapy Services (PDF)6/30/2023
CP.MP.181Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)6/30/2023
CP.MP.133Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)8/31/2023
CP.MP.242Pulmonary Function Testing (PDF)10/31/2022
CP.MP.150Phototherapy for Neonatal Hyperbilirubinemia (PDF)10/31/2023
CP.MP.70Proton and Neutron Beam Therapies (PDF)11/30/2022
CP.MP.51Reduction Mammoplasty and Gynecomastia Surgery (PDF)7/31/2023
CP.MP.210Repair of Nasal Valve Compromise (PDF)5/31/2023
CP.MP.126Sacroiliac Joint Fusion (PDF)6/30/2023
CP.MP.166Sacroiliac Joint Interventions for Pain Management (PDF)8/31/2023
CP.MP.174Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)11/30/2022
CP.MP.165Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)8/31/2023
CP.MP.146Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Disorders (PDF)9/30/2023
CP.MP.185Skin Substitutes for Chronic Wounds (PDF)10/31/2022
CP.MP.97Testing Select GU Conditions (PDF)10/31/2022
CP.MP.127Total Artificial Heart (PDF)7/31/2023
CP.MP.154Thyroid Hormones and Insulin Testing in Pediatrics (PDF)9/30/2023
CP.MP.151Transcatheter Closure of Patent Foramen Ovale (PDF)11/30/2022
CP.MP.247Transplant Service Documentation Requirements (PDF)12/31/2022
CP.MP.169Trigger Point Injections for Pain Management (PDF)8/31/2023
CP.MP.38Ultrasound in Pregnancy (PDF)10/31/2023
CP.MP.142Urinary Incontinence Devices and Treatments (PDF)6/30/2023
CP.MP.98Urodynamic Testing (PDF)3/1/2023
CP.MP.99Wheelchair Seating (PDF)3/1/2023
CP.MP.12Vagus Nerve Stimulation (PDF)8/31/2023
CP.MP.143Wireless Motility Capsule (PDF)9/30/2023
CP.MP.46Ventricular Assist Devices (PDF)5/31/2023

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Western Sky Community Care Payment Policy Manual apply with respect to Western Sky Community Care members. Policies in the Western Sky Community Care Payment Policy Manual may have either a Western Sky Community Care or a “Centene” heading.  In addition, Western Sky Community Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Western Sky Community Care.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Pharmacy Policies

Policy TitlePolicy NumberEffective Date
Abaloparatide (Tymlos) (PDF)CP.PHAR.345July 1, 2017
Abametapir (Xeglyze) (PDF)CP.PMN.253December 1, 2020
Abemaciclib (Verzenio) (PDF)CP.PHAR.355October 24, 2017
Abiraterone (Zytiga,
Yonsa) (PDF)
CP.PHAR.84October 1, 2011
AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230July 1, 2016
Abrocitinib (Cibinqo) (PDF)CP.PHAR.578June 1, 2022
Acalabrutinib (Calquence) (PDF)CP.PHAR.366March 1, 2018
Acyclovir Buccal Tablet (Sitavig) (PDF)CP.PMN.210September 1, 2019
Adefovir (Hepsera) (PDF)CP.PHAR.142August 28, 2018
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)CP.PHAR.229June 1, 2016
Aducanumab-avwa (Aduhelm) (PDF)CP.PHAR.468June 1, 2020
Afamelanotide (Scenesse) (PDF)CP.PHAR.444March 1, 2020
Afatinib (Gilotrif) (PDF)CP.PHAR.298January 1, 2017
Aflibercept (Eylea) (PDF)CP.PHAR.184March 1, 2016
Agalsidase Beta (Fabrazyme) (PDF)CP.PHAR.158 February 1, 2016
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)CP.PMN.138March 13, 2018
Alectinib (Alecensa) (PDF)CP.PHAR.369November 16, 2016
Alemtuzumab (Lemtrada) (PDF)CP.PHAR.243August 1, 2016
Alendronate (Binosto, Fosamax Plus D) (PDF)CP.PMN.88February 28, 2018
Alglucosidase Alfa (Lumizyme) (PDF)CP.PHAR.160February 1, 2016
Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF)CP.PHAR.562March 1, 2022
Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF)CP.PHAR.563March 1, 2022
Alpelisib (Piqray, Vijoice) (PDF)CP.PHAR.430September 1, 2019
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)CP.PHAR.94March 1, 2012
Amantadine ER (Gocovri, Osmolex ER)CP.PMN.89October 10, 2017
Ambrisentan (Letairis) (PDF)CP.PHAR.190March 1, 2016
Amifampridine (Firdapse) (PDF)CP.PHAR.411January 22, 2019
Amikacin (Arikayce) (PDF)CP.PHAR.401November 13, 2018
Amisulpride (Barhemsys) (PDF)CP.PMN.236September 1, 2020
Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544September 1, 2021
Anifrolumab-fnia (Saphnelo) (PDF)CP.PHAR.551December 1, 2021
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)CP.PHAR.217May 1, 2016
Antithrombin III (ATryn, Thrombate III) (PDF)CP.PHAR.564March 1, 2022
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)CP.PHAR.506December 1, 2020
Apalutamide (Erleada) (PDF)CP.PCH.45March 1, 2022
Apomorphine (Apokyn, Kynmobi) (PDF)CP.PHAR.488September 1, 2020
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.19November 30, 2016
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.19November 30, 2016
Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (PDF)CP.PHAR.290 December 1, 2016
Aripiprazole Orally Disintegrating Tablet (PDF)CP.PCH.37March 1, 2021
Armodafinil (Nuvigil) (PDF)CP.PMN.35August 1, 2009
Asciminib (Scemblix) (PDF)CP.PHAR.565March 1, 2022
Asenapine (Saphris, Secuado) (PDF)CP.PMN.15December 1, 2014
Asfotase Alfa (Strensiq) (PDF)CP.PHAR.328March 1, 2017
Aspirin/Dipyridamole (Aggrenox) (PDF)CP.PMN.20September 1, 2006
Atezolizumab (Tecentriq) (PDF)CP.PHAR.235June 1, 2016
Atogepant (Qulipta) (PDF)CP.PHAR.566March 1, 2022
Avacopan (Tavneos) (PDF)CP.PHAR.515March 1, 2021
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF)CP.PHAR.521March 1, 2021
Avapritinib (Ayvakit) (PDF)CP.PHAR.454March 1, 2020
Avatrombopag (Doptelet) (PDF)CP.PHAR.130July 17, 2018
Avelumab (Bavencio) (PDF)CP.PHAR.333May 1, 2017
Axicabtagene Ciloleucel (Yescarta) (PDF)CP.PHAR.362October 31, 2017
Axitinib (Inlyta) (PDF)CP.PHAR.100May 1, 2012
Azacitidine (Onureg, Vidaza) (PDF)CP.PHAR.387August 28, 2018
Azelaic Acid (Finacea Topical Gel/Foam) (PDF)HIM.PA.119November 9, 2017
Aztreonam (Cayston) (PDF)CP.PHAR.209May 1, 2016
Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) (PDF)CP.PHAR.149November 9, 2017
Baloxavir Marboxil (Xofluza) (PDF)CP.PMN.185October 30, 2018
Bedaquiline (Sirturo) (PDF)CP.PMN.212December 1, 2019
Belantamab Mafodotin-blmf (Blenrep) (PDF)CP.PHAR.469June 1, 2020
Belatacept (Nulojix) (PDF)CP.PHAR.201November 9, 2017
Belimumab (Benlysta) (PDF)CP.PHAR.88October 1, 2011
Belinostat (Beleodaq) (PDF)CP.PHAR.311February 1, 2017
Belumosudil (Rezurock) (PDF)CP.PHAR.552December 1, 2021
Belzutifan (Welireg) (PDF)CP.PHAR.553December 1, 2021
Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF)CP.PMN.237September 1, 2020
Bendamustine (Belrapzo, Bendeka, Treanda) (PDF)CP.PHAR.307February 1, 2017
Benralizumab (Fasenra) (PDF)CP.PHAR.373January 16, 2018
Benznidazole (PDF)CP.PMN.90October 17, 2017
Betaine (Cystadane) (PDF)CP.PHAR.143August 28, 2018
Betamethasone Dipropionate Spray (Sernivo) (PDF)CP.PMN.182December 1, 2018
Betibeglogene Autotemcel (Zynteglo) (PDF)CP.PHAR.545September 1, 2021
Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) (PDF)CP.PHAR.93October 31, 2011
Bexarotene (Targretin Capsules, Gel) (PDF)CP.PHAR.75September 1, 2011
Bezlotoxumab (Zinplava) (PDF)CP.PHAR.300November 16, 2016
Bimatoprost Implant (Durysta) (PDF)CP.PHAR.486June 1, 2020
Binimetinib (Mektovi) (PDF)CP.PHAR.50July 24, 2018
Biologic and Non-biologic DMARDs (PDF)HIM.PA.SP60January 1, 2020
Blinatumomab (Blincyto) (PDF)CP.PHAR.312February 1, 2017
Bortezomib (Velcade) (PDF)CP.PHAR.410December 11, 2018
Bosentan (Tracleer) (PDF)CP.PHAR.191March 1, 2016
Bosutinib (Bosulif) (PDF)CP.PHAR.105October 1, 2012
Brand Name Override and Non-Formulary Medications (PDF)HIM.PA.103December 1, 2014
Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.303February 1, 2017
Brexanolone (Zulresso) (PDF)CP.PHAR.417April 16, 2019
Brexpiprazole (Rexulti) (PDF)CP.PMN.68November 5, 2015
Brexucabtagene Autoleucel (Tecartus) (PDF)CP.PHAR.472June 1, 2020
Brigatinib (Alunbrig) (PDF)CP.PHAR.342July 17, 2017
Brimonidine Tartrate (Mirvaso) (PDF)CP.PMN.192November 15, 2016
Brinzolamide/Brimonidine (Simbrinza) (PDF)HIM.PA.15September 4, 2018
Brivaracetam (Briviact) (PDF)CP.PCH.26May 21, 2019
Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.445February 29, 2020
Budesonide (Tarpeyo) (PDF)CP.PHAR.572March 1, 2022
Budesonide (Uceris) (PDF)CP.PCH.11August 14, 2018
Buprenorphine (Subutex) (PDF)CP.PMN.82September 1, 2017
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF)CP.PHAR.289November 16, 2016
Buprenorphine/Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)CP.PMN.81September 1, 2017
Bupropion/Naltrexone (Contrave) (PDF)CP.PCH.12May 1, 2017
Burosumab-twza (Crysvita) (PDF)CP.PHAR.11May 8, 2018
Butorphanol Nasal Spray (PDF)HIM.PA.46December 1, 2014
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)CP.PHAR.202March 1, 2016
Cabazitaxel (Jevtana) (PDF)CP.PHAR.316February 1, 2017
Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)CP.PHAR.573March 1, 2022
Cabozantinib (Cabometyx, Cometriq) (PDF)CP.PHAR.111June 1, 2013
Calcifediol (Rayaldee) (PDF)CP.PMN.76 November 1, 2016
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF)CP.PMN.181December 1, 2018
Canakinumab (Ilaris) (PDF)CP.PHAR.246August 1, 2016
Cannabidiol (Epidiolex) (PDF)CP.PMN.164July 17, 2018
Capecitabine (Xeloda) (PDF)CP.PHAR.60May 1, 2011
Caplacizumab-yhdp (Cablivi) (PDF)CP.PHAR.416March 12, 2019
Capmatinib (Tabrecta) (PDF)CP.PHAR.494September 1, 2020
Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) (PDF)CP.PMN.238September 1, 2020
Carfilzomib (Kyprolis) (PDF)CP.PHAR.309February 1, 2017
Carglumic Acid (Carbaglu) (PDF)CP.PHAR.206May 1, 2016
Cariprazine (Vraylar) (PDF)CP.PMN.91November 16, 2016
Casimersen (Amondys 45) (PDF)CP.PHAR.470June 1, 2020
Casirivimab and Imdevimab (REGEN-COV) (PDF)CP.PHAR.520December 22, 2020
Celecoxib (Celebrex, Elyxyb) (PDF)CP.PMN.122January 1, 2007
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397October 16, 2018
Cenegermin-bkbj (Oxervate) (PDF)CP.PMN.186October 9, 2018
Cenobamate (Xcopri) (PDF)CP.PMN.231March 1, 2020
Ceritinib (Zykadia) (PDF)CP.PHAR.349July 1, 2017
Cerliponase Alfa (Brineura) (PDF)CP.PHAR.338July 1, 2017
Cetuximab (Erbitux) (PDF)CP.PHAR.317February 1, 2017
Chenodiol (Chenodal) (PDF)CP.PMN.239September 1, 2020
Chlorambucil (Leukeran) (PDF)CP.PHAR.554December 1, 2021
Chloramphenicol Sodium Succinate (PDF)CP.PHAR.388December 1, 2018
Cholic Acid (Cholbam) (PDF)CP.PHAR.390December 1, 2018
Ciclopirox (Penlac) (PDF)CP.PMN.24September 1, 2007
Ciltacabtagene Autoleucel (Carvykti) (PDF)CP.PHAR.533May 7, 2021
Cinacalcet (Sensipar) (PDF)CP.PHAR.61May 1, 2011
Ciprofloxacin/Dexamethasone (Ciprodex) (PDF)CP.PMN.248December 1, 2020
Ciprofloxacin/Fluocinolone (Otovel) (PDF)CP.PMN.249December 1, 2020
Cladribine (Mavenclad) (PDF)CP.PHAR.422September 1, 2019
Clascoterone (Winlevi) (PDF)CP.PMN.257February 28, 2021
Clinical Policy: Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260July 1, 2016
Clobazam (Onfi, Sympazan) (PDF)CP.PMN.54November 1, 2012
CNS Stimulants (PDF)CP.PMN.92March 1, 2018
Cobimetinib (Cotellic) (PDF)CP.PHAR.380November 16, 2016
Colesevelam (Welchol) (PDF)CP.PMN.250December 1, 2020
Collagenase Clostridium Histolyticum (Xiaflex) (PDF)CP.PHAR.82October 1, 2011
Colonoscopy Preparation Products (PDF)CP.PCH.43December 1, 2021
Compounded Medications (PDF)CP.PMN.280September 1, 2022
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)CP.PMN.258March 1, 2021
Continuous Glucose Monitors (PDF)CP.PMN.214December 1, 2019
Copanlisib (Aliqopa) (PDF)CP.PHAR.357October 17, 2017
Corticosteroids
for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)
CP.PHAR.385May 29, 2018
Cosyntropin (Cortrosyn) (PDF)CP.PHAR.203April 1, 2016
Crisaborole (Eucrisa) (PDF)CP.PMN.110February 21, 2017
Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449March 1, 2020
Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449March 1, 2020
Crizotinib (Xalkori) (PDF)CP.PHAR.90November 1, 2011
Cyclosporine (Cequa, Restasis, Verkazia) (PDF)CP.PMN.48May 1, 2012
Cysteamine Ophthalmic (Cystaran, Cystadrops) (PDF)CP.PMN.130August 1, 2017
Cysteamine oral (Cystagon, Procysbi) (PDF)CP.PHAR.155   February 1, 2016
Cytomegalovirus Immune Globulin (CytoGam) (PDF)CP.PHAR.277September 1, 2018
Dabrafenib (Tafinlar) (PDF)CP.PHAR.239November 16, 2016
Dacomitinib (Vizimpro) (PDF)CP.PHAR.399October 16, 2018
Dalfampridine (Ampyra) (PDF)CP.PHAR.248August 1, 2016
Dalteparin (Fragmin) (PDF)CP.PHAR.225May 1, 2016
Dapsone (Aczone Gel) (PDF) CP.PCH.32December 1, 2020
Daptomycin (Cubicin, Cubicin RF) (PDF)CP.PHAR.351November 30, 2017
Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF)CP.PHAR.310July 1, 2017
Darbepoetin Alfa (Aranesp) (PDF)CP.PHAR.236June 1, 2016
Darolutamide (Nubeqa) (PDF)CP.PHAR.435December 1, 2019
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF)HIM.PA.SP61August 1, 2020
Dasatinib (Sprycel) (PDF)CP.PHAR.72June 1, 2012
Daunorubicin/Cytarabine (Vyxeos) (PDF)CP.PHAR.352December 1, 2017
Decitabine/Cedazuridine (Inqovi) (PDF)CP.PHAR.479June 1, 2020
Deferasirox (Exjade, Jadenu) (PDF)CP.PHAR.145November 1, 2015
Deferoxamine (Desferal) (PDF)CP.PHAR.146November 1, 2015
Deflazacort (Emflaza) (PDF)CP.PHAR.331March 1, 2017
Degarelix Acetate (Firmagon) (PDF)CP.PHAR.170November 9, 2017
Delafloxacin (Baxdela) (PDF)CP.PMN.115November 9, 2017
Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.58March 1, 2011
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)CP.PHAR.214May 1, 2016
Deutetrabenazine (Austedo) (PDF)CP.PCH.42June 1, 2021
Dexlansoprazole (Dexilant) (PDF)HIM.PA.05January 1, 2020
Dexrazoxane (Totect) (PDF)CP.PHAR.418March 19, 2019
Dextromethorphan/Bupropion (Auvelity) (PDF)CP.PMN.284December 1, 2022
Dextromethorphan-Quinidine (Nuedexta) (PDF)CP.PMN.93March 1, 2018
Diazepam Nasal Spray (Valtoco) (PDF)CP.PMN.216December 1, 2019
Dichlorphenamide (Keveyis) (PDF)CP.PMN.261March 1, 2021
Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF)CP.PCH.28September 1, 2020
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (PDF)CP.PCH.41February 1, 2021
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)HIM.PA.58March 1, 2018
Dolasetron (Anzemet) (PDF)CP.PMN.141September 1, 2006
Dornase Alfa (Pulmozyme) (PDF)CP.PHAR.212May 1, 2016
Dostarlimab-gxly (Jemperli) (PDF)CP.PHAR.540September 1, 2021
Doxepin (Silenor, Prudoxin, Zonalon) (PDF)HIM.PA.147November 17, 2017
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)CP.PMN.79May 1, 2017
Dupilumab (Dupixent) (PDF)CP.PHAR.336May 1, 2017
Durvalumab (Imfinzi) (PDF)CP.PHAR.339July 1, 2017
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF)CP.PMN.128May 1, 2016
Duvelisib (Copiktra) (PDF)CP.PHAR.400October 16, 2018
Ecallantide (Kalbitor) (PDF)CP.PHAR.177March 1, 2016
Eculizumab (Soliris) (PDF)CP.PHAR.97March 1, 2012
Edaravone (Radicava, Radivaca ORS) (PDF)CP.PHAR.343July 1, 2017
Efgartigimod Alfa-fcab (Vyvgart) (PDF)CP.PHAR.555December 1, 2021
Efinaconazole (Jublia) (PDF)CP.PMN.25August 1, 2016
Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (PDF)CP.PHAR.136August 28, 2018
Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.419April 23, 2019
Elbasvir/Grazoprevir (Zepatier) (PDF)HIM.PA.SP62August 1, 2020
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)CP.PHAR.440December 1, 2019
Eliglustat (Cerdelga) (PDF)CP.PHAR.153February 1, 2016
Elivaldogene Autotemcel (Skysona) (PDF)CP.PHAR.556December 1, 2021
Elosulfase Alfa (Vimizim) (PDF)CP.PHAR.162 February 1, 2016
Elotuzumab (Empliciti) (PDF)CP.PHAR.308February 1, 2017
Eltrombopag (Promacta) (PDF)CP.PHAR.180March 1, 2016
Eluxadoline (Viberzi) (PDF)CP.PMN.170December 1, 2018
Emapalumab-lzsg (Gamifant) (PDF)CP.PHAR.402December 11, 2018
Emicizumab-kxwh (Hemlibra) (PDF)CP.PHAR.370March 1, 2018
Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF)CP.PMN.235June 1, 2020
Enasidenib (Idhifa) (PDF)CP.PHAR.363September 5, 2017
Encorafenib (Braftovi) (PDF)CP.PHAR.127July 24, 2018
Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455March 1, 2020
Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41June 1, 2010
Enoxaparin (Lovenox) (PDF)CP.PHAR.224May 1, 2016
Entecavir (Baraclude) (PDF)HIM.PA.08February 19, 2019
Entrectinib (Rozlytrek) (PDF)CP.PHAR.441December 1, 2019
Enzalutamide (Xtandi) (PDF)HIM.PA.164March 1, 2022
Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF)CP.PHAR.237June 1, 2016
Epoprostenol (Flolan, Veletri) (PDF)CP.PHAR.192March 1, 2016
Eptinezumab-jjmr (Vyepti) (PDF)HIM.PA.SP64October 1, 2020
Erdafitinib (Balversa) (PDF)CP.PHAR.423September 1, 2019
Erenumab-aaoe (Aimovig) (PDF)HIM.PA.SP65October 1, 2020
Eribulin Mesylate (Halaven) (PDF)CP.PHAR.318March 1, 2017
Erlotinib (Tarceva) (PDF)CP.PHAR.74September 1, 2011
Erwinia Asparaginase (Erwinaze, Rylaze) (PDF)CP.PHAR.301February 1, 2017
Esketamine (Spravato) (PDF)CP.PMN.199March 12, 2019
Estradiol Vaginal Ring (Femring) (PDF)CP.PMN.263January 1, 2022
Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379March 20, 2018
Eteplirsen (Exondys 51) (PDF)CP.PHAR.288December 1, 2016
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)CP.PHAR.63June 1, 2011
Evinacumab-dgnb (Evkeeza) (PDF)CP.PHAR.511December 1, 2020
Evolocumab (Repatha) (PDF)HIM.PA.156June 1, 2021
Factor IX (Human, Recombinant) (PDF)CP.PHAR.218May 1, 2016
Factor IX Complex, Human (Profilnine) (PDF)CP.PHAR.219May 1, 2016
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF)CP.PHAR.220May 1, 2016
Factor VIII (Human, Recombinant) (PDF)CP.PHAR.215 May 1, 2016
Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (PDF)CP.PHAR.216May 1, 2016
Factor XIII A-Subunit, Recombinant (Tretten) (PDF)CP.PHAR.222May 1, 2016
Factor XIII, Human (Corifact) (PDF)CP.PHAR.221May 1, 2016
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.456March 1, 2020
Faricimab-svoa (Vabysmo) (PDF)CP.PHAR.581June 1, 2022
Febuxostat (Uloric) (PDF)CP.PMN.57August 1, 2013
Fedratinib (Inrebic) (PDF)CP.PHAR.442December 1, 2019
Fenfluramine (Fintepla)CP.PMN.246September 1, 2020
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)CP.PMN.127June 1, 2015
Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234June 1, 2016
Ferric Derisomaltose (Monoferric) (PDF)CP.PHAR.480June 1, 2020
Ferric Gluconate (Ferrlecit) (PDF)CP.PHAR.166March 1, 2016
Ferric Maltol (Accrufer) (PDF)CP.PMN.213December 1, 2019
Ferumoxytol (Feraheme) (PDF)CP.PHAR.165March 1, 2016
Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF)CP.PHAR.526June 1, 2021
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko) (PDF)CP.PHAR.297December 1, 2016
Finerenone (Kerendia) (PDF)CP.PMN.266December 1, 2021
Fingolimod (Gilenya, Tascenso ODT) (PDF)CP.PCH.38February 1, 2021
Flibanserin (Addyi) (PDF)CP.PHAR.446March 1, 2020
Fluorouracil Cream (Tolak) (PDF)CP.PMN.165December 1, 2018
Fluticasone Propionate (Xhance) (PDF)CP.PMN.95October 24, 2017
Fondaparinux (Arixtra) (PDF)CP.PHAR.226May 1, 2016
Fosdenopterin (Nulibry) (PDF)CP.PHAR.471June 1, 2020
Fostamatinib (Tavalisse) (PDF)CP.PHAR.24June 5, 2018
Fostemsavir (Rukobia) (PDF)CP.PHAR.516March 1, 2021
Fremanezumab-vfrm (Ajovy) (PDF)HIM.PA.SP66October 1, 2020
Fulvestrant (Faslodex Injection) (PDF)CP.PHAR.424September 1, 2019
Gabapentin ER (Gralise, Horizant) (PDF)CP.PMN.240September 1, 2020
Galcanezumab-gnlm (Emgality) (PDF)HIM.PA.SP67October 1, 2020
Galsulfase (Naglazyme) (PDF)CP.PHAR.161  February 1, 2016
Ganaxolone (Ztalmy) (PDF)CP.PMN.278June 1, 2022
Gefitinib (Iressa) (PDF)CP.PHAR.68November 16, 2016
Gemtuzumab Ozogamicin (Mylotarg) (PDF)CP.PHAR.358October 3, 2017
Gilteritinib (Xospata) (PDF)CP.PHAR.412January 15, 2019
Givosiran (Givlaari) (PDF)CP.PHAR.457March 1, 2020
Glasdegib (Daurismo) (PDF)CP.PHAR.413January 8, 2019
Glatiramer Acetate (Copaxone, Glatopa) (PDF)HIM.PA.SP68March 1, 2021
Glecaprevir/Pibrentasvir (Mavyret) (PDF)HIM.PA.SP36 August 31, 2019
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)HIM.PA.53March 1, 2018
Glycerol Phenylbutyrate (Ravicti) (PDF)CP.PHAR.207April 30, 2016
Golodirsen (Vyondys 53) (PDF)CP.PHAR.453March 1, 2020
Goserelin Acetate (Zoladex) (PDF)CP.PHAR.171November 9, 2017
Granisetron (Sancuso, Sustol) (PDF)CP.PMN.74November 1, 2016
Halcinonide (Halog) (PDF)HIM.PA.20August 28, 2018
Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF)CP.PMN.180December 1, 2018
Halobetasol Propionate/Tazarotene (Duobrii) (PDF)CP.PMN.208September 1, 2019
Hemin (Panhematin) (PDF)CP.PHAR.181February 1, 2016
Histrelin Acetate (Vantas, Supprelin LA) (PDF)CP.PHAR.172November 9, 2017
House Dust Mite Allergen Extract (Odactra) (PDF)CP.PMN.111 August 31, 2017
Human Growth Hormone (Somapacitan, Somatropin) (PDF)HIM.PA.161January 1, 2022
Hyaluronate Derivatives (PDF)CP.PHAR.05October 1, 2008
Hydroxyprogesterone Caproate (Makena/compound) (PDF)CP.PHAR.14November 20, 2017
Hydroxyurea (Siklos) (PDF)CP.PMN.193February 19, 2019
Ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.378April 17, 2018
Ibandronate Injection (Boniva) (PDF)CP.PHAR.189November 15, 2017
Ibrutinib (Imbruvica) (PDF)CP.PHAR.126October 1, 2015
Ibuprofen/Famotidine (Duexis) (PDF)CP.PMN.120June 1, 2018
Icatibant (Firazyr) (PDF)CP.PHAR.178March 1, 2016
Icosapent Ethyl (Vascepa) (PDF)CP.PMN.187November 20, 2018
Idecabtagene Vicleucel (Abecma) (PDF)CP.PHAR.481June 1, 2020
Idelalisib (Zydelig) (PDF)CP.PHAR.133December 1, 2018
Idursulfase (Elaprase) (PDF)CP.PHAR.156 February 1, 2016
Iloperidone (Fanapt) (PDF)CP.PMN.32December 1, 2014
Iloprost (Ventavis) (PDF)CP.PHAR.193March 1, 2016
Imatinib (Gleevec) (PDF)CP.PHAR.65June 1, 2011
Imiglucerase (Cerezyme) (PDF)CP.PHAR.154 February 1, 2016
Immune Globulins (PDF)CP.PHAR.103August 1, 2012
Inclisiran (Leqvio) (PDF)CP.PHAR.568March 1, 2022
IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231July 1, 2016
Inebilizumab-cdon (Uplizna) (PDF)CP.PHAR.458March 1, 2020
Infertility and Fertility Preservation (PDF)CP.PHAR.131November 16, 2016
Infigratinib (Truseltiq) (PDF)CP.PHAR.547September 1, 2021
Inhaled Agents for Asthma and COPD (PDF)HIM.PA.153March 1, 2021
Inotersen (Tegsedi) (PDF)CP.PHAR.405November 20, 2018
Inotuzumab Ozogamicin (Besponsa) (PDF)CP.PHAR.359September 26, 2017
Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)CP.PHAR.534June 1, 2021
Insulin Glargine (Rezvoglar, Semglee, Toujeo) (PDF)HIM.PA.09March 1, 2019
Interferon Beta-1a (Avonex, Rebif) (PDF)CP.PHAR.255August 1, 2016
Interferon Beta-1b (Betaseron, Extavia) (PDF)CP.PCH.46March 1, 2022
Interferon Gamma- 1b (Actimmune) (PDF)CP.PHAR.52June 1, 2010
Iobenguane I-131 (Azedra) (PDF)CP.PHAR.459March 1, 2020
Ipilimumab (Yervoy) (PDF)CP.PHAR.319April 17, 2018
Irinotecan Liposome (Onivyde) (PDF)CP.PHAR.304February 1, 2017
Iron Sucrose (Venofer) (PDF)CP.PHAR.167March 1, 2016
Isatuximab-irfc (Sarclisa) (PDF)CP.PHAR.482June 1, 2020
Isavuconazonium (Cresemba) (PDF)CP.PMN.154November 16, 2016
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)CP.PMN.143December 1, 2014
Istradefylline (Nourianz) (PDF)CP.PMN.217March 1, 2020
Itraconazole (Sporanox, Tolsura) (PDF)CP.PMN.124November 1, 2006
Ivabradine (Corlanor) (PDF)CP.PMN.70November 1, 2015
Ivacaftor (Kalydeco) (PDF)CP.PHAR.210May 1, 2016
Ivermectin (Stromectol, Sklice) (PDF)CP.PMN.269December 1, 2021
Ivosidenib (Tibsovo) (PDF)CP.PHAR.137August 21, 2018
Ixazomib (Ninlaro) (PDF)CP.PHAR.302February 1, 2017
Ketorolac Nasal Spray (Sprix) (PDF)CP.PMN.282December 1, 2022
Lanadelumab-fylo (Takhzyro) (PDF)CP.PHAR.396September 25, 2018
Lanreotide (Somatuline Depot) (PDF)CP.PHAR.391August 14, 2018
Lapatinib (Tykerb) (PDF)CP.PHAR.79November 9, 2017
Laronidase (Aldurazyme) (PDF)CP.PHAR.152February 1, 2016
Larotrectinib (Vitrakvi) (PDF)CP.PHAR.414January 15, 2018
Lasmiditan (Reyvow) (PDF)CP.PMN.218March 1, 2020
Latanoprostene Bunod (Vyzulta) (PDF)CP.PMN.108March 1, 2018
Ledipasvir/Sofosbuvir (Harvoni) (PDF)HIM.PA.SP3August 31, 2016
Lefamulin (Xenleta) (PDF)CP.PMN.219March 1, 2020
Lenalidomide (Revlimid) (PDF)CP.PHAR.71July 1, 2011
Lenvatinib (Lenvima) (PDF)CP.PHAR.138December 1, 2018
Letermovir (Prevymis) (PDF)CP.PHAR.367March 1, 2018
Leucovorin Injection (PDF)CP.PHAR.393December 1, 2018
Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (PDF)CP.PHAR.173November 9, 2017
Levodopa Inhalation Powder (Inbrija) (PDF)CP.PMN.267December 1, 2021
Levoketoconazole (Recorlev) (PDF)CP.PMN.275June 1, 2022
Levoleucovorin (Fusilev, Khapzory) (PDF)CP.PHAR.151November 9, 2017
Levomilnacipran (Fetzima) (PDF)HIM.PA.125November 9, 2017
L-glutamine (Endari) (PDF)CP.PMN.116November 9, 2017
Lidocaine Transdermal (Lidoderm, ZTlido) (PDF)CP.PMN.08September 1, 2006
Lifitegrast (Xiidra) (PDF)CP.PMN.73November 9, 2017
Linaclotide (Linzess) (PDF)CP.PMN.71November 1, 2015
Linezolid (Zyvox) (PDF)CP.PMN.27September 1, 2016
Lisocabtagene Maraleucel (Breyanzi) (PDF)CP.PHAR.483June 1, 2020
Lofexidine (Lucemyra) (PDF)CP.PMN.152August 1, 2018
Lomustine (Gleostine) (PDF)CP.PHAR.507December 1, 2020
Lonafarnib (Zokinvy) (PDF)CP.PHAR.499September 1, 2020
Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)CP.PHAR.539September 1, 2021
Lorlatinib (Lorbrena) (PDF)CP.PHAR.406December 11, 2018
Loteprednol etabonate (Eysuvis) (PDF)CP.PMN.260March 1, 2021
Lubiprostone (Amitiza) (PDF)CP.PMN.142December 1, 2014
Luliconazole Cream (Luzu) (PDF)CP.PMN.166August 28, 2018
Lumacaftor/Ivacaftor (Orkambi) (PDF)CP.PHAR.213May 1, 2016
Lumasiran (Oxlumo) (PDF)CP.PHAR.473June 1, 2020
Lumateperone (Caplyta) (PDF)CP.PMN.232March 1, 2020
Lurasidone (Latuda) (PDF)CP.PMN.50December 1, 2014
Lurbinectedin (Zepzelca) (PDF)CP.PHAR.500September 1, 2020
Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.450March 1, 2020
Lusutrombopag (Mulpleta) (PDF)CP.PHAR.407September 18, 2018
Lutetium Lu 177 Dotatate (Lutathera) (PDF)CP.PHAR.384May 22, 2018
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF)CP.PHAR.582June 1, 2022
Macitentan (Opsumit) (PDF)CP.PHAR.194March 1, 2016
Mannitol (Bronchitol) (PDF)CP.PHAR.518March 1, 2021
Maralixibat (Livmarli) (PDF)CP.PHAR.543September 1, 2021
Margetuximab-cmkb (Margenza) (PDF)CP.PHAR.522March 1, 2021
Maribavir (Livtencity) (PDF)CP.PMN.271March 1, 2022
Mavacamten (Camzyos) (PDF)CP.PMN.272March 1, 2022
Mecamylamine (Vecamyl) (PDF)CP.PMN.136May 1, 2017
Mecasermin (Increlex) (PDF)CP.PHAR.150March 1, 2011
Mechlorethamine Gel (Valchlor) (PDF)CP.PHAR.381November 16, 2016
Megestrol Acetate (Megace ES) (PDF)CP.PMN.179December 1, 2018
Melphalan flufenamide (Pepaxto) (PDF)CP.PHAR.535June 1, 2021
Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF)CP.PCH.30September 1, 2020
Mepolizumab (Nucala) (PDF)CP.PHAR.200April 1, 2016
Mercaptopurine (Purixan) (PDF)CP.PHAR.447March 1, 2020
Metformin ER (Fortamet, Glumetza) (PDF)CP.PMN.72October 31, 2015
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)CP.PHAR.134December 1, 2018
Methoxsalen (Uvadex) (PDF)HIM.PA.17September 4, 2018
Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)CP.PHAR.238June 1, 2016
Methylnaltrexone Bromide (Relistor) (PDF)CP.PMN.169December 1, 2018
Metoclopramide (Gimoti) (PDF)CP.PMN.252December 1, 2020
Metreleptin (Myalept) (PDF)CP.PHAR.425September 1, 2019
Midazolam (Nayzilam) (PDF)CP.PMN.211September 1, 2019
Midostaurin (Rydapt) (PDF)CP.PHAR.344June 1, 2017
Mifepristone (Korlym) (PDF)CP.PHAR.101May 1, 2012
Migalastat (Galafold) (PDF)CP.PHAR.394September 11, 2018
Miglustat (Zavesca) (PDF)CP.PHAR.164 February 1, 2016
Milnacipran (Savella) (PDF)CP.PMN.125August 1, 2012
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF)CP.PMN.80April 30, 2017
Mitapivat (Pyrukynd) (PDF)CP.PHAR.558December 1, 2021
Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)CP.PHAR.495September 1, 2020
Mitoxantrone (PDF)CP.PHAR.258August 1, 2016
Mobocertinib (Exkivity) (PDF)CP.PHAR.559December 1, 2021
Modafinil (Provigil) (PDF)CP.PMN.39May 1, 2008
Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.139September 4, 2018
Mometasone (Nasonex) (PDF)HIM.PA.93December 1, 2014
Mometasone Furoate (Sinuva) (PDF)CP.PHAR.448March 1, 2020
Montelukast Oral Granules (Singulair) (PDF)HIM.PA.129November 9, 2017
Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.398October 16, 2018
Nafarelin Acetate (Synarel) (PDF)CP.PHAR.174November 9, 2017
Naltrexone (Vivitrol) (PDF)CP.PHAR.96March 1, 2012
Naproxen Oral Suspension (Naprosyn) (PDF)HIM.PA.130November 9, 2017
Naproxen/Esomeprazole (Vimovo) (PDF)CP.PMN.117June 1, 2018
Natalizumab (Tysabri) (PDF)CP.PHAR.259July 1, 2016
Naxitamab-gqgk (Danyelza) (PDF)CP.PHAR.523March 1, 2021
Necitumumab (Portrazza) (PDF)CP.PHAR.320March 1, 2017
Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF)CP.PMN.167August 28, 2018
Neratinib (Nerlynx) (PDF)CP.PHAR.365September 5, 2017
Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF)CP.PMN.118February 13, 2018
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)CP.PMN.158September 1, 2006
Nifurtimox (Lampit) (PDF)CP.PMN.256December 1, 2020
Nilotinib (Tasigna) (PDF)CP.PHAR.76September 1, 2011
Nintedanib (Ofev) (PDF)CP.PHAR.285October 1, 2016
Niraparib (Zejula) (PDF)CP.PHAR.408May 9, 2017
Nitazoxanide (Alinia) (PDF)HIM.PA.152December 1, 2020
Nitisinone (Nityr, Orfadin) (PDF)CP.PHAR.132August 28, 2018
Nivolumab (Opdivo) (PDF)CP.PHAR.121  July 1, 2015
Nivolumab and Relatlimab-rmbw (Opdualag) (PDF)CP.PHAR.588September 1, 2022
No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (PDF)HIM.PA.33May 1, 2016
Non-Calcium Phosphate Binders (PDF)CP.PMN.04November 15, 2017
Non-Formulary and Formulary Contraceptives (PDF)HIM.PA.100May 1, 2015
Non-Formulary Test Strips (PDF)HIM.PA.34February 1, 2016
Nusinersen (Spinraza) (PDF)CP.PHAR.327November 28, 2017
Obeticholic Acid (Ocaliva) (PDF)CP.PHAR.287November 1, 2016
Obinutuzumab (Gazyva) (PDF)CP.PHAR.305February 1, 2017
Ocrelizumab (Ocrevus) (PDF)CP.PHAR.335April 1, 2017
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)CP.PHAR.40March 1, 2010
Odevixibat (Bylvay) (PDF)CP.PHAR.528June 1, 2021
Ofatumumab (Arzerra, Kesimpta) (PDF)CP.PHAR.306February 1, 2017
Off-Label Drug Use (PDF)HIM.PA.154February 1, 2021
Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)CP.PHAR.292December 1, 2016
Olanzapine/Samidorphan (Lybalvi) (PDF)CP.PMN.265September 1, 2021
Olaparib (Lynparza) (PDF)CP.PHAR.360October 3, 2017
Olaratumab (Lartruvo) (PDF)CP.PHAR.326March 1, 2017
Olipudase Alfa-rpcp (Xenpozyme) (PDF)CP.PHAR.586June 2, 2022
Omacetaxine (Synribo) (PDF)CP.PHAR.108April 1, 2013
Omadacycline (Nuzyra) (PDF)CP.PMN.188November 20, 2018
Omalizumab (Xolair) (PDF)CP.PHAR.01October 1, 2008
OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.232July 1, 2016
Onasemnogene Abeparvovec (Zolgensma) (PDF)CP.PHAR.421June 7, 2019
Ondansetron (Zuplenz) (PDF)CP.PMN.45September 1, 2006
Ophthalmic Corticosteroids (PDF)HIM.PA.03January 1, 2020
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)CP.PHAR.536June 1, 2021
Opicapone (Ongentys) (PDF)CP.PMN.245September 1, 2020
Opioid Analgesics* (PDF)HIM.PA.139August 1, 2018
Osilodrostat (Isturisa) (PDF)CP.PHAR.487September 1, 2020
Osimertinib (Tagrisso) (PDF)CP.PHAR.294December 1, 2016
Ospemifene (Osphena) (PDF)CP.PMN.168August 28, 2018
Overactive Bladder Agents (PDF)CP.PMN.198May 1, 2016
Oxymetazoline (Rhofade, Upneeq) (PDF)CP.PMN.86November 15, 2016
Ozanimod (Zeposia) (PDF)CP.PHAR.462March 1, 2020
Ozenoxacin (Xepi) (PDF)CP.PMN.119January 30, 2018
Paclitaxel, Protein-Bound (Abraxane) (PDF)CP.PHAR.176 July 1, 2015
Pacritinib (Vonjo) (PDF)CP.PHAR.583June 1, 2022
Palbociclib (Ibrance) (PDF)CP.PHAR.125October 1, 2015
Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF)CP.PHAR.291December 1, 2016
Palivizumab (Synagis) (PDF)CP.PHAR.16July 31, 2009
Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF)CP.PCH.44March 1, 2022
Panitumumab (Vectibix) (PDF)CP.PHAR.321March 1, 2017
Panobinostat (Farydak) (PDF)CP.PHAR.382November 16, 2016
Parathyroid Hormone (Natpara) (PDF)CP.PHAR.282November 16, 2016
Paricalcitol Injection (Zemplar) (PDF)CP.PHAR.270August 1, 2016
Pasireotide (Signifor, Signifor LAR) (PDF)CP.PHAR.332March 1, 2017
Patiromer (Veltassa) (PDF)CP.PMN.205September 1, 2019
Patisiran (Onpattro) (PDF)CP.PHAR.395September 11, 2018
Pazopanib (Votrient) (PDF)CP.PHAR.81October 1, 2011
Peanut Allergen Powder-dnfp (Palforzia) (PDF)CP.PMN.220March 1, 2020
Pegaptanib (Macugen) (PDF)CP.PHAR.185March 1, 2016
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF)CP.PHAR.353September 5, 2017
Pegcetacoplan (Empaveli, APL-2) (PDF)CP.PHAR.524March 1, 2021
Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziexten) (PDF)CP.PHAR.296December 1, 2016
Peginterferon Alfa-2a,b (Pegasys, PegIntron) (PDF)CP.PHAR.89October 1, 2011
Peginterferon Beta-1a (Plegridy) (PDF)CP.PHAR.271August 1, 2016
Pegloticase (Krystexxa) (PDF)CP.PHAR.115June 1, 2013
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140July 31, 2018
Pegvisomant (Somavert) (PDF)CP.PHAR.389December 1, 2018
Pembrolizumab (Keytruda) (PDF)CP.PHAR.322March 1, 2017
Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.368October 31, 2017
Pemigatinib (Pemazyre) (PDF)CP.PHAR.496September 1, 2020
Penicillamine (Cuprimine) (PDF)CP.PCH.09December 1, 2018
Perampanel (Fycompa) (PDF)CP.PMN.156November 16, 2016
Pertuzumab (Perjeta) (PDF)CP.PHAR.227June 1, 2016
Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF)CP.PHAR.501September 1, 2020
Pexidartinib (Turalio) (PDF)CP.PHAR.436December 1, 2019
Phendimetrazine (PDF)CP.PCH.47June 1, 2022
Phentermine (Adipex-P, Lomaira) (PDF)CP.PCH.13May 1, 2017
Pilocarpine (Vuity) (PDF)CP.PMN.270December 1, 2021
Pimavanserin (Nuplazid) (PDF)CP.PMN.140November 16, 2016
Pirfenidone (Esbriet) (PDF)CP.PHAR.286October 1, 2016
Pitolisant (Wakix) (PDF)CP.PMN.221March 1, 2020
Plasminogen, Human-tvmh (Ryplazim) (PDF)CP.PHAR.513June 3, 2021
Plecanatide (Trulance) (PDF)HIM.PA.158June 1, 2021
Plerixafor (Mozobil) (PDF)CP.PHAR.323March 1, 2017
Polatuzumab Vedotin-piiq (Polivy) (PDF)CP.PHAR.433September 1, 2019
Pomalidomide (Pomalyst) (PDF)CP.PHAR.116July 1, 2013
Ponatinib (Iclusig) (PDF)CP.PHAR.112June 1, 2013
Ponesimod (Ponvory) (PDF)CP.PHAR.537June 1, 2021
Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF)HIM.PA.143October 31, 2017
Pralatrexate (Folotyn) (PDF)CP.PHAR.313February 1, 2017
Pramlintide (Symlin) (PDF)CP.PMN.129June 1, 2018
Prasterone (Intrarosa) (PDF)CP.PMN.99December 20, 2016
Pregabalin (Lyrica, Lyrica CR) (PDF)CP.PMN.33January 1, 2007
Pretomanid (PDF)CP.PMN.222March 1, 2020
Progesterone (Crinone, Endometrin, Milprosa) (PDF)CP.PMN.243September 1, 2020
Propranolol HCl Oral Solution (Hemangeol) (PDF)CP.PMN.58May 1, 2014
Protein C Concentrate, Human (Ceprotin) (PDF)CP.PHAR.330March 1, 2017
Prucalopride (Motegrity) (PDF)HIM.PA.159June 1, 2021
Pyrimethamine (Daraprim) (PDF)CP.PMN.44 November 1, 2015
Quetiapine Extended-Release (Seroquel XR) (PDF)CP.PMN.64December 1, 2014
Quinine Sulfate (Qualaquin) (PDF)CP.PMN.262June 1, 2021
Ramucirumab (Cyramza) (PDF)CP.PHAR.119May 1, 2015
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (PDF)CP.PHAR.186April 1, 2016
Rasagiline (Azilect) (PDF)HIM.PA.89December 1, 2014
Ravulizumab-cwvz (Ultomiris) (PDF)CP.PHAR.415February 19, 2019
Regorafenib (Stivarga) (PDF)CP.PHAR.107December 1, 2012
Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) (PDF)CP.PHAR.529June 1, 2021
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF)CP.PHAR.168March 1, 2016
Reslizumab (Cinqair) (PDF)CP.PHAR.223May 1, 2016
Ribavirin (Rebetol, Ribasphere) (PDF)CP.PHAR.141November 16, 2016
Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF)CP.PHAR.334May 1, 2017
Rifabutin (Mycobutin) (PDF)CP.PMN.223March 1, 2020
Rifamycin (Aemcolo) (PDF)CP.PMN.196January 8, 2019
Rifaximin (Xifaxan) (PDF)CP.PMN.47November 1, 2011
Rilonacept (Arcalyst) (PDF)CP.PHAR.266November 16, 2016
RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.233July 1, 2016
Rimegepant (Nurtec ODT) (PDF)CP.PHAR.490September 1, 2020
Riociguat (Adempas) (PDF)CP.PHAR.195March 1, 2016
Ripretinib (Qinlock) (PDF)CP.PHAR.502September 1, 2020
Risdiplam (Evrysdi) (PDF)CP.PHAR.477August 6, 2020
Risedronate (Actonel, Atelvia) (PDF)CP.PMN.100March 1, 2018
Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF)CP.PHAR.293December 1, 2016
Rolapitant (Varubi) (PDF)CP.PMN.102February 1, 2017
Romidepsin (Istodax) (PDF)CP.PHAR.314January 1, 2017
Romiplostim (Nplate) (PDF)CP.PHAR.179March 1, 2016
Romosozumab-aqqg (Evenity) (PDF)CP.PHAR.428September 1, 2019
Ropeginterferon Alfa-2b-njft (BESREMi) (PDF)CP.PHAR.570March 1, 2022
Rucaparib (Rubraca) (PDF)CP.PHAR.350September 1, 2017
Rufinamide (Banzel) (PDF)CP.PMN.157December 1, 2014
Ruxolitinib (Jakafi, Opzelura) (PDF)CP.PHAR.98March 1, 2012
Sacituzumab Govitecan-hziy (Trodelvy) (PDF)CP.PHAR.475June 1, 2020
Sacituzumab Govitecan-hziy (Trodelvy) (PDF)CP.PHAR.475June 1, 2020
Sacubitril/Valsartan (Entresto) (PDF)CP.PMN.67November 1, 2015
Safinamide (Xadago) (PDF)CP.PMN.113July 1, 2017
Sapropterin Dihydrochloride (Kuvan) (PDF)CP.PHAR.43February 1, 2010
Sarecycline (Seysara) (PDF)CP.PMN.189November 13, 2018
Sargramostim (Leukine) (PDF)CP.PHAR.295December 1, 2016
Satralizumab-mwge (Enspryng) (PDF)CP.PHAR.463March 1, 2020
Sebelipase Alfa (Kanuma) (PDF)CP.PHAR.159February 1, 2016
Secnidazole (Solosec) (PDF)CP.PMN.103October 24, 2017
Selexipag (Uptravi) (PDF)CP.PHAR.196March 1, 2016
Selinexor (Xpovio) (PDF)CP.PHAR.431September 1, 2019
Selpercatinib (Retevmo) (PDF)CP.PHAR.478June 1, 2020
Selumetinib (Koselugo) (PDF)CP.PHAR.464March 1, 2020
Setmelanotide (Imcivree) (PDF)CP.PHAR.491September 1, 2020
Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF)CP.PMN.83 August 31, 2017
Sildenafil (Revatio) (PDF)CP.PHAR.197March 1, 2016
Sildenafil for ED (Viagra) (PDF)CP.PCH.07June 1, 2018
Siltuximab (Sylvant) (PDF)CP.PHAR.329March 1, 2017
Siponimod (Mayzent) (PDF)CP.PHAR.427September 1, 2019
Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (PDF)CP.PHAR.574March 1, 2022
Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (PDF)CP.PMN.42May 1, 2011
Sodium Phenylbutyrate (Buphenyl, Pheburane) (PDF)CP.PHAR.208May 1, 2016
Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF)CP.PHAR.584June 1, 2022
Sodium Zirconium Cyclosilicate (Lokelma) (PDF)CP.PMN.163July 24, 2018
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)HIM.PA.91January 1, 2015
Sofosbuvir (Sovaldi) (PDF)HIM.PA.SP2 August 31, 2016
Sofosbuvir/Velpatasvir (Epclusa) (PDF)HIM.PA.SP1August 31, 2016
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)HIM.PA.SP63 August 1, 2020
Solriamfetol (Sunosi) (PDF)CP.PMN.209September 1, 2019
Sonidegib (Odomzo) (PDF)CP.PHAR.272May 1, 2012
Sorafenib (Nexavar) (PDF)CP.PHAR.69July 1, 2011
Spinosad (Natroba) (PDF)HIM.PA.134November 9, 2017
Step Therapy (PDF)HIM.PA.109August 1, 2017
Stiripentol (Diacomit) (PDF)CP.PMN.184September 25, 2018
Sunitinib (Sutent) (PDF)CP.PHAR.73September 1, 2011
Sutimlimab-jome (Enjaymo) (PDF)CP.PHAR.503February 3, 2022
Suvorexant (Belsomra) (PDF)CP.PMN.109February 1, 2017
Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF)CP.PMN.85 August 31, 2017
Tadalafil (Adcirca, Alyq, Tadliq) (PDF)CP.PHAR.198March 1, 2016
Tadalafil BPH - ED (Cialis) (PDF)CP.PMN.132June 1, 2018
Tafamidis (Vyndaqel, Vyndamax) (PDF)CP.PHAR.432September 1, 2019
Tafasitamab-cxix (Monjuvi) (PDF)CP.PHAR.508December 1, 2020
Talazoparib (Talzenna) (PDF)CP.PHAR.409November 27, 2018
Taliglucerase Alfa (Elelyso) (PDF)HIM.PA.162January 1, 2022
Talimogene laherepvec (Imlygic) (PDF)CP.PHAR.542September 1, 2021
Tapinarof (Vtama) (PDF)CP.PMN.283December 1, 2022
Tasimelteon (Hetlioz, Hetlioz LQ) (PDF)CP.PMN.104February 1, 2017
Tavaborole (Kerydin) (PDF)CP.PMN.105March 1, 2018
Tazarotene (Arazlo, Fabior, Tazorac) (PDF)CP.PMN.244September 1, 2020
Tazemetostat (Tazverik) (PDF)CP.PHAR.452March 1, 2020
Tebentafusp-tebn (Kimmtrak) (PDF)CP.PHAR.575June 1, 2022
Tedizolid (Sivextro) (PDF)CP.PMN.62March 1, 2015
Teduglutide (Gattex) (PDF)CP.PHAR.114May 1, 2013
Tegaserod (Zelnorm) (PDF)HIM.PA.160June 1, 2021
Telotristat Ethyl (Xermelo) (PDF)CP.PHAR.337June 1, 2017
Temozolomide (Temodar) (PDF)CP.PHAR.77September 1, 2011
Temsirolimus (Torisel) (PDF)CP.PHAR.324March 1, 2017
Tenapanor (Ibsrela) (PDF)CP.PMN.224March 1, 2020
Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)CP.PMN.268December 1, 2021
Tepotinib (Tepmetko) (PDF)CP.PHAR.530June 1, 2021
Teprotumumab (Tepezza) (PDF)CP.PHAR.465January 21, 2020
Teriflunomide (Aubagio) (PDF)CP.PCH.40February 1, 2021
Teriparatide (Forteo) (PDF)CP.PHAR.188November 15, 2017
Tesamorelin (Egrifta SV) (PDF)CP.PHAR.109March 1, 2014
Testosterone (Androderm) (PDF)HIM.PA.87December 1, 2014
Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (PDF)CP.PHAR.354August 1, 2017
Tetrabenazine (Xenazine) (PDF)CP.PHAR.92December 1, 2011
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)CP.PHAR.377April 3, 2018
Tezepelumab-ekko (Tezspire) (PDF)CP.PHAR.576June 1, 2022
Thalidomide (Thalomid) (PDF)CP.PHAR.78September 1, 2011
Thioguanine (Tabloid) (PDF)CP.PHAR.437December 1, 2019
Thyrotropin Alfa (Thyrogen) (PDF)CP.PHAR.95March 1, 2012
Timothy Grass Pollen Allergen Extract (Grastek) (PDF)CP.PMN.84 August 31, 2017
Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.361September 26, 2017
Tisotumab Vedotin-tftv (Tivdak) (PDF)CP.PHAR.561December 1, 2021
Tivozanib (Fotivda) (PDF)CP.PHAR.538June 1, 2021
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF)CP.PHAR.211May 1, 2016
Tolvaptan (Jynarque, Samsca) (PDF)CP.PHAR.27June 5, 2018
Topical Acne Treatment (PDF)HIM.PA.71December 1, 2014
Topical Immunomodulators (PDF)CP.PMN.107September 1, 2006
Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF)CP.PMN.281September 1, 2022
Topotecan (Hycamtin) (PDF)CP.PHAR.64June 1, 2011
Trabectedin (Yondelis) (PDF)CP.PHAR.204May 1, 2016
Tralokinumab-ldrm (Adbry) (PDF)CP.PHAR.577June 1, 2022
Trametinib (Mekinist) (PDF)CP.PHAR.240July 1, 2016
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)CP.PHAR.228June 1, 2016
Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI) (PDF)CP.PHAR.199 March 1, 2016
Triamcinolone ER Injection (Zilretta) (PDF)CP.PHAR.371March 1, 2018
Triclabendazole (Egaten) (PDF)CP.PMN.207September 1, 2019
Trientine (Cuvrior, Syprine) (PDF)CP.PHAR.438December 1, 2019
Trifarotene (Aklief) (PDF)CP.PMN.225March 1, 2020
Trifluridine/Tipiracil (Lonsurf) (PDF)CP.PHAR.383November 16, 2016
Triheptanoin (Dojolvi) (PDF)CP.PHAR.509December 1, 2020
Triptorelin Pamoate (Trelstar, Triptodur) (PDF)CP.PHAR.175November 9, 2017
Tucatinib (Tukysa) (PDF)CP.PHAR.497September 1, 2020
Ubrogepant (Ubrelvy) (PDF)CP.PHAR.476June 1, 2020
Ulcer Therapy Combinations (PDF)CP.PMN.277June 1, 2022
Umbralisib (Ukoniq) (PDF)CP.PHAR.531June 1, 2021
Uridine Triacetate (Vistogard) (PDF)HIM.PA.SP55November 9, 2017
Valbenazine (Ingrezza) (PDF)CP.PCH.48September 1, 2022
Valganciclovir (Valcyte) (PDF)CP.PCH.06November 16, 2016
Valrubicin (Valstar) (PDF)CP.PHAR.439December 1, 2019
Vandetanib (Caprelsa) (PDF)CP.PHAR.80October 1, 2011
Varenicline (Tyrvaya) (PDF)CP.PMN.273March 1, 2022
Velaglucerase Alfa (VPRIV) (PDF)HIM.PA.163January 1, 2022
Vemurafenib (Zelboraf) (PDF)CP.PHAR.91November 1, 2011
Venetoclax (Venclexta) (PDF)CP.PHAR.129September 1, 2018
Verteporfin (Visudyne) (PDF)CP.PHAR.187March 1, 2016
Vestronidase Alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374January 19, 2018
Vigabatrin (Sabril) (PDF)CP.PHAR.169 February 1, 2016
Vilazodone (Viibryd) (PDF)CP.PMN.145August 1, 2012
Viloxazine (Qelbree) (PDF)CP.PMN.264June 1, 2021
Viltolarsen (Viltepso) (PDF)CP.PHAR.484August 12, 2020
Vincristine Sulfate Liposome Injection (Marqibo) (PDF)CP.PHAR.315February 1, 2017
Vismodegib (Erivedge) (PDF)CP.PHAR.273August 1, 2016
Voclosporin (Lupkynis) (PDF)CP.PHAR.504September 1, 2020
Vorapaxar (Zontivity) (PDF)HIM.PA.146October 31, 2017
Voretigene Neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.372March 1, 2018
Vorinostat (Zolinza) (PDF)CP.PHAR.83December 1, 2012
Vortioxetine (Trintellix) (PDF)CP.PMN.65 May 31, 2017
Vosoritide (Voxzogo) (PDF)CP.PHAR.525March 1, 2021
Voxelotor (Oxbryta) (PDF)CP.PHAR.451March 1, 2020
Vutrisiran (Amvuttra) (PDF)CP.PHAR.550December 1, 2021
Zanubrutinib (Brukinsa) (PDF)CP.PHAR.467March 1, 2020
Ziv-aflibercept (Zaltrap) (PDF)CP.PHAR.325March 1, 2017
Zoledronic Acid (Reclast, Zometa) (PDF)CP.PHAR.59March 1, 2011