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 WellCare of North Carolina Clinical Policy Manual apply to WellCare of North Carolina members. Policies in the WellCare of North Carolina Clinical Policy Manual may have either a WellCare of North Carolina or a “Centene” heading. WellCare of North Carolina utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a WellCare of North Carolina 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 WellCare of North Carolina. In addition, WellCare of North Carolina 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 WellCare of North Carolina.   

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

Clinical Policy List

A-GH-OP-Z
ADHD Assessment and Treatment (PDF)
Effective Date: 1/1/2022		H Pylori Testing (PDF)
Effective Date: 1/1/2022		Pancreas transplant (PDF)
Effective Date: 2/28/2022
Air Ambulance (PDF)
Effective Date: 1/1/2022
Heart-Lung Transplant (PDF)
Effective Date: 2/28/2022
Pediatric heart transplant (PDF)
Effective Date: 1/1/2022
Allergy Testing (PDF)
Effective Date: 1/1/2022
Holter Monitors (PDF)
Effective Date: 1/1/2022		Pediatric Liver Transplant (PDF)
Effective Date: 2/28/2022
Allogeneic hematopoietic cell transplants for sickle cell anemia and beta-thalassemia (PDF)
Effective Date: 1/1/2022
Home Birth (PDF)
Effective Date: 1/31/2022
Pediatric Oral Function Therapy (PDF)
Effective Date: 5/30/2022
Ambulatory EEG (PDF)
Effective Date: 1/1/2022
Home phototherapy for neonatal hyperbilirubinemia (PDF)
Effective Date: 1/1/2022
 
Articular Cartilage Defect Repairs (PDF)
Effective Date: 1/1/2022
Homocysteine Testing (PDF)
Effective Date: 1/1/2022		Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: 5/30/2022
 Hospice Services (PDF)
Effective Date: 1/1/2022		Physical, Occupational, and Speech Therapy Services (PDF)
Effective Date: 1/1/2022
Assisted Reproductive Technology (PDF)
Effective Date: 1/1/2022
Hyperemesis gravidarum treatment (PDF)
Effective Date: 2/28/2022		Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: 1/1/2022
Bone-anchored hearing aid (PDF)
Effective Date: 1/1/2022
Hyperhidrosis treatments (PDF)
Effective Date: 1/31/2022		 
 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
Effective Date: 1/1/2022		Posterior tibial nerve stimulation for voiding dysfunction (PDF)
Effective Date: 8/31/2022
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/2022
Implantable Intrathecal Pain Pump (PDF)
Effective Date: 1/31/2022		PROM Testing (PDF)
Effective Date: 1/1/2022
Burn Surgery (PDF)
Effective Date: 1/1/2022		Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
Effective Date: 2/28/2022		Proton and neutron beam therapies (PDF)
Effective Date: 11/30/2022
 Inhaled nitric oxide (PDF)
Effective Date: 4/30/2022		Radial Head Implant (PDF)
Effective Date: 5/30/2022
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 1/1/2022		Intensity-Modulated Radiotherapy (PDF)
Effective Date: 1/1/2022
Radiofrequency Ablation of Uterine Fibroids (PDF)
Effective Date: 2/28/2022
Caudal or Interlaminar Epidural Steroid Injections (PDF)
Effective Date: 1/1/2022		Intestinal and multivisceral transplant (PDF)
Effective Date: 2/28/2022		Reduction mammoplasty and gynecomastia surgery (PDF)
Effective Date: 7/30/2022
 Intradiscal Steroid Injections for Pain Management (PDF)
Effective Date: 8/31/2022		Repair of Nasal Valve Compromise (PDF)
Effective Date: 5/30/2022
Clinical Trials (PDF)
Effective Date: 6/30/2022		Laser Skin Treatment (PDF)
Effective Date: 1/1/2022		 
Cochlear Implant Replacements (PDF)
Effective Date: 7/30/2022		Long Term Care Placement Criteria (PDF)
Effective Date: 4/30/2022		Sacroiliac joint fusion (PDF)
Effective Date: 6/30/2022
 Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/2022		Sacroiliac Joint Interventions for Pain Management (PDF)
Effective Date: 8/31/2022

Dental Anesthesia (PDF)
Effective Date: 1/1/2022		Lung Transplantation (PDF)
Effective Date: 2/28/2022		Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF)
Effective Date: 4/30/2022
Diaphragmatic/Phrenic Nerve Stimulation (PDF)
Effective Date: 1/1/2022		Lysis of Epidural Lesions (PDF)
Effective Date: 5/30/2022		Selective Dorsal Rhizotomy (PDF)
Effective Date: 1/1/2022
Digital EEG Analysis (PDF)
Effective Date: 1/1/2022
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 1/1/2022		Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF)
Effective Date: 8/31/2022
Disc Decompression Procedures (PDF)
Effective Date: 5/30/2022		Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
Effective Date: 1/1/2022		Short Inpatient Hospital Stay (PDF)
Effective Date: 1/1/2022
 Multiple Sleep Latency Testing (PDF)
Effective Date: 4/30/2022		Skilled Nursing Facility Leveling (PDF)
Effective Date: 2/4/2022
Donor lymphocyte infusion (PDF)
Effective Date: 1/1/2022		Neonatal abstinence syndrome guidelines (PDF)
Effective Date: 2/28/2022		Skin Substitutes for Chronic Wounds (PDF)
Effective Date: 4/30/2022
Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (PDF)
Effective Date: 1/1/2022		Neonatal sepsis management (PDF)
Effective Date: 7/30/2022
Spinal Cord Stimulation (PDF)
Effective Date: 2/28/2022
Durable Medical Equipment (DME) (PDF)
Effective Date: 1/1/2022		Nerve Blocks for Pain Management (PDF)
Effective Date: 8/31/2022		Stereotactic Body Radiation Therapy (PDF)
Effective Date: 1/31/2022
EEG in Evaluation of Headache (PDF)
Effective Date: 1/1/2022		Neuromuscular Electrical Stimulation (NMES) (PDF)
Effective Date: 7/30/2022		Tandem Transplant (PDF)
Effective Date: 2/28/2022
Electric Tumor Treating Fields (PDF)
Effective Date: 1/1/2022		NICU Apnea Bradycardia Guidelines (PDF)
Effective Date: 6/30/2022		Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis) (PDF)
Effective Date: 1/1/2022
 NICU discharge guidelines (PDF)
Effective Date: 6/30/2022		 
Endometrial Ablation (PDF)
Effective Date: 1/1/2022		Non-Invasive Home Ventilators (PDF)
Effective Date: 6/30/2022		Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/2022
 Non-myeloablative allogeneic stem cell transplants (PDF)
Effective Date: 2/28/2022		Total artificial heart (PDF)
Effective Date: 1/1/2022
Evoked Potentials (PDF)
Effective Date: 1/1/2022		Obstetrical Home Health Care Programs (PDF)
Effective Date: 1/1/2022		Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Effective Date: 4/30/2022
Facet Joint Interventions (PDF)
Effective Date: 7/30/2022		Optic nerve decompression surgery (PDF)
Effective Date: 7/30/2022		Transcatheter closure of patent foramen ovale (PDF)
Effective Date: 1/1/2022
Fecal incontinence treatments (PDF)
Effective Date: 7/30/2022		 Trigger Point Injections for Pain Management (PDF)
Effective Date: 8/31/2022
Ferriscan R2-MRI (PDF)
Effective Date: 1/1/2022		Osteogenic Stimulation (PDF)
Effective Date: 9/30/2022		Ultrasound in Pregnancy (PDF)
Effective Date: 1/1/2022
Fertility preservation (PDF) 
Effective Date: 5/30/2022		Outpatient Cardiac Rehabilitation (PDF)
Effective Date: 5/30/2022		Urinary Incontinence Devices and Treatments (PDF)
Effective Date: 1/1/2022
Fetal surgery in utero for prenatally diagnosed malformations (PDF)
Effective Date: 7/30/2022		Oxygen Use and Concentrators (PDF)
Effective Date: 1/1/2022		Urodynamic Testing (PDF)
Effective Date: 1/1/2022
Functional MRI (PDF)
Effective Date: 2/28/2022
 Vagus Nerve Stimulation (PDF)
Effective Date: 8/31/2022
Gastric Electrical Stimulation (PDF)
Effective Date: 2/28/2022		 Ventricular Assist Devices (PDF)
Effective Date: 2/28/2022
Gender Affirming Procedures (PDF)
Effective Date: 1/1/2022		 Vitamin D Testing in Children (PDF)
Effective Date: 1/1/2022
  Wheelchair Seating (PDF)
Effective Date: 1/1/2022
  Wireless Motility Capsule (PDF)
Effective Date: 1/1/2022

Payment Policy List

A-GH-PQ-Z
3 Day Payment Window (PDF)
Effective Date: 1/1/2022		Leveling of Care: Evaluation and Management Overcoding (PDF)
Effective Date: 1/1/2022
Renal Hemodialysis
Effective Date: 1/1/2022
30 Day Readmission (PDF)
Effective Date: 1/1/2022

Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF)
Effective Date: 1/1/2022		Scanning computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF)
Effective Date: 1/1/2022
340B Drug Payment Reduction (PDF)
Effective Date: 1/1/2022
Multiple Procedure Payment Reduction for Therapeutic Services (PDF)
Effective Date: 1/1/2022		Sleep Studies Place of Service (PDF)
Effective Date: 1/1/2022
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/2022
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: 1/1/2022		Urine Specimen Validity Testing (PDF)
Effective Date: 1/1/2022
External Ocular Photography (PDF)
Effective Date: 1/1/2022		Non-Emergent ER Services (fka Leveling of ER Services) (PDF)
Effective Date: 1/1/2022
Visual Field Testing (PDF)
Effective Date: 1/1/2022
Fluorescein Angiography (PDF)
Effective Date: 1/1/2022		Non-Obstetrical and OB Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 1/1/2022
Wheelchair Accessories (PDF)
Effective Date: 1/1/2022
Fundus Photography (PDF)
Effective Date: 1/1/2022		Physician's Consultation Services (PDF)
Effective Date: 1/1/2022		 
Gonioscopy (PDF)
Effective Date: 1/1/2022		Problem-Oriented Visits with Preventative Visits (PDF)
Effective Date: 1/1/2022
 
 Problem-Oriented Visits with Surgical Procedures (PDF)
Effective Date: 1/1/2022
 

Pharmacy Policy List

A-GH-PQ-Z
Abaloparatide (Tymlos) (PDF)
Effective Date: 1/1/2022		Halcinonide (Halog) (PDF)
Effective Date: 1/1/2022		Quetiapine Extended-Release (Seroquel XR) (PDF)
Effective Date: 1/1/2022
Abametapir (Xeglyze) (PDF)
Effective Date: 1/1/2022		Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF)
Effective Date: 1/1/2022		Quinine Sulfate (Qualaquin) (PDF)
Effective Date: 1/1/2022
Abemaciclib (Verzenio) (PDF)
Effective Date: 1/1/2022		Halobetasol Propionate/Tazarotene (Duobrii) (PDF)
Effective Date: 1/1/2022		Ramucirumab (Cyramza) (PDF)
Effective Date: 1/1/2022
Abiraterone (Zytiga, Yonsa) (PDF)
Effective Date: 1/1/2022		Hemin (Panhematin) (PDF)
Effective Date: 1/1/2022		Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF)
Effective Date: 1/1/2022
AbobotulinumtoxinA (Dysport) (PDF)
Effective Date: 1/1/2022		Histrelin Acetate (Vantas, Supprelin LA) (PDF)
Effective Date: 1/1/2022
Rasagiline (Azilect) (PDF)
Effective Date: 1/1/2022
Acyclovir Buccal Tablet (Sitavig) (PDF)
Effective Date: 1/1/2022		House dust mite allergen extract (Odactra) (PDF)
Effective Date: 1/1/2022		Ravulizumab-cwvz (Ultomiris) (PDF)
Effective Date: 1/1/2022
Adefovir (Hepsera) (PDF)
Effective Date: 1/1/2022		Human Growth Hormone (Somapacitan, Somatropin) (PDF)
Effective Date: 1/1/2022		Regorafenib (Stivarga) (PDF)
Effective Date: 1/1/2022
Ado-Trastuzumab Emtansine (Kadcyla) (PDF)
Effective Date: 1/1/2022		Hyaluronate Derivatives (PDF)
Effective Date: 1/1/2022		Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) (PDF)
Effective Date: 1/1/2022
Aducanumab-avwa (Aduhelm) (PDF)
Effective Date: 1/1/2022		Hydroxyprogesterone Caproate (Makena/compound) (PDF)
Effective Date: 1/1/2022
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF)
Effective Date: 1/1/2022
Afamelanotide (Scenesse) (PDF)
Effective Date: 1/1/2022		Hydroxyurea (Siklos) (PDF)
Effective Date: 1/1/2022
Afatinib (Gilotrif) (PDF)
Effective Date: 1/1/2022		Ibalizumab-uiyk (Trogarzo) (PDF)
Effective Date: 1/1/2022		Reslizumab (Cinqair) (PDF)
Effective Date: 1/1/2022
Aflibercept (Eylea) (PDF)
Effective Date: 1/1/2022		Ibandronate Injection (Boniva) (PDF)
Effective Date: 1/1/2022		Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF)
Effective Date: 1/1/2022
Agalsidase Beta (Fabrazyme) (PDF)
Effective Date: 1/1/2022		Ibrutinib (Imbruvica) (PDF)
Effective Date: 1/1/2022		Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF)
Effective Date: 1/1/2022
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)
Effective Date: 1/1/2022		Ibuprofen/Famotidine (Duexis) (PDF)
Effective Date: 1/1/2022		Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF)
Effective Date: 1/1/2022
Alectinib (Alecensa) (PDF)
Effective Date: 1/1/2022		Icatibant (Firazyr) (PDF)
Effective Date: 1/1/2022		Rifamycin (Aemcolo) (PDF)
Effective Date: 1/1/2022
Alemtuzumab (Lemtrada) (PDF)
Effective Date: 1/1/2022		Icosapent Ethyl (Vascepa) (PDF)
Effective Date: 1/1/2022		Rifaximin (Xifaxan) (PDF)
Effective Date: 1/1/2022
Alendronate (Binosto, Fosamax Plus D) (PDF)
Effective Date: 1/1/2022		Idecabtagene Vicleucel (Abecma) (PDF)
Effective Date: 1/1/2022		Rilonacept (Arcalyst) (PDF)
Effective Date: 1/1/2022
Alglucosidase Alfa (Lumizyme) (PDF)
Effective Date: 1/1/2022		Idelalisib (Zydelig) (PDF)
Effective Date: 1/1/2022		RimabotulinumtoxinB (Myobloc) (PDF)
Effective Date: 1/1/2022
Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF)
Effective Date: 1/1/2022		Idursulfase (Elaprase) (PDF)
Effective Date: 1/1/2022		Rimegepant (Nurtec ODT) (PDF)
Effective Date: 1/1/2022
Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF)
Effective Date: 1/1/2022		Iloperidone (Fanapt) (PDF)
Effective Date: 1/1/2022		Riociguat (Adempas) (PDF)
Effective Date: 1/1/2022
Alpelisib (Piqray) (PDF)
Effective Date: 1/1/2022		Iloprost (Ventavis) (PDF)
Effective Date: 1/1/2022		Ripretinib (Qinlock) (PDF)
Effective Date: 1/1/2022
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)
Effective Date: 1/1/2022		Imatinib (Gleevec) (PDF)
Effective Date: 1/1/2022		Risdiplam (Evrysdi) (PDF)
Effective Date: 1/1/2022
Amantadine ER (Gocovri, Osmolex ER) (PDF)
Effective Date: 1/1/2022		Imiglucerase (Cerezyme) (PDF)
Effective Date: 1/1/2022		Risedronate (Actonel, Atelvia) (PDF)
Effective Date: 1/1/2022
Ambrisentan (Letairis) (PDF)
Effective Date: 1/1/2022		Immune Globulins (PDF)
Effective Date: 1/1/2022		Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF)
Effective Date: 1/1/2022
Amifampridine (Firdapse, Ruzurgi) (PDF)
Effective Date: 1/1/2022		Inclisiran (Leqvio) (PDF)
Effective Date: 1/1/2022		Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)
Effective Date: 1/1/2022
Amikacin (Arikayce) (PDF)
Effective Date: 1/1/2022		IncobotulinumtoxinA (Xeomin) (PDF)
Effective Date: 1/1/2022		Rolapitant (Varubi) (PDF)
Effective Date: 1/1/2022
Amisulpride (Barhemsys) (PDF)
Effective Date: 1/1/2022		Inebilizumab-cdon (Uplizna) (PDF)
Effective Date: 1/1/2022		Romidepsin (Istodax) (PDF)
Effective Date: 1/1/2022
Amivantamab-vmjw (Rybrevant) (PDF)
Effective Date: 1/1/2022		Infertility and Fertility Preservation (PDF)
Effective Date: 1/1/2022
Romiplostim (Nplate) (PDF)
Effective Date: 1/1/2022
Anifrolumab-fnia (Saphnelo) (PDF)
Effective Date: 1/1/2022		Infigratinib (Truseltiq) (PDF)
Effective Date: 1/1/2022		Romosozumab-aqqg (Evenity) (PDF)
Effective Date: 1/1/2022
Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)
Effective Date: 1/1/2022		Inhaled Agents for Asthma and COPD (PDF)
Effective Date: 1/1/2022		Ropeginterferon Alfa-2b-njft (BESREMi) (PDF)
Effective Date: 1/1/2022
Antithrombin III (ATryn, Thrombate III) (PDF)
Effective Date: 1/1/2022		Inotersen (Tegsedi) (PDF)
Effective Date: 1/1/2022		Rucaparib (Rubraca) (PDF)
Effective Date: 1/1/2022
Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
Effective Date: 1/1/2022		Inotuzumab Ozogamicin (Besponsa) (PDF)
Effective Date: 1/1/2022		Rufinamide (Banzel) (PDF)
Effective Date: 1/1/2022
Apalutamide (Erleada) (PDF)
Effective Date: 1/1/2022		Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)
Effective Date: 1/1/2022		Ruxolitinib (Jakafi, Opzelura) (PDF)
Effective Date: 1/1/2022
Apomorphine (Apokyn, Kynmobi) (PDF)
Effective Date: 1/1/2022		Insulin Glargine (Rezvoglar, Semglee, Toujeo) (PDF)
Effective Date: 1/1/2022		Sacituzumab Govitecan-hziy (Trodelvy) (PDF)
Effective Date: 1/1/2022
Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)
Effective Date: 1/1/2022		Interferon Beta-1a (Avonex, Rebif) (PDF)
Effective Date: 1/1/2022		Sacubitril/Valsartan (Entresto) (PDF)
Effective Date: 1/1/2022

Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (PDF)
Effective Date: 1/1/2022		Interferon Beta-1b (Betaseron, Extavia) (PDF)
Effective Date: 1/1/2022		Safinamide (Xadago) (PDF)
Effective Date: 1/1/2022
Interferon Gamma- 1b (Actimmune) (PDF)
Effective Date: 1/1/2022		Sapropterin Dihydrochloride (Kuvan) (PDF)
Effective Date: 1/1/2022
Aripiprazole Orally Disintegrating Tablet (PDF)
Effective Date: 1/1/2022		Iobenguane I-131 (Azedra) (PDF)
Effective Date: 1/1/2022		Sarecycline (Seysara) (PDF)
Effective Date: 1/1/2022
Armodafinil (Nuvigil) (PDF)
Effective Date: 1/1/2022		Ipilimumab (Yervoy) (PDF)
Effective Date: 1/1/2022		Sargramostim (Leukine) (PDF)
Effective Date: 1/1/2022
Asciminib (Scemblix) (PDF)
Effective Date: 1/1/2022		Irinotecan Liposome (Onivyde) (PDF)
Effective Date: 1/1/2022		Satralizumab-mwge (Enspryng) (PDF)
Effective Date: 1/1/2022
Asenapine (Saphris, Secuado) (PDF)
Effective Date: 1/1/2022		Iron Sucrose (Venofer) (PDF)
Effective Date: 1/1/2022		Sebelipase Alfa (Kanuma) (PDF)
Effective Date: 1/1/2022
Asfotase Alfa (Strensiq) (PDF)
Effective Date: 1/1/2022		Isatuximab-irfc (Sarclisa) (PDF)
Effective Date: 1/1/2022		Secnidazole (Solosec) (PDF)
Effective Date: 1/1/2022
Aspirin/Dipyridamole (Aggrenox) (PDF)
Effective Date: 1/1/2022		Isavuconazonium (Cresemba) (PDF)
Effective Date: 1/1/2022		Selexipag (Uptravi) (PDF)
Effective Date: 1/1/2022
Atezolizumab (Tecentriq) (PDF)
Effective Date: 1/1/2022		Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)
Effective Date: 1/1/2022		Selinexor (Xpovio) (PDF)
Effective Date: 1/1/2022
Avacopan (Tavneos) (PDF)
Effective Date: 1/1/2022
Istradefylline (Nourianz) (PDF)
Effective Date: 1/1/2022		Selpercatinib (Retevmo) (PDF)
Effective Date: 1/1/2022
Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF)
Effective Date: 1/1/2022		Itraconazole (Sporanox, Tolsura) (PDF)
Effective Date: 1/1/2022		Selumetinib (Koselugo) (PDF)
Effective Date: 1/1/2022
Avapritinib (Ayvakit) (PDF)
Effective Date: 1/1/2022		Ivabradine (Corlanor) (PDF)
Effective Date: 1/1/2022		Setmelanotide (Imcivree) (PDF)
Effective Date: 1/1/2022
Avatrombopag (Doptelet) (PDF)
Effective Date: 1/1/2022		Ivacaftor (Kalydeco) (PDF)
Effective Date: 1/1/2022		Short ragweed pollen allergen extract (Ragwitek) (PDF)
Effective Date: 1/1/2022
Avelumab (Bavencio) (PDF)
Effective Date: 1/1/2022		Ivermectin (Stromectol, Sklice) (PDF)
Effective Date: 1/1/2022		Sildenafil (Revatio) (PDF)
Effective Date: 1/1/2022
Axicabtagene Ciloleucel (Yescarta) (PDF)
Effective Date: 1/1/2022		Ivosidenib (Tibsovo) (PDF)
Effective Date: 1/1/2022		Sildenafil for ED (Viagra) (PDF)
Effective Date: 1/1/2022
Axitinib (Inlyta) (PDF)
Effective Date: 1/1/2022		Ixazomib (Ninlaro) (PDF)
Effective Date: 1/1/2022		Siltuximab (Sylvant) (PDF)
Effective Date: 1/1/2022
Azacitidine (Onureg, Vidaza) (PDF)
Effective Date: 1/1/2022		lacosamide (Vimpat) (PDF)
Effective Date: 1/1/2022		Siponimod (Mayzent) (PDF)
Effective Date: 1/1/2022
Azelaic Acid (Finacea Topical Gel) (PDF)
Effective Date: 1/1/2022		Lactitol (Pizensy) (PDF)
Effective Date: 1/1/2022		Sirolimus Protein-Bound Particles (Fyarro) (PDF)
Effective Date: 1/1/2022
Aztreonam (Cayston) (PDF)
Effective Date: 1/1/2022		Lanadelumab-fylo (Takhzyro) (PDF)
Effective Date: 1/1/2022		Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav)  (PDF)
Effective Date: 1/1/2022
Baclofen (Gablofen, Lioresal, Lyvispah,  Ozobax) (PDF)
Effective Date: 1/1/2022		Lanreotide (Somatuline Depot) (PDF)
Effective Date: 1/1/2022		Sodium Phenylbutyrate (Buphenyl) (PDF)
Effective Date: 1/1/2022
Baloxavir Marboxil (Xofluza) (PDF)
Effective Date: 1/1/2022		Lapatinib (Tykerb) (PDF)
Effective Date: 1/1/2022		Sodium zirconium cyclosilicate (Lokelma) (PDF)
Effective Date: 1/1/2022
Laronidase (Aldurazyme) (PDF)
Effective Date: 1/1/2022		Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)
Effective Date: 1/1/2022

Bedaquiline (Sirturo) (PDF)
Effective Date: 1/1/2022		Larotrectinib (Vitrakvi) (PDF)
Effective Date: 1/1/2022		Sofosbuvir (Sovaldi) (PDF)
Effective Date: 1/1/2022
Lasmiditan (Reyvow) (PDF)
Effective Date: 1/1/2022		Sofosbuvir/Velpatasvir (Epclusa) (PDF)
Effective Date: 1/1/2022
Belantamab Mafodotin (Blenrep) (PDF)
Effective Date: 1/1/2022		Latanoprostene Bunod (Vyzulta) (PDF)
Effective Date: 1/1/2022		Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)
Effective Date: 1/1/2022
Belatacept (Nulojix) (PDF)
Effective Date: 1/1/2022		Ledipasvir/Sofosbuvir (Harvoni) (PDF)
Effective Date: 1/1/2022		Solriamfetol (Sunosi) (PDF)
Effective Date: 1/1/2022
Belimumab (Benlysta) (PDF)
Effective Date: 1/1/2022		Lefamulin (Xenleta) (PDF)
Effective Date: 1/1/2022		Sonidegib (Odomzo) (PDF)
Effective Date: 1/1/2022
Belinostat (Beleodaq) (PDF)
Effective Date: 1/1/2022		Lenalidomide (Revlimid) (PDF)
Effective Date: 1/1/2022		Sorafenib (Nexavar) (PDF)
Effective Date: 1/1/2022
Belumosudil (Rezurock) (PDF)
Effective Date: 1/1/2022		Lenvatinib (Lenvima) (PDF)
Effective Date: 1/1/2022		Sotorasib (Lumakras) (PDF)
Effective Date: 1/1/2022
Belzutifan (Welireg) (PDF)
Effective Date: 1/1/2022		Letermovir (Prevymis) (PDF)
Effective Date: 1/1/2022
Spinosad (Natroba) (PDF)
Effective Date: 1/1/2022
Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF)
Effective Date: 1/1/2022		Leucovorin Injection (PDF)
Effective Date: 1/1/2022
Bendamustine (Belrapzo, Bendeka, Treanda) (PDF)
Effective Date: 1/1/2022		Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (PDF)
Effective Date: 1/1/2022		Step Therapy (PDF)
Effective Date: 1/1/2022
Benralizumab (Fasenra) (PDF)
Effective Date: 1/1/2022		Levodopa Inhalation Powder (Inbrija) (PDF)
Effective Date: 1/1/2022		Stiripentol (Diacomit) (PDF)
Effective Date: 1/1/2022
Benznidazole (PDF)
Effective Date: 1/1/2022		Levoleucovorin (Fusilev, Khapzory) (PDF)
Effective Date: 1/1/2022		Sunitinib (Sutent) (PDF)
Effective Date: 1/1/2022
Betaine (Cystadane) (PDF)
Effective Date: 1/1/2022		Levomilnacipran (Fetzima) (PDF)
Effective Date: 1/1/2022		Sutimlimab (PDF)
Effective Date: 1/1/2022
Betamethasone Dipropionate Spray (Sernivo) (PDF)
Effective Date: 1/1/2022		L-glutamine (Endari) (PDF)
Effective Date: 1/1/2022		Suvorexant (Belsomra) (PDF)
Effective Date: 1/1/2022
Lidocaine transdermal (Lidoderm, ZTlido) (PDF)
Effective Date: 1/1/2022		Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF)
Effective Date: 1/1/2022
Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)
Effective Date: 1/1/2022		Lifitegrast (Xiidra) (PDF)
Effective Date: 1/1/2022		Tadalafil (Adcirca, Alyq) (PDF)
Effective Date: 1/1/2022
Bexarotene (Targretin Capsules, Gel) (PDF)
Effective Date: 1/1/2022		Linaclotide (Linzess) (PDF)
Effective Date: 1/1/2022		Tadalafil BHP - ED (Cialis) (PDF)
Effective Date: 1/1/2022
Bezlotoxumab (Zinplava) (PDF)
Effective Date: 1/1/2022		Linezolid (Zyvox) (PDF)
Effective Date: 1/1/2022		Tafamidis (Vyndaqel, Vyndamax) (PDF)
Effective Date: 1/1/2022
Bimatoprost Implant (Durysta) (PDF)
Effective Date: 1/1/2022		Lisocabtagene Maraleucel (Breyanzi) (PDF)
Effective Date: 1/1/2022		Tafasitamab-cxix (Monjuvi) (PDF)
Effective Date: 1/1/2022
Binimetinib (Mektovi) (PDF)
Effective Date: 1/1/2022		Lofexidine (Lucemyra) (PDF)
Effective Date: 1/1/2022		Talazoparib (Talzenna) (PDF)
Effective Date: 1/1/2022
Biologic DMARDs (PDF)
Effective Date: 1/1/2022		Lomustine (Gleostine) (PDF)
Effective Date: 1/1/2022		Taliglucerase Alfa (Elelyso) (PDF)
Effective Date: 1/1/2022
Blinatumomab (Blincyto) (PDF)
Effective Date: 1/1/2022		Lonafarnib (Zokinvy) (PDF)
Effective Date: 1/1/2022		Talimogene laherepvec (Imlygic) (PDF)
Effective Date: 1/1/2022
Bortezomib (Velcade) (PDF)
Effective Date: 1/1/2022		Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)
Effective Date: 1/1/2022		Tasimelteon (Hetlioz, Hetlioz LQ) (PDF)
Effective Date: 1/1/2022
Bosentan (Tracleer) (PDF)
Effective Date: 1/1/2022		Lorcaserin (Belviq, Belviq XR) (PDF)
Effective Date: 1/1/2022		Tavaborole (Kerydin) (PDF)
Effective Date: 1/1/2022
Bosutinib (Bosulif) (PDF)
Effective Date: 1/1/2022		Lorlatinib (Lorbrena) (PDF)
Effective Date: 1/1/2022		Tazarotene (Arazlo, Fabior, Tazorac) (PDF)
Effective Date: 1/1/2022
Brand Name Override and Non-Formulary Medications (PDF)
Effective Date: 1/1/2022		Loteprednol etabonate (Eysuvis) (PDF)
Effective Date: 1/1/2022		Tazemetostat (Tazverik) (PDF)
Effective Date: 1/1/2022
Brentuximab Vedotin (Adcetris) (PDF)
Effective Date: 1/1/2022		Lubiprostone (Amitiza) (PDF)
Effective Date: 1/1/2022		Tedizolid (Sivextro) (PDF)
Effective Date: 1/1/2022
Brexanolone (Zulresso) (PDF)
Effective Date: 1/1/2022		Luliconazole Cream (Luzu)(PDF)
Effective Date: 1/1/2022		Teduglutide (Gattex) (PDF)
Effective Date: 1/1/2022
Brexpiprazole (Rexulti) (PDF)
Effective Date: 1/1/2022		Lumacaftor/Ivacaftor (Orkambi) (PDF)
Effective Date: 1/1/2022		Tegaserod (Zelnorm) (PDF)
Effective Date: 1/1/2022
Brexucabtagene Autoleucel (Tecartus)
Effective Date: 1/1/2022		Lumasiran (Oxlumo) (PDF)
Effective Date: 1/1/2022		Telotristat Ethyl (Xermelo) (PDF)
Effective Date: 1/1/2022
Brigatinib (Alunbrig) (PDF)
Effective Date: 1/1/2022		Lumateperone (Caplyta) (PDF)
Effective Date: 1/1/2022		Temozolomide (Temodar) (PDF)
Effective Date: 1/1/2022
Brimonidine Tartrate (Mirvaso) (PDF)
Effective Date: 1/1/2022		Lurasidone (Latuda) (PDF)
Effective Date: 1/1/2022		Temsirolimus (Torisel) (PDF)
Effective Date: 1/1/2022
Brinzolamide/Brimonidine (Simbrinza) (PDF)
Effective Date: 1/1/2022		Lurbinectedin (Zepzelca) (PDF)
Effective Date: 1/1/2022		Tenapanor (Ibsrela) (PDF)
Effective Date: 1/1/2022
Brivaracetam (Briviact) (PDF)
Effective Date: 1/1/2022		Luspatercept-aamt (Reblozyl) (PDF)
Effective Date: 1/1/2022		Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)
Effective Date: 1/1/2022
Brolucizumab-dbll (Beovu) (PDF)
Effective Date: 1/1/2022		Lusutrombopag (Mulpleta) (PDF)
Effective Date: 1/1/2022
Budesonide (Tarpeyo) (PDF)
Effective Date: 1/1/2022		Lutetium Lu 177 dotatate (Lutathera) (PDF)
Effective Date: 1/1/2022		Tepotinib (Tepmetko) (PDF)
Effective Date: 1/1/2022
Budesonide (Uceris) (PDF)
Effective Date: 1/1/2022		Macitentan (Opsumit) (PDF)
Effective Date: 1/1/2022		Teprotumumab (Tepezza) (PDF)
Effective Date: 1/1/2022
Buprenorphine (Subutex) (PDF)
Effective Date: 1/1/2022		Mannitol (Bronchitol) (PDF)
Effective Date: 1/1/2022		Teriflunomide (Aubagio) (PDF)
Effective Date: 1/1/2022
Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF)
Effective Date: 1/1/2022		Maralixibat (Livmarli) (PDF)
Effective Date: 1/1/2022		Teriparatide (Forteo) (PDF)
Effective Date: 1/1/2022

Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)
Effective Date: 1/1/2022		Margetuximab-cmkb (Margenza) (PDF)
Effective Date: 1/1/2022		Tesamorelin (Egrifta SV) (PDF)
Effective Date: 1/1/2022
Maribavir (Livtencity) (PDF)
Effective Date: 1/1/2022		Testosterone (Androderm) (PDF)
Effective Date: 1/1/2022
Bupropion/Naltrexone (Contrave) (PDF)
Effective Date: 1/1/2022
Mecamylamine (Vecamyl) (PDF)
Effective Date: 1/1/2022		Testosterone (Testopel, Jatenzo) (PDF)
Effective Date: 1/1/2022
Burosumab-twza (Crysvita) (PDF)
Effective Date: 1/1/2022		Tetrabenazine (Xenazine) (PDF)
Effective Date: 1/1/2022
Butorphanol Nasal Spray (PDF)
Effective Date: 1/1/2022		Mecasermin (Increlex) (PDF)
Effective Date: 1/1/2022		Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)
Effective Date: 1/1/2022
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)
Effective Date: 1/1/2022		Mechlorethamine Gel (Valchlor) (PDF)
Effective Date: 1/1/2022		Thalidomide (Thalomid) (PDF)
Effective Date: 1/1/2022
Cabazitaxel (Jevtana) (PDF)
Effective Date: 1/1/2022		Megestrol Acetate (Megace ES) (PDF)
Effective Date: 1/1/2022		Thioguanine (Tabloid) (PDF)
Effective Date: 1/1/2022
Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)
Effective Date: 1/1/2022		Melphalan flufenamide (Pepaxto) (PDF)
Effective Date: 1/1/2022		Thyrotropin alfa (Thyrogen) (PDF)
Effective Date: 1/1/2022
Cabozantinib (Cabometyx, Cometriq) (PDF)
Effective Date: 1/1/2022		Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF)
Effective Date: 1/1/2022
Timothy grass pollen allergen extract (Grastek) (PDF)
Effective Date: 1/1/2022
Calcifediol (Rayaldee) (PDF)
Effective Date: 1/1/2022		Mepolizumab (Nucala) (PDF)
Effective Date: 1/1/2022		Tisagenlecleucel (Kymriah) (PDF)
Effective Date: 1/1/2022
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF)
Effective Date: 1/1/2022		Mercaptopurine (Purixan) (PDF)
Effective Date: 1/1/2022		Tisotumab vedotin-tftv (Tivdak) (PDF)
Effective Date: 1/1/2022
Canakinumab (Ilaris) (PDF)
Effective Date: 1/1/2022		Metformin ER (Fortamet, Glumetza) (PDF)
Effective Date: 1/1/2022		Tivozanib (Fotivda) (PDF)
Effective Date: 1/1/2022
Cannabidiol (Epidiolex) (PDF)
Effective Date: 1/1/2022		Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)
Effective Date: 1/1/2022
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF)
Effective Date: 1/1/2022
Capecitabine (Xeloda) (PDF)
Effective Date: 1/1/2022		Methoxsalen (Uvadex) (PDF)
Effective Date: 1/1/2022
Caplacizumab-yhdp (Cablivi) (PDF)
Effective Date: 1/1/2022		Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)
Effective Date: 1/1/2022		Tolvaptan (Jynarque, Samsca) (PDF)
Effective Date: 1/1/2022
Capmatinib (Tabrecta) (PDF)
Effective Date: 1/1/2022		Methylnaltrexone Bromide (Relistor) (PDF)
Effective Date: 1/1/2022		Topical Acne Treatment (PDF)
Effective Date: 1/1/2022

Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) (PDF)
Effective Date: 1/1/2022		Metoclopramide (Gimoti) (PDF)
Effective Date: 1/1/2022		Topical Immunomodulators (PDF)
Effective Date: 1/1/2022
Metreleptin (Myalept) (PDF)
Effective Date: 1/1/2022		Topotecan (Hycamtin) (PDF)
Effective Date: 1/1/2022
Carfilzomib (Kyprolis) (PDF)
Effective Date: 1/1/2022		Midazolam (Nayzilam) (PDF)
Effective Date: 1/1/2022		Trabectedin (Yondelis) (PDF)
Effective Date: 1/1/2022
Carglumic Acid (Carbaglu) (PDF)
Effective Date: 1/1/2022		Midostaurin (Rydapt) (PDF)
Effective Date: 1/1/2022		Trametinib (Mekinist) (PDF)
Effective Date: 1/1/2022
Casimersen (Amondys 45) (PDF)
Effective Date: 1/1/2022		Mifepristone (Korlym) (PDF)
Effective Date: 1/1/2022		Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)
Effective Date: 1/1/2022
Casirivimab and Imdevimab (REGEN-COV) (PDF)
Effective Date: 1/1/2022		Migalastat (Galafold) (PDF)
Effective Date: 1/1/2022		Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
Effective Date: 1/1/2022
Celecoxib (Celebrex, Elyxyb) (PDF)
Effective Date: 1/1/2022		Miglustat (Zavesca) (PDF)
Effective Date: 1/1/2022		Triamcinolone ER Injection (Zilretta) (PDF)
Effective Date: 1/1/2022
Cemiplimab-rwlc (Libtayo) (PDF)
Effective Date: 1/1/2022		Milnacipran (Savella) (PDF)
Effective Date: 1/1/2022		Triclabendazole (Egaten) (PDF)
Effective Date: 1/1/2022
Cenegermin-bkbj (Oxervate) (PDF)
Effective Date: 1/1/2022		Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF)
Effective Date: 1/1/2022		Trientine (Syprine) (PDF)
Effective Date: 1/1/2022
Cenobamate (Xcopri) (PDF)
Effective Date: 1/1/2022		Trifarotene (Aklief) (PDF)
Effective Date: 1/1/2022
Ceritinib (Zykadia) (PDF)
Effective Date: 1/1/2022		Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)
Effective Date: 1/1/2022		Trifluridine/Tipiracil (Lonsurf) (PDF)
Effective Date: 1/1/2022
Cerliponase alfa (Brineura) (PDF)
Effective Date: 1/1/2022		Mitoxantrone (Novantrone) (PDF)
Effective Date: 1/1/2022		Triheptanoin (Dojolvi) (PDF)
Effective Date: 1/1/2022
Cetuximab (Erbitux) (PDF)
Effective Date: 1/1/2022		Mobocertinib (Exkivity) (PDF)
Effective Date: 1/1/2022		Triptorelin Pamoate (Trelstar, Triptodur) (PDF)
Effective Date: 1/1/2022
Chenodiol (Chenodal) (PDF)
Effective Date: 1/1/2022		Modafinil (Provigil) (PDF)
Effective Date: 1/1/2022		Tucatinib (Tukysa) (PDF)
Effective Date: 1/1/2022
Chlorambucil (Leukeran) (PDF)
Effective Date: 1/1/2022		Mogamulizumab-kpkc (Poteligeo) (PDF)
Effective Date: 1/1/2022		Ubrogepant (Ubrelvy) (PDF)
Effective Date: 1/1/2022
Chloramphenicol Sodium Succinate (PDF)
Effective Date: 1/1/2022		Mometasone (Nasonex) (PDF)
Effective Date: 1/1/2022
Umbralisib (Ukoniq) (PDF)
Effective Date: 1/1/2022
Cholic Acid (Cholbam) (PDF)
Effective Date: 1/1/2022		Mometasone Furoate (Sinuva) (PDF)
Effective Date: 1/1/2022
Ciclopirox (Penlac) (PDF)
Effective Date: 1/1/2022		Montelukast Oral Granules (Singulair) (PDF)
Effective Date: 1/1/2022		Uridine Triacetate (Vistogard) (PDF)
Effective Date: 1/1/2022

Cinacalcet (Sensipar) (PDF)
Effective Date: 1/1/2022		Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)
Effective Date: 1/1/2022		Valganciclovir (Valcyte) (PDF)
Effective Date: 1/1/2022

Ciprofloxacin/Dexamethasone (Ciprodex) (PDF)
Effective Date: 1/1/2022		Nafarelin Acetate (Synarel) (PDF)
Effective Date: 1/1/2022		Valproate Sodium for Intravenous Injection (Depacon) (PDF)
Effective Date: 1/1/2022
Naltrexone (Vivitrol) (PDF)
Effective Date: 1/1/2022		Valrubicin (Valstar) (PDF)
Effective Date: 1/1/2022
Ciprofloxacin/Fluocinolone (Otovel) (PDF)
Effective Date: 1/1/2022		Naproxen Oral Suspension (Naprosyn) (PDF)
Effective Date: 1/1/2022		Vandetanib (Caprelsa) (PDF)
Effective Date: 1/1/2022
Cladribine (Mavenclad) (PDF)
Effective Date: 1/1/2022		Naproxen/Esomeprazole (Vimovo) (PDF)
Effective Date: 1/1/2022		Varenicline (Tyrvaya) (PDF)
Effective Date: 1/1/2022
Clascoterone (Winlevi) (PDF)
Effective Date: 1/1/2022		Velaglucerase Alfa (VPRIV) (PDF)
Effective Date: 1/1/2022
Clobazam (Onfi, Sympazan) (PDF)
Effective Date: 1/1/2022		Natalizumab (Tysabri) (PDF)
Effective Date: 1/1/2022		Vemurafenib (Zelboraf) (PDF)
Effective Date: 1/1/2022
CNS Stimulants (PDF)
Effective Date: 1/1/2022		Naxitamab-gqgk (Danyelza) (PDF)
Effective Date: 1/1/2022		Venetoclax (Venclexta) (PDF)
Effective Date: 1/1/2022
Cobimetinib (Cotellic) (PDF)
Effective Date: 1/1/2022		Nebivolol (Bystolic) (PDF)
Effective Date: 1/1/2022
Verteporfin (Visudyne) (PDF)
Effective Date: 1/1/2022
Colchicine (Colcrys) (PDF)
Effective Date: 1/1/2022		Necitumumab (Portrazza) (PDF)
Effective Date: 1/1/2022		Vestronidase alfa-vjbk (Mepsevii) (PDF)
Effective Date: 1/1/2022
Colesevelam (Welchol) (PDF)
Effective Date: 1/1/2022		Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF)
Effective Date: 1/1/2022		Vigabatrin (Sabril) (PDF)
Effective Date: 1/1/2022
Collagenase Clostridium Histolyticum (Xiaflex) (PDF)
Effective Date: 1/1/2022		Neratinib (Nerlynx) (PDF)
Effective Date: 1/1/2022		Vilazodone (Viibryd) (PDF)
Effective Date: 1/1/2022
Colonoscopy Preparation Products (PDF)
Effective Date: 1/1/2022		Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF)
Effective Date: 1/1/2022		Viltolarsen (Viltepso) (PDF)
Effective Date: 1/1/2022
Compounded Medications (PDF)
Effective Date: 1/1/2022		Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)
Effective Date: 1/1/2022		Vincristine Sulfate Liposome Injection (Marqibo) (PDF)
Effective Date: 1/1/2022
Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)
Effective Date: 1/1/2022		Nifurtimox (Lampit) (PDF)
Effective Date: 1/1/2022		Vismodegib (Erivedge) (PDF)
Effective Date: 1/1/2022
Continuous Glucose Monitors (PDF)
Effective Date: 1/1/2022		Nilotinib (Tasigna) (PDF)
Effective Date: 1/1/2022		Voclosporin (Lupkynis) (PDF)
Effective Date: 1/1/2022
Copanlisib (Aliqopa) (PDF)
Effective Date: 1/1/2022		Nintedanib (Ofev) (PDF)
Effective Date: 1/1/2022		Vorapaxar (Zontivity) (PDF)
Effective Date: 1/1/2022
Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)
Effective Date: 1/1/2022		Niraparib (Zejula) (PDF)
Effective Date: 1/1/2022		Voretigene Neparvovec-rzyl (Luxturna) (PDF)
Effective Date: 1/1/2022
Cosyntropin (Cortrosyn) (PDF)
Effective Date: 1/1/2022		Nitazoxanide (Alinia) (PDF)
Effective Date: 1/1/2022		Vorinostat (Zolinza) (PDF)
Effective Date: 1/1/2022
Crisaborole (Eucrisa) (PDF)
Effective Date: 1/1/2022		Nitisinone (Nityr, Orfadin) (PDF)
Effective Date: 1/1/2022		Vortioxetine (Trintellix) (PDF)
Effective Date: 1/1/2022
Crizanlizumab-tmca (Adakveo) (PDF)
Effective Date: 1/1/2022		Nivolumab (Opdivo) (PDF)
Effective Date: 1/1/2022		Vosoritide (Voxzogo) (PDF)
Effective Date: 1/1/2022
Crizotinib (Xalkori) (PDF)
Effective Date: 1/1/2022		No Coverage Criteria (PDF)
Effective Date: 1/1/2022		Voxelotor (Oxbryta) (PDF)
Effective Date: 1/1/2022
Cyclosporine (Cequa, Restasis, Verkazia) (PDF)
Effective Date: 1/1/2022		Non-Calcium Phosphate Binders (PDF)
Effective Date: 1/1/2022
Cysteamine ophthalmic (Cystaran, Cystadrops) (PDF)
Effective Date: 1/1/2022		Non-Formulary and Formulary Contraceptives (PDF)
Effective Date: 1/1/2022		Zanubrutinib (Brukinsa) (PDF)
Effective Date: 1/1/2022
Cysteamine oral (Cystagon, Procysbi) (PDF)
Effective Date: 1/1/2022		Non-Formulary Test Strips (PDF)
Effective Date: 1/1/2022		Ziv-aflibercept (Zaltrap) (PDF)
Effective Date: 1/1/2022
Cytomegalovirus Immune Globulin (Cytogam) (PDF)
Effective Date: 1/1/2022		Nusinersen (Spinraza) (PDF)
Effective Date: 1/1/2022		Zoledronic Acid (Reclast, Zometa) (PDF)
Effective Date: 1/1/2022
Dabrafenib (Tafinlar) (PDF)
Effective Date: 1/1/2022		Obeticholic Acid (Ocaliva) (PDF)
Effective Date: 1/1/2022		Viloxazine (Qelbree) (PDF)
Effective Date: 1/1/2022
Dacomitinib (Vizimpro) (PDF)
Effective Date: 1/1/2022		Obinutuzumab (Gazyva) (PDF)
Effective Date: 1/1/2022		 
Dalfampridine (Ampyra) (PDF)
Effective Date: 1/1/2022		Ocrelizumab (Ocrevus) (PDF)
Effective Date: 1/1/2022		 
Dalteparin (Fragmin) (PDF)
Effective Date: 1/1/2022		Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)
Effective Date: 1/1/2022		 
Dapsone (Aczone Gel) (PDF)
Effective Date: 1/1/2022		Odevixibat (Bylvay) (PDF)
Effective Date: 1/1/2022		 
Daptomycin (Cubicin, Cubicin RF) (PDF)
Effective Date: 1/1/2022		Ofatumumab (Arzerra, Kesimpta) (PDF)
Effective Date: 1/1/2022		 
Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF)
Effective Date: 1/1/2022		Off-Label Drug Use (PDF)
Effective Date: 1/1/2022		 
Darbepoetin Alfa (Aranesp) (PDF)
Effective Date: 1/1/2022		Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)
Effective Date: 1/1/2022		 
Darolutamide (Nubeqa) (PDF)
Effective Date: 1/1/2022		Olanzapine/Samidorphan (Lybalvi) (PDF)
Effective Date: 1/1/2022		 
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF)
Effective Date: 1/1/2022		Olaparib (Lynparza) (PDF)
Effective Date: 1/1/2022		 
Dasatinib (Sprycel) (PDF)
Effective Date: 1/1/2022		Olaratumab (Lartruvo) (PDF)
Effective Date: 1/1/2022		 
Daunorubicin/Cytarabine (Vyxeos) (PDF)
Effective Date: 1/1/2022		Omacetaxine (Synribo) (PDF)
Effective Date: 1/1/2022		 
Decitabine/Cedazuridine (Inqovi) (PDF)
Effective Date: 1/1/2022		Omadacycline (Nuzyra) (PDF)
Effective Date: 1/1/2022		 
Deferasirox (Exjade, Jadenu) (PDF)
Effective Date: 1/1/2022		Omalizumab (Xolair) (PDF)
Effective Date: 1/1/2022		 
Deferoxamine (Desferal) (PDF)
Effective Date: 1/1/2022		OnabotulinumtoxinA (Botox) (PDF)
Effective Date: 1/1/2022		 
Deflazacort (Emflaza) (PDF)
Effective Date: 1/1/2022		Onasemnogene Abeparvovec (Zolgensma) (PDF)
Effective Date: 1/1/2022		 
Degarelix Acetate (Firmagon) (PDF)
Effective Date: 1/1/2022		Ondansetron (Zuplenz) (PDF)
Effective Date: 1/1/2022		 
Delafloxacin (Baxdela) (PDF)
Effective Date: 1/1/2022		Ophthalmic Corticosteroids (PDF)
Effective Date: 1/1/2022		 
Denosumab (Prolia, Xgeva) (PDF)
Effective Date: 1/1/2022		Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)
Effective Date: 1/1/2022		 
Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)
Effective Date: 1/1/2022		Opicapone (Ongentys) (PDF)
Effective Date: 1/1/2022		 
Deutetrabenazine (Austedo) (PDF)
Effective Date: 1/1/2022		Opioid Analgesics (PDF)
Effective Date: 1/1/2022		 
Dexlansoprazole (Dexilant) (PDF)
Effective Date: 1/1/2022		Osilodrostat (Isturisa) (PDF)
Effective Date: 1/1/2022		 
Dexrazoxane (Zinecard, Totect) (PDF)
Effective Date: 1/1/2022		Osimertinib (Tagrisso) (PDF)
Effective Date: 1/1/2022		 
Dextromethorphan-Quinidine (Nuedexta) (PDF)
Effective Date: 1/1/2022		Ospemifene (Osphena) (PDF)
Effective Date: 1/1/2022		 
Diazepam Nasal Spray (Valtoco) (PDF)
Effective Date: 1/1/2022		Overactive Bladder Agents (PDF)
Effective Date: 1/1/2022		 
Dichlorphenamide (Keveyis) (PDF)
Effective Date: 1/1/2022		Oxymetazoline (Rhofade, Upneeq) (PDF)
Effective Date: 1/1/2022		 
Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF)
Effective Date: 1/1/2022		Ozanimod (Zeposia) (PDF)
Effective Date: 1/1/2022		 
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (PDF)
Effective Date: 1/1/2022		Ozenoxacin (Xepi) (PDF)
Effective Date: 1/1/2022		 
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
Effective Date: 1/1/2022		Paclitaxel, Protein-Bound (Abraxane) (PDF)
Effective Date: 1/1/2022		 
Dolasetron (Anzemet) (PDF)
Effective Date: 1/1/2022		Palbociclib (Ibrance) (PDF)
Effective Date: 1/1/2022		 

Dornase Alfa (Pulmozyme) (PDF)
Effective Date: 1/1/2022		Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF)
Effective Date: 1/1/2022		 
Palivizumab (Synagis) (PDF)
Effective Date: 1/1/2022		 
Dostarlimab-gxly (Jemperli) (PDF)
Effective Date: 1/1/2022
Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF)
Effective Date: 1/1/2022		 
Doxepin (Silenor, Prudoxin, Zonalon) (PDF)
Effective Date: 1/1/2022		 
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)
Effective Date: 1/1/2022		Panitumumab (Vectibix) (PDF)
Effective Date: 1/1/2022		 
Dupilumab (Dupixent) (PDF)
Effective Date: 1/1/2022		Panobinostat (Farydak) (PDF)
Effective Date: 1/1/2022		 
Durvalumab (Imfinzi) (PDF)
Effective Date: 1/1/2022		Parathyroid Hormone (Natpara) (PDF)
Effective Date: 1/1/2022		 
Duvelisib (Copiktra) (PDF)
Effective Date: 1/1/2022
Paricalcitol Injection (Zemplar) (PDF)
Effective Date: 1/1/2022		 
Ecallantide (Kalbitor) (PDF)
Effective Date: 1/1/2022		Pasireotide (Signifor, Signifor LAR) (PDF)
Effective Date: 1/1/2022		 
Eculizumab (Soliris) (PDF)
Effective Date: 1/1/2022		Patiromer (Veltassa) (PDF)
Effective Date: 1/1/2022		 
Edaravone (Radicava) (PDF)
Effective Date: 1/1/2022		Patisiran (Onpattro) (PDF)
Effective Date: 1/1/2022		 
Efgartigimod Alfa-fcab (Vyvgart) (PDF)
Effective Date: 1/1/2022		Pazopanib (Votrient) (PDF)
Effective Date: 1/1/2022		 
Efinaconazole (Jublia) (PDF)
Effective Date: 1/1/2022		Peanut Allergen Powder-dnfp (Palforzia) (PDF)
Effective Date: 1/1/2022		 
Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (PDF)
Effective Date: 1/1/2022		Pegaptanib (Macugen) (PDF)
Effective Date: 1/1/2022		 
Elapegademase-lvlr (Revcovi) (PDF)
Effective Date: 1/1/2022		Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF)
Effective Date: 1/1/2022		 
Elbasvir/Grazoprevir (Zepatier) (PDF)
Effective Date: 1/1/2022		Pegcetacoplan (Empaveli) (PDF)
Effective Date: 1/1/2022		 
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)
Effective Date: 1/1/2022		Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastim-apgf (Nyvepria) (PDF)
Effective Date: 1/1/2022		 
Eliglustat (Cerdelga) (PDF)
Effective Date: 1/1/2022		Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF)
Effective Date: 1/1/2022		 
Elivaldogene Autotemcel (PDF)
Effective Date: 1/1/2022		Peginterferon Beta-1a (Plegridy) (PDF)
Effective Date: 1/1/2022		 
Elosulfase Alfa (Vimizim) (PDF)
Effective Date: 1/1/2022		Pegloticase (Krystexxa) (PDF)
Effective Date: 1/1/2022		 
Elotuzumab (Empliciti) (PDF)
Effective Date: 1/1/2022
Pegvaliase-pqpz (Palynziq) (PDF)
Effective Date: 1/1/2022		 
Eltrombopag (Promacta) (PDF)
Effective Date: 1/1/2022		 
Eluxadoline (Viberzi) (PDF)
Effective Date: 1/1/2022		Pegvisomant (Somavert) (PDF)
Effective Date: 1/1/2022		 
Emapalumab-lzsg (Gamifant) (PDF)
Effective Date: 1/1/2022		Pembrolizumab (Keytruda) (PDF)
Effective Date: 1/1/2022		 
Emicizumab-kxwh (Hemlibra) (PDF)
Effective Date: 1/1/2022		Pemetrexed (Alimta, Pemfexy) (PDF)
Effective Date: 1/1/2022		 
Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF)
Effective Date: 1/1/2022		Pemigatinib (Pemazyre) (PDF)
Effective Date: 1/1/2022		 
Enasidenib (Idhifa) (PDF)
Effective Date: 1/1/2022		Penicillamine (Cuprimine) (PDF)
Effective Date: 1/1/2022		 
Encorafenib (Braftovi) (PDF)
Effective Date: 1/1/2022		Perampanel (Fycompa) (PDF)
Effective Date: 1/1/2022		 
Enfortumab Vedotin-ejfv (Padcev) (PDF)
Effective Date: 1/1/2022		Pertuzumab (Perjeta) (PDF)
Effective Date: 1/1/2022		 
Enfuvirtide (Fuzeon) (PDF)
Effective Date: 1/1/2022		Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF)
Effective Date: 1/1/2022		 
Enoxaparin (Lovenox) (PDF)
Effective Date: 1/1/2022		Pexidartinib (Turalio) (PDF)
Effective Date: 1/1/2022		 
Entecavir (Baraclude) (PDF)
Effective Date: 1/1/2022		Phendimetrazine IR (Bontril PDM) (PDF)
Effective Date: 1/1/2022		 
Entrectinib (Rozlytrek) (PDF)
Effective Date: 1/1/2022		Phentermine (Adipex-P, Lomaira) (PDF)
Effective Date: 1/1/2022		 
Enzalutamide (Xtandi) (PDF)
Effective Date: 1/1/2022		Pilocarpine (PDF)
Effective Date: 1/1/2022		 
Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF)
Effective Date: 1/1/2022		Pimavanserin (Nuplazid) (PDF)
Effective Date: 1/1/2022		 
Epoprostenol (Flolan, Veletri) (PDF)
Effective Date: 1/1/2022		Pirfenidone (Esbriet) (PDF)
Effective Date: 1/1/2022		 
Eptinezumab-jjmr (Vyepti) (PDF)
Effective Date: 1/1/2022		Pitolisant (Wakix) (PDF)
Effective Date: 1/1/2022		 
Erdafitinib (Balversa) (PDF)
Effective Date: 1/1/2022		Plasminogen, human-tvmh (Ryplazim) (PDF)
Effective Date: 1/1/2022		 
Erenumab-aaoe (Aimovig) (PDF)
Effective Date: 1/1/2022		Plecanatide (Trulance) (PDF)
Effective Date: 1/1/2022		 
Eribulin Mesylate (Halaven) (PDF)
Effective Date: 1/1/2022		Plerixafor (Mozobil) (PDF)
Effective Date: 1/1/2022		 
Erlotinib (Tarceva) (PDF)
Effective Date: 1/1/2022		Polatuzumab Vedotin-piiq (Polivy) (PDF)
Effective Date: 1/1/2022		 
Erwinia Asparaginase (Erwinaze, Rylaze) (PDF)
Effective Date: 1/1/2022		Pomalidomide (Pomalyst) (PDF)
Effective Date: 1/1/2022		 
Esketamine (Spravato) (PDF)
Effective Date: 1/1/2022		Ponatinib (Iclusig) (PDF)
Effective Date: 1/1/2022		 
Estradiol Vaginal Ring (Femring) (PDF)
Effective Date: 1/1/2022		Ponesimod (Ponvory) (PDF)
Effective Date: 1/1/2022		 
Etelcalcetide (Parsabiv) (PDF)
Effective Date: 1/1/2022		Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF)
Effective Date: 1/1/2022		 
Eteplirsen (Exondys 51) (PDF)
Effective Date: 1/1/2022		Pralatrexate (Folotyn) (PDF)
Effective Date: 1/1/2022		 
Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)
Effective Date: 1/1/2022		Pramlintide (Symlin) (PDF)
Effective Date: 1/1/2022		 
Evinacumab-dgnb (Evkeeza) (PDF)
Effective Date: 1/1/2022		Prasterone (Intrarosa) (PDF)
Effective Date: 1/1/2022		 
Evolocumab (Repatha) (PDF)
Effective Date: 1/1/2022		Pregabalin (Lyrica, Lyrica CR) (PDF)
Effective Date: 1/1/2022		 
Factor IX (Human, Recombinant) (PDF)
Effective Date: 1/1/2022		Pretomanid (PDF)
Effective Date: 1/1/2022		 
Factor IX Complex, Human (Profilnine) (PDF)
Effective Date: 1/1/2022		Progesterone (Crinone, Endometrin, Milprosa) (PDF)
Effective Date: 1/1/2022		 
Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF)
Effective Date: 1/1/2022		Propranolol HCl Oral Solution (Hemangeol) (PDF)
Effective Date: 1/1/2022		 
Factor VIII (Human, Recombinant) (PDF)
Effective Date: 1/1/2022		Protein C Concentrate, Human (Ceprotin) (PDF)
Effective Date: 1/1/2022		 
Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (PDF)
Effective Date: 1/1/2022		Prucalopride (Motegrity) (PDF)
Effective Date: 1/1/2022		 
Factor XIII A-Subunit, Recombinant (Tretten) (PDF)
Effective Date: 1/1/2022		Pyrimethamine (Daraprim) (PDF)
Effective Date: 1/1/2022		 
Factor XIII, Human (Corifact) (PDF)
Effective Date: 1/1/2022		  
Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)
Effective Date: 1/1/2022		  
Febuxostat (Uloric) (PDF)
Effective Date: 1/1/2022		  
Fedratinib (Inrebic) (PDF)
Effective Date: 1/1/2022		  
Fenfluramine (Fintepla) (PDF)
Effective Date: 1/1/2022		  
Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)
Effective Date: 1/1/2022		  
Ferric Carboxymaltose (Injectafer) (PDF)
Effective Date: 1/1/2022		  
Ferric Derisomaltose (Monoferric) (PDF)
Effective Date: 1/1/2022		  
Ferric Gluconate (Ferrlecit) (PDF)
Effective Date: 1/1/2022		  
Ferric Maltol (Accrufer) (PDF)
Effective Date: 1/1/2022		  
Ferumoxytol (Feraheme) (PDF)
Effective Date: 1/1/2022		  
Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF)
Effective Date: 1/1/2022		  
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) (PDF)
Effective Date: 1/1/2022		  
Finerenone (Kerendia) (PDF)
Effective Date: 1/1/2022		  
Fingolimod (Gilenya) (PDF)
Effective Date: 1/1/2022		  
Flibanserin (Addyi) (PDF)
Effective Date: 1/1/2022		  
Fluorouracil Cream (Tolak) (PDF)
Effective Date: 1/1/2022		  
Fluticasone Propionate (Xhance) (PDF)
Effective Date: 1/1/2022		  
Fondaparinux (Arixtra) (PDF)
Effective Date: 1/1/2022		  
Fosdenopterin (Nulibry) (PDF)
Effective Date: 1/1/2022		  
Fostamatinib (Tavalisse) (PDF)
Effective Date: 1/1/2022		  
Fostemsavir (Rukobia) (PDF)
Effective Date: 1/1/2022		  
Fremanezumab-vfrm (Ajovy) (PDF)
Effective Date: 1/1/2022		  
Fulvestrant (Faslodex Injection) (PDF)
Effective Date: 1/1/2022		  
Gabapentin ER (Gralise, Horizant) (PDF)
Effective Date: 1/1/2022		  
Galcanezumab-gnlm (Emgality) (PDF)
Effective Date: 1/1/2022		  
Galsulfase (Naglazyme) (PDF)
Effective Date: 1/1/2022		  
Gefitinib (Iressa) (PDF)
Effective Date: 1/1/2022		  
Gemtuzumab Ozogamicin (Mylotarg) (PDF)
Effective Date: 1/1/2022		  
Gilteritinib (Xospata) (PDF)
Effective Date: 1/1/2022		  
Givosiran (Givlaari) (PDF)
Effective Date: 1/1/2022		  
Glasdegib (Daurismo) (PDF)
Effective Date: 1/1/2022		  
Glatiramer Acetate (Copaxone, Glatopa) (PDF)
Effective Date: 1/1/2022		  
Glecaprevir/Pibrentasvir (Mavyret) (PDF)
Effective Date: 1/1/2022		  
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)
Effective Date: 1/1/2022		  
Glycerol Phenylbutyrate (Ravicti) (PDF)
Effective Date: 1/1/2022		  
Golodirsen (Vyondys 53) (PDF)
Effective Date: 1/1/2022		  
Goserelin Acetate (Zoladex) (PDF)
Effective Date: 1/1/2022		  
Granisetron (Sancuso, Sustol) (PDF)
Effective Date: 1/1/2022