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-G	H-O	P-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-G	H-P	Q-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-G	H-P	Q-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
Baloxavir Marboxil (Xofluza) (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
Bedaquiline (Sirturo) (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	Spinosad (Natroba) (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	Mecamylamine (Vecamyl) (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	Umbralisib (Ukoniq) (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	Voxelotor (Oxbryta) (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
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Doxepin (Silenor, Prudoxin, Zonalon) (PDF) Effective Date: 1/1/2022
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Efinaconazole (Jublia) (PDF) Effective Date: 1/1/2022	Peanut Allergen Powder-dnfp (Palforzia) (PDF) Effective Date: 1/1/2022
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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
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Erdafitinib (Balversa) (PDF) Effective Date: 1/1/2022	Plasminogen, human-tvmh (Ryplazim) (PDF) Effective Date: 1/1/2022
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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
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