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.
- Acupuncture (CP.MP.92) (PDF)
- Adopted Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF)
- Air Ambulance (CP.MP.175) (PDF) Effective Date: 1/1/2022
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (CP.MP.108) (PDF) Effective Date: 1/1/2022
- Ambulatory EEG (CP.MP.96) (PDF) Effective Date: 1/1/2022
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF) Effective Date: 1/1/2022
- Bariatric Surgery (CP.MP.37) (PDF)
- Behavioral Health Treatment Documentation Requirements (CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF) Effective Date: 1/1/2022
- Burn Surgery (CP.MP.186) (PDF) Effective Date: 1/1/2022
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF) Effective Date: 1/1/2022
- Clinical Trials (CP.MP.94) (PDF) Effective Date: 6/30/2022
- Cochlear Implant Replacements (CP.MP.14) (PDF) Effective Date: 7/30/2022
- Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Cardiac Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Dermatologic Conditions (V1.2024) (PDF)
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (V1.2024) (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Eye Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (V1.2024) (PDF)
- Concert Genetic Testing: General Approach to Genetic and Molecular Testing (V1.2024) (PDF)
- Concert Genetic Testing: Hearing Loss (V1.2024) (PDF)
- Concert Genetic Testing: Hematologic Conditions (non-cancerous) (V1.2024) (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility (V1.2024) (PDF)
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Kidney Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Lung Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (V1.2024) (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (V1.2024) (PDF)
- Concert Genetic Testing: Non-invasive Prenatal Screening (NIPS) (V1.2024) (PDF)
- Concert Genetic Testing: Pharmacogenetics (V1.2024) (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing (V1.2024) (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (V1.2024) (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (V1.2024) (PDF)
- Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (V1.2024) (PDF)
- Concert Genetics Oncology: Algorithmic Testing (V1.2024) (PDF)
- Concert Genetics Oncology: Cancer Screening (V1.2024) (PDF)
- Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (V1.2024) (PDF)
- Concert Genetics Oncology: Cytogenetic Testing (V1.2024) (PDF)
- Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (V1.2024) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF) Effective Date: 1/1/2022
- Disc Decompression Procedures (CP.MP.114) (PDF) Effective Date: 5/30/2022
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF) Effective Date: 1/1/2022
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (CP.MP.107) (PDF) Effective Date: 1/1/2022
- Electric Tumor Treating Fields (Optune) (CP.MP.145) (PDF) Effective Date: 1/1/2022
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (PDF) Effective Date: 7/30/2022
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF) Effective Date: 7/30/2022
- Ferriscan R2-MRI (CP.MP.53) (PDF) Effective Date: 1/1/2022
- Fertility Preservation (CP.MP.130) (PDF) Effective Date: 5/30/2022
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF) Effective Date: 7/30/2022
- Functional MRI (CP.MP.43) (PDF) Effective Date: 2/28/2022
- Gastric Electrical Stimulation (CP.MP.40) (PDF) Effective Date: 2/28/2022
- Gender Affirming Procedures (CP.MP.95) (PDF) Effective Date: 1/1/2022
- Heart-Lung Transplant (CP.MP.132) (PDF) Effective Date: 2/28/2022
- Home Births (CP.MP.136) (PDF) Effective Date: 1/31/2022
- Home Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF) Effective Date: 1/1/2022
- Hospice Services (CP.MP.54) (PDF) Effective Date: 1/1/2022
- Hyperemesis gravidarum treatment (CP.MP.34) (PDF) Effective Date: 2/28/2022
- Hyperhidrosis Treatments (CP.MP.62) (PDF) Effective Date: 1/31/2022
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF) Effective Date: 1/1/2022
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF) Effective Date: 1/31/2022
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF) Effective Date: 2/28/2022
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF) Effective Date: 1/1/2022
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF) Effective Date: 2/28/2022
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF) Effective Date: 1/1/2022
- Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF) Effective Date: 4/30/2022
- Lung Transplantation (CP.MP.57) (PDF) Effective Date: 2/28/2022
- Lysis of Epidural Lesions (CP.MP.116) (PDF) Effective Date: 5/30/2022
- Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144) (PDF) Effective Date: 1/1/2022
- Multiple Sleep Latency Testing (CP.MP.24) (PDF) Effective Date: 4/30/2022
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF) Effective Date: 2/28/2022
- Neonatal Sepsis Management (CP.MP.85) (PDF) Effective Date: 7/30/2022
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170) (PDF) Effective Date: 8/31/2022
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF) Effective Date: 7/30/2022
- NICU Apnea Bradycardia Guidelines (CP.MP.82) (PDF) Effective Date: 6/30/2022
- NICU Discharge Guidelines (CP.MP.81) (PDF) Effective Date: 6/30/2022
- Home Ventilators (CP.MP.184) (PDF) Effective Date: 6/30/2022
- Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF) Effective Date: 2/28/2022
- Obstetrical Home Care Programs (CP.MP.91) (PDF) Effective Date: 1/1/2022
- Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy (CP.MP.249) (PDF)
- Optic nerve decompression surgery (CP.MP.128) (PDF) Effective Date: 7/30/2022
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF) Effective Date: 9/30/2022
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF) Effective Date: 5/30/2022
- Outpatient Oxygen Use (CP.MP.190) (PDF) Effective Date: 1/1/2022
- Pancreas Transplantation (CP.MP.102) (PDF) Effective Date: 2/28/2022
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF) Effective Date: 1/1/2022
- Pediatric Liver Transplant (CP.MP.120) (PDF) Effective Date: 2/28/2022
- Pediatric Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF) Effective Date: 5/30/2022
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF) Effective Date: 5/30/2022
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF) Effective Date: 1/1/2022
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF) Effective Date: 8/31/2022
- PROM Testing (CP.MP.149) (PDF) Effective Date: 1/1/2022
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF) Effective Date: 11/30/2022
- Radial Head Implant (CP.MP.148) (PDF) Effective Date: 5/30/2022
- Radiofrequency Ablation of Uterine Fibroids (CP.MP.187) (PDF) Effective Date: 2/28/2022
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF) Effective Date: 7/30/2022
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF) Effective Date: 5/30/2022
- Sacroiliac Joint Fusion (CP.MP.126) (PDF) Effective Date: 6/30/2022
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF) Effective Date: 8/31/2022
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (CP.MP.146) (PDF) Effective Date: 4/30/2022
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF) Effective Date: 1/1/2022
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) (PDF) Effective Date: 8/31/2022
- Short Inpatient Hospital Stay (CP.MP.182) (PDF) Effective Date: 1/1/2022
- Skilled Nursing Facility Leveling (CP.MP.206) (PDF) Effective Date: 2/4/2022
- Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) (PDF) Effective Date: 4/30/2022
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF) Effective Date: 2/28/2022
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF) Effective Date: 1/31/2022
- Tandem Transplant (CP.MP.162) (PDF) Effective Date: 2/28/2022
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF) Effective Date: 4/30/2022
- Total Artificial Heart (CP.MP.127) (PDF) Effective Date: 1/1/2022
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF) Effective Date: 4/30/2022
- Transcatheter Closure of Patent Foramen Ovale (CP.MP.151) (PDF) Effective Date: 1/1/2022
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF) Effective Date: 8/31/2022
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF) Effective Date: 1/1/2022
- Vagus Nerve Stimulation (CP.MP.12) (PDF) Effective Date: 8/31/2022
- Ventricular Assist Devices (CP.MP.46) (PDF) Effective Date: 2/28/2022
- 3 Day Payment Window (CC.PP.500) (PDF) Effective Date: 1/1/2022
- 30 Day Readmission (CC.PP.501) (PDF) Effective Date: 1/1/2022
- Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.BH.124) (PDF) Effective Date: 1/1/2022
- Allergy Testing (CP.MP.100) (PDF) Effective Date: 1/1/2022
- Bronchial Thermoplasty (CP.MP.110) (PDF) Effective Date: 1/1/2022
- Cardiac Biomarker Testing for Acute MI (CP.MP.156) (PDF) Effective Date: 1/1/2022
- Digital EEG Spike Analysis (CP.MP.105) (PDF) Effective Date 6/1/2024
- 340B Drug Payment Reduction (CC.PP.070) (PDF) Effective Date: 1/1/2022
- Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (CP.MP.50) (PDF) Effective Date: 1/1/2022
- EEG in the Evaluation of Headache (CP.MP.155) (PDF) Effective Date: 6/1/2024
- Endometrial Ablation (CP.MP.106) (PDF) Effective Date: 1/1/2022
- Evoked Potential Testing (CP.MP.134) (PDF) Effective Date: 6/1/2024
- Extended Ophthalmoscopy (CP.VP.26) (PDF) Effective Date: 1/1/2022
- External Ocular Photography (OC.UM.CP.0043) (PDF) Effective Date: 1/1/2022
- Fluorescein Angiography (CP.VP.28) (PDF) Effective Date: 1/1/2022
- Fundus Photography (OC.UM.CP.0029) (PDF) Effective Date: 1/1/2022
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209) (PDF)
- Gonioscopy (CP.VP.31) (PDF) Effective Date: 1/1/2022
- H Pylori Testing (CP.MP.153) (PDF) Effective Date: 1/1/2022
- Holter Monitors (CP.MP.113) (PDF) Effective Date: 6/1/2024
- Homocysteine Testing (CP.MP.121) (PDF) Effective Date: 1/1/2022
- Laser Therapy for Skin Conditions (CP.MP.123) (PDF) Effective Date: 6/1/2024
- Leveling of Care: Evaluation and Management Overcoding (CC.PP.066) (PDF) Effective Date: 1/1/2022
- Low-Frequency Ultrasound Wound Therapy (CP.MP.139) (PDF) Effective Date: 1/1/2022
- Measurement of Serum 1,25-dihydroxyvitamin D (CP.MP.152) (PDF) Effective Date: 6/1/2024
- Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (CC.PP.065) (PDF) Effective Date: 1/1/2022
- Multiple Procedure Payment Reduction for Therapeutic Services (CC.PP.068) (PDF) Effective Date: 1/1/2022
- Multiple Procedure Reduction: Ophthalmology (CC.PP.069) (PDF) Effective Date: 1/1/2022
- Non-Emergent ER Services (fka Leveling of ER Services) (CC.PP.053) (PDF) Effective Date: 1/1/2022
- Non-Obstetrical and OB Pelvic and Transvaginal Ultrasounds (CC.PP.061) (PDF) Effective Date: 1/1/2022
- Physician's Consultation Services (CC.PP.054) (PDF) Effective Date: 1/1/2022
- Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181) (PDF) Effective Date: 1/1/2022
- Problem-Oriented Visits with Preventative Visits (CC.PP.057) (PDF) Effective Date: 1/1/2022
- Problem-Oriented Visits with Surgical Procedures (CC.PP.052) (PDF) Effective Date: 1/1/2022
- Pulmonary Function Testing (CP.MP.242) (PDF) Effective Date: 6/1/2024
- Renal Hemodialysis (CC.PP.067) (PDF) Effective Date: 1/1/2022
- Scanning computerized Ophthalmic Diagnostic Imaging (SCODI) (CP.VP.14) (PDF) Effective Date: 1/1/2022
- Sleep Studies Place of Service (CC.PP.035) (PDF) Effective Date: 1/1/2022
- Testing for Select Genitourinary Conditions (CP.MP.97) (PDF) Effective Date: 6/1/2024
- Thyroid Testing in Pediatrics (CP.MP.154) (PDF) Effective Date: 1/1/2022
- Ultrasound in Pregnancy (CP.MP.38) (PDF) Effective Date: 1/1/2022
- Urine Specimen Validity Testing (CC.PP.056) (PDF) Effective Date: 1/1/2022
- Urodynamic Testing (CP.MP.98) (PDF) Effective Date: 6/1/2024
- Visual Field Testing (CP.VP.63) (PDF) Effective Date: 1/1/2022
- Vitamin D Testing in Children (CP.MP.157) (PDF) Effective Date: 1/1/2022
- Wheelchair Accessories (CC.PP.502) (PDF) Effective Date: 1/1/2022
- Wheelchair Seating (CP.MP.99) (PDF) Effective Date: 1/1/2022
- Wireless Motility Capsule (CP.MP.143) (PDF) Effective Date: 1/1/2022
- Abaloparatide (Tymlos) (PDF)
- Abametapir (Xeglyze) (PDF)
- Abemaciclib (Verzenio) (PDF)
- Abiraterone (Zytiga, Yonsa) (PDF)
- AbobotulinumtoxinA (Dysport) (PDF)
- Acyclovir Buccal Tablet (Sitavig) (PDF)
- Adefovir (Hepsera) (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) (PDF)
- Aducanumab-avwa (Aduhelm) (PDF)
- Afamelanotide (Scenesse) (PDF)
- Afatinib (Gilotrif) (PDF)
- Aflibercept (Eylea) (PDF)
- Agalsidase Beta (Fabrazyme) (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)
- Alectinib (Alecensa) (PDF)
- Alemtuzumab (Lemtrada) (PDF)
- Alendronate (Binosto, Fosamax Plus D) (PDF)
- Alglucosidase Alfa (Lumizyme) (PDF)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF)
- Alpelisib (Piqray) (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)
- Amantadine ER (Gocovri, Osmolex ER) (PDF)
- Ambrisentan (Letairis) (PDF)
- Amifampridine (Firdapse, Ruzurgi) (PDF)
- Amikacin (Arikayce) (PDF)
- Amisulpride (Barhemsys) (PDF)
- Amivantamab-vmjw (Rybrevant) (PDF)
- Anifrolumab-fnia (Saphnelo) (PDF)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)
- Antithrombin III (ATryn, Thrombate III) (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)
- Apalutamide (Erleada) (PDF)
- Apomorphine (Apokyn, Kynmobi) (PDF)
- Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (PDF)
- Aripiprazole Orally Disintegrating Tablet (PDF)
- Armodafinil (Nuvigil) (PDF)
- Asciminib (Scemblix) (PDF)
- Asenapine (Saphris, Secuado) (PDF)
- Asfotase Alfa (Strensiq) (PDF)
- Aspirin/Dipyridamole (Aggrenox) (PDF)
- Atezolizumab (Tecentriq) (PDF)
- Avacopan (Tavneos) (PDF)
- Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF)
- Avapritinib (Ayvakit) (PDF)
- Avatrombopag (Doptelet) (PDF)
- Avelumab (Bavencio) (PDF)
- Axicabtagene Ciloleucel (Yescarta) (PDF)
- Axitinib (Inlyta) (PDF)
- Azacitidine (Onureg, Vidaza) (PDF)
- Azelaic Acid (Finacea Topical Gel) (PDF)
- Aztreonam (Cayston) (PDF)
- Baclofen (Gablofen, Lioresal, Lyvispah, Ozobax) (PDF)
- Baloxavir Marboxil (Xofluza) (PDF)
- Bedaquiline (Sirturo) (PDF)
- Belantamab Mafodotin (Blenrep) (PDF)
- Belatacept (Nulojix) (PDF)
- Belimumab (Benlysta) (PDF)
- Belinostat (Beleodaq) (PDF)
- Belumosudil (Rezurock) (PDF)
- Belzutifan (Welireg) (PDF)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF)
- Bendamustine (Belrapzo, Bendeka, Treanda) (PDF)
- Benralizumab (Fasenra) (PDF)
- Benznidazole (PDF)
- Betaine (Cystadane) (PDF)
- Betamethasone Dipropionate Spray (Sernivo) (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)
- Bexarotene (Targretin Capsules, Gel) (PDF)
- Bezlotoxumab (Zinplava) (PDF)
- Bimatoprost Implant (Durysta) (PDF)
- Binimetinib (Mektovi) (PDF)
- Biologic DMARDs (PDF)
- Blinatumomab (Blincyto) (PDF)
- Bortezomib (Velcade) (PDF)
- Bosentan (Tracleer) (PDF)
- Bosutinib (Bosulif) (PDF)
- Brand Name Override and Non-Formulary Medications (PDF)
- Brentuximab Vedotin (Adcetris) (PDF)
- Brexanolone (Zulresso) (PDF)
- Brexpiprazole (Rexulti) (PDF)
- Brexucabtagene Autoleucel (Tecartus)
- Brigatinib (Alunbrig) (PDF)
- Brimonidine Tartrate (Mirvaso) (PDF)
- Brinzolamide/Brimonidine (Simbrinza) (PDF)
- Brivaracetam (Briviact) (PDF)
- Brolucizumab-dbll (Beovu) (PDF)
- Budesonide (Tarpeyo) (PDF)
- Budesonide (Uceris) (PDF)
- Buprenorphine (Subutex) (PDF)
- Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)
- Bupropion/Naltrexone (Contrave) (PDF)
- Burosumab-twza (Crysvita) (PDF)
- Butorphanol Nasal Spray (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)
- Cabazitaxel (Jevtana) (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)
- Cabozantinib (Cabometyx, Cometriq) (PDF)
- Calcifediol (Rayaldee) (PDF)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF)
- Canakinumab (Ilaris) (PDF)
- Cannabidiol (Epidiolex) (PDF)
- Capecitabine (Xeloda) (PDF)
- Caplacizumab-yhdp (Cablivi) (PDF)
- Capmatinib (Tabrecta) (PDF)
- Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) (PDF)
- Carfilzomib (Kyprolis) (PDF)
- Carglumic Acid (Carbaglu) (PDF)
- Casimersen (Amondys 45) (PDF)
- Casirivimab and Imdevimab (REGEN-COV) (PDF)
- Celecoxib (Celebrex, Elyxyb) (PDF)
- Cemiplimab-rwlc (Libtayo) (PDF)
- Cenegermin-bkbj (Oxervate) (PDF)
- Cenobamate (Xcopri) (PDF)
- Ceritinib (Zykadia) (PDF)
- Cerliponase alfa (Brineura) (PDF)
- Cetuximab (Erbitux) (PDF)
- Chenodiol (Chenodal) (PDF)
- Chlorambucil (Leukeran) (PDF)
- Chloramphenicol Sodium Succinate (PDF)
- Cholic Acid (Cholbam) (PDF)
- Ciclopirox (Penlac) (PDF)
- Cinacalcet (Sensipar) (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) (PDF)
- Cladribine (Mavenclad) (PDF)
- Clascoterone (Winlevi) (PDF)
- Clobazam (Onfi, Sympazan) (PDF)
- CNS Stimulants (PDF)
- Cobimetinib (Cotellic) (PDF)
- Colchicine (Colcrys) (PDF)
- Colesevelam (Welchol) (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) (PDF)
- Colonoscopy Preparation Products (PDF)
- Compounded Medications (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)
- Continuous Glucose Monitors (PDF)
- Copanlisib (Aliqopa) (PDF)
- Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)
- Cosyntropin (Cortrosyn) (PDF)
- Crisaborole (Eucrisa) (PDF)
- Crizanlizumab-tmca (Adakveo) (PDF)
- Crizotinib (Xalkori) (PDF)
- Cyclosporine (Cequa, Restasis, Verkazia) (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops) (PDF)
- Cysteamine oral (Cystagon, Procysbi) (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) (PDF)
- Dabrafenib (Tafinlar) (PDF)
- Dacomitinib (Vizimpro) (PDF)
- Dalfampridine (Ampyra) (PDF)
- Dalteparin (Fragmin) (PDF)
- Dapsone (Aczone Gel) (PDF)
- Daptomycin (Cubicin, Cubicin RF) (PDF)
- Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF)
- Darbepoetin Alfa (Aranesp) (PDF)
- Darolutamide (Nubeqa) (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF)
- Dasatinib (Sprycel) (PDF)
- Daunorubicin/Cytarabine (Vyxeos) (PDF)
- Decitabine/Cedazuridine (Inqovi) (PDF)
- Deferasirox (Exjade, Jadenu) (PDF)
- Deferoxamine (Desferal) (PDF)
- Deflazacort (Emflaza) (PDF)
- Degarelix Acetate (Firmagon) (PDF)
- Delafloxacin (Baxdela) (PDF)
- Denosumab (Prolia, Xgeva) (PDF)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)
- Deutetrabenazine (Austedo) (PDF)
- Dexlansoprazole (Dexilant) (PDF)
- Dexrazoxane (Zinecard, Totect) (PDF)
- Dextromethorphan-Quinidine (Nuedexta) (PDF)
- Diazepam Nasal Spray (Valtoco) (PDF)
- Dichlorphenamide (Keveyis) (PDF)
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF)
- Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)
- Dolasetron (Anzemet) (PDF)
- Dornase Alfa (Pulmozyme) (PDF)
- Dostarlimab-gxly (Jemperli) (PDF)
- Doxepin (Silenor, Prudoxin, Zonalon) (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)
- Dupilumab (Dupixent) (PDF)
- Durvalumab (Imfinzi) (PDF)
- Duvelisib (Copiktra) (PDF)
- Ecallantide (Kalbitor) (PDF)
- Eculizumab (Soliris) (PDF)
- Edaravone (Radicava) (PDF)
- Efgartigimod Alfa-fcab (Vyvgart) (PDF)
- Efinaconazole (Jublia) (PDF)
- Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (PDF)
- Elapegademase-lvlr (Revcovi) (PDF)
- Elbasvir/Grazoprevir (Zepatier) (PDF)
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)
- Eliglustat (Cerdelga) (PDF)
- Elivaldogene Autotemcel (PDF)
- Elosulfase Alfa (Vimizim) (PDF)
- Elotuzumab (Empliciti) (PDF)
- Eltrombopag (Promacta) (PDF)
- Eluxadoline (Viberzi) (PDF)
- Emapalumab-lzsg (Gamifant) (PDF)
- Emicizumab-kxwh (Hemlibra) (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF)
- Enasidenib (Idhifa) (PDF)
- Encorafenib (Braftovi) (PDF)
- Enfortumab Vedotin-ejfv (Padcev) (PDF)
- Enfuvirtide (Fuzeon) (PDF)
- Enoxaparin (Lovenox) (PDF)
- Entecavir (Baraclude) (PDF)
- Entrectinib (Rozlytrek) (PDF)
- Enzalutamide (Xtandi) (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF)
- Epoprostenol (Flolan, Veletri) (PDF)
- Eptinezumab-jjmr (Vyepti) (PDF)
- Erdafitinib (Balversa) (PDF)
- Erenumab-aaoe (Aimovig) (PDF)
- Eribulin Mesylate (Halaven) (PDF)
- Erlotinib (Tarceva) (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) (PDF)
- Esketamine (Spravato) (PDF)
- Estradiol Vaginal Ring (Femring) (PDF)
- Etelcalcetide (Parsabiv) (PDF)
- Eteplirsen (Exondys 51) (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)
- Evinacumab-dgnb (Evkeeza) (PDF)
- Evolocumab (Repatha) (PDF)
- Factor IX (Human, Recombinant) (PDF)
- Factor IX Complex, Human (Profilnine) (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF)
- Factor VIII (Human, Recombinant) (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (PDF)
- Factor XIII A-Subunit, Recombinant (Tretten) (PDF)
- Factor XIII, Human (Corifact) (PDF)
- Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)
- Febuxostat (Uloric) (PDF)
- Fedratinib (Inrebic) (PDF)
- Fenfluramine (Fintepla) (PDF)
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)
- Ferric Carboxymaltose (Injectafer) (PDF)
- Ferric Derisomaltose (Monoferric) (PDF)
- Ferric Gluconate (Ferrlecit) (PDF)
- Ferric Maltol (Accrufer) (PDF)
- Ferumoxytol (Feraheme) (PDF)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym) (PDF)
- Finerenone (Kerendia) (PDF)
- Fingolimod (Gilenya) (PDF)
- Flibanserin (Addyi) (PDF)
- Fluorouracil Cream (Tolak) (PDF)
- Fluticasone Propionate (Xhance) (PDF)
- Fondaparinux (Arixtra) (PDF)
- Fosdenopterin (Nulibry) (PDF)
- Fostamatinib (Tavalisse) (PDF)
- Fostemsavir (Rukobia) (PDF)
- Fremanezumab-vfrm (Ajovy) (PDF)
- Fulvestrant (Faslodex Injection) (PDF)
- Gabapentin ER (Gralise, Horizant) (PDF)
- Galcanezumab-gnlm (Emgality) (PDF)
- Galsulfase (Naglazyme) (PDF)
- Gefitinib (Iressa) (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) (PDF)
- Gilteritinib (Xospata) (PDF)
- Givosiran (Givlaari) (PDF)
- Glasdegib (Daurismo) (PDF)
- Glatiramer Acetate (Copaxone, Glatopa) (PDF)
- Glecaprevir/Pibrentasvir (Mavyret) (PDF)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)
- Glycerol Phenylbutyrate (Ravicti) (PDF)
- Golodirsen (Vyondys 53) (PDF)
- Goserelin Acetate (Zoladex) (PDF)
- Granisetron (Sancuso, Sustol) (PDF)
- Halcinonide (Halog) (PDF)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF)
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF)
- Hemin (Panhematin) (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) (PDF)
- House dust mite allergen extract (Odactra) (PDF)
- Human Growth Hormone (Somapacitan, Somatropin) (PDF)
- Hyaluronate Derivatives (PDF)
- Hydroxyprogesterone Caproate (Makena/compound) (PDF)
- Hydroxyurea (Siklos) (PDF)
- Ibalizumab-uiyk (Trogarzo) (PDF)
- Ibandronate Injection (Boniva) (PDF)
- Ibrutinib (Imbruvica) (PDF)
- Ibuprofen/Famotidine (Duexis) (PDF)
- Icatibant (Firazyr) (PDF)
- Icosapent Ethyl (Vascepa) (PDF)
- Idecabtagene Vicleucel (Abecma) (PDF)
- Idelalisib (Zydelig) (PDF)
- Idursulfase (Elaprase) (PDF)
- Iloperidone (Fanapt) (PDF)
- Iloprost (Ventavis) (PDF)
- Imatinib (Gleevec) (PDF)
- Imiglucerase (Cerezyme) (PDF)
- Immune Globulins (PDF)
- Inclisiran (Leqvio) (PDF)
- IncobotulinumtoxinA (Xeomin) (PDF)
- Inebilizumab-cdon (Uplizna) (PDF)
- Infertility and Fertility Preservation (PDF)
- Infigratinib (Truseltiq) (PDF)
- Inhaled Agents for Asthma and COPD (PDF)
- Inotersen (Tegsedi) (PDF)
- Inotuzumab Ozogamicin (Besponsa) (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)
- Insulin Glargine (Rezvoglar, Semglee, Toujeo) (PDF)
- Interferon Beta-1a (Avonex, Rebif) (PDF)
- Interferon Beta-1b (Betaseron, Extavia) (PDF)
- Interferon Gamma- 1b (Actimmune) (PDF)
- Iobenguane I-131 (Azedra) (PDF)
- Ipilimumab (Yervoy) (PDF)
- Irinotecan Liposome (Onivyde) (PDF)
- Iron Sucrose (Venofer) (PDF)
- Isatuximab-irfc (Sarclisa) (PDF)
- Isavuconazonium (Cresemba) (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)
- Istradefylline (Nourianz) (PDF)
- Itraconazole (Sporanox, Tolsura) (PDF)
- Ivabradine (Corlanor) (PDF)
- Ivacaftor (Kalydeco) (PDF)
- Ivermectin (Stromectol, Sklice) (PDF)
- Ivosidenib (Tibsovo) (PDF)
- Ixazomib (Ninlaro) (PDF)
- lacosamide (Vimpat) (PDF)
- Lactitol (Pizensy) (PDF)
- Lanadelumab-fylo (Takhzyro) (PDF)
- Lanreotide (Somatuline Depot) (PDF)
- Lapatinib (Tykerb) (PDF)
- Laronidase (Aldurazyme) (PDF)
- Larotrectinib (Vitrakvi) (PDF)
- Lasmiditan (Reyvow) (PDF)
- Latanoprostene Bunod (Vyzulta) (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) (PDF)
- Lefamulin (Xenleta) (PDF)
- Lenalidomide (Revlimid) (PDF)
- Lenvatinib (Lenvima) (PDF)
- Letermovir (Prevymis) (PDF)
- Leucovorin Injection (PDF)
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (PDF)
- Levodopa Inhalation Powder (Inbrija) (PDF)
- Levoleucovorin (Fusilev, Khapzory) (PDF)
- Levomilnacipran (Fetzima) (PDF)
- L-glutamine (Endari) (PDF)
- Lidocaine transdermal (Lidoderm, ZTlido) (PDF)
- Lifitegrast (Xiidra) (PDF)
- Linaclotide (Linzess) (PDF)
- Linezolid (Zyvox) (PDF)
- Lisocabtagene Maraleucel (Breyanzi) (PDF)
- Lofexidine (Lucemyra) (PDF)
- Lomustine (Gleostine) (PDF)
- Lonafarnib (Zokinvy) (PDF)
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)
- Lorcaserin (Belviq, Belviq XR) (PDF)
- Lorlatinib (Lorbrena) (PDF)
- Loteprednol etabonate (Eysuvis) (PDF)
- Lubiprostone (Amitiza) (PDF)
- Luliconazole Cream (Luzu)(PDF)
- Lumacaftor/Ivacaftor (Orkambi) (PDF)
- Lumasiran (Oxlumo) (PDF)
- Lumateperone (Caplyta) (PDF)
- Lurasidone (Latuda) (PDF)
- Lurbinectedin (Zepzelca) (PDF)
- Luspatercept-aamt (Reblozyl) (PDF)
- Lusutrombopag (Mulpleta) (PDF)
- Lutetium Lu 177 dotatate (Lutathera) (PDF)
- Macitentan (Opsumit) (PDF)
- Mannitol (Bronchitol) (PDF)
- Maralixibat (Livmarli) (PDF)
- Margetuximab-cmkb (Margenza) (PDF)
- Maribavir (Livtencity) (PDF)
- Mecamylamine (Vecamyl) (PDF)
- Mecasermin (Increlex) (PDF)
- Mechlorethamine Gel (Valchlor) (PDF)
- Megestrol Acetate (Megace ES) (PDF)
- Melphalan flufenamide (Pepaxto) (PDF)
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF)
- Mepolizumab (Nucala) (PDF)
- Mercaptopurine (Purixan) (PDF)
- Metformin ER (Fortamet, Glumetza) (PDF)
- Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)
- Methoxsalen (Uvadex) (PDF)
- Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)
- Methylnaltrexone Bromide (Relistor) (PDF)
- Metoclopramide (Gimoti) (PDF)
- Metreleptin (Myalept) (PDF)
- Midazolam (Nayzilam) (PDF)
- Midostaurin (Rydapt) (PDF)
- Mifepristone (Korlym) (PDF)
- Migalastat (Galafold) (PDF)
- Miglustat (Zavesca) (PDF)
- Milnacipran (Savella) (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)
- Mitoxantrone (Novantrone) (PDF)
- Mobocertinib (Exkivity) (PDF)
- Modafinil (Provigil) (PDF)
- Mogamulizumab-kpkc (Poteligeo) (PDF)
- Mometasone (Nasonex) (PDF)
- Mometasone Furoate (Sinuva) (PDF)
- Montelukast Oral Granules (Singulair) (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)
- Nafarelin Acetate (Synarel) (PDF)
- Naltrexone (Vivitrol) (PDF)
- Naproxen Oral Suspension (Naprosyn) (PDF)
- Naproxen/Esomeprazole (Vimovo) (PDF)
- Natalizumab (Tysabri) (PDF)
- Naxitamab-gqgk (Danyelza) (PDF)
- Nebivolol (Bystolic) (PDF)
- Necitumumab (Portrazza) (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF)
- Neratinib (Nerlynx) (PDF)
- Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)
- Nifurtimox (Lampit) (PDF)
- Nilotinib (Tasigna) (PDF)
- Nintedanib (Ofev) (PDF)
- Niraparib (Zejula) (PDF)
- Nitazoxanide (Alinia) (PDF)
- Nitisinone (Nityr, Orfadin) (PDF)
- Nivolumab (Opdivo) (PDF)
- No Coverage Criteria (PDF)
- Non-Calcium Phosphate Binders (PDF)
- Non-Formulary and Formulary Contraceptives (PDF)
- Non-Formulary Test Strips (PDF)
- Nusinersen (Spinraza) (PDF)
- Obeticholic Acid (Ocaliva) (PDF)
- Obinutuzumab (Gazyva) (PDF)
- Ocrelizumab (Ocrevus) (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)
- Odevixibat (Bylvay) (PDF)
- Ofatumumab (Arzerra, Kesimpta) (PDF)
- Off-Label Drug Use (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)
- Olanzapine/Samidorphan (Lybalvi) (PDF)
- Olaparib (Lynparza) (PDF)
- Olaratumab (Lartruvo) (PDF)
- Omacetaxine (Synribo) (PDF)
- Omadacycline (Nuzyra) (PDF)
- Omalizumab (Xolair) (PDF)
- OnabotulinumtoxinA (Botox) (PDF)
- Onasemnogene Abeparvovec (Zolgensma) (PDF)
- Ondansetron (Zuplenz) (PDF)
- Ophthalmic Corticosteroids (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)
- Opicapone (Ongentys) (PDF)
- Opioid Analgesics (PDF)
- Osilodrostat (Isturisa) (PDF)
- Osimertinib (Tagrisso) (PDF)
- Ospemifene (Osphena) (PDF)
- Overactive Bladder Agents (PDF)
- Oxymetazoline (Rhofade, Upneeq) (PDF)
- Ozanimod (Zeposia) (PDF)
- Ozenoxacin (Xepi) (PDF)
- Paclitaxel, Protein-Bound (Abraxane) (PDF)
- Palbociclib (Ibrance) (PDF)
- Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF)
- Palivizumab (Synagis) (PDF)
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF)
- Panitumumab (Vectibix) (PDF)
- Panobinostat (Farydak) (PDF)
- Parathyroid Hormone (Natpara) (PDF)
- Paricalcitol Injection (Zemplar) (PDF)
- Pasireotide (Signifor, Signifor LAR) (PDF)
- Patiromer (Veltassa) (PDF)
- Patisiran (Onpattro) (PDF)
- Pazopanib (Votrient) (PDF)
- Peanut Allergen Powder-dnfp (Palforzia) (PDF)
- Pegaptanib (Macugen) (PDF)
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF)
- Pegcetacoplan (Empaveli) (PDF)
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastim-apgf (Nyvepria) (PDF)
- Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) (PDF)
- Peginterferon Beta-1a (Plegridy) (PDF)
- Pegloticase (Krystexxa) (PDF)
- Pegvaliase-pqpz (Palynziq) (PDF)
- Pegvisomant (Somavert) (PDF)
- Pembrolizumab (Keytruda) (PDF)
- Pemetrexed (Alimta, Pemfexy) (PDF)
- Pemigatinib (Pemazyre) (PDF)
- Penicillamine (Cuprimine) (PDF)
- Perampanel (Fycompa) (PDF)
- Pertuzumab (Perjeta) (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF)
- Pexidartinib (Turalio) (PDF)
- Phendimetrazine IR (Bontril PDM) (PDF)
- Phentermine (Adipex-P, Lomaira) (PDF)
- Pilocarpine (PDF)
- Pimavanserin (Nuplazid) (PDF)
- Pirfenidone (Esbriet) (PDF)
- Pitolisant (Wakix) (PDF)
- Plasminogen, human-tvmh (Ryplazim) (PDF)
- Plecanatide (Trulance) (PDF)
- Plerixafor (Mozobil) (PDF)
- Polatuzumab Vedotin-piiq (Polivy) (PDF)
- Pomalidomide (Pomalyst) (PDF)
- Ponatinib (Iclusig) (PDF)
- Ponesimod (Ponvory) (PDF)
- Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF)
- Pralatrexate (Folotyn) (PDF)
- Pramlintide (Symlin) (PDF)
- Prasterone (Intrarosa) (PDF)
- Pregabalin (Lyrica, Lyrica CR) (PDF)
- Pretomanid (PDF)
- Progesterone (Crinone, Endometrin, Milprosa) (PDF)
- Propranolol HCl Oral Solution (Hemangeol) (PDF)
- Protein C Concentrate, Human (Ceprotin) (PDF)
- Prucalopride (Motegrity) (PDF)
- Pyrimethamine (Daraprim) (PDF)
- Quetiapine Extended-Release (Seroquel XR) (PDF)
- Quinine Sulfate (Qualaquin) (PDF)
- Ramucirumab (Cyramza) (PDF)
- Ranibizumab (Byooviz, Lucentis, Susvimo) (PDF)
- Rasagiline (Azilect) (PDF)
- Ravulizumab-cwvz (Ultomiris) (PDF)
- Regorafenib (Stivarga) (PDF)
- Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF)
- Reslizumab (Cinqair) (PDF)
- Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF)
- Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF)
- Rifamycin (Aemcolo) (PDF)
- Rifaximin (Xifaxan) (PDF)
- Rilonacept (Arcalyst) (PDF)
- RimabotulinumtoxinB (Myobloc) (PDF)
- Rimegepant (Nurtec ODT) (PDF)
- Riociguat (Adempas) (PDF)
- Ripretinib (Qinlock) (PDF)
- Risdiplam (Evrysdi) (PDF)
- Risedronate (Actonel, Atelvia) (PDF)
- Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)
- Rolapitant (Varubi) (PDF)
- Romidepsin (Istodax) (PDF)
- Romiplostim (Nplate) (PDF)
- Romosozumab-aqqg (Evenity) (PDF)
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF)
- Rucaparib (Rubraca) (PDF)
- Rufinamide (Banzel) (PDF)
- Ruxolitinib (Jakafi, Opzelura) (PDF)
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF)
- Sacubitril/Valsartan (Entresto) (PDF)
- Safinamide (Xadago) (PDF)
- Sapropterin Dihydrochloride (Kuvan) (PDF)
- Sarecycline (Seysara) (PDF)
- Sargramostim (Leukine) (PDF)
- Satralizumab-mwge (Enspryng) (PDF)
- Sebelipase Alfa (Kanuma) (PDF)
- Secnidazole (Solosec) (PDF)
- Selexipag (Uptravi) (PDF)
- Selinexor (Xpovio) (PDF)
- Selpercatinib (Retevmo) (PDF)
- Selumetinib (Koselugo) (PDF)
- Setmelanotide (Imcivree) (PDF)
- Short ragweed pollen allergen extract (Ragwitek) (PDF)
- Sildenafil (Revatio) (PDF)
- Sildenafil for ED (Viagra) (PDF)
- Siltuximab (Sylvant) (PDF)
- Siponimod (Mayzent) (PDF)
- Sirolimus Protein-Bound Particles (Fyarro) (PDF)
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (PDF)
- Sodium Phenylbutyrate (Buphenyl) (PDF)
- Sodium zirconium cyclosilicate (Lokelma) (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)
- Sofosbuvir (Sovaldi) (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)
- Solriamfetol (Sunosi) (PDF)
- Sonidegib (Odomzo) (PDF)
- Sorafenib (Nexavar) (PDF)
- Sotorasib (Lumakras) (PDF)
- Spinosad (Natroba) (PDF)
- Step Therapy (PDF)
- Stiripentol (Diacomit) (PDF)
- Sunitinib (Sutent) (PDF)
- Sutimlimab (PDF)
- Suvorexant (Belsomra) (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF)
- Tadalafil (Adcirca, Alyq) (PDF)
- Tadalafil BHP - ED (Cialis) (PDF)
- Tafamidis (Vyndaqel, Vyndamax) (PDF)
- Tafasitamab-cxix (Monjuvi) (PDF)
- Talazoparib (Talzenna) (PDF)
- Taliglucerase Alfa (Elelyso) (PDF)
- Talimogene laherepvec (Imlygic) (PDF)
- Tasimelteon (Hetlioz, Hetlioz LQ) (PDF)
- Tavaborole (Kerydin) (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF)
- Tazemetostat (Tazverik) (PDF)
- Tedizolid (Sivextro) (PDF)
- Teduglutide (Gattex) (PDF)
- Tegaserod (Zelnorm) (PDF)
- Telotristat Ethyl (Xermelo) (PDF)
- Temozolomide (Temodar) (PDF)
- Temsirolimus (Torisel) (PDF)
- Tenapanor (Ibsrela) (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)
- Tepotinib (Tepmetko) (PDF)
- Teprotumumab (Tepezza) (PDF)
- Teriflunomide (Aubagio) (PDF)
- Teriparatide (Forteo) (PDF)
- Tesamorelin (Egrifta SV) (PDF)
- Testosterone (Androderm) (PDF)
- Testosterone (Testopel, Jatenzo) (PDF)
- Tetrabenazine (Xenazine) (PDF)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)
- Thalidomide (Thalomid) (PDF)
- Thioguanine (Tabloid) (PDF)
- Thyrotropin alfa (Thyrogen) (PDF)
- Timothy grass pollen allergen extract (Grastek) (PDF)
- Tisagenlecleucel (Kymriah) (PDF)
- Tisotumab vedotin-tftv (Tivdak) (PDF)
- Tivozanib (Fotivda) (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF)
- Tolvaptan (Jynarque, Samsca) (PDF)
- Topical Acne Treatment (PDF)
- Topical Immunomodulators (PDF)
- Topotecan (Hycamtin) (PDF)
- Trabectedin (Yondelis) (PDF)
- Trametinib (Mekinist) (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF)
- Triamcinolone ER Injection (Zilretta) (PDF)
- Triclabendazole (Egaten) (PDF)
- Trientine (Syprine) (PDF)
- Trifarotene (Aklief) (PDF)
- Trifluridine/Tipiracil (Lonsurf) (PDF)
- Triheptanoin (Dojolvi) (PDF)
- Triptorelin Pamoate (Trelstar, Triptodur) (PDF)
- Tucatinib (Tukysa) (PDF)
- Ubrogepant (Ubrelvy) (PDF)
- Umbralisib (Ukoniq) (PDF)
- Uridine Triacetate (Vistogard) (PDF)
- Valganciclovir (Valcyte) (PDF)
- Valproate Sodium for Intravenous Injection (Depacon) (PDF)
- Valrubicin (Valstar) (PDF)
- Vandetanib (Caprelsa) (PDF)
- Varenicline (Tyrvaya) (PDF)
- Velaglucerase Alfa (VPRIV) (PDF)
- Vemurafenib (Zelboraf) (PDF)
- Venetoclax (Venclexta) (PDF)
- Verteporfin (Visudyne) (PDF)
- Vestronidase alfa-vjbk (Mepsevii) (PDF)
- Vigabatrin (Sabril) (PDF)
- Vilazodone (Viibryd) (PDF)
- Viltolarsen (Viltepso) (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) (PDF)
- Vismodegib (Erivedge) (PDF)
- Voclosporin (Lupkynis) (PDF)
- Vorapaxar (Zontivity) (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) (PDF)
- Vorinostat (Zolinza) (PDF)
- Vortioxetine (Trintellix) (PDF)
- Vosoritide (Voxzogo) (PDF)
- Voxelotor (Oxbryta) (PDF)
- Viloxazine (Qelbree) (PDF)
- Zanubrutinib (Brukinsa) (PDF)
- Ziv-aflibercept (Zaltrap) (PDF)
- Zoledronic Acid (Reclast, Zometa) (PDF)