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
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