A-G |
H-P |
Q-Z |
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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 |
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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 |
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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 |
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