HAVE AN ENROLLMENT NEED? SHOP OUR PLANS
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 Ambetter from Nebraska Total Care Clinical Policy Manual apply to Ambetter from Nebraska Total Care members. Policies in the Ambetter from Nebraska Total Care Clinical Policy Manual may have either a Ambetter from Nebraska Total Care or a “Centene” heading. Ambetter from Nebraska Total Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from Nebraska Total Care 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 Ambetter from Nebraska Total Care. In addition, Ambetter from Nebraska Total Care 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 Ambetter from Nebraska Total Care.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Ambetter from Nebraska Total Care Payment Policy Manual apply with respect to Nebraska Total Care members. Policies in the Ambetter from Nebraska Total Care Payment Policy Manual may have either a Ambetter from Nebraska Total Care or a “Centene” heading. In addition, Nebraska Total Care may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Ambetter from Nebraska Total Care. If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Pharmacy Policies
- Abaloparatide (Tymlos) (PDF) Effective Date: 7/1/2017
- Abametapir (Xeglyze) (PDF) Effective Date: 12/1/2020
- Abemaciclib (Verzenio) (PDF) Effective Date: 10/24/2017
- Abiraterone (Zytiga, Yonsa) (PDF) Effective Date: 10/1/2011
- AbobotulinumtoxinA (Dysport) (PDF) Effective Date: 7/1/2016
- Abrocitinib (Cibinqo) (PDF) Effective Date: 6/1/2022
- Acalabrutinib (Calquence) (PDF) Effective Date: 3/1/2018
- Acyclovir Buccal Tablet (Sitavig) (PDF) Effective Date: 9/1/2019
- Adefovir (Hepsera) (PDF) Effective Date: 8/28/2018
- Ado-Trastuzumab Emtansine (Kadcyla) (PDF) Effective Date: 6/1/2016
- Aducanumab-avwa (Aduhelm) (PDF) Effective Date: 6/1/2020
- Afamelanotide (Scenesse) (PDF) Effective Date: 3/1/2020
- Afatinib (Gilotrif) (PDF) Effective Date: 1/1/2017
- Aflibercept (Eylea) (PDF) Effective Date: 3/1/2016
- Agalsidase Beta (Fabrazyme) (PDF) Effective Date: 2/1/2016
- Age Limit Override (Codeine, Tramadol, Hydrocodone) Effective Date: 3/13/2018
- Alectinib (Alecensa) (PDF) Effective Date: 11/16/2016 Alemtuzumab (Lemtrada) (PDF) Effective Date: 8/1/2016
- Alendronate (Binosto, Fosamax Plus D) (PDF) Effective Date: 2/28/2018
- Alglucosidase Alfa (Lumizyme) (PDF) Effective Date: 2/1/2016
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF) Effective Date: 3/1/2022
- Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF) Effective Date: 3/1/2022
- Alpelisib (Piqray, Vijoice) (PDF) Effective Date: 9/1/2019
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF) Effective Date: 3/1/2012
- Amantadine ER (Gocovri, Osmolex ER) (PDF) Effective Date: 10/10/2017
- Ambrisentan (Letairis) (PDF) Effective Date: 3/1/2016
- Amifampridine (Firdapse) (PDF) Effective Date: 1/22/2019
- Amikacin (Arikayce) (PDF) Effective Date: 11/13/2018
- Amisulpride (Barhemsys) (PDF) Effective Date: 9/1/2020
- Amivantamab-vmjw (Rybrevant) (PDF) Effective Date: 9/1/2021
- Anifrolumab-fnia (Saphnelo) (PDF) Effective Date: 12/1/2021
- Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF) Effective Date: 5/1/2016
- Antithrombin III (ATryn, Thrombate III) (PDF) Effective Date: 3/1/2022
- Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF) Effective Date: 12/1/2020
- Apalutamide (Erleada) (PDF) Effective Date: 3/1/2022
- Apomorphine (Apokyn, Kynmobi) (PDF) Effective Date: 9/1/2020
- Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF) Effective Date: 11/30/2016
- Aripiprazole Long-Acting Injections (Abilify Maintena,
- Aristada, Aristada Initio) (PDF) Effective Date: 12/1/2016
- Aripiprazole Orally Disintegrating Tablet (PDF) Effective Date: 3/1/2021
- Armodafinil (Nuvigil) (PDF) Effective Date: 8/1/2009
- Asciminib (Scemblix) (PDF) Effective Date: 3/1/2022
- Asenapine (Saphris, Secuado) (PDF) Effective Date: 12/1/2014
- Asfotase Alfa (Strensiq) (PDF) Effective Date: 3/1/2017
- Aspirin/Dipyridamole (Aggrenox) (PDF) Effective Date: 9/1/2006
- Atezolizumab (Tecentriq) (PDF) Effective Date: 6/1/2016
- Atogepant (Qulipta) (PDF) Effective Date: 3/1/2022
- Avacincaptad pegol (Izervay) (PDF) Effective Date: 12/1/2023
- Avacopan (Tavneos) (PDF) Effective Date: 3/1/2021
- Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF) Effective Date: 3/1/2021
- Avapritinib (Ayvakit) (PDF) Effective Date: 3/1/2020
- Avatrombopag (Doptelet) (PDF) Effective Date: 7/17/2018
- Avelumab (Bavencio) (PDF) Effective Date: 5/1/2017
- Axicabtagene Ciloleucel (Yescarta) (PDF) Effective Date: 10/31/2017
- Axitinib (Inlyta) (PDF) Effective Date: 5/1/2012
- Azacitidine (Onureg, Vidaza) (PDF) Effective Date: 8/28/2018
- Azelaic Acid (Finacea Topical Gel/Foam) (PDF) Effective Date: 11/9/2017
- Aztreonam (Cayston) (PDF) Effective Date: 5/1/2016
- Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) (PDF) Effective Date: 11/9/2017
- Baloxavir Marboxil (Xofluza) (PDF) Effective Date: 10/30/2018
- Bedaquiline (Sirturo) (PDF) Effective Date: 12/1/2019
- Belantamab Mafodotin-blmf (Blenrep) (PDF) Effective Date: 6/1/2020
- Belatacept (Nulojix) (PDF) Effective Date: 11/9/2017
- Belimumab (Benlysta) (PDF) Effective Date: 10/1/2011
- Belinostat (Beleodaq) (PDF) Effective Date: 2/1/2017
- Belumosudil (Rezurock) (PDF) Effective Date: 12/1/2021
- Belzutifan (Welireg) (PDF) Effective Date: 12/1/2021
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF) Effective Date: 9/1/2020
- Bendamustine (Belrapzo, Bendeka, Treanda) (PDF) Effective Date: 2/1/2023
- Benralizumab (Fasenra) (PDF) Effective Date: 1/16/2018
- Benznidazole (PDF) Effective Date: 10/17/2017
- Betaine (Cystadane) (PDF) Effective Date: 8/28/2018
- Betamethasone Dipropionate Spray (Sernivo) (PDF) Effective Date: 12/1/2018
- Betibeglogene Autotemcel (Zynteglo) (PDF) Effective Date: 2/1/2023
- Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) (PDF) Effective Date: 10/31/2011
- Bexarotene (Targretin Capsules, Gel) (PDF) Effective Date: 9/1/2011
- Bezlotoxumab (Zinplava) (PDF) Effective Date: 11/16/2016
- Bimatoprost Implant (Durysta) (PDF) Effective Date: 6/1/2020
- Binimetinib (Mektovi) (PDF) Effective Date: 7/24/2018
- Biologic and Non-biologic DMARDs (PDF) Effective Date: 2/1/2023
- Blinatumomab (Blincyto) (PDF) Effective Date: 2/1/2017
- Bortezomib (Velcade) (PDF) Effective Date: 12/11/2018
- Bosentan (Tracleer) (PDF) Effective Date: 3/1/2016
- Bosutinib (Bosulif) (PDF) Effective Date: 10/1/2012
- Brand Name Override and Non-Formulary Medications (PDF) Effective Date: 12/1/2014
- Brentuximab Vedotin (Adcetris) (PDF) Effective Date: 2/1/2017
- Brexanolone (Zulresso) (PDF) Effective Date: 4/16/2019
- Brexpiprazole (Rexulti) (PDF) Effective Date: 11/5/2015
- Brexucabtagene Autoleucel (Tecartus) (PDF) Effective Date: 6/1/2020
- Brigatinib (Alunbrig) (PDF) Effective Date: 7/17/2017
- Brimonidine Tartrate (Mirvaso) (PDF) Effective Date: 11/15/2016
- Brinzolamide/Brimonidine (Simbrinza) (PDF) Effective Date: 9/4/2018
- Brivaracetam (Briviact) (PDF) Effective Date: 5/21/2019
- Brolucizumab-dbll (Beovu) (PDF) Effective Date: 2/29/2020
- Budesonide (Tarpeyo) (PDF) Effective Date: 3/1/2022
- Budesonide (Uceris) (PDF) Effective Date: 8/14/2018
- Buprenorphine (Subutex) (PDF) Effective Date: 9/1/2017
- Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF) Effective Date: 11/16/2016
- Buprenorphine/Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF) Effective Date: 9/1/2017
- Bupropion/Naltrexone (Contrave) (PDF) Effective Date: 5/1/2017
- Burosumab-twza (Crysvita) (PDF) Effective Date: 5/8/2018
- Butorphanol Nasal Spray (PDF) Effective Date: 12/1/2014
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF) Effective Date: 3/1/2016
- Cabazitaxel (Jevtana) (PDF) Effective Date: 2/1/2017
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF) Effective Date: 3/1/2022
- Cabozantinib (Cabometyx, Cometriq) (PDF) Effective Date: 6/1/2013
- Calcifediol (Rayaldee) (PDF) Effective Date: 11/1/2016
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF) Effective Date: 12/1/2018
- Canakinumab (Ilaris) (PDF) Effective Date: 8/1/2016
- Cannabidiol (Epidiolex) (PDF) Effective Date: 7/17/2018
- Capecitabine (Xeloda) (PDF) Effective Date: 5/1/2011
- Caplacizumab-yhdp (Cablivi) (PDF) Effective Date: 3/12/2019
- Capmatinib (Tabrecta) (PDF) Effective Date: 9/1/2020
- Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) (PDF) Effective Date: 9/1/2020
- Carfilzomib (Kyprolis) (PDF) Effective Date: 2/1/2017
- Carglumic Acid (Carbaglu) (PDF) Effective Date: 5/1/2016
- Cariprazine (Vraylar) (PDF) Effective Date: 11/16/2016
- Casimersen (Amondys 45) (PDF) Effective Date: 6/1/2020
- Casirivimab and Imdevimab (REGEN-COV) (PDF) Effective Date: 12/22/2020
- Celecoxib (Celebrex, Elyxyb) (PDF) Effective Date: 1/1/2007
- Cemiplimab-rwlc (Libtayo) (PDF) Effective Date: 10/16/2018
- Cenegermin-bkbj (Oxervate) (PDF) Effective Date: 10/9/2018
- Cenobamate (Xcopri) (PDF) Effective Date: 3/1/2020
- Ceritinib (Zykadia) (PDF) Effective Date: 7/1/2017
- Cerliponase Alfa (Brineura) (PDF) Effective Date: 7/1/2017
- Cetuximab (Erbitux) (PDF) Effective Date: 2/1/2017
- Chenodiol (Chenodal) (PDF) Effective Date: 9/1/2020
- Chlorambucil (Leukeran) (PDF) Effective Date: 12/1/2021
- Chloramphenicol Sodium Succinate (PDF) Effective Date: 12/1/2018
- Cholic Acid (Cholbam) (PDF) Effective Date: 12/1/2018
- Ciclopirox (Penlac) (PDF) Effective Date: 9/1/2007
- Ciltacabtagene Autoleucel (Carvykti) (PDF) Effective Date: 5/7/2021
- Cinacalcet (Sensipar) (PDF) Effective Date: 5/1/2011
- Ciprofloxacin/Dexamethasone (Ciprodex) (PDF) Effective Date: 12/1/2020
- Ciprofloxacin/Fluocinolone (Otovel) (PDF) Effective Date: 12/1/2020
- Cladribine (Mavenclad) (PDF) Effective Date: 9/1/2019
- Clascoterone (Winlevi) (PDF) Effective Date: 2/28/2021
- Clinical Policy: Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF) Effective Date: 7/1/2016
- Clobazam (Onfi, Sympazan) (PDF) Effective Date: 11/1/2012
- CNS Stimulants (PDF) Effective Date: 3/1/2018
- Cobimetinib (Cotellic) (PDF) Effective Date: 2/1/2023
- Colesevelam (Welchol) (PDF) Effective Date: 12/1/2020
- Collagenase Clostridium Histolyticum (Xiaflex) (PDF) Effective Date: 10/1/2011
- Colonoscopy Preparation Products (PDF) Effective Date: 12/1/2021
- Compounded Medications (PDF) Effective Date: 9/1/2022
- Conjugated Estrogens/Bazedoxifene (Duavee) (PDF) Effective Date: 3/1/2021
- Continuous Glucose Monitors (PDF) Effective Date: 12/1/2019
- Copanlisib (Aliqopa) (PDF) Effective Date: 10/17/2017
- Corticosteroids for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF) Effective Date: 5/29/2018
- Cosyntropin (Cortrosyn) (PDF) Effective Date: 4/1/2016
- Crisaborole (Eucrisa) (PDF) Effective Date: 2/21/2017 Crizanlizumab-tmca (Adakveo) (PDF) Effective Date: 3/1/2020
- Crizotinib (Xalkori) (PDF) Effective Date: 11/1/2011 Cyclosporine (Cequa, Restasis, Verkazia) (PDF) Effective Date: 5/1/2012
- Cysteamine Ophthalmic (Cystaran, Cystadrops) (PDF) Effective Date: 8/1/2017
- Cysteamine oral (Cystagon, Procysbi) (PDF) Effective Date: 2/1/2016
- Cytomegalovirus Immune Globulin (CytoGam) (PDF) Effective Date: 9/1/2018
- Dabrafenib (Tafinlar) (PDF) Effective Date: 11/16/2016
- Dacomitinib (Vizimpro) (PDF) Effective Date: 10/16/2018
- Dalfampridine (Ampyra) (PDF) Effective Date: 8/1/2016
- Dalteparin (Fragmin) (PDF) Effective Date: 5/1/2016
- Daprodustat (Jesduvroq) (PDF) Effective Date: 6/1/2023
- Dapsone (Aczone Gel) (PDF) Effective Date: 12/1/2020
- Daptomycin (Cubicin, Cubicin RF) (PDF) Effective Date: 11/30/2017
- Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF) Effective Date: 7/1/2017
- Darbepoetin Alfa (Aranesp) (PDF) Effective Date: 6/1/2016
- Darolutamide (Nubeqa) (PDF) Effective Date: 12/1/2019
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF) Effective Date: 2/1/2023
- Dasatinib (Sprycel) (PDF) Effective Date: 6/1/2012
- Daunorubicin/Cytarabine (Vyxeos) (PDF) Effective Date: 12/1/2017
- DaxibotulinumtoxinA-lanm (Daxxify) (PDF) Effective Date: 12/1/2023
- Decitabine/Cedazuridine (Inqovi) (PDF) Effective Date: 6/1/2020
- Deferasirox (Exjade, Jadenu) (PDF) Effective Date: 11/1/2015
- Deferoxamine (Desferal) (PDF) Effective Date: 11/1/2015
- Deflazacort (Emflaza) (PDF) Effective Date: 3/1/2017
- Degarelix Acetate (Firmagon) (PDF) Effective Date: 11/9/2017
- Delafloxacin (Baxdela) (PDF) Effective Date: 11/9/2017
- Delandistrogene Moxeparvovec (SRP-9001) (PDF) Effective Date: 12/1/2022
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF) Effective Date: 5/1/2016
- Deutetrabenazine (Austedo) (PDF) Effective Date: 6/1/2021
- Dexrazoxane (Totect) (PDF) Effective Date: 3/19/2019
- Dextromethorphan/Bupropion (Auvelity) (PDF) Effective Date: 12/1/2022
- Dextromethorphan-Quinidine (Nuedexta) (PDF) Effective Date: 3/1/2018
- Diazepam Nasal Spray (Valtoco) (PDF) Effective Date: 12/1/2019
- Dichlorphenamide (Keveyis) (PDF) Effective Date: 3/1/2021
- Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF) Effective Date: 9/1/2020
- Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (PDF) Effective Date: 2/1/2021
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF) Effective Date: 3/1/2018
- Dolasetron (Anzemet) (PDF) Effective Date: 9/1/2006
- Dornase Alfa (Pulmozyme) (PDF) Effective Date: 5/1/2016
- Dostarlimab-gxly (Jemperli) (PDF) Effective Date: 9/1/2021
- Doxepin (Silenor, Prudoxin, Zonalon) (PDF) Effective Date: 11/17/2017
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF) Effective Date: 5/1/2017
- Dupilumab (Dupixent) (PDF) Effective Date: 5/1/2017
- Durvalumab (Imfinzi) (PDF) Effective Date: 7/1/2017
- Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF) Effective Date: 5/1/2016
- Duvelisib (Copiktra) (PDF) Effective Date: 10/16/2018
- Ecallantide (Kalbitor) (PDF) Effective Date: 3/1/2016
- Edaravone (Radicava, Radivaca ORS) (PDF) Effective Date: 7/1/2017
- Efgartigimod Alfa-fcab (Vyvgart) (PDF) Effective Date: 12/1/2021
- Efinaconazole (Jublia) (PDF) Effective Date: 8/1/2016
- Eladocagene Exuparvovec (Upstaza) (PDF) Effective Date: 12/1/2022
- Elapegademase-lvlr (Revcovi) (PDF) Effective Date: 4/23/2019
- Elbasvir/Grazoprevir (Zepatier) (PDF) Effective Date: 2/1/2023
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF) Effective Date: 12/1/2019
- Eliglustat (Cerdelga) (PDF) Effective Date: 2/1/2016
- Elivaldogene Autotemcel (Skysona) (PDF) Effective Date: 12/1/2021
- Elosulfase Alfa (Vimizim) (PDF) Effective Date: 2/1/2016
- Elotuzumab (Empliciti) (PDF) Effective Date: 2/1/2017
- Elranatamab-bcmm (Elrexfio) (PDF) Effective Date: 12/1/2023
- Eltrombopag (Promacta) (PDF) Effective Date: 3/1/2016
- Eluxadoline (Viberzi) (PDF) Effective Date: 12/1/2018
- Emapalumab-lzsg (Gamifant) (PDF) Effective Date: 12/11/2018
- Emicizumab-kxwh (Hemlibra) (PDF) Effective Date: 3/1/2018
- Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF) Effective Date: 6/1/2020
- Enasidenib (Idhifa) (PDF) Effective Date: 9/5/2017
- Encorafenib (Braftovi) (PDF) Effective Date: 7/24/2018
- Enfuvirtide (Fuzeon) (PDF) Effective Date: 6/1/2010
- Enoxaparin (Lovenox) (PDF) Effective Date: 5/1/2016
- Entecavir (Baraclude) (PDF) Effective Date: 2/19/2019
- Entrectinib (Rozlytrek) (PDF) Effective Date: 12/1/2019
- Enzalutamide (Xtandi) (PDF) Effective Date: 3/1/2022
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF) Effective Date: 6/1/2016
- Epoprostenol (Flolan, Veletri) (PDF) Effective Date: 3/1/2016
- Eptinezumab-jjmr (Vyepti) (PDF) Effective Date: 10/1/2020
- Erdafitinib (Balversa) (PDF) Effective Date: 9/1/2019
- Erenumab-aaoe (Aimovig) (PDF) Effective Date: 10/1/2020
- Eribulin Mesylate (Halaven) (PDF) Effective Date: 3/1/2017
- Erlotinib (Tarceva) (PDF) Effective Date: 9/1/2011
- Erwinia Asparaginase (Erwinaze, Rylaze) (PDF) Effective Date: 2/1/2017
- Esketamine (Spravato) (PDF) Effective Date: 3/12/2019
- Estradiol Vaginal Ring (Femring) (PDF) Effective Date: 1/1/2022
- Etelcalcetide (Parsabiv) (PDF) Effective Date: 3/20/2018
- Eteplirsen (Exondys 51) (PDF) Effective Date: 12/1/2016
- Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF) Effective Date: 6/1/2011
- Evinacumab-dgnb (Evkeeza) (PDF) Effective Date: 12/1/2020
- Evolocumab (Repatha) (PDF) Effective Date: 6/1/2021
- Factor IX (Human, Recombinant) (PDF) Effective Date: 5/1/2016
- Factor IX Complex, Human (Profilnine) (PDF) Effective Date: 5/1/2016
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF) Effective Date: 5/1/2016
- Factor VIII (Human, Recombinant) (PDF) Effective Date: 5/1/2016
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (PDF) Effective Date: 5/1/2016
- Factor XIII A-Subunit, Recombinant (Tretten) (PDF) Effective Date: 5/1/2016
- Factor XIII, Human (Corifact) (PDF) Effective Date: 5/1/2016
- Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF) Effective Date: 3/1/2020
- Faricimab-svoa (Vabysmo) (PDF) Effective Date: 6/1/2022
- Febuxostat (Uloric) (PDF) Effective Date: 8/1/2013
- Fedratinib (Inrebic) (PDF) Effective Date: 12/1/2019
- Fenfluramine (Fintepla) (PDF) Effective Date: 9/1/2020
- Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF) Effective Date: 6/1/2015
- Ferric Carboxymaltose (Injectafer) (PDF) Effective Date: 6/1/2016
- Ferric Derisomaltose (Monoferric) (PDF) Effective Date: 6/1/2020
- Ferric Maltol (Accrufer) (PDF) Effective Date: 12/1/2019
- Ferumoxytol (Feraheme) (PDF) Effective Date: 3/1/2016
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF) Effective Date: 6/1/2021
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko) (PDF) Effective Date: 12/1/2016
- Finerenone (Kerendia) (PDF) Effective Date: 12/1/2021
- Fingolimod (Gilenya, Tascenso ODT) (PDF) Effective Date: 2/1/2021
- Flibanserin (Addyi) (PDF) Effective Date: 3/1/2020
- Fluorouracil Cream (Tolak) (PDF) Effective Date: 12/1/2018
- Fluticasone Propionate (Xhance) (PDF) Effective Date: 10/24/2017
- Fondaparinux (Arixtra) (PDF) Effective Date: 5/1/2016
- Fosdenopterin (Nulibry) (PDF) Effective Date: 6/1/2020
- Fostamatinib (Tavalisse) (PDF) Effective Date: 6/5/2018
- Fostemsavir (Rukobia) (PDF) Effective Date: 3/1/2021
- Fremanezumab-vfrm (Ajovy) (PDF) Effective Date: 10/1/2020
- Fulvestrant (Faslodex Injection) (PDF) Effective Date: 9/1/2019
- Gabapentin ER (Gralise, Horizant) (PDF) Effective Date: 9/1/2020
- Galcanezumab-gnlm (Emgality) (PDF) Effective Date: 10/1/2020
- Galsulfase (Naglazyme) (PDF) Effective Date: 2/1/2016
- Ganaxolone (Ztalmy) (PDF) Effective Date: 6/1/2022
- Gefitinib (Iressa) (PDF) Effective Date: 11/16/2016
- Gemtuzumab Ozogamicin (Mylotarg) (PDF) Effective Date: 10/3/2017
- Gilteritinib (Xospata) (PDF) Effective Date: 1/15/2019
- Givosiran (Givlaari) (PDF) Effective Date: 3/1/2020
- Glasdegib (Daurismo) (PDF) Effective Date: 1/8/2019
- Glecaprevir/Pibrentasvir (Mavyret) (PDF) Effective Date: 2/1/2023
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF) Effective Date: 3/1/2018
- Glycerol Phenylbutyrate (Ravicti) (PDF) Effective Date: 4/30/2016
- Golodirsen (Vyondys 53) (PDF) Effective Date: 3/1/2020
- Goserelin Acetate (Zoladex) (PDF) Effective Date: 11/9/2017
- Granisetron (Sancuso, Sustol) (PDF) Effective Date: 11/1/2016
- Halcinonide (Halog) (PDF) Effective Date: 8/28/2018
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF) Effective Date: 12/1/2018
- Halobetasol Propionate/Tazarotene (Duobrii) (PDF) Effective Date: 9/1/2019
- Hemin (Panhematin) (PDF) Effective Date: 2/1/2016
- Histrelin Acetate (Vantas, Supprelin LA) (PDF) Effective Date: 11/9/2017
- House Dust Mite Allergen Extract (Odactra) (PDF) Effective Date: 8/31/2017
- Human Growth Hormone (Somapacitan, Somatropin) (PDF) Effective Date: 1/1/2022
- Hyaluronate Derivatives (PDF) Effective Date: 10/1/2008
- Hydroxyprogesterone Caproate (Makena/compound) (PDF) Effective Date: 11/20/2017
- Hydroxyurea (Siklos) (PDF) Effective Date: 2/19/2019
- Ibalizumab-uiyk (Trogarzo) (PDF) Effective Date: 4/17/2018
- Ibandronate Injection (Boniva) (PDF) Effective Date: 11/15/2017
- Ibrutinib (Imbruvica) (PDF) Effective Date: 10/1/2015
- Ibuprofen/Famotidine (Duexis) (PDF) Effective Date: 6/1/2018
- Icatibant (Firazyr) (PDF) Effective Date: 3/1/2016
- Icosapent Ethyl (Vascepa) (PDF) Effective Date: 11/20/2018
- Idecabtagene Vicleucel (Abecma) (PDF) Effective Date: 6/1/2020
- Idelalisib (Zydelig) (PDF) Effective Date: 12/1/2018
- Idursulfase (Elaprase) (PDF) Effective Date: 2/1/2016
- Iloperidone (Fanapt) (PDF) Effective Date: 12/1/2014
- Iloprost (Ventavis) (PDF) Effective Date: 3/1/2016
- Imatinib (Gleevec) (PDF) Effective Date: 6/1/2011
- Imiglucerase (Cerezyme) (PDF) Effective Date: 2/1/2016
- Immune Globulins (PDF) Effective Date: 8/1/2012
- Inclisiran (Leqvio) (PDF) Effective Date: 3/1/2022
- IncobotulinumtoxinA (Xeomin) (PDF) Effective Date: 7/1/2016
- Inebilizumab-cdon (Uplizna) (PDF) Effective Date: 3/1/2020
- Infertility and Fertility Preservation (PDF) Effective Date: 11/16/2016
- Infigratinib (Truseltiq) (PDF) Effective Date: 9/1/2021
- Inhaled Agents for Asthma and COPD (PDF) Effective Date: 3/1/2021
- Inotersen (Tegsedi) (PDF) Effective Date: 11/20/2018
- Inotuzumab Ozogamicin (Besponsa) (PDF) Effective Date: 9/26/2017
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF) Effective Date: 6/1/2021
- Insulin Glargine (Rezvoglar, Semglee, Toujeo) (PDF) Effective Date: 3/1/2019
- Interferon Beta-1a (Avonex, Rebif) (PDF) Effective Date: 8/1/2016
- Interferon Beta-1b (Betaseron, Extavia) (PDF) Effective Date: 3/1/2022
- Interferon Gamma- 1b (Actimmune) (PDF) Effective Date: 6/1/2010
- Iobenguane I-131 (Azedra) (PDF) Effective Date: 3/1/2020
- Ipilimumab (Yervoy) (PDF) Effective Date: 4/17/2018
- Irinotecan Liposome (Onivyde) (PDF) Effective Date: 2/1/2017
- Isatuximab-irfc (Sarclisa) (PDF) Effective Date: 6/1/2020
- Isavuconazonium (Cresemba) (PDF) Effective Date: 11/16/2016
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF) Effective Date: 12/1/2014
- Istradefylline (Nourianz) (PDF) Effective Date: 3/1/2020
- Itraconazole (Sporanox, Tolsura) (PDF) Effective Date: 11/1/2006
- Ivabradine (Corlanor) (PDF) Effective Date: 11/1/2015
- Ivacaftor (Kalydeco) (PDF) Effective Date: 5/1/2016
- Ivermectin (Stromectol, Sklice) (PDF) Effective Date: 12/1/2021
- Ivosidenib (Tibsovo) (PDF) Effective Date: 8/21/2018
- Ixazomib (Ninlaro) (PDF) Effective Date: 2/1/2017
- Ketorolac Nasal Spray (Sprix) (PDF) Effective Date: 12/1/2022
- Lanadelumab-fylo (Takhzyro) (PDF) Effective Date: 9/25/2018
- Lanreotide (Somatuline Depot) (PDF) Effective Date: 8/14/2018
- Lapatinib (Tykerb) (PDF) Effective Date: 11/9/2017
- Laronidase (Aldurazyme) (PDF) Effective Date: 2/1/2016
- Larotrectinib (Vitrakvi) (PDF) Effective Date: 1/15/2018
- Lasmiditan (Reyvow) (PDF) Effective Date: 3/1/2020
- Ledipasvir/Sofosbuvir (Harvoni) (PDF) Effective Date: 2/1/2023
- Lefamulin (Xenleta) (PDF) Effective Date: 3/1/2020
- Lenalidomide (Revlimid) (PDF) Effective Date: 7/1/2011
- Leniolisib (Joenja) (PDF) Effective Date: 5/1/2023
- Lenvatinib (Lenvima) (PDF) Effective Date: 12/1/2018
- Letermovir (Prevymis) (PDF) Effective Date: 3/1/2018
- Leucovorin Injection (PDF) Effective Date: 12/1/2018
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (PDF) Effective Date: 11/9/2017
- Levodopa Inhalation Powder (Inbrija) (PDF) Effective Date: 12/1/2021
- Levoketoconazole (Recorlev) (PDF) Effective Date: 6/1/2022
- Levoleucovorin (Fusilev, Khapzory) (PDF) Effective Date: 11/9/2017
- Levomilnacipran (Fetzima) (PDF) Effective Date: 11/9/2017
- L-glutamine (Endari) (PDF) Effective Date: 11/9/2017
- Lidocaine Transdermal (Lidoderm, ZTlido) (PDF) Effective Date: 9/1/2006
- Lifitegrast (Xiidra) (PDF) Effective Date: 11/9/2017
- Linaclotide (Linzess) (PDF) Effective Date: 11/1/2015
- Linezolid (Zyvox) (PDF) Effective Date: 9/1/2016
- Lisocabtagene Maraleucel (Breyanzi) (PDF) Effective Date: 6/1/2020
- Lofexidine (Lucemyra) (PDF) Effective Date: 8/1/2018
- Lomustine (Gleostine) (PDF) Effective Date: 12/1/2020
- Lonafarnib (Zokinvy) (PDF) Effective Date: 9/1/2020
- Loncastuximab Tesirine-lpyl (Zynlonta) (PDF) Effective Date: 9/1/2021
- Lorlatinib (Lorbrena) (PDF) Effective Date: 12/11/2018
- Loteprednol etabonate (Eysuvis) (PDF) Effective Date: 3/1/2021
- Lotilaner (Xdemvy) (PDF) Effective Date: 12/1/2023
- Lubiprostone (Amitiza) (PDF) Effective Date: 12/1/2014
- Luliconazole Cream (Luzu) (PDF) Effective Date: 8/28/2018
- Lumacaftor/Ivacaftor (Orkambi) (PDF) Effective Date: 5/1/2016
- Lumasiran (Oxlumo) (PDF) Effective Date: 6/1/2020
- Lumateperone (Caplyta) (PDF) Effective Date: 3/1/2020
- Lurbinectedin (Zepzelca) (PDF) Effective Date: 9/1/2020
- Luspatercept-aamt (Reblozyl) (PDF) Effective Date: 3/1/2020
- Lusutrombopag (Mulpleta) (PDF) Effective Date: 9/18/2018
- Lutetium Lu 177 Dotatate (Lutathera) (PDF) Effective Date: 5/22/2018
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF) Effective Date: 6/1/2022
- Macitentan (Opsumit) (PDF) Effective Date: 3/1/2016
- Mannitol (Bronchitol) (PDF) Effective Date: 3/1/2021
- Maralixibat (Livmarli) (PDF) Effective Date: 9/1/2021
- Margetuximab-cmkb (Margenza) (PDF) Effective Date: 3/1/2021
- Maribavir (Livtencity) (PDF) Effective Date: 3/1/2022
- Mavacamten (Camzyos) (PDF) Effective Date: 3/1/2022
- Mecamylamine (Vecamyl) (PDF) Effective Date: 5/1/2017
- Mecasermin (Increlex) (PDF) Effective Date: 3/1/2011
- Mechlorethamine Gel (Valchlor) (PDF) Effective Date: 11/16/2016
- Megestrol Acetate (Megace ES) (PDF) Effective Date: 12/1/2018
- Melphalan (Hepzato) (PDF) Effective Date: 12/1/2023
- Melphalan flufenamide (Pepaxto) (PDF) Effective Date: 2/1/2023
- Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF) Effective Date: 9/1/2020
- Mepolizumab (Nucala) (PDF) Effective Date: 4/1/2016
- Mercaptopurine (Purixan) (PDF) Effective Date: 3/1/2020
- Metformin ER (Fortamet, Glumetza) (PDF) Effective Date: 10/31/2015
- Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF) Effective Date: 12/1/2018
- Methoxsalen (Uvadex) (PDF) Effective Date: 9/4/2018
- Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF) Effective Date: 6/1/2016
- Methylnaltrexone Bromide (Relistor) (PDF) Effective Date: 12/1/2018
- Metoclopramide (Gimoti) (PDF) Effective Date: 12/1/2020
- Metreleptin (Myalept) (PDF) Effective Date: 9/1/2019
- Midazolam (Nayzilam) (PDF) Effective Date: 9/1/2019
- Midostaurin (Rydapt) (PDF) Effective Date: 6/1/2017
- Mifepristone (Korlym) (PDF) Effective Date: 5/1/2012
- Migalastat (Galafold) (PDF) Effective Date: 9/11/2018
- Miglustat (Zavesca) (PDF) Effective Date: 2/1/2016
- Milnacipran (Savella) (PDF) Effective Date: 8/1/2012
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF) Effective Date: 4/30/2017
- Mitapivat (Pyrukynd) (PDF) Effective Date: 12/1/2021
- Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF) Effective Date: 9/1/2020
- Mitoxantrone (PDF) Effective Date: 8/1/2016
- Mobocertinib (Exkivity) (PDF) Effective Date: 12/1/2021
- Modafinil (Provigil) (PDF) Effective Date: 5/1/2008
- Mogamulizumab-kpkc (Poteligeo) (PDF) Effective Date: 9/4/2018
- Mometasone (Nasonex) (PDF) Effective Date: 12/1/2014
- Mometasone Furoate (Sinuva) (PDF) Effective Date: 3/1/2020
- Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF) Effective Date: 10/16/2018
- Nafarelin Acetate (Synarel) (PDF) Effective Date: 11/9/2017
- Naltrexone (Vivitrol) (PDF) Effective Date: 3/1/2012
- Naproxen Oral Suspension (Naprosyn) (PDF) Effective Date: 11/9/2017
- Naproxen/Esomeprazole (Vimovo) (PDF) Effective Date: 6/1/2018
- Natalizumab (Tysabri) (PDF) Effective Date: 7/1/2016
- Naxitamab-gqgk (Danyelza) (PDF) Effective Date: 3/1/2021
- Necitumumab (Portrazza) (PDF) Effective Date: 3/1/2017
- Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF) Effective Date: 8/28/2018
- Neratinib (Nerlynx) (PDF) Effective Date: 9/5/2017
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF) Effective Date: 9/1/2006
- Nifurtimox (Lampit) (PDF) Effective Date: 12/1/2020
- Nilotinib (Tasigna) (PDF) Effective Date: 9/1/2011
- Nintedanib (Ofev) (PDF) Effective Date: 10/1/2016
- Niraparib and Abiraterone (Akeega) (PDF) Effective Date: 12/1/2023
- Niraparib (Zejula) (PDF) Effective Date: 5/9/2017
- Nitazoxanide (Alinia) (PDF) Effective Date: 12/1/2020
- Nitisinone (Nityr, Orfadin) (PDF) Effective Date: 8/28/2018
- Nivolumab (Opdivo) (PDF) Effective Date: 7/1/2015
- Nivolumab and Relatlimab-rmbw (Opdualag) (PDF) Effective Date: 9/1/2022
- No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (PDF) Effective Date: 5/1/2016
- Non-Calcium Phosphate Binders (PDF) Effective Date: 11/15/2017
- Non-Formulary and Formulary Contraceptives (PDF) Effective Date: 5/1/2015
- Non-Formulary Test Strips (PDF) Effective Date: 2/1/2016
- Nusinersen (Spinraza) (PDF) Effective Date: 11/28/2017
- Obeticholic Acid (Ocaliva) (PDF) Effective Date: 11/1/2016
- Obinutuzumab (Gazyva) (PDF) Effective Date: 2/1/2017
- Ocrelizumab (Ocrevus) (PDF) Effective Date: 4/1/2017
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF) Effective Date: 3/1/2010
- Odevixibat (Bylvay) (PDF) Effective Date: 6/1/2021
- Ofatumumab (Arzerra, Kesimpta) (PDF) Effective Date: 2/1/2017
- Off-Label Drug Use (PDF) Effective Date: 2/1/2023
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF) Effective Date: 12/1/2016
- Olanzapine/Samidorphan (Lybalvi) (PDF) Effective Date: 9/1/2021
- Olaparib (Lynparza) (PDF) Effective Date: 10/3/2017
- Olipudase Alfa-rpcp (Xenpozyme) (PDF) Effective Date: 6/2/2022
- Omacetaxine (Synribo) (PDF) Effective Date: 4/1/2013
- Omadacycline (Nuzyra) (PDF) Effective Date: 11/20/2018
- Omalizumab (Xolair) (PDF) Effective Date: 10/1/2008
- Omaveloxolone (Skyclarys) (PDF) Effective Date: 6/1/2023
- OnabotulinumtoxinA (Botox) (PDF) Effective Date: 7/1/2016
- Onasemnogene Abeparvovec (Zolgensma) (PDF) Effective Date: 6/7/2019
- Ondansetron (Zuplenz) (PDF) Effective Date: 9/1/2006
- Ophthalmic Corticosteroids (PDF) Effective Date: 1/1/2020
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) Effective Date: 6/1/2021
- Opicapone (Ongentys) (PDF) Effective Date: 9/1/2020
- Opioid Analgesics* (PDF) Effective Date: 8/1/2018
- Osilodrostat (Isturisa) (PDF) Effective Date: 9/1/2020
- Osimertinib (Tagrisso) (PDF) Effective Date: 12/1/2016
- Ospemifene (Osphena) (PDF) Effective Date: 8/28/2018
- Overactive Bladder Agents (PDF) Effective Date: 5/1/2016
- Oxymetazoline (Rhofade, Upneeq) (PDF) Effective Date: 11/15/2016
- Ozanimod (Zeposia) (PDF) Effective Date: 3/1/2020
- Ozenoxacin (Xepi) (PDF) Effective Date: 1/30/2018
- Paclitaxel, Protein-Bound (Abraxane) (PDF) Effective Date: 7/1/2015
- Pacritinib (Vonjo) (PDF) Effective Date: 6/1/2022
- Palbociclib (Ibrance) (PDF) Effective Date: 10/1/2015
- Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF) Effective Date: 12/1/2016
- Palivizumab (Synagis) (PDF) Effective Date: 7/31/2009
- Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF) Effective Date: 3/1/2022
- Panitumumab (Vectibix) (PDF) Effective Date: 3/1/2017
- Panobinostat (Farydak) (PDF) Effective Date: 11/16/2016
- Parathyroid Hormone (Natpara) (PDF) Effective Date: 11/16/2016
- Paricalcitol Injection (Zemplar) (PDF) Effective Date: 8/1/2016
- Pasireotide (Signifor, Signifor LAR) (PDF) Effective Date: 3/1/2017
- Patiromer (Veltassa) (PDF) Effective Date: 9/1/2019
- Patisiran (Onpattro) (PDF) Effective Date: 9/11/2018
- Pazopanib (Votrient) (PDF) Effective Date: 10/1/2011
- Peanut Allergen Powder-dnfp (Palforzia) (PDF) Effective Date: 3/1/2020
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF) Effective Date: 9/5/2017
- Pegcetacoplan (Empaveli, Syfovre) (PDF) Effective Date: 3/1/2021
- Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziexten (PDF) Effective Date: 2/1/2023
- Peginterferon Alfa-2a,b (Pegasys, PegIntron) (PDF) Effective Date: 10/1/2011
- Peginterferon Beta-1a (Plegridy) (PDF) Effective Date: 8/1/2016
- Pegloticase (Krystexxa) (PDF) Effective Date: 6/1/2013
- Pegvaliase-pqpz (Palynziq) (PDF) Effective Date: 7/31/2018
- Pegvisomant (Somavert) (PDF) Effective Date: 12/1/2018
- Pembrolizumab (Keytruda) (PDF) Effective Date: 3/1/2017
- Pemetrexed (Alimta, Pemfexy) (PDF) Effective Date: 10/31/2017
- Pemigatinib (Pemazyre) (PDF) Effective Date: 9/1/2020
- Penicillamine (Cuprimine) (PDF) Effective Date: 12/1/2018
- Perampanel (Fycompa) (PDF) Effective Date: 11/16/2016
- Pertuzumab (Perjeta) (PDF) Effective Date: 6/1/201
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) Effective Date: 9/1/2020
- Pexidartinib (Turalio) (PDF) Effective Date: 12/1/2019
- Phendimetrazine (PDF) Effective Date: 6/1/2022
- Phentermine (Adipex-P, Lomaira) (PDF) Effective Date: 5/1/2017
- Pilocarpine (Vuity) (PDF) Effective Date: 12/1/2021
- Pimavanserin (Nuplazid) (PDF) Effective Date: 11/16/2016
- Pirfenidone (Esbriet) (PDF) Effective Date: 10/1/2016
- Pitolisant (Wakix) (PDF) Effective Date: 3/1/2020
- Plasminogen, Human-tvmh (Ryplazim) (PDF) Effective Date: 6/3/2021
- Plecanatide (Trulance) (PDF) Effective Date: 6/1/2021
- Plerixafor (Mozobil) (PDF) Effective Date: 3/1/2017
- Polatuzumab Vedotin-piiq (Polivy) (PDF) Effective Date: 9/1/2019
- Pomalidomide (Pomalyst) (PDF) Effective Date: 7/1/2013
- Ponatinib (Iclusig) (PDF) Effective Date: 6/1/2013
- Ponesimod (Ponvory) (PDF) Effective Date: 6/1/2021
- Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF) Effective Date: 10/31/2017
- Pralatrexate (Folotyn) (PDF) Effective Date: 2/1/2017
- Pramlintide (Symlin) (PDF) Effective Date: 6/1/2018
- Prasterone (Intrarosa) (PDF) Effective Date: 12/20/2016
- Pregabalin (Lyrica, Lyrica CR) (PDF) Effective Date: 1/1/2007
- Pretomanid (PDF) Effective Date: 3/1/2020
- Progesterone (Crinone, Endometrin, Milprosa) (PDF) Effective Date: 9/1/2020
- Propranolol HCl Oral Solution (Hemangeol) (PDF) Effective Date: 5/1/2014
- Protein C Concentrate, Human (Ceprotin) (PDF) Effective Date: 3/1/2017
- Prucalopride (Motegrity) (PDF) Effective Date: 6/1/2021
- Pyrimethamine (Daraprim) (PDF) Effective Date: 11/1/2015
- Quetiapine Extended-Release (Seroquel XR) (PDF) Effective Date: 12/1/2014
- Quinine Sulfate (Qualaquin) (PDF) Effective Date: 6/1/2021
- Quizartinib (Vanflyta) (PDF) Effective Date: 12/1/2023
- Ramucirumab (Cyramza) (PDF) Effective Date: 5/1/2015
- Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (PDF) Effective Date: 4/1/2016
- Rasagiline (Azilect) (PDF) Effective Date: 12/1/2014
- Ravulizumab-cwvz (Ultomiris) (PDF) Effective Date: 2/19/2019
- Regorafenib (Stivarga) (PDF) Effective Date: 12/1/2012
- Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) (PDF) Effective Date: 6/1/2021
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF) Effective Date: 3/1/2016
- Reslizumab (Cinqair) (PDF) Effective Date: 5/1/2016
- Retifanlimab-dlwr (Zynz) (PDF) Effective Date: 6/1/2023
- Ribavirin (Rebetol, Ribasphere) (PDF) Effective Date: 11/16/2016
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF) Effective Date: 5/1/2017
- Rifabutin (Mycobutin) (PDF) Effective Date: 3/1/2020
- Rifamycin (Aemcolo) (PDF) Effective Date: 1/8/2019
- Rifaximin (Xifaxan) (PDF) Effective Date: 11/1/2011
- Rilonacept (Arcalyst) (PDF) Effective Date: 11/16/2016
- RimabotulinumtoxinB (Myobloc) (PDF) Effective Date: 7/1/2016
- Rimegepant (Nurtec ODT) (PDF) Effective Date: 9/1/2020
- Riociguat (Adempas) (PDF) Effective Date: 3/1/2016
- Ripretinib (Qinlock) (PDF) Effective Date: 9/1/2020
- Ripretinib (Qinlock) (PDF) Effective Date: 9/1/2020
- Risdiplam (Evrysdi) (PDF) Effective Date: 8/6/2020
- Risedronate (Actonel, Atelvia) (PDF) Effective Date: 3/1/2018
- Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF) Effective Date: 12/1/2016
- Rolapitant (Varubi) (PDF) Effective Date: 2/1/2017
- Romidepsin (Istodax) (PDF) Effective Date: 1/1/2017
- Romiplostim (Nplate) (PDF) Effective Date: 3/1/2016
- Romosozumab-aqqg (Evenity) (PDF) Effective Date: 9/1/2019
- Ropeginterferon Alfa-2b-njft (BESREMi) (PDF) Effective Date: 3/1/2022
- Rozanolixizumab-noli (Rystiggo) (PDF)
Effective Date: 12/1/2023 - Rucaparib (Rubraca) (PDF) Effective Date: 9/1/2017
- Rufinamide (Banzel) (PDF) Effective Date: 12/1/2014
- Ruxolitinib (Jakafi, Opzelura) (PDF) Effective Date: 3/1/2012
- Sacituzumab Govitecan-hziy (Trodelvy) (PDF) Effective Date: 6/1/2020
- Sacubitril/Valsartan (Entresto) (PDF) Effective Date: 11/1/2015
- Safinamide (Xadago) (PDF) Effective Date: 7/1/2017
- Sapropterin Dihydrochloride (Kuvan) (PDF) Effective Date: 2/1/2010
- Sarecycline (Seysara) (PDF) Effective Date: 11/13/2018
- Sargramostim (Leukine) (PDF) Effective Date: 12/1/2016
- Satralizumab-mwge (Enspryng) (PDF) Effective Date: 3/1/2020
- Sebelipase Alfa (Kanuma) (PDF) Effective Date: 2/1/2016
- Secnidazole (Solosec) (PDF) Effective Date: 10/24/2017
- Selexipag (Uptravi) (PDF) Effective Date: 3/1/2016
- Selinexor (Xpovio) (PDF) Effective Date: 9/1/2019
- Selpercatinib (Retevmo) (PDF) Effective Date: 6/1/2020
- Selumetinib (Koselugo) (PDF) Effective Date: 3/1/2020
- Setmelanotide (Imcivree) (PDF) Effective Date: 9/1/2020
- Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF) Effective Date: 8/31/2017
- Sildenafil (Revatio) (PDF) Effective Date: 3/1/2016
- Sildenafil for ED (Viagra) (PDF) Effective Date: 6/1/2018
- Siltuximab (Sylvant) (PDF) Effective Date: 3/1/2017
- Siponimod (Mayzent) (PDF) Effective Date: 9/1/2019
- Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (PDF) Effective Date: 3/1/2022
- Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (PDF) Effective Date: 5/1/2011
- Sodium Phenylbutyrate (Buphenyl, Pheburane) (PDF) Effective Date: 5/1/2016
- Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF) Effective Date: 6/1/2022
- Sodium Zirconium Cyclosilicate (Lokelma) (PDF) Effective Date: 7/24/2018
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) Effective Date: 1/1/2015
- Sofosbuvir (Sovaldi) (PDF) Effective Date: 2/1/2023
- Sofosbuvir/Velpatasvir (Epclusa) (PDF) Effective Date: 2/1/2023
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF) Effective Date: 2/1/2023
- Solriamfetol (Sunosi) (PDF) Effective Date: 9/1/2019
- Sonidegib (Odomzo) (PDF) Effective Date: 5/1/2012
- Sorafenib (Nexavar) (PDF) Effective Date: 7/1/2011
- Sotorasib (Lumakras) (PDF) Effective Date: 9/1/2021
- Sparsentan (Filspari) (PDF) Effective Date: 6/1/2023
- Spinosad (Natroba) (PDF) Effective Date: 11/9/2017
- Step Therapy (PDF) Effective Date: 8/1/2017
- Stiripentol (Diacomit) (PDF) Effective Date: 9/25/2018
- Sunitinib (Sutent) (PDF) Effective Date: 9/1/2011
- Sutimlimab-jome (Enjaymo) (PDF) Effective Date: 2/3/2022
- Suvorexant (Belsomra) (PDF) Effective Date: 2/1/2017
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF) Effective Date: 8/31/2017
- Tadalafil (Adcirca, Alyq, Tadliq) (PDF) Effective Date: 3/1/2016
- Tadalafil BPH - ED (Cialis) (PDF) Effective Date: 6/1/2018
- Tafamidis (Vyndaqel, Vyndamax) (PDF) Effective Date: 9/1/2019
- Tafasitamab-cxix (Monjuvi) (PDF) Effective Date: 12/1/2020
- Talazoparib (Talzenna) (PDF) Effective Date: 11/27/2018
- Taliglucerase Alfa (Elelyso) (PDF) Effective Date: 1/1/2022
- Talimogene laherepvec (Imlygic) (PDF) Effective Date: 9/1/2021
- Talquetamab-tgvs (Talvey) (PDF) Effective Date: 12/1/2023
- Tapinarof (Vtama) (PDF) Effective Date: 12/1/2022
- Tasimelteon (Hetlioz, Hetlioz LQ) (PDF) Effective Date: 2/1/2017
- Tavaborole (Kerydin) (PDF) Effective Date: 3/1/2018
- Tazarotene (Arazlo, Fabior, Tazorac) (PDF) Effective Date: 9/1/2020
- Tazemetostat (Tazverik) (PDF) Effective Date: 3/1/2020
- Tebentafusp-tebn (Kimmtrak) (PDF) Effective Date: 6/1/2022
- Tedizolid (Sivextro) (PDF) Effective Date: 3/1/2015
- Teduglutide (Gattex) (PDF) Effective Date: 5/1/2013
- Tegaserod (Zelnorm) (PDF) Effective Date: 6/1/2021
- Telotristat Ethyl (Xermelo) (PDF) Effective Date: 6/1/2017
- Temozolomide (Temodar) (PDF) Effective Date: 9/1/2011
- Temsirolimus (Torisel) (PDF) Effective Date: 3/1/2017
- Tenapanor (Ibsrela) (PDF) Effective Date: 3/1/2020
- Tenofovir Alafenamide Fumarate (Vemlidy) (PDF) Effective Date: 12/1/2021
- Teplizumab (PRV-031) (PDF) Effective Date: 9/1/2020
- Tepotinib (Tepmetko) (PDF) Effective Date: 6/1/2021
- Teprotumumab (Tepezza) (PDF) Effective Date: 1/21/2020
- Teriflunomide (Aubagio) (PDF) Effective Date: 2/1/2021
- Teriparatide (Forteo) (PDF) Effective Date: 11/15/2017
- Tesamorelin (Egrifta SV) (PDF) Effective Date: 3/1/2014
- Testosterone (Androderm) (PDF) Effective Date: 12/1/2014
- Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (PDF) Effective Date: 8/1/2017
- Tetrabenazine (Xenazine) (PDF) Effective Date: 12/1/2011
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF) Effective Date: 4/3/2018
- Tezepelumab-ekko (Tezspire) (PDF) Effective Date: 6/1/2022
- Thalidomide (Thalomid) (PDF) Effective Date: 9/1/2011
- Thioguanine (Tabloid) (PDF) Effective Date: 12/1/2019
- Thyrotropin Alfa (Thyrogen) (PDF) Effective Date: 3/1/2012
- Timothy Grass Pollen Allergen Extract (Grastek) (PDF) Effective Date: 8/31/2017
- Tisagenlecleucel (Kymriah) (PDF) Effective Date: 9/26/2017
- Tisotumab Vedotin-tftv (Tivdak) (PDF) Effective Date: 12/1/2021
- Tivozanib (Fotivda) (PDF) Effective Date: 6/1/2021
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF) Effective Date: 5/1/2016
- Tolvaptan (Jynarque, Samsca) (PDF) Effective Date: 6/5/2018
- Topical Acne Treatment (PDF) Effective Date: 12/1/2014
- Topical Immunomodulators (PDF) Effective Date: 9/1/2006
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF) Effective Date: 2/1/2023
- Topotecan (Hycamtin) (PDF) Effective Date: 6/1/2011
- Trabectedin (Yondelis) (PDF) Effective Date: 5/1/2016
- Tralokinumab-ldrm (Adbry) (PDF) Effective Date: 6/1/2022
- Trametinib (Mekinist) (PDF) Effective Date: 7/1/2016
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF) Effective Date: 6/1/2016
- Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI) (PDF) Effective Date: 3/1/2016
- Triamcinolone ER Injection (Zilretta) (PDF) Effective Date: 3/1/2018
- Triclabendazole (Egaten) (PDF) Effective Date: 9/1/2019
- Trientine (Cuvrior, Syprine) (PDF) Effective Date: 12/1/2019
- Trifarotene (Aklief) (PDF) Effective Date: 3/1/2020
- Trifluridine/Tipiracil (Lonsurf) (PDF) Effective Date: 11/16/2016
- Triheptanoin (Dojolvi) (PDF) Effective Date: 12/1/2020
- Triptorelin Pamoate (Trelstar, Triptodur) (PDF) Effective Date: 11/9/2017
- Trofinetide (Daybue) (PDF) Effective Date: 6/1/2023
- Tucatinib (Tukysa) (PDF) Effective Date: 9/1/2020
- Ubrogepant (Ubrelvy) (PDF) Effective Date: 6/1/2020
- Ulcer Therapy Combinations (PDF) Effective Date: 6/1/2022
- Umbralisib (Ukoniq) (PDF) Effective Date: 6/1/2021
- Uridine Triacetate (Vistogard) (PDF) Effective Date: 11/9/2017
- Valbenazine (Ingrezza) (PDF) Effective Date: 9/1/2022
- Valganciclovir (Valcyte) (PDF) Effective Date: 11/16/2016
- Valrubicin (Valstar) (PDF) Effective Date: 12/1/2019
- Vandetanib (Caprelsa) (PDF) Effective Date: 10/1/2011
- Varenicline (Tyrvaya) (PDF) Effective Date: 3/1/2022
- Velaglucerase Alfa (VPRIV) (PDF) Effective Date: 1/1/2022
- Velmanase Alfa-tycv (Lamzede) (PDF) Effective Date: 6/1/2023
- Vemurafenib (Zelboraf) (PDF) Effective Date: 11/1/2011
- Venetoclax (Venclexta) (PDF) Effective Date: 9/1/2018
- Verteporfin (Visudyne) (PDF) Effective Date: 3/1/2016
- Vestronidase Alfa-vjbk (Mepsevii) (PDF) Effective Date: 1/19/2018
- Vigabatrin (Sabril) (PDF) Effective Date: 2/1/2016
- Vilazodone (Viibryd) (PDF) Effective Date: 8/1/2012
- Viloxazine (Qelbree) (PDF) Effective Date: 6/1/2021
- Viltolarsen (Viltepso) (PDF) Effective Date: 8/12/2020
- Vincristine Sulfate Liposome Injection (Marqibo) (PDF) Effective Date: 2/1/2017
- Vismodegib (Erivedge) (PDF) Effective Date: 8/1/2016
- Voclosporin (Lupkynis) (PDF) Effective Date: 9/1/2020
- Vorapaxar (Zontivity) (PDF) Effective Date: 10/31/2017
- Voretigene Neparvovec-rzyl (Luxturna) (PDF) Effective Date: 3/1/2018
- Vorinostat (Zolinza) (PDF) Effective Date: 12/1/2012
- Vortioxetine (Trintellix) (PDF) Effective Date: 5/31/2017
- Vosoritide (Voxzogo) (PDF) Effective Date: 3/1/2021
- Voxelotor (Oxbryta) (PDF) Effective Date: 3/1/2020
- Vutrisiran (Amvuttra) (PDF) Effective Date: 12/1/2021
- Zanubrutinib (Brukinsa) (PDF) Effective Date: 3/1/2020
- Zavegepant (Zavzpret) (PDF) Effective Date: 6/1/2023
- Ziv-aflibercept (Zaltrap) (PDF) Effective Date: 3/1/2017
- Zoledronic Acid (Reclast, Zometa) (PDF) Effective Date: 3/1/2011
- Zuranolone (Zurzuvae) (PDF)
Effective Date: 12/1/2023