Políticas clínicas y de pago

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 Western Sky Community Care Clinical Policy Manual apply to Ambetter from Western Sky Community Care members. Policies in the Ambetter from Western Sky Community Care Clinical Policy Manual may have either a Ambetter from Western Sky Community Care or a “Centene” heading. Ambetter from Western Sky Community Care utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from Western Sky Community 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 Western Sky Community Care. In addition, Ambetter from Western Sky Community 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 Western Sky Community Care.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Policy TitlePolicy Number
CP.MP.15725-hydroxyvitamin D Testing in Children and Adolescents (PDF)
CP.MP.92Acupuncture (PDF)
CPG GridAdopted Clinical Practice and Preventive Health Guidelines (PDF)
CP.MP.124ADHD Assessment and Treatment (PDF)
CP.MP.100Allergy Testing and Therapy (PDF)
CP.MP.108Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia (PDF)
CP.MP.175Air Ambulance (PDF)
CP.MP.158Ambulatory Surgery Center Optimization (PDF)
CP.BH.104Applied Behavior Analysis (PDF)
CP.BH.105Applied Behavioral Analysis Documentation Requirements (PDF)
CP.MP.55Assisted Reproductive Technology (PDF)
CP.MP.168Biofeedback (PDF)
CP.MP.93Bone-Anchored Hearing Aid (PDF)
CP.MP.110Bronchial Thermoplasty (PDF)
CP.MP.186Burn Surgery (PDF)
CP.MP.156Cardiac Biomarker Testing (PDF)
CP.MP.164Caudal or Interlaminar Epidural Steroid Injections (PDF)
CP.MP.94Clinical Trials (PDF)
CP.MP.14Cochlear Implant Replacements (PDF)
V1.2024Concert Genetics Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Cardiac Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Dermatologic Conditions (PDF)
V1.2024Concert Genetics Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Eye Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Gastroenterologic Disorders (Non-Cancerous) (PDF)
V1.2024Concert Genetics Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)
V1.2024Concert Genetics Genetic Testing: Hearing Loss (PDF)
V1.2024Concert Genetics Genetic Testing: Hematologic Conditions (Non-Cancerous) (PDF)
V1.2024Concert Genetics Genetic Testing: Hereditary Cancer Susceptibility (PDF)
V1.2024Concert Genetics Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Kidney Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Lung Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)
V1.2024Concert Genetics Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)
V1.2024Concert Genetics Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)
V1.2024Concert Genetics Genetic Testing: Pharmacogenetics (PDF)
V1.2024Concert Genetics Genetic Testing: Preimplantation Genetic Testing (PDF)
V1.2024Concert Genetics Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
V1.2024Concert Genetics Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)
V1.2024Concert Genetics Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)
V1.2024Concert Genetics Oncology: Algorithmic Testing (PDF)
V1.2024Concert Genetics Oncology: Cancer Screening (PDF)
V1.2024Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)
V1.2024Concert Genetics Oncology: Cytogenetic Testing (PDF)
V1.2024Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)
CP.MP.31Cosmetic and Reconstructive Procedures (PDF)
CP.MP.203Diaphragmatic/Phrenic Nerve Stimulation (PDF)
CP.MP.105Digital EEG Spike Analysis (PDF)  
CP.MP.114Disc Decompression (PDF)
CP.MP.115Discography (PDF)
CP.MP.101Donor Lymphocyte Infusion (PDF)
CP.MP.50Drugs of Abuse: Definitive Testing (PDF)
CP.MP.107Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)
CP.MP.155EEG in the Evaluation of Headache (PDF)
CP.MP.145Electric Tumor Treating Fields (PDF)
CP.MP.106Endometrial Ablation (PDF)
CP.MP.134Evoked Potential Testing (PDF)
CP.MP.171Facet Joint Interventions (PDF)
CP.MP.248Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)
CP.MP.137Fecal Incontinence Treatments (PDF)
CP.MP.129Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)
CP.MP.53Ferriscan R2-MRI (PDF)
CP.MP.130Fertility Preservation (PDF)
CP.MP.209Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
CP.MP.95Gender-Affirming Procedures (PDF)
CP.MP.153Helicobacter Pylori Serology Testing (PDF)
CP.MP.113Holter Monitors (PDF)
CP.MP.136Home Births (PDF)
CP.MP.184Home Ventilators (PDF)
CP.MP.121Homocysteine Testing (PDF)
CP.MP.54Hospice Services (PDF)
CP.MP.62Hyperhidrosis Treatments (PDF)
NM.CP.MP.504Immobalized Lipase Cartridges (Relizorb) (PDF)
CP.MP.173Implantable Intrathecal or Epidural Pain Pump (PDF)
CP.MP.243Implantable Loop Recorder (PDF)
CP.MP.58Intestinal and Multivisceral Transplant (PDF)
CP.MP.69Intensity- Modulated Radiotherapy (PDF)
CP.MP.167Intradiscal Steroid Injections for Pain Management (PDF)
CP.MP.180Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)
CP.MP.61IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)
CP.MP.250Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)
CP.MP.123Laser Therapy for Skin Conditions (PDF)
CP.MP.244Liposuction for Lipedema (PDF)
CP.MP.139Low-frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)
CP.MP.57Lung Transplantation (PDF)
CP.MP.116Lysis of Epidural Lesions (PDF)
CP.MP.152Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
CP.MP.144Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
CP.MP.170Nerve Blocks and Neurolysis for Pain Management (PDF)
CP.MP.86Neonatal Abstinence Syndrome Guidelines (PDF)
CP.MP.85Neonatal Sepsis Management (PDF)
CP.MP.48Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)
CP.MP.82NICU Apnea Bradycardia Guidelines (PDF)
CP.MP.81NICU Discharge Guidelines (PDF)
CP.MP.91Obstetrical Home Care Programs (PDF)
CP.MP.249Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)
CP.MP.202Orthognathic Surgery (PDF)
CP.MP.194Osteogenic Stimulation (PDF)
CP.MP.176Outpatient Cardiac Rehabilitation (PDF)
CP.MP.190Outpatient Oxygen Use (PDF)
CP.MP.102Pancreas Transplantation (PDF)
CP.MP.109Panniculectomy (PDF)
CP.MP.138Pediatric Heart Transplant (PDF)
CP.MP.246Pediatric Kidney Transplant (PDF)
CP.MP.188Pediatric Oral Function Therapy (PDF)
CP.MP.147Percutaneous Left Atrial Appendage Closure for Stroke Prevention (PDF)
CP.MP.49Physical, Occupational, and Speech Therapy Services (PDF)
CP.MP.181Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
CP.MP.133Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)
CP.MP.70Proton and Neutron Beam Therapies (PDF)
CP.MP.242Pulmonary Function Testing (PDF)
CP.MP.150Phototherapy for Neonatal Hyperbilirubinemia (PDF)
CP.MP.70Proton and Neutron Beam Therapies (PDF)
CP.MP.51Reduction Mammoplasty and Gynecomastia Surgery (PDF)
CP.MP.210Repair of Nasal Valve Compromise (PDF)
CP.MP.126Sacroiliac Joint Fusion (PDF)
CP.MP.166Sacroiliac Joint Interventions for Pain Management (PDF)
CP.MP.174Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)
CP.MP.165Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)
CP.MP.146Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Disorders (PDF)
NM.CP.MP.182Short Inpatient Hospital Stay (PDF)
CP.MP.185Skin Substitutes for Chronic Wounds (PDF)
CP.MP.117Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)
CP.MP.22Stereotactic Body Radiation Therapy (PDF)
CP.MP.97Testing Select GU Conditions (PDF)
CP.MP.127Total Artificial Heart (PDF)
CP.MP.154Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
CP.MP.151Transcatheter Closure of Patent Foramen Ovale (PDF)
CP.MP.247Transplant Service Documentation Requirements (PDF)
CP.MP.169Trigger Point Injections for Pain Management (PDF)
CP.MP.38Ultrasound in Pregnancy (PDF)
CP.MP.142Urinary Incontinence Devices and Treatments (PDF)
CP.MP.98Urodynamic Testing (PDF)
CP.MP.99Wheelchair Seating (PDF)
CP.MP.12Vagus Nerve Stimulation (PDF)
CP.MP.143Wireless Motility Capsule (PDF)
CP.MP.46Ventricular Assist Devices (PDF)

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 Western Sky Community Care Payment Policy Manual apply with respect to Western Sky Community Care members. Policies in the Western Sky Community Care Payment Policy Manual may have either a Western Sky Community Care or a “Centene” heading.  In addition, Western Sky Community 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 Western Sky Community 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

    Policy TitlePolicy NumberEffective Date
    Abaloparatide (Tymlos) (PDF)CP.PHAR.345July 1, 2017
    Abametapir (Xeglyze) (PDF)CP.PMN.253December 1, 2020
    Abemaciclib (Verzenio) (PDF)CP.PHAR.355October 24, 2017
    Abiraterone (Zytiga,
    Yonsa) (PDF)
    CP.PHAR.84October 1, 2011
    AbobotulinumtoxinA (Dysport) (PDF)CP.PHAR.230July 1, 2016
    Abrocitinib (Cibinqo) (PDF)CP.PHAR.578June 1, 2022
    Acalabrutinib (Calquence) (PDF)CP.PHAR.366March 1, 2018
    Acyclovir Buccal Tablet (Sitavig) (PDF)CP.PMN.210September 1, 2019
    Adefovir (Hepsera) (PDF)CP.PHAR.142August 28, 2018
    Ado-Trastuzumab Emtansine (Kadcyla) (PDF)CP.PHAR.229June 1, 2016
    Aducanumab-avwa (Aduhelm) (PDF)CP.PHAR.468June 1, 2020
    Afamelanotide (Scenesse) (PDF)CP.PHAR.444March 1, 2020
    Afatinib (Gilotrif) (PDF)CP.PHAR.298January 1, 2017
    Aflibercept (Eylea) (PDF)CP.PHAR.184March 1, 2016
    Agalsidase Beta (Fabrazyme) (PDF)CP.PHAR.158 February 1, 2016
    Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF)CP.PMN.138March 13, 2018
    Alectinib (Alecensa) (PDF)CP.PHAR.369November 16, 2016
    Alemtuzumab (Lemtrada) (PDF)CP.PHAR.243August 1, 2016
    Alendronate (Binosto, Fosamax Plus D) (PDF)CP.PMN.88February 28, 2018
    Alglucosidase Alfa (Lumizyme) (PDF)CP.PHAR.160February 1, 2016
    Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (PDF)CP.PHAR.562March 1, 2022
    Allogenic Processed Thymus Tissue-agdc (Rethymic) (PDF)CP.PHAR.563March 1, 2022
    Alpelisib (Piqray, Vijoice) (PDF)CP.PHAR.430September 1, 2019
    Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)CP.PHAR.94March 1, 2012
    Amantadine ER (Gocovri, Osmolex ER)CP.PMN.89October 10, 2017
    Ambrisentan (Letairis) (PDF)CP.PHAR.190March 1, 2016
    Amifampridine (Firdapse) (PDF)CP.PHAR.411January 22, 2019
    Amikacin (Arikayce) (PDF)CP.PHAR.401November 13, 2018
    Amisulpride (Barhemsys) (PDF)CP.PMN.236September 1, 2020
    Amivantamab-vmjw (Rybrevant) (PDF) CP.PHAR.544September 1, 2021
    Anifrolumab-fnia (Saphnelo) (PDF)CP.PHAR.551December 1, 2021
    Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF)CP.PHAR.217May 1, 2016
    Antithrombin III (ATryn, Thrombate III) (PDF)CP.PHAR.564March 1, 2022
    Antithymocyte Globulin (Atgam, Thymoglobulin) (PDF)CP.PHAR.506December 1, 2020
    Apalutamide (Erleada) (PDF)CP.PCH.45March 1, 2022
    Apomorphine (Apokyn, Kynmobi) (PDF)CP.PHAR.488September 1, 2020
    Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.19November 30, 2016
    Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF)CP.PMN.19November 30, 2016
    Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada, Aristada Initio) (PDF)CP.PHAR.290 December 1, 2016
    Aripiprazole Orally Disintegrating Tablet (PDF)CP.PCH.37March 1, 2021
    Armodafinil (Nuvigil) (PDF)CP.PMN.35August 1, 2009
    Asciminib (Scemblix) (PDF)CP.PHAR.565March 1, 2022
    Asenapine (Saphris, Secuado) (PDF)CP.PMN.15December 1, 2014
    Asfotase Alfa (Strensiq) (PDF)CP.PHAR.328March 1, 2017
    Aspirin/Dipyridamole (Aggrenox) (PDF)CP.PMN.20September 1, 2006
    Atezolizumab (Tecentriq) (PDF)CP.PHAR.235June 1, 2016
    Atogepant (Qulipta) (PDF)CP.PHAR.566March 1, 2022
    Avacopan (Tavneos) (PDF)CP.PHAR.515March 1, 2021
    Avalglucosidase Alfa-ngpt (Nexviazyme) (PDF)CP.PHAR.521March 1, 2021
    Avapritinib (Ayvakit) (PDF)CP.PHAR.454March 1, 2020
    Avatrombopag (Doptelet) (PDF)CP.PHAR.130July 17, 2018
    Avelumab (Bavencio) (PDF)CP.PHAR.333May 1, 2017
    Axicabtagene Ciloleucel (Yescarta) (PDF)CP.PHAR.362October 31, 2017
    Axitinib (Inlyta) (PDF)CP.PHAR.100May 1, 2012
    Azacitidine (Onureg, Vidaza) (PDF)CP.PHAR.387August 28, 2018
    Azelaic Acid (Finacea Topical Gel/Foam) (PDF)HIM.PA.119November 9, 2017
    Aztreonam (Cayston) (PDF)CP.PHAR.209May 1, 2016
    Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) (PDF)CP.PHAR.149November 9, 2017
    Baloxavir Marboxil (Xofluza) (PDF)CP.PMN.185October 30, 2018
    Bedaquiline (Sirturo) (PDF)CP.PMN.212December 1, 2019
    Belantamab Mafodotin-blmf (Blenrep) (PDF)CP.PHAR.469June 1, 2020
    Belatacept (Nulojix) (PDF)CP.PHAR.201November 9, 2017
    Belimumab (Benlysta) (PDF)CP.PHAR.88October 1, 2011
    Belinostat (Beleodaq) (PDF)CP.PHAR.311February 1, 2017
    Belumosudil (Rezurock) (PDF)CP.PHAR.552December 1, 2021
    Belzutifan (Welireg) (PDF)CP.PHAR.553December 1, 2021
    Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) (PDF)CP.PMN.237September 1, 2020
    Bendamustine (Belrapzo, Bendeka, Treanda) (PDF)CP.PHAR.307February 1, 2017
    Benralizumab (Fasenra) (PDF)CP.PHAR.373January 16, 2018
    Benznidazole (PDF)CP.PMN.90October 17, 2017
    Betaine (Cystadane) (PDF)CP.PHAR.143August 28, 2018
    Betamethasone Dipropionate Spray (Sernivo) (PDF)CP.PMN.182December 1, 2018
    Betibeglogene Autotemcel (Zynteglo) (PDF)CP.PHAR.545September 1, 2021
    Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) (PDF)CP.PHAR.93October 31, 2011
    Bexarotene (Targretin Capsules, Gel) (PDF)CP.PHAR.75September 1, 2011
    Bezlotoxumab (Zinplava) (PDF)CP.PHAR.300November 16, 2016
    Bimatoprost Implant (Durysta) (PDF)CP.PHAR.486June 1, 2020
    Binimetinib (Mektovi) (PDF)CP.PHAR.50July 24, 2018
    Biologic and Non-biologic DMARDs (PDF)HIM.PA.SP60January 1, 2020
    Blinatumomab (Blincyto) (PDF)CP.PHAR.312February 1, 2017
    Bortezomib (Velcade) (PDF)CP.PHAR.410December 11, 2018
    Bosentan (Tracleer) (PDF)CP.PHAR.191March 1, 2016
    Bosutinib (Bosulif) (PDF)CP.PHAR.105October 1, 2012
    Brand Name Override and Non-Formulary Medications (PDF)HIM.PA.103December 1, 2014
    Brentuximab Vedotin (Adcetris) (PDF)CP.PHAR.303February 1, 2017
    Brexanolone (Zulresso) (PDF)CP.PHAR.417April 16, 2019
    Brexpiprazole (Rexulti) (PDF)CP.PMN.68November 5, 2015
    Brexucabtagene Autoleucel (Tecartus) (PDF)CP.PHAR.472June 1, 2020
    Brigatinib (Alunbrig) (PDF)CP.PHAR.342July 17, 2017
    Brimonidine Tartrate (Mirvaso) (PDF)CP.PMN.192November 15, 2016
    Brinzolamide/Brimonidine (Simbrinza) (PDF)HIM.PA.15September 4, 2018
    Brivaracetam (Briviact) (PDF)CP.PCH.26May 21, 2019
    Brolucizumab-dbll (Beovu) (PDF)CP.PHAR.445February 29, 2020
    Budesonide (Tarpeyo) (PDF)CP.PHAR.572March 1, 2022
    Budesonide (Uceris) (PDF)CP.PCH.11August 14, 2018
    Buprenorphine (Subutex) (PDF)CP.PMN.82September 1, 2017
    Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF)CP.PHAR.289November 16, 2016
    Buprenorphine/Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF)CP.PMN.81September 1, 2017
    Bupropion/Naltrexone (Contrave) (PDF)CP.PCH.12May 1, 2017
    Burosumab-twza (Crysvita) (PDF)CP.PHAR.11May 8, 2018
    Butorphanol Nasal Spray (PDF)HIM.PA.46December 1, 2014
    C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF)CP.PHAR.202March 1, 2016
    Cabazitaxel (Jevtana) (PDF)CP.PHAR.316February 1, 2017
    Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) (PDF)CP.PHAR.573March 1, 2022
    Cabozantinib (Cabometyx, Cometriq) (PDF)CP.PHAR.111June 1, 2013
    Calcifediol (Rayaldee) (PDF)CP.PMN.76 November 1, 2016
    Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) (PDF)CP.PMN.181December 1, 2018
    Canakinumab (Ilaris) (PDF)CP.PHAR.246August 1, 2016
    Cannabidiol (Epidiolex) (PDF)CP.PMN.164July 17, 2018
    Capecitabine (Xeloda) (PDF)CP.PHAR.60May 1, 2011
    Caplacizumab-yhdp (Cablivi) (PDF)CP.PHAR.416March 12, 2019
    Capmatinib (Tabrecta) (PDF)CP.PHAR.494September 1, 2020
    Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) (PDF)CP.PMN.238September 1, 2020
    Carfilzomib (Kyprolis) (PDF)CP.PHAR.309February 1, 2017
    Carglumic Acid (Carbaglu) (PDF)CP.PHAR.206May 1, 2016
    Cariprazine (Vraylar) (PDF)CP.PMN.91November 16, 2016
    Casimersen (Amondys 45) (PDF)CP.PHAR.470June 1, 2020
    Casirivimab and Imdevimab (REGEN-COV) (PDF)CP.PHAR.520December 22, 2020
    Celecoxib (Celebrex, Elyxyb) (PDF)CP.PMN.122January 1, 2007
    Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397October 16, 2018
    Cenegermin-bkbj (Oxervate) (PDF)CP.PMN.186October 9, 2018
    Cenobamate (Xcopri) (PDF)CP.PMN.231March 1, 2020
    Ceritinib (Zykadia) (PDF)CP.PHAR.349July 1, 2017
    Cerliponase Alfa (Brineura) (PDF)CP.PHAR.338July 1, 2017
    Cetuximab (Erbitux) (PDF)CP.PHAR.317February 1, 2017
    Chenodiol (Chenodal) (PDF)CP.PMN.239September 1, 2020
    Chlorambucil (Leukeran) (PDF)CP.PHAR.554December 1, 2021
    Chloramphenicol Sodium Succinate (PDF)CP.PHAR.388December 1, 2018
    Cholic Acid (Cholbam) (PDF)CP.PHAR.390December 1, 2018
    Ciclopirox (Penlac) (PDF)CP.PMN.24September 1, 2007
    Ciltacabtagene Autoleucel (Carvykti) (PDF)CP.PHAR.533May 7, 2021
    Cinacalcet (Sensipar) (PDF)CP.PHAR.61May 1, 2011
    Ciprofloxacin/Dexamethasone (Ciprodex) (PDF)CP.PMN.248December 1, 2020
    Ciprofloxacin/Fluocinolone (Otovel) (PDF)CP.PMN.249December 1, 2020
    Cladribine (Mavenclad) (PDF)CP.PHAR.422September 1, 2019
    Clascoterone (Winlevi) (PDF)CP.PMN.257February 28, 2021
    Clinical Policy: Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)CP.PHAR.260July 1, 2016
    Clobazam (Onfi, Sympazan) (PDF)CP.PMN.54November 1, 2012
    CNS Stimulants (PDF)CP.PMN.92March 1, 2018
    Cobimetinib (Cotellic) (PDF)CP.PHAR.380November 16, 2016
    Colesevelam (Welchol) (PDF)CP.PMN.250December 1, 2020
    Collagenase Clostridium Histolyticum (Xiaflex) (PDF)CP.PHAR.82October 1, 2011
    Colonoscopy Preparation Products (PDF)CP.PCH.43December 1, 2021
    Compounded Medications (PDF)CP.PMN.280September 1, 2022
    Conjugated Estrogens/Bazedoxifene (Duavee) (PDF)CP.PMN.258March 1, 2021
    Continuous Glucose Monitors (PDF)CP.PMN.214December 1, 2019
    Copanlisib (Aliqopa) (PDF)CP.PHAR.357October 17, 2017
    Corticosteroids
    for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutiq) (PDF)
    CP.PHAR.385May 29, 2018
    Cosyntropin (Cortrosyn) (PDF)CP.PHAR.203April 1, 2016
    Crisaborole (Eucrisa) (PDF)CP.PMN.110February 21, 2017
    Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449March 1, 2020
    Crizanlizumab-tmca (Adakveo) (PDF)CP.PHAR.449March 1, 2020
    Crizotinib (Xalkori) (PDF)CP.PHAR.90November 1, 2011
    Cyclosporine (Cequa, Restasis, Verkazia) (PDF)CP.PMN.48May 1, 2012
    Cysteamine Ophthalmic (Cystaran, Cystadrops) (PDF)CP.PMN.130August 1, 2017
    Cysteamine oral (Cystagon, Procysbi) (PDF)CP.PHAR.155   February 1, 2016
    Cytomegalovirus Immune Globulin (CytoGam) (PDF)CP.PHAR.277September 1, 2018
    Dabrafenib (Tafinlar) (PDF)CP.PHAR.239November 16, 2016
    Dacomitinib (Vizimpro) (PDF)CP.PHAR.399October 16, 2018
    Dalfampridine (Ampyra) (PDF)CP.PHAR.248August 1, 2016
    Dalteparin (Fragmin) (PDF)CP.PHAR.225May 1, 2016
    Dapsone (Aczone Gel) (PDF) CP.PCH.32December 1, 2020
    Daptomycin (Cubicin, Cubicin RF) (PDF)CP.PHAR.351November 30, 2017
    Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) (PDF)CP.PHAR.310July 1, 2017
    Darbepoetin Alfa (Aranesp) (PDF)CP.PHAR.236June 1, 2016
    Darolutamide (Nubeqa) (PDF)CP.PHAR.435December 1, 2019
    Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) (PDF)HIM.PA.SP61August 1, 2020
    Dasatinib (Sprycel) (PDF)CP.PHAR.72June 1, 2012
    Daunorubicin/Cytarabine (Vyxeos) (PDF)CP.PHAR.352December 1, 2017
    Decitabine/Cedazuridine (Inqovi) (PDF)CP.PHAR.479June 1, 2020
    Deferasirox (Exjade, Jadenu) (PDF)CP.PHAR.145November 1, 2015
    Deferoxamine (Desferal) (PDF)CP.PHAR.146November 1, 2015
    Deflazacort (Emflaza) (PDF)CP.PHAR.331March 1, 2017
    Degarelix Acetate (Firmagon) (PDF)CP.PHAR.170November 9, 2017
    Delafloxacin (Baxdela) (PDF)CP.PMN.115November 9, 2017
    Denosumab (Prolia, Xgeva) (PDF)CP.PHAR.58March 1, 2011
    Desmopressin Acetate (DDAVP, Stimate, Nocdurna, Noctiva) (PDF)CP.PHAR.214May 1, 2016
    Deutetrabenazine (Austedo) (PDF)CP.PCH.42June 1, 2021
    Dexlansoprazole (Dexilant) (PDF)HIM.PA.05January 1, 2020
    Dexrazoxane (Totect) (PDF)CP.PHAR.418March 19, 2019
    Dextromethorphan/Bupropion (Auvelity) (PDF)CP.PMN.284December 1, 2022
    Dextromethorphan-Quinidine (Nuedexta) (PDF)CP.PMN.93March 1, 2018
    Diazepam Nasal Spray (Valtoco) (PDF)CP.PMN.216December 1, 2019
    Dichlorphenamide (Keveyis) (PDF)CP.PMN.261March 1, 2021
    Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) (PDF)CP.PCH.28September 1, 2020
    Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) (PDF)CP.PCH.41February 1, 2021
    Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF)HIM.PA.58March 1, 2018
    Dolasetron (Anzemet) (PDF)CP.PMN.141September 1, 2006
    Dornase Alfa (Pulmozyme) (PDF)CP.PHAR.212May 1, 2016
    Dostarlimab-gxly (Jemperli) (PDF)CP.PHAR.540September 1, 2021
    Doxepin (Silenor, Prudoxin, Zonalon) (PDF)HIM.PA.147November 17, 2017
    Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF)CP.PMN.79May 1, 2017
    Dupilumab (Dupixent) (PDF)CP.PHAR.336May 1, 2017
    Durvalumab (Imfinzi) (PDF)CP.PHAR.339July 1, 2017
    Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) (PDF)CP.PMN.128May 1, 2016
    Duvelisib (Copiktra) (PDF)CP.PHAR.400October 16, 2018
    Ecallantide (Kalbitor) (PDF)CP.PHAR.177March 1, 2016
    Eculizumab (Soliris) (PDF)CP.PHAR.97March 1, 2012
    Edaravone (Radicava, Radivaca ORS) (PDF)CP.PHAR.343July 1, 2017
    Efgartigimod Alfa-fcab (Vyvgart) (PDF)CP.PHAR.555December 1, 2021
    Efinaconazole (Jublia) (PDF)CP.PMN.25August 1, 2016
    Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (PDF)CP.PHAR.136August 28, 2018
    Elapegademase-lvlr (Revcovi) (PDF)CP.PHAR.419April 23, 2019
    Elbasvir/Grazoprevir (Zepatier) (PDF)HIM.PA.SP62August 1, 2020
    Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF)CP.PHAR.440December 1, 2019
    Eliglustat (Cerdelga) (PDF)CP.PHAR.153February 1, 2016
    Elivaldogene Autotemcel (Skysona) (PDF)CP.PHAR.556December 1, 2021
    Elosulfase Alfa (Vimizim) (PDF)CP.PHAR.162 February 1, 2016
    Elotuzumab (Empliciti) (PDF)CP.PHAR.308February 1, 2017
    Eltrombopag (Promacta) (PDF)CP.PHAR.180March 1, 2016
    Eluxadoline (Viberzi) (PDF)CP.PMN.170December 1, 2018
    Emapalumab-lzsg (Gamifant) (PDF)CP.PHAR.402December 11, 2018
    Emicizumab-kxwh (Hemlibra) (PDF)CP.PHAR.370March 1, 2018
    Emtricitabine/Tenofovir Alafenamide (Descovy) (PDF)CP.PMN.235June 1, 2020
    Enasidenib (Idhifa) (PDF)CP.PHAR.363September 5, 2017
    Encorafenib (Braftovi) (PDF)CP.PHAR.127July 24, 2018
    Enfortumab Vedotin-ejfv (Padcev) (PDF)CP.PHAR.455March 1, 2020
    Enfuvirtide (Fuzeon) (PDF)CP.PHAR.41June 1, 2010
    Enoxaparin (Lovenox) (PDF)CP.PHAR.224May 1, 2016
    Entecavir (Baraclude) (PDF)HIM.PA.08February 19, 2019
    Entrectinib (Rozlytrek) (PDF)CP.PHAR.441December 1, 2019
    Enzalutamide (Xtandi) (PDF)HIM.PA.164March 1, 2022
    Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) (PDF)CP.PHAR.237June 1, 2016
    Epoprostenol (Flolan, Veletri) (PDF)CP.PHAR.192March 1, 2016
    Eptinezumab-jjmr (Vyepti) (PDF)HIM.PA.SP64October 1, 2020
    Erdafitinib (Balversa) (PDF)CP.PHAR.423September 1, 2019
    Erenumab-aaoe (Aimovig) (PDF)HIM.PA.SP65October 1, 2020
    Eribulin Mesylate (Halaven) (PDF)CP.PHAR.318March 1, 2017
    Erlotinib (Tarceva) (PDF)CP.PHAR.74September 1, 2011
    Erwinia Asparaginase (Erwinaze, Rylaze) (PDF)CP.PHAR.301February 1, 2017
    Esketamine (Spravato) (PDF)CP.PMN.199March 12, 2019
    Estradiol Vaginal Ring (Femring) (PDF)CP.PMN.263January 1, 2022
    Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379March 20, 2018
    Eteplirsen (Exondys 51) (PDF)CP.PHAR.288December 1, 2016
    Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF)CP.PHAR.63June 1, 2011
    Evinacumab-dgnb (Evkeeza) (PDF)CP.PHAR.511December 1, 2020
    Evolocumab (Repatha) (PDF)HIM.PA.156June 1, 2021
    Factor IX (Human, Recombinant) (PDF)CP.PHAR.218May 1, 2016
    Factor IX Complex, Human (Profilnine) (PDF)CP.PHAR.219May 1, 2016
    Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF)CP.PHAR.220May 1, 2016
    Factor VIII (Human, Recombinant) (PDF)CP.PHAR.215 May 1, 2016
    Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) (PDF)CP.PHAR.216May 1, 2016
    Factor XIII A-Subunit, Recombinant (Tretten) (PDF)CP.PHAR.222May 1, 2016
    Factor XIII, Human (Corifact) (PDF)CP.PHAR.221May 1, 2016
    Fam-Trastuzumab Deruxtecan-nxki (Enhertu) (PDF)CP.PHAR.456March 1, 2020
    Faricimab-svoa (Vabysmo) (PDF)CP.PHAR.581June 1, 2022
    Febuxostat (Uloric) (PDF)CP.PMN.57August 1, 2013
    Fedratinib (Inrebic) (PDF)CP.PHAR.442December 1, 2019
    Fenfluramine (Fintepla)CP.PMN.246September 1, 2020
    Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF)CP.PMN.127June 1, 2015
    Ferric Carboxymaltose (Injectafer) (PDF)CP.PHAR.234June 1, 2016
    Ferric Derisomaltose (Monoferric) (PDF)CP.PHAR.480June 1, 2020
    Ferric Gluconate (Ferrlecit) (PDF)CP.PHAR.166March 1, 2016
    Ferric Maltol (Accrufer) (PDF)CP.PMN.213December 1, 2019
    Ferumoxytol (Feraheme) (PDF)CP.PHAR.165March 1, 2016
    Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) (PDF)CP.PHAR.526June 1, 2021
    Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko) (PDF)CP.PHAR.297December 1, 2016
    Finerenone (Kerendia) (PDF)CP.PMN.266December 1, 2021
    Fingolimod (Gilenya, Tascenso ODT) (PDF)CP.PCH.38February 1, 2021
    Flibanserin (Addyi) (PDF)CP.PHAR.446March 1, 2020
    Fluorouracil Cream (Tolak) (PDF)CP.PMN.165December 1, 2018
    Fluticasone Propionate (Xhance) (PDF)CP.PMN.95October 24, 2017
    Fondaparinux (Arixtra) (PDF)CP.PHAR.226May 1, 2016
    Fosdenopterin (Nulibry) (PDF)CP.PHAR.471June 1, 2020
    Fostamatinib (Tavalisse) (PDF)CP.PHAR.24June 5, 2018
    Fostemsavir (Rukobia) (PDF)CP.PHAR.516March 1, 2021
    Fremanezumab-vfrm (Ajovy) (PDF)HIM.PA.SP66October 1, 2020
    Fulvestrant (Faslodex Injection) (PDF)CP.PHAR.424September 1, 2019
    Gabapentin ER (Gralise, Horizant) (PDF)CP.PMN.240September 1, 2020
    Galcanezumab-gnlm (Emgality) (PDF)HIM.PA.SP67October 1, 2020
    Galsulfase (Naglazyme) (PDF)CP.PHAR.161  February 1, 2016
    Ganaxolone (Ztalmy) (PDF)CP.PMN.278June 1, 2022
    Gefitinib (Iressa) (PDF)CP.PHAR.68November 16, 2016
    Gemtuzumab Ozogamicin (Mylotarg) (PDF)CP.PHAR.358October 3, 2017
    Gilteritinib (Xospata) (PDF)CP.PHAR.412January 15, 2019
    Givosiran (Givlaari) (PDF)CP.PHAR.457March 1, 2020
    Glasdegib (Daurismo) (PDF)CP.PHAR.413January 8, 2019
    Glatiramer Acetate (Copaxone, Glatopa) (PDF)HIM.PA.SP68March 1, 2021
    Glecaprevir/Pibrentasvir (Mavyret) (PDF)HIM.PA.SP36 August 31, 2019
    Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF)HIM.PA.53March 1, 2018
    Glycerol Phenylbutyrate (Ravicti) (PDF)CP.PHAR.207April 30, 2016
    Golodirsen (Vyondys 53) (PDF)CP.PHAR.453March 1, 2020
    Goserelin Acetate (Zoladex) (PDF)CP.PHAR.171November 9, 2017
    Granisetron (Sancuso, Sustol) (PDF)CP.PMN.74November 1, 2016
    Halcinonide (Halog) (PDF)HIM.PA.20August 28, 2018
    Halobetasol Propionate (Bryhali, Lexette, Ultravate) (PDF)CP.PMN.180December 1, 2018
    Halobetasol Propionate/Tazarotene (Duobrii) (PDF)CP.PMN.208September 1, 2019
    Hemin (Panhematin) (PDF)CP.PHAR.181February 1, 2016
    Histrelin Acetate (Vantas, Supprelin LA) (PDF)CP.PHAR.172November 9, 2017
    House Dust Mite Allergen Extract (Odactra) (PDF)CP.PMN.111 August 31, 2017
    Human Growth Hormone (Somapacitan, Somatropin) (PDF)HIM.PA.161January 1, 2022
    Hyaluronate Derivatives (PDF)CP.PHAR.05October 1, 2008
    Hydroxyprogesterone Caproate (Makena/compound) (PDF)CP.PHAR.14November 20, 2017
    Hydroxyurea (Siklos) (PDF)CP.PMN.193February 19, 2019
    Ibalizumab-uiyk (Trogarzo) (PDF)CP.PHAR.378April 17, 2018
    Ibandronate Injection (Boniva) (PDF)CP.PHAR.189November 15, 2017
    Ibrutinib (Imbruvica) (PDF)CP.PHAR.126October 1, 2015
    Ibuprofen/Famotidine (Duexis) (PDF)CP.PMN.120June 1, 2018
    Icatibant (Firazyr) (PDF)CP.PHAR.178March 1, 2016
    Icosapent Ethyl (Vascepa) (PDF)CP.PMN.187November 20, 2018
    Idecabtagene Vicleucel (Abecma) (PDF)CP.PHAR.481June 1, 2020
    Idelalisib (Zydelig) (PDF)CP.PHAR.133December 1, 2018
    Idursulfase (Elaprase) (PDF)CP.PHAR.156 February 1, 2016
    Iloperidone (Fanapt) (PDF)CP.PMN.32December 1, 2014
    Iloprost (Ventavis) (PDF)CP.PHAR.193March 1, 2016
    Imatinib (Gleevec) (PDF)CP.PHAR.65June 1, 2011
    Imiglucerase (Cerezyme) (PDF)CP.PHAR.154 February 1, 2016
    Immune Globulins (PDF)CP.PHAR.103August 1, 2012
    Inclisiran (Leqvio) (PDF)CP.PHAR.568March 1, 2022
    IncobotulinumtoxinA (Xeomin) (PDF)CP.PHAR.231July 1, 2016
    Inebilizumab-cdon (Uplizna) (PDF)CP.PHAR.458March 1, 2020
    Infertility and Fertility Preservation (PDF)CP.PHAR.131November 16, 2016
    Infigratinib (Truseltiq) (PDF)CP.PHAR.547September 1, 2021
    Inhaled Agents for Asthma and COPD (PDF)HIM.PA.153March 1, 2021
    Inotersen (Tegsedi) (PDF)CP.PHAR.405November 20, 2018
    Inotuzumab Ozogamicin (Besponsa) (PDF)CP.PHAR.359September 26, 2017
    Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)CP.PHAR.534June 1, 2021
    Insulin Glargine (Rezvoglar, Semglee, Toujeo) (PDF)HIM.PA.09March 1, 2019
    Interferon Beta-1a (Avonex, Rebif) (PDF)CP.PHAR.255August 1, 2016
    Interferon Beta-1b (Betaseron, Extavia) (PDF)CP.PCH.46March 1, 2022
    Interferon Gamma- 1b (Actimmune) (PDF)CP.PHAR.52June 1, 2010
    Iobenguane I-131 (Azedra) (PDF)CP.PHAR.459March 1, 2020
    Ipilimumab (Yervoy) (PDF)CP.PHAR.319April 17, 2018
    Irinotecan Liposome (Onivyde) (PDF)CP.PHAR.304February 1, 2017
    Iron Sucrose (Venofer) (PDF)CP.PHAR.167March 1, 2016
    Isatuximab-irfc (Sarclisa) (PDF)CP.PHAR.482June 1, 2020
    Isavuconazonium (Cresemba) (PDF)CP.PMN.154November 16, 2016
    Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF)CP.PMN.143December 1, 2014
    Istradefylline (Nourianz) (PDF)CP.PMN.217March 1, 2020
    Itraconazole (Sporanox, Tolsura) (PDF)CP.PMN.124November 1, 2006
    Ivabradine (Corlanor) (PDF)CP.PMN.70November 1, 2015
    Ivacaftor (Kalydeco) (PDF)CP.PHAR.210May 1, 2016
    Ivermectin (Stromectol, Sklice) (PDF)CP.PMN.269December 1, 2021
    Ivosidenib (Tibsovo) (PDF)CP.PHAR.137August 21, 2018
    Ixazomib (Ninlaro) (PDF)CP.PHAR.302February 1, 2017
    Ketorolac Nasal Spray (Sprix) (PDF)CP.PMN.282December 1, 2022
    Lanadelumab-fylo (Takhzyro) (PDF)CP.PHAR.396September 25, 2018
    Lanreotide (Somatuline Depot) (PDF)CP.PHAR.391August 14, 2018
    Lapatinib (Tykerb) (PDF)CP.PHAR.79November 9, 2017
    Laronidase (Aldurazyme) (PDF)CP.PHAR.152February 1, 2016
    Larotrectinib (Vitrakvi) (PDF)CP.PHAR.414January 15, 2018
    Lasmiditan (Reyvow) (PDF)CP.PMN.218March 1, 2020
    Latanoprostene Bunod (Vyzulta) (PDF)CP.PMN.108March 1, 2018
    Ledipasvir/Sofosbuvir (Harvoni) (PDF)HIM.PA.SP3August 31, 2016
    Lefamulin (Xenleta) (PDF)CP.PMN.219March 1, 2020
    Lenalidomide (Revlimid) (PDF)CP.PHAR.71July 1, 2011
    Lenvatinib (Lenvima) (PDF)CP.PHAR.138December 1, 2018
    Letermovir (Prevymis) (PDF)CP.PHAR.367March 1, 2018
    Leucovorin Injection (PDF)CP.PHAR.393December 1, 2018
    Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) (PDF)CP.PHAR.173November 9, 2017
    Levodopa Inhalation Powder (Inbrija) (PDF)CP.PMN.267December 1, 2021
    Levoketoconazole (Recorlev) (PDF)CP.PMN.275June 1, 2022
    Levoleucovorin (Fusilev, Khapzory) (PDF)CP.PHAR.151November 9, 2017
    Levomilnacipran (Fetzima) (PDF)HIM.PA.125November 9, 2017
    L-glutamine (Endari) (PDF)CP.PMN.116November 9, 2017
    Lidocaine Transdermal (Lidoderm, ZTlido) (PDF)CP.PMN.08September 1, 2006
    Lifitegrast (Xiidra) (PDF)CP.PMN.73November 9, 2017
    Linaclotide (Linzess) (PDF)CP.PMN.71November 1, 2015
    Linezolid (Zyvox) (PDF)CP.PMN.27September 1, 2016
    Lisocabtagene Maraleucel (Breyanzi) (PDF)CP.PHAR.483June 1, 2020
    Lofexidine (Lucemyra) (PDF)CP.PMN.152August 1, 2018
    Lomustine (Gleostine) (PDF)CP.PHAR.507December 1, 2020
    Lonafarnib (Zokinvy) (PDF)CP.PHAR.499September 1, 2020
    Loncastuximab Tesirine-lpyl (Zynlonta) (PDF)CP.PHAR.539September 1, 2021
    Lorlatinib (Lorbrena) (PDF)CP.PHAR.406December 11, 2018
    Loteprednol etabonate (Eysuvis) (PDF)CP.PMN.260March 1, 2021
    Lubiprostone (Amitiza) (PDF)CP.PMN.142December 1, 2014
    Luliconazole Cream (Luzu) (PDF)CP.PMN.166August 28, 2018
    Lumacaftor/Ivacaftor (Orkambi) (PDF)CP.PHAR.213May 1, 2016
    Lumasiran (Oxlumo) (PDF)CP.PHAR.473June 1, 2020
    Lumateperone (Caplyta) (PDF)CP.PMN.232March 1, 2020
    Lurasidone (Latuda) (PDF)CP.PMN.50December 1, 2014
    Lurbinectedin (Zepzelca) (PDF)CP.PHAR.500September 1, 2020
    Luspatercept-aamt (Reblozyl) (PDF)CP.PHAR.450March 1, 2020
    Lusutrombopag (Mulpleta) (PDF)CP.PHAR.407September 18, 2018
    Lutetium Lu 177 Dotatate (Lutathera) (PDF)CP.PHAR.384May 22, 2018
    Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF)CP.PHAR.582June 1, 2022
    Macitentan (Opsumit) (PDF)CP.PHAR.194March 1, 2016
    Mannitol (Bronchitol) (PDF)CP.PHAR.518March 1, 2021
    Maralixibat (Livmarli) (PDF)CP.PHAR.543September 1, 2021
    Margetuximab-cmkb (Margenza) (PDF)CP.PHAR.522March 1, 2021
    Maribavir (Livtencity) (PDF)CP.PMN.271March 1, 2022
    Mavacamten (Camzyos) (PDF)CP.PMN.272March 1, 2022
    Mecamylamine (Vecamyl) (PDF)CP.PMN.136May 1, 2017
    Mecasermin (Increlex) (PDF)CP.PHAR.150March 1, 2011
    Mechlorethamine Gel (Valchlor) (PDF)CP.PHAR.381November 16, 2016
    Megestrol Acetate (Megace ES) (PDF)CP.PMN.179December 1, 2018
    Melphalan flufenamide (Pepaxto) (PDF)CP.PHAR.535June 1, 2021
    Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) (PDF)CP.PCH.30September 1, 2020
    Mepolizumab (Nucala) (PDF)CP.PHAR.200April 1, 2016
    Mercaptopurine (Purixan) (PDF)CP.PHAR.447March 1, 2020
    Metformin ER (Fortamet, Glumetza) (PDF)CP.PMN.72October 31, 2015
    Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF)CP.PHAR.134December 1, 2018
    Methoxsalen (Uvadex) (PDF)HIM.PA.17September 4, 2018
    Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) (PDF)CP.PHAR.238June 1, 2016
    Methylnaltrexone Bromide (Relistor) (PDF)CP.PMN.169December 1, 2018
    Metoclopramide (Gimoti) (PDF)CP.PMN.252December 1, 2020
    Metreleptin (Myalept) (PDF)CP.PHAR.425September 1, 2019
    Midazolam (Nayzilam) (PDF)CP.PMN.211September 1, 2019
    Midostaurin (Rydapt) (PDF)CP.PHAR.344June 1, 2017
    Mifepristone (Korlym) (PDF)CP.PHAR.101May 1, 2012
    Migalastat (Galafold) (PDF)CP.PHAR.394September 11, 2018
    Miglustat (Zavesca) (PDF)CP.PHAR.164 February 1, 2016
    Milnacipran (Savella) (PDF)CP.PMN.125August 1, 2012
    Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) (PDF)CP.PMN.80April 30, 2017
    Mitapivat (Pyrukynd) (PDF)CP.PHAR.558December 1, 2021
    Mitomycin for Pyelocalyceal Solution (Jelmyto) (PDF)CP.PHAR.495September 1, 2020
    Mitoxantrone (PDF)CP.PHAR.258August 1, 2016
    Mobocertinib (Exkivity) (PDF)CP.PHAR.559December 1, 2021
    Modafinil (Provigil) (PDF)CP.PMN.39May 1, 2008
    Mogamulizumab-kpkc (Poteligeo) (PDF)CP.PHAR.139September 4, 2018
    Mometasone (Nasonex) (PDF)HIM.PA.93December 1, 2014
    Mometasone Furoate (Sinuva) (PDF)CP.PHAR.448March 1, 2020
    Montelukast Oral Granules (Singulair) (PDF)HIM.PA.129November 9, 2017
    Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF)CP.PHAR.398October 16, 2018
    Nafarelin Acetate (Synarel) (PDF)CP.PHAR.174November 9, 2017
    Naltrexone (Vivitrol) (PDF)CP.PHAR.96March 1, 2012
    Naproxen Oral Suspension (Naprosyn) (PDF)HIM.PA.130November 9, 2017
    Naproxen/Esomeprazole (Vimovo) (PDF)CP.PMN.117June 1, 2018
    Natalizumab (Tysabri) (PDF)CP.PHAR.259July 1, 2016
    Naxitamab-gqgk (Danyelza) (PDF)CP.PHAR.523March 1, 2021
    Necitumumab (Portrazza) (PDF)CP.PHAR.320March 1, 2017
    Neomycin/Fluocinolone Cream (Neo-Synalar) (PDF)CP.PMN.167August 28, 2018
    Neratinib (Nerlynx) (PDF)CP.PHAR.365September 5, 2017
    Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF)CP.PMN.118February 13, 2018
    Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF)CP.PMN.158September 1, 2006
    Nifurtimox (Lampit) (PDF)CP.PMN.256December 1, 2020
    Nilotinib (Tasigna) (PDF)CP.PHAR.76September 1, 2011
    Nintedanib (Ofev) (PDF)CP.PHAR.285October 1, 2016
    Niraparib (Zejula) (PDF)CP.PHAR.408May 9, 2017
    Nitazoxanide (Alinia) (PDF)HIM.PA.152December 1, 2020
    Nitisinone (Nityr, Orfadin) (PDF)CP.PHAR.132August 28, 2018
    Nivolumab (Opdivo) (PDF)CP.PHAR.121  July 1, 2015
    Nivolumab and Relatlimab-rmbw (Opdualag) (PDF)CP.PHAR.588September 1, 2022
    No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update (PDF)HIM.PA.33May 1, 2016
    Non-Calcium Phosphate Binders (PDF)CP.PMN.04November 15, 2017
    Non-Formulary and Formulary Contraceptives (PDF)HIM.PA.100May 1, 2015
    Non-Formulary Test Strips (PDF)HIM.PA.34February 1, 2016
    Nusinersen (Spinraza) (PDF)CP.PHAR.327November 28, 2017
    Obeticholic Acid (Ocaliva) (PDF)CP.PHAR.287November 1, 2016
    Obinutuzumab (Gazyva) (PDF)CP.PHAR.305February 1, 2017
    Ocrelizumab (Ocrevus) (PDF)CP.PHAR.335April 1, 2017
    Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) (PDF)CP.PHAR.40March 1, 2010
    Odevixibat (Bylvay) (PDF)CP.PHAR.528June 1, 2021
    Ofatumumab (Arzerra, Kesimpta) (PDF)CP.PHAR.306February 1, 2017
    Off-Label Drug Use (PDF)HIM.PA.154February 1, 2021
    Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)CP.PHAR.292December 1, 2016
    Olanzapine/Samidorphan (Lybalvi) (PDF)CP.PMN.265September 1, 2021
    Olaparib (Lynparza) (PDF)CP.PHAR.360October 3, 2017
    Olaratumab (Lartruvo) (PDF)CP.PHAR.326March 1, 2017
    Olipudase Alfa-rpcp (Xenpozyme) (PDF)CP.PHAR.586June 2, 2022
    Omacetaxine (Synribo) (PDF)CP.PHAR.108April 1, 2013
    Omadacycline (Nuzyra) (PDF)CP.PMN.188November 20, 2018
    Omalizumab (Xolair) (PDF)CP.PHAR.01October 1, 2008
    OnabotulinumtoxinA (Botox) (PDF)CP.PHAR.232July 1, 2016
    Onasemnogene Abeparvovec (Zolgensma) (PDF)CP.PHAR.421June 7, 2019
    Ondansetron (Zuplenz) (PDF)CP.PMN.45September 1, 2006
    Ophthalmic Corticosteroids (PDF)HIM.PA.03January 1, 2020
    Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF)CP.PHAR.536June 1, 2021
    Opicapone (Ongentys) (PDF)CP.PMN.245September 1, 2020
    Opioid Analgesics* (PDF)HIM.PA.139August 1, 2018
    Osilodrostat (Isturisa) (PDF)CP.PHAR.487September 1, 2020
    Osimertinib (Tagrisso) (PDF)CP.PHAR.294December 1, 2016
    Ospemifene (Osphena) (PDF)CP.PMN.168August 28, 2018
    Overactive Bladder Agents (PDF)CP.PMN.198May 1, 2016
    Oxymetazoline (Rhofade, Upneeq) (PDF)CP.PMN.86November 15, 2016
    Ozanimod (Zeposia) (PDF)CP.PHAR.462March 1, 2020
    Ozenoxacin (Xepi) (PDF)CP.PMN.119January 30, 2018
    Paclitaxel, Protein-Bound (Abraxane) (PDF)CP.PHAR.176 July 1, 2015
    Pacritinib (Vonjo) (PDF)CP.PHAR.583June 1, 2022
    Palbociclib (Ibrance) (PDF)CP.PHAR.125October 1, 2015
    Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) (PDF)CP.PHAR.291December 1, 2016
    Palivizumab (Synagis) (PDF)CP.PHAR.16July 31, 2009
    Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) (PDF)CP.PCH.44March 1, 2022
    Panitumumab (Vectibix) (PDF)CP.PHAR.321March 1, 2017
    Panobinostat (Farydak) (PDF)CP.PHAR.382November 16, 2016
    Parathyroid Hormone (Natpara) (PDF)CP.PHAR.282November 16, 2016
    Paricalcitol Injection (Zemplar) (PDF)CP.PHAR.270August 1, 2016
    Pasireotide (Signifor, Signifor LAR) (PDF)CP.PHAR.332March 1, 2017
    Patiromer (Veltassa) (PDF)CP.PMN.205September 1, 2019
    Patisiran (Onpattro) (PDF)CP.PHAR.395September 11, 2018
    Pazopanib (Votrient) (PDF)CP.PHAR.81October 1, 2011
    Peanut Allergen Powder-dnfp (Palforzia) (PDF)CP.PMN.220March 1, 2020
    Pegaptanib (Macugen) (PDF)CP.PHAR.185March 1, 2016
    Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) (PDF)CP.PHAR.353September 5, 2017
    Pegcetacoplan (Empaveli, APL-2) (PDF)CP.PHAR.524March 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)CP.PHAR.296December 1, 2016
    Peginterferon Alfa-2a,b (Pegasys, PegIntron) (PDF)CP.PHAR.89October 1, 2011
    Peginterferon Beta-1a (Plegridy) (PDF)CP.PHAR.271August 1, 2016
    Pegloticase (Krystexxa) (PDF)CP.PHAR.115June 1, 2013
    Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140July 31, 2018
    Pegvisomant (Somavert) (PDF)CP.PHAR.389December 1, 2018
    Pembrolizumab (Keytruda) (PDF)CP.PHAR.322March 1, 2017
    Pemetrexed (Alimta, Pemfexy) (PDF)CP.PHAR.368October 31, 2017
    Pemigatinib (Pemazyre) (PDF)CP.PHAR.496September 1, 2020
    Penicillamine (Cuprimine) (PDF)CP.PCH.09December 1, 2018
    Perampanel (Fycompa) (PDF)CP.PMN.156November 16, 2016
    Pertuzumab (Perjeta) (PDF)CP.PHAR.227June 1, 2016
    Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF)CP.PHAR.501September 1, 2020
    Pexidartinib (Turalio) (PDF)CP.PHAR.436December 1, 2019
    Phendimetrazine (PDF)CP.PCH.47June 1, 2022
    Phentermine (Adipex-P, Lomaira) (PDF)CP.PCH.13May 1, 2017
    Pilocarpine (Vuity) (PDF)CP.PMN.270December 1, 2021
    Pimavanserin (Nuplazid) (PDF)CP.PMN.140November 16, 2016
    Pirfenidone (Esbriet) (PDF)CP.PHAR.286October 1, 2016
    Pitolisant (Wakix) (PDF)CP.PMN.221March 1, 2020
    Plasminogen, Human-tvmh (Ryplazim) (PDF)CP.PHAR.513June 3, 2021
    Plecanatide (Trulance) (PDF)HIM.PA.158June 1, 2021
    Plerixafor (Mozobil) (PDF)CP.PHAR.323March 1, 2017
    Polatuzumab Vedotin-piiq (Polivy) (PDF)CP.PHAR.433September 1, 2019
    Pomalidomide (Pomalyst) (PDF)CP.PHAR.116July 1, 2013
    Ponatinib (Iclusig) (PDF)CP.PHAR.112June 1, 2013
    Ponesimod (Ponvory) (PDF)CP.PHAR.537June 1, 2021
    Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF)HIM.PA.143October 31, 2017
    Pralatrexate (Folotyn) (PDF)CP.PHAR.313February 1, 2017
    Pramlintide (Symlin) (PDF)CP.PMN.129June 1, 2018
    Prasterone (Intrarosa) (PDF)CP.PMN.99December 20, 2016
    Pregabalin (Lyrica, Lyrica CR) (PDF)CP.PMN.33January 1, 2007
    Pretomanid (PDF)CP.PMN.222March 1, 2020
    Progesterone (Crinone, Endometrin, Milprosa) (PDF)CP.PMN.243September 1, 2020
    Propranolol HCl Oral Solution (Hemangeol) (PDF)CP.PMN.58May 1, 2014
    Protein C Concentrate, Human (Ceprotin) (PDF)CP.PHAR.330March 1, 2017
    Prucalopride (Motegrity) (PDF)HIM.PA.159June 1, 2021
    Pyrimethamine (Daraprim) (PDF)CP.PMN.44 November 1, 2015
    Quetiapine Extended-Release (Seroquel XR) (PDF)CP.PMN.64December 1, 2014
    Quinine Sulfate (Qualaquin) (PDF)CP.PMN.262June 1, 2021
    Ramucirumab (Cyramza) (PDF)CP.PHAR.119May 1, 2015
    Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) (PDF)CP.PHAR.186April 1, 2016
    Rasagiline (Azilect) (PDF)HIM.PA.89December 1, 2014
    Ravulizumab-cwvz (Ultomiris) (PDF)CP.PHAR.415February 19, 2019
    Regorafenib (Stivarga) (PDF)CP.PHAR.107December 1, 2012
    Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) (PDF)CP.PHAR.529June 1, 2021
    Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF)CP.PHAR.168March 1, 2016
    Reslizumab (Cinqair) (PDF)CP.PHAR.223May 1, 2016
    Ribavirin (Rebetol, Ribasphere) (PDF)CP.PHAR.141November 16, 2016
    Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) (PDF)CP.PHAR.334May 1, 2017
    Rifabutin (Mycobutin) (PDF)CP.PMN.223March 1, 2020
    Rifamycin (Aemcolo) (PDF)CP.PMN.196January 8, 2019
    Rifaximin (Xifaxan) (PDF)CP.PMN.47November 1, 2011
    Rilonacept (Arcalyst) (PDF)CP.PHAR.266November 16, 2016
    RimabotulinumtoxinB (Myobloc) (PDF)CP.PHAR.233July 1, 2016
    Rimegepant (Nurtec ODT) (PDF)CP.PHAR.490September 1, 2020
    Riociguat (Adempas) (PDF)CP.PHAR.195March 1, 2016
    Ripretinib (Qinlock) (PDF)CP.PHAR.502September 1, 2020
    Risdiplam (Evrysdi) (PDF)CP.PHAR.477August 6, 2020
    Risedronate (Actonel, Atelvia) (PDF)CP.PMN.100March 1, 2018
    Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF)CP.PHAR.293December 1, 2016
    Rolapitant (Varubi) (PDF)CP.PMN.102February 1, 2017
    Romidepsin (Istodax) (PDF)CP.PHAR.314January 1, 2017
    Romiplostim (Nplate) (PDF)CP.PHAR.179March 1, 2016
    Romosozumab-aqqg (Evenity) (PDF)CP.PHAR.428September 1, 2019
    Ropeginterferon Alfa-2b-njft (BESREMi) (PDF)CP.PHAR.570March 1, 2022
    Rucaparib (Rubraca) (PDF)CP.PHAR.350September 1, 2017
    Rufinamide (Banzel) (PDF)CP.PMN.157December 1, 2014
    Ruxolitinib (Jakafi, Opzelura) (PDF)CP.PHAR.98March 1, 2012
    Sacituzumab Govitecan-hziy (Trodelvy) (PDF)CP.PHAR.475June 1, 2020
    Sacituzumab Govitecan-hziy (Trodelvy) (PDF)CP.PHAR.475June 1, 2020
    Sacubitril/Valsartan (Entresto) (PDF)CP.PMN.67November 1, 2015
    Safinamide (Xadago) (PDF)CP.PMN.113July 1, 2017
    Sapropterin Dihydrochloride (Kuvan) (PDF)CP.PHAR.43February 1, 2010
    Sarecycline (Seysara) (PDF)CP.PMN.189November 13, 2018
    Sargramostim (Leukine) (PDF)CP.PHAR.295December 1, 2016
    Satralizumab-mwge (Enspryng) (PDF)CP.PHAR.463March 1, 2020
    Sebelipase Alfa (Kanuma) (PDF)CP.PHAR.159February 1, 2016
    Secnidazole (Solosec) (PDF)CP.PMN.103October 24, 2017
    Selexipag (Uptravi) (PDF)CP.PHAR.196March 1, 2016
    Selinexor (Xpovio) (PDF)CP.PHAR.431September 1, 2019
    Selpercatinib (Retevmo) (PDF)CP.PHAR.478June 1, 2020
    Selumetinib (Koselugo) (PDF)CP.PHAR.464March 1, 2020
    Setmelanotide (Imcivree) (PDF)CP.PHAR.491September 1, 2020
    Short Ragweed Pollen Allergen Extract (Ragwitek) (PDF)CP.PMN.83 August 31, 2017
    Sildenafil (Revatio) (PDF)CP.PHAR.197March 1, 2016
    Sildenafil for ED (Viagra) (PDF)CP.PCH.07June 1, 2018
    Siltuximab (Sylvant) (PDF)CP.PHAR.329March 1, 2017
    Siponimod (Mayzent) (PDF)CP.PHAR.427September 1, 2019
    Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) (PDF)CP.PHAR.574March 1, 2022
    Sodium Oxybate (Xyrem) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) (PDF)CP.PMN.42May 1, 2011
    Sodium Phenylbutyrate (Buphenyl, Pheburane) (PDF)CP.PHAR.208May 1, 2016
    Sodium Phenylbutyrate/Taurursodiol (Relyvrio) (PDF)CP.PHAR.584June 1, 2022
    Sodium Zirconium Cyclosilicate (Lokelma) (PDF)CP.PMN.163July 24, 2018
    Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF)HIM.PA.91January 1, 2015
    Sofosbuvir (Sovaldi) (PDF)HIM.PA.SP2 August 31, 2016
    Sofosbuvir/Velpatasvir (Epclusa) (PDF)HIM.PA.SP1August 31, 2016
    Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF)HIM.PA.SP63 August 1, 2020
    Solriamfetol (Sunosi) (PDF)CP.PMN.209September 1, 2019
    Sonidegib (Odomzo) (PDF)CP.PHAR.272May 1, 2012
    Sorafenib (Nexavar) (PDF)CP.PHAR.69July 1, 2011
    Spinosad (Natroba) (PDF)HIM.PA.134November 9, 2017
    Step Therapy (PDF)HIM.PA.109August 1, 2017
    Stiripentol (Diacomit) (PDF)CP.PMN.184September 25, 2018
    Sunitinib (Sutent) (PDF)CP.PHAR.73September 1, 2011
    Sutimlimab-jome (Enjaymo) (PDF)CP.PHAR.503February 3, 2022
    Suvorexant (Belsomra) (PDF)CP.PMN.109February 1, 2017
    Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (PDF)CP.PMN.85 August 31, 2017
    Tadalafil (Adcirca, Alyq, Tadliq) (PDF)CP.PHAR.198March 1, 2016
    Tadalafil BPH - ED (Cialis) (PDF)CP.PMN.132June 1, 2018
    Tafamidis (Vyndaqel, Vyndamax) (PDF)CP.PHAR.432September 1, 2019
    Tafasitamab-cxix (Monjuvi) (PDF)CP.PHAR.508December 1, 2020
    Talazoparib (Talzenna) (PDF)CP.PHAR.409November 27, 2018
    Taliglucerase Alfa (Elelyso) (PDF)HIM.PA.162January 1, 2022
    Talimogene laherepvec (Imlygic) (PDF)CP.PHAR.542September 1, 2021
    Tapinarof (Vtama) (PDF)CP.PMN.283December 1, 2022
    Tasimelteon (Hetlioz, Hetlioz LQ) (PDF)CP.PMN.104February 1, 2017
    Tavaborole (Kerydin) (PDF)CP.PMN.105March 1, 2018
    Tazarotene (Arazlo, Fabior, Tazorac) (PDF)CP.PMN.244September 1, 2020
    Tazemetostat (Tazverik) (PDF)CP.PHAR.452March 1, 2020
    Tebentafusp-tebn (Kimmtrak) (PDF)CP.PHAR.575June 1, 2022
    Tedizolid (Sivextro) (PDF)CP.PMN.62March 1, 2015
    Teduglutide (Gattex) (PDF)CP.PHAR.114May 1, 2013
    Tegaserod (Zelnorm) (PDF)HIM.PA.160June 1, 2021
    Telotristat Ethyl (Xermelo) (PDF)CP.PHAR.337June 1, 2017
    Temozolomide (Temodar) (PDF)CP.PHAR.77September 1, 2011
    Temsirolimus (Torisel) (PDF)CP.PHAR.324March 1, 2017
    Tenapanor (Ibsrela) (PDF)CP.PMN.224March 1, 2020
    Tenofovir Alafenamide Fumarate (Vemlidy) (PDF)CP.PMN.268December 1, 2021
    Tepotinib (Tepmetko) (PDF)CP.PHAR.530June 1, 2021
    Teprotumumab (Tepezza) (PDF)CP.PHAR.465January 21, 2020
    Teriflunomide (Aubagio) (PDF)CP.PCH.40February 1, 2021
    Teriparatide (Forteo) (PDF)CP.PHAR.188November 15, 2017
    Tesamorelin (Egrifta SV) (PDF)CP.PHAR.109March 1, 2014
    Testosterone (Androderm) (PDF)HIM.PA.87December 1, 2014
    Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) (PDF)CP.PHAR.354August 1, 2017
    Tetrabenazine (Xenazine) (PDF)CP.PHAR.92December 1, 2011
    Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)CP.PHAR.377April 3, 2018
    Tezepelumab-ekko (Tezspire) (PDF)CP.PHAR.576June 1, 2022
    Thalidomide (Thalomid) (PDF)CP.PHAR.78September 1, 2011
    Thioguanine (Tabloid) (PDF)CP.PHAR.437December 1, 2019
    Thyrotropin Alfa (Thyrogen) (PDF)CP.PHAR.95March 1, 2012
    Timothy Grass Pollen Allergen Extract (Grastek) (PDF)CP.PMN.84 August 31, 2017
    Tisagenlecleucel (Kymriah) (PDF)CP.PHAR.361September 26, 2017
    Tisotumab Vedotin-tftv (Tivdak) (PDF)CP.PHAR.561December 1, 2021
    Tivozanib (Fotivda) (PDF)CP.PHAR.538June 1, 2021
    Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF)CP.PHAR.211May 1, 2016
    Tolvaptan (Jynarque, Samsca) (PDF)CP.PHAR.27June 5, 2018
    Topical Acne Treatment (PDF)HIM.PA.71December 1, 2014
    Topical Immunomodulators (PDF)CP.PMN.107September 1, 2006
    Topiramate Extended-Release (Qudexy XR, Trokendi XR) (PDF)CP.PMN.281September 1, 2022
    Topotecan (Hycamtin) (PDF)CP.PHAR.64June 1, 2011
    Trabectedin (Yondelis) (PDF)CP.PHAR.204May 1, 2016
    Tralokinumab-ldrm (Adbry) (PDF)CP.PHAR.577June 1, 2022
    Trametinib (Mekinist) (PDF)CP.PHAR.240July 1, 2016
    Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)CP.PHAR.228June 1, 2016
    Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI) (PDF)CP.PHAR.199 March 1, 2016
    Triamcinolone ER Injection (Zilretta) (PDF)CP.PHAR.371March 1, 2018
    Triclabendazole (Egaten) (PDF)CP.PMN.207September 1, 2019
    Trientine (Cuvrior, Syprine) (PDF)CP.PHAR.438December 1, 2019
    Trifarotene (Aklief) (PDF)CP.PMN.225March 1, 2020
    Trifluridine/Tipiracil (Lonsurf) (PDF)CP.PHAR.383November 16, 2016
    Triheptanoin (Dojolvi) (PDF)CP.PHAR.509December 1, 2020
    Triptorelin Pamoate (Trelstar, Triptodur) (PDF)CP.PHAR.175November 9, 2017
    Tucatinib (Tukysa) (PDF)CP.PHAR.497September 1, 2020
    Ubrogepant (Ubrelvy) (PDF)CP.PHAR.476June 1, 2020
    Ulcer Therapy Combinations (PDF)CP.PMN.277June 1, 2022
    Umbralisib (Ukoniq) (PDF)CP.PHAR.531June 1, 2021
    Uridine Triacetate (Vistogard) (PDF)HIM.PA.SP55November 9, 2017
    Valbenazine (Ingrezza) (PDF)CP.PCH.48September 1, 2022
    Valganciclovir (Valcyte) (PDF)CP.PCH.06November 16, 2016
    Valrubicin (Valstar) (PDF)CP.PHAR.439December 1, 2019
    Vandetanib (Caprelsa) (PDF)CP.PHAR.80October 1, 2011
    Varenicline (Tyrvaya) (PDF)CP.PMN.273March 1, 2022
    Velaglucerase Alfa (VPRIV) (PDF)HIM.PA.163January 1, 2022
    Vemurafenib (Zelboraf) (PDF)CP.PHAR.91November 1, 2011
    Venetoclax (Venclexta) (PDF)CP.PHAR.129September 1, 2018
    Verteporfin (Visudyne) (PDF)CP.PHAR.187March 1, 2016
    Vestronidase Alfa-vjbk (Mepsevii) (PDF)CP.PHAR.374January 19, 2018
    Vigabatrin (Sabril) (PDF)CP.PHAR.169 February 1, 2016
    Vilazodone (Viibryd) (PDF)CP.PMN.145August 1, 2012
    Viloxazine (Qelbree) (PDF)CP.PMN.264June 1, 2021
    Viltolarsen (Viltepso) (PDF)CP.PHAR.484August 12, 2020
    Vincristine Sulfate Liposome Injection (Marqibo) (PDF)CP.PHAR.315February 1, 2017
    Vismodegib (Erivedge) (PDF)CP.PHAR.273August 1, 2016
    Voclosporin (Lupkynis) (PDF)CP.PHAR.504September 1, 2020
    Vorapaxar (Zontivity) (PDF)HIM.PA.146October 31, 2017
    Voretigene Neparvovec-rzyl (Luxturna) (PDF)CP.PHAR.372March 1, 2018
    Vorinostat (Zolinza) (PDF)CP.PHAR.83December 1, 2012
    Vortioxetine (Trintellix) (PDF)CP.PMN.65 May 31, 2017
    Vosoritide (Voxzogo) (PDF)CP.PHAR.525March 1, 2021
    Voxelotor (Oxbryta) (PDF)CP.PHAR.451March 1, 2020
    Vutrisiran (Amvuttra) (PDF)CP.PHAR.550December 1, 2021
    Zanubrutinib (Brukinsa) (PDF)CP.PHAR.467March 1, 2020
    Ziv-aflibercept (Zaltrap) (PDF)CP.PHAR.325March 1, 2017
    Zoledronic Acid (Reclast, Zometa) (PDF)CP.PHAR.59March 1, 2011