Clinical, Payment and Pharmacy 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 SilverSummit Healthplan Clinical Policy Manual apply to SilverSummit Healthplan members. Policies in the SilverSummit Healthplan Clinical Policy Manual may have either a SilverSummit Healthplan or a “Centene” heading.  SilverSummit Healthplan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a SilverSummit Healthplan 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 SilverSummit Healthplan. In addition, SilverSummit Healthplan 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 SilverSummit Healthplan.   

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

Medicaid Clinical and Behavioral Health Policies

Policy NamePolicy Number
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)CP.MP.157
Acupuncture (PDF)CP.MP.92
Adopted Clinical Practice and Preventive Health Guidelines (PDF)CPG Grid
Air Ambulance (PDF)CP.MP.175
Allergy Testing and Therapy (PDF)CP.MP.100
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (PDF)CP.MP.108
Applied Behavior Analysis (PDF)CP.BH.104
Articular Cartilage Defect Repairs (PDF)CP.MP.26
Assisted Reproductive Technology (PDF)CP.MP.55
Bariatric Surgery (PDF)CP.MP.37
Behavioral Health Treatment Document Requirements (PDF)CP.BH.500
Biofeedback (PDF)CP.MP.168
Bone-Anchored Hearing Aid (PDF)CP.MP.93
Bronchial Thermoplasty (PDF)CP.MP.110
Burn Surgery (PDF)CP.MP.186
Cardiac Biomarker Testing (PDF)CP.MP.156
Caudal or Interlaminar Epidural Steroid Injections (PDF)CP.MP.164
Clinical Trials (PDF)CP.MP.94
Cochlear Implant Replacements (PDF)CP.MP.14
Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (PDF)V2.2024
Concert Genetic Testing: Cardiac Disorders (PDF)V2.2024
Concert Genetic Testing: Dermatologic Conditions (PDF)V2.2024
Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (PDF)V2.2024
Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF)V2.2024
Concert Genetic Testing: Eye Disorders (PDF)V2.2024
Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (PDF)V2.2024
Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)V2.2024
Concert Genetic Testing: Hearing Loss (PDF)V2.2024
Concert Genetic Testing: Hematologic Conditions (non-cancerous) (PDF)V2.2024
Concert Genetic Testing: Hereditary Cancer Susceptibility (PDF)V2.2024
Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (PDF)V2.2024
Concert Genetic Testing: Kidney Disorders (PDF)V2.2024
Concert Genetic Testing: Lung Disorders (PDF)V2.2024
Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (PDF)V2.2024
Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (PDF)V2.2024
Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (PDF)V2.2024
Concert Genetic Testing: Pharmacogenetics (PDF)V2.2024
Concert Genetic Testing: Preimplantation Genetic Testing (PDF)V2.2024
Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)V2.2024
Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (PDF)V2.2024
Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (PDF)V2.2024
Concert Genetics Oncology: Algorithmic Testing (PDF)V2.2024
Concert Genetics Oncology: Cancer Screening (PDF)V2.2024
Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)V2.2024
Concert Genetics Oncology: Cytogenetic Testing (PDF)V2.2024
Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)V2.2024
Cosmetic and Reconstructive Procedures (PDF)CP.MP.31
Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder (PDF)CP.BH.201
Diaphragmatic/Phrenic Nerve Stimulation (PDF)CP.MP.203
Digital EEG Spike Analysis (PDF)CP.MP.105
Disc Decompression Procedures (PDF)CP.MP.114
Discography (PDF)CP.MP.115
Donor Lymphocyte Infusion (PDF)CP.MP.101
Drugs of Abuse: Definitive Testing (PDF)CP.MP.50
Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)CP.MP.107
EEG in the Evaluation of Headache (PDF)CP.MP.155
Electric Tumor Treating Fields (Optune) (PDF)CP.MP.145
Endometrial Ablation (PDF)CP.MP.106
Evoked Potential Testing (PDF)CP.MP.134
Experimental Technologies (PDF)CP.MP.36
Facet Joint Interventions (PDF)CP.MP.171
Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)CP.MP.248
Fecal Incontinence Treatments (PDF)CP.MP.137
Fertility Preservation (PDF)CP.MP.130
Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)CP.MP.129
Functional MRI (PDF)CP.MP.43
Gastric Electrical Stimulation (PDF)CP.MP.40
Gender-Affirming Procedures (PDF)CP.MP.95
Heart-Lung Transplant (PDF)CP.MP.132
Holter Monitors (PDF)CP.MP.113
Home Births (PDF)CP.MP.136
Home Ventilators (PDF)CP.MP.184
Homocysteine Testing (PDF)CP.MP.121
Hospice Services (PDF)CP.MP.54
Hyperhidrosis Treatments (PDF)CP.MP.62
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF)CP.MP.180
Implantable Intrathecal or Epidural Pain Pump (PDF)CP.MP.173
Implantable Loop Recorder (PDF)CP.MP.243
Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)CP.MP.160
Intensity-Modulated Radiotherapy (PDF)CP.MP.69
Intestinal and Multivisceral Transplant (PDF)CP.MP.58
Intradiscal Steroid Injections for Pain Management (PDF)CP.MP.167
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF)CP.MP.61
Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)CP.MP.250
Laser Therapy for Skin Conditions (PDF)CP.MP.123
Liposuction for Lipedema (PDF)CP.MP.244
Long Term Care Placement (PDF)CP.MP.71
Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF)CP.MP.139
Lung Transplantation (PDF)CP.MP.57
Lysis of Epidural Lesions (PDF)CP.MP.116
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)CP.MP.152
Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)CP.MP.144
Multiple Sleep Latency Testing (PDF)CP.MP.24
Neurofeedback for Behavioral Health Disorders (PDF)NV.CP.BH.300
Nerve Blocks and Neurolysis for Pain Management (PDF)CP.MP.170
Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (PDF)CP.MP.48
Nonmyeloablative Allogeneic Stem Cell Transplants (PDF)CP.MP.141
Obstetrical Home Care Programs (PDF)CP.MP.91
Omisirge (omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)CP.MP.249
Oncology Algorithmic Testing (PDF)CP.MP.237
Oncology Cancer Screening (PDF)CP.MP.238
Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (PDF)CP.MP.239
Oncology Cytogenetic Testing (PDF)CP.MP.240
Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)CP.MP.241
Orthognathic Surgery (PDF)CP.MP.202
Osteogenic Stimulation (PDF)CP.MP.194
Outpatient Cardiac Rehabilitation (PDF)CP.MP.176
Outpatient Oxygen Use (PDF)CP.MP.190
Pancreas Transplantation (PDF)CP.MP.102
Panniculectomy (PDF)CP.MP.109
Pediatric Heart Transplant (PDF)CP.MP.138
Pediatric Kidney Transplant (PDF)CP.MP.246
Pediatric Liver Transplant (PDF)CP.MP.120
Pediatric Oral Function Therapy (PDF)CP.MP.188
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)CP.MP.147
Physical, Occupational, and Speech Therapy Services (PDF)CP.MP.49
Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)CP.MP.133
Proton and Neutron Beam Therapies (PDF)CP.MP.70
Pulmonary Function Testing (PDF)CP.MP.242
Reduction Mammoplasty and Gynecomastia Surgery (PDF)CP.MP.51
Repair of Nasal Valve Compromise (PDF)CP.MP.210
Sacroiliac Joint Fusion (PDF)CP.MP.126
Sacroiliac Joint Interventions for Pain Management (PDF)CP.MP.166
Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (PDF)CP.MP.146
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF)CP.MP.174
Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (PDF)CP.MP.165
Short Inpatient Hospital Stay (PDF)CP.MP.182
Skin and Soft Tissue Substitutes for Chronic Wounds (PDF)CP.MP.185
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF)CP.MP.117
Stereotactic Body Radiation Therapy (PDF)CP.MP.22
Tandem Transplant (PDF)CP.MP.162
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)CP.MP.154
Total Artificial Heart (PDF)CP.MP.127
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)CP.MP.163
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF)CP.BH.200
Transplant Service Documentation Requirements (PDF)CP.MP.247
Trigger Point Injections for Pain Management (PDF)CP.MP.169
Ultrasound in Pregnancy (PDF)CP.MP.38
Urinary Incontinence Devices and Treatments (PDF)CP.MP.142
Urodynamic Testing (PDF)CP.MP.98
Vagus Nerve Stimulation (PDF)CP.MP.12
Ventricular Assist Devices (PDF)CP.MP.46
Wireless Motility Capsule (PDF)(CP.MP.143)CP.MP.143

 

 

 

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

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

Policy Name                                                      Effective Date
3-Day Payment Window (PDF)                       7/1/14
Add on Code Billed Without Primary Code (PDF) 1/1/13
Assistant Surgeon (PDF) 1/1/14
Attention Deficit Hyperactivity Disorder Assessment and Treatment (CP.BH.124) (PDF)5/30/24
Bilateral Procedures (PDF) 1/1/14
Cerumen Removal (PDF) 1/1/14
Coding Overview (PDF) 1/1/13                   
Concert Laboratory Payment Policy (CG.CC.PP.01) (PDF)     
  6/1/24
Cosmetic Procedures (PDF) 1/1/14
Distinct Procedural Modifiers (PDF) 1/1/13
Duplicate Primary Code Billing (PDF) 1/1/14
E&M Medical Decision-Making (PDF) 6/1/17
EM Bundling Edits (PDF) 1/1/13
Extended Ophthalmoscopy (CP.VP.26) (PDF)5/30/24
Fluorescein Angiography (CP.VP.28) (PDF)5/30/24
Fundus Photography (CP.VP.29) (PDF)5/30/24
Genetic and Molecular Testing (CG.PP.551) (PDF) 5/1/24
Global Maternity Billing (PDF) 1/1/13
Gonioscopy (CP.VP.31) (PDF)5/30/24
Hospital Visit Codes Billed with Labs (PDF) 1/1/18
Infectious Disease: Dermatologic Lab Testing (CG.CP.MP.03) (PDF) 6/1/24
Infectious Disease: Gastroenterologic Lab Testing (CG.CP.MP.04) (PDF) 6/1/24
Infectious Disease: Genitourinary Lab Testing (CG.CP.MP.07) (PDF) 6/1/24
Infectious Disease: Multisystem Lab Testing (CG.CP.MP.02) (PDF) 6/1/24
Infectious Disease: Primary Care & Preventive Lab Screening (CG.CP.MP.05) (PDF) 6/1/24
Infectious Disease: Respiratory Lab Testing (CG.CP.MP.01) (PDF) 6/1/24
Infectious Disease: Vector-borne and Tropical Diseases Lab Testing (CG.CP.MP.06) (PDF) 6/1/24
Inpatient Consultation (PDF) 1/1/14
Inpatient Only Procedures (PDF) 1/1/13
IV Hydration (PDF) 1/1/13
Leveling of ER Services (PDF) 1/1/17
Maximum Units (PDF) 1/1/13
Moderate Conscious Sedation (PDF)                                  1/1/13
Modifier -25 clinical validation (PDF) 1/1/13
Modifier -59 clinical validation (PDF) 1/1/14
Modifier DOS Validation (PDF) 1/1/13
Modifier to Procedure Code Validation (PDF) 1/1/13
Multiple CPT Code Replacement (PDF) 1/1/14
NCCI Unbundling (PDF) 1/1/13
Never Paid Events (PDF) 1/1/13
New Patient (PDF) 1/1/14
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) 6/1/18
Outpatient Consultation (PDF) 1/1/14
Optum Comprehensive Payment Integrity (PDF) 6/1/23
Place of Service Mismatch (PDF) 9/1/18
Physician Visit Codes Billed with Labs (PDF) 1/1/13
Physician's Consultation Services (PDF) 11/1/17
Physician's Office Lab Testing (PDF) 4/1/24
Post-Operative Visits (PDF) 1/1/14
Pre-Operative Visits (PDF) 1/1/14
Problem Oriented Visits with Preventative Visits (PDF) 1/1/18
Professional Component (PDF) 1/1/18
Pulse Oximetry (PDF) 1/1/14
Same Day Visits (PDF) 3/1/18
Scanning Computerized Ophthalmic Diagnostic Imaging (CP.VP.14) (PDF) 5/30/24
Skilled Nursing Facility Leveling (CC.PP.206) (PDF) 9/19/24
Sepsis Diagnosis (PDF)
 4/1/24
Severe Malnutrition (PDF)
 4/1/24
Status "B" Bundled Services (PDF) 1/1/14
Supplies Billed on Same Day As Surgery (PDF) 1/1/13
Transgender Related Services (PDF) 1/1/17
Unbundled Professional Services (PDF) 1/1/14
Unbundled Surgical Procedures (PDF) 1/1/14
Unlisted Procedure Codes (PDF) 1/1/14
Urine Specimen Validity Testing (PDF) 1/1/18
Visual Field Testing (CP.VP.63) (PDF)5/30/24
Wheelchair Seating (CP.MP.99) (PDF)5/30/24

Pharmacy Policies
Please see specific policy for effective and revision dates.

 

Policy TitlePolicy Number
Abaloparatide (Tymlos)(PDF)CP.PHAR.345
Abametapir (Xeglyze)(PDF)CP.PMN.253
Abatacept (Orencia)(PDF)CP.PHAR.241
Abemaciclib (Verzenio)(PDF)CP.PHAR.355
Abiraterone (Zytiga, Yonsa)(PDF)CP.PHAR.84
AbobotulinumtoxinA (Dysport)(PDF)CP.PHAR.230
Abrocitinib (Cibinqo) (PDF)CP.PHAR.578
Acalabrutinib (Calquence)(PDF)CP.PHAR.366
ACEI and ARB Duplicate Therapy (PDF)CP.PMN.61
Acitretin (Soriatane)(PDF)CP.PMN.40 
Acyclovir Buccal Tablet (Sitavig)(PDF)CP.PMN.210
Adagrasib (Krazati) (PDF)CP.PHAR.605
Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz), Adalimumab-aacf (Idacio), Adalimumab-aaty (Yuflyma), Adalimumab-aqvh(PDF)CP.PHAR.242
ADAMTS13, Recombinant-krhn (Adzynma)(PDF)CP.PHAR.635
Adefovir (Hepsera)(PDF)CP.PHAR.142
Ado-Trastuzumab Emtansine (Kadcyla)(PDF)CP.PHAR.229
Aducanumab-avwa (Aduhelm)(PDF)CP.PHAR.468
Afamelanotide (Scenesse)(PDF)CP.PHAR.444
Afatinib (Gilotrif)(PDF)CP.PHAR.298
Aflibercept (Eylea, Eylea HD)(PDF)CP.PHAR.184
Agalsidase Beta (Fabrazyme)(PDF)CP.PHAR.158  
Age Limit for Topical Tretinoin(PDF)CP.PMN.191
Age Limit Override (Codeine, Tramadol, Hydrocodone)(PDF)CP.PMN.138
Alectinib (Alecensa)(PDF)CP.PHAR.369
Alemtuzumab (Lemtrada)(PDF)CP.PHAR.243
Alendronate (Binosto, Fosamax Plus D)(PDF)CP.PMN.88
Alglucosidase Alfa (Lumizyme)(PDF)CP.PHAR.160
Alirocumab (Praluent)(PDF)CP.PHAR.124
Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft)(PDF)CP.PHAR.562
Allogenic Processed Thymus Tissue-agdc (Rethymic)(PDF)CP.PHAR.563
Alosetron (Lotronex)(PDF)CP.PMN.153
Alpelisib (Piqray, Vijoice)(PDF)CP.PHAR.430
Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF)CP.PHAR.94
Amantadine ER (Gocovri, Osmolex ER)(PDF)CP.PMN.89
Ambrisentan (Letairis)(PDF)CP.PHAR.190
Amifampridine (Firdapse)(PDF)CP.PHAR.411
Amikacin (Arikayce)(PDF)CP.PHAR.401
Amisulpride (Barhemsys)(PDF)CP.PMN.236
Amivantamab-vmjw (Rybrevant)(PDF)CP.PHAR.544
Amlodipine/Atorvastatin (Caduet)(PDF)CP.PMN.176
Anakinra (Kineret)(PDF)CP.PHAR.244
Anifrolumab-fnia (Saphnelo)(PDF)CP.PHAR.551
Anti-Inhibitor Coagulant Complex, Human (Feiba)(PDF)CP.PHAR.217
Antithrombin III (ATryn, Thrombate III)(PDF)CP.PHAR.564
Antithymocyte Globulin (Atgam, Thymoglobulin)(PDF)CP.PHAR.506
Apalutamide (Erleada)(PDF)CP.PHAR.376
Apomorphine (Apokyn, Kynmobi)(PDF)CP.PHAR.488
Apremilast (Otezla)(PDF)CP.PHAR.245
Aprepitant (Aponvie, Emend, Cinvanti), Fosaprepitant (Emend for injection, Focinvez)(PDF)CP.PMN.19
Aprocitentan (Tryvio)(PDF)CP.PHAR.676
Aripiprazole Long-Acting Injections (Abilify Maintena, Abilify Asimtufii, Aristada, Aristada Initio)(PDF)CP.PHAR.290 
Armodafinil (Nuvigil)(PDF)CP.PMN.35
Asciminib (Scemblix)(PDF)CP.PHAR.565
Asenapine (Saphris, Secuado)(PDF)CP.PMN.15
Asfotase Alfa (Strensiq)(PDF)CP.PHAR.328
Aspirin/Dipyridamole (Aggrenox)(PDF)CP.PMN.20
Atezolizumab (Tecentriq)(PDF)CP.PHAR.235
Atogepant (Qulipta) (PDF)CP.PHAR.566
Avacincaptad Pegol (Izervay)(PDF)CP.PHAR.641
Avacopan (Tavneos)(PDF)CP.PHAR.515
Avalglucosidase Alfa-ngpt (Nexviazyme)(PDF)CP.PHAR.521
Avapritinib (Ayvakit) (PDF)CP.PHAR.454
Avatrombopag (Doptelet)(PDF)CP.PHAR.130
Avelumab (Bavencio)(PDF)CP.PHAR.333
Axicabtagene Ciloleucel (Yescarta)(PDF)CP.PHAR.362
Axitinib (Inlyta)(PDF)CP.PHAR.100
Azacitidine (Onureg, Vidaza)(PDF)CP.PHAR.387
Aztreonam (Cayston)(PDF)CP.PHAR.209
Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax)(PDF)CP.PHAR.149
Baloxavir Marboxil (Xofluza)(PDF)CP.PMN.185
Baricitinib (Olumiant)(PDF)CP.PHAR.135
Bedaquiline (Sirturo)(PDF)CP.PMN.212
Belantamab Mafodotin-blmf (Blenrep)(PDF)CP.PHAR.469
Belatacept (Nulojix)(PDF)CP.PHAR.201
Belimumab (Benlysta)(PDF)CP.PHAR.88
Belinostat (Beleodaq)(PDF)CP.PHAR.311
Belumosudil (Rezurock)(PDF)CP.PHAR.552
Belzutifan (Welireg)(PDF)CP.PHAR.553
Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet)(PDF)CP.PMN.237
Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta)(PDF)CP.PHAR.307
Benralizumab (Fasenra)(PDF)CP.PHAR.373
Benznidazole(PDF)CP.PMN.90
Benzyl Alcohol (Ulesfia)(PDF)CP.PMN.202
Berdazimer (Zelsuvmi)(PDF)CP.PMN.293
Beremagene geperpavec-svdt (Vyjuvek)(PDF)CP.PHAR.592
Berotralstat (Orladeyo)(PDF)CP.PHAR.485
Betaine (Cystadane)(PDF)CP.PHAR.143
Betamethasone Dipropionate Spray (Sernivo)(PDF)CP.PMN.182
Betibeglogene Autotemcel (Zynteglo)(PDF)CP.PHAR.545
Bevacizumab (Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev)(PDF)CP.PHAR.93
Bexarotene (Targretin Capsules, Gel) (PDF)CP.PHAR.75
Bezlotoxumab (Zinplava)(PDF)CP.PHAR.300
Bimatoprost Implant (Durysta)(PDF)CP.PHAR.486
Bimekizumab-bkzx (Bimzelx) (PDF)CP.PHAR.660
Binimetinib (Mektovi) (PDF)CP.PHAR.50
Birch Triterpenes (Filsuvez)(PDF)CP.PHAR.669
Blinatumomab (Blincyto)(PDF)CP.PHAR.312
Blood Glucose Test Strip Quantity Limit - Not Receiving Insulin(PDF)CP.PMN.151
Bortezomib (Velcade)(PDF)CP.PHAR.410
Bosentan (Tracleer)(PDF)CP.PHAR.191
Bosutinib (Bosulif)(PDF)CP.PHAR.105
Brand Name Override (PDF)CP.PMN.22
Brentuximab Vedotin (Adcetris)(PDF)CP.PHAR.303
Brexanolone (Zulresso)(PDF)CP.PHAR.417 
Brexpiprazole (Rexulti)(PDF)CP.PMN.68
Brexucabtagene Autoleucel (Tecartus)(PDF)CP.PHAR.472
Brigatinib (Alunbrig)(PDF)CP.PHAR.342
Brimonidine Tartrate (Mirvaso)(PDF)CP.PMN.192
Brodalumab (Siliq)(PDF)CP.PHAR.375
Brolucizumab-dbll (Beovu)(PDF)CP.PHAR.445 
Budesonide (Eohilia, Uceris)(PDF)CP.PMN.294
Budesonide (Tarpeyo)(PDF)CP.PHAR.572
Buprenorphine (Subutex)(PDF)CP.PMN.82
Buprenorphine Injection (Sublocade, Brixadi)(PDF)CP.PHAR.289
Buprenorphine/Naloxone (Suboxone, Zubsolv)(PDF)CP.PMN.81
Burosumab-twza (Crysvita)(PDF)CP.PHAR.11
C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest)(PDF)CP.PHAR.202
Cabazitaxel (Jevtana)(PDF)CP.PHAR.316
Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva)(PDF)CP.PHAR.573
Cabozantinib (Cabometyx, Cometriq)(PDF)CP.PHAR.111
Calcifediol (Rayaldee)(PDF)CP.PMN.76 
Calcipotriene/Betamethasone Dipropionate Foam (Enstilar)(PDF)CP.PMN.181
Canakinumab (Ilaris)(PDF)CP.PHAR.246
Cannabidiol (Epidiolex)(PDF)CP.PMN.164
Capecitabine (Xeloda)(PDF)CP.PHAR.60
Capivasertib (Truqap) (PDF)CP.PHAR.663
Caplacizumab-yhdp (Cablivi)(PDF)CP.PHAR.416
Capmatinib (Tabrecta)(PDF)CP.PHAR.494
Carbamazepine ER (Equetro)(PDF)CP.PMN.137
Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy)(PDF)CP.PMN.238
Carfilzomib (Kyprolis)(PDF)CP.PHAR.309
Carglumic Acid (Carbaglu)(PDF)CP.PHAR.206
Cariprazine (Vraylar)(PDF)CP.PMN.91
Casimersen (Amondys 45)(PDF)CP.PHAR.470
Celecoxib (Celebrex, Elyxyb)(PDF)CP.PMN.122
Cemiplimab-rwlc (Libtayo) (PDF)CP.PHAR.397
Cenegermin-bkbj (Oxervate)(PDF)CP.PMN.186
Cenobamate (Xcopri)(PDF)CP.PMN.231
Ceritinib (Zykadia)(PDF)CP.PHAR.349
Cerliponase Alfa (Brineura)(PDF)CP.PHAR.338
Certolizumab (Cimzia)(PDF)CP.PHAR.247
Cetuximab (Erbitux)(PDF)CP.PHAR.317
Chenodiol (Chenodal)(PDF)CP.PMN.239
Cholic Acid (Cholbam)(PDF)CP.PHAR.390
Chlorambucil (Leukeran)(PDF)CP.PHAR.554
Chloramphenicol Sodium Succinate(PDF)CP.PHAR.388
Ciclopirox Topical Solution 8%(PDF)CP.PMN.24
Ciltacabtagene Autoleucel (Carvykti)(PDF)CP.PHAR.533
Cinacalcet (Sensipar)(PDF)CP.PHAR.61
Cipaglucosidase Alfa-atga + Miglustat (Pombiliti + Opfolda)(PDF)CP.PHAR.567
Ciprofloxacin/Dexamethasone (Ciprodex)(PDF)CP.PMN.248
Ciprofloxacin/Fluocinolone (Otovel)(PDF)CP.PMN.249
Cladribine (Mavenclad)(PDF)CP.PHAR.422
Clascoterone (Winlevi) (PDF)CP.PMN.257
Clinical Policy: Laronidase (Aldurazyme)(PDF)CP.PHAR.152
Clobazam (Onfi, Sympazan)(PDF)CP.PMN.54
Clomipramine (Anafranil)(PDF)CP.PMN.197
Clozapine Orally Disintegrating Tablet (PDF)CP.PMN.12
CNS Stimulants(PDF)CP.PMN.92
Cobimetinib (Cotellic)(PDF)CP.PHAR.380
Colchicine (Colcrys, Lodoco)(PDF)CP.PMN.123
Colesevelam (Welchol)(PDF)CP.PMN.250
Collagenase Clostridium Histolyticum (Xiaflex) (PDF)CP.PHAR.82
Compounded Medications(PDF)CP.PMN.280
Conjugated Estrogens/Bazedoxifene (Duavee)(PDF)CP.PMN.258
Continuous Glucose Monitors(PDF)CP.PMN.214
Copanlisib (Aliqopa)(PDF)CP.PHAR.357
Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq)(PDF)CP.PHAR.385
Cosyntropin (Cortrosyn)(PDF)CP.PHAR.203
Crisaborole (Eucrisa)(PDF)CP.PMN.110
Crizanlizumab-tmca (Adakveo)(PDF)CP.PHAR.449
Crizotinib (Xalkori) (PDF)CP.PHAR.90
Cyclosporine (Cequa, Restasis, Verkazia, Vevye)(PDF)CP.PMN.48
Cysteamine Ophthalmic (Cystaran, Cystadrops)(PDF)CP.PMN.130
Cysteamine oral (Cystagon, Procysbi)(PDF)CP.PHAR.155   
Cytomegalovirus Immune Globulin (CytoGam)(PDF)CP.PHAR.277
  
  



Policy TitlePolicy Number
Dabigatran (Pradaxa)(PDF)CP.PMN.49
Dabrafenib (Tafinlar)(PDF)CP.PHAR.239
Dacomitinib (Vizimpro)(PDF)CP.PHAR.399
Dalfampridine (Ampyra)(PDF)CP.PHAR.248
Dalteparin (Fragmin)(PDF)CP.PHAR.225
Daprodustat (Jesduvroq)(PDF)CP.PHAR.628
Daptomycin (Cubicin, Cubicin RF, Dapzura RT)(PDF)CP.PHAR.351
Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro)(PDF)CP.PHAR.310
Darbepoetin Alfa (Aranesp)(PDF)CP.PHAR.236
Darolutamide (Nubeqa)(PDF)CP.PHAR.435
Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak)(PDF)CP.PHAR.278
Dasatinib (Sprycel, Phyrago)(PDF)CP.PHAR.72
Daunorubicin/Cytarabine (Vyxeos)(PDF)CP.PHAR.352
DaxibotulinumtoxinA-lanm (Daxxify)(PDF)CP.PHAR.651
Decitabine/Cedazuridine (Inqovi)(PDF)CP.PHAR.479
Deferasirox (Exjade, Jadenu)(PDF)CP.PHAR.145
Deferiprone (Ferriprox)(PDF)CP.PHAR.147
Deferoxamine (Desferal)(PDF)CP.PHAR.146
Deflazacort (Emflaza)(PDF)CP.PHAR.331
Degarelix Acetate (Firmagon)(PDF)CP.PHAR.170
Delafloxacin (Baxdela)(PDF)CP.PMN.115
Delandistrogene Moxeparvovec-rokl (Elevidys)(PDF)CP.PHAR.593
Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost)(PDF)CP.PHAR.58
Desmopressin Acetate (DDAVP, Stimate, Nocdurna)(PDF)CP.PHAR.214
Deucravacitinib (Sotyktu)(PDF)CP.PHAR.607
Deutetrabenazine (Austedo, Austedo XR)(PDF)CP.PHAR.341
Dexrazoxane (Totect)(PDF)CP.PHAR.418
Dextromethorphan/Bupropion (Auvelity)(PDF)CP.PMN.284
Dextromethorphan-Quinidine (Nuedexta)(PDF)CP.PMN.93
Diazepam (Libervant, Valtoco)(PDF)CP.PMN.216
Dichlorphenamide (Keveyis)(PDF)CP.PMN.261
Diclofenac (Pennsaid)(PDF)CP.PMN.274
Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam)(PDF)CP.PHAR.249
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors(PDF)CP.PMN.03
Dolasetron (Anzemet)(PDF)CP.PMN.141
Dornase Alfa (Pulmozyme)(PDF)CP.PHAR.212
Dostarlimab-gxly (Jemperli)(PDF)CP.PHAR.540
Doxepin (Silenor)(PDF)CP.PMN.175
Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea)(PDF)CP.PMN.79
Dronabinol (Marinol, Syndros)(PDF)CP.PMN.159
Droxidopa (Northera)(PDF)CP.PMN.17
Dupilumab (Dupixent)(PDF)CP.PHAR.336
Durvalumab (Imfinzi)(PDF)CP.PHAR.339
Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn)(PDF)CP.PMN.128
Duvelisib (Copiktra)(PDF)CP.PHAR.400
Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members(PDF)CP.PMN.234
Ecallantide (Kalbitor)(PDF)CP.PHAR.177
Eculizumab (Soliris)(PDF)CP.PHAR.97
Edaravone (Radicava, Radivaca ORS)(PDF)CP.PHAR.343
Edoxaban (Savaysa)(PDF)CP.PMN.227
Efgartigimod Alfa-fcab, Efgartigimod/Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo)(PDF)CP.PHAR.555
Efinaconazole (Jublia)(PDF)CP.PMN.25
Eflornithine (Iwilfin)(PDF)CP.PHAR.670
Elacestrant (Orserdu) (PDF)CP.PHAR.623 
Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn)(PDF)CP.PHAR.136
Elapegademase-lvlr (Revcovi)(PDF)CP.PHAR.419
Elbasvir/Grazoprevir (Zepatier)(PDF)CP.PHAR.275
Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta)(PDF)CP.PHAR.440
Eliglustat (Cerdelga)(PDF)CP.PHAR.153
Elivaldogene Autotemcel (Skysona)(PDF)CP.PHAR.556
Elosulfase Alfa (Vimizim)(PDF)CP.PHAR.162
Elotuzumab (Empliciti)(PDF)CP.PHAR.308
Elranatamab-bcmm (Elrexfio)(PDF)CP.PHAR.652
Eltrombopag (Alvaiz, Promacta)(PDF)CP.PHAR.180
Eluxadoline (Viberzi)(PDF)CP.PMN.170
Emicizumab-kxwh (Hemlibra)(PDF)CP.PHAR.370
Emapalumab-lzsg (Gamifant)(PDF)CP.PHAR.402
Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF)CP.PMN.235
Enasidenib (Idhifa)(PDF)CP.PHAR.363
Encorafenib (Braftovi)(PDF)CP.PHAR.127
Enfortumab Vedotin-ejfv (Padcev)(PDF)CP.PHAR.455
Enfuvirtide (Fuzeon)(PDF)CP.PHAR.41
Enoxaparin (Lovenox)(PDF)CP.PHAR.224
Entrectinib (Rozlytrek)(PDF)CP.PHAR.441
Enzalutamide (Xtandi)(PDF)CP.PHAR.106
Epcoritamab-bysp (Epkinly)(PDF)CP.PHAR.634
Epinephrine (Auvi-Q, EpiPen, EpiPen Jr) Quantity Limit Override(PDF)CP.PMN.144
Eplontersen (Wainua)(PDF)CP.PHAR.633
Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit)(PDF)CP.PHAR.237
Epoprostenol (Flolan, Veletri)(PDF)CP.PHAR.192
Eptinezumab-jjmr (Vyepti)(PDF)CP.PHAR.489
Erdafitinib (Balversa)(PDF)CP.PHAR.423
Erenumab-aooe (Aimovig)(PDF)CP.PHAR.128
Eribulin Mesylate (Halaven)(PDF)CP.PHAR.318
Erlotinib (Tarceva)(PDF)CP.PHAR.74
Erwinia Asparaginase (Rylaze)(PDF)CP.PHAR.301
Esketamine (Spravato)(PDF)CP.PMN.199
Estradiol Vaginal Ring (Femring)(PDF)CP.PMN.263
Etanercept (Enbrel)(PDF)CP.PHAR.250
Etelcalcetide (Parsabiv) (PDF)CP.PHAR.379
Eteplirsen (Exondys 51)(PDF)CP.PHAR.288
Etranacogene Dezaparvovec-drlb (Hemgenix)(PDF)CP.PHAR.580
Etrasimod (Velsipity)(PDF)CP.PHAR.661
Everolimus (Afinitor, Afinitor Disperz, Zortress)(PDF)CP.PHAR.63
Evinacumab-dgnb (Evkeeza)(PDF)CP.PHAR.511
Evolocumab (Repatha)(PDF)CP.PHAR.123
Exagamglogene Autotemcel (Casgevy) (PDF)CP.PHAR.603
Factor IX (Human, Recombinant)(PDF)CP.PHAR.218
Factor IX Complex, Human (Profilnine)(PDF)CP.PHAR.219
Factor VIIa, Recombinant (NovoSeven RT, SevenFact)(PDF)CP.PHAR.220
Factor VIII (Human, Recombinant)(PDF)CP.PHAR.215 
Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi)(PDF)CP.PHAR.216
Factor XIII A-Subunit, Recombinant (Tretten)(PDF)CP.PHAR.222
Factor XIII, Human (Corifact)(PDF)CP.PHAR.221
Fam-Trastuzumab Deruxtecan-nxki (Enhertu)(PDF)CP.PHAR.456
Faricimab-svoa (Vabysmo) (PDF)CP.PHAR.581
Febuxostat (Uloric)(PDF)CP.PMN.57
Fecal Microbiota Spores, Live-brpk (Vowst)(PDF)CP.PHAR.632
Fecal Microbiota, Live-jslm (Rebyota)(PDF)CP.PHAR.613
Fedratinib (Inrebic)(PDF)CP.PHAR.442
Fenfluramine (Fintepla)(PDF)CP.PMN.246
Fentanyl IR (Actiq, Fentora, Lazanda, Subsys)(PDF)CP.PMN.127
Ferric Carboxymaltose (Injectafer)(PDF)CP.PHAR.234
Ferric Derisomaltose (Monoferric)(PDF)CP.PHAR.480
Ferric Maltol (Accrufer)(PDF)CP.PMN.213
Ferric Pyrophosphate (Triferic, Triferic Avnu)(PDF)CP.PHAR.624
Ferumoxytol (Feraheme)(PDF)CP.PHAR.165
Fezolinetant (Veozah)(PDF)CP.PMN.289
Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP)(PDF)CP.PHAR.526
Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko)(PDF)CP.PHAR.297
Finerenone (Kerendia)(PDF)CP.PMN.266
Fingolimod (Gilenya, Tascenso ODT)(PDF)CP.PHAR.251
Fluorouracil Cream (Tolak)(PDF)CP.PMN.165
Fluticasone Propionate (Xhance)(PDF)CP.PMN.95
Fondaparinux (Arixtra)(PDF)CP.PHAR.226
Fosdenopterin (Nulibry)(PDF)CP.PHAR.471
Fostamatinib (Tavalisse)(PDF)CP.PHAR.24
Fostemsavir (Rukobia)(PDF)CP.PHAR.516
Fremanezumab-vfrm (Ajovy)(PDF)CP.PHAR.403
Fruquintinib (Fruzaqla)(PDF)CP.PHAR.666
Fulvestrant (Faslodex Injection)(PDF)CP.PHAR.424
Furosemide (Furoscix)(PDF)CP.PHAR.608
Futibatinib (Lytgobi)(PDF)CP.PHAR.604



Policy TitlePolicy Number
Gabapentin ER (Gralise, Horizant)(PDF)CP.PMN.240
Galcanezumab-gnlm (Emgality)(PDF)CP.PHAR.404
Galsulfase (Naglazyme)(PDF)CP.PHAR.161  
Ganaxolone (Ztalmy)(PDF)CP.PMN.278
Gefitinib (Iressa)(PDF)CP.PHAR.68
Gemtuzumab Ozogamicin (Mylotarg)(PDF)CP.PHAR.358
Gepirone (Exxua)(PDF)CP.PMN.292
Gilteritinib (Xospata)(PDF)CP.PHAR.412
Givosiran (Givlaari)(PDF)CP.PHAR.457
Glasdegib (Daurismo)(PDF)CP.PHAR.413
Glatiramer Acetate (Copaxone, Glatopa)(PDF)CP.PHAR.252
Glaucoma Agents(PDF)CP.PMN.286
Glecaprevir/Pibrentasvir (Mavyret)(PDF)CP.PHAR.348
Glofitamab-gxbm (Columvi)(PDF)CP.PHAR.636
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists(PDF)CP.PMN.183
Glycerol Phenylbutyrate (Ravicti)(PDF)CP.PHAR.207
Glycopyrronium (Qbrexza)(PDF)CP.PMN.177
Golimumab (Simponi, Simponi Aria)(PDF)CP.PHAR.253
Golodirsen (Vyondys 53)(PDF)CP.PHAR.453
Goserelin Acetate (Zoladex)(PDF)CP.PHAR.171
Granisetron (Sancuso, Sustol)(PDF)CP.PMN.74
Guselkumab (Tremfya)(PDF)CP.PHAR.364
Halobetasol Propionate (Bryhali, Lexette, Ultravate)(PDF)CP.PMN.180
Halobetasol Propionate/Tazarotene (Duobrii)(PDF)CP.PMN.208
Hemin (Panhematin)(PDF)CP.PHAR.181
Histrelin Acetate (Vantas, Supprelin LA)(PDF)CP.PHAR.172
House Dust Mite Allergen Extract (Odactra)(PDF)CP.PMN.111 
Human Growth Hormone (Somapacitan, Somatrogon, Somatropin)(PDF)CP.PHAR.517
Hyaluronate Derivatives(PDF)CP.PHAR.05
Hydroxyurea (Siklos)(PDF)CP.PMN.193
Ibalizumab-uiyk (Trogarzo)(PDF)CP.PHAR.378
Ibandronate Injection (Boniva)(PDF)CP.PHAR.189
Ibandronate Oral (Boniva)(PDF)CP.PMN.96
Ibrutinib (Imbruvica)(PDF)CP.PHAR.126
Ibuprofen/Famotidine (Duexis)(PDF)CP.PMN.120
Icatibant (Firazyr)(PDF)CP.PHAR.178
Icosapent Ethyl (Vascepa)(PDF)CP.PMN.187
Idecabtagene Vicleucel (Abecma)(PDF)CP.PHAR.481
Idelalisib (Zydelig)(PDF)CP.PHAR.133
Idursulfase (Elaprase)(PDF)CP.PHAR.156 
Iloperidone (Fanapt)(PDF)CP.PMN.32
Iloprost (Ventavis)(PDF)CP.PHAR.193
Imatinib (Gleevec)(PDF)CP.PHAR.65
Imiglucerase (Cerezyme)(PDF)CP.PHAR.154 
Immune Globulins(PDF)CP.PHAR.103
Immunization Coverage(PDF)CP.PHAR.28
Inclisiran (Leqvio)(PDF)CP.PHAR.568
IncobotulinumtoxinA (Xeomin)(PDF)CP.PHAR.231
Inebilizumab-cdon (Uplizna)(PDF)CP.PHAR.458
Infertility and Fertility Preservation(PDF)CP.PHAR.131
Infigratinib (Truseltiq) (PDF)CP.PHAR.547
Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra, Zymfentra), and Infliximab-abda (Renflexis)(PDF)CP.PHAR.254
Inhaled Agents for Asthma and COPD(PDF)CP.PMN.259
Inotersen (Tegsedi)(PDF)CP.PHAR.405
Inotuzumab Ozogamicin (Besponsa)(PDF)CP.PHAR.359
Insulin degludec (Tresiba) (PDF)CP.PMN.285
Insulin Delivery Systems (V-Go, Omnipod, InPen)(PDF)CP.PHAR.534
Interferon Beta-1a (Avonex, Rebif)(PDF)CP.PHAR.255
Interferon Beta-1b (Betaseron, Extavia)(PDF)CP.PHAR.256
Interferon Gamma- 1b (Actimmune)(PDF)CP.PHAR.52
Iobenguane I-131 (Azedra)(PDF)CP.PHAR.459
Ipilimumab (Yervoy)(PDF)CP.PHAR.319
Iptacopan (Fabhalta)(PDF)CP.PHAR.656
Irinotecan Liposome (Onivyde)(PDF)CP.PHAR.304
Isatuximab-irfc (Sarclisa) (PDF)CP.PHAR.482
Isavuconazonium (Cresemba)(PDF)CP.PMN.154
Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane)(PDF)CP.PMN.143
Istradefylline (Nourianz)(PDF)CP.PMN.217
Itraconazole (Sporanox, Tolsura)(PDF)CP.PMN.124
Ivabradine (Corlanor)(PDF)CP.PMN.70
Ivacaftor (Kalydeco)(PDF)CP.PHAR.210
Ivermectin (Stromectol, Sklice)(PDF)CP.PMN.269
Ivosidenib (Tibsovo)(PDF)CP.PHAR.137
Ixazomib (Ninlaro)(PDF)CP.PHAR.302
Ixekizumab (Taltz)(PDF)CP.PHAR.257

 

Policy TitlePolicy Number
Ketorolac Nasal Spray (Sprix)(PDF)CP.PMN.282
Lacosamide (Motpoly XR, Vimpat)(PDF)CP.PMN.155
Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi)(PDF)CP.PMN.251
Lanadelumab-fylo (Takhzyro)(PDF)CP.PHAR.396
Lanreotide (Somatuline Depot and Unbranded)(PDF)CP.PHAR.391
Lapatinib (Tykerb)(PDF)CP.PHAR.79
Larotrectinib (Vitrakvi)(PDF)CP.PHAR.414
Lasmiditan (Reyvow)(PDF)CP.PMN.218
Lecanemab-irmb (Leqembi)(PDF)CP.PHAR.596
Ledipasvir/Sofosbuvir (Harvoni)(PDF)CP.PHAR.279
Lefamulin (Xenleta)(PDF)CP.PMN.219
Lenacapavir (Sunlenca)(PDF) CP.PHAR.622
Lenalidomide (Revlimid)(PDF)CP.PHAR.71
Leniolisib (Joenja) (PDF)CP.PHAR.597
Lenvatinib (Lenvima)(PDF)CP.PHAR.138
Letermovir (Prevymis)(PDF)CP.PHAR.367
Leucovorin Injection(PDF)CP.PHAR.393
Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi)(PDF)CP.PHAR.173
Levodopa Inhalation Powder (Inbrija)(PDF)CP.PMN.267
Levoketoconazole (Recorlev)(PDF)CP.PMN.275
Levoleucovorin (Fusilev, Khapzory)(PDF)CP.PHAR.151
L-glutamine (Endari)(PDF)CP.PMN.116
Lidocaine Transdermal (Lidoderm, ZTlido)(PDF)CP.PMN.08
Lifileucel (Amtagvi)(PDF)CP.PHAR.598
Lifitegrast (Xiidra)(PDF)CP.PMN.73
Linaclotide (Linzess)(PDF)CP.PMN.71
Lindane Shampoo(PDF)CP.PMN.09 
Linezolid (Zyvox)(PDF)CP.PMN.27
Lisdexamfetamine (Vyvanse)(PDF)CP.PMN.121
Lisocabtagene Maraleucel (Breyanzi)(PDF)CP.PHAR.483
Lofexidine (Lucemyra)(PDF)CP.PMN.152
Lomitapide (Juxtapid)(PDF)CP.PHAR.283
Lomustine (Gleostine)(PDF)CP.PHAR.507
Lonafarnib (Zokinvy)(PDF)CP.PHAR.499
Loncastuximab Tesirine-lpyl (Zynlonta)(PDF)CP.PHAR.539
Long-term Antibiotic Treatment for Tick-borne Diseases(PDF)CP.PMN.279
Lorlatinib (Lorbrena)(PDF)CP.PHAR.406
Loteprednol etabonate (Eysuvis)(PDF)CP.PMN.260
Lotilaner (Xdemvy)(PDF)CP.PMN.291
Lovotibeglogene Autotemcel (Lyfgenia)(PDF)CP.PHAR.627
Lubiprostone (Amitiza)(PDF)CP.PMN.142
Luliconazole Cream (Luzu)(PDF)CP.PMN.166
Lumacaftor/Ivacaftor (Orkambi)(PDF)CP.PHAR.213
Lumasiran (Oxlumo)(PDF)CP.PHAR.473
Lumateperone (Caplyta)(PDF)CP.PMN.232
Lurbinectedin (Zepzelca)(PDF)CP.PHAR.500
Luspatercept-aamt (Reblozyl)(PDF)CP.PHAR.450
Lusutrombopag (Mulpleta)(PDF)CP.PHAR.407
Lutetium Lu 177 Dotatate (Lutathera)(PDF)CP.PHAR.384
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) (PDF)CP.PHAR.582

 

Policy TitlePolicy Number
Macitentan (Opsumit)(PDF)CP.PHAR.194
Mannitol (Bronchitol)(PDF)CP.PHAR.518
Maralixibat (Livmarli)(PDF)CP.PHAR.543
Margetuximab-cmkb (Margenza)(PDF)CP.PHAR.522
Maribavir (Livtencity)(PDF)CP.PMN.271
Mavacamten (Camzyos)(PDF)CP.PMN.272
Mecamylamine (Vecamyl)(PDF)CP.PMN.136
Mecasermin (Increlex)(PDF)CP.PHAR.150
Mechlorethamine Gel (Valchlor)(PDF)CP.PHAR.381
Megestrol Acetate (Megace ES)(PDF)CP.PMN.179
Melphalan (Hepzato)(PDF)CP.PHAR.653
Melphalan Flufenamide (Pepaxto)(PDF)CP.PHAR.535
Mepolizumab (Nucala)(PDF)CP.PHAR.200
Mercaptopurine (Purixan)(PDF)CP.PHAR.447
Metformin ER (Fortamet, Glumetza)(PDF)CP.PMN.72
Methadone Hydrochloride(PDF)CP.PMN.161
Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex, Jylamvo(PDF)CP.PHAR.134
Methoxy Polyethylene Glycol-Epoetin Beta (Mircera)(PDF)CP.PHAR.238
Methylnaltrexone Bromide (Relistor)(PDF)CP.PMN.169
Metoclopramide (Gimoti)(PDF)CP.PMN.252
Metreleptin (Myalept)(PDF)CP.PHAR.425
Midazolam (Nayzilam)(PDF)CP.PMN.211
Midostaurin (Rydapt)(PDF)CP.PHAR.344
Mifepristone (Korlym)(PDF)CP.PHAR.101
Migalastat (Galafold)(PDF)CP.PHAR.394
Miglustat (Zavesca)(PDF)CP.PHAR.164 
Milnacipran (Savella)(PDF)CP.PMN.125
Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi)(PDF)CP.PMN.80
Minocycline Micronized Foam (Amzeeq)(PDF)CP.PMN.242
Mirikizumab-mrkz (Omvoh) (PDF)CP.PHAR.662 
Mirvetuximab soravatansine-gynx (Elahere)(PDF)CP.PHAR.617
Mitapivat (Pyrukynd)(PDF)CP.PHAR.558
Mitomycin for Pyelocalyceal Solution (Jelmyto)(PDF)CP.PHAR.495
Mitoxantrone(PDF)CP.PHAR.258
Mobocertinib (Exkivity)(PDF)CP.PHAR.559
Modafinil (Provigil)(PDF)CP.PMN.39
Mogamulizumab-kpkc (Poteligeo)(PDF)CP.PHAR.139
Momelotinib (Ojjaara) (PDF)CP.PHAR.654
Mometasone Furoate (Sinuva)(PDF)CP.PHAR.448
Mosunetuzumab-axgb (Lunsumio)(PDF)CP.PHAR.618
Motixafortide (Aphexda)(PDF)CP.PHAR.655
Moxetumomab pasudotox-tdfk (Lumoxiti)(PDF)CP.PHAR.398
Nabumetone Double-Strength (Relafen DS)(PDF)CP.PMN.287
Nadofaragene Firadenovec-vncg (Adstiladrin)(PDF)CP.PHAR.461
Nafarelin Acetate (Synarel)(PDF)CP.PHAR.174
Naldemedine (Symproic)(PDF)CP.PMN.112
Nalmefene (Opvee)(PDF)CP.PHAR.638
Naloxegol (Movantik)(PDF)CP.PMN.171
Naltrexone (Vivitrol)(PDF)CP.PHAR.96
Naproxen/Esomeprazole (Vimovo)(PDF)CP.PMN.117
Natalizumab (Tysabri), Natalizumab-sztn (Tyruko)(PDF)CP.PHAR.259
Naxitamab-gqgk (Danyelza)(PDF)CP.PHAR.523
Necitumumab (Portrazza)(PDF)CP.PHAR.320
Nedosiran (Rivfloza)(PDF)CP.PHAR.619
Neomycin/Fluocinolone Cream (Neo-Synalar)(PDF)CP.PMN.167
Neratinib (Nerlynx)(PDF)CP.PHAR.365
Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV)(PDF)CP.PMN.158
Nifurtimox (Lampit)(PDF)CP.PMN.256
Nilotinib (Tasigna)(PDF)CP.PHAR.76
Nintedanib (Ofev)(PDF)CP.PHAR.285
Niraparib (Zejula)(PDF)CP.PHAR.408
Niraparib and Abiraterone Acetate (Akeega)(PDF)CP.PHAR.645
Nirmatrelvir and Ritonavir (Paxlovid)(PDF)CP.PMN.288
Nirogacestat (Ogsiveo)(PDF)CP.PHAR.671
Nirsevimab-alip (Beyfortus)(PDF)CP.PHAR.614
Nitisinone (Nityr, Orfadin)(PDF)CP.PHAR.132
Nivolumab (Opdivo)(PDF)CP.PHAR.121  
Nivolumab and Relatlimab-rmbw (Opdualag)(PDF)CP.PHAR.588
No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update(PDF)CP.PMN.255
Non-Calcium Phosphate Binders(PDF)CP.PMN.04
Non-Preferred Blood Glucose Monitors/Test Strips(PDF)CP.PMN.215
Nusinersen (Spinraza)(PDF)CP.PHAR.327
Obeticholic Acid (Ocaliva)(PDF)CP.PHAR.287
Obinutuzumab (Gazyva)(PDF)CP.PHAR.305
Ocrelizumab (Ocrevus)(PDF)CP.PHAR.335
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot,  Mycapssa)(PDF)CP.PHAR.40
Odevixibat (Bylvay)(PDF)CP.PHAR.528
Ofatumumab (Arzerra, Kesimpta)(PDF)CP.PHAR.306
Off-Label Use (PDF)CP.PMN.53
Olanzapine Long-Acting Injection (Zyprexa Relprevv)(PDF)CP.PHAR.292
Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis)(PDF)CP.PMN.29
Olanzapine/Samidorphan (Lybalvi)(PDF)CP.PMN.265
Olaparib (Lynparza)(PDF)CP.PHAR.360
Olipudase Alfa-rpcp (Xenpozyme)(PDF)CP.PHAR.586
Olutasidenib (Rezlidhia)(PDF)CP.PHAR.615
Omacetaxine (Synribo)(PDF)CP.PHAR.108
Omadacycline (Nuzyra)(PDF)CP.PMN.188
Omalizumab (Xolair)(PDF)CP.PHAR.01
Omaveloxolone (Skyclarys)(PDF)CP.PHAR.590
Omega-3-Acid Ethyl Esters (Lovaza)(PDF)CP.PMN.52
OnabotulinumtoxinA (Botox)(PDF)CP.PHAR.232
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous)(PDF)CP.PHAR.536
Opicapone (Ongentys)(PDF)CP.PMN.245
Opioid Analgesics*(PDF)CP.PMN.97
Osilodrostat (Isturisa)(PDF)CP.PHAR.487
Osimertinib (Tagrisso)(PDF)CP.PHAR.294
Ospemifene (Osphena)(PDF)CP.PMN.168
Overactive Bladder Agents(PDF)CP.PMN.198
Oxymetazoline (Rhofade, Upneeq)(PDF)CP.PMN.86
Ozanimod (Zeposia) (PDF)CP.PHAR.462
Ozenoxacin (Xepi)(PDF)CP.PMN.119

 

Policy TitlePolicy Number
Paclitaxel, Protein-Bound (Abraxane)(PDF)CP.PHAR.176 
Pacritinib (Vonjo)(PDF)CP.PHAR.583
Palbociclib (Ibrance)(PDF)CP.PHAR.125
Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza, Erzofri)(PDF)CP.PHAR.291
Palivizumab (Synagis)(PDF)CP.PHAR.16
Palovarotene (Sohonos)(PDF)CP.PHAR.548
Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep)(PDF)CP.PMN.226
Panitumumab (Vectibix)(PDF)CP.PHAR.321
Parathyroid Hormone (Natpara)(PDF)CP.PHAR.282
Paricalcitol Injection (Zemplar)(PDF)CP.PHAR.270
Pasireotide (Signifor, Signifor LAR)(PDF)CP.PHAR.332
Patiromer (Veltassa)(PDF)CP.PMN.205
Patisiran (Onpattro)(PDF)CP.PHAR.395
Pazopanib (Votrient)(PDF)CP.PHAR.81
Peanut Allergen Powder-dnfp (Palforzia)(PDF)CP.PMN.220
Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas)(PDF)CP.PHAR.353
Pegcetacoplan (Empaveli, Syfovre)(PDF)CP.PHAR.524
Pegfilgrastim/Biosimilars, Eflapegrastim, Efbemalenograstim(PDF)CP.PHAR.296
Peginterferon Alfa-2a (Pegasys)(PDF)CP.PHAR.89
Peginterferon Beta-1a (Plegridy)(PDF)CP.PHAR.271
Pegloticase (Krystexxa)(PDF)CP.PHAR.115
Pegunigalsidase Alfa-iwxj (Elfabrio)(PDF)CP.PHAR.512
Pegvaliase-pqpz (Palynziq) (PDF)CP.PHAR.140
Pegvisomant (Somavert)(PDF)CP.PHAR.389
Pembrolizumab (Keytruda)(PDF)CP.PHAR.322
Pemetrexed (Alimta, Pemfexy)(PDF)CP.PHAR.368
Pemigatinib (Pemazyre)(PDF)CP.PHAR.496
Pentosan Polysulfate Sodium (Elmiron)(PDF)CP.PMN.276
Perampanel (Fycompa)(PDF)CP.PMN.156
Perfluorohexyloctane (Miebo)(PDF)CP.PMN.290
Perindopril/Amlodipine (Prestalia)(PDF)CP.PMN.174
Pertuzumab (Perjeta)(PDF)CP.PHAR.227
Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo)(PDF)CP.PHAR.501
Pexidartinib (Turalio)(PDF)CP.PHAR.436
Pilocarpine (Qlosi, Vuity)(PDF)CP.PMN.270
Pimavanserin (Nuplazid)(PDF)CP.PMN.140
Pirfenidone (Esbriet)(PDF)CP.PHAR.286
Pirtobrutinib (Jaypirca)(PDF)CP.PHAR.620
Pitolisant (Wakix)(PDF)CP.PMN.221
Plasminogen, Human-tvmh (Ryplazim)(PDF)CP.PHAR.513
Plecanatide (Trulance)(PDF)CP.PMN.87
Plerixafor (Mozobil)(PDF)CP.PHAR.323
Polatuzumab Vedotin-piiq (Polivy)(PDF)CP.PHAR.433
Pomalidomide (Pomalyst) (PDF)CP.PHAR.116
Ponatinib (Iclusig)(PDF)CP.PHAR.112
Ponesimod (Ponvory)(PDF)CP.PHAR.537
Pozelimab-bbfg (Veopoz)(PDF)CP.PHAR.626
Pralatrexate (Folotyn)(PDF)CP.PHAR.313
Pralsetinib (Gavreto)(PDF)CP.PHAR.514
Pramlintide (Symlin)(PDF)CP.PMN.129
Prasterone (Intrarosa)(PDF)CP.PMN.99
Pregabalin (Lyrica, Lyrica CR)(PDF)CP.PMN.33
Pretomanid(PDF)CP.PMN.222
Progesterone (Crinone, Endometrin)(PDF)CP.PMN.243
Propranolol HCl Oral Solution (Hemangeol)(PDF)CP.PMN.58
Protein C Concentrate, Human (Ceprotin)(PDF)CP.PHAR.330
Prucalopride (Motegrity)(PDF)CP.PMN.194
Pyrimethamine (Daraprim)(PDF)CP.PMN.44 
Quantity Limit Override and Dose Optimization(PDF)CP.PMN.59
Quetiapine Extended-Release (Seroquel XR)(PDF)CP.PMN.64
Quinine Sulfate (Qualaquin)(PDF)CP.PMN.262
Quizartinib (Vanflyta)(PDF)CP.PHAR.646
Ramelteon (Rozerem)(PDF)CP.PMN.173
Ramucirumab (Cyramza)(PDF)CP.PHAR.119
Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo)(PDF)CP.PHAR.186
Ranolazine (Ranexa, Aspruzyo Sprinkle)(PDF)CP.PMN.34
Ravulizumab-cwvz (Ultomiris)(PDF)CP.PHAR.415
Regorafenib (Stivarga)(PDF)CP.PHAR.107
Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree)(PDF)CP.PHAR.529
Repository Corticotropin Injection (Acthar Gel, Purified Cortrophin Gel)(PDF)CP.PHAR.168
Repotrectinib (Augtyro)(PDF)CP.PHAR.667
Request for Medically Necessary Drug Not on the PDL(PDF)CP.PMN.16
Reslizumab (Cinqair)(PDF)CP.PHAR.223
Resmetirom (Rezdiffra)(PDF)CP.PHAR.647
Respiratory syncytial virus vaccine (Abrysvo)(PDF)CP.PHAR.658
Retifanlimab-dlwr (Zynyz)(PDF)CP.PHAR.629
Ribavirin (Rebetol, Ribasphere)(PDF)CP.PHAR.141
Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara)(PDF)CP.PHAR.334
Rifabutin (Mycobutin)(PDF)CP.PMN.223
Rifamycin (Aemcolo)(PDF)CP.PMN.196
Rifapentine (Priftin)(PDF)CP.PMN.05
Rifaximin (Xifaxan)(PDF)CP.PMN.47
Rilonacept (Arcalyst)(PDF)CP.PHAR.266
RimabotulinumtoxinB (Myobloc)(PDF)CP.PHAR.233
Rimegepant (Nurtec ODT)(PDF)CP.PHAR.490
Riociguat (Adempas)(PDF)CP.PHAR.195
Ripretinib (Qinlock)(PDF)CP.PHAR.502
Risankizumab-rzaa (Skyrizi)(PDF)CP.PHAR.426
Risdiplam (Evrysdi)(PDF)CP.PHAR.477
Risedronate (Actonel, Atelvia)(PDF)CP.PMN.100
Risperidone Long-Acting Injection (Perseris, Risperdal Consta, Risvan, Rykindo, Uzedy)(PDF)CP.PHAR.293
Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela)(PDF)CP.PHAR.260
Rivaroxaban (Xarelto)(PDF)CP.PMN.247
Rivastigmine (Exelon)(PDF)CP.PMN.101
Roflumilast (Daliresp, Zoryve)(PDF)CP.PMN.46 
Rolapitant (Varubi)(PDF)CP.PMN.102
Romidepsin (Istodax)(PDF)CP.PHAR.314
Romiplostim (Nplate)(PDF)CP.PHAR.179
Romosozumab-aqqg (Evenity)(PDF)CP.PHAR.428
Ropeginterferon Alfa-2b-njft (BESREMi)(PDF)CP.PHAR.570
Rozanolixizumab-noli (Rystiggo)(PDF)CP.PHAR.648
Rucaparib (Rubraca)(PDF)CP.PHAR.350
Rufinamide (Banzel)(PDF)CP.PMN.157
Ruxolitinib (Jakafi, Opzelura)(PDF)CP.PHAR.98

 

Policy TitlePolicy Number 
Sacituzumab Govitecan-hziy (Trodelvy)(PDF)CP.PHAR.475 
Sacubitril/Valsartan (Entresto)(PDF)CP.PMN.67 
Safinamide (Xadago)(PDF)CP.PMN.113 
Sapropterin Dihydrochloride (Kuvan)(PDF)CP.PHAR.43 
Sarecycline (Seysara)(PDF)CP.PMN.189 
Sargramostim (Leukine)(PDF)CP.PHAR.295 
Sarilumab (Kevzara)(PDF)CP.PHAR.346 
Satralizumab-mwge (Enspryng)(PDF)CP.PHAR.463 
Sebelipase Alfa (Kanuma)(PDF)CP.PHAR.159 
Secnidazole (Solosec)(PDF)CP.PMN.103 
Secukinumab (Cosentyx)(PDF)CP.PHAR.261 
Selexipag (Uptravi)(PDF)CP.PHAR.196 
Selinexor (Xpovio)(PDF)CP.PHAR.431 
Selpercatinib (Retevmo)(PDF)CP.PHAR.478 
Selumetinib (Koselugo)(PDF)CP.PHAR.464 
Semaglutide (Wegovy)(PDF)CP.PMN.295 
Setmelanotide (Imcivree)(PDF)CP.PHAR.491 
Short Ragweed Pollen Allergen Extract (Ragwitek)(PDF)CP.PMN.83  
Sildenafil (Revatio, Liqrev)(PDF)CP.PHAR.197 
Siltuximab (Sylvant)(PDF)CP.PHAR.329 
Siponimod (Mayzent)(PDF)CP.PHAR.427 
Sipuleucel-T (Provenge)(PDF)CP.PHAR.120 
Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor)(PDF)CP.PHAR.574 
Sodium Oxybate (Xyrem, Lumryz) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav)(PDF)CP.PMN.42 
Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva) (PDF)CP.PHAR.208 
Sodium Phenylbutyrate/Taurursodiol (Relyvrio)(PDF)CP.PHAR.584 
Sodium Thiosulfate (Pedmark)(PDF)CP.PHAR.610 
Sodium Zirconium Cyclosilicate (Lokelma)(PDF)CP.PMN.163 
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors(PDF)CP.PMN.14 
Sofosbuvir (Sovaldi)(PDF)CP.PHAR.281 
Sofosbuvir/Velpatasvir (Epclusa)(PDF)CP.PHAR.268  
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi)(PDF)CP.PHAR.347 
Solriamfetol (Sunosi)(PDF)CP.PMN.209 
Sonidegib (Odomzo)(PDF)CP.PHAR.272 
Sorafenib (Nexavar)(PDF)CP.PHAR.69 
Sotatercept (Winrevair)(PDF)CP.PHAR.657 
Sotorasib (Lumakras) (PDF)CP.PHAR.549 
Sparsentan (Filspari)(PDF)CP.PHAR.631 
Spesolimab-sbzo (Spevigo)(PDF)CP.PHAR.606 
SSRI/SNRI Duplicate Therapy(PDF)CP.PMN.60  
Step Therapy(PDF)CP.PST.01 
Stiripentol (Diacomit)(PDF)CP.PMN.184 
Sunitinib (Sutent)(PDF)CP.PHAR.73 
Sutimlimab-jome (Enjaymo)(PDF)CP.PHAR.503 
Suvorexant (Belsomra)(PDF)CP.PMN.109 
Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair)(PDF)CP.PMN.85  
Tadalafil (Adcirca, Alyq, Tadliq)(PDF)CP.PHAR.198 
Tadalafil BPH - ED (Cialis)(PDF)CP.PMN.132 
Tafamidis (Vyndaqel, Vyndamax)(PDF)CP.PHAR.432 
Tafasitamab-cxix (Monjuvi)(PDF)CP.PHAR.508 
Talazoparib (Talzenna) (PDF)CP.PHAR.409 
Taliglucerase Alfa (Elelyso)(PDF)CP.PHAR.157 
Talimogene laherepvec (Imlygic)(PDF)CP.PHAR.542 
Talquetamab-tgvs (Talvey)(PDF)CP.PHAR.649 
Tapinarof (Vtama)(PDF)CP.PMN.283 
Tasimelteon (Hetlioz, Hetlioz LQ)(PDF)CP.PMN.104 
Tavaborole (Kerydin)(PDF)CP.PMN.105 
Tazarotene (Arazlo, Fabior, Tazorac)(PDF)CP.PMN.244 
Tazemetostat (Tazverik)(PDF)CP.PHAR.452 
Tebentafusp-tebn (Kimmtrak)(PDF)CP.PHAR.575 
Teclistamab-cqyv (Tecvayli)(PDF)CP.PHAR.611 
Tedizolid (Sivextro)(PDF)CP.PMN.62 
Teduglutide (Gattex)(PDF)CP.PHAR.114 
Tegaserod (Zelnorm)(PDF)CP.PMN.206 
Telotristat Ethyl (Xermelo)(PDF)CP.PHAR.337 
Temozolomide (Temodar)(PDF)CP.PHAR.77 
Temsirolimus (Torisel)(PDF)CP.PHAR.324 
Tenapanor (Ibsrela, Xphozah)(PDF)CP.PMN.224 
Tenofovir Alafenamide Fumarate (Vemlidy)(PDF)CP.PMN.268 
Teplizumab-mzwv (Tzield)(PDF)CP.PHAR.492 
Tepotinib (Tepmetko) (PDF)CP.PHAR.530 
Teprotumumab (Tepezza)(PDF)CP.PHAR.465 
Teriflunomide (Aubagio)(PDF)CP.PHAR.262 
Teriparatide (Forteo, Bonsity)(PDF)CP.PHAR.188 
Tesamorelin (Egrifta SV)(PDF)CP.PHAR.109 
Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando)(PDF)CP.PHAR.354 
Tetrabenazine (Xenazine)(PDF)CP.PHAR.92 
Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF)CP.PHAR.377 
Tezepelumab-ekko (Tezspire)(PDF)CP.PHAR.576 
Thalidomide (Thalomid)(PDF)CP.PHAR.78 
Thioguanine (Tabloid)(PDF)CP.PHAR.437 
Thyrotropin Alfa (Thyrogen)(PDF)CP.PHAR.95 
Tildrakizumab-asmn (Ilumya)(PDF)CP.PHAR.386 
Timothy Grass Pollen Allergen Extract (Grastek)(PDF)CP.PMN.84  
Tisagenlecleucel (Kymriah)(PDF)CP.PHAR.361 
Tisotumab Vedotin-tftv (Tivdak)(PDF)CP.PHAR.561 
Tivozanib (Fotivda)(PDF)CP.PHAR.538 
Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler)(PDF)CP.PHAR.211 
Tocilizumab (Actemra), Tocilizumab-bavi (Tofidence), Tocilizumab-aazg (Tyenne)(PDF)CP.PHAR.263 
Tofacitinib (Xeljanz, Xeljanz XR)(PDF)CP.PHAR.267 
Tofersen (Qalsody)(PDF)CP.PHAR.591 
Tolvaptan (Jynarque, Samsca) (PDF)CP.PHAR.27 
Topical Immunomodulators(PDF)CP.PMN.107 
Topiramate Extended-Release (Qudexy XR, Trokendi XR)(PDF)CP.PMN.281 
Topotecan (Hycamtin)(PDF)CP.PHAR.64 
Toremifene (Fareston)(PDF)CP.PMN.126 
Toripalimab-tpzi (Loqtorzi) (PDF)CP.PHAR.668 
Trabectedin (Yondelis)(PDF)CP.PHAR.204 
Tralokinumab-ldrm (Adbry)(PDF)CP.PHAR.577 
Trametinib (Mekinist)(PDF)CP.PHAR.240 
Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase(PDF)CP.PHAR.228 
Travoprost Implant (iDose TR)(PDF)CP.PHAR.672 
Tremelimumab-actl (Imjudo)(PDF)CP.PHAR.612 
Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI)(PDF)CP.PHAR.199  
Triamcinolone ER Injection (Zilretta)(PDF)CP.PHAR.371 
Triclabendazole (Egaten)(PDF)CP.PMN.207 
Trientine (Cuvrior, Syprine)(PDF)CP.PHAR.438 
Trifarotene (Aklief)(PDF)CP.PMN.225 
Trifluridine/Tipiracil (Lonsurf)(PDF)CP.PHAR.383 
Triheptanoin (Dojolvi)(PDF)CP.PHAR.509 
Triptorelin Pamoate (Trelstar, Triptodur)(PDF)CP.PHAR.175 
Trofinetide (Daybue) (PDF)CP.PHAR.600 
Tucatinib (Tukysa) (PDF)CP.PHAR.497 
Ublituximab-xiiy (Briumvi) (PDF)CP.PHAR.621 
Ubrogepant (Ubrelvy) (PDF)CP.PHAR.476 
Ulcer Therapy Products (PDF)CP.PMN.277 
Umbralisib (Ukoniq) (PDF)CP.PHAR.531 
Upadacitinib (Rinvoq) (PDF)CP.PHAR.443 
Ustekinumab (Stelara), Ustekinumab-aauz (Otulfi), Ustekinumab-ttwe (Pyzchiva), Ustekinumab-aekn (Selarsdi), Ustekinumab-auub (Wezlana)
CP.PHAR.264