Pharmacy
Preferred Drug Lists
Search for a DrugExternal Link
This list contains information about drugs covered by the plan. Please check back for updates, as PDLs are periodically amended.
Printed Preferred Drug Lists
- 'Ohana QUEST (Medicaid) Preferred Drug List (PDF)External Link
- 'Ohana QUEST (Medicaid) Machine Readable FileExternal Link
- 'Ohana QUEST (Medicaid) Dual Eligible Preferred Drug List (PDF)
- 'Ohana QUEST (Medicaid) Notice of Change (PDF)External Link
Coverage Determination Requests
Request a coverage decision and/or exception or file an appeal of a drug coverage decision.
Medication Appeals
You may appeal a coverage determination decision by contacting our Pharmacy Appeals Department.
Through their ongoing collaboration, WellCare and SurescriptsExternal Link have partnered to provide free ePA services for all your WellCare patients.
Clinical Pharmacy Policies
- Abaloparatide (Tymlos) CP.PHAR.345 (PDF)
- Abametapir (Xeglyze) CP.PMN.253 (PDF)
- Abatacept (Orencia) CP.PHAR.241 (PDF)
- Abemaciclib (Verzenio) CP.PHAR.355 (PDF)
- Abiraterone (Zytiga, Yonsa) CP.PHAR.84 (PDF)
- AbobotulinumtoxinA (Dysport) CP.PHAR.230 (PDF)
- Abrocitinib (Cibinqo) CP.PHAR.578 (PDF)
- Acalabrutinib (Calquence) CP.PHAR.366 (PDF)
- ACEI and ARB Duplicate Therapy CP.PMN.61 (PDF)
- Acitretin (Soriatane) CP.PMN.40 (PDF)
- Acyclovir Buccal Tablet (Sitavig) CP.PMN.210 (PDF)
- Adagrasib (Krazati) CP.PHAR.605 (PDF)
- 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 (Yu CP.PHAR.242 (PDF)
- Adefovir (Hepsera) CP.PHAR.142 (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla) CP.PHAR.229 (PDF)
- Aducanumab-avwa (Aduhelm) CP.PHAR.468 (PDF)
- Afamelanotide (Scenesse) CP.PHAR.444 (PDF)
- Afatinib (Gilotrif) CP.PHAR.298 (PDF)
- Aflibercept (Eylea) CP.PHAR.184 (PDF)
- Agalsidase Beta (Fabrazyme) CP.PHAR.158 (PDF)
- Age Limit for Topical Tretinoin CP.PMN.191 (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) CP.PMN.138 (PDF)
- Alectinib (Alecensa) CP.PHAR.369 (PDF)
- Alemtuzumab (Lemtrada) CP.PHAR.243 (PDF)
- Alendronate (Binosto, Fosamax Plus D) CP.PMN.88 (PDF)
- Alglucosidase Alfa (Lumizyme) CP.PHAR.160 (PDF)
- Alirocumab (Praluent) CP.PHAR.124 (PDF)
- Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) CP.PHAR.562 (PDF)
- Allogenic Processed Thymus Tissue-agdc (Rethymic) CP.PHAR.563 (PDF)
- Alosetron (Lotronex) CP.PMN.153 (PDF)
- Alpelisib (Piqray, Vijoice) CP.PHAR.430 (PDF)
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) CP.PHAR.94 (PDF)
- Amantadine ER (Gocovri, Osmolex ER) CP.PMN.89 (PDF)
- Ambrisentan (Letairis) CP.PHAR.190 (PDF)
- Amifampridine (Firdapse) CP.PHAR.411 (PDF)
- Amikacin (Arikayce) CP.PHAR.401 (PDF)
- Amisulpride (Barhemsys) CP.PMN.236 (PDF)
- Amivantamab-vmjw (Rybrevant) CP.PHAR.544 (PDF)
- Amlodipine/Atorvastatin (Caduet) CP.PMN.176 (PDF)
- Anakinra (Kineret) CP.PHAR.244 (PDF)
- Anifrolumab-fnia (Saphnelo) CP.PHAR.551 (PDF)
- Anti-Inhibitor Coagulant Complex, Human (Feiba) CP.PHAR.217 (PDF)
- Antithrombin III (ATryn, Thrombate III) CP.PHAR.564 (PDF)
- Antithymocyte Globulin (Atgam, Thymoglobulin) CP.PHAR.506 (PDF)
- Apadamtase alfa (TAK-755) CP.PHAR.635 (PDF)
- Apalutamide (Erleada) CP.PHAR.376 (PDF)
- Apomorphine (Apokyn, Kynmobi) CP.PHAR.488 (PDF)
- Apremilast (Otezla) CP.PHAR.245 (PDF)
- Aprepitant (Aponvie, Emend, Cinvanti), Fosaprepitant (Emend for injection) CP.PMN.19 (PDF)
- Arimoclomol CP.PHAR.510 (PDF)
- Aripiprazole Long-Acting Injections (Abilify Maintena, Abilify Asimtufii, Aristada, Aristada Initio) CP.PHAR.290 (PDF)
- Armodafinil (Nuvigil) CP.PMN.35 (PDF)
- Asciminib (Scemblix) CP.PHAR.565 (PDF)
- Asenapine (Saphris, Secuado) CP.PMN.15 (PDF)
- Asfotase Alfa (Strensiq) CP.PHAR.328 (PDF)
- Aspirin/Dipyridamole (Aggrenox) CP.PMN.20 (PDF)
- Atezolizumab (Tecentriq) CP.PHAR.235 (PDF)
- Atidarsagene Autotemcel (OTL-200) CP.PHAR.602 (PDF)
- Atogepant (Qulipta) CP.PHAR.566 (PDF)
- Avacopan (Tavneos) CP.PHAR.515 (PDF)
- Avalglucosidase Alfa-ngpt (Nexviazyme) CP.PHAR.521 (PDF)
- Avapritinib (Ayvakit) CP.PHAR.454 (PDF)
- Avatrombopag (Doptelet) CP.PHAR.130 (PDF)
- Avelumab (Bavencio) CP.PHAR.333 (PDF)
- Axicabtagene Ciloleucel (Yescarta) CP.PHAR.362 (PDF)
- Axitinib (Inlyta) CP.PHAR.100 (PDF)
- Azacitidine (Onureg, Vidaza) CP.PHAR.387 (PDF)
- Aztreonam (Cayston) CP.PHAR.209 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) CP.PHAR.202 (PDF)
- Cabazitaxel (Jevtana) CP.PHAR.316 (PDF)
- Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) CP.PHAR.573 (PDF)
- Cabozantinib (Cabometyx, Cometriq) CP.PHAR.111 (PDF)
- Calcifediol (Rayaldee) CP.PMN.76 (PDF)
- Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) CP.PMN.181 (PDF)
- Canakinumab (Ilaris) CP.PHAR.246 (PDF)
- Cannabidiol (Epidiolex) CP.PMN.164 (PDF)
- Capecitabine (Xeloda) CP.PHAR.60 (PDF)
- Caplacizumab-yhdp (Cablivi) CP.PHAR.416 (PDF)
- Capmatinib (Tabrecta) CP.PHAR.494 (PDF)
- Carbamazepine ER (Equetro) CP.PMN.137 (PDF)
- Carbetocin CP.PHAR.546 (PDF)
- Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) CP.PMN.238 (PDF)
- Carfilzomib (Kyprolis) CP.PHAR.309 (PDF)
- Carglumic Acid (Carbaglu) CP.PHAR.206 (PDF)
- Cariprazine (Vraylar) CP.PMN.91 (PDF)
- Casimersen (Amondys 45) CP.PHAR.470 (PDF)
- Celecoxib (Celebrex, Elyxyb) CP.PMN.122 (PDF)
- Cemiplimab-rwlc (Libtayo) CP.PHAR.397 (PDF)
- Cenegermin-bkbj (Oxervate) CP.PMN.186 (PDF)
- Cenobamate (Xcopri) CP.PMN.231 (PDF)
- Ceritinib (Zykadia) CP.PHAR.349 (PDF)
- Cerliponase alfa (Brineura) CP.PHAR.338 (PDF)
- Certolizumab (Cimzia) CP.PHAR.247 (PDF)
- Cetuximab (Erbitux) CP.PHAR.317 (PDF)
- Chenodiol (Chenodal) CP.PMN.239 (PDF)
- Chlorambucil (Leukeran) CP.PHAR.554 (PDF)
- Chloramphenicol Sodium Succinate CP.PHAR.388 (PDF)
- Cholic Acid (Cholbam) CP.PHAR.390 (PDF)
- Ciclopirox (Penlac) CP.PMN.24 (PDF)
- Ciltacabtagene Autoleucel (Carvykti) CP.PHAR.533 (PDF)
- Cinacalcet (Sensipar) CP.PHAR.61 (PDF)
- Cipaglucosidase Alfa/Miglustat (AT-GAA) CP.PHAR.567 (PDF)
- Ciprofloxacin/Dexamethasone (Ciprodex) CP.PMN.248 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel) CP.PMN.249 (PDF)
- Cladribine (Mavenclad) CP.PHAR.422 (PDF)
- Clascoterone (Winlevi) CP.PMN.257 (PDF)
- Clobazam (Onfi, Sympazan) CP.PMN.54 (PDF)
- Clomipramine (Anafranil) CP.PMN.197 (PDF)
- Clozapine Orally Disintegrating Tablet CP.PMN.12 (PDF)
- CNS Stimulants CP.PMN.92 (PDF)
- Cobimetinib (Cotellic) CP.PHAR.380 (PDF)
- Colchicine (Colcrys) CP.PMN.123 (PDF)
- Colesevelam (Welchol) CP.PMN.250 (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex) CP.PHAR.82 (PDF)
- Compounded Medications CP.PMN.280 (PDF)
- Concizumab (NN7415) CP.PHAR.625 (PDF)
- Conflict of Interest and Confidentiality Agreement for Pharmacy and Therapeutics Committee Membership CC.PHAR.17 (PDF)
- Conjugated Estrogens/Bazedoxifene (Duavee) CP.PMN.258 (PDF)
- Continuous Glucose Monitors CP.PMN.214 (PDF)
- Copanlisib (Aliqopa) CP.PHAR.357 (PDF)
- Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) CP.PHAR.385 (PDF)
- Cosyntropin (Cortrosyn) CP.PHAR.203 (PDF)
- Crisaborole (Eucrisa) CP.PMN.110 (PDF)
- Crizanlizumab-tmca (Adakveo) CP.PHAR.449 (PDF)
- Crizotinib (Xalkori) CP.PHAR.90 (PDF)
- Cyclosporine (Cequa, Restasis, Verkazia, Vevye) CP.PMN.48 (PDF)
- Cysteamine Ophthalmic (Cystaran, Cystadrops) CP.PMN.130 (PDF)
- Cysteamine oral (Cystagon, Procysbi) CP.PHAR.155 (PDF)
- Cytomegalovirus Immune Globulin (Cytogam) CP.PHAR.277 (PDF)
- Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members CP.PMN.234 (PDF)
- Ecallantide (Kalbitor) CP.PHAR.177 (PDF)
- Eculizumab (Soliris) CP.PHAR.97 (PDF)
- Edaravone (Radicava, Radicava ORS) CP.PHAR.343 (PDF)
- Edoxaban (Savaysa) CP.PMN.227 (PDF)
- Efgartigimod Alfa-fcab, Efgartigimod/-Hyaluronidase-qvfc (Vyvgart, Vyvgart Hytrulo) CP.PHAR.555 (PDF)
- Efinaconazole (Jublia) CP.PMN.25 (PDF)
- Elacestrant (Orserdu) CP.PHAR.623 (PDF)
- Eladocagene Exuparvovec (Upstaza) CP.PHAR.595 (PDF)
- Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) CP.PHAR.136 (PDF)
- Elapegademase-lvlr (Revcovi) CP.PHAR.419 (PDF)
- Elbasvir/Grazoprevir (Zepatier) CP.PHAR.275 (PDF)
- Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) CP.PHAR.440 (PDF)
- Eliglustat (Cerdelga) CP.PHAR.153 (PDF)
- Elivaldogene Autotemcel (Skysona) CP.PHAR.556 (PDF)
- Elosulfase Alfa (Vimizim) CP.PHAR.162 (PDF)
- Elotuzumab (Empliciti) CP.PHAR.308 (PDF)
- Eltrombopag (Promacta) CP.PHAR.180 (PDF)
- Eluxadoline (Viberzi) CP.PMN.170 (PDF)
- Emapalumab-lzsg (Gamifant) CP.PHAR.402 (PDF)
- Emicizumab-kxwh (Hemlibra) CP.PHAR.370 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy) CP.PMN.235 (PDF)
- Enasidenib (Idhifa) CP.PHAR.363 (PDF)
- Encorafenib (Braftovi) CP.PHAR.127 (PDF)
- Enfortumab Vedotin-ejfv (Padcev) CP.PHAR.455 (PDF)
- Enfuvirtide (Fuzeon) CP.PHAR.41 (PDF)
- Enoxaparin (Lovenox) CP.PHAR.224 (PDF)
- Entrectinib (Rozlytrek) CP.PHAR.441 (PDF)
- Enzalutamide (Xtandi) CP.PHAR.106 (PDF)
- Epcoritamab-bysp (Epkinly) CP.PHAR.634 (PDF)
- Epinephrine (Auvi-Q, EpiPen, EpiPen Jr) Quantity Limit Override CP.PMN.144 (PDF)
- Eplontersen (AKCEA-TTR-LRx) CP.PHAR.633 (PDF)
- Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) CP.PHAR.237 (PDF)
- Epoprostenol (Flolan, Veletri) CP.PHAR.192 (PDF)
- Eptinezumab-jjmr (Vyepti) CP.PHAR.489 (PDF)
- Erdafitinib (Balversa) CP.PHAR.423 (PDF)
- Erenumab-aaoe (Aimovig) CP.PHAR.128 (PDF)
- Eribulin Mesylate (Halaven) CP.PHAR.318 (PDF)
- Erlotinib (Tarceva) CP.PHAR.74 (PDF)
- Erwinia Asparaginase (Erwinaze, Rylaze) CP.PHAR.301 (PDF)
- Esketamine (Spravato) CP.PMN.199 (PDF)
- Estradiol Vaginal Ring (Femring) CP.PMN.263 (PDF)
- Etanercept (Enbrel) CP.PHAR.250 (PDF)
- Etelcalcetide (Parsabiv) CP.PHAR.379 (PDF)
- Eteplirsen (Exondys 51) CP.PHAR.288 (PDF)
- Etranacogene Dezaparvovec-drlb (Hemgenix) CP.PHAR.580 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress) CP.PHAR.63 (PDF)
- Evinacumab-dgnb (Evkeeza) CP.PHAR.511 (PDF)
- Evolocumab (Repatha) CP.PHAR.123 (PDF)
- Exagamglogene Autotemcel (Exa-Cel) CP.PHAR.603 (PDF)
- Gabapentin ER (Gralise, Horizant) CP.PMN.240 (PDF)
- Galcanezumab-gnlm (Emgality) CP.PHAR.404 (PDF)
- Galsulfase (Naglazyme) CP.PHAR.161 (PDF)
- Ganaxolone (Ztalmy) CP.PMN.278 (PDF)
- Gefitinib (Iressa) CP.PHAR.68 (PDF)
- Gemtuzumab Ozogamicin (Mylotarg) CP.PHAR.358 (PDF)
- Generic Drug Additions to PDL CC.PHAR.14 (PDF)
- Gilteritinib (Xospata) CP.PHAR.412 (PDF)
- Givosiran (Givlaari) CP.PHAR.457 (PDF)
- Glasdegib (Daurismo) CP.PHAR.413 (PDF)
- Glatiramer Acetate (Copaxone, Glatopa) CP.PHAR.252 (PDF)
- Glaucoma Agents CP.PMN.286 (PDF)
- Glecaprevir-Pibrentasvir (Mavyret) CP.PHAR.348 (PDF)
- Glofitamab-gxbm (Columvi) CP.PHAR.636 (PDF)
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists CP.PMN.183 (PDF)
- Glycerol Phenylbutyrate (Ravicti) CP.PHAR.207 (PDF)
- Glycopyrronium (Qbrexza) CP.PMN.177 (PDF)
- Golimumab (Simponi, Simponi Aria) CP.PHAR.253 (PDF)
- Golodirsen (Vyondys 53) CP.PHAR.453 (PDF)
- Goserelin Acetate (Zoladex) CP.PHAR.171 (PDF)
- Granisetron (Sancuso, Sustol) CP.PMN.74 (PDF)
- Guselkumab (Tremfya) CP.PHAR.364 (PDF)
- Ibalizumab-uiyk (Trogarzo) CP.PHAR.378 (PDF)
- Ibandronate Injection (Boniva) CP.PHAR.189 (PDF)
- Ibandronate Oral (Boniva) CP.PMN.96 (PDF)
- Ibrutinib (Imbruvica) CP.PHAR.126 (PDF)
- Ibuprofen/Famotidine (Duexis) CP.PMN.120 (PDF)
- Icatibant (Firazyr) CP.PHAR.178 (PDF)
- Icosapent Ethyl (Vascepa) CP.PMN.187 (PDF)
- Idecabtagene Vicleucel (Abecma) CP.PHAR.481 (PDF)
- Idelalisib (Zydelig) CP.PHAR.133 (PDF)
- Idursulfase (Elaprase) CP.PHAR.156 (PDF)
- Iloperidone (Fanapt) CP.PMN.32 (PDF)
- Iloprost (Ventavis) CP.PHAR.193 (PDF)
- Imatinib (Gleevec) CP.PHAR.65 (PDF)
- Imiglucerase (Cerezyme) CP.PHAR.154 (PDF)
- Immune Globulins CP.PHAR.103 (PDF)
- Immunization coverage CP.PHAR.28 (PDF)
- Inclisiran (Leqvio) CP.PHAR.568 (PDF)
- IncobotulinumtoxinA (Xeomin) CP.PHAR.231 (PDF)
- Inebilizumab-cdon (Uplizna) CP.PHAR.458 (PDF)
- Infertility and Fertility Preservation CP.PHAR.131 (PDF)
- Infigratinib (Truseltiq) CP.PHAR.547 (PDF)
- Infliximab (Remicade), Infliximab-axxq (Avsola), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) CP.PHAR.254 (PDF)
- Inhaled Agents for Asthma and COPD CP.PMN.259 (PDF)
- Inotersen (Tegsedi) CP.PHAR.405 (PDF)
- Inotuzumab Ozogamicin (Besponsa) CP.PHAR.359 (PDF)
- Insulin degludec (Tresiba) CP.PMN.285 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) CP.PHAR.534 (PDF)
- Interferon Beta-1a (Avonex, Rebif) CP.PHAR.255 (PDF)
- Interferon Beta-1b (Betaseron, Extavia) CP.PHAR.256 (PDF)
- Interferon Gamma- 1b (Actimmune) CP.PHAR.52 (PDF)
- Iobenguane I-131 (Azedra) CP.PHAR.459 (PDF)
- Ipilimumab (Yervoy) CP.PHAR.319 (PDF)
- Irinotecan Liposome (Onivyde) CP.PHAR.304 (PDF)
- Isatuximab-irfc (Sarclisa) CP.PHAR.482 (PDF)
- Isavuconazonium (Cresemba) CP.PMN.154 (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) CP.PMN.143 (PDF)
- Istradefylline (Nourianz) CP.PMN.217 (PDF)
- Itraconazole (Sporanox, Tolsura) CP.PMN.124 (PDF)
- Ivabradine (Corlanor) CP.PMN.70 (PDF)
- Ivacaftor (Kalydeco) CP.PHAR.210 (PDF)
- Ivermectin (Stromectol, Sklice) CP.PMN.269 (PDF)
- Ivosidenib (Tibsovo) CP.PHAR.137 (PDF)
- Ixazomib (Ninlaro) CP.PHAR.302 (PDF)
- Ixekizumab (Taltz) CP.PHAR.257 (PDF)
- Macitentan (Opsumit) CP.PHAR.194 (PDF)
- Mannitol (Bronchitol) CP.PHAR.518 (PDF)
- Maralixibat (Livmarli) CP.PHAR.543 (PDF)
- Margetuximab-cmkb (Margenza) CP.PHAR.522 (PDF)
- Maribavir (Livtencity) CP.PMN.271 (PDF)
- Mavacamten (Camzyos) CP.PMN.272 (PDF)
- Mecamylamine (Vecamyl) CP.PMN.136 (PDF)
- Mecasermin (Increlex) CP.PHAR.150 (PDF)
- Mechlorethamine Gel (Valchlor) CP.PHAR.381 (PDF)
- Medicaid Preferred Drug List Audit Support CC.PHAR.22 (PDF)
- Megestrol Acetate (Megace ES) CP.PMN.179 (PDF)
- Melphalan flufenamide (Pepaxto) CP.PHAR.535 (PDF)
- Mepolizumab (Nucala) CP.PHAR.200 (PDF)
- Mercaptopurine (Purixan) CP.PHAR.447 (PDF)
- Mesenchymal Stem Cell-NTF Cells (NurOwn) CP.PHAR.637 (PDF)
- Metformin ER (Fortamet, Glumetza) CP.PMN.72 (PDF)
- Methadone Hydrochloride CP.PMN.161 (PDF)
- Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex, Jylamvo) CP.PHAR.134 (PDF)
- Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) CP.PHAR.238 (PDF)
- Methylnaltrexone Bromide (Relistor) CP.PMN.169 (PDF)
- Metoclopramide (Gimoti) CP.PMN.252 (PDF)
- Metreleptin (Myalept) CP.PHAR.425 (PDF)
- Midazolam (Nayzilam) CP.PMN.211 (PDF)
- Midostaurin (Rydapt) CP.PHAR.344 (PDF)
- Mifepristone (Korlym) CP.PHAR.101 (PDF)
- Migalastat (Galafold) CP.PHAR.394 (PDF)
- Miglustat (Zavesca) CP.PHAR.164 (PDF)
- Milnacipran (Savella) CP.PMN.125 (PDF)
- Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) CP.PMN.80 (PDF)
- Minocycline Micronized Foam (Amzeeq) CP.PMN.242 (PDF)
- Mirvetuximab soravatansine-gynx (Elahere) CP.PHAR.617 (PDF)
- Mitapivat (Pyrukynd) CP.PHAR.558 (PDF)
- Mitomycin for Pyelocalyceal Solution (Jelmyto) CP.PHAR.495 (PDF)
- Mitoxantrone CP.PHAR.258 (PDF)
- Mobocertinib (Exkivity) CP.PHAR.559 (PDF)
- Modafinil (Provigil) CP.PMN.39 (PDF)
- Mogamulizumab-kpkc (Poteligeo) CP.PHAR.139 (PDF)
- Mometasone Furoate (Sinuva) CP.PHAR.448 (PDF)
- Mosunetuzumab-axgb (Lunsumio) CP.PHAR.618 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti) CP.PHAR.398 (PDF)
- Obeticholic Acid (Ocaliva) CP.PHAR.287 (PDF)
- Obinutuzumab (Gazyva) CP.PHAR.305 (PDF)
- Ocrelizumab (Ocrevus) CP.PHAR.335 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa) CP.PHAR.40 (PDF)
- Odevixibat (Bylvay) CP.PHAR.528 (PDF)
- Ofatumumab (Arzerra, Kesimpta) CP.PHAR.306 (PDF)
- Off-Label Use CP.PMN.53 (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) CP.PHAR.292 (PDF)
- Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis) CP.PMN.29 (PDF)
- Olanzapine/Samidorphan (Lybalvi) CP.PMN.265 (PDF)
- Olaparib (Lynparza) CP.PHAR.360 (PDF)
- Olaratumab (Lartruvo) CP.PHAR.326 (PDF)
- Olipudase Alfa-rpcp (Xenpozyme) CP.PHAR.586 (PDF)
- Olutasidenib (Rezlidhia) CP.PHAR.615 (PDF)
- Omacetaxine (Synribo) CP.PHAR.108 (PDF)
- Omadacycline (Nuzyra) CP.PMN.188 (PDF)
- Omalizumab (Xolair) CP.PHAR.01 (PDF)
- Omaveloxolone (Skyclarys) CP.PHAR.590 (PDF)
- Omburtamab (Omblastys) CP.PHAR.585 (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza) CP.PMN.52 (PDF)
- OnabotulinumtoxinA (Botox) CP.PHAR.232 (PDF)
- Onasemnogene Abeparvovec (Zolgensma) CP.PHAR.421 (PDF)
- Ondansetron (Zuplenz) CP.PMN.45 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) CP.PHAR.536 (PDF)
- Opicapone (Ongentys) CP.PMN.245 (PDF)
- Opioid Analgesics CP.PMN.97 (PDF)
- Osilodrostat (Isturisa) CP.PHAR.487 (PDF)
- Osimertinib (Tagrisso) CP.PHAR.294 (PDF)
- Ospemifene (Osphena) CP.PMN.168 (PDF)
- Overactive Bladder Agents CP.PMN.198 (PDF)
- Oxymetazoline (Rhofade, Upneeq) CP.PMN.86 (PDF)
- Ozanimod (Zeposia) CP.PHAR.462 (PDF)
- Ozenoxacin (Xepi) CP.PMN.119 (PDF)
- Sacituzumab Govitecan-hziy (Trodelvy) CP.PHAR.475 (PDF)
- Sacubitril/Valsartan (Entresto) CP.PMN.67 (PDF)
- Safinamide (Xadago) CP.PMN.113 (PDF)
- Sapropterin Dihydrochloride (Kuvan) CP.PHAR.43 (PDF)
- Sarecycline (Seysara) CP.PMN.189 (PDF)
- Sargramostim (Leukine) CP.PHAR.295 (PDF)
- Sarilumab (Kevzara) CP.PHAR.346 (PDF)
- Satralizumab-mwge (Enspryng) CP.PHAR.463 (PDF)
- Sebelipase Alfa (Kanuma) CP.PHAR.159 (PDF)
- Secnidazole (Solosec) CP.PMN.103 (PDF)
- Secukinumab (Cosentyx) CP.PHAR.261 (PDF)
- Selexipag (Uptravi) CP.PHAR.196 (PDF)
- Selinexor (Xpovio) CP.PHAR.431 (PDF)
- Selpercatinib (Retevmo) CP.PHAR.478 (PDF)
- Selumetinib (Koselugo) CP.PHAR.464 (PDF)
- Setmelanotide (Imcivree) CP.PHAR.491 (PDF)
- Short ragweed pollen allergen extract (Ragwitek) CP.PMN.83 (PDF)
- Sildenafil (Revatio, Liqrev) CP.PHAR.197 (PDF)
- Siltuximab (Sylvant) CP.PHAR.329 (PDF)
- Siponimod (Mayzent) CP.PHAR.427 (PDF)
- Sipuleucel-T (Provenge) CP.PHAR.120 (PDF)
- Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) CP.PHAR.574 (PDF)
- Sodium Oxybate (Xyrem, Lumryz) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav) CP.PMN.42 (PDF)
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva) CP.PHAR.208 (PDF)
- Sodium Phenylbutyrate/Taurursodiol (Relyvrio) CP.PHAR.584 (PDF)
- Sodium thiosulfate (Pedmark) CP.PHAR.610 (PDF)
- Sodium zirconium cyclosilicate (Lokelma) CP.PMN.163 (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors CP.PMN.14 (PDF)
- Sofosbuvir (Sovaldi) CP.PHAR.281 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa) CP.PHAR.268 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) CP.PHAR.347 (PDF)
- Solriamfetol (Sunosi) CP.PMN.209 (PDF)
- Sonidegib (Odomzo) CP.PHAR.272 (PDF)
- Sorafenib (Nexavar) CP.PHAR.69 (PDF)
- Sotorasib (Lumakras) CP.PHAR.549 (PDF)
- Sparsentan (Filspari) CP.PHAR.631 (PDF)
- Spesolimab-sbzo (Spevigo) CP.PHAR.606 (PDF)
- SSRI SNRI Duplicate Thearapy CP.PMN.60 (PDF)
- State-Specific Pharmacy Guideline Process CP.PHAR.00 (PDF)
- Step Therapy WCG.CP.PST.01 (PDF)
- Stiripentol (Diacomit) CP.PMN.184 (PDF)
- Sunitinib (Sutent) CP.PHAR.73 (PDF)
- Sutimlimab-jome (Enjaymo) CP.PHAR.503 (PDF)
- Suvorexant (Belsomra) CP.PMN.109 (PDF)
- Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) CP.PHAR.149 (PDF)
- Baloxavir Marboxil (Xofluza) CP.PMN.185 (PDF)
- Bardoxolone Methyl (RTA 402) CP.PHAR.560 (PDF)
- Baricitinib (Olumiant) CP.PHAR.135 (PDF)
- Bebtelovimab (LY-CoV1404) CP.PHAR.579 (PDF)
- Bedaquiline (Sirturo) CP.PMN.212 (PDF)
- Belantamab Mafodotin-blmf (Blenrep) CP.PHAR.469 (PDF)
- Belatacept (Nulojix) CP.PHAR.201 (PDF)
- Belimumab (Benlysta) CP.PHAR.88 (PDF)
- Belinostat (Beleodaq) CP.PHAR.311 (PDF)
- Belumosudil (Rezurock) CP.PHAR.552 (PDF)
- Belzutifan (Welireg) CP.PHAR.553 (PDF)
- Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) CP.PMN.237 (PDF)
- Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) CP.PHAR.307 (PDF)
- Benralizumab (Fasenra) CP.PHAR.373 (PDF)
- Benznidazole CP.PMN.90 (PDF)
- Benzyl alcohol (Ulesfia) CP.PMN.202 (PDF)
- Beremagene geperpavec-svdt (Vyjuvek) CP.PHAR.592 (PDF)
- Berotralstat (Orladeyo) CP.PHAR.485 (PDF)
- Betaine (Cystadane) CP.PHAR.143 (PDF)
- Betamethasone Dipropionate Spray (Sernivo) CP.PMN.182 (PDF)
- Betibeglogene Autotemcel (Zynteglo) CP.PHAR.545 (PDF)
- Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) CP.PHAR.93 (PDF)
- Bexarotene (Targretin Capsules, Gel) CP.PHAR.75 (PDF)
- Bezlotoxumab (Zinplava) CP.PHAR.300 (PDF)
- Bimatoprost Implant (Durysta) CP.PHAR.486 (PDF)
- Binimetinib (Mektovi) CP.PHAR.50 (PDF)
- Blinatumomab (Blincyto) CP.PHAR.312 (PDF)
- Blood Glucose Test Strip Quantity Limit - Not Receiving Insulin CP.PMN.151 (PDF)
- Bortezomib (Velcade) CP.PHAR.410 (PDF)
- Bosentan (Tracleer) CP.PHAR.191 (PDF)
- Bosutinib (Bosulif) CP.PHAR.105 (PDF)
- Brand Name Override CP.PMN.22 (PDF)
- Bremelanotide (Vyleesi) CP.PHAR.434 (PDF)
- Brentuximab Vedotin (Adcetris) CP.PHAR.303 (PDF)
- Brexanolone (Zulresso) CP.PHAR.417 (PDF)
- Brexpiprazole (Rexulti) CP.PMN.68 (PDF)
- Brexucabtagene Autoleucel (Tecartus) CP.PHAR.472 (PDF)
- Brigatinib (Alunbrig) CP.PHAR.342 (PDF)
- Brimonidine Tartrate (Mirvaso) CP.PMN.192 (PDF)
- Brodalumab (Siliq) CP.PHAR.375 (PDF)
- Brolucizumab-dbll (Beovu) CP.PHAR.445 (PDF)
- Budesonide (Tarpeyo) CP.PHAR.572 (PDF)
- Bulevirtide (Hepcludex) CP.PHAR.589 (PDF)
- Buprenorphine (Subutex) CP.PMN.82 (PDF)
- Buprenorphine Injection (Sublocade, Brixadi) CP.PHAR.289 (PDF)
- Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) CP.PMN.81 (PDF)
- Burosumab-twza (Crysvita) CP.PHAR.11 (PDF)
- Dabigatran (Pradaxa) CP.PMN.49 (PDF)
- Dabrafenib (Tafinlar) CP.PHAR.239 (PDF)
- Dacomitinib (Vizimpro) CP.PHAR.399 (PDF)
- Dalfampridine (Ampyra) CP.PHAR.248 (PDF)
- Dalteparin (Fragmin) CP.PHAR.225 (PDF)
- Daprodustat (Jesduvroq) CP.PHAR.628 (PDF)
- Daptomycin (Cubicin, Cubicin RF, Dapzura RT) CP.PHAR.351 (PDF)
- Daratumumab (Darzalex), Daratumumab/Hyaluronidase-fihj (Darzalex Faspro) CP.PHAR.310 (PDF)
- Darbepoetin Alfa (Aranesp) CP.PHAR.236 (PDF)
- Darolutamide (Nubeqa) CP.PHAR.435 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) CP.PHAR.278 (PDF)
- Dasatinib (Sprycel) CP.PHAR.72 (PDF)
- Daunorubicin/Cytarabine (Vyxeos) CP.PHAR.352 (PDF)
- Decitabine/Cedazuridine (Inqovi) CP.PHAR.479 (PDF)
- Deferasirox (Exjade, Jadenu) CP.PHAR.145 (PDF)
- Deferiprone (Ferriprox) CP.PHAR.147 (PDF)
- Deferoxamine (Desferal) CP.PHAR.146 (PDF)
- Deflazacort (Emflaza) CP.PHAR.331 (PDF)
- Degarelix Acetate (Firmagon) CP.PHAR.170 (PDF)
- Delafloxacin (Baxdela) CP.PMN.115 (PDF)
- Delandistrogene moxeparvovec-rokl (Elevidys) CP.PHAR.593 (PDF)
- Denosumab (Prolia, Xgeva) CP.PHAR.58 (PDF)
- Desmopressin Acetate (DDAVP, Stimate, Nocdurna) CP.PHAR.214 (PDF)
- Deucravacitinib (Sotyktu) CP.PHAR.607 (PDF)
- Deutetrabenazine (Austedo, Austedo XR) CP.PHAR.341 (PDF)
- Dexrazoxane (Totect) CP.PHAR.418 (PDF)
- Dextromethorphan/Bupropion (Auvelity) CP.PMN.284 (PDF)
- Dextromethorphan-Quinidine (Nuedexta) CP.PMN.93 (PDF)
- Diazepam Nasal Spray (Valtoco) CP.PMN.216 (PDF)
- Dichlorphenamide (Keveyis) CP.PMN.261 (PDF)
- Diclofenac (Pennsaid) CP.PMN.274 (PDF)
- Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) CP.PHAR.249 (PDF)
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors CP.PMN.03 (PDF)
- Dolasetron (Anzemet) CP.PMN.141 (PDF)
- Donanemab (LY3002813) CP.PHAR.594 (PDF)
- Donislecel (Lantidra) CP.PHAR.569 (PDF)
- Dornase Alfa (Pulmozyme) CP.PHAR.212 (PDF)
- Dostarlimab-gxly (Jemperli) CP.PHAR.540 (PDF)
- Doxepin (Silenor) CP.PMN.175 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) CP.PMN.79 (PDF)
- Dronabinol (Marinol, Syndros) CP.PMN.159 (PDF)
- Droxidopa (Northera) CP.PMN.17 (PDF)
- Dupilumab (Dupixent) CP.PHAR.336 (PDF)
- Durvalumab (Imfinzi) CP.PHAR.339 (PDF)
- Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) CP.PMN.128 (PDF)
- Duvelisib (Copiktra) CP.PHAR.400 (PDF)
- Factor IX (Human, Recombinant) CP.PHAR.218 (PDF)
- Factor IX Complex, Human (Profilnine) CP.PHAR.219 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact) CP.PHAR.220 (PDF)
- Factor VIII (Human, Recombinant) CP.PHAR.215 (PDF)
- Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) CP.PHAR.216 (PDF)
- Factor XIII A-Subunit, Recombinant (Tretten) CP.PHAR.222 (PDF)
- Factor XIII, Human (Corifact) CP.PHAR.221 (PDF)
- Fam-Trastuzumab Deruxtecan-nxki (Enhertu) CP.PHAR.456 (PDF)
- Faricimab-svoa (Vabysmo) CP.PHAR.581 (PDF)
- Febuxostat (Uloric) CP.PMN.57 (PDF)
- Fecal Microbiota Spores, Live-brpk (Vowst) CP.PHAR.632 (PDF)
- Fecal Microbiota, Live-jslm (Rebyota) CP.PHAR.613 (PDF)
- Fedratinib (Inrebic) CP.PHAR.442 (PDF)
- Fenfluramine (Fintepla) CP.PMN.246 (PDF)
- Fentanyl IR (Actiq, Fentora, Lazanda, Subsys) CP.PMN.127 (PDF)
- Ferric Carboxymaltose (Injectafer) CP.PHAR.234 (PDF)
- Ferric Derisomaltose (Monoferric) CP.PHAR.480 (PDF)
- Ferric Maltol (Accrufer) CP.PMN.213 (PDF)
- Ferric Pyrophosphate (Triferic, Triferic Avnu ) CP.PHAR.624 (PDF)
- Ferumoxytol (Feraheme) CP.PHAR.165 (PDF)
- Fezolinetant (Veozah) CP.PMN.289 (PDF)
- Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) CP.PHAR.526 (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko) CP.PHAR.297 (PDF)
- Finerenone (Kerendia) CP.PMN.266 (PDF)
- Fingolimod (Gilenya, Tascenso ODT) CP.PHAR.251 (PDF)
- Flibanserin (Addyi) CP.PHAR.446 (PDF)
- Fluorouracil Cream (Tolak) CP.PMN.165 (PDF)
- Fluticasone Propionate (Xhance) CP.PMN.95 (PDF)
- Fondaparinux (Arixtra) CP.PHAR.226 (PDF)
- Fosdenopterin (Nulibry) CP.PHAR.471 (PDF)
- Fostamatinib (Tavalisse) CP.PHAR.24 (PDF)
- Fostemsavir (Rukobia) CP.PHAR.516 (PDF)
- Fremanezumab-vfrm (Ajovy) CP.PHAR.403 (PDF)
- Fulvestrant (Faslodex Injection) CP.PHAR.424 (PDF)
- Furosemide (Furoscix) CP.PHAR.608 (PDF)
- Futibatinib (Lytgobi) CP.PHAR.604 (PDF)
- Halobetasol Propionate (Bryhali, Lexette, Ultravate) CP.PMN.180 (PDF)
- Halobetasol Propionate/Tazarotene (Duobrii) CP.PMN.208 (PDF)
- Hemin (Panhematin) CP.PHAR.181 (PDF)
- Histrelin Acetate (Vantas, Supprelin LA) CP.PHAR.172 (PDF)
- House dust mite allergen extract (Odactra) CP.PMN.111 (PDF)
- Human Growth Hormone (Somapacitan, Somatrogon, Somatropin) CP.PHAR.517 (PDF)
- Hyaluronate Derivatives WCG.CP.PHAR.05 (PDF)
- Hydroxyprogesterone Caproate (Makena/compound) CP.PHAR.14 (PDF)
- Hydroxyurea (Siklos) CP.PMN.193 (PDF)
- Lacosamide (Motpoly XR, Vimpat) CP.PMN.155 (PDF)
- Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) CP.PMN.251 (PDF)
- Lanadelumab-fylo (Takhzyro) CP.PHAR.396 (PDF)
- Lanreotide (Somatuline Depot) CP.PHAR.391 (PDF)
- Lapatinib (Tykerb) CP.PHAR.79 (PDF)
- Laronidase (Aldurazyme) CP.PHAR.152 (PDF)
- Larotrectinib (Vitrakvi) CP.PHAR.414 (PDF)
- Lasmiditan (Reyvow) CP.PMN.218 (PDF)
- Lecanemab-irmb (Leqembi) CP.PHAR.596 (PDF)
- Ledipasvir/Sofosbuvir (Harvoni) CP.PHAR.279 (PDF)
- Lefamulin (Xenleta) CP.PMN.219 (PDF)
- Lenacapavir (Sunlenca) CP.PHAR.622 (PDF)
- Lenalidomide (Revlimid) CP.PHAR.71 (PDF)
- Leniolisib (Joenja) CP.PHAR.597 (PDF)
- Lenvatinib (Lenvima) CP.PHAR.138 (PDF)
- Letermovir (Prevymis) CP.PHAR.367 (PDF)
- Leucovorin Injection CP.PHAR.393 (PDF)
- Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi) CP.PHAR.173 (PDF)
- Levodopa Inhalation Powder (Inbrija) CP.PMN.267 (PDF)
- Levoketoconazole (Recorlev) CP.PMN.275 (PDF)
- Levoleucovorin (Fusilev, Khapzory) CP.PHAR.151 (PDF)
- L-glutamine (Endari) CP.PMN.116 (PDF)
- Lidocaine transdermal (Lidoderm, ZTlido) CP.PMN.08 (PDF)
- Lifileucel (LN-144) CP.PHAR.598 (PDF)
- Lifitegrast (Xiidra) CP.PMN.73 (PDF)
- Linaclotide (Linzess) CP.PMN.71 (PDF)
- Lindane shampoo CP.PMN.09 (PDF)
- Line Extension Additions to PDL CC.PHAR.15 (PDF)
- Linezolid (Zyvox) CP.PMN.27 (PDF)
- Lisdexamfetamine (Vyvanse) CP.PMN.121 (PDF)
- Lisocabtagene Maraleucel (Breyanzi) CP.PHAR.483 (PDF)
- Lofexidine (Lucemyra) CP.PMN.152 (PDF)
- Lomitapide (Juxtapid) CP.PHAR.283 (PDF)
- Lomustine (Gleostine) CP.PHAR.507 (PDF)
- Lonafarnib (Zokinvy) CP.PHAR.499 (PDF)
- Loncastuximab Tesirine-lpyl (Zynlonta) CP.PHAR.539 (PDF)
- Long-term Antibiotic Treatment for Tick-borne Diseases CP.PMN.279 (PDF)
- Lorlatinib (Lorbrena) CP.PHAR.406 (PDF)
- Loteprednol etabonate (Eysuvis) CP.PMN.260 (PDF)
- Lovotibeglogene Autotemcel (Lovo-Cel) CP.PHAR.627 (PDF)
- Lubiprostone (Amitiza) CP.PMN.142 (PDF)
- Luliconazole Cream (Luzu) CP.PMN.166 (PDF)
- Lumacaftor/Ivacaftor (Orkambi) CP.PHAR.213 (PDF)
- Lumasiran (Oxlumo) CP.PHAR.473 (PDF)
- Lumateperone (Caplyta) CP.PMN.232 (PDF)
- Lurbinectedin (Zepzelca) CP.PHAR.500 (PDF)
- Luspatercept-aamt (Reblozyl) CP.PHAR.450 (PDF)
- Lusutrombopag (Mulpleta) CP.PHAR.407 (PDF)
- Lutetium Lu 177 dotatate (Lutathera) CP.PHAR.384 (PDF)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) CP.PHAR.582 (PDF)
- Nabumetone Double-Strength (Relafen DS) CP.PMN.287 (PDF)
- Nadofaragene Firadenovec-vncg (Adstiladrin) CP.PHAR.461 (PDF)
- Nafarelin Acetate (Synarel) CP.PHAR.174 (PDF)
- Naldemedine (Symproic) CP.PMN.112 (PDF)
- Nalmefene (Opvee) CP.PHAR.638 (PDF)
- Naloxegol (Movantik) CP.PMN.171 (PDF)
- Naltrexone (Vivitrol) CP.PHAR.96 (PDF)
- Naproxen/Esomeprazole (Vimovo) CP.PMN.117 (PDF)
- Narsoplimab (OMS721) CP.PHAR.527 (PDF)
- Natalizumab (Tysabri) CP.PHAR.259 (PDF)
- Naxitamab-gqgk (Danyelza) CP.PHAR.523 (PDF)
- Necitumumab (Portrazza) CP.PHAR.320 (PDF)
- Nedosiran (DCR-PHXC) CP.PHAR.619 (PDF)
- Neomycin/Fluocinolone Cream (Neo-Synalar) CP.PMN.167 (PDF)
- Neratinib (Nerlynx) CP.PHAR.365 (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) CP.PMN.158 (PDF)
- Nifurtimox (Lampit) CP.PMN.256 (PDF)
- Nilotinib (Tasigna) CP.PHAR.76 (PDF)
- Nintedanib (Ofev) CP.PHAR.285 (PDF)
- Niraparib (Zejula) CP.PHAR.408 (PDF)
- Nirmatrelvir and Ritonavir (Paxlovid) CP.PMN.288 (PDF)
- Nirsevimab (Beyfortus) CP.PHAR.614 (PDF)
- Nitisinone (Nityr, Orfadin) CP.PHAR.132 (PDF)
- Nivolumab (Opdivo) CP.PHAR.121 (PDF)
- Nivolumab and Relatlimab-rmbw (Opdualag) CP.PHAR.588 (PDF)
- No Coverage Criteria, Recent Label Changes Pending Clinical Policy Update CP.PMN.255 (PDF)
- Non-Calcium Phosphate Binders CP.PMN.04 (PDF)
- Non-Preferred Blood Glucose Monitors/Test Strips CP.PMN.215 (PDF)
- Nusinersen (Spinraza) CP.PHAR.327 (PDF)
- Paclitaxel, Protein-Bound (Abraxane) CP.PHAR.176 (PDF)
- Pacritinib (Vonjo) CP.PHAR.583 (PDF)
- Palbociclib (Ibrance) CP.PHAR.125 (PDF)
- Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) CP.PHAR.291 (PDF)
- Palivizumab (Synagis) CP.PHAR.16 (PDF)
- Palovarotene CP.PHAR.548 (PDF)
- Pancrelipase (Creon, Pancreaze, Pertyze, Viokace, Zenpep) CP.PMN.226 (PDF)
- Panitumumab (Vectibix) CP.PHAR.321 (PDF)
- Panobinostat (Farydak) CP.PHAR.382 (PDF)
- Parathyroid Hormone (Natpara) CP.PHAR.282 (PDF)
- Paricalcitol Injection (Zemplar) CP.PHAR.270 (PDF)
- Pasireotide (Signifor, Signifor LAR) CP.PHAR.332 (PDF)
- Patiromer (Veltassa) CP.PMN.205 (PDF)
- Patisiran (Onpattro) CP.PHAR.395 (PDF)
- Pazopanib (Votrient) CP.PHAR.81 (PDF)
- Peanut Allergen Powder-dnfp (Palforzia) CP.PMN.220 (PDF)
- Pegaspargase (Oncaspar), Calaspargase Pegol-mknl (Asparlas) CP.PHAR.353 (PDF)
- Pegcetacoplan (Empaveli, APL-2) CP.PHAR.524 (PDF)
- 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 CP.PHAR.296 (PDF)
- Peginterferon Alfa-2a (Pegasys) CP.PHAR.89 (PDF)
- Peginterferon Beta-1a (Plegridy) CP.PHAR.271 (PDF)
- Pegloticase (Krystexxa) CP.PHAR.115 (PDF)
- Pegunigalsidase Alfa-iwxj (Elfabrio) CP.PHAR.512 (PDF)
- Pegvaliase-pqpz (Palynziq) CP.PHAR.140 (PDF)
- Pegvisomant (Somavert) CP.PHAR.389 (PDF)
- Pegzilarginase (AEB1102) CP.PHAR.587 (PDF)
- Pembrolizumab (Keytruda) CP.PHAR.322 (PDF)
- Pemetrexed (Alimta, Pemfexy) CP.PHAR.368 (PDF)
- Pemigatinib (Pemazyre) CP.PHAR.496 (PDF)
- Pentosan Polysulfate Sodium (Elmiron) CP.PMN.276 (PDF)
- Perampanel (Fycompa) CP.PMN.156 (PDF)
- Perfluorohexyloctane (Miebo) CP.PMN.290 (PDF)
- Perindopril/Amlodipine (Prestalia) CP.PMN.174 (PDF)
- Pertuzumab (Perjeta) CP.PHAR.227 (PDF)
- Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) CP.PHAR.501 (PDF)
- Pexidartinib (Turalio) CP.PHAR.436 (PDF)
- Pharmacy & Therapeutics Committee CC.PHAR.13 (PDF)
- Pharmacy Prior Authorization and Medical Necessity Criteria CC.PHAR.08 (PDF)
- Pharmacy Program CC.PHAR.09 (PDF)
- Pilocarpine (Vuity) CP.PMN.270 (PDF)
- Pimavanserin (Nuplazid) CP.PMN.140 (PDF)
- Pirfenidone (Esbriet) CP.PHAR.286 (PDF)
- Pirtobrutinib (Jaypirca) CP.PHAR.620 (PDF)
- Pitolisant (Wakix) CP.PMN.221 (PDF)
- Plasminogen, human-tvmh (Ryplazim) CP.PHAR.513 (PDF)
- Plecanatide (Trulance) CP.PMN.87 (PDF)
- Plerixafor (Mozobil) CP.PHAR.323 (PDF)
- Polatuzumab Vedotin-piiq (Polivy) CP.PHAR.433 (PDF)
- Pomalidomide (Pomalyst) CP.PHAR.116 (PDF)
- Ponatinib (Iclusig) CP.PHAR.112 (PDF)
- Ponesimod (Ponvory) CP.PHAR.537 (PDF)
- Pozelimab (REGN3918) CP.PHAR.626 (PDF)
- Prademagene Zamikeracel (EB-101) CP.PHAR.609 (PDF)
- Pralatrexate (Folotyn) CP.PHAR.313 (PDF)
- Pralsetinib (Gavreto) CP.PHAR.514 (PDF)
- Pramlintide (Symlin) CP.PMN.129 (PDF)
- Prasterone (Intrarosa) CP.PMN.99 (PDF)
- Pregabalin (Lyrica, Lyrica CR) CP.PMN.33 (PDF)
- Pretomanid CP.PMN.222 (PDF)
- Progesterone (Crinone, Endometrin, Milprosa) CP.PMN.243 (PDF)
- Propranolol HCl Oral Solution (Hemangeol) CP.PMN.58 (PDF)
- Protein C Concentrate, Human (Ceprotin) CP.PHAR.330 (PDF)
- Provider Requests for Pharmacy Profiles CC.PHAR.11 (PDF)
- Prucalopride (Motegrity) CP.PMN.194 (PDF)
- Pyrimethamine (Daraprim) CP.PMN.44 (PDF)
- Ramelteon (Rozerem) CP.PMN.173 (PDF)
- Ramucirumab (Cyramza) CP.PHAR.119 (PDF)
- Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo) CP.PHAR.186 (PDF)
- Ranolazine (Ranexa, Aspruzyo Sprinkle) CP.PMN.34 (PDF)
- Ravulizumab-cwvz (Ultomiris) CP.PHAR.415 (PDF)
- Regorafenib (Stivarga) CP.PHAR.107 (PDF)
- Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree) CP.PHAR.529 (PDF)
- Remestemcel-L (Ryoncil) CP.PHAR.474 (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) CP.PHAR.168 (PDF)
- Request for Medically Necessary Drug Not on the PDL CP.PMN.16 (PDF)
- Reslizumab (Cinqair) CP.PHAR.223 (PDF)
- Retifanlimab-dlwr (Zynyz) CP.PHAR.629 (PDF)
- Ribavirin (Rebetol, Ribasphere) CP.PHAR.141 (PDF)
- Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) CP.PHAR.334 (PDF)
- Rifabutin (Mycobutin) CP.PMN.223 (PDF)
- Rifamycin (Aemcolo) CP.PMN.196 (PDF)
- Rifapentine (Priftin) CP.PMN.05 (PDF)
- Rifaximin (Xifaxan) CP.PMN.47 (PDF)
- Rilonacept (Arcalyst) CP.PHAR.266 (PDF)
- RimabotulinumtoxinB (Myobloc) CP.PHAR.233 (PDF)
- Rimegepant (Nurtec ODT) CP.PHAR.490 (PDF)
- Riociguat (Adempas) CP.PHAR.195 (PDF)
- Ripretinib (Qinlock) CP.PHAR.502 (PDF)
- Risankizumab-rzaa (Skyrizi) CP.PHAR.426 (PDF)
- Risdiplam (Evrysdi) CP.PHAR.477 (PDF)
- Risedronate (Actonel, Atelvia) CP.PMN.100 (PDF)
- Risperidone Long-Acting Injection (Perseris, Risperdal Consta, Rykindo, Uzedy) CP.PHAR.293 (PDF)
- Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) CP.PHAR.260 (PDF)
- Rivaroxaban (Xarelto) CP.PMN.247 (PDF)
- Rivastigmine (Exelon) CP.PMN.101 (PDF)
- Roflumilast (Daliresp, Zoryve) CP.PMN.46 (PDF)
- Rolapitant (Varubi) CP.PMN.102 (PDF)
- Romidepsin (Istodax) CP.PHAR.314 (PDF)
- Romiplostim (Nplate) CP.PHAR.179 (PDF)
- Romosozumab-aqqg (Evenity) CP.PHAR.428 (PDF)
- Ropeginterferon Alfa-2b-njft (BESREMi) CP.PHAR.570 (PDF)
- RP-L201 CP.PHAR.599 (PDF)
- Rucaparib (Rubraca) CP.PHAR.350 (PDF)
- Rufinamide (Banzel) CP.PMN.157 (PDF)
- Ruxolitinib (Jakafi, Opzelura) CP.PHAR.98 (PDF)
- Tadalafil (Adcirca, Alyq, Tadliq) CP.PHAR.198 (PDF)
- Tadalafil BHP - ED (Cialis) CP.PMN.132 (PDF)
- Tafamidis (Vyndaqel, Vyndamax) CP.PHAR.432 (PDF)
- Tafasitamab-cxix (Monjuvi) CP.PHAR.508 (PDF)
- Talazoparib (Talzenna) CP.PHAR.409 (PDF)
- Taliglucerase Alfa (Elelyso) CP.PHAR.157 (PDF)
- Talimogene laherepvec (Imlygic) CP.PHAR.542 (PDF)
- Tapinarof (Vtama) CP.PMN.283 (PDF)
- Tasimelteon (Hetlioz, Hetlioz LQ) CP.PMN.104 (PDF)
- Tavaborole (Kerydin) CP.PMN.105 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac) CP.PMN.244 (PDF)
- Tazemetostat (Tazverik) CP.PHAR.452 (PDF)
- Tebentafusp-tebn (Kimmtrak) CP.PHAR.575 (PDF)
- Teclistamab-cqyv (Tecvayli) CP.PHAR.611 (PDF)
- Tedizolid (Sivextro) CP.PMN.62 (PDF)
- Teduglutide (Gattex) CP.PHAR.114 (PDF)
- Tegaserod (Zelnorm) CP.PMN.206 (PDF)
- Telotristat Ethyl (Xermelo) CP.PHAR.337 (PDF)
- Temozolomide (Temodar) CP.PHAR.77 (PDF)
- Temsirolimus (Torisel) CP.PHAR.324 (PDF)
- Tenapanor (Ibsrela) CP.PMN.224 (PDF)
- Tenofovir Alafenamide Fumarate (Vemlidy) CP.PMN.268 (PDF)
- Teplizumab-mzwv (Tzield) CP.PHAR.492 (PDF)
- Tepotinib (Tepmetko) CP.PHAR.530 (PDF)
- Teprotumumab (Tepezza) CP.PHAR.465 (PDF)
- Teriflunomide (Aubagio) CP.PHAR.262 (PDF)
- Teriparatide (Forteo) CP.PHAR.188 (PDF)
- Tesamorelin (Egrifta SV) CP.PHAR.109 (PDF)
- Testosterone (Testopel, Jatenzo, Kyzatrex, Tlando) CP.PHAR.354 (PDF)
- Tetrabenazine (Xenazine) CP.PHAR.92 (PDF)
- Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) CP.PHAR.377 (PDF)
- Tezepelumab-ekko (Tezspire) CP.PHAR.576 (PDF)
- Thalidomide (Thalomid) CP.PHAR.78 (PDF)
- Thioguanine (Tabloid) CP.PHAR.437 (PDF)
- Thyrotropin alfa (Thyrogen) CP.PHAR.95 (PDF)
- Tildrakizumab-asmn (Ilumya) CP.PHAR.386 (PDF)
- Timothy grass pollen allergen extract (Grastek) CP.PMN.84 (PDF)
- Tisagenlecleucel (Kymriah) CP.PHAR.361 (PDF)
- Tisotumab Vedotin-tftv (Tivdak) CP.PHAR.561 (PDF)
- Tivozanib (Fotivda) CP.PHAR.538 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) CP.PHAR.211 (PDF)
- Tocilizumab (Actemra) CP.PHAR.263 (PDF)
- Tofacitinib (Xeljanz, Xeljanz XR) CP.PHAR.267 (PDF)
- Tofersen (Qalsody) CP.PHAR.591 (PDF)
- Tolvaptan (Jynarque, Samsca) CP.PHAR.27 (PDF)
- Topical Immunomodulators CP.PMN.107 (PDF)
- Topiramate Extended-Release (Qudexy XR, Trokendi XR) CP.PMN.281 (PDF)
- Topotecan (Hycamtin) CP.PHAR.64 (PDF)
- Toremifene (Fareston) CP.PMN.126 (PDF)
- Trabectedin (Yondelis) CP.PHAR.204 (PDF)
- Tralokinumab-ldrm (Adbry) CP.PHAR.577 (PDF)
- Trametinib (Mekinist) CP.PHAR.240 (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase CP.PHAR.228 (PDF)
- Tremelimumab-actl (Imjudo) CP.PHAR.612 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso) CP.PHAR.199 (PDF)
- Triamcinolone ER Injection (Zilretta) CP.PHAR.371 (PDF)
- Triclabendazole (Egaten) CP.PMN.207 (PDF)
- Trientine (Cuvrior, Syprine) CP.PHAR.438 (PDF)
- Trifarotene (Aklief) CP.PMN.225 (PDF)
- Trifluridine/Tipiracil (Lonsurf) CP.PHAR.383 (PDF)
- Triheptanoin (Dojolvi) CP.PHAR.509 (PDF)
- Triptorelin Pamoate (Trelstar, Triptodur) CP.PHAR.175 (PDF)
- Trofineatide (Daybue) CP.PHAR.600 (PDF)
- Troriluzole (BHV-4157) CP.PHAR.639 (PDF)
- Tucatinib (Tukysa) CP.PHAR.497 (PDF)
- Valbenazine (Ingrezza) CP.PHAR.340 (PDF)
- Valoctocogene Roxaparvovec-rvox (Roctavian) CP.PHAR.466 (PDF)
- Valrubicin (Valstar) CP.PHAR.439 (PDF)
- Vandetanib (Caprelsa) CP.PHAR.80 (PDF)
- Varenicline (Tyrvaya) CP.PMN.273 (PDF)
- Vedolizumab (Entyvio) CP.PHAR.265 (PDF)
- Velaglucerase Alfa (VPRIV) CP.PHAR.163 (PDF)
- Velmanase Alfa-tycv (Lamzede) CP.PHAR.601 (PDF)
- Vemurafenib (Zelboraf) CP.PHAR.91 (PDF)
- Venetoclax (Venclexta) CP.PHAR.129 (PDF)
- Verteporfin (Visudyne) CP.PHAR.187 (PDF)
- Vestronidase Alfa-vjbk (Mepsevii) CP.PHAR.374 (PDF)
- Vigabatrin (Sabril) CP.PHAR.169 (PDF)
- Vilazodone (Viibryd) CP.PMN.145 (PDF)
- Viloxazine (Qelbree) CP.PMN.264 (PDF)
- Viltolarsen (Viltepso) CP.PHAR.484 (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo) CP.PHAR.315 (PDF)
- Vismodegib (Erivedge) CP.PHAR.273 (PDF)
- Voclosporin (Lupkynis) CP.PHAR.504 (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) CP.PHAR.372 (PDF)
- Vorinostat (Zolinza) CP.PHAR.83 (PDF)
- Vortioxetine (Trintellix) CP.PMN.65 (PDF)
- Vosoritide (Voxzogo) CP.PHAR.525 (PDF)
- Voxelotor (Oxbryta) CP.PHAR.451 (PDF)
- Vutrisiran (Amvuttra) CP.PHAR.550 (PDF)