Kansas Clinical Payment Policies | Ambetter from Sunflower Health Plan
Clinical & Payment Policies
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures. 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.
Not all policies found in the Sunflower Health Plan Clinical Policy Manual apply to all Sunflower Health Plan members. Sunflower policies are applied according to member eligibility and medical necessity criteria as defined in policy CP.MP.68. Policies in the Sunflower Health Plan Clinical Policy Manual may have either a Sunflower or a “Centene” heading. Sunflower utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Sunflower 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 Sunflower. In addition, Sunflower 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 Sunflower Health Plan.
If you have any questions regarding these policies, please contact Customer Service and ask to be directed to the Medical Management department.
For members 18 years of age or older authorizations for oncology-related chemotherapeutic drugs and supportive agents are administered by New Century Health. For members 17 years of age or younger the oncology clinical policies listed below apply.
| Policy Number | Medication Name |
|---|---|
| CP.PCH.06 (PDF) | VALCYTE, Valganciclovir HCl |
| CP.PCH.07 (PDF) | VIAGRA, Sildenafil Citrate |
| CP.PCH.09 (PDF) | CUPRIMINE, Penicillamine |
| CP.PCH.11 (PDF) | UCERIS, Budesonide (Intrarectal) |
| CP.PCH.12 (PDF) | CONTRAVE, Naltrexone HCl-Bupropion HCl |
| CP.PCH.13 (PDF) | ADIPEX-P, Phentermine HCl |
| CP.PCH.26 (PDF) | BRIVIACT, Brivaracetam |
| CP.PCH.27 (PDF) | Compounded Medications |
| CP.PCH.28 (PDF) | Diclofenac (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex) |
| CP.PCH.30 (PDF) | Memantine ER (Namenda XR), Memantine/Donepezil (Namzaric) |
| CP.PCH.32 (PDF) | Dapsone (Aczone Gel) |
| CP.PCH.37 (PDF) | Aripiprazole Orally Disintegrating Tablet |
| CP.PCH.38 (PDF) | Fingolimod (Gilenya) |
| CP.PCH.40 (PDF) | Teriflunomide (Aubagio) |
| CP.PCH.41 (PDF) | Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam) |
| CP.PCH.42 (PDF) | Deutetrabenazine (Austedo) |
| CP.PCH.43 (PDF) | CLENPIQ, Sodium Picosulfate-Magnesium Oxide-Anhydrous Citric Acid OSMOPREP, Sodium Phosphate Monobasic-Sodium Phosphate Dibasic MOVIPREP, PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-Ascorbic Acid PREPOPIK, Sodium Picosulfate-Magnesium Oxide-Anhydrous Citric Acid |
| CP.PCH.44 (PDF) | Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) |
| CP.PCH.45 (PDF) | Apalutamide (Erleada) |
| CP.PCH.46 (PDF) | Interferon Beta-1b (Betaseron, Extavia) |
| CP.PCH.47 (PDF) | Phendimetrazine |
| CP.PCH.48 (PDF) | Valbenazine (Ingrezza) |
| CP.PCH.49 (PDF) | Omalizumab (Xolair®) |
| CP.PHAR.01 (PDF) | XOLAIR, Omalizumab |
| CP.PHAR.05 (PDF) | Hyaluronate Derivatives |
| CP.PHAR.11 (PDF) | CRYSVITA, Burosumab-twza |
| CP.PHAR.14 (PDF) | MAKENA, Hydroxyprogesterone Caproate HYDROXYPROGESTERONE CAPROATE, Hydroxyprogesterone Caproate |
| CP.PHAR.16 (PDF) | SYNAGIS, Palivizumab |
| CP.PHAR.24 (PDF) | TAVALISSE, Fostamatinib Disodium |
| CP.PHAR.27 (PDF) | JYNARQUE, Tolvaptan SAMSCA, Tolvaptan |
| CP.PHAR.40 (PDF) | SANDOSTATIN, Octreotide Acetate SANDOSTATIN LAR DEPOT, Octreotide Acetate |
| CP.PHAR.41 (PDF) | FUZEON, Enfuvirtide |
| CP.PHAR.43 (PDF) | KUVAN, Sapropterin Dihydrochloride |
| CP.PHAR.50 (PDF) | MEKTOVI, Binimetinib |
| CP.PHAR.52 (PDF) | ACTIMMUNE, Interferon Gamma-1B |
| CP.PHAR.58 (PDF) | PROLIA, Denosumab XGEVA, Denosumab |
| CP.PHAR.59 (PDF) | RECLAST, Zoledronic Acid ZOMETA, Zoledronic Acid |
| CP.PHAR.60 (PDF) | XELODA, Capecitabine |
| CP.PHAR.61 (PDF) | SENSIPAR, Cinacalcet HCl |
| CP.PHAR.63 (PDF) | AFINITOR, Everolimus ZORTRESS, Everolimus (Immunosuppressant) AFINITOR DISPERZ, Everolimus |
| CP.PHAR.64 (PDF) | HYCAMTIN, Topotecan HCl |
| CP.PHAR.65 (PDF) | GLEEVEC, Imatinib Mesylate |
| CP.PHAR.68 (PDF) | Gefitinib (Iressa) |
| CP.PHAR.69 (PDF) | NEXAVAR, Sorafenib Tosylate |
| CP.PHAR.71 (PDF) | REVLIMID, Lenalidomide |
| CP.PHAR.72 (PDF) | SPRYCEL, Dasatinib |
| CP.PHAR.73 (PDF) | SUTENT, Sunitinib Malate |
| CP.PHAR.74 (PDF) | TARCEVA, Erlotinib HCl |
| CP.PHAR.75 (PDF) | TARGRETIN, Bexarotene |
| CP.PHAR.76 (PDF) | TASIGNA, Nilotinib HCl |
| CP.PHAR.77 (PDF) | TEMODAR, Temozolomide |
| CP.PHAR.78 (PDF) | THALOMID, Thalidomide |
| CP.PHAR.79 (PDF) | TYKERB, Lapatinib Ditosylate |
| CP.PHAR.80 (PDF) | CAPRELSA, Vandetanib |
| CP.PHAR.81 (PDF) | VOTRIENT, Pazopanib HCl |
| CP.PHAR.82 (PDF) | XIAFLEX, Collagenase Clostridium Histolyticum |
| CP.PHAR.83 (PDF) | ZOLINZA, Vorinostat |
| CP.PHAR.84 (PDF) | ZYTIGA, Abiraterone Acetate YONSA, Abiraterone Acetate |
| CP.PHAR.88 (PDF) | BENLYSTA, Belimumab |
| CP.PHAR.89 (PDF) | PEGASYS, Peginterferon alfa-2a SYLATRON, Peginterferon alfa-2b (Antineoplastic) PEGINTRON, Peginterferon alfa-2b |
| CP.PHAR.90 (PDF) | XALKORI, Crizotinib |
| CP.PHAR.91 (PDF) | ZELBORAF, Vemurafenib |
| CP.PHAR.92 (PDF) | XENAZINE, Tetrabenazine |
| CP.PHAR.93 (PDF) | AVASTIN, Bevacizumab ZIRABEV MVASI |
| CP.PHAR.94 (PDF) | ARALAST NP, Alpha1-Proteinase Inhibitor (Human) GLASSIA, Alpha1-Proteinase Inhibitor (Human) ZEMAIRA, Alpha1-Proteinase Inhibitor (Human) PROLASTIN-C, Alpha1-Proteinase Inhibitor (Human) |
| CP.PHAR.95 (PDF) | THYROGEN, Thyrotropin Alfa |
| CP.PHAR.96 (PDF) | Naltrexone (Vivitrol) |
| CP.PHAR.97 (PDF) | SOLIRIS, Eculizumab |
| CP.PHAR.98 (PDF) | JAKAFI, Ruxolitinib Phosphate |
| CP.PHAR.100 (PDF) | INLYTA, Axitinib |
| CP.PHAR.101 (PDF) | Mifepristone (Korlym) |
| CP.PHAR.103 (PDF) | Immune Globulins |
| CP.PHAR.105 (PDF) | BOSULIF, Bosutinib |
| CP.PHAR.106 (PDF) | XTANDI, Enzalutamide |
| CP.PHAR.107 (PDF) | STIVARGA, Regorafenib |
| CP.PHAR.108 (PDF) | SYNRIBO, Omacetaxine Mepesuccinate |
| CP.PHAR.109 (PDF) | EGRIFTA, Tesamorelin Acetate |
| CP.PHAR.111 (PDF) | COMETRIQ, Cabozantinib S-Malate CABOMETYX, Cabozantinib S-Malate |
| CP.PHAR.112 (PDF) | Ponatinib (Iclusig) |
| CP.PHAR.114 (PDF) | GATTEX, Teduglutide (rDNA) |
| CP.PHAR.115 (PDF) | Pegloticase (Krystexxa) |
| CP.PHAR.116 (PDF) | POMALYST, Pomalidomide |
| CP.PHAR.119 (PDF) | CYRAMZA, Ramucirumab |
| CP.PHAR.120 (PDF) | PROVENGE, Sipuleucel-T |
| CP.PHAR.121 (PDF) | OPDIVO, Nivolumab |
| CP.PHAR.123 (PDF) | REPATHA, Evolocumab |
| CP.PHAR.124 (PDF) | Alirocumab (Praluent) |
| CP.PHAR.125 (PDF) | Palbociclib (Ibrance) |
| CP.PHAR.126 (PDF) | IMBRUVICA, Ibrutinib |
| CP.PHAR.127 (PDF) | BRAFTOVI, Encorafenib |
| CP.PHAR.128 (PDF) | AIMOVIG, Erenumab-aooe |
| CP.PHAR.129 (PDF) | Venetoclax (Venclexta) |
| CP.PHAR.130 (PDF) | DOPTELET, Avatrombopag Maleate |
| CP.PHAR.131 (PDF) | Infertility and Fertility Preservation |
| CP.PHAR.132 (PDF) | NITYR, Nitisinone ORFADIN, Nitisinon |
| CP.PHAR.133 (PDF) | ZYDELIG, Idelalisib |
| CP.PHAR.134 (PDF) | OTREXUP, Methotrexate (Antirheumatic) XATMEP, Methotrexate RASUVO, Methotrexate (Antirheumatic) |
| CP.PHAR.136 (PDF) | Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) |
| CP.PHAR.137 (PDF) | TIBSOVO, Ivosidenib |
| CP.PHAR.138 (PDF) | LENVIMA, Lenvatinib Mesylate |
| CP.PHAR.139 (PDF) | POTELIGEO, Mogamulizumab-kpkc |
| CP.PHAR.140 (PDF) | PALYNZIQ, Pegvaliase-pqpz |
| CP.PHAR.141 (PDF) | COPEGUS, Ribavirin (Hepatitis C) RIBASPHERE RIBAPAK, Ribavirin (Hepatitis C) RIBASPHERE, Ribavirin (Hepatitis C) MODERIBA, Ribavirin (Hepatitis C) REBETOL, Ribavirin (Hepatitis C) |
| CP.PHAR.142 (PDF) | HEPSERA, Adefovir Dipivoxil |
| CP.PHAR.143 (PDF) | CYSTADANE, Betaine |
| CP.PHAR.145 (PDF) | JADENU, Deferasirox EXJADE, Deferasirox |
| CP.PHAR.146 (PDF) | DESFERAL, Deferoxamine Mesylate |
| CP.PHAR.147 (PDF) | Deferiprone (Ferriprox) |
| CP.PHAR.149 (PDF) | LIORESAL INTRATHECAL, Baclofen GABLOFEN, Baclofen OZOBAX, Baclofen |
| CP.PHAR.150 (PDF) | INCRELEX, Mecasermin |
| CP.PHAR.151 (PDF) | Levoleucovorin (Fusilev, Khapzory) |
| CP.PHAR.152 (PDF) | ALDURAZYME, Laronidase |
| CP.PHAR.153 (PDF) | CERDELGA, Eliglustat Tartrate |
| CP.PHAR.154 (PDF) | CEREZYME, Imiglucerase |
| CP.PHAR.155 (PDF) | CYSTAGON, Cysteamine Bitartrate |
| CP.PHAR.156 (PDF) | ELAPRASE, Idursulfase |
| CP.PHAR.157 (PDF) | ELELYSO, Taliglucerase Alfa |
| CP.PHAR.158 (PDF) | FABRAZYME, Agalsidase beta |
| CP.PHAR.159 (PDF) | KANUMA, Sebelipase Alfa |
| CP.PHAR.160 (PDF) | LUMIZYME, Alglucosidase Alfa |
| CP.PHAR.161 (PDF) | NAGLAZYME, Galsulfase |
| CP.PHAR.162 (PDF) | VIMIZIM, Elosulfase Alfa |
| CP.PHAR.163 (PDF) | VPRIV, Velaglucerase Alfa |
| CP.PHAR.164 (PDF) | ZAVESCA, Miglustat |
| CP.PHAR.165 (PDF) | Ferumoxytol (Feraheme) |
| CP.PHAR.168 (PDF) | H.P. ACTHAR, Corticotropin |
| CP.PHAR.169 (PDF) | SABRIL, Vigabatrin |
| CP.PHAR.170 (PDF) | FIRMAGON, Degarelix Acetate |
| CP.PHAR.171 (PDF) | ZOLADEX, Goserelin Acetate |
| CP.PHAR.172 (PDF) | SUPPRELIN LA, Histrelin Acetate (CPP) VANTAS, Histrelin Acetate |
| CP.PHAR.173 (PDF) | ELIGARD, Leuprolide Acetate (3 Month) LUPRON DEPOT-PED, Leuprolide Acetate (CPP) LUPRON DEPOT, Leuprolide Acetate LUPANETA PACK, Leuprolide Acetate & Norethindrone Acetate |
| CP.PHAR.174 (PDF) | SYNAREL, Nafarelin Acetate |
| CP.PHAR.175 (PDF) | TRIPTODUR, Triptorelin Pamoate (CPP) TRELSTAR, Triptorelin Pamoate |
| CP.PHAR.176 (PDF) | ABRAXANE, Paclitaxel Protein-Bound Particles |
| CP.PHAR.177 (PDF) | Ecallantide (Kalbitor) |
| CP.PHAR.178 (PDF) | FIRAZYR, Icatibant Acetate |
| CP.PHAR.179 (PDF) | NPLATE, Romiplostim |
| CP.PHAR.180 (PDF) | PROMACTA, Eltrombopag Olamine |
| CP.PHAR.181 (PDF) | Hemin (Panhematin) |
| CP.PHAR.184 (PDF) | EYLEA, Aflibercept |
| CP.PHAR.186 (PDF) | LUCENTIS, Ranibizumab |
| CP.PHAR.187 (PDF) | Verteporfin |
| CP.PHAR.188 (PDF) | FORTEO, Teriparatide (Recombinant) |
| CP.PHAR.189 (PDF) | BONIVA INJ, Ibandronate Sodium |
| CP.PHAR.190 (PDF) | LETAIRIS, Ambrisentan |
| CP.PHAR.191 (PDF) | TRACLEER, Bosentan |
| CP.PHAR.192 (PDF) | FLOLAN, Epoprostenol Sodium VELETRI, Epoprostenol Sodium |
| CP.PHAR.193 (PDF) | VENTAVIS, Iloprost |
| CP.PHAR.194 (PDF) | OPSUMIT, Macitentan |
| CP.PHAR.195 (PDF) | ADEMPAS, Riociguat |
| CP.PHAR.196 (PDF) | Selexipag (Uptravi) |
| CP.PHAR.197 (PDF) | REVATIO, Sildenafil Citrate (Pulmonary Hypertension) |
| CP.PHAR.198 (PDF) | ADCIRCA, Tadalafil (Pulmonary Hypertension) |
| CP.PHAR.199 (PDF) | REMODULIN, Treprostinil Sodium TYVASO, Treprostinil ORENITRAM, Treprostinil Diolamine |
| CP.PHAR.200 (PDF) | NUCALA, Mepolizumab |
| CP.PHAR.201 (PDF) | NULOJIX, Belatacept |
| CP.PHAR.202 (PDF) | RUCONEST, C1 Esterase Inhibitor (Recombinant) BERINERT, C1 Esterase Inhibitor (Human) HAEGARDA, C1 Esterase Inhibitor (Human) CINRYZE, C1 Esterase Inhibitor (Human) |
| CP.PHAR.203 (PDF) | Cosyntropin (Cortrosyn) |
| CP.PHAR.204 (PDF) | YONDELIS, Trabectedin |
| CP.PHAR.206 (PDF) | CARBAGLU, Carglumic Acid |
| CP.PHAR.207 (PDF) | Glycerol Phenylbutyrate (Ravicti) |
| CP.PHAR.208 (PDF) | Sodium Phenylbutyrate (Buphenyl) |
| CP.PHAR.209 (PDF) | CAYSTON, Aztreonam Lysine |
| CP.PHAR.210 (PDF) | KALYDECO, Ivacaftor |
| CP.PHAR.211 (PDF) | TOBI, Tobramycin KITABIS PAK, Tobramycin BETHKIS, Tobramycin TOBI PODHALER, Tobramycin |
| CP.PHAR.212 (PDF) | PULMOZYME, Dornase Alfa |
| CP.PHAR.213 (PDF) | ORKAMBI, Lumacaftor-Ivacaftor |
| CP.PHAR.214 (PDF) | DDAVP, Desmopressin Acetate NOCDURNA, Desmopressin Acetate STIMATE, Desmopressin Acetate NOCTIVA, Desmopressin Acetate |
| CP.PHAR.215 (PDF) | Factor VIII (Human, Recombinant) |
| CP.PHAR.216 (PDF) | Factor VIII/von Willebrand Factor Complex (Human – Alphanate, Humate-P, Wilate); von Willebrand Factor (Recombinant – Vonvendi) |
| CP.PHAR.217 (PDF) | FEIBA, Antiinhibitor Coagulant Complex |
| CP.PHAR.218 (PDF) | Factor IX (Human, Recombinant) |
| CP.PHAR.219 (PDF) | BEBULIN, Factor IX Complex PROFILNINE, Factor IX Complex |
| CP.PHAR.220 (PDF) | NOVOSEVEN RT, Coagulation Factor VIIa (Recombinant) |
| CP.PHAR.221 (PDF) | CORIFACT, Factor XIII Concentrate (Human) |
| CP.PHAR.222 (PDF) | TRETTEN, Coagulation Factor XIII A-Subunit (Recombinant) |
| CP.PHAR.223 (PDF) | Reslizumab (Cinqair) |
| CP.PHAR.224 (PDF) | Enoxaparin (Lovenox) |
| CP.PHAR.225 (PDF) | FRAGMIN, Dalteparin Sodium |
| CP.PHAR.226 (PDF) | ARIXTRA, Fondaparinux Sodium |
| CP.PHAR.227 (PDF) | PERJETA, Pertuzumab |
| CP.PHAR.228 (PDF) | TRAZIMERA ONTRUZANT HERZUMA HERCEPTIN HYLECTA, Trastuzumab-Hyaluronidase-oysk HERCEPTIN, Trastuzumab OGIVRI, Trastuzumab-dkst KANJINTI |
| CP.PHAR.229 (PDF) | KADCYLA, Ado-Trastuzumab Emtansine |
| CP.PHAR.230 (PDF) | DYSPORT, AbobotulinumtoxinA |
| CP.PHAR.231 (PDF) | XEOMIN, IncobotulinumtoxinA |
| CP.PHAR.232 (PDF) | BOTOX, OnabotulinumtoxinA |
| CP.PHAR.233 (PDF) | MYOBLOC, RimabotulinumtoxinB |
| CP.PHAR.234 (PDF) | Ferric Carboxymaltose (Injectafer) |
| CP.PHAR.235 (PDF) | TECENTRIQ, Atezolizumab |
| CP.PHAR.236 (PDF) | ARANESP ALBUMIN FREE, Darbepoetin Alfa |
| CP.PHAR.237 (PDF) | EPOGEN, Epoetin Alfa PROCRIT, Epoetin Alfa RETACRIT, Epoetin Alfa-epbx |
| CP.PHAR.238 (PDF) | MIRCERA, Methoxy Polyethylene Glycol-Epoetin Beta |
| CP.PHAR.239 (PDF) | TAFINLAR, Dabrafenib Mesylate |
| CP.PHAR.240 (PDF) | MEKINIST, Trametinib Dimethyl Sulfoxide |
| CP.PHAR.243 (PDF) | LEMTRADA, Alemtuzumab (MS) |
| CP.PHAR.246 (PDF) | ILARIS, Canakinumab |
| CP.PHAR.248 (PDF) | AMPYRA, Dalfampridine |
| CP.PHAR.249 (PDF) | TECFIDERA, Dimethyl Fumarate VUMERITY, Diroximel Fumarate |
| CP.PHAR.251 (PDF) | GILENYA, Fingolimod HCl |
| CP.PHAR.252 (PDF) | COPAXONE, Glatiramer Acetate GLATOPA, Glatiramer Acetate |
| CP.PHAR.255 (PDF) | AVONEX, Interferon Beta-1a REBIF, Interferon Beta-1a |
| CP.PHAR.256 (PDF) | EXTAVIA, Interferon Beta-1b BETASERON, Interferon Beta-1b |
| CP.PHAR.258 (PDF) | NOVANTRONE, Mitoxantrone HCl |
| CP.PHAR.259 (PDF) | TYSABRI MS, Natalizumab |
| CP.PHAR.260 (PDF) | TRUXIMA, Rituximab-abbs RITUXAN HYCELA, Rituximab-Hyaluronidase Human RITUXAN, Rituximab RUXIENCE |
| CP.PHAR.266 (PDF) | ARCALYST, Rilonacept |
| CP.PHAR.270 (PDF) | ZEMPLAR, Paricalcitol |
| CP.PHAR.271 (PDF) | Peginterferon Beta-1a (Plegridy) |
| CP.PHAR.272 (PDF) | ODOMZO, Sonidegib Phosphate |
| CP.PHAR.273 (PDF) | ERIVEDGE, Vismodegib |
| CP.PHAR.277 (PDF) | CYTOGAM, Cytomegalovirus Immune Globulin (Human) |
| CP.PHAR.282 (PDF) | Parathyroid Hormone (Natpara) |
| CP.PHAR.283 (PDF) | Lomitapide (Juxtapid) |
| CP.PHAR.285 (PDF) | OFEV, Nintedanib Esylate |
| CP.PHAR.286 (PDF) | Pirfenidone (Esbriet) |
| CP.PHAR.287 (PDF) | Obeticholic Acid (Ocaliva) |
| CP.PHAR.288 (PDF) | EXONDYS 51, Eteplirsen |
| CP.PHAR.289 (PDF) | PROBUPHINE IMPLANT KIT, Buprenorphine HCl SUBLOCADE, Buprenorphine PROBUPHINE IMPLANT KIT, Buprenorphine HCl SUBLOCADE, Buprenorphine |
| CP.PHAR.290 (PDF) | ARISTADA, Aripiprazole Lauroxil ABILIFY MAINTENA, Aripiprazole ARISTADA INITIO, Aripiprazole Lauroxil |
| CP.PHAR.291 (PDF) | Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza) |
| CP.PHAR.292 (PDF) | ZYPREXA RELPREVV, Olanzapine Pamoate |
| CP.PHAR.293 (PDF) | RISPERDAL CONSTA, Risperidone Microspheres PERSERIS, Risperidone |
| CP.PHAR.294 (PDF) | Osimertinib (Tagrisso) |
| CP.PHAR.295 (PDF) | LEUKINE, Sargramostim |
| CP.PHAR.296 (PDF) |
|
| CP.PHAR.297 (PDF) | GRANIX, Tbo-Filgrastim ZARXIO, Filgrastim-sndz NEUPOGEN, Filgrastim NIVESTYM, Filgrastim-aafi |
| CP.PHAR.298 (PDF) | GILOTRIF, Afatinib Dimaleate |
| CP.PHAR.300 (PDF) | Bezlotoxumab (Zinplava) |
| CP.PHAR.301 (PDF) | ERWINAZE, Asparaginase Erwinia Chrysanthemi |
| CP.PHAR.302 (PDF) | NINLARO, Ixazomib Citrate |
| CP.PHAR.303 (PDF) | ADCETRIS, Brentuximab Vedotin |
| CP.PHAR.304 (PDF) | ONIVYDE, Irinotecan HCl Liposome |
| CP.PHAR.305 (PDF) | GAZYVA, Obinutuzumab |
| CP.PHAR.306 (PDF) | Ofatumumab (Arzerra®, Kesimpta®) |
| CP.PHAR.307 (PDF) | Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) |
| CP.PHAR.308 (PDF) | EMPLICITI, Elotuzumab |
| CP.PHAR.309 (PDF) | KYPROLIS, Carfilzomib |
| CP.PHAR.310 (PDF) | DARZALEX, Daratumumab |
| CP.PHAR.311 (PDF) | BELEODAQ, Belinostat |
| CP.PHAR.312 (PDF) | BLINCYTO, Blinatumomab |
| CP.PHAR.313 (PDF) | FOLOTYN, Pralatrexate |
| CP.PHAR.314 (PDF) | ISTODAX (OVERFILL), Romidepsin |
| CP.PHAR.315 (PDF) | MARQIBO, Vincristine Sulfate Liposome |
| CP.PHAR.316 (PDF) | JEVTANA, Cabazitaxel |
| CP.PHAR.317 (PDF) | ERBITUX, Cetuximab |
| CP.PHAR.318 (PDF) | HALAVEN, Eribulin Mesylate |
| CP.PHAR.319 (PDF) | YERVOY, Ipilimumab |
| CP.PHAR.320 (PDF) | PORTRAZZA, Necitumumab |
| CP.PHAR.321 (PDF) | VECTIBIX, Panitumumab |
| CP.PHAR.322 (PDF) | KEYTRUDA, Pembrolizumab |
| CP.PHAR.323 (PDF) | MOZOBIL, Plerixafor |
| CP.PHAR.324 (PDF) | TORISEL, Temsirolimus |
| CP.PHAR.325 (PDF) | ZALTRAP, Ziv-Aflibercept |
| CP.PHAR.326 (PDF) | LARTRUVO, Olaratumab |
| CP.PHAR.327 (PDF) | SPINRAZA, Nusinersen |
| CP.PHAR.328 (PDF) | Asfotase Alfa (Strensiq) |
| CP.PHAR.329 (PDF) | Siltuximab (Sylvant) |
| CP.PHAR.330 (PDF) | CEPROTIN, Protein C Concentrate (Human) |
| CP.PHAR.331 (PDF) | EMFLAZA, Deflazacort |
| CP.PHAR.332 (PDF) | SIGNIFOR, Pasireotide Diaspartate SIGNIFOR LAR, Pasireotide Pamoate |
| CP.PHAR.333 (PDF) | BAVENCIO, Avelumab |
| CP.PHAR.334 (PDF) | Ribociclib (Kisqali), Ribociclib/Letrozole (Kisqali Femara) |
| CP.PHAR.335 (PDF) | OCREVUS, Ocrelizumab |
| CP.PHAR.336 (PDF) | DUPIXENT, Dupilumab DUPIXENT, Dupilumab (Asthma) |
| CP.PHAR.337 (PDF) | Telotristat Ethyl (Xermelo) |
| CP.PHAR.338 (PDF) | BRINEURA, Cerliponase Alfa |
| CP.PHAR.339 (PDF) | IMFINZI, Durvalumab |
| CP.PHAR.341 (PDF) | AUSTEDO, Deutetrabenazine |
| CP.PHAR.342 (PDF) | Brigatinib (Alunbrig) |
| CP.PHAR.343 (PDF) | RADICAVA, Edaravone |
| CP.PHAR.344 (PDF) | Midostaurin (Rydapt) |
| CP.PHAR.345 (PDF) | TYMLOS, Abaloparatide |
| CP.PHAR.349 (PDF) | ZYKADIA, Ceritinib |
| CP.PHAR.350 (PDF) | Rucaparib (Rubraca) |
| CP.PHAR.351 (PDF) | CUBICIN RF, Daptomycin CUBICIN, Daptomycin |
| CP.PHAR.352 (PDF) | VYXEOS, Daunorubicin-Cytarabine Liposome |
| CP.PHAR.353 (PDF) | ONCASPAR, Pegaspargase ASPARLAS, Calaspargase Pegol-mknl |
| CP.PHAR.354 (PDF) | JATENZO TESTOPEL, Testosterone |
| CP.PHAR.355 (PDF) | Abemaciclib (Verzenio) |
| CP.PHAR.357 (PDF) | ALIQOPA, Copanlisib HCl |
| CP.PHAR.358 (PDF) | MYLOTARG, Gemtuzumab Ozogamicin |
| CP.PHAR.359 (PDF) | BESPONSA, Inotuzumab Ozogamicin |
| CP.PHAR.360 (PDF) | LYNPARZA, Olaparib |
| CP.PHAR.361 (PDF) | KYMRIAH, Tisagenlecleucel |
| CP.PHAR.362 (PDF) | YESCARTA, Axicabtagene Ciloleucel |
| CP.PHAR.363 (PDF) | Enasidenib (Idhifa) |
| CP.PHAR.365 (PDF) | Neratinib (Nerlynx) |
| CP.PHAR.367 (PDF) | PREVYMIS, Letermovir |
| CP.PHAR.368 (PDF) | ALIMTA, Pemetrexed Disodium |
| CP.PHAR.369 (PDF) | Alectinib (Alecensa) |
| CP.PHAR.370 (PDF) | HEMLIBRA, Emicizumab-kxwh |
| CP.PHAR.371 (PDF) | ZILRETTA, Triamcinolone Acetonide |
| CP.PHAR.372 (PDF) | LUXTURNA, Voretigene Neparvovec-rzyl |
| CP.PHAR.373 (PDF) | FASENRA, Benralizumab |
| CP.PHAR.374 (PDF) | MEPSEVII, Vestronidase alfa-vjbk |
| CP.PHAR.377 (PDF) | Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) |
| CP.PHAR.378 (PDF) | TROGARZO, Ibalizumab-uiyk |
| CP.PHAR.379 (PDF) | PARSABIV, Etelcalcetide HCl |
| CP.PHAR.380 (PDF) | Cobimetinib (Cotellic) |
| CP.PHAR.381 (PDF) | Mechlorethamine Gel (Valchlor) |
| CP.PHAR.382 (PDF) | Panobinostat (Farydak) |
| CP.PHAR.383 (PDF) | Trifluridine/Tipiracil (Lonsurf) |
| CP.PHAR.384 (PDF) | LUTATHERA, Lutetium Lu 177 Dotatate |
| CP.PHAR.385 (PDF) | YUTIQ, Fluocinolone Acetonide (Ophth) OZURDEX, Dexamethasone (Ophth) RETISERT, Fluocinolone Acetonide (Ophth) ILUVIEN, Fluocinolone Acetonide (Ophth) |
| CP.PHAR.387 (PDF) | VIDAZA, Azacitidine |
| CP.PHAR.388 (PDF) | CHLORAMPHENICOL SODIUM SUCCINATE, Chloramphenicol Sodium Succinate |
| CP.PHAR.389 (PDF) | SOMAVERT, Pegvisomant |
| CP.PHAR.390 (PDF) | CHOLBAM, Cholic Acid |
| CP.PHAR.391 (PDF) | SOMATULINE DEPOT, Lanreotide Acetate |
| CP.PHAR.393 (PDF) | LEUCOVORIN CALCIUM, Leucovorin Calcium |
| CP.PHAR.394 (PDF) | GALAFOLD, Migalastat HCl |
| CP.PHAR.395 (PDF) | ONPATTRO, Patisiran Sodium |
| CP.PHAR.396 (PDF) | TAKHZYRO, Lanadelumab-flyo |
| CP.PHAR.397 (PDF) | LIBTAYO, Cemiplimab-rwlc |
| CP.PHAR.398 (PDF) | LUMOXITI, Moxetumomab Pasudotox-tdfk |
| CP.PHAR.399 (PDF) | VIZIMPRO, Dacomitinib |
| CP.PHAR.400 (PDF) | COPIKTRA, Duvelisib |
| CP.PHAR.401 (PDF) | ARIKAYCE, Amikacin Sulfate Liposome |
| CP.PHAR.402 (PDF) | GAMIFANT, Emapalumab-lzsg |
| CP.PHAR.405 (PDF) | TEGSEDI, Inotersen Sodium |
| CP.PHAR.406 (PDF) | LORBRENA, Lorlatinib |
| CP.PHAR.407 (PDF) | MULPLETA, Lusutrombopag |
| CP.PHAR.408 (PDF) | Niraparib (Zejula) |
| CP.PHAR.409 (PDF) | TALZENNA, Talazoparib Tosylate |
| CP.PHAR.410 (PDF) | VELCADE, Bortezomib |
| CP.PHAR.411 (PDF) | FIRDAPSE, Amifampridine Phosphate RUZURGI, Amifampridine |
| CP.PHAR.412 (PDF) | XOSPATA, Gilteritinib Fumarate |
| CP.PHAR.413 (PDF) | DAURISMO, Glasdegib Maleate |
| CP.PHAR.414 (PDF) | VITRAKVI, Larotrectinib Sulfate |
| CP.PHAR.415 (PDF) | ULTOMIRIS, Ravulizumab-cwvz |
| CP.PHAR.416 (PDF) | CABLIVI, Caplacizumab-yhdp |
| CP.PHAR.417 (PDF) | ZULRESSO, Brexanolone |
| CP.PHAR.418 (PDF) | ZINECARD, Dexrazoxane HCl TOTECT, Dexrazoxane HCl |
| CP.PHAR.419 (PDF) | REVCOVI, Elapegademase-lvlr |
| CP.PHAR.421 (PDF) | ZOLGENSMA, Onasemnogene Abeparvovec-xioi |
| CP.PHAR.422 (PDF) | MAVENCLAD, Cladribine (Multiple Sclerosis) |
| CP.PHAR.423 (PDF) | BALVERSA, Erdafitinib |
| CP.PHAR.424 (PDF) | FASLODEX, Fulvestrant |
| CP.PHAR.425 (PDF) | MYALEPT, Metreleptin |
| CP.PHAR.427 (PDF) | MAYZENT, Siponimod Fumarate |
| CP.PHAR.428 (PDF) | EVENITY, Romosozumab-aqqg |
| CP.PHAR.430 (PDF) | PIQRAY, Alpelisib |
| CP.PHAR.431 (PDF) | XPOVIO, Selinexor |
| CP.PHAR.432 (PDF) | VYNDAQEL, Tafamidis Meglumine (Cardiac) VYNDAMAX, |
| CP.PHAR.433 (PDF) | POLIVY, Polatuzumab Vedotin-piiq |
| CP.PHAR.434 (PDF) | Bremelanotide (Vyleesi) |
| CP.PHAR.435 (PDF) | NUBEQA, Darolutamide |
| CP.PHAR.436 (PDF) | TURALIO, Pexidartinib HCl |
| CP.PHAR.437 (PDF) | TABLOID, Thioguanine |
| CP.PHAR.438 (PDF) | SYPRINE, Trientine HCl |
| CP.PHAR.439 (PDF) | VALSTAR, Valrubicin |
| CP.PHAR.440 (PDF) | TRIKAFTA, Elexacaftor-Tezacaftor-Ivacaftor |
| CP.PHAR.441 (PDF) | ROZLYTREK, Entrectinib |
| CP.PHAR.442 (PDF) | INREBIC, Fedratinib HCl |
| CP.PHAR.444 (PDF) | Afamelanotide (Scenesse) |
| CP.PHAR.445 (PDF) | Brolucizumab-dbll (Beovu) |
| CP.PHAR.446 (PDF) | Flibanserin (Addyi) |
| CP.PHAR.447 (PDF) | Mercaptopurine (Purixan) |
| CP.PHAR.448 (PDF) | Mometasone Furoate (Sinuva) |
| CP.PHAR.449 (PDF) | ADAKVEO, Crizanlizumab-tmca |
| CP.PHAR.450 (PDF) | REBLOZYL, Luspatercept-aamt |
| CP.PHAR.451 (PDF) | OXBRYTA, Voxelotor |
| CP.PHAR.452 (PDF) | EPZ-6438 TAZEMETOSTAT EPZ438 |
| CP.PHAR.453 (PDF) | VYONDYS 53, Golodirsen |
| CP.PHAR.454 (PDF) | Avapritinib (Ayvakit) |
| CP.PHAR.455 (PDF) | Enfortumab Vedotin-ejfv (Padcev) |
| CP.PHAR.456 (PDF) | Fam-Trastuzumab Deruxtecan-nxki (Enhertu) |
| CP.PHAR.457 (PDF) | Givosiran (Givlaari) |
| CP.PHAR.458 (PDF) | Inebilizumab-cdon (Uplizna) |
| CP.PHAR.459 (PDF) | Iobenguane I-131 (Azedra) |
| CP.PHAR.461 (PDF) | Nadofaragene Firadenovec (Instiladrin) |
| CP.PHAR.462 (PDF) | Ozanimod (Zeposia) |
| CP.PHAR.463 (PDF) | Satralizumab-mwge (Enspryng) |
| CP.PHAR.464 (PDF) | Selumetinib (Koselugo) |
| CP.PHAR.465 (PDF) | Teprotumumab (Tepezza) |
| CP.PHAR.466 (PDF) | Valoctocogene Roxaparvovec |
| CP.PHAR.467 (PDF) | Zanubrutinib (Brukinsa) |
| CP.PHAR.468 (PDF) | Aducanumab-avwa (Aduhelm) |
| CP.PHAR.469 (PDF) | Belantamab Mafodotin (Blenrep) |
| CP.PHAR.470 (PDF) | Casimersen (Amondys 45) |
| CP.PHAR.471 (PDF) | Fosdenopterin (Nulibry) |
| CP.PHAR.472 (PDF) | Brexucabtagene Autoleucel (Tecartus) |
| CP.PHAR.473 (PDF) | Lumasiran (Oxlumo) |
| CP.PHAR.475 (PDF) | Sacituzumab Govitecan-hziy (Trodelvy) |
| CP.PHAR.476 (PDF) | Ubrogepant (Ubrelvy) |
| CP.PHAR.477 (PDF) | Risdiplam (Evrysdi) |
| CP.PHAR.478 (PDF) | Selpercatinib (Retevmo) |
| CP.PHAR.479 (PDF) | Decitabine/Cedazuridine (Inqovi) |
| CP.PHAR.480 (PDF) | Ferric Derisomaltose (Monoferric) |
| CP.PHAR.481 (PDF) | Idecabtagene Vicleucel (BB2121) |
| CP.PHAR.482 (PDF) | Isatuximab-irfc (Sarclisa) |
| CP.PHAR.483 (PDF) | Lisocabtagene Maraleucel (Breyanzi) |
| CP.PHAR.484 (PDF) | Viltolarsen (Viltepso) |
| CP.PHAR.485 (PDF) | Berotralstat (Orladeyo) |
| CP.PHAR.486 (PDF) | Bimatoprost Implant (Durysta) |
| CP.PHAR.487 (PDF) | Osilodrostat (Isturisa) |
| CP.PHAR.488 (PDF) | APOKYN, Apomorphine Hydrochloride |
| CP.PHAR.490 (PDF) | Rimegepant (Nurtec ODT) |
| CP.PHAR.491 (PDF) | Setmelanotide (Imcivree) |
| CP.PHAR.492 (PDF) | Teplizumab (PRV-031) |
| CP.PHAR.494 (PDF) | Capmatinib (Tabrecta) |
| CP.PHAR.495 (PDF) | Mitomycin for Pyelocalyceal Solution (Jelmyto) |
| CP.PHAR.496 (PDF) | Pemigatinib (Pemazyre) |
| CP.PHAR.497 (PDF) | Tucatinib (Tukysa) |
| CP.PHAR.499 (PDF) | Lonafarnib (Zokinvy) |
| CP.PHAR.500 (PDF) | Lurbinectedin (Zepzelca) |
| CP.PHAR.501 (PDF) | Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) |
| CP.PHAR.502 (PDF) | Ripretinib (Qinlock) |
| CP.PHAR.503 (PDF) | Sutimlimab-jome (Enjaymo) |
| CP.PHAR.504 (PDF) | Voclosporin (Lupkynis) |
| CP.PHAR.506 (PDF) | Antithymocyte Globulin (Atgam, Thymoglobulin) |
| CP.PHAR.507 (PDF) | Lomustine (Gleostine) |
| CP.PHAR.508 (PDF) | Tafasitamab-cxix (Monjuvi) |
| CP.PHAR.509 (PDF) | Triheptanoin (Dojolvi) |
| CP.PHAR.511 (PDF) | Evinacumab |
| CP.PHAR.513 (PDF) | Plasminogen (Ryplazim) |
| CP.PHAR.514 (PDF) | Pralsetinib (Gavreto) |
| CP.PHAR.515 (PDF) | Avacopan (Tavneos) |
| CP.PHAR.516 (PDF) | Fostemsavir (Rukobia) |
| CP.PHAR.518 (PDF) | Mannitol (Bronchitol) |
| CP.PHAR.521 (PDF) | Avalglucosidase Alfa-ngpt (Nexviazyme) |
| CP.PHAR.522 (PDF) | Margetuximab-cmkb (Margenza) |
| CP.PHAR.523 (PDF) | Naxitamab-gqgk (Danyelza) |
| CP.PHAR.524 (PDF) | Pegcetacoplan (Empaveli) |
| CP.PHAR.525 (PDF) | Vosoritide (Voxzogo) |
| CP.PHAR.526 (PDF) | Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP) |
| CP.PHAR.528 (PDF) | Odevixibat (A4250) |
| CP.PHAR.529 (PDF) |
|
| CP.PHAR.530 (PDF) | Tepotinib (Tepmetko) |
| CP.PHAR.531 (PDF) | Umbralisib (Ukoniq) |
| CP.PHAR.533 (PDF) | Ciltacabtagene Autoleucel |
| CP.PHAR.534 (PDF) | Insulin Delivery Systems (V-Go, Omnipod, InPen) |
| CP.PHAR.535 (PDF) | Melphalan flufenamide (Pepaxto) |
| CP.PHAR.536 (PDF) | Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) |
| CP.PHAR.537 (PDF) | Ponesimod (Ponvory) |
| CP.PHAR.538 (PDF) | Tivozanib (Fotivda) |
| CP.PHAR.539 (PDF) | Loncastuximab Tesirine-lpyl (Zynlonta) |
| CP.PHAR.540 (PDF) | Dostarlimab-gxly (Jemperli) |
| CP.PHAR.541 (PDF) | Sotrovimab (VIR-7831) |
| CP.PHAR.542 (PDF) | Talimogene laherepvec (Imlygic) |
| CP.PHAR.543 (PDF) | Maralixibat (LUM001) |
| CP.PHAR.544 (PDF) | Amivantamab-vmjw (Rybrevant) |
| CP.PHAR.545 (PDF) | Betibeglogene Autotemcel |
| CP.PHAR.546 (PDF) | Carbetocin |
| CP.PHAR.547 (PDF) | Infigratinib (Truseltiq) |
| CP.PHAR.548 (PDF) | Palovarotene (Brand Name) |
| CP.PHAR.549 (PDF) | Sotorasib (Lumakras) |
| CP.PHAR.550 (PDF) | Vutrisiran (ALN-TTRsc02) |
| CP.PHAR.551 (PDF) | Anifrolumab-fnia (Saphnelo) |
| CP.PHAR.552 (PDF) | Belumosudil (Rezurock) |
| CP.PHAR.553 (PDF) | Belzutifan (Welireg) |
| CP.PHAR.554 (PDF) | LEUKERAN, Chlorambucil |
| CP.PHAR.555 (PDF) | Efgartigimod Alfa-fcab (Vyvgart) |
| CP.PHAR.556 (PDF) | Elivaldogene Autotemcel |
| CP.PHAR.558 (PDF) | Mitapivat (Pyrukynd) |
| CP.PHAR.559 (PDF) | Mobocertinib (Exkivity) |
| CP.PHAR.561 (PDF) | Tisotumab vedotin-tftv (Tivdak) |
| CP.PHAR.562 (PDF) | Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) |
| CP.PHAR.563 (PDF) | Allogenic Processed Thymus Tissue-agdc (Rethymic) |
| CP.PHAR.564 (PDF) | Antithrombin III (ATryn, Thrombate III) |
| CP.PHAR.565 (PDF) | Asciminib (Scemblix) |
| CP.PHAR.566 (PDF) | Atogepant (Qulipta) |
| CP.PHAR.568 (PDF) | Inclisiran (Leqvio) |
| CP.PHAR.570 (PDF) | Ropeginterferon Alfa-2b-njft (BESREMi) |
| CP.PHAR.572 (PDF) | Budesonide (Tarpeyo) |
| CP.PHAR.573 (PDF) | Cabotegravir (Apretude), Cabotegravir/Rilpivirine (Cabenuva) |
| CP.PHAR.574 (PDF) | Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) |
| CP.PHAR.575 (PDF) | Tebentafusp-tebn (Kimmtrak) |
| CP.PHAR.576 (PDF) | Tezepelumab-ekko (Tezspire) |
| CP.PHAR.577 (PDF) | Tralokinumab-ldrm (Adbry) |
| CP.PHAR.578 (PDF) | Abrocitinib (Cibinqo) |
| CP.PHAR.580 (PDF) | Etranacogene Dezaparvovec (AMT-061) |
| CP.PHAR.581 (PDF) | Faricimab-svoa (Vabysmo) |
| CP.PHAR.582 (PDF) | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) |
| CP.PHAR.583 (PDF) | Pacritinib (Vonjo) |
| CP.PHAR.584 (PDF) | Sodium Phenylbutyrate/Taurursodiol (AMX0035) |
| CP.PHAR.586 (PDF) | Olipudase alfa (GZ402665) |
| CP.PHAR.588 (PDF) | Nivolumab and Relatlimab-rmbw (Opdualag) |
| CP.PHAR.590 (PDF) | Omaveloxolone (RTA-408) |
| CP.PHAR.624 (PDF) | Ferric Pyrophosphate (Triferic, Triferic Avnu) |
| CP.PMN.04 (PDF) | VELPHORO, Sucroferric Oxyhydroxide |
| CP.PMN.08 (PDF) | Lidocaine Transdermal (Lidoderm, ZTlido) |
| CP.PMN.15 (PDF) | Asenapine (Saphris, Secuado) |
| CP.PMN.17 (PDF) | Droxidopa (Northera) |
| CP.PMN.19 (PDF) | Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) |
| CP.PMN.20 (PDF) | Aspirin/Dipyridamole (Aggrenox) |
| CP.PMN.24 (PDF) | Ciclopirox (Penlac) |
| CP.PMN.25 (PDF) | JUBLIA, Efinaconazole |
| CP.PMN.27 (PDF) | ZYVOX, Linezolid |
| CP.PMN.32 (PDF) | FANAPT, Iloperidone |
| CP.PMN.33 (PDF) | LYRICA, Pregabalin |
| CP.PMN.35 (PDF) | NUVIGIL, Armodafinil |
| CP.PMN.39 (PDF) | PROVIGIL, Modafinil |
| CP.PMN.42 (PDF) | XYREM, Sodium Oxybate |
| CP.PMN.44 (PDF) | DARAPRIM, Pyrimethamine |
| CP.PMN.45 (PDF) | Ondansetron (Zuplenz) |
| CP.PMN.46 (PDF) | Roflumilast (Daliresp) |
| CP.PMN.47 (PDF) | XIFAXAN, Rifaximin |
| CP.PMN.48 (PDF) | RESTASIS, Cyclosporine (Ophth) |
| CP.PMN.52 (PDF) | Omega-3-Acid Ethyl Esters (Lovaza) |
| CP.PMN.53 (PDF) | Off-Label Use, No Coverage Criteria, |
| CP.PMN.54 (PDF) | SYMPAZAN, Clobazam ONFI, Clobazam |
| CP.PMN.57 (PDF) | ULORIC, Febuxostat |
| CP.PMN.58 (PDF) | HEMANGEOL, Propranolol HCl |
| CP.PMN.62 (PDF) | SIVEXTRO, Tedizolid Phosphate |
| CP.PMN.64 (PDF) | SEROQUEL XR, Quetiapine Fumarate |
| CP.PMN.65 (PDF) | TRINTELLIX, Vortioxetine HBr |
| CP.PMN.67 (PDF) | ENTRESTO, Sacubitril-Valsartan |
| CP.PMN.68 (PDF) | REXULTI, Brexpiprazole |
| CP.PMN.70 (PDF) | CORLANOR, Ivabradine HCl |
| CP.PMN.71 (PDF) | LINZESS, Linaclotide |
| CP.PMN.72 (PDF) | Metformin ER (Fortamet, Glumetza) |
| CP.PMN.73 (PDF) | Lifitegrast (Xiidra) |
| CP.PMN.74 (PDF) | Granisetron (Sancuso, Sustol) |
| CP.PMN.76 (PDF) | Calcifediol (Rayaldee) |
| CP.PMN.79 (PDF) | Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) |
| CP.PMN.80 (PDF) | Minocycline ER (Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi) |
| CP.PMN.81 (PDF) | SUBOXONE, Buprenorphine HCl-Naloxone HCl Dihydrate BUNAVAIL, Buprenorphine HCl-Naloxone HCl Dihydrate |
| CP.PMN.82 (PDF) | SUBUTEX, Buprenorphine HCl |
| CP.PMN.83 (PDF) | Short Ragweed Pollen Allergen Extract (Ragwitek) |
| CP.PMN.84 (PDF) | GRASTEK, Timothy Grass Pollen Allergen Extract |
| CP.PMN.85 (PDF) | Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) |
| CP.PMN.86 (PDF) | Oxymetazoline (Rhofade, Upneeq) |
| CP.PMN.87 (PDF) | Plecanatide (Trulance) |
| CP.PMN.88 (PDF) | BINOSTO, Alendronate Sodium FOSAMAX PLUS D, Alendronate Sodium-Cholecalciferol |
| CP.PMN.89 (PDF) | Amantadine ER (Gocovri, Osmolex ER) |
| CP.PMN.90 (PDF) | BENZNIDAZOLE, Benznidazole |
| CP.PMN.91 (PDF) | Cariprazine (Vraylar) |
| CP.PMN.92 (PDF) | CNS Stimulants |
| CP.PMN.93 (PDF) | NUEDEXTA, Dextromethorphan HBr-Quinidine Sulfate |
| CP.PMN.95 (PDF) | Fluticasone Propionate (Xhance) |
| CP.PMN.99 (PDF) | Prasterone (Intrarosa) |
| CP.PMN.100 (PDF) | ATELVIA, Risedronate Sodium ACTONEL, Risedronate Sodium |
| CP.PMN.101 (PDF) | EXELON, Rivastigmine |
| CP.PMN.102 (PDF) | VARUBI, Rolapitant HCl |
| CP.PMN.103 (PDF) | SOLOSEC, Secnidazole |
| CP.PMN.104 (PDF) | HETLIOZ, Tasimelteon |
| CP.PMN.105 (PDF) | KERYDIN, Tavaborole |
| CP.PMN.107 (PDF) | PROTOPIC, Tacrolimus (Topical) ELIDEL, Pimecrolimus |
| CP.PMN.109 (PDF) | BELSOMRA, Suvorexant |
| CP.PMN.110 (PDF) | EUCRISA, Crisaborole |
| CP.PMN.111 (PDF) | House Dust Mite Allergen Extract (Odactra) |
| CP.PMN.112 (PDF) | Naldemedine (Symproic) |
| CP.PMN.113 (PDF) | Safinamide (Xadago) |
| CP.PMN.115 (PDF) | BAXDELA, Delafloxacin Meglumine |
| CP.PMN.116 (PDF) | L-glutamine (Endari) |
| CP.PMN.117 (PDF) | Naproxen/Esomeprazole (Vimovo) |
| CP.PMN.119 (PDF) | Ozenoxacin (Xepi) |
| CP.PMN.120 (PDF) | Ibuprofen/Famotidine (Duexis) |
| CP.PMN.122 (PDF) | CELEBREX, Celecoxib |
| CP.PMN.123 (PDF) | Colchicine (Colcrys) |
| CP.PMN.124 (PDF) | SPORANOX, Itraconazole ONMEL, Itraconazole TOLSURA, Itraconazole |
| CP.PMN.125 (PDF) | SAVELLA, Milnacipran HCl |
| CP.PMN.127 (PDF) | ABSTRAL, Fentanyl Citrate SUBSYS, Fentanyl LAZANDA, Fentanyl Citrate FENTORA, Fentanyl Citrate ACTIQ, Fentanyl Citrate |
| CP.PMN.128 (PDF) | Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn) |
| CP.PMN.129 (PDF) | SYMLIN, Pramlintide Acetate |
| CP.PMN.130 (PDF) | CYSTARAN, Cysteamine HCl |
| CP.PMN.132 (PDF) | CIALIS, Tadalafil |
| CP.PMN.136 (PDF) | VECAMYL, Mecamylamine HCl |
| CP.PMN.138 (PDF) | Age Limit Override (Codeine, Tramadol, Hydrocodone), HYDROCODONE, Hydrocodone Bitartrate HYDROCODONE TRAMADOL, Tramadol HCl CODEINE |
| CP.PMN.139 (PDF) | Naloxone (Evzio) |
| CP.PMN.140 (PDF) | Pimavanserin (Nuplazid) |
| CP.PMN.141 (PDF) | ANZEMET, Dolasetron Mesylate |
| CP.PMN.142 (PDF) | AMITIZA, Lubiprostone |
| CP.PMN.143 (PDF) | ABSORICA, Isotretinoin AMNESTEEM, Isotretinoin MYORISAN, Isotretinoin ZENATANE, Isotretinoin CLARAVIS, Isotretinoin |
| CP.PMN.145 (PDF) | VIIBRYD, Vilazodone HCl |
| CP.PMN.152 (PDF) | LUCEMYRA, Lofexidine HCl |
| CP.PMN.153 (PDF) | Alosetron (Lotronex) |
| CP.PMN.154 (PDF) | Isavuconazonium (Cresemba) |
| CP.PMN.155 (PDF) | VIMPAT, Lacosamide |
| CP.PMN.156 (PDF) | FYCOMPA, Perampanel |
| CP.PMN.157 (PDF) | BANZEL, Rufinamide |
| CP.PMN.158 (PDF) | AKYNZEO IV, Fosnetupitant Choride-Palonosetron HCl AKYNZEO, Netupitant-Palonosetron |
| CP.PMN.159 (PDF) | Dronabinol (Marinol, Syndros) |
| CP.PMN.163 (PDF) | Sodium Zirconium Cyclosilicate (Lokelma) |
| CP.PMN.164 (PDF) | EPIDIOLEX, Cannabidiol |
| CP.PMN.165 (PDF) | TOLAK, Fluorouracil (Topical) |
| CP.PMN.166 (PDF) | LUZU, Luliconazole |
| CP.PMN.167 (PDF) | NEO-SYNALAR KIT, Neomycin-Fluocinolone & Emollient |
| CP.PMN.168 (PDF) | OSPHENA, Ospemifene |
| CP.PMN.169 (PDF) | RELISTOR, Methylnaltrexone Bromide |
| CP.PMN.170 (PDF) | Eluxadoline (Viberzi) |
| CP.PMN.172 (PDF) | Zolpidem Tartrate (Edluar, Intermezzo, Zolpimist) |
| CP.PMN.173 (PDF) | Ramelteon (Rozerem) |
| CP.PMN.174 (PDF) | Perindopril/Amlodipine (Prestalia) |
| CP.PMN.175 (PDF) | Doxepin (Silenor) |
| CP.PMN.176 (PDF) | Amlodipine/Atorvastatin (Caduet) |
| CP.PMN.177 (PDF) | Glycopyrronium (Qbrexza) |
| CP.PMN.179 (PDF) | MEGACE ES, Megestrol Acetate (Appetite) |
| CP.PMN.180 (PDF) | Halobetasol Propionate (Bryhali, Lexette, Ultravate) |
| CP.PMN.181 (PDF) | Calcipotriene/Betamethasone Dipropionate Foam (Enstilar) |
| CP.PMN.182 (PDF) | Betamethasone Dipropionate Spray (Sernivo) |
| CP.PMN.184 (PDF) | DIACOMIT, Stiripentol |
| CP.PMN.185 (PDF) | Baloxavir Marboxil (Xofluza) |
| CP.PMN.186 (PDF) | OXERVATE, Cenegermin-bkbj |
| CP.PMN.187 (PDF) | VASCEPA, Icosapent Ethyl |
| CP.PMN.188 (PDF) | NUZYRA, Omadacycline Tosylate |
| CP.PMN.189 (PDF) | Sarecycline (Seysara) |
| CP.PMN.192 (PDF) | MIRVASO, Brimonidine Tartrate (Topical) |
| CP.PMN.193 (PDF) | Hydroxyurea (Siklos) |
| CP.PMN.196 (PDF) | Rifamycin (Aemcolo) |
| CP.PMN.198 (PDF) | MYRBETRIQ, Mirabegron VESICARE, Solifenacin Succinate TOVIAZ, Fesoterodine Fumarate ENABLEX, Darifenacin Hydrobromide |
| CP.PMN.199 (PDF) | SPRAVATO, Esketamine HCl |
| CP.PMN.205 (PDF) | Patiromer (Veltassa) |
| CP.PMN.207 (PDF) | EGATEN, Triclabendazole |
| CP.PMN.208 (PDF) | Halobetasol Propionate/Tazarotene (Duobrii) |
| CP.PMN.209 (PDF) | SUNOSI, Solriamfetol HCl |
| CP.PMN.210 (PDF) | Acyclovir Buccal Tablet (Sitavig), Ophthalmic Ointment (Avaclyr) |
| CP.PMN.211 (PDF) | NAYZILAM, Midazolam (Anticonvulsant) |
| CP.PMN.212 (PDF) | SIRTURO, Bedaquiline Fumarate |
| CP.PMN.213 (PDF) | ACCRUFER, |
| CP.PMN.214 (PDF) | Continuous Glucose Monitors |
| CP.PMN.216 (PDF) | VALTOCO, Diazepam (Anticonvulsant) |
| CP.PMN.217 (PDF) | Istradefylline (Nourianz) |
| CP.PMN.218 (PDF) | Lasmiditan (Reyvow) |
| CP.PMN.219 (PDF) | Lefamulin (Xenleta) |
| CP.PMN.220 (PDF) | Peanut Allergen Powder-dnfp (Palforzia) |
| CP.PMN.221 (PDF) | Pitolisant (Wakix) |
| CP.PMN.222 (PDF) | Pretomanid |
| CP.PMN.223 (PDF) | MYCOBUTIN, Rifabutin |
| CP.PMN.224 (PDF) | Tenapanor (Ibsrela) |
| CP.PMN.225 (PDF) | Trifarotene (Aklief) |
| CP.PMN.231 (PDF) | Cenobamate (Xcopri) |
| CP.PMN.232 (PDF) | Lumateperone (Caplyta) |
| CP.PMN.235 (PDF) | Emtricitabine/Tenofovir Alafenamide (Descovy) |
| CP.PMN.236 (PDF) | Amisulpride (Barhemsys) |
| CP.PMN.237 (PDF) | Bempedoic Acid (Nexletol), Bempedoic Acid/Ezetimibe (Nexlizet) |
| CP.PMN.238 (PDF) | Carbidopa/Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy) |
| CP.PMN.239 (PDF) | Chenodiol (Chenodal) |
| CP.PMN.240 (PDF) | Gabapentin ER (Gralise, Horizant) |
| CP.PMN.242 (PDF) | Minocycline Micronized Foam (Amzeeq) |
| CP.PMN.243 (PDF) | Progesterone (Crinone, Endometrin, Milprosa) |
| CP.PMN.244 (PDF) | Tazarotene (Arazlo, Fabior, Tazorac) |
| CP.PMN.245 (PDF) | Opicapone (Ongentys) |
| CP.PMN.246 (PDF) | Fenfluramine (Fintepla) |
| CP.PMN.248 (PDF) | Ciprofloxacin/Dexamethasone (Ciprodex) |
| CP.PMN.249 (PDF) | Ciprofloxacin/Fluocinolone (Otovel) |
| CP.PMN.250 (PDF) | Colesevelam (WelChol) |
| CP.PMN.251 (PDF) | Lactic Acid/Citric Acid/Potassium Bitartrate (Phexxi) |
| CP.PMN.252 (PDF) | Metoclopramide (Gimoti) |
| CP.PMN.253 (PDF) | Abametapir (Xeglyze) |
| CP.PMN.255 (PDF) | No Coverage Criteria |
| CP.PMN.256 (PDF) | Nifurtimox (Lampit) |
| CP.PMN.257 (PDF) | Clascoterone (Winlevi) |
| CP.PMN.258 (PDF) | DUAVEE, Conjugated Estrogens-Bazedoxifene |
| CP.PMN.260 (PDF) | Loteprednol etabonate (Eysuvis) |
| CP.PMN.261 (PDF) | KEVEYIS, Dichlorphenamide |
| CP.PMN.262 (PDF) | Quinine Sulfate (Qualaquin) |
| CP.PMN.263 (PDF) | Estradiol Vaginal Ring (Femring) |
| CP.PMN.264 (PDF) | Viloxazine (Qelbree) |
| CP.PMN.265 (PDF) | Olanzapine/Samidorphan (Lybalvi) |
| CP.PMN.266 (PDF) | Finerenone (Kerendia) |
| CP.PMN.267 (PDF) | Levodopa Inhalation Powder (Inbrija) |
| CP.PMN.268 (PDF) | Tenofovir Alafenamide Fumarate (Vemlidy) |
| CP.PMN.269 (PDF) | SKLICE, Ivermectin (Pediculicide) |
| CP.PMN.270 (PDF) | Pilocarpine (Vuity) |
| CP.PMN.271 (PDF) | Maribavir (Livtencity) |
| CP.PMN.272 (PDF) | Camzyos (mavacamten) |
| CP.PMN.273 (PDF) | Varenicline (Tyrvaya) |
| CP.PMN.275 (PDF) | Levoketoconazole (Recorlev) |
| CP.PMN.277 (PDF) | Ulcer Therapy Combinations |
| CP.PMN.278 (PDF) | Ganaxolone (Ztalmy) |
| CP.PMN.280 (PDF) | Compounded Medications |
| CP.PMN.281 (PDF) | Topiramate Extended-Release (Qudexy XR, Trokendi XR) |
| HIM.PA.03 (PDF) | Ophthalmic Corticosteroids |
| HIM.PA.05 (PDF) | DEXILANT, Dexlansoprazole |
| HIM.PA.08 (PDF) | BARACLUDE, Entecavir |
| HIM.PA.09 (PDF) | TRESIBA, Insulin Degludec |
| HIM.PA.15 (PDF) | SIMBRINZA, Brinzolamide-Brimonidine Tartrate |
| HIM.PA.17 (PDF) | UVADEX, Methoxsalen (Photopheresis) |
| HIM.PA.20 (PDF) | HALOG, Halcinonide |
| HIM.PA.33 (PDF) | Formulary Medications Without Specific Guidelines, |
| HIM.PA.34 (PDF) | Non-Formulary Test Strips, |
| HIM.PA.46 (PDF) | BUTORPHANOL TARTRATE, Butorphanol Tartrate |
| HIM.PA.53 (PDF) |
|
| HIM.PA.58 (PDF) | ONGLYZA, Saxagliptin HCl GLYXAMBI, Empagliflozin-Linagliptin NESINA, Alogliptin Benzoate |
| HIM.PA.71 (PDF) | DUAC, Clindamycin Phosphate-Benzoyl Peroxide (Refrigerate) RETIN-A MICRO, Tretinoin Microsphere BENZAMYCIN, Benzoyl Peroxide-Erythromycin DIFFERIN (cream, gel), Adapalene |
| HIM.PA.87 (PDF) | ANDRODERM, Testosterone |
| HIM.PA.89 (PDF) | AZILECT, Rasagiline Mesylate |
| HIM.PA.91 (PDF) | Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors - The following agents contain a sodium-glucose co-transporter 2 (SGLT2) inhibitor and require prior authorization: bexagliflozin (Brenzavvy™), canagliflozin (Invokana®), canagliflozin/metformin (Invokamet®, Invokamet® XR), dapagliflozin (Farxiga®), dapagliflozin/metformin (Xigduo® XR), dapagliflozin/saxagliptin (Qtern®), empagliflozin/linagliptin (Glyxambi®), empagliflozin/linagliptin/metformin (Trijardy™ XR), empagliflozin/metformin (Synjardy®, Synjardy® XR), ertugliflozin (Steglatro®), ertugliflozin/metformin (Segluromet®), and ertugliflozin/sitagliptin (Steglujan™). |
| HIM.PA.93 (PDF) | NASONEX, Mometasone Furoate (Nasal) |
| HIM.PA.100 (PDF) | Non-Formulary and Formulary Contraceptives |
| HIM.PA.103 (PDF) | Brand Name Override and Non-Formulary Medication Policy, |
| HIM.PA.109 (PDF) | Step Therapy |
| HIM.PA.119 (PDF) | FINACEA, Azelaic Acid |
| HIM.PA.125 (PDF) | FETZIMA, Levomilnacipran HCl |
| HIM.PA.129 (PDF) | SINGULAIR, Montelukast Sodium |
| HIM.PA.130 (PDF) | NAPROSYN, Naproxen |
| HIM.PA.134 (PDF) | NATROBA, Spinosad |
| HIM.PA.139 (PDF) | Opioid Analgesics, |
| HIM.PA.143 (PDF) | KLOR-CON, Potassium Chloride |
| HIM.PA.146 (PDF) | ZONTIVITY, Vorapaxar Sulfate |
| HIM.PA.147 (PDF) | ZONALON, Doxepin HCl (Antipruritic) PRUDOXIN, Doxepin HCl (Antipruritic) SILENOR, Doxepin HCl (Sleep) |
| HIM.PA.152 (PDF) | Nitazoxanide (Alinia) |
| HIM.PA.153 (PDF) | Inhaled Agents for Asthma and COPD |
| HIM.PA.154 (PDF) | Off-Label Drug Use |
| HIM.PA.156 (PDF) | Evolocumab (Repatha) |
| HIM.PA.158 (PDF) | Plecanatide (Trulance) |
| HIM.PA.159 (PDF) | Prucalopride (Motegrity) |
| HIM.PA.160 (PDF) | Tegaserod (Zelnorm) |
| HIM.PA.161 (PDF) |
|
| HIM.PA.166 (PDF) | Evinacumab-dgnb (Evkeeza) |
| HIM.PA.SP1 (PDF) | EPCLUSA, Sofosbuvir-Velpatasvir |
| HIM.PA.SP2 (PDF) | SOVALDI, Sofosbuvir |
| HIM.PA.SP3 (PDF) | HARVONI, Ledipasvir-Sofosbuvir |
| HIM.PA.SP36 (PDF) | MAVYRET, Glecaprevir-Pibrentasvir |
| HIM.PA.SP55 (PDF) | VISTOGARD, Uridine Triacetate (Emergency Treatment) |
| HIM.PA.SP60 (PDF) | Biologic DMARDs. The following are biologic and non-biologic disease-modifying anti-rheumatic drugs (DMARDs) requiring prior authorization: tocilizumab (Actemra®), infliximab-axxq (Avsola™), certolizumab pegol (Cimzia®), secukinumab (Cosentyx®), etanercept (Enbrel®), vedolizumab (Entyvio®), adalimumab (Humira®), tildrakizumab-asmn (Ilumya™), infliximab-dyyb (Inflectra®), sarilumab (Kevzara®), anakinra (Kineret®), baricitinib (Olumiant®), abatacept (Orencia®), apremilast (Otezla®), infliximab (Remicade®), infliximab-abda (Renflexis™), upadacitinib (Rinvoq™), brodalumab (Siliq™), golimumab (Simponi®, Simponi Aria®), risankizumab-rzaa (Skyrizi™), ustekinumab (Stelara®), ixekizumab (Taltz®), guselkumab (Tremfya®), natalizumab (Tysabri®), tofacitinib (Xeljanz®, Xeljanz® XR), ozanimod (Zeposia®). |
| HIM.PA.SP61 (PDF) | Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak) |
| HIM.PA.SP62 (PDF) | ZEPATIER, Elbasvir-Grazoprevir |
| HIM.PA.SP63 (PDF) | Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) |
| HIM.PA.SP64 (PDF) | Eptinezumab-jjmr (Vyepti) |
| HIM.PA.SP65 (PDF) | Erenumab-aaoe (Aimovig) |
| HIM.PA.SP66 (PDF) | AJOVY, Fremanezumab-vfrm |
| HIM.PA.SP67 (PDF) | Galcanezumab-gnlm (Emgality) |
| HIM.PA.SP68 (PDF) | Glatiramer Acetate (Copaxone, Glatopa) |
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