Rx Policy Title | Policy Number | Effective Date |
---|
Obecabtagene autoleucel (Aucatzyl) (PDF) | CP.PHAR.675 | 01/01/2025 |
obinutuzumab (Gazyva) (PDF) | CP.PHAR.305 | 11/14/2018 |
Ocrelizumab (Ocrevus) (PDF) | CP.PHAR.335 | 05/16/2019 |
octreotide acetate (Sandostatin, Sandostatin LAR) (PDF) | CP.PHAR.40 | 02/14/2019 |
Off Label Use Policy (PDF) | CP.PMN.53 | 03/01/2022 |
Olanzapine-samidorphan (Lybalvi) (PDF) | CP.PMN.265 | 07/01/2021 |
Olipudase alfa (XENPOZYME) (PDF) | CP.PHAR.586 | 01/01/2023 |
omacetaxine (Synribo) (PDF) | CP.PHAR.108 | 05/14/2019 |
Omaveloxolone (Skyclarys) (PDF) | CP.PHAR.590 | 06/01/2023 |
OnabotulinumtoxinA (Botox) (PDF) | CP.PHAR.232 | 09/13/2019 |
Onasemnogene abeparvovec (Zolgensma) (PDF) | CP.PHAR.421 | 08/12/2019 |
Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) (PDF) | CP.PHAR.536 | 06/01/2021 |
Osilodrostat (Isturisa) (PDF) | CP.PHAR.487 | 05/06/2020 |
Ospemifene (Osphena) (PDF) | CP.PMN.168 | 05/15/2019 |
oxymetazoline (Rhofade) (PDF) | CP.PMN.86 | 5/15/2019 |
Ozenoxacin (Xepi) (PDF) | CP.PMN.119 | 06/01/2021 |
Paclitaxel, Protein Bound (Abraxane) (PDF) | CP.PHAR.176 | 07/18/2020 |
palivizumab (Synagis) (PDF) | CP.PHAR.16 | 11/01/2020 |
Palopegteriparatide (Yorvipath) (PDF) | CP.PHAR.696 | 10/01/2024 |
Palovarotene (Sohonos) (PDF) | CP.PHAR.548 | 11/01/2023 |
panitumumab (Vectibix) (PDF) | CP.PHAR.321 | 11/17/2018 |
Parathyroid hormone (Natpara) (PDF) | CP.PHAR.282 | 08/15/2019 |
Paricalcitol (Zemplar) (PDF) | CP.PHAR.270 | 08/10/2019 |
pasireotide (Signifor LAR) (PDF) | CP.PHAR.332 | 11/14/2018 |
Patiromer (Veltassa) (PDF) | CP.PMN.205 | 08/12/2019 |
pegaspargase (Oncaspar) (PDF) | CP.PHAR.353 | 11/14/2018 |
Pegcetacoplan (Empaveli,Skyfovre) (PDF) | CP.PHAR.524 | 07/01/2021 |
peginterferon alfa-2b (Sylatron) (PDF) | CP.PHAR.89 | 08/17/2019 |
pegloticase (Krystexxa) (PDF) | CP.PHAR.115 | 02/14/2019 |
Pegunigalsidase Alfa (Elfabrio) (PDF) | CP.PHAR.512 | 09/01/2023 |
Pegvaliase-pqpz (Palynziq) (PDF) | CP.PHAR.140 | 02/01/2019 |
pegvisomant (Somavert) (PDF) | CP.PHAR.389 | 11/20/2018 |
pembrolizumab (Keytruda) (PDF) | CP.PHAR.322 | 08/16/2019 |
pemetrexed (Alimta) (PDF) | CP.PHAR.368 | 04/02/2019 |
Pentosan polysulfate sodium (Elmiron) (PDF) | CP.PMN.276 | 06/01/2022 |
Pertuzumab (Perjeta) (PDF) | CP.PHAR.227 | 05/17/2019 |
Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo) (PDF) | CP.PHAR.501 | 09/01/2020 |
Plasminogen (Ryplazim) (PDF) | CP.PHAR.513 | 10/01/2021 |
plerixafor (Mozobil) (PDF) | CP.PHAR.323 | 08/13/2019 |
Polatuzuman vedotin – piiq (Polivy) (PDF) | CP.PHAR.433 | 08/16/2019 |
Pozelimab-bbfg (Veopoz) (PDF) | CP.PHAR.626 | 11/01/2023 |
Prademagene Zamikeracel (Zevaskyn) (PDF) | CP.PHAR.609 | 07/01/2025 |
pralatrexate (Folotyn) (PDF) | CP.PHAR.313 | 11/17/2018 |
Prasterone (Intrarosa) (PDF) | CP.PMN.99 | 02/18/2019 |
pregabalin (Lyrica) (PDF) | CP.PMN.33 | 05/01/2025 |
Pretomanid (PDF) | CP.PMN.222 | 09/01/2021 |
Progesterone (Crinone, Endometrin, Milprosa) (PDF) | CP.PMN.243 | 05/06/2020 |
protein c concentrate, human (Ceprotin) (PDF) | CP.PHAR.330 | 02/15/2019 |
Pyrimethamine (Daraprim) (PDF) | CP.PMN.44 | 05/06/2020 |
QL of Diabetic Test Strips not receiving insulin (PDF) | CP.PMN.151 | 02/14/2019 |
Quantity Limit Overrides (PDF) | CP.PMN.59 | 02/01/2019 |
Quetiapine ER (Seroquel XR) (PDF) | CP.PMN.64 | 05/06/2020 |
Quinine Sulfate (Qualaquin) (PDF) | CP.PMN.262 | 06/01/2021 |
ramucirumab (Cyramza) (PDF) | CP.PHAR.119 | 09/13/2019 |
ranibizumab (Byooviz, Lucentis, Susvimo) (PDF) | CP.PHAR.186 | 06/26/2019 |
Ravulizumab-cwvz (Ultomiris) (PDF) | CP.PHAR.415 | 05/13/2019 |
Remestemcel-L-rknd
(Ryoncil) (PDF) | CP.PHAR.474 | 04/01/2025 |
Repository Corticotropin Injection (H.P. Acthar Gel, Purified Cortrophin Gel) (PDF) | CP.PHAR.168 | 04/02/2019 |
Request for Medically Necessary Drug not on the PDL (PDF) | CP.PMN.16 | 11/14/2018 |
reslizumab (Cinqair) (PDF) | CP.PHAR.223 | 02/14/2019 |
Resmetirom (Rezdiffra) (PDF) | CP.PHAR.647 | 04/01/2024 |
revakinagene taroretcel (Encelto) (PDF) | CP.PHAR.697 | 05/01/2025 |
retifanlimab-dlwr (Zynz) (PDF) | CP.PHAR.629 | 06/01/2023 |
rifapentine (Priftin) (PDF) | CP.PMN.05 | 02/15/2019 |
RimabotulinumtoxinB (Myobloc) (PDF) | CP.PHAR.233 | 05/16/2019 |
Risdiplam (Evrysdi) (PDF) | CP.PHAR.477 | 11/01/2020 |
risperidone la inj (Perseris, Risperdal Consta, Risvan, Rykindo, Uzedy) (PDF) | CP.PHAR.293 | 06/01/2024 |
Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) (PDF) | CP.PHAR.260 | 6/26/2019 |
romidepsin (Istodax) (PDF) | CP.PHAR.314 | 03/06/2019 |
romiplostim (Nplate) (PDF) | CP.PHAR.179 | 03/06/2019 |
Romosozumab-aqqg (Evenity) (PDF) | CP.PHAR.428 | 08/12/2019 |
Ropeginterferon alfa-2b-njft (Besremi) (PDF) | CP.PHAR.570 | 03/01/2022 |
Rozanolixizumab-noli (Rystiggo) (PDF) | CP.PHAR.648 | 10/01/2023 |
rufinamide (Banzel) (PDF) | CP.PMN.157 | 08/17/2019 |
Sacituzumab govitecan-hziy (Trodelvy) (PDF) | CP.PHAR.475 | 03/01/2021 |
sapropterin (Kuvan) (PDF) | CP.PHAR.43 | 05/16/2019 |
Sarecycline (Seysara) (PDF) | CP.PMN.189 | 05/30/2019 |
sargramostim (Leukine) (PDF) | CP.PHAR.295 | 08/15/2019 |
sebelipase alfa (Kanuma) (PDF) | CP.PHAR.159 | 05/17/2019 |
Semaglutide (Wegovy) (PDF) | NE.PMN.295 | 07/01/2024 |
Setmelanotide (Imcivree) (PDF) | CP.PHAR.491 | 06/01/2021 |
siltuximab (Sylvant) (PDF) | CP.PHAR.329 | 02/15/2019 |
Sipuleucel-T (Provenge) (PDF) | CP.PHAR.120 | 05/16/2019 |
Sodium Oxybate (Xyrem, Lumryz) and Calcium Magnesium Potassium Sodium Oxybate (Xywav) (PDF) | CP.PMN.42 | 05/17/2019 |
sodium phenylbutyrate (Buphenyl) (PDF) | CP.PHAR.208 | 02/14/2019 |
Sodium Phenylbutyrate-Taurursodiol (Relyvrio) (PDF) | CP.PHAR.584 | 01/01/2023 |
Sodium thiosulfate (Pedmark) (PDF) | CP.PHAR.610 | 03/01/2023 |
Sodium zirconium cyclosilicate (Lokelma) (PDF) | CP.PMN.163 | 08/17/2019 |
sotatercept (Winrevair) (PDF) | CP.PHAR.657 | 05/01/2024 |
sparsentan (Filspari) (PDF) | CP.PHAR.631 | 06/01/2023 |
Stiripentol (Diacomit) (PDF) | CP.PMN.184 | 11/26/2018 |
Sutimlimab (Enjaymo) (PDF) | CP.PHAR.503 | 03/01/2022 |
Tadalafil BPH - ED (Cialis) (PDF) | CP.PMN.132 | 05/06/2020 |
Tafamidis meglumine, Tafamidis (Vyndaquel, Vyndamax) (PDF) | CP.PHAR.432 | 08/16/2019 |
Tafasitamab-cxix (Monjuvi) (PDF) | CP.PHAR.508 | 11/01/2020 |
taliglucerase alfa (Elelyso) (PDF) | CP.PHAR.157 | 05/17/2019 |
Talimogene laherparepvec (Imlygic) (PDF) | CP.PHAR.542 | 07/01/2021 |
Talquetamab-tgvs (Talvey) (PDF) | CP.PHAR.649 | 10/01/2023 |
tarlatamab-dlle (Imdelltra) (PDF) | CP.PHAR.685 | 08/01/2024 |
Tebentafusp-tebn (Kimmtrak) (PDF) | CP.PHAR.575 | 06/01/2022 |
Teclistamab-cqyv (Tecvayli) (PDF) | CP.PHAR.611 | 03/01/2023 |
teduglutide (Gattex) (PDF) | CP.PHAR.114 | 09/13/2019 |
Telotristat ethyl (Xermelo) (PDF) | CP.PHAR.337 | 05/16/2019 |
temasmorelin (Egrifta) (PDF) | CP.PHAR.109 | 8/15/2019 |
temsirolimus (Torisel) (PDF) | CP.PHAR.324 | 11/20/2018 |
Teplizumab-mzwv (Tzield) (PDF) | CP.PHAR.492 | 03/01/2023 |
Teprotumumab (Tepezza) (PDF) | CP.PHAR.465 | 05/06/2020 |
testosterone pellet (Testopel) (PDF) | CP.PHAR.354 | 09/13/2019 |
thyrotropin alfa (Thyrogen) (PDF) | CP.PHAR.95 | 08/15/2019 |
tisagenlecleucel (Kymriah) (PDF) | CP.PHAR.361 | 05/01/2022 |
Tislelizumab-jsgr (Tevimbra) (PDF) | CP.PHAR.686 | 08/01/2024 |
Tisotumab vedotin - tftv (Tivdak) (PDF) | CP.PHAR.561 | 12/01/2021 |
tocilizumab (Actemra) (PDF) | CP.PHAR.263 | 06/01/2021 |
Tofersen (Qalsody) (PDF) | CP.PHAR.591 | 07/01/2023 |
Tolvaptan (Jynarque, Samsca) (PDF) | CP.PHAR.27 | 08/15/2019 |
Topiramate ER (Qudexy XR, Trokendi XR (PDF) | CP.PMN.281 | 08/01/2022 |
Toripalimab (Loqtorzi) (PDF) | CP.PHAR.668 | 02/01/2024 |
trabectedin (Yondelis) (PDF) | CP.PHAR.204 | 02/14/2019 |
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) | CP.PHAR.228 | 09/13/2019 |
travoprost (iDose TR) (PDF) | CP.PHAR.672 | 03/01/2024 |
Tremelimumab-actl (Imjudo) (PDF) | CP.PHAR.612 | 03/01/2023 |
Triamcinolone ER Injection (Zilretta) (PDF) | CP.PHAR.371 | 02/15/2019 |
Triclabendazole (Egaten) (PDF) | CP.PMN.207 | 08/12/2019 |
Trientine (Syprine) (PDF) | CP.PHAR.438 | 05/06/2020 |
Triheptanoin (Dojolvi) (PDF) | CP.PHAR.509 | 11/01/2020 |
triptorelin pamoate (Trelstar, Triptodur) (PDF) | CP.PHAR.175 | 08/16/2019 |
Trofinetide (Daybue) (PDF) | CP.PHAR.600 | 06/01/2023 |
Ublituximab-xiiy (Briumvi) (PDF) | CP.PHAR.621 | 06/01/2023 |
Ulcer Therapy Combinations (Omeclamox Pak, Pylera, Talicia) (PDF) | CP.PMN.277 | 06/01/2022 |
Valoctocogene Roxaparvovec (Roctavian) (PDF) | CP.PHAR.466 | 09/01/2023 |
Valrubicin (Valstar) (PDF) | CP.PHAR.439 | 05/06/2020 |
Vamorolone (Agamree) (PDF) | CP.PHAR.659 | 02/01/2024 |
velaglucerase alfa (VPRIV) (PDF) | CP.PHAR.163 | 05/16/2019 |
Velmanase Alfa (Lamazym, Lamzede) (PDF) | CP.PHAR.601 | 06/01/2023 |
verteporfin (Visudyne) (PDF) | CP.PHAR.187 | 02/13/2019 |
vestronidase alfa-vjbk (Mepsevii) (PDF) | CP.PHAR.374 | 05/17/2019 |
vigabatrin (Sabril) (PDF) | CP.PHAR.169 | 08/10/2019 |
vilazodone (Viibryd) (PDF) | CP.PMN.145 | 08/17/2019 |
Viltolarsen (Viltepso) (PDF) | CP.PHAR.484 | 09/01/2020 |
Voclosporin (Lupkynis) (PDF) | CP.PHAR.504 | 06/01/2021 |
Voretigene neparvovec-rzyl (Luxturna) (PDF) | CP.PHAR.372 | 02/15/2019 |
vortioxetine HBr (Trintellix) (PDF) | CP.PMN.65 | 08/16/2019 |
Vosoritide (Voxzogo) (PDF) | CP.PHAR.525 | 01/01/2022 |
vutrisiran (Amvuttra) (PDF) | CP.PHAR.550 | 12/01/2022 |
Xanomeline and trospium (Cobenfy) (PDF) | CP.PMN.299 | 03/01/2025 |
zanidatamab-hrii (Ziihera) (PDF) | CP.PHAR.709 | 03/01/2025 |
zenocutuzumab-zbco (Bizengri) (PDF) | CP.PHAR.713 | 03/01/2025 |
zilucoplan (ZILBRYSQ) (PDF) | CP.PHAR.616 | 01/01/2025 |
ziv-aflibercept (Zaltrap) (PDF) | CP.PHAR.325 | 11/20/2018 |
zolbetuximab (Vyloy) (PDF) | CP.PHAR.705 | 01/01/2025 |
zoledronic acid (Reclast, Zometa) (PDF) | CP.PHAR.59 | 02/14/2019 |
Zuranolone (Zurzuvae) (PDF) | CP.PHAR.650 | 10/01/2023 |