Rx Policy Title |
Policy Number |
Effective Date |
---|
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 |
ofatumumab (Arzerra) (PDF) |
CP.PHAR.306 |
11/17/2018 |
Off Label Use Policy (PDF) |
CP.PMN.53 |
03/01/2022 |
Olanzapine-samidorphan (Lybalvi) (PDF) |
CP.PMN.265 |
07/01/2021 |
olaratumab (Lartruvo) (PDF) |
CP.PHAR.326 |
11/20/2018 |
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 |
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 |
Patisiran (Onpattro) (PDF) |
CP.PHAR.395 |
11/26/2018 |
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 |
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 |
pralatrexate (Folotyn) (PDF) |
CP.PHAR.313 |
11/17/2018 |
Prasterone (Intrarosa) (PDF) |
CP.PMN.99 |
02/18/2019 |
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 |
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 |
retifanlimab-dlwr (Zynz) (PDF) |
CP.PHAR.629 |
06/01/2023 |
Rifamycin (Aemcolo) (PDF) |
CP.PMN.196 |
05/13/2019 |
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 |
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 |
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 |
Setmelanotide (Imcivree) (PDF) |
CP.PHAR.491 |
06/01/2021 |
Short ragweed pollen allergen extract (Ragwitek) (PDF) |
CP.PMN.83 |
08/16/2019 |
siltuximab (Sylvant) (PDF) |
CP.PHAR.329 |
02/15/2019 |
Sipuleucel-T (Provenge) (PDF) |
CP.PHAR.120 |
05/16/2019 |
sodium oxybate (Xyrem) (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 |
sparsentan (Filspari) (PDF) |
CP.PHAR.631 |
06/01/2023 |
Spesolimab-sbzo (Spevigo) (PDF) |
CP.PHAR.606 |
03/01/2023 |
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 |
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 |
Tegaserod (Zelnorm) (PDF) |
CP.PMN.206 |
08/12/2019 |
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 |
Tezepelumab (Tezspire) (PDF) |
CP.PHAR.576 |
06/01/2022 |
thyrotropin alfa (Thyrogen) (PDF) |
CP.PHAR.95 |
08/15/2019 |
Timothy grass pollen allergen extract (Grastek) (PDF) |
CP.PMN.84 |
08/16/2019 |
tisagenlecleucel (Kymriah) (PDF) |
CP.PHAR.361 |
05/01/2022 |
Tisotumab vedotin - tftv (Tivdak) (PDF) |
CP.PHAR.561 |
12/01/2021 |
tocilizumab (Actemra) (PDF) |
CP.PHAR.263 |
06/01/2021 |
Tolvaptan (Jynarque, Samsca) (PDF) |
CP.PHAR.27 |
08/15/2019 |
Topiramate ER (Qudexy XR, Trokendi XR (PDF) |
CP.PMN.281 |
08/01/2022 |
trabectedin (Yondelis) (PDF) |
CP.PHAR.204 |
02/14/2019 |
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) |
CP.PHAR.228 |
09/13/2019 |
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 |
Umbralisib (Ukoniq) (PDF) |
CP.PHAR.531 |
06/01/2021 |
Valproate (Depacon) (PDF) |
CP.PHAR.429 |
08/12/2019 |
Valrubicin (Valstar) (PDF) |
CP.PHAR.439 |
05/06/2020 |
Vedolizumab (Entyvio) (PDF) |
CP.PHAR.265 |
05/16/2019 |
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 |
vincristine sulfate liposome injection (Marqibo) (PDF) |
CP.PHAR.315 |
11/17/2018 |
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 |
ziv-aflibercept (Zaltrap) (PDF) |
CP.PHAR.325 |
11/20/2018 |
zoledronic acid (Reclast, Zometa) (PDF) |
CP.PHAR.59 |
02/14/2019 |