| Fecha de vigencia | Policy Name | Reviewed Date |
| 1/1/2013 |
Naglazyme® (galsulfase)
| 8/16/2023 |
| 1/1/2020 |
Nalocet® (oxycodone/acetaminophen) tablet
| 10/19/2022 |
| 1/1/2024 |
Namenda XR® (memantine extended-release)
| 8/16/2023 |
| 1/1/2019 |
Namenda XR® (memantine) extended-release capsules
| 2/15/2023 |
| 1/1/2019 |
Namzaric® (memantine and donepezil) extended-release capsules
| 2/15/2023 |
| 1/1/2021 |
Nascobal® (cyanocobalamin)
| 5/17/2023 |
| 5/7/2015 |
Natpara® (parathyroid hormone)
| 8/16/2023 |
| 1/1/2023 |
Nebivolol (generic Bystolic)
| 9/20/2023 |
| 1/1/2021 |
Nebulized Beta Agonists
| 6/21/2023 |
| 1/1/2021 |
Nerlynx (neratinib)
| 6/21/2023 |
| 5/10/2012 |
Neupro® (rotigotine) transdermal patch
| 1/18/2023 |
| 1/1/2022 |
Nexavar (sorafenib)
| 6/21/2023 |
| 1/1/2024 |
Nexavar (sorafenib)
| 7/19/2023 |
| 10/26/2022 |
Nexiclon™ XR (clonidine ER) tablet
| 10/18/2023 |
| 5/1/2021 |
Nexletol® (bempedoic acid)
| 9/21/2022 |
| 10/20/2021 |
Nexviazyme™ (avalglucosidase alfa-ngpt) Injection
| 9/20/2023 |
| 1/1/2020 |
Niacin-containing agents
| 2/15/2023 |
| 1/1/2022 |
Ninlaro® (ixazomib)
| 8/16/2023 |
| 1/1/2019 |
Nitisinone Products
| 4/19/2023 |
| 10/17/2018 |
Nocdurna® (desmopressin)
| 7/19/2023 |
| 1/1/2021 |
Nocdurna® (desmopressin)
| 7/19/2023 |
| 1/1/2021 |
Noctiva™ (desmopressin)
| 7/19/2023 |
| 1/1/2020 |
Non-Benzodiazepine Hypnotics
| 6/21/2023 |
| 6/3/2020 |
Non-FDA Approved Medications
| 5/18/2022 |
| 1/1/2019 |
Non-Formulary Exceptions
| 11/2/2023 |
| 7/26/2023 |
Non-Preferred Adalimumab Biosimilar Products
| 7/19/2023 |
| 10/13/2023 |
Non-Preferred Adalimumab Products
| 9/20/2023 |
| 11/22/2023 |
Non-Preferred Adalimumab Products
| 11/15/2023 |
| 11/22/2023 |
Non-Preferred Adalimumab Products
| 11/15/2023 |
| 1/1/2024 |
Non-Preferred Continuous Glucose Monitoring Systems
| 10/18/2023 |
| 1/1/2023 |
Non-Preferred GLP Analogs
| 9/20/2023 |
| 1/1/2024 |
Non-Preferred Infliximab products - Renflexis (infliximab-abda) and Avsola (infliximab-axxq)
| 9/20/2023 |
| 1/1/2024 |
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq)
| 9/20/2023 |
| 1/1/2024 |
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq), Remicade (infliximab), unbranded Infliximab
| 6/21/2023 |
| 1/1/2023 |
Non-Preferred Multiple Sclerosis Interferons
| 5/17/2023 |
| 1/1/2023 |
Non-Preferred Multiple Sclerosis Interferons
| 9/20/2023 |
| 1/1/2024 |
Non-Preferred Multiple Sclerosis Interferons
| 6/21/2023 |
| 1/1/2023 |
Non-Preferred Oral Multiple Sclerosis Products
| 9/20/2023 |
| 1/1/2024 |
Non-Preferred Oral Multiple Sclerosis Products
| 8/16/2023 |
| 1/1/2024 |
Non-Preferred Oral Multiple Sclerosis Products
| 6/21/2023 |
| 1/1/2024 |
Non-preferred Pegfilgrastim Products - Fylnetra (pegfilgrastim-pbbk), Nyvepria (pegfilgrastim-apfg), Stimufend (pegfilgrastim-fpgk), and Udenyca (pegfilgrastim-cbqv)
| 7/19/2023 |
| 1/1/2023 |
Non-Preferred SGLT2
| 9/20/2023 |
| 1/1/2023 |
Non-Preferred Filgrastim Products - Neupogen (filgrastim) and Releuko (filgrastim-ayow)
| 9/20/2023 |
| 1/1/2023 |
Non-preferred Pegfilgrastim Products - Fylnetra (pegfilgrastim-pbbk), Neulasta (pegfilgrastim), Stimufend (pegfilgrastim-fpgk), and Udenyca (pegfilgrastim-cbqv)
| 5/25/2023 |
| 1/1/2023 |
Non-preferred Pegfilgrastim Products - Fylnetra (pegfilgrastim-pbbk), Neulasta (pegfilgrastim), Nyvepria (pegfilgrastim-apfg), Stimufend (pegfilgrastim-fpgk) and Ziextenzo (pegfilgrastim-bmez)
| 9/20/2023 |
| 1/1/2023 |
Non-preferred Pegfilgrastim Products - Fylnetra (pegfilgrastim-pbbk), Nyvepria (pegfilgrastim-apfg), Stimufend (pegfilgrastim-fpgk) and Ziextenzo (pegfilgrastim- bmez)
| 9/20/2023 |
| 1/1/2023 |
Antihistamínicos no sedantes
| 3/15/2023 |
| 1/1/2021 |
Nonsteroidal Anti-Inflammatory Drug Products
| 10/19/2022 |
| 1/1/2023 |
Nonsteroidal Anti-Inflammatory Drug Products
| 3/15/2023 |
| 1/1/2024 |
Nonsteroidal Anti-Inflammatory Drug Products
| 9/20/2023 |
| 1/1/2024 |
Nonsteroidal Anti-Inflammatory Drug Products
| 7/19/2023 |
| 6/22/2022 |
Norliqva® (amlodipine) oral solution
| 5/17/2023 |
| 1/1/2018 |
Northera® (droxidopa)
| 2/15/2023 |
| 1/1/2022 |
Nourianz™ (istradefylline) tablets
| 2/15/2023 |
| 1/1/2014 |
Novarel®, Pregnyl® (human chorionic gonadotropin)
| 8/16/2023 |
| 1/20/2017 |
NovoSeven® RT (Coagulation Factor VIIa [Recombinant])
| 11/15/2023 |
| 11/1/2006 |
Noxafil® (posaconazole)
| 11/15/2023 |
| 1/1/2021 |
Nplate® (romiplostim)
| 11/15/2023 |
| 1/1/2020 |
NSAID Combination Products
| 12/14/2022 |
| 1/1/2022 |
Nubeqa® (darolutamide)
| 12/14/2022 |
| 1/1/2020 |
Nucynta® (tapentadol)
| 2/15/2023 |
| 1/1/2022 |
Nuedexta® (dextromethorphan and quinidine)
| 7/19/2023 |
| 6/16/2021 |
Nulibry™ (fosdenopterin) intravenous solution
| 3/15/2023 |
| 1/1/2020 |
Nulojix® (belatacept)
| 3/15/2023 |
| 1/1/2021 |
Nuplazid™ (pimavanserin)
| 7/19/2023 |
| 5/20/2020 |
Nurtec™ ODT (rimegepant)
| 5/18/2023 |
| 1/1/2022 |
Nurtec™ ODT (rimegepant)
| 5/18/2023 |
| 1/1/2024 |
Nurtec™ ODT (rimegepant)
| 6/21/2023 |
| 1/1/2018 |
Nuvigil® (armodafinil)
| 3/15/2023 |