Fecha de vigencia | Policy Name | Reviewed Date |
5/24/2023 |
Cuvrior™ (trientine tetrahydrochloride) tablets
| 5/17/2023 |
5/24/2023 |
Daybue™ (trofinetide) oral solution
| 5/17/2023 |
5/24/2023 |
Igalmi™ (dexmedetomidine)
| 5/17/2023 |
5/24/2023 |
Syfovre™ (pegcetacoplan) intravitreal solution
| 5/17/2023 |
5/24/2023 |
Zynyz (retifanlimab-dlwr)
| 5/17/2023 |
4/26/2023 |
Jaypirca (pirtobrutinib)
| 4/19/2023 |
4/26/2023 |
Pradaxa® (dabigatran etexilate) oral pellet
| 4/19/2023 |
4/26/2023 |
Tzield© (teplizumab) intravenous solution
| 4/19/2023 |
4/19/2023 |
Orserdu (elacestrant)
| 3/30/2023 |
3/23/2023 |
Continuidad de la atención
| 3/23/2023 |
3/22/2023 |
Krazati (adagrasib)
| 3/2/2023 |
3/22/2023 |
Lunsumio (mosunetuzumab-axgb)
| 3/15/2023 |
3/22/2023 |
Sunlenca (lenacapavir)
| 3/15/2023 |
3/1/2023 |
Productos Bevacizumab
| 2/23/2023 |
2/22/2023 |
Relyvrio™ (sodium phenylbutyrate/taurursodiol)
| 2/15/2023 |
2/22/2023 |
Rezlidhia (olutasidenib)
| 2/15/2023 |
2/22/2023 |
Sotyktu (deucravacitinib)
| 2/15/2023 |
2/22/2023 |
Sotyktu (deucravacitinib)
| 2/15/2023 |
2/15/2023 |
Imjudo (tremelimumab-actl)
| 1/19/2023 |
2/15/2023 |
Lytgobi (futibatinib)
| 1/19/2023 |
1/25/2023 |
Rebyota™ (fecal microbiota, live-jslm)
| 1/18/2023 |
1/25/2023 |
Tascenso ODT™ (fingolimod)
| 1/18/2023 |
1/1/2023 |
Abecma® (idecabtagene vicleucel)
| 4/19/2023 |
1/1/2023 |
Abraxane (nab) paclitaxel
| 9/22/2022 |
1/1/2023 |
Abraxane (nab) paclitaxel

| 5/17/2023 |
1/1/2023 |
Abraxane (nab- paclitaxel)

| 5/17/2023 |
1/1/2023 |
Aemcolo® (rifamycin)
| 3/15/2023 |
1/1/2023 |
Afinitor/Afinitor Disperz (everolimus)

| 5/17/2023 |
1/1/2023 |
Aklief® (trifarotene)

| 5/17/2023 |
1/1/2023 |
Alpha-1 Proteinase Inhibitors (Aralast NP®, Glassia®, Zemaira®)
| 10/6/2022 |
1/1/2023 |
Amitiza® (lubiprostone)

| 5/17/2023 |
1/1/2023 |
Amzeeq (minocycline) topical foam

| 5/17/2023 |
1/1/2023 |
Angiotensin Blocking Agents

| 5/17/2023 |
1/1/2023 |
Aranesp® (darbepoetin alfa)
| 7/20/2022 |
1/1/2023 |
Aubagio® (teriflunomide) tablet
| 3/16/2023 |
1/1/2023 |
Auryxia® (ferric citrate)
| 3/15/2023 |
1/1/2023 |
Avsola® (infliximab-axxq)
| 11/16/2022 |
1/1/2023 |
Bafiertam® (monomethyl fumarate) capsule, delayed release

| 5/17/2023 |
1/1/2023 |
Bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta)
| 7/20/2022 |
1/1/2023 |
Beovu® (brolucizumab)
| 4/19/2023 |
1/1/2023 |
Bevacizumab products
| 2/23/2023 |
1/1/2023 |
Bortezomib products (Velcade and Bortezomib for injection)
| 10/19/2022 |
1/1/2023 |
Bowel Prep Agents

| 5/17/2023 |
1/1/2023 |
Breyanzi® (lisocabtagene maraleucel)
| 4/19/2023 |
1/1/2023 |
Brukinsa™ (zanubrutinib)
| 2/16/2023 |
1/1/2023 |
Buprenorphine Containing Products
| 12/14/2022 |
1/1/2023 |
CFTR Modulators
| 7/20/2022 |
1/1/2023 |
Carvykti™ (ciltacabtagene autoleucel)
| 4/19/2023 |
1/1/2023 |
Cholbam® (cholic acid) capsules
| 10/6/2022 |
1/1/2023 |
DPP-IV, SGLT2 Combination Products
| 7/20/2022 |
1/1/2023 |
Deferasirox Products
| 11/16/2022 |
1/1/2023 |
Deferasirox Tablet
| 8/17/2022 |
1/1/2023 |
Dexilant® (dexlansoprazole)

| 5/17/2023 |
1/1/2023 |
Diacomit® (stiripentol)
| 11/16/2022 |
1/1/2023 |
Differin® (adapalene) and Epiduo® (adapalene and benzoyl peroxide)

| 5/17/2023 |
1/1/2023 |
Dopamine Agonists
| 9/21/2022 |
1/1/2023 |
Dysport® (botulinum toxin)
| 1/18/2023 |
1/1/2023 |
Elahere (mirvetuximab soravtansine-gynx)
| 12/14/2022 |
1/1/2023 |
Elzonris™ (tagraxofusp-erzs)

| 5/17/2023 |
1/1/2023 |
Enhertu (fam-trastuzumab deruxtecan-nxki)
| 9/21/2022 |
1/1/2023 |
Eplerenone Products
| 7/20/2022 |
1/1/2023 |
Epoetin Alfa (Epogen, Procrit, Retacrit)
| 11/10/2022 |
1/1/2023 |
Esbriet® (pirfenidone)
| 1/19/2023 |
1/1/2023 |
Eulexin (Flutamide)
| 5/17/2023 |
1/1/2023 |
Evenity™ (romosozumab-aqqg)

| 5/17/2023 |
1/1/2023 |
Eylea® (aflibercept)
| 4/19/2023 |
1/1/2023 |
Eysuvis™ (loteprednol etabonate)
| 3/15/2023 |
1/1/2023 |
Finacea® (azelaic acid) topical foam
| 9/21/2022 |
1/1/2023 |
Fintepla® (fenfluramine) Oral Solution
| 8/17/2022 |
1/1/2023 |
Fycompa® (perampanel)
| 3/15/2023 |
1/1/2023 |
Gloperba® (colchicine) Oral solution
| 2/15/2023 |
1/1/2023 |
Helicobacter Pylori Agents
| 4/19/2023 |
1/1/2023 |
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

| 5/17/2023 |
1/1/2023 |
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)
| 8/17/2022 |
1/1/2023 |
Hypomethylating agents (azacitidine, decitabine)
| 8/17/2022 |
1/1/2023 |
Ibrance (palbociclib)

| 5/17/2023 |
1/1/2023 |
Ibrance (palbociclib)

| 5/17/2023 |
1/1/2023 |
Icosapent Ethyl (generic Vascepa)
| 8/17/2022 |
1/1/2023 |
Inflectra ® (infliximab-dyyb)
| 1/18/2023 |
1/1/2023 |
Inhaled Corticosteroids - Long Acting Beta Agonists Inhalers
| 8/17/2022 |
1/1/2023 |
Intranasal Rhinitis Agents
| 10/19/2022 |
1/1/2023 |
Intranasal Rhinitis Agents
| 10/19/2022 |
1/1/2023 |
Istodax (romidepsin)
| 4/19/2023 |
1/1/2023 |
Jemperli (dostarlimab-gxly)
| 9/22/2022 |
1/1/2023 |
Jynarque® (tolvaptan)

| 5/17/2023 |
1/1/2023 |
Keytruda (pembrolizumab)
| 4/19/2023 |
1/1/2023 |
Kisqali (ribociclib)
| 10/6/2022 |
1/1/2023 |
Kisqali (ribociclib)
| 11/16/2022 |
1/1/2023 |
Kymriah™ (tisagenlecleucel)
| 4/19/2023 |
1/1/2023 |
Kynmobi® (apomorphine hydrochloride) sublingual film
| 10/6/2022 |
1/1/2023 |
Levoleucovorin products (Fusilev, Khapzory)
| 9/22/2022 |
1/1/2023 |
Levothyroxine Products
| 12/14/2022 |
1/1/2023 |
Linzess® (linaclotide)
| 8/17/2022 |
1/1/2023 |
Liposomal doxorubucin
| 8/17/2022 |
1/1/2023 |
Lokelma® (sodium zirconium cyclosilicate)
| 4/19/2023 |
1/1/2023 |
Lotronex® (alosetron HCl)

| 5/17/2023 |
1/1/2023 |
Lynparza (olaparib)
| 12/14/2022 |
1/1/2023 |
Mavenclad® (cladribine)

| 5/17/2023 |
1/1/2023 |
Mavenclad® (cladribine) tablet
| 12/14/2022 |
1/1/2023 |
Mayzent® (siponimod) tablet

| 5/17/2023 |
1/1/2023 |
Medical Necessity Determinations
| 10/20/2022 |
1/1/2023 |
Methotrexate Injection (Otrexup®, Rasuvo®)
| 2/15/2023 |
1/1/2023 |
Methotrexate Injection (Otrexup®, Reditrex®)
| 2/15/2023 |
1/1/2023 |
Motegrity® (prucalopride)

| 5/17/2023 |
1/1/2023 |
Muscle Relaxants
| 7/20/2022 |
1/1/2023 |
Myobloc® (botulinum toxin)
| 1/18/2023 |
1/1/2023 |
Naloxone Products (Kloxxado™, Zimhi™)
| 3/15/2023 |
1/1/2023 |
Nebivolol (generic Bystolic)
| 9/21/2022 |
1/1/2023 |
Non-Preferred GLP Analogs
| 9/21/2022 |
1/1/2023 |
Non-Preferred Multiple Sclerosis Interferons
| 12/14/2022 |
1/1/2023 |
Non-Preferred Multiple Sclerosis Interferons

| 5/17/2023 |
1/1/2023 |
Non-Preferred Oral Multiple Sclerosis Products
| 12/14/2022 |
1/1/2023 |
Non-Preferred SGLT2
| 7/20/2022 |
1/1/2023 |
Non-Preferred Filgrastim Products - Neupogen (filgrastim) and Releuko (filgrastim-ayow)
| 8/17/2022 |
1/1/2023 |
Antihistamínicos no sedantes
| 3/15/2023 |
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)
| 12/21/2022 |
1/1/2023 |
Non-preferred Pegfilgrastim Products - Fylnetra (pegfilgrastim-pbbk), Nyvepria (pegfilgrastim-apfg), Stimufend (pegfilgrastim-fpgk) and Ziextenzo (pegfilgrastim- bmez)
| 12/21/2022 |
1/1/2023 |
Nonsteroidal Anti-Inflammatory Drug Products
| 3/15/2023 |
1/1/2023 |
Ocaliva® (obeticholic acid)
| 9/21/2022 |
1/1/2023 |
Ocrevus® (ocrelizumab) Intravenous Solution
| 4/19/2023 |
1/1/2023 |
Ocrevus® (ocrelizumab) intravenous solution
| 12/14/2022 |
1/1/2023 |
Olinvyk® (olicerdine)
| 3/15/2023 |
1/1/2023 |
Onpattro® (patisiran)
| 7/20/2022 |
1/1/2023 |
Opdivo (nivolumab)
| 7/20/2022 |
1/1/2023 |
Opdualag (nivolumab and relatlimab-rmbw)
| 9/22/2022 |
1/1/2023 |
Ophthalmic Prostaglandins
| 3/15/2023 |
1/1/2023 |
Ophthalmic Cyclosporine (Cequa™, generic Restasis)
| 3/15/2023 |
1/1/2023 |
Ophthalmic Cyclosporine (Cequa™, generic Restasis)
| 4/19/2023 |
1/1/2023 |
Opioid Days' Supply Limitation
| 10/27/2022 |
1/1/2023 |
Orgovyx (relugolix) tablets
| 5/18/2022 |
1/1/2023 |
Otezla® (apremilast)
| 10/6/2022 |
1/1/2023 |
Pediatric Cardiovascular Products
| 12/14/2022 |
1/1/2023 |
Polivy™ (polatuzumab vedotin-piiq)
| 4/19/2023 |
1/1/2023 |
Ponvory® (ponesimod) tablet

| 5/17/2023 |
1/1/2023 |
Preferred Filgrastim Products - Nivestym (filgrastim-aafi) and Zarxio (filgrastim-sndz)
| 8/17/2022 |
1/1/2023 |
Preferred Pegfilgrastim Products - Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), and Udenyca (pegfilgrastim-cbqv)
| 8/17/2022 |
1/1/2023 |
Preferred Pegfilgrastim Products - Fulphila (pegfilgrastim-jmdb), Nyvepria (pegfilgrastim-apfg), and Ziextenzo (pegfilgrastim-bmez)
| 8/17/2022 |
1/1/2023 |
Preferred Pegfilgrastim Products - Fulphila (pegfilgrastim-jmdb) and Udenyca (pegfilgrastim- cbqv)
| 8/17/2022 |
1/1/2023 |
Prolastin-C® (alpha-1 proteinase inhibitor)
| 10/6/2022 |
1/1/2023 |
Pyrukynd® (mitapivat)
| 10/6/2022 |
1/1/2023 |
Rasuvo® (methotrexate injection)
| 2/15/2023 |
1/1/2023 |
Renflexis® (infliximab-abda)
| 1/18/2023 |
1/1/2023 |
Revlimid (lenalidomida)
| 2/2/2023 |
1/1/2023 |
Rinvoq® (upadacitinib)
| 11/16/2022 |
1/1/2023 |
Risperidone Orally Disintegrating Tablets
| 7/20/2022 |
1/1/2023 |
Rituxan Hycela™ (rituximab/hyaluronidase)
| 8/17/2022 |
1/1/2023 |
Rituxan Hycela™ (rituximab/hyaluronidase)
| 8/17/2022 |
1/1/2023 |
Rituximab Products
| 7/20/2022 |
1/1/2023 |
Rolvedon™ (eflapegrastim-xnst)
| 12/14/2022 |
1/1/2023 |
Rolvedon™ (eflapegrastim-xnst)
| 12/14/2022 |
1/1/2023 |
Rolvedon™ (eflapegrastim-xnst)
| 12/14/2022 |
1/1/2023 |
Rubraca (rucaparib)

| 5/17/2023 |
1/1/2023 |
Rytary® (carbidopa and levodopa) extended release capsules
| 4/19/2023 |
1/1/2023 |
Signifor® LAR (pasireotide)
| 9/22/2022 |
1/1/2023 |
Site of Care and Specialty Medication Sourcing for Injectable Drugs
| 2/8/2023 |
1/1/2023 |
Somavert® (pegvisomant)
| 4/19/2023 |
1/1/2023 |
Stivarga (regorafenib)
| 10/6/2022 |
1/1/2023 |
Sunosi™ (solriamfetol)
| 8/17/2022 |
1/1/2023 |
Sunosi™ (solriamfetol)
| 8/17/2022 |
1/1/2023 |
Sutent (sunitinib)

| 5/17/2023 |
1/1/2023 |
Sympazan®(clobazam) Oral Film
| 7/20/2022 |
1/1/2023 |
Symproic® (naldemedine)

| 5/17/2023 |
1/1/2023 |
Tecartus™ (brexucabtagene autoleucel)
| 4/19/2023 |
1/1/2023 |
Tecentriq® (atezolizumab)
| 2/15/2023 |
1/1/2023 |
Tecvayli (teclistamab-cqyv)
| 12/14/2022 |
1/1/2023 |
Topical Acne Products

| 5/17/2023 |
1/1/2023 |
Topical Antivirals
| 5/18/2022 |
1/1/2023 |
Topical Antivirals

| 5/17/2023 |
1/1/2023 |
Topical Clindamycin (clindamycin gel, Clindagel®)

| 5/17/2023 |
1/1/2023 |
Topical Diflorasone

| 5/17/2023 |
1/1/2023 |
Topical Onychomycotic Agents

| 5/17/2023 |
1/1/2023 |
Topical Psoriasis Agents
| 6/15/2022 |
1/1/2023 |
Topical Retinoid Products

| 5/17/2023 |
1/1/2023 |
Topical Tazarotene Products (Arazlo®, Fabior®)

| 5/17/2023 |
1/1/2023 |
Topical Vitamin D Products

| 5/17/2023 |
1/1/2023 |
Tramadol hydrochloride extended release (ConZip, generic Conzip, tramadol ER tablet)
| 2/15/2023 |
1/1/2023 |
Tramadol hydrochloride extended release capsules (ConZip, generic Conzip)
| 2/15/2023 |
1/1/2023 |
Trastuzumab Products
| 7/20/2022 |
1/1/2023 |
Trulance® (plecanatide)

| 5/17/2023 |
1/1/2023 |
Tykerb (lapatinib)

| 5/17/2023 |
1/1/2023 |
Tyrvaya™ (varenicline)
| 3/15/2023 |
1/1/2023 |
Tyrvaya™ (varenicline)
| 4/19/2023 |
1/1/2023 |
Tysabri (natalizumab) intravenous solution
| 12/21/2022 |
1/1/2023 |
Tysabri® (natalizumab) Intravenous Solution
| 4/19/2023 |
1/1/2023 |
Vabysmo™ (faricimab-svoa)
| 4/19/2023 |
1/1/2023 |
Varubi (rolapitant)
| 7/20/2022 |
1/1/2023 |
Ventavis® (iloprost)
| 10/6/2022 |
1/1/2023 |
Verzenio (abemaciclib)
| 4/19/2023 |
1/1/2023 |
Viberzi® (eluxadoline)

| 5/17/2023 |
1/1/2023 |
Viibryd® (vilazodone)
| 8/17/2022 |
1/1/2023 |
Vumerity® (diroximel fumarate) capsule, delayed release
| 4/19/2023 |
1/1/2023 |
Wakix® (pitolisant)
| 8/17/2022 |
1/1/2023 |
Wakix® (pitolisant)
| 8/17/2022 |
1/1/2023 |
Welchol® (colesevelam)
| 8/17/2022 |
1/1/2023 |
Winlevi® (clascoterone)

| 5/17/2023 |
1/1/2023 |
Xarelto® (rivaroxaban) oral suspension
| 9/21/2022 |
1/1/2023 |
Xatmep™ (methotrexate) oral solution
| 10/7/2022 |
1/1/2023 |
Xeljanz and Xeljanz XR® (tofacitinib)

| 5/17/2023 |
1/1/2023 |
Xeljanz and Xeljanz XR® (tofacitinib)

| 5/17/2023 |
1/1/2023 |
Xifaxan® (rifaximin)
| 10/19/2022 |
1/1/2023 |
Xifaxan® (rifaximin)

| 5/17/2023 |
1/1/2023 |
Xiidra® (lifitegrast ophthalmic solution)
| 4/19/2023 |
1/1/2023 |
Xofigo® (radium Ra 223 dichloride)
| 7/20/2022 |
1/1/2023 |
Xyrem® (sodium oxybate)
| 3/30/2023 |
1/1/2023 |
Xyrem® (sodium oxybate)
| 3/30/2023 |
1/1/2023 |
Xywav™ (calcium, magnesium, potassium, and sodium oxybates)
| 8/17/2022 |
1/1/2023 |
Xywav™ (calcium, magnesium, potassium, and sodium oxybates)
| 8/17/2022 |
1/1/2023 |
Yescarta™ (axicabtagene ciloleucel)
| 4/19/2023 |
1/1/2023 |
Zejula (niraparib)
| 12/14/2022 |
1/1/2023 |
Zeposia® (ozanimod) capsule

| 5/17/2023 |
1/1/2023 |
Zeposia® (ozanimod) capsules
| 10/19/2022 |
1/1/2023 |
Zydelig® (idelalisib)
| 7/20/2022 |
12/28/2022 |
Furoscix® (furosemide)
| 12/14/2022 |
12/28/2022 |
Pheburane® (sodium phenylbutyrate) oral pellets
| 12/14/2022 |
12/1/2022 |
Medical Necessity Determinations
| 10/20/2022 |
11/30/2022 |
Auvelity™ (dextromethorphan and bupropion)
| 3/2/2023 |
11/30/2022 |
Pedmark ® (sodium thiosulfate injection)
| 11/16/2022 |
11/30/2022 |
Vivjoa™ (oteseconazole)
| 11/16/2022 |
11/30/2022 |
Xenpozyme™ (olipudase alfa) intravenous solution
| 11/16/2022 |
11/23/2022 |
Methocarbamol tablet
| 11/16/2022 |
11/23/2022 |
Spevigo® (spesolimab-sbzo)
| 11/16/2022 |
11/23/2022 |
Zoryve® (roflumilast) cream
| 1/5/2023 |
11/1/2022 |
Cimerli™ (ranibizumab-eqrn)
| 4/19/2023 |
10/26/2022 |
Camzyos™ (mavacamten)
| 10/19/2022 |
10/26/2022 |
Nexiclon™ XR (clonidine ER) tablet
| 10/19/2022 |
10/26/2022 |
Zonisade™ (zonisamide) oral suspension
| 10/19/2022 |
9/28/2022 |
Amvuttra™ (vutrisiran)
| 9/21/2022 |
9/28/2022 |
Entadfi™ (finasteride and tadalafil)
| 9/21/2022 |
9/28/2022 |
Hyftor™ (sirolimus topical gel)
| 9/21/2022 |
9/28/2022 |
Inhaled Corticosteroid and Long Acting Beta Agonists
| 9/21/2022 |
9/28/2022 |
Meloxicam oral suspension
| 9/21/2022 |
9/28/2022 |
Tascenso ODT™ (fingolimod)
| 1/18/2023 |
9/28/2022 |
Vtama® (tapinarof) cream
| 9/21/2022 |
9/28/2022 |
fluticasone propionate HFA inhaler
| 9/21/2022 |
9/1/2022 |
Qulipta™ (atogepant)

| 5/18/2023 |
9/1/2022 |
Reyvow™ (lasmiditan)
| 8/18/2022 |
9/1/2022 |
Ubrelvy™ (ubrogepant)
| 8/18/2022 |
9/1/2022 |
Vyepti™ (eptinezumab)

| 5/18/2023 |
8/24/2022 |
Verkazia® eye drops in a dropperette
| 8/17/2022 |
7/27/2022 |
Adlarity® (donepezil) transdermal patch
| 4/19/2023 |
7/27/2022 |
Beovu® (brolucizumab)
| 4/19/2023 |
7/27/2022 |
Enjaymo™ (sutimlimab-jome)
| 7/20/2022 |
7/27/2022 |
Ibsrela® (tenapanor)
| 7/20/2022 |
7/27/2022 |
Korsuva™ (difelikefalin)
| 7/20/2022 |
7/27/2022 |
Quviviq™ (daridorexant)
| 7/20/2022 |
7/27/2022 |
RoxyBond™ tablet, oral ONLY (not feeding tubes)
| 1/5/2023 |
7/27/2022 |
Vijoice® (alpelisib) tablets
| 7/20/2022 |
7/27/2022 |
Ztalmy® (ganaxolone) Oral Suspension
| 7/20/2022 |
7/1/2022 |
Olumiant® (baricitinib)
| 6/23/2022 |
7/1/2022 |
Olumiant® (baricitinib)
| 6/23/2022 |
6/22/2022 |
Byooviz™ (ranibizumab-nuna)
| 4/19/2023 |
6/22/2022 |
Camcevi (leuprolide mesylate)

| 5/17/2023 |
6/22/2022 |
Leqvio® (inclisiran)

| 5/17/2023 |
6/22/2022 |
Norliqva® (amlodipine) oral solution

| 5/17/2023 |
6/22/2022 |
Pluvicto (lutetium Lu 177 vipivotide tetraxetan)

| 5/17/2023 |
6/22/2022 |
Tezspire™ (tezepelumab-ekko)

| 5/17/2023 |
6/1/2022 |
Glucagon Products

| 5/17/2023 |
5/26/2022 |
AHCA Continuity of Care
| 5/19/2022 |
5/25/2022 |
Cibinqo™ (abrocitinib)
| 3/15/2023 |
5/25/2022 |
Vabysmo™ (faricimab-svoa)
| 4/19/2023 |
5/18/2022 |
Vonjo (pacritinib)
| 5/18/2022 |
4/27/2022 |
Adbry™ (tralokinumab-ldrm)
| 4/19/2023 |
4/27/2022 |
Aduhelm™ (aducanumab-avwa) intravenous solution
| 3/15/2023 |
4/27/2022 |
Carvykti™ (ciltacabtagene autoleucel)
| 4/19/2023 |
4/27/2022 |
Carvykti™ (ciltacabtagene autoleucel)
| 4/19/2023 |
4/27/2022 |
Pemetrexed Products
| 4/19/2023 |
4/27/2022 |
Recorlev® (levoketoconazole) Tablet
| 4/19/2023 |
4/27/2022 |
Ryplazim® (plasminogen, human-tvmh)
| 4/19/2023 |
4/20/2022 |
Soaanz® (torsemide)
| 4/19/2023 |
4/13/2022 |
Opdualag (nivolumab and relatlimab-rmbw)
| 4/7/2022 |
3/23/2022 |
Kimmtrak (tebentafusp-tebn)
| 3/16/2022 |
3/23/2022 |
Seglentis® (celecoxib-tramadol)
| 12/14/2022 |
3/23/2022 |
Vyvgart™ (efgartigimod alfa-fcab) intravenous injection
| 1/18/2023 |
3/16/2022 |
Susvimo™ (ranibizumab)
| 4/19/2023 |
3/16/2022 |
Tavneos™ (avacopan)
| 2/15/2023 |
2/23/2022 |
Brimonidine-timolol eye drops (generic Combigan)
| 12/14/2022 |
2/23/2022 |
Dartisla ODT (glycopyrrolate)
| 1/18/2023 |
2/23/2022 |
Fyarro (sirolimus protein-bound particles for injectable suspension)
| 12/14/2022 |
2/23/2022 |
Tarpeyo™ (budesonide) delayed-release capsules
| 2/15/2023 |
2/23/2022 |
Voxzogo™ (vosoritide)
| 2/15/2023 |
2/23/2022 |
Xipere™ (triamcinolone acetonide)
| 12/14/2022 |
2/16/2022 |
Besremi (ropeginterferon alfa-2b-njft)
| 2/15/2023 |
2/2/2022 |
Opsumit® (macitentan)
| 1/18/2023 |
1/26/2022 |
Opzelura™ (ruxolitinib)
| 10/19/2022 |
1/19/2022 |
Livtencity (maribavir) tablet
| 1/18/2023 |
1/1/2022 |
ADHD Long Acting Stimulants
| 11/16/2022 |
1/1/2022 |
APOKYN® (apomorphine hydrochloride) subcutaneous injection
| 1/18/2023 |
1/1/2022 |
Actemra® (tocilizumab) Subcutaneous
| 3/15/2023 |
1/1/2022 |
Actemra® (tocilizumab) Subcutaneous
| 3/15/2023 |
1/1/2022 |
Actinic Keratosis Agents
| 8/17/2022 |
1/1/2022 |
Afinitor/Afinitor Disperz (everolimus)
| 7/20/2022 |
1/1/2022 |
Alecensa (alectinib)

| 5/17/2023 |
1/1/2022 |
Anticholinergics and Central Nervous System Polypharmacy Agents
| 8/17/2022 |
1/1/2022 |
Austedo® & Austedo® XR (deutetrabenazine)

| 5/17/2023 |
1/1/2022 |
Avsola™ (infliximab-axxq)
| 11/16/2022 |
1/1/2022 |
Azilect® (rasagiline) tablets
| 1/18/2023 |
1/1/2022 |
Balversa™ (erdafitinib)
| 8/17/2022 |
1/1/2022 |
Banzel® (rufinamide)
| 3/15/2023 |
1/1/2022 |
Benlysta® (belimumab)
| 4/19/2023 |
1/1/2022 |
Berinert® (C1 esterase inhibitor, human)
| 8/17/2022 |
1/1/2022 |
Berinert® (C1 esterase inhibitor, human)
| 8/17/2022 |
1/1/2022 |
Betaseron® (interferon beta-1b)
| 7/20/2022 |
1/1/2022 |
BiDil® (isosorbide dinitrate/hydralazine)
| 8/17/2022 |
1/1/2022 |
Bortezomib products (Velcade and Bortezomib for injection)
| 8/17/2022 |
1/1/2022 |
Bosentan Products
| 3/15/2023 |
1/1/2022 |
Bosulif® (bosutinib)
| 5/18/2022 |
1/1/2022 |
Bosulif® (bosutinib)
| 5/18/2022 |
1/1/2022 |
Bowel Prep Agents
| 9/1/2022 |
1/1/2022 |
Buprenorphine transdermal patch
| 12/14/2022 |
1/1/2022 |
Bupropion Containing Products (Aplenzin®, Forfivo® XL)
| 10/19/2022 |
1/1/2022 |
Carvedilol ER
| 5/18/2022 |
1/1/2022 |
Cimzia® (certolizumab pegol)
| 11/17/2022 |
1/1/2022 |
Cimzia® (certolizumab pegol)
| 12/14/2022 |
1/1/2022 |
Cinryze® (C1 esterase inhibitor, human)
| 8/17/2022 |
1/1/2022 |
Cinryze® (C1 esterase inhibitor, human)
| 8/17/2022 |
1/1/2022 |
Consensi® (amlodipine-celecoxib)

| 5/17/2023 |
1/1/2022 |
Corlanor® (ivabradine)

| 5/25/2023 |
1/1/2022 |
Cosentyx® (secukinumab)
| 1/18/2023 |
1/1/2022 |
Darzalex Faspro™ (daratumumab and hyaluronidase- fihj)
| 8/17/2022 |
1/1/2022 |
Darzalex® (daratumumab)
| 8/17/2022 |
1/1/2022 |
Dayvigo™ (lemborexant)
| 7/21/2022 |
1/1/2022 |
Defitelio® (defibrotide sodium)
| 10/19/2022 |
1/1/2022 |
Desmopressin Nasal Spray
| 7/21/2022 |
1/1/2022 |
Dexchlorpheniramine oral solution
| 3/15/2023 |
1/1/2022 |
Dihydroergotamine Products
| 10/19/2022 |
1/1/2022 |
Duopa® (carbidopa and levodopa) enteral suspension
| 2/15/2023 |
1/1/2022 |
Dupixent® (dupilumab) injection
| 11/16/2022 |
1/1/2022 |
EMSAM® (selegiline transdermal system)
| 7/21/2022 |
1/1/2022 |
Elidel® (pimecrolimus)
| 4/19/2023 |
1/1/2022 |
Empliciti (elotuzumab)
| 8/17/2022 |
1/1/2022 |
Enbrel® (etanercept)

| 5/17/2023 |
1/1/2022 |
Entocort® (budesonide)

| 5/17/2023 |
1/1/2022 |
Entyvio® (vedolizumab)
| 11/16/2022 |
1/1/2022 |
Epidiolex® (cannabidiol) oral solution
| 2/15/2023 |
1/1/2022 |
Erleada™ (apalutamide)
| 12/14/2022 |
1/1/2022 |
Eucrisa® (crisaborole)
| 4/19/2023 |
1/1/2022 |
Exondys 51™ (eteplirsen) intravenous solution
| 2/15/2023 |
1/1/2022 |
Eylea® (aflibercept)
| 4/19/2023 |
1/1/2022 |
Ferriprox® (deferiprone)
| 8/17/2022 |
1/1/2022 |
Fetzima® (levomilnacipran)
| 10/19/2022 |
1/1/2022 |
Firazyr® (icatibant)
| 8/17/2022 |
1/1/2022 |
Gilenya® (fingolimod)
| 7/20/2022 |
1/1/2022 |
Gocovri® (amantadine) extended-release capsules
| 2/15/2023 |
1/1/2022 |
Granix® (tbo-filgrastim)
| 7/20/2022 |
1/1/2022 |
Growth Hormone (Hormona del crecimiento)
| 2/15/2023 |
1/1/2022 |
Haegarda® (C1 esterase inhibitor, human)
| 8/17/2022 |
1/1/2022 |
Humira® (adalimumab)

| 5/17/2023 |
1/1/2022 |
IVIG (Immune Globulin)
| 2/15/2023 |
1/1/2022 |
Iclusig® (ponatinib)

| 5/17/2023 |
1/1/2022 |
Ilumya® (tildrakizumab)
| 11/16/2022 |
1/1/2022 |
Imbruvica® (ibrutinib)
| 10/19/2022 |
1/1/2022 |
Imbruvica® (ibrutinib)
| 3/16/2022 |
1/1/2022 |
Inbrija ® (levodopa) capsule for inhalation
| 7/20/2022 |
1/1/2022 |
Inbrija® (levodopa) capsule for inhalation
| 7/20/2022 |
1/1/2022 |
Infliximab intravenous solution
| 1/18/2023 |
1/1/2022 |
Ingrezza® (valbenazine)
| 7/28/2022 |
1/1/2022 |
Inlyta (axitinib)
| 7/20/2022 |
1/1/2022 |
Intravenous Iron Products
| 4/19/2023 |
1/1/2022 |
Kalbitor® (ecallantide)
| 8/17/2022 |
1/1/2022 |
Kalbitor® (ecallantide)
| 8/17/2022 |
1/1/2022 |
Keppra XR® (levetiracetam extended-release)
| 2/15/2023 |
1/1/2022 |
Kevzara® (sarilumab)
| 4/19/2023 |
1/1/2022 |
Kineret® (anakinra)
| 7/20/2022 |
1/1/2022 |
Kineret® (anakinra)
| 8/17/2022 |
1/1/2022 |
Koselugo (selumetinib)

| 5/17/2023 |
1/1/2022 |
Kuvan® (sapropterin)

| 5/17/2023 |
1/1/2022 |
Kyprolis® (carfilzomib)
| 8/17/2022 |
1/1/2022 |
Lenvima (lenvatinib)
| 4/19/2023 |
1/1/2022 |
Lifetime Dosing Limits
| 10/21/2021 |
1/1/2022 |
Livalo® (pitavastatin)

| 5/17/2023 |
1/1/2022 |
Long Acting Anticholinergics

| 5/17/2023 |
1/1/2022 |
Long Acting Opioids
| 2/15/2023 |
1/1/2022 |
Lorbrena (lorlatinib)

| 5/17/2023 |
1/1/2022 |
Lucentis® (ranibizumab)
| 4/19/2023 |
1/1/2022 |
Lynparza (olaparib)
| 12/14/2022 |
1/1/2022 |
Mircera® (methoxy polyethylene glycol-epoetin beta)
| 11/3/2022 |
1/1/2022 |
Myrbetriq® and Myrbetriq® Granules (mirabegron)
| 8/17/2022 |
1/1/2022 |
Nexavar (sorafenib)
| 7/20/2022 |
1/1/2022 |
Ninlaro® (ixazomib)
| 8/17/2022 |
1/1/2022 |
Nourianz™ (istradefylline) tablets
| 2/15/2023 |
1/1/2022 |
Nubeqa® (darolutamide)
| 12/14/2022 |
1/1/2022 |
Nuedexta® (dextromethorphan and quinidine)
| 7/20/2022 |
1/1/2022 |
Nurtec™ ODT (rimegepant)

| 5/18/2023 |
1/1/2022 |
Ocrevus® (ocrelizumab)
| 11/17/2021 |
1/1/2022 |
Opioid Days' Supply Limitation
| 10/27/2022 |
1/1/2022 |
Oral Acne Antibiotics

| 5/17/2023 |
1/1/2022 |
Orencia® (abatacept) Subcutaneous
| 2/15/2023 |
1/1/2022 |
Orencia® (abatacept) Subcutaneous

| 5/17/2023 |
1/1/2022 |
Orencia® IV (abatacept)
| 1/18/2023 |
1/1/2022 |
Orenitram® (treprostinil)
| 4/19/2023 |
1/1/2022 |
Otic Antibiotics

| 5/17/2023 |
1/1/2022 |
Overactive Bladder Agents
| 8/17/2022 |
1/1/2022 |
Oxycodone-Acetaminophen Products
| 7/20/2022 |
1/1/2022 |
Panretin® (alitretinoin)
| 4/19/2023 |
1/1/2022 |
Pegasys (peginterferon alpha-2a)
| 8/17/2022 |
1/1/2022 |
Pomalyst® (pomalidomide)
| 11/16/2022 |
1/1/2022 |
Preferred Multiple Sclerosis Products
| 3/16/2023 |
1/1/2022 |
Inhibidores de la bomba de protones
| 3/30/2023 |
1/1/2022 |
Rayos® (prednisone delayed-release)
| 4/19/2023 |
1/1/2022 |
Reditrex® (methotrexate)
| 2/15/2023 |
1/1/2022 |
Renflexis® (infliximab-abda)
| 1/18/2023 |
1/1/2022 |
Rexulti (brexpiprazole)
| 12/14/2022 |
1/1/2022 |
Ridaura® (auranofin)
| 4/19/2023 |
1/1/2022 |
Rocklatan® (netarsudil and latanoprost)
| 7/20/2022 |
1/1/2022 |
Rubraca (rucaparib)

| 5/17/2023 |
1/1/2022 |
Ruconest® (C1 esterase inhibitor, recombinant)
| 8/17/2022 |
1/1/2022 |
Ruconest® (C1 esterase inhibitor, recombinant)
| 8/17/2022 |
1/1/2022 |
Samsca® (tolvaptan)

| 5/17/2023 |
1/1/2022 |
Sancuso (granisetron) Transdermal
| 8/17/2022 |
1/1/2022 |
Sandostatin® S.C., Sandostatin LAR® Depot (octreotide acetate for injection)
| 4/19/2023 |
1/1/2022 |
Sarclisa (isatuximab-irfc)
| 8/18/2021 |
1/1/2022 |
Siliq® (brodalumab) injection
| 4/19/2023 |
1/1/2022 |
Siliq® (brodalumab) injection
| 4/19/2023 |
1/1/2022 |
Simponi® (golimumab)
| 4/19/2023 |
1/1/2022 |
Simponi® (golimumab)
| 4/19/2023 |
1/1/2022 |
Skyrizi® (risankizumab-rzaa)
| 1/18/2023 |
1/1/2022 |
Sovaldi® (sofosbuvir)
| 8/18/2022 |
1/1/2022 |
Sprycel® (dasatinib)
| 5/18/2022 |
1/1/2022 |
Sprycel® (dasatinib)
| 5/18/2022 |
1/1/2022 |
Statin Products
| 4/19/2023 |
1/1/2022 |
Statin Products
| 4/19/2023 |
1/1/2022 |
Stelara® (ustekinumab)
| 9/21/2022 |
1/1/2022 |
Sublingual Allergen Extract

| 5/17/2023 |
1/1/2022 |
Sucraid® (sacrosidase)
| 8/17/2022 |
1/1/2022 |
Synagis® (palivizumab)
| 10/19/2022 |
1/1/2022 |
Takhzyro™ (lanadelumab-flyo)
| 8/17/2022 |
1/1/2022 |
Takhzyro™ (lanadelumab-flyo)
| 8/17/2022 |
1/1/2022 |
Taltz® (ixekizumab)
| 11/17/2022 |
1/1/2022 |
Taltz® (ixekizumab)
| 12/14/2022 |
1/1/2022 |
Tasigna® (nilotinib)
| 5/18/2022 |
1/1/2022 |
Tasigna® (nilotinib)
| 5/18/2022 |
1/1/2022 |
Tecfidera® (dimethyl fumarate)
| 7/20/2022 |
1/1/2022 |
Tepezza™ (teprotumumab)
| 12/14/2022 |
1/1/2022 |
Tobramycin for Inhalation
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