Fecha de vigencia | Policy Name | Reviewed Date |
1/24/2019 |
Drug Management Program-Opioid Program

| 11/21/2023 |
10/13/2023 |
Preferred Adalimumab Products

| 11/21/2023 |
11/15/2023 |
Akeega (niraparib and abiraterone acetate)
| 11/15/2023 |
1/1/2020 |
Antidepressant Agents

| 11/15/2023 |
1/1/2020 |
Aptiom® (eslicarbazepine acetate)

| 11/15/2023 |
1/1/2020 |
Braftovi™ (encorafenib) and Mektovi® (binimetinib)

| 11/15/2023 |
11/22/2023 |
Brixadi™ (buprenorphine)
| 11/15/2023 |
1/1/2024 |
Byooviz™ (ranibizumab-nuna)
| 11/15/2023 |
1/1/2020 |
Clindagel® (clindamycin phosphate gel)

| 11/15/2023 |
11/22/2023 |
Cosentyx (secukinumab) intravenous solution
| 11/15/2023 |
11/22/2023 |
Cosentyx (secukinumab) intravenous solution
| 11/15/2023 |
11/22/2023 |
Cosentyx (secukinumab) intravenous solution
| 11/15/2023 |
1/1/2021 |
Cotellic® (cobimetinib)

| 11/15/2023 |
1/1/2021 |
Cotellic® (cobimetinib)

| 11/15/2023 |
1/1/2023 |
Diacomit® (stiripentol)

| 11/15/2023 |
4/21/2021 |
Dupixent® (dupilumab) injection

| 11/15/2023 |
1/1/2022 |
Dupixent® (dupilumab) injection

| 11/15/2023 |
9/29/2008 |
Elaprase® (idursulfase)

| 11/15/2023 |
1/1/2020 |
Eligard® (leuprolide acetate)

| 11/15/2023 |
11/15/2023 |
Elrexfio (elranatamab-bcmm)
| 11/15/2023 |
1/1/2020 |
Emflaza® (deflazacort)

| 11/15/2023 |
11/22/2023 |
Entyvio® (vedolizumab)

| 11/15/2023 |
11/22/2023 |
Entyvio® (vedolizumab)

| 11/15/2023 |
11/22/2023 |
Entyvio® (vedolizumab)

| 11/15/2023 |
7/20/2017 |
FEIBA NF (Anti-Inhibitor Coagulant Complex)

| 11/15/2023 |
1/1/2020 |
Firdapse® (amifampridine)

| 11/15/2023 |
12/28/2022 |
Furoscix® (furosemide)

| 11/15/2023 |
1/1/2019 |
Gattex® (teduglutide)

| 11/15/2023 |
1/20/2021 |
Gimoti™ (metoclopramide)

| 11/15/2023 |
3/18/2020 |
Givlaari® (givosiran)

| 11/15/2023 |
12/9/2020 |
Hemady™ (dexamethasone tablet)

| 11/15/2023 |
1/1/2016 |
Intuniv® (guanfacine extended-release tablets)

| 11/15/2023 |
1/20/2016 |
Kanuma® (sebelipase alfa)

| 11/15/2023 |
1/1/2016 |
Kapvay® (clonidine extended-release)

| 11/15/2023 |
1/1/2023 |
Keytruda (pembrolizumab)

| 11/15/2023 |
1/1/2020 |
Lamotrigine Products

| 11/15/2023 |
1/1/2017 |
Leuprolide acetate

| 11/15/2023 |
12/12/2018 |
Lexette® (halobetasol) Topical Foam

| 11/15/2023 |
1/1/2011 |
Lumizyme® (alglucosidase alpha)

| 11/15/2023 |
1/1/2020 |
Lupron® (leuprolide acetate) and Generic Depot Products

| 11/15/2023 |
1/1/2024 |
Lybalvi (olanzapine and samidorphan)
| 11/15/2023 |
1/1/2020 |
Molindone hydrochloride

| 11/15/2023 |
11/22/2023 |
Motpoly XR (lacosamide extended release)
| 11/15/2023 |
11/22/2023 |
Non-Preferred Adalimumab Products

| 11/15/2023 |
11/22/2023 |
Non-Preferred Adalimumab Products

| 11/15/2023 |
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 |
1/20/2017 |
Obizur [antihemophilic (recombinant), porcine sequence]

| 11/15/2023 |
1/1/2023 |
Opdivo (nivolumab)

| 11/15/2023 |
6/19/2019 |
Orphenadrine Products

| 11/15/2023 |
1/1/2020 |
Oxaydo® (oxycodone HCL)

| 11/15/2023 |
4/21/2021 |
Oxlumo® (lumasiran)

| 11/15/2023 |
1/1/2020 |
Oxtellar XR® (oxcarbazepine extended release)

| 11/15/2023 |
1/1/2023 |
Pediatric Cardiovascular Products

| 11/15/2023 |
11/30/2022 |
Pedmark ® (sodium thiosulfate injection)

| 11/15/2023 |
6/6/2013 |
Procysbi® (cysteamine)

| 11/15/2023 |
1/1/2018 |
Rapid-Acting Fentanyl Products

| 11/15/2023 |
1/1/2024 |
Rexulti (brexpiprazole)
| 11/15/2023 |
10/14/2020 |
Rhopressa® (netarsudil), Rocklatan® (netarsudil and latanoprost)

| 11/15/2023 |
1/1/2024 |
Rinvoq (upadacitinib)
| 11/15/2023 |
1/1/2020 |
Rozerem (ramelteon)

| 11/15/2023 |
11/22/2023 |
Rystiggo (rozanolixizumab-noli)
| 11/15/2023 |
12/15/2021 |
Saphnelo™ (anifrolumab-fnia)

| 11/15/2023 |
3/21/2018 |
Sinuva™ (mometasone furoate) sinus implant

| 11/15/2023 |
5/2/2013 |
Sirturo® (bedaquiline)

| 11/15/2023 |
2/21/2018 |
Solosec™ (secnidazole)

| 11/15/2023 |
11/23/2022 |
Spevigo® (spesolimab-sbzo)

| 11/15/2023 |
1/1/2020 |
Sprix® (ketorolac tromethamine) nasal spray

| 11/15/2023 |
1/1/2020 |
Sublocade™ (buprenorphine extended-release) injection

| 11/15/2023 |
11/22/2023 |
Talvey (talquetamab)
| 11/15/2023 |
1/1/2018 |
Thrombate III® [Antithrombin III (Human)]

| 11/15/2023 |
1/1/2018 |
Topical Doxepin Products (doxepin, Prudoxin®, Zonalon®)

| 11/15/2023 |
1/1/2023 |
Topical Vitamin D Products

| 11/15/2023 |
5/16/2018 |
Trogarzo™ (ibalizumab-uiyk)

| 11/15/2023 |
5/25/2022 |
Vabysmo™ (faricimab-svoa)

| 11/15/2023 |
1/1/2023 |
Vabysmo™ (faricimab-svoa)

| 11/15/2023 |
1/1/2020 |
Visudyne® (verteporfin)

| 11/15/2023 |
11/30/2022 |
Vivjoa™ (oteseconazole)

| 11/15/2023 |
11/22/2023 |
Xdemvy™ (lotilaner)
| 11/15/2023 |
11/30/2022 |
Xenpozyme™ (olipudase alfa) intravenous solution

| 11/15/2023 |
2/23/2022 |
Xipere™ (triamcinolone acetonide)

| 11/15/2023 |
4/20/2016 |
Xuriden® (uridine triacetate)

| 11/15/2023 |
11/22/2023 |
Ycanth™ (cantharidin)
| 11/15/2023 |
1/1/2020 |
ZTlido® (lidocaine topical system)

| 11/15/2023 |
10/16/2019 |
Zelnorm™ (tegaserod)

| 11/15/2023 |
1/1/2017 |
Zoladex® (goserelin)

| 11/15/2023 |
11/23/2022 |
Zoryve® (roflumilast) cream

| 11/15/2023 |
1/1/2016 |
Zyclara® (imiquimod)

| 11/15/2023 |
5/1/2021 |
Zypitamag® (pitavastatin)

| 11/15/2023 |
1/1/2021 |
Zypitamag™ (pitavastatin)

| 11/15/2023 |
1/1/2019 |
Non-Formulary Exceptions

| 11/2/2023 |
11/8/2023 |
Ojjaara (momelotinib)
| 11/2/2023 |
11/1/2019 |
Rozlytrek™ (entrectinib)

| 11/2/2023 |
10/25/2023 |
AIRSUPRA (albuterol and budesonide) inhalation aerosol
| 10/18/2023 |
12/9/2020 |
Alkindi® (hydrocortisone) sprinkle capsule
| 10/18/2023 |
1/1/2019 |
Allergy Ophthalmics
| 10/18/2023 |
1/1/2020 |
Ampyra® (dalfampridine)
| 10/18/2023 |
1/1/2019 |
Azopt® (brinzolamide ophthalmic suspension) 1%
| 10/18/2023 |
2/23/2022 |
Brimonidine-timolol eye drops (generic Combigan)
| 10/18/2023 |
1/1/2022 |
Bupropion Containing Products (Aplenzin®, Forfivo® XL)
| 10/18/2023 |
10/26/2022 |
Camzyos™ (mavacamten)
| 10/18/2023 |
1/1/2024 |
Caplyta (lumateperone)
| 10/18/2023 |
4/28/2011 |
Caprelsa® (vandetanib)
| 10/18/2023 |
1/1/2020 |
Carbinoxamine 6mg tablet
| 10/18/2023 |
1/1/2015 |
Chenodal™ (chenodiol)
| 10/18/2023 |
5/9/2013 |
Cysteamine Ophthalmic Products (Cystaran™, Cystadrops®)
| 10/18/2023 |
2/17/2021 |
Danyelza® (naxitamab-gqgk)
| 10/18/2023 |
1/1/2023 |
Deferasirox Products
| 10/18/2023 |
1/1/2023 |
Deferasirox Tablet
| 10/18/2023 |
1/1/2024 |
Deferasirox products
| 10/18/2023 |
1/1/2022 |
Defitelio® (defibrotide sodium)
| 10/18/2023 |
1/1/2021 |
Duexis® (ibuprofen-famotidine) tablet
| 10/18/2023 |
10/16/2019 |
Duloxetine Containing Products
| 10/18/2023 |
1/1/2018 |
Effient® (prasugrel)
| 10/18/2023 |
9/27/2023 |
Elevidys (delandistrogene moxeparvovec-rokl)
| 10/18/2023 |
1/1/2023 |
Epoetin Alfa (Epogen, Procrit, Retacrit)
| 10/18/2023 |
12/15/2021 |
Eprontia™ (topiramate) oral solution
| 10/18/2023 |
2/9/2012 |
Erivedge® (vismodegib)
| 10/18/2023 |
11/11/2020 |
Evrysdi® (risdiplam)
| 10/18/2023 |
1/1/2024 |
Ferriprox® (deferiprone)
| 10/18/2023 |
1/1/2022 |
Fetzima® (levomilnacipran)
| 10/18/2023 |
2/23/2022 |
Fyarro (sirolimus protein-bound particles for injectable suspension)
| 10/18/2023 |
1/1/2020 |
Gralise® (gabapentin)
| 10/18/2023 |
10/15/2015 |
Keveyis® (dichlorphenamide)
| 10/18/2023 |
1/1/2020 |
Lidocaine 5% topical ointment
| 10/18/2023 |
10/8/2021 |
Long Acting Insulins
| 10/18/2023 |
1/1/2020 |
Lonsurf® (trifluridine and tipiracil)
| 10/18/2023 |
1/1/2023 |
Lynparza (olaparib)
| 10/18/2023 |
1/1/2016 |
Megace® ES (megestrol acetate)
| 10/18/2023 |
11/23/2022 |
Methocarbamol tablet
| 10/18/2023 |
1/1/2022 |
Mircera® (methoxy polyethylene glycol-epoetin beta)
| 10/18/2023 |
10/26/2022 |
Nexiclon™ XR (clonidine ER) tablet
| 10/18/2023 |
1/1/2024 |
Non-Preferred Continuous Glucose Monitoring Systems
| 10/18/2023 |
10/29/2015 |
Odomzo® (sonidegib)
| 10/18/2023 |
1/1/2020 |
Ophthalmic Antibiotics
| 10/18/2023 |
1/1/2020 |
Ophthalmic Non-Steroidal Anti-Inflammatory Drugs
| 10/18/2023 |
3/6/2019 |
Oxandrin® (oxandrolone)
| 10/18/2023 |
1/1/2016 |
Oxandrolone
| 10/18/2023 |
1/1/2016 |
Pancreatic Enzymes
| 10/18/2023 |
1/1/2020 |
Pancreatic Enzymes
| 10/18/2023 |
6/3/2020 |
Pemazyre™ (pemigatinib)
| 10/18/2023 |
1/1/2024 |
Preferred Continuous Glucose Monitoring Systems
| 10/18/2023 |
1/1/2020 |
Previous Treatment/Prior Therapy/Trial
| 10/18/2023 |
9/21/2016 |
Probuphine® (buprenorphine) Implant
| 10/18/2023 |
1/1/2020 |
Qudexy XR®, Trokendi XR® (topiramate)
| 10/18/2023 |
7/8/2020 |
Retevmo™ (selpercatinib)
| 10/18/2023 |
5/16/2018 |
Rhopressa® (netarsudil)
| 10/18/2023 |
1/1/2019 |
Savella® (milnacipran)
| 10/18/2023 |
2/20/2019 |
Short Acting Beta Agonists
| 10/18/2023 |
5/22/2014 |
Sitavig® (acyclovir)
| 10/18/2023 |
1/1/2020 |
Spritam® (levetiracetam)
| 10/18/2023 |
1/1/2020 |
Stem cell mobilizing agents (Mozobil, Aphexda, Plerixafor)
| 10/18/2023 |
1/1/2022 |
Synagis® (palivizumab)
| 10/18/2023 |
11/21/2012 |
Synribo® (omacetaxine mepesuccinate)
| 10/18/2023 |
1/1/2022 |
Tobramycin for Inhalation
| 10/18/2023 |
1/1/2024 |
Tobramycin for Inhalation
| 10/18/2023 |
1/16/2019 |
Tolsura (itraconazole)
| 10/18/2023 |
1/1/2021 |
Topical Psoriasis Agents
| 10/18/2023 |
1/1/2023 |
Topical Psoriasis Agents
| 10/18/2023 |
1/1/2022 |
Trintellix (vortioxetine)
| 10/18/2023 |
1/1/2009 |
VFEND® (voriconazole)
| 10/18/2023 |
10/18/2023 |
Vanflyta (quizartinib)
| 10/18/2023 |
10/25/2023 |
Vowst (fecal microbiota spores, live-brpk)
| 10/18/2023 |
1/1/2024 |
Vraylar (cariprazine)
| 10/18/2023 |
7/19/2017 |
Xadago® (safinamide)
| 10/18/2023 |
5/20/2020 |
Xcopri® (cenobamate)
| 10/18/2023 |
1/1/2021 |
ZTlido™ (lidocaine topical system)
| 10/18/2023 |
8/5/2010 |
Zuplenz® (ondansetron oral soluble film)
| 10/18/2023 |
6/19/2019 |
Medical Necessity Determinations
| 10/12/2023 |
12/1/2022 |
Medical Necessity Determinations
| 10/12/2023 |
1/1/2023 |
Medical Necessity Determinations
| 10/12/2023 |
1/1/2022 |
Opioid Days' Supply Limitation
| 10/12/2023 |
1/1/2019 |
Opioid Days' Supply Limitation
| 10/12/2023 |
11/3/2021 |
Opioid Days' Supply Limitation - Florida Statute 456.44(5)(a) Prescription Supply Limits
| 10/12/2023 |
2/1/2021 |
Opioid Utilization Program - Concurrent Use of Opioids and Benzodiazepines (COB) edits
| 10/12/2023 |
1/1/2024 |
Stivarga (regorafenib)
| 10/12/2023 |
1/1/2023 |
Stivarga (regorafenib)
| 10/12/2023 |
1/1/2023 |
Aflibercept Products (Eylea®, Eylea® HD)
| 10/5/2023 |
1/1/2022 |
Aflibercept Products (Eylea®, Eylea® HD)
| 10/5/2023 |
1/1/2024 |
ADHD Long Acting Stimulants
| 9/20/2023 |
1/1/2022 |
ADHD Long Acting Stimulants
| 9/20/2023 |
1/1/2019 |
Actemra® (tocilizumab) Intravenous
| 9/20/2023 |
1/1/2019 |
Actemra® (tocilizumab) Intravenous
| 9/20/2023 |
1/1/2022 |
Actemra® (tocilizumab) Subcutaneous
| 9/20/2023 |
1/1/2022 |
Actemra® (tocilizumab) Subcutaneous
| 9/20/2023 |
1/1/2020 |
Actemra® IV (tocilizumab)
| 9/20/2023 |
1/1/2024 |
Afinitor/Afinitor Disperz (everolimus)
| 9/20/2023 |
1/1/2013 |
Aldurazyme® (laronidase)
| 9/20/2023 |
1/1/2016 |
Alpha-1 Proteinase Inhibitors (Aralast NP®, Glassia®)
| 9/20/2023 |
1/1/2023 |
Alpha-1 Proteinase Inhibitors (Aralast NP®, Glassia®, Zemaira®)
| 9/20/2023 |
1/1/2024 |
Alpha-1 Proteinase Inhibitors (Prolastin-C®, Zemaira®)
| 9/20/2023 |
1/1/2016 |
Alpha-1 Proteinase Inhibitors (Prolastin-C®, Zemaira®)
| 9/20/2023 |
1/1/2024 |
Alphagan® P (brimonidine)
| 9/20/2023 |
9/28/2022 |
Amvuttra™ (vutrisiran)
| 9/20/2023 |
1/1/2023 |
Avsola® (infliximab-axxq)
| 9/20/2023 |
6/17/2020 |
Avsola® (infliximab-axxq)
| 9/20/2023 |
1/1/2022 |
Avsola™ (infliximab-axxq)
| 9/20/2023 |
1/1/2024 |
Azopt® (brinzolamide ophthalmic suspension) 1%
| 9/20/2023 |
1/1/2024 |
Beovu® (brolucizumab)
| 9/20/2023 |
1/1/2021 |
Cabometyx™ (cabozantinib)
| 9/20/2023 |
1/1/2023 |
Cholbam® (cholic acid)
| 9/20/2023 |
1/1/2020 |
Cimzia (certolizumab pegol)
| 9/20/2023 |
1/1/2022 |
Cimzia® (certolizumab pegol)
| 9/20/2023 |
1/1/2022 |
Cimzia® (certolizumab pegol)
| 9/20/2023 |
9/27/2023 |
Columvi™ (glofitamab-gxbm)
| 9/20/2023 |
11/11/2020 |
Conjupri® (levamlodipine)
| 9/20/2023 |
1/1/2006 |
Medicamentos para tos y resfríos
| 9/20/2023 |
1/1/2024 |
Daxxify® (daxibotulinumtoxinA-lanm)
| 9/20/2023 |
10/1/2023 |
Daxxify® (daxibotulinumtoxinA-lanm)
| 9/20/2023 |
1/1/2017 |
Diabetic Test Strips and Meters
| 9/20/2023 |
1/1/2022 |
Dihydroergotamine Products
| 9/20/2023 |
1/1/2023 |
Enhertu (fam-trastuzumab deruxtecan-nxki)
| 9/20/2023 |
1/20/2021 |
Enspryng™ (satralizumab-mwge)
| 9/20/2023 |
11/17/2021 |
Exkivity (mobocertinib)
| 9/20/2023 |
1/1/2023 |
Finacea® (azelaic acid) topical foam
| 9/20/2023 |
11/11/2020 |
Gavreto™ (pralsetinib)
| 9/20/2023 |
1/1/2021 |
Growth Hormone (Hormona del crecimiento)
| 9/20/2023 |
1/1/2022 |
Growth Hormone (Hormona del crecimiento)
| 9/20/2023 |
9/28/2022 |
Hyftor™ (sirolimus topical gel)
| 9/20/2023 |
1/1/2024 |
Ibsrela® (tenapanor)
| 9/20/2023 |
11/22/2023 |
Ilumya® (tildrakizumab)

| 9/20/2023 |
11/22/2023 |
Ilumya® (tildrakizumab)

| 9/20/2023 |
11/22/2023 |
Ilumya™ (tildrakizumab)

| 9/20/2023 |
1/1/2023 |
Inflectra ® (infliximab-dyyb)
| 9/20/2023 |
1/1/2019 |
Inflectra® (infliximab-dyyb)
| 9/20/2023 |
1/1/2022 |
Infliximab intravenous solution
| 9/20/2023 |
1/1/2022 |
Ingrezza® (valbenazine)
| 9/20/2023 |
9/28/2022 |
Inhaled Corticosteroid and Long Acting Beta Agonists
| 9/20/2023 |
1/1/2024 |
Intranasal Rhinitis Agents
| 9/20/2023 |
1/1/2023 |
Intranasal Rhinitis Agents
| 9/20/2023 |
1/1/2024 |
Intravenous Iron Products
| 9/20/2023 |
9/27/2023 |
Izervay™ (avacincaptad pegol)
| 9/20/2023 |
1/1/2020 |
Jakafi® (ruxolitinib)
| 9/20/2023 |
8/1/2021 |
Jemperli (dostarlimab-gxly)
| 9/20/2023 |
1/1/2023 |
Jemperli (dostarlimab-gxly)
| 9/20/2023 |
9/27/2023 |
Joenja® (leniolisib)
| 9/20/2023 |
11/17/2021 |
Kerendia® (finerenone)
| 9/20/2023 |
11/17/2021 |
Kerendia® (finerenone)
| 9/20/2023 |
1/1/2022 |
Kineret® (anakinra)
| 9/20/2023 |
1/1/2022 |
Kineret® (anakinra)
| 9/20/2023 |
8/23/2023 |
Leqembi™ (lecanemab-irmb)
| 9/20/2023 |
1/1/2023 |
Levoleucovorin products (Fusilev, Khapzory)
| 9/20/2023 |
9/27/2023 |
Litfulo™ (ritlecitinib)
| 9/20/2023 |
1/1/2024 |
Long Acting Opioids
| 9/20/2023 |
1/1/2024 |
Mavenclad® (cladribine)
| 9/20/2023 |
1/1/2023 |
Mavenclad® (cladribine)
| 9/20/2023 |
1/1/2023 |
Nebivolol (generic Bystolic)
| 9/20/2023 |
10/20/2021 |
Nexviazyme™ (avalglucosidase alfa-ngpt) Injection
| 9/20/2023 |
10/13/2023 |
Non-Preferred Adalimumab Products
| 9/20/2023 |
1/1/2023 |
Non-Preferred GLP Analogs
| 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) and Avsola (infliximab-axxq)
| 9/20/2023 |
1/1/2023 |
Non-Preferred Multiple Sclerosis Interferons
| 9/20/2023 |
1/1/2023 |
Non-Preferred Oral Multiple Sclerosis Products
| 9/20/2023 |
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), 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 |
1/1/2024 |
Nonsteroidal Anti-Inflammatory Drug Products
| 9/20/2023 |
1/1/2023 |
Ocaliva® (obeticholic acid)
| 9/20/2023 |
1/1/2023 |
Ocrevus® (ocrelizumab)
| 9/20/2023 |
7/1/2022 |
Olumiant® (baricitinib)
| 9/20/2023 |
7/1/2022 |
Olumiant® (baricitinib)
| 9/20/2023 |
12/9/2020 |
Ongentys® (opicapone)
| 9/20/2023 |
1/20/2016 |
Onivyde ® (liposomal irinotecan)
| 9/20/2023 |
11/11/2020 |
Onureg™ (azacitidine)
| 9/20/2023 |
1/1/2024 |
Ophthalmic Antibiotics
| 9/20/2023 |
1/1/2024 |
Ophthalmic Beta Blockers
| 9/20/2023 |
1/26/2022 |
Opzelura™ (ruxolitinib)
| 9/20/2023 |
1/1/2020 |
Orencia® (abatacept) Intraveneous
| 9/20/2023 |
1/1/2022 |
Orencia® (abatacept) Intraveneous
| 9/20/2023 |
1/1/2019 |
Orencia® (abatacept) Intravenous
| 9/20/2023 |
1/1/2022 |
Orencia® (abatacept) Subcutaneous
| 9/20/2023 |
1/1/2022 |
Orencia® (abatacept) Subcutaneous
| 9/20/2023 |
1/1/2023 |
Otezla® (apremilast)
| 9/20/2023 |
1/1/2022 |
Pomalyst® (pomalidomide)
| 9/20/2023 |
10/13/2023 |
Preferred Adalimumab Products
| 9/20/2023 |
10/13/2023 |
Preferred Adalimumab Products
| 9/20/2023 |
1/1/2024 |
Preferred Infliximab Products - Inflectra (infliximab-dyyb)
| 9/20/2023 |
1/1/2024 |
Preferred Infliximab Products - Remicade (infliximab), Inflectra (infliximab-dyyb), and infliximab
| 9/20/2023 |
1/1/2022 |
Preferred Multiple Sclerosis Products
| 9/20/2023 |
1/1/2023 |
Preferred Filgrastim Products - Nivestym (filgrastim-aafi) and Zarxio (filgrastim-sndz)
| 9/20/2023 |
1/1/2023 |
Preferred Pegfilgrastim Products - Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), and Udenyca (pegfilgrastim-cbqv)
| 9/20/2023 |
1/1/2023 |
Preferred Pegfilgrastim Products - Fulphila (pegfilgrastim-jmdb) and Udenyca (pegfilgrastim- cbqv)
| 9/20/2023 |
2/21/2018 |
Prevymis™ (letermovir)
| 9/20/2023 |
1/1/2023 |
Prolastin-C® (alpha-1 proteinase inhibitor)
| 9/20/2023 |
1/1/2023 |
Pyrukynd® (mitapivat)
| 9/20/2023 |
12/19/2018 |
Qbrexza® (glycopyrronium)
| 9/20/2023 |
1/20/2021 |
Qdolo™ (tramadol) oral solution
| 9/20/2023 |
1/1/2024 |
Qelbree (viloxazine)
| 9/20/2023 |
5/19/2021 |
Qelbree™ (viloxazine)
| 9/20/2023 |
1/1/2024 |
Quviviq (daridorexant)
| 9/20/2023 |
1/1/2021 |
Regranex® (becaplermin)
| 9/20/2023 |
1/1/2020 |
Remicade® (infliximab)
| 9/20/2023 |
1/1/2019 |
Remicade® (infliximab)
| 9/20/2023 |
1/1/2020 |
Renflexis (infliximab-abda)
| 9/20/2023 |
1/1/2022 |
Renflexis® (infliximab-abda)
| 9/20/2023 |
1/1/2023 |
Renflexis® (infliximab-abda)
| 9/20/2023 |
1/1/2023 |
Revlimid (lenalidomida)
| 9/20/2023 |
10/8/2021 |
Rezurock (belumosudil)
| 9/20/2023 |
1/1/2023 |
Rinvoq® (upadacitinib)
| 9/20/2023 |
1/1/2024 |
Rocklatan® (netarsudil and latanoprost)
| 9/20/2023 |
1/1/2024 |
Sandostatin® S.C., Sandostatin LAR® Depot (octreotide acetate for injection)
| 9/20/2023 |
1/22/2015 |
Savaysa® (edoxaban)
| 9/20/2023 |
1/1/2023 |
Signifor® LAR (pasireotide)
| 9/20/2023 |
1/1/2022 |
Siliq® (brodalumab) injection
| 9/20/2023 |
1/1/2022 |
Siliq® (brodalumab) injection
| 9/20/2023 |
1/1/2024 |
Simbrinza™ (brinzolamide/brimonidine ophthalmic suspension)
| 9/20/2023 |
1/1/2019 |
Simponi ARIA (golimumab)
| 9/20/2023 |
1/1/2022 |
Simponi® (golimumab)
| 9/20/2023 |
1/1/2022 |
Simponi® (golimumab)
| 9/20/2023 |
2/22/2023 |
Sotyktu (deucravacitinib)
| 9/20/2023 |
2/22/2023 |
Sotyktu (deucravacitinib)
| 9/20/2023 |
1/1/2024 |
Spiriva Handihaler® (tiotropium bromide) ETB
| 9/20/2023 |
1/1/2022 |
Stelara® (ustekinumab)
| 9/20/2023 |
1/1/2024 |
Susvimo™ (ranibizumab)
| 9/20/2023 |
1/1/2021 |
Tadalafil Products - PAH Indication Only
| 9/20/2023 |
1/1/2022 |
Taltz® (ixekizumab)
| 9/20/2023 |
1/1/2022 |
Taltz® (ixekizumab)
| 9/20/2023 |
12/12/2018 |
Tegsedi® (inotersen)
| 9/20/2023 |
7/15/2020 |
Thalomid® (thalidomide)
| 9/20/2023 |
1/1/2024 |
Tivdak (tisotumab vedotin-tftv)
| 9/20/2023 |
1/1/2024 |
Torisel (temsirolimus)
| 9/20/2023 |
1/1/2019 |
Torisel® (temsirolimus)
| 9/20/2023 |
1/1/2022 |
Tremfya® (guselkumab)
| 9/20/2023 |
1/1/2024 |
Triptans
| 9/20/2023 |
10/21/2021 |
Trudhesa™ (dihydroergotamine mesylate)
| 9/20/2023 |
1/1/2024 |
Trulance® (plecanatide)
| 9/20/2023 |
1/1/2023 |
Tysabri (natalizumab)
| 9/20/2023 |
9/3/2015 |
Unituxin® (dinutuximab)
| 9/20/2023 |
1/20/2021 |
Upneeq™ (oxymetazoline)
| 9/20/2023 |
1/1/2021 |
Vemlidy® (tenofovir alafenamide)
| 9/20/2023 |
1/1/2023 |
Ventavis® (iloprost)
| 9/20/2023 |
5/18/2022 |
Vonjo (pacritinib)
| 9/20/2023 |
9/28/2022 |
Vtama® (tapinarof) cream
| 9/20/2023 |
9/27/2023 |
Vyjuvek™ (beremagene geperpavec-svdt)
| 9/20/2023 |
11/1/2021 |
|