Formularios de proveedores
Salud conductual
Reclamaciones y código CPT
Waiver of Liability
PDF, 8 KB
PDF, 8 KB
Continuación de la atención
Contratación
Credentialing Application
PDF, 278 KB
PDF, 278 KB
Relacionados con los miembros
Notificación de autorización previa e ingreso hospitalario
Notificación de ingreso
Autorización previa
Recursos
Prior Authorization Requirements
PDF, 758 KB
PDF, 758 KB
Medicamentos con autorización previa - Comercial
Abecma (Medical)
PDF, 215 KB
PDF, 215 KB
Abrysvo (Medical)
PDF, 147 KB
PDF, 147 KB
Actimmune (Medical)
PDF, 176 KB
PDF, 176 KB
Adakveo (Medical)
PDF, 205 KB
PDF, 205 KB
Adasuve (Medical)
PDF, 158 KB
PDF, 158 KB
Adstiladrin (Medical)
PDF, 221 KB
PDF, 221 KB
Aduhelm (Medical)
PDF, 353 KB
PDF, 353 KB
Adzynma (Medical)
PDF, 264 KB
PDF, 264 KB
Aldurazyme (Medical)
PDF, 220 KB
PDF, 220 KB
Alhemo (Medical)
PDF, 214 KB
PDF, 214 KB
Aliqopa IV (Medical)
PDF, 167 KB
PDF, 167 KB
Amphotericin B Liposome (Medical)
PDF, 199 KB
PDF, 199 KB
Amtagvi (Medical)
PDF, 217 KB
PDF, 217 KB
Amvuttra (Medical)
PDF, 256 KB
PDF, 256 KB
Aphexda (Medical)
PDF, 179 KB
PDF, 179 KB
Aucatzyl (Medical)
PDF, 240 KB
PDF, 240 KB
Azedra (Medical)
PDF, 257 KB
PDF, 257 KB
Benlysta (Medical)
PDF, 259 KB
PDF, 259 KB
Beqvez (Medical)
PDF, 276 KB
PDF, 276 KB
Berinert IV (Medical)
PDF, 218 KB
PDF, 218 KB
Besponsa IV (Medical)
PDF, 217 KB
PDF, 217 KB
Beyfortus (Medical)
PDF, 205 KB
PDF, 205 KB
Boruzu (Medical)
PDF, 206 KB
PDF, 206 KB
Botox | Xeomin (Medical)
PDF, 201 KB
PDF, 201 KB
Breyanzi (Medical)
PDF, 221 KB
PDF, 221 KB
Brineura IV (Medical)
PDF, 209 KB
PDF, 209 KB
Briumvi (Medical)
PDF, 198 KB
PDF, 198 KB
Brixadi│Sublocade (Medical)
PDF, 181 KB
PDF, 181 KB
Cabenuva LAP (Medical)
PDF, 169 KB
PDF, 169 KB
Carvykti (Medical)
PDF, 215 KB
PDF, 215 KB
Casgevy (Medical)
PDF, 264 KB
PDF, 264 KB
Cimzia Lyophilized IV (Medical)
PDF, 199 KB
PDF, 199 KB
Cinqair IV (Medical)
PDF, 175 KB
PDF, 175 KB
Cosentyx IV (Medical)
PDF, 219 KB
PDF, 219 KB
Cresemba (Medical)
PDF, 216 KB
PDF, 216 KB
Crysvita Injection (Medical)
PDF, 218 KB
PDF, 218 KB
Dalvance (Medical)
PDF, 191 KB
PDF, 191 KB
Datroway (Medical)
PDF, 242 KB
PDF, 242 KB
Daxxify (Medical)
PDF, 167 KB
PDF, 167 KB
Denosumab Biosimilars - Oncology Indications (Medical)
(PREFERRED: Osenvelt | Wyost) (NON-PREFERRED: Aukelso | Bilprevda | Bomyntra | Xbryk | Xgeva | Xtrenbo)
PDF, 175 KB
(PREFERRED: Osenvelt | Wyost) (NON-PREFERRED: Aukelso | Bilprevda | Bomyntra | Xbryk | Xgeva | Xtrenbo)
PDF, 175 KB
Denosumab Biosimilars - Osteoporosis Indications (Medical)
(PREFERRED: Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Enoby | Ospomyv | Prolia)
PDF, 173 KB
(PREFERRED: Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Enoby | Ospomyv | Prolia)
PDF, 173 KB
Dextenza (Medical)
PDF, 204 KB
PDF, 204 KB
Durysta (Medical)
PDF, 175 KB
PDF, 175 KB
Eculizumab IV Products - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
(Bkemv | Epysqli | Soliris)
PDF, 205 KB
(Bkemv | Epysqli | Soliris)
PDF, 205 KB
Eculizumab IV Products - Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
(Bkemv | Epysqli | Soliris)
PDF, 247 KB
(Bkemv | Epysqli | Soliris)
PDF, 247 KB
Eculizumab Products IV - Generalized Myasthenia Gravis (gMG) (Medical)
(Bkemv | Epysqli | Soliris)
PDF, 235 KB
(Bkemv | Epysqli | Soliris)
PDF, 235 KB
Elaprase IV (Medical)
PDF, 232 KB
PDF, 232 KB
Elevidys (Medical)
PDF, 189 KB
PDF, 189 KB
Elfabrio IV (Medical)
PDF, 225 KB
PDF, 225 KB
Emblaveo (Medical)
PDF, 191 KB
PDF, 191 KB
Empaveli (Medical)
PDF, 241 KB
PDF, 241 KB
Encelto (Medical)
PDF, 201 KB
PDF, 201 KB
Enjaymo (Medical)
PDF, 249 KB
PDF, 249 KB
Entyvio IV (Medical)
PDF, 191 KB
PDF, 191 KB
Evenity (Medical)
PDF, 201 KB
PDF, 201 KB
Evkeeza (Medical)
PDF, 209 KB
PDF, 209 KB
Fabrazyme IV (Medical)
PDF, 215 KB
PDF, 215 KB
Factor IX Deficiency Therapy (Hemophilia B) (Medical)
(AlphaNine | Alprolix | BeneFIX | Idelvion | Ixinity | Profilnine | Rebinyn | Rixubis)
PDF, 373 KB
(AlphaNine | Alprolix | BeneFIX | Idelvion | Ixinity | Profilnine | Rebinyn | Rixubis)
PDF, 373 KB
Factor VIIa (Bypassing Agents for Hemophilia A and B) (Medical)
(NovoSeven RT | Sevenfact)
PDF, 284 KB
(NovoSeven RT | Sevenfact)
PDF, 284 KB
Factor VIII Deficiency Therapy (Hemophilia A) (Medical)
(Advate | Adynovate | Afstyla | Alphanate | ALTUVIIIO | Eloctate | Esperoct | Hemofil M | Humate-P | Jivi | Koate | Kogenate | Kovaltry | Novoeight | Nuwiq | Obizur | Recominate | Wilate | Xyntha)
PDF, 403 KB
(Advate | Adynovate | Afstyla | Alphanate | ALTUVIIIO | Eloctate | Esperoct | Hemofil M | Humate-P | Jivi | Koate | Kogenate | Kovaltry | Novoeight | Nuwiq | Obizur | Recominate | Wilate | Xyntha)
PDF, 403 KB
Fasenra (Medical)
PDF, 231 KB
PDF, 231 KB
Feiba (Medical)
PDF, 273 KB
PDF, 273 KB
Fetroja (Medical)
PDF, 177 KB
PDF, 177 KB
Fuzeon (Medical)
PDF, 202 KB
PDF, 202 KB
Gamifant IV (Medical)
PDF, 253 KB
PDF, 253 KB
Givlaari (Medical)
PDF, 227 KB
PDF, 227 KB
Hemgenix (Medical)
PDF, 260 KB
PDF, 260 KB
Hemophilia Factors (IV) (Medical)
PDF, 166 KB
PDF, 166 KB
Hyaluronate Acids (Medical)
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Hymovis One | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 243 KB
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Hymovis One | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 243 KB
Hympavzi (Medical)
PDF, 217 KB
PDF, 217 KB
iDose TR (Medical)
PDF, 176 KB
PDF, 176 KB
Ilumya SQ (Medical)
PDF, 172 KB
PDF, 172 KB
Imaavy (Medical)
PDF, 201 KB
PDF, 201 KB
Imlygic (Medical)
PDF, 200 KB
PDF, 200 KB
Immune Globulin Intravenous (IVIG) (immunodeficiency) Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Hyqvia | Panzyga)
PDF, 242 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Hyqvia | Panzyga)
PDF, 242 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Disorders) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 276 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 276 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Sjögren’s Syndrome Neuropathies) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 262 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 262 KB
Immune Globulin Intravenous (IVIG) (Multifocal Motor Neuropathy (MMN)) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 232 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 232 KB
Immune Globulin Intravenous (IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gammaplex | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Alyglo | Asceniv | Panzyga | Yimmugo)
PDF, 237 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gammaplex | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Alyglo | Asceniv | Panzyga | Yimmugo)
PDF, 237 KB
Immune Globulin SQ (IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)
(PREFERRED: Cutaquiq | Cuvitru | Gammagard | Gamunex-C | Hizentra | Xembify) (NON-PREFERRED: Hyqvia)
PDF, 250 KB
(PREFERRED: Cutaquiq | Cuvitru | Gammagard | Gamunex-C | Hizentra | Xembify) (NON-PREFERRED: Hyqvia)
PDF, 250 KB
Infliximab Products (Medical)
(PREFERRED: Renflexis & unbranded Infliximab) (Non-Preferred: Avsola | Inflectra | Remicade| Zymfrentra)
PDF, 241 KB
(PREFERRED: Renflexis & unbranded Infliximab) (Non-Preferred: Avsola | Inflectra | Remicade| Zymfrentra)
PDF, 241 KB
Itvisma (Medical)
PDF, 228 KB
PDF, 228 KB
IV Tocilizumab Products - Giant Cell Arteritis (GCA) (Medical)
(PREFERRED: Actemra IV, Tyenne IV) (NON-PREFERRED: Tofidence IV)
PDF, 189 KB
(PREFERRED: Actemra IV, Tyenne IV) (NON-PREFERRED: Tofidence IV)
PDF, 189 KB
Kalbitor (Medical)
PDF, 216 KB
PDF, 216 KB
Kanuma (Medical)
PDF, 216 KB
PDF, 216 KB
Kepivance (Medical)
PDF, 211 KB
PDF, 211 KB
Kimyrsa │Orbactiv (Medical)
PDF, 194 KB
PDF, 194 KB
Kisunla (Medical)
PDF, 408 KB
PDF, 408 KB
Korsuva (Medical)
PDF, 200 KB
PDF, 200 KB
Krystexxa (Medical)
PDF, 252 KB
PDF, 252 KB
Kymriah (Medical)
PDF, 249 KB
PDF, 249 KB
Lamzede (Medical)
PDF, 179 KB
PDF, 179 KB
Lantidra (Medical)
PDF, 202 KB
PDF, 202 KB
Lemtrada IV (Medical)
PDF, 171 KB
PDF, 171 KB
Lenmeldy (Medical)
PDF, 267 KB
PDF, 267 KB
Leqembi (Medical)
PDF, 559 KB
PDF, 559 KB
Leqvio (Medical)
PDF, 259 KB
PDF, 259 KB
Lumizyme (Medical)
PDF, 196 KB
PDF, 196 KB
Lutathera (Medical)
PDF, 246 KB
PDF, 246 KB
Luxturna (Medical)
PDF, 170 KB
PDF, 170 KB
Lyfgenia (Medical)
PDF, 264 KB
PDF, 264 KB
Macular Degeneration Drugs (Medical)
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Eylea HD | Lucentis | Pavblu | Susvimo | Vabysmo)
PDF, 237 KB
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Eylea HD | Lucentis | Pavblu | Susvimo | Vabysmo)
PDF, 237 KB
Mepsevii IV (Medical)
PDF, 176 KB
PDF, 176 KB
Myobloc (Medical)
PDF, 167 KB
PDF, 167 KB
Naglazyme (Medical)
PDF, 201 KB
PDF, 201 KB
Nexviazyme | Pombiliti (Medical)
PDF, 259 KB
PDF, 259 KB
Noninfectious Uveitis Drugs (Medical)
(Iluvien│Retisert│Yutiq)
PDF, 231 KB
(Iluvien│Retisert│Yutiq)
PDF, 231 KB
Nplate (Medical)
PDF, 243 KB
PDF, 243 KB
Nulibry (Medical)
PDF, 243 KB
PDF, 243 KB
Nulojix (Medical)
PDF, 212 KB
PDF, 212 KB
Nuzyra (Medical)
PDF, 183 KB
PDF, 183 KB
Omisirge (Medical)
PDF, 264 KB
PDF, 264 KB
Onapgo (Medical)
PDF, 182 KB
PDF, 182 KB
Onpattro IV (Medical)
PDF, 258 KB
PDF, 258 KB
Oxlumo | Rivfloza (Medical)
PDF, 212 KB
PDF, 212 KB
Panhematin (Medical)
PDF, 184 KB
PDF, 184 KB
Papzimeos (Medical)
PDF, 195 KB
PDF, 195 KB
Parenteral Iron Products (Medical)
(PREFERRED: Feraheme (ESRD on Dialysis)│Ferrlecit│INFeD│ Venofer) (NON-PREFERRED: Feraheme (Non-ESRD)│Injectafer│Monoferric)
PDF, 159 KB
(PREFERRED: Feraheme (ESRD on Dialysis)│Ferrlecit│INFeD│ Venofer) (NON-PREFERRED: Feraheme (Non-ESRD)│Injectafer│Monoferric)
PDF, 159 KB
Pemetrexed Injections (Medical)
PDF, 209 KB
PDF, 209 KB
plerixafor (Mozobil) (Medical)
PDF, 218 KB
PDF, 218 KB
Pluvicto (Medical)
PDF, 221 KB
PDF, 221 KB
Prevymis IV (Medical)
PDF, 198 KB
PDF, 198 KB
Prialt (Medical)
PDF, 142 KB
PDF, 142 KB
Primaxin IV (Medical)
PDF, 187 KB
PDF, 187 KB
Qalsody (Medical)
PDF, 253 KB
PDF, 253 KB
Qfitlia (Medical)
PDF, 239 KB
PDF, 239 KB
Qutenza (Medical)
PDF, 165 KB
PDF, 165 KB
Reblozyl (Medical)
PDF, 249 KB
PDF, 249 KB
Rebyota (Medical)
PDF, 207 KB
PDF, 207 KB
Recarbrio (Medical)
PDF, 189 KB
PDF, 189 KB
Rezzayo (Medical)
PDF, 192 KB
PDF, 192 KB
Rituxan Hycela IV (Medical)
PDF, 168 KB
PDF, 168 KB
Roctavian (Medical)
PDF, 233 KB
PDF, 233 KB
Ryoncil (Medical)
PDF, 216 KB
PDF, 216 KB
Ryplazim (Medical)
PDF, 223 KB
PDF, 223 KB
Rystiggo (Medical)
PDF, 182 KB
PDF, 182 KB
Saphnelo (Medical)
PDF, 235 KB
PDF, 235 KB
Scenesse (Medical)
PDF, 211 KB
PDF, 211 KB
Simulect (Medical)
PDF, 172 KB
PDF, 172 KB
Sivextro (Medical)
PDF, 185 KB
PDF, 185 KB
Skysona (Medical)
PDF, 257 KB
PDF, 257 KB
Spevigo (Medical)
PDF, 234 KB
PDF, 234 KB
Spinraza (Medical)
PDF, 271 KB
PDF, 271 KB
Sunlenca (Medical)
PDF, 232 KB
PDF, 232 KB
Tecartus (Medical)
PDF, 223 KB
PDF, 223 KB
Tecelra (Medical)
PDF, 234 KB
PDF, 234 KB
Teflaro (Medical)
PDF, 181 KB
PDF, 181 KB
Tegsedi SQ Injection (Medical)
PDF, 199 KB
PDF, 199 KB
Tepezza (Medical)
PDF, 234 KB
PDF, 234 KB
Testosterone Replacement Therapy Injectable (Medical)
(Aveed | Azmiro | TestoPel) Medication being provided by the physician's office
PDF, 253 KB
(Aveed | Azmiro | TestoPel) Medication being provided by the physician's office
PDF, 253 KB
Tezspire (Medical)
PDF, 259 KB
PDF, 259 KB
Tocilizumab products IV (Medical)
PDF, 245 KB
PDF, 245 KB
Trogarzo IV (Medical)
PDF, 164 KB
PDF, 164 KB
Tygacil (Medical)
PDF, 201 KB
PDF, 201 KB
Tysabri IV (Medical)
PDF, 222 KB
PDF, 222 KB
Tzield (Medical)
PDF, 252 KB
PDF, 252 KB
Unituxin (Medical)
PDF, 213 KB
PDF, 213 KB
Uplizna (Medical)
PDF, 219 KB
PDF, 219 KB
Vabomere (Medical)
PDF, 160 KB
PDF, 160 KB
Veopoz (Medical)
PDF, 218 KB
PDF, 218 KB
Vibativ (Medical)
PDF, 185 KB
PDF, 185 KB
Vimizim IV (Medical)
PDF, 215 KB
PDF, 215 KB
Visudyne (Medical)
PDF, 187 KB
PDF, 187 KB
Vyalev (Medical)
PDF, 175 KB
PDF, 175 KB
Vyepti (Medical)
PDF, 226 KB
PDF, 226 KB
Vyjuvek (Medical)
PDF, 222 KB
PDF, 222 KB
Xacduro (Medical)
PDF, 226 KB
PDF, 226 KB
Xenleta (Medical)
PDF, 162 KB
PDF, 162 KB
Xenpozyme (Medical)
PDF, 237 KB
PDF, 237 KB
Xerava (Medical)
PDF, 176 KB
PDF, 176 KB
Xiaflex (Medical)
PDF, 205 KB
PDF, 205 KB
Xolair (Medical)
PDF, 637 KB
PDF, 637 KB
Ycanth (Medical)
PDF, 170 KB
PDF, 170 KB
Yescarta (Medical)
PDF, 218 KB
PDF, 218 KB
Zemdri (Medical)
PDF, 177 KB
PDF, 177 KB
Zevaskyn (Medical)
PDF, 212 KB
PDF, 212 KB
Zevtera (Medical)
PDF, 209 KB
PDF, 209 KB
Zinplava (Medical)
PDF, 232 KB
PDF, 232 KB
Zolgensma IV (Medical)
PDF, 282 KB
PDF, 282 KB
Zulresso Injection (Medical)
PDF, 172 KB
PDF, 172 KB
Zynteglo (Medical)
PDF, 231 KB
PDF, 231 KB
Fármacos de farmacia con autorización previa - Comercial
Abrysvo (Pharmacy)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
ACA Copay Waiver - Aspirin 81 mg
PDF, 141 KB
PDF, 141 KB
Actimmune SQ
PDF, 196 KB
PDF, 196 KB
Adalimumab Preferred Products
(Self -Funded Commercial Group Preferreds: Cyltezo | Humira | Yuflyma) (Fully Insured Commercial Groups Preferreds: adalimumab-adbm | Simlandi)
PDF, 245 KB
(Self -Funded Commercial Group Preferreds: Cyltezo | Humira | Yuflyma) (Fully Insured Commercial Groups Preferreds: adalimumab-adbm | Simlandi)
PDF, 245 KB
Adbry
PDF, 264 KB
PDF, 264 KB
Addyi
PDF, 151 KB
PDF, 151 KB
Afrezza
PDF, 156 KB
PDF, 156 KB
Albuterol Inhalers
(Generic ProAir HFA, Generic Proventil HFA, Generic Ventolin HFA, Generic Xopenex, ProAir, Proventil HFA)
PDF, 137 KB
(Generic ProAir HFA, Generic Proventil HFA, Generic Ventolin HFA, Generic Xopenex, ProAir, Proventil HFA)
PDF, 137 KB
Alhemo (Pharmacy)
PDF, 202 KB
PDF, 202 KB
Alosetron, Lotronex, Viberzi
PDF, 231 KB
PDF, 231 KB
Alvaiz | eltrombopag (Promacta)
PDF, 230 KB
PDF, 230 KB
Ancobon, Flucytosine
PDF, 152 KB
PDF, 152 KB
Antidepressant Drugs
(Fetzima, Trintellix, vilazodone, Viibryd)
PDF, 162 KB
(Fetzima, Trintellix, vilazodone, Viibryd)
PDF, 162 KB
Antiparkinson Agents
carbidopa-levodopa ER (Rytary ABA) | Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone (Tasmar) | Rytary | Xadago
PDF, 220 KB
carbidopa-levodopa ER (Rytary ABA) | Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone (Tasmar) | Rytary | Xadago
PDF, 220 KB
Anzupgo
PDF, 200 KB
PDF, 200 KB
Apomorphine Products
(Apokyn | apomorphine hydrochloride | Onapgo)
PDF, 181 KB
(Apokyn | apomorphine hydrochloride | Onapgo)
PDF, 181 KB
Aqneursa
PDF, 156 KB
PDF, 156 KB
Arcalyst
PDF, 323 KB
PDF, 323 KB
Arikayce
PDF, 184 KB
PDF, 184 KB
Atypical Antipsychotics
PDF, 185 KB
PDF, 185 KB
Atypical Antipsychotics
(asenapine (generic Saphris) | Caplyta | Cobenify | Fanapt | lurasidone (generic Latuda) | paliperidone (generic Invega) | Rexulti | Vraylar)
PDF, 174 KB
(asenapine (generic Saphris) | Caplyta | Cobenify | Fanapt | lurasidone (generic Latuda) | paliperidone (generic Invega) | Rexulti | Vraylar)
PDF, 174 KB
Austedo
PDF, 165 KB
PDF, 165 KB
Auvelity ER
PDF, 188 KB
PDF, 188 KB
Auvi-Q Auto-Injector
PDF, 155 KB
PDF, 155 KB
Benign Prostate Hyperplasia (BPH)
(Tadalafil 2.5 or 5 mg)
PDF, 152 KB
(Tadalafil 2.5 or 5 mg)
PDF, 152 KB
Benlysta SQ (Pharmacy)
PDF, 284 KB
PDF, 284 KB
Bimzelx
PDF, 187 KB
PDF, 187 KB
Blujepa
PDF, 182 KB
PDF, 182 KB
Blujepa
PDF, 198 KB
PDF, 198 KB
Brexafemme
PDF, 185 KB
PDF, 185 KB
Brinsupri
PDF, 215 KB
PDF, 215 KB
Brixadi, Sublocade
PDF, 178 KB
PDF, 178 KB
Bronchitol
PDF, 205 KB
PDF, 205 KB
Butorphanol (Stadol) Nasal Spray
PDF, 150 KB
PDF, 150 KB
Bylvay
PDF, 230 KB
PDF, 230 KB
Cabenuva
PDF, 154 KB
PDF, 154 KB
Cablivi
PDF, 224 KB
PDF, 224 KB
Camzyos
PDF, 145 KB
PDF, 145 KB
Carglumic Acid (Carbaglu)
PDF, 202 KB
PDF, 202 KB
Central Nervous System (CNS) Stimulants (Non-Preferred)
(Adhansia XR | Adzenys ER suspension | amphetamine ER ODT (Adzenys XR ODT) | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | methylphenidate ER (Aptensio XR) | methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR | Xelstrym)
PDF, 179 KB
(Adhansia XR | Adzenys ER suspension | amphetamine ER ODT (Adzenys XR ODT) | amphetamine sulfate (Evekeo) | Azstarys | Cotempla XR-ODT | Dyanavel XR | Evekeo ODT | Jornay PM | methylphenidate ER (Aptensio XR) | methylphenidate TD Patch (Daytrana) | Mydayis | Quillichew ER | Quillivant XR | Xelstrym)
PDF, 179 KB
Chenodal
PDF, 178 KB
PDF, 178 KB
Cholbam
PDF, 197 KB
PDF, 197 KB
Cibinqo
PDF, 193 KB
PDF, 193 KB
Cimzia SQ
PDF, 226 KB
PDF, 226 KB
Cinacalcet (Sensipar)
PDF, 203 KB
PDF, 203 KB
Continuous Glucose Monitors (CGM)
(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)
PDF, 187 KB
(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)
PDF, 187 KB
Cosentyx SQ
PDF, 223 KB
PDF, 223 KB
Crenessity
PDF, 246 KB
PDF, 246 KB
Cresemba
PDF, 203 KB
PDF, 203 KB
Crinone
PDF, 153 KB
PDF, 153 KB
Ctexli
PDF, 185 KB
PDF, 185 KB
Cuvrior, Syprine, Trientine
PDF, 182 KB
PDF, 182 KB
Cystaran, Cystadrops
PDF, 187 KB
PDF, 187 KB
Daybue
PDF, 218 KB
PDF, 218 KB
Deferasirox, Exjade, Jadenu
PDF, 227 KB
PDF, 227 KB
Diacomit
PDF, 159 KB
PDF, 159 KB
Dichlorphenamide (Keveyis)
PDF, 162 KB
PDF, 162 KB
Dojolvi
PDF, 232 KB
PDF, 232 KB
Doptelet
PDF, 236 KB
PDF, 236 KB
Doxylamine-Pyridoxine (Diclegis)
PDF, 148 KB
PDF, 148 KB
Droxidopa (Northera)
PDF, 182 KB
PDF, 182 KB
Duavee
PDF, 160 KB
PDF, 160 KB
Duexis, Vimovo
PDF, 200 KB
PDF, 200 KB
Duopa (Pharmacy)
PDF, 144 KB
PDF, 144 KB
Dupixent
PDF, 322 KB
PDF, 322 KB
Duvyzat
PDF, 196 KB
PDF, 196 KB
Egrifta
PDF, 207 KB
PDF, 207 KB
Ekterly
PDF, 214 KB
PDF, 214 KB
Emflaza
PDF, 194 KB
PDF, 194 KB
Empaveli (Pharmacy)
PDF, 236 KB
PDF, 236 KB
Emsam
PDF, 147 KB
PDF, 147 KB
Emverm
PDF, 196 KB
PDF, 196 KB
Enbrel
PDF, 204 KB
PDF, 204 KB
Enspryng
PDF, 146 KB
PDF, 146 KB
Entyvio (Pharmacy)
PDF, 185 KB
PDF, 185 KB
Eohilia
PDF, 181 KB
PDF, 181 KB
Epidiolex
PDF, 184 KB
PDF, 184 KB
Erythropoiesis Stimulating Agents (ESAs)
(Aranesp, Epogen, Mircera, Procrit, Retacrit)
PDF, 227 KB
(Aranesp, Epogen, Mircera, Procrit, Retacrit)
PDF, 227 KB
Ethacrynic Acid (Edecrin)
PDF, 144 KB
PDF, 144 KB
Eucrisa
PDF, 218 KB
PDF, 218 KB
Evrysdi
PDF, 184 KB
PDF, 184 KB
Exxua
PDF, 203 KB
PDF, 203 KB
Ezetimibe-Simvastatin (Vytorin)
PDF, 155 KB
PDF, 155 KB
Fabhalta
PDF, 264 KB
PDF, 264 KB
Fasenra (Pharmacy)
PDF, 231 KB
PDF, 231 KB
Filspari
PDF, 208 KB
PDF, 208 KB
Filsuvez
PDF, 194 KB
PDF, 194 KB
Fintepla
PDF, 198 KB
PDF, 198 KB
Firdapse
PDF, 170 KB
PDF, 170 KB
Flector Patch
PDF, 141 KB
PDF, 141 KB
Flucytosine
PDF, 148 KB
PDF, 148 KB
Forteo, Tymlos, Teriparatide
PDF, 180 KB
PDF, 180 KB
Forzinity
PDF, 162 KB
PDF, 162 KB
Furoscix | Lasix Onyu
PDF, 172 KB
PDF, 172 KB
Galafold
PDF, 170 KB
PDF, 170 KB
Gastric Acid Suppression Drugs (Non-Preferred)
(Dexlansoprazole, Omeprazole/Sodium Bicarbonate, Voquezna)
PDF, 158 KB
(Dexlansoprazole, Omeprazole/Sodium Bicarbonate, Voquezna)
PDF, 158 KB
Gastrointestinal Motility Drugs
(Ibsrela, Prucalopride (Motegrity), Relistor, Trulance, Zelnorm)
PDF, 176 KB
(Ibsrela, Prucalopride (Motegrity), Relistor, Trulance, Zelnorm)
PDF, 176 KB
Gattex
PDF, 285 KB
PDF, 285 KB
Glucagon-Like Peptide (GLP-1) Receptor Agonists
(Bydureon Bcise, Exenatide (Byetta), Liraglutide (Victoza), Mounjaro, Ozempic, Rybelsus, Trulicity)
PDF, 170 KB
(Bydureon Bcise, Exenatide (Byetta), Liraglutide (Victoza), Mounjaro, Ozempic, Rybelsus, Trulicity)
PDF, 170 KB
Glycopyrrolate (Cuvposa)
PDF, 186 KB
PDF, 186 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Pharmacy)
(PREFERRED: Eligard | Leuprolide | Lupron Depot | Lupron Depot-Ped | Trelstar | Zoladex) (NON-PREFERRED: (Fensolvi | Supprelin LA | Synarel | Triptodur)
PDF, 237 KB
(PREFERRED: Eligard | Leuprolide | Lupron Depot | Lupron Depot-Ped | Trelstar | Zoladex) (NON-PREFERRED: (Fensolvi | Supprelin LA | Synarel | Triptodur)
PDF, 237 KB
Granulocyte Colony-Stimulating Factors (G-CSF)
(Granix, Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Leukine, Fulphila, Fylnetra, Neulasta, Nyvepria, Rolvedon, Ryzneuta, Stimufend, Udenyca, Ziextenzo)
PDF, 218 KB
(Granix, Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Leukine, Fulphila, Fylnetra, Neulasta, Nyvepria, Rolvedon, Ryzneuta, Stimufend, Udenyca, Ziextenzo)
PDF, 218 KB
Grastek, Oralair
PDF, 171 KB
PDF, 171 KB
Hemangeol
PDF, 164 KB
PDF, 164 KB
Hepatitis-C Antiviral (HCV) Drugs
(Preferred: Sofosbuvir/Elpatasvir, Ledipasvir/Sofobuvir, Mavyret)(Non-Preferred: Epclusa, Harvoni, Sovaldi, Viekira Pak, Vosevi, Zepatier)
PDF, 243 KB
(Preferred: Sofosbuvir/Elpatasvir, Ledipasvir/Sofobuvir, Mavyret)(Non-Preferred: Epclusa, Harvoni, Sovaldi, Viekira Pak, Vosevi, Zepatier)
PDF, 243 KB
Hereditary Angioedema Drugs - Acute Treatment
(Icatibant, Firazyr, Sajazir)
PDF, 201 KB
(Icatibant, Firazyr, Sajazir)
PDF, 201 KB
Human Chorionic Gonadotropin (hCG) - Pre-Pubertal Cryptorchidism
(Novarel, Pregnyl, Ovidrel, Chorionic Gonadotropin)
PDF, 197 KB
(Novarel, Pregnyl, Ovidrel, Chorionic Gonadotropin)
PDF, 197 KB
Hympavzi (Pharmacy)
PDF, 208 KB
PDF, 208 KB
Icosapent Ethyl (Vascepa)
PDF, 200 KB
PDF, 200 KB
Ilumya (Pharmacy)
PDF, 173 KB
PDF, 173 KB
Imcivree
PDF, 199 KB
PDF, 199 KB
Increlex
PDF, 176 KB
PDF, 176 KB
Inflammatory Bowel Disease Drugs
(budesonide ER 9mg, Dipentum, Mesalamine DR 800mg)
PDF, 158 KB
(budesonide ER 9mg, Dipentum, Mesalamine DR 800mg)
PDF, 158 KB
Ingrezza
PDF, 189 KB
PDF, 189 KB
Inhaled Corticosteroid (ICS) with Long-Acting Beta-2 Agonist (LABA) Inhalers
(AirDuo Digihaler, AirDuo RespiClick, Budesonide-Formoterol, Dulera, Fluticasone-Salmeterol, Fluticasone Furoate-Vilanterol, Wixela Inhub)
PDF, 172 KB
(AirDuo Digihaler, AirDuo RespiClick, Budesonide-Formoterol, Dulera, Fluticasone-Salmeterol, Fluticasone Furoate-Vilanterol, Wixela Inhub)
PDF, 172 KB
Inhaled Corticosteroids (ICS) (Non-Preferred)
(Alvesco | ArmonAir Digihaler | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA | Pulmicort Flexhaler)
PDF, 162 KB
(Alvesco | ArmonAir Digihaler | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA | Pulmicort Flexhaler)
PDF, 162 KB
Inpefa
PDF, 141 KB
PDF, 141 KB
Insomnia Drugs
(Belsomra, Dayvigo, doxepin, quazepam (Doral), Quviviq, ramelteon (Rozerem))
PDF, 161 KB
(Belsomra, Dayvigo, doxepin, quazepam (Doral), Quviviq, ramelteon (Rozerem))
PDF, 161 KB
Insulins (Non-Preferred)
(NON-PREFERRED: Admelog | Apidra | Basaglar | Fiasp | Humalog U-200 | insulin aspart | insulin aspart protamine 70/30 | insulin degludec | insulin glargine vial/SoloStar | insulin glargine Solostar/Max Solostar | Kirsty | Levemir | Lyumjev | Merilog Solostar | Novolin 70/30 | Novolin N | Novolin R | Novolog | NovoLOG Mix 70/30 | Semglee | Tresiba)
PDF, 171 KB
(NON-PREFERRED: Admelog | Apidra | Basaglar | Fiasp | Humalog U-200 | insulin aspart | insulin aspart protamine 70/30 | insulin degludec | insulin glargine vial/SoloStar | insulin glargine Solostar/Max Solostar | Kirsty | Levemir | Lyumjev | Merilog Solostar | Novolin 70/30 | Novolin N | Novolin R | Novolog | NovoLOG Mix 70/30 | Semglee | Tresiba)
PDF, 171 KB
Isturisa
PDF, 191 KB
PDF, 191 KB
Ivermectin, Stromectol Tablets
PDF, 128 KB
PDF, 128 KB
Jascayd
PDF, 220 KB
PDF, 220 KB
Jesduvroq
PDF, 162 KB
PDF, 162 KB
Joenja
PDF, 194 KB
PDF, 194 KB
Juxtapid
PDF, 184 KB
PDF, 184 KB
Jynarque
PDF, 267 KB
PDF, 267 KB
Kalydeco
PDF, 172 KB
PDF, 172 KB
Kebilidi
PDF, 213 KB
PDF, 213 KB
Kerendia
PDF, 299 KB
PDF, 299 KB
Kevzara
PDF, 168 KB
PDF, 168 KB
Kineret
PDF, 252 KB
PDF, 252 KB
Korlym
PDF, 168 KB
PDF, 168 KB
Koselugo
PDF, 197 KB
PDF, 197 KB
Lampit, Benznidazole
PDF, 237 KB
PDF, 237 KB
Leqembi Iqlik
PDF, 550 KB
PDF, 550 KB
L-glutamine (Endari)
PDF, 161 KB
PDF, 161 KB
Libervant | Nayzilam | Valtoco
PDF, 163 KB
PDF, 163 KB
Litfulo
PDF, 163 KB
PDF, 163 KB
Livmarli
PDF, 234 KB
PDF, 234 KB
Livtencity
PDF, 253 KB
PDF, 253 KB
Lodoco
PDF, 170 KB
PDF, 170 KB
Lupkynis
PDF, 198 KB
PDF, 198 KB
Lynkuet | Veozah
PDF, 166 KB
PDF, 166 KB
Marplan
PDF, 140 KB
PDF, 140 KB
Metaxalone (generic Skelaxin)
PDF, 155 KB
PDF, 155 KB
Migraine Treatment - Injectable Calcitonin Gene-Related Peptide (CGRP) Antagonists
(Preferred: Aimovig, Emgality) (Non-Preferred: Ajovy)
PDF, 243 KB
(Preferred: Aimovig, Emgality) (Non-Preferred: Ajovy)
PDF, 243 KB
Migraine Treatment - Non-injectable Drugs
(Preferred: Nurtec ODT, Qulipta) (Non-Preferred: Reyvow, Ubrelvy, Zavzpret)
PDF, 214 KB
(Preferred: Nurtec ODT, Qulipta) (Non-Preferred: Reyvow, Ubrelvy, Zavzpret)
PDF, 214 KB
Miplyffa
PDF, 187 KB
PDF, 187 KB
Mulpleta
PDF, 172 KB
PDF, 172 KB
Multiple Sclerosis Drugs
(Avonex | Bafiertam | Betaseron | Extavia | cladribine (Mavenclad) | Kesimpta | Mavenclad | Plegridy | Ponvory | Rebif | Vumerity | Zeposia)
PDF, 198 KB
(Avonex | Bafiertam | Betaseron | Extavia | cladribine (Mavenclad) | Kesimpta | Mavenclad | Plegridy | Ponvory | Rebif | Vumerity | Zeposia)
PDF, 198 KB
Myalept
PDF, 178 KB
PDF, 178 KB
Mytesi
PDF, 160 KB
PDF, 160 KB
Nasal Corticosteroids
(Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)
PDF, 194 KB
(Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)
PDF, 194 KB
Natpara
PDF, 176 KB
PDF, 176 KB
Nemluvio
PDF, 234 KB
PDF, 234 KB
Neupro
PDF, 143 KB
PDF, 143 KB
Nexletol, Nexlizet
PDF, 264 KB
PDF, 264 KB
Nitazoxanide (Alinia)
PDF, 133 KB
PDF, 133 KB
Nitisinone Products
Harliku | nitisinone | Nityr | Orfadin
PDF, 175 KB
Harliku | nitisinone | Nityr | Orfadin
PDF, 175 KB
Nocdurna
PDF, 156 KB
PDF, 156 KB
Nuedexta
PDF, 159 KB
PDF, 159 KB
Nulibry
PDF, 233 KB
PDF, 233 KB
Nuplazid
PDF, 179 KB
PDF, 179 KB
OFEV
PDF, 252 KB
PDF, 252 KB
Ohtuvayre
PDF, 195 KB
PDF, 195 KB
Olumiant
PDF, 174 KB
PDF, 174 KB
Omvoh
PDF, 230 KB
PDF, 230 KB
Oncology Drugs (Pharmacy Benefit)
PDF, 186 KB
PDF, 186 KB
Opfolda
PDF, 203 KB
PDF, 203 KB
Ophthalmic Corticosteroid Injections (Medical)
(Ozurdex, Iluvien, Xipere)
PDF, 232 KB
(Ozurdex, Iluvien, Xipere)
PDF, 232 KB
Ophthalmic Drugs - Antihistamines
(Alocril, Alomide, Bepotastine Besilate 1.5%, Zerviate)
PDF, 143 KB
(Alocril, Alomide, Bepotastine Besilate 1.5%, Zerviate)
PDF, 143 KB
Ophthalmic Drugs - Dry Eye
(Cequa | Lacrisert | Miebo | Restasis Multidose | Tryptyr | Tyrvaya)
PDF, 160 KB
(Cequa | Lacrisert | Miebo | Restasis Multidose | Tryptyr | Tyrvaya)
PDF, 160 KB
Ophthalmic Drugs - Glaucoma
(Betoptic-S | brimonidine 0.1% (Alphagan-P) | Omlonti | Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | timolol (Betimol) | travoprost 0.004% (Travatan Z) | Vyzulta)
PDF, 145 KB
(Betoptic-S | brimonidine 0.1% (Alphagan-P) | Omlonti | Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | timolol (Betimol) | travoprost 0.004% (Travatan Z) | Vyzulta)
PDF, 145 KB
Opioids
PDF, 230 KB
PDF, 230 KB
Opzelura
PDF, 147 KB
PDF, 147 KB
Orencia SQ (Pharmacy)
PDF, 179 KB
PDF, 179 KB
Orilissa
PDF, 168 KB
PDF, 168 KB
Orkambi
PDF, 196 KB
PDF, 196 KB
Orlynvah
PDF, 152 KB
PDF, 152 KB
Osphena
PDF, 140 KB
PDF, 140 KB
Otezla | Otezla XR
PDF, 220 KB
PDF, 220 KB
Otrexup, Rasuvo, Reditrex
PDF, 135 KB
PDF, 135 KB
Overactive Bladder Drugs
(fesoterodine (Toviaz), Gemtesa, mirabegron (Myrbetriq))
PDF, 165 KB
(fesoterodine (Toviaz), Gemtesa, mirabegron (Myrbetriq))
PDF, 165 KB
Oxbryta
PDF, 206 KB
PDF, 206 KB
Oxervate
PDF, 211 KB
PDF, 211 KB
Palforzia
PDF, 228 KB
PDF, 228 KB
Palynziq Injection
PDF, 181 KB
PDF, 181 KB
Parathyroid Hormone Analogs
(teriparatide (Forteo), Tymlos, Teriparatide)
PDF, 176 KB
(teriparatide (Forteo), Tymlos, Teriparatide)
PDF, 176 KB
Penciclovir (Denavir)
PDF, 149 KB
PDF, 149 KB
Phosphate Binders
Ferric Citrate (Auryxia) | lanthanum chewable tablet (Fosrenol) | Velphoro
PDF, 156 KB
Ferric Citrate (Auryxia) | lanthanum chewable tablet (Fosrenol) | Velphoro
PDF, 156 KB
Pimecrolimus (Elidel)
PDF, 128 KB
PDF, 128 KB
Pirfenidone (Esbriet)
PDF, 158 KB
PDF, 158 KB
Pitavastatin, Livalo, Zypitamag
PDF, 154 KB
PDF, 154 KB
Pradaxa
PDF, 196 KB
PDF, 196 KB
Praluent | Repatha
PDF, 255 KB
PDF, 255 KB
Pretomanid
PDF, 179 KB
PDF, 179 KB
Prevymis (Pharmacy)
PDF, 178 KB
PDF, 178 KB
Procysbi
PDF, 168 KB
PDF, 168 KB
Prophylaxis Hereditary Angioedema Drugs (Pharmacy)
(PREFERRED: Cinryze | Haegarda | Takhzyro) (NON:PREFERRED: Andembry | Dawnzera | Orladeyo)
PDF, 234 KB
(PREFERRED: Cinryze | Haegarda | Takhzyro) (NON:PREFERRED: Andembry | Dawnzera | Orladeyo)
PDF, 234 KB
Pulmozyme
PDF, 202 KB
PDF, 202 KB
Pyrimethamine (Daraprim)
PDF, 227 KB
PDF, 227 KB
Pyrukynd
PDF, 197 KB
PDF, 197 KB
Qbrexza
PDF, 176 KB
PDF, 176 KB
Qelbree
PDF, 158 KB
PDF, 158 KB
Qfitlia (Pharmacy)
PDF, 205 KB
PDF, 205 KB
Radicava ORS
PDF, 211 KB
PDF, 211 KB
Ragwitek
PDF, 167 KB
PDF, 167 KB
Rayaldee
PDF, 188 KB
PDF, 188 KB
Recombinant Growth Hormone (rhGH)
(Preferred: Omnitrope, Norditropin)
(Non-Preferred: Genotropin, Humatrope, Ngenla, Nutropin, Nutropin AQ, Saizen, Sogroya, Skytrofa, Zomacton)PDF, 181 KB
(Preferred: Omnitrope, Norditropin)
(Non-Preferred: Genotropin, Humatrope, Ngenla, Nutropin, Nutropin AQ, Saizen, Sogroya, Skytrofa, Zomacton)PDF, 181 KB
Recorlev
PDF, 206 KB
PDF, 206 KB
Redemplo
PDF, 184 KB
PDF, 184 KB
Relyvrio
PDF, 185 KB
PDF, 185 KB
Repository Corticotropin Drugs - Infantile Spasms
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 171 KB
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 171 KB
Repository Corticotropin Drugs - Myositis
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 200 KB
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 200 KB
Repository Corticotropin Drugs - Nephrotic Syndrome
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 224 KB
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 224 KB
Repository Corticotropin Drugs - Ocular Diseases
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 252 KB
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 252 KB
Repository Corticotropin Drugs - Other Indications
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 201 KB
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 201 KB
Repository Corticotropin Drugs - Sarcoidosis
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 172 KB
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 172 KB
Repository Corticotropin Drugs - Systemic Lupus Erythematosus
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 225 KB
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)
PDF, 225 KB
Revcovi
PDF, 234 KB
PDF, 234 KB
Rezdiffra
PDF, 192 KB
PDF, 192 KB
Rezurock
PDF, 155 KB
PDF, 155 KB
Rhapsido
PDF, 175 KB
PDF, 175 KB
Rinvoq | Rinvoq LQ
PDF, 238 KB
PDF, 238 KB
Roflumilast (Generic Daliresp)
PDF, 159 KB
PDF, 159 KB
Rukobia
PDF, 161 KB
PDF, 161 KB
Saliva Substitutes
(Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx)
PDF, 160 KB
(Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx)
PDF, 160 KB
Sapropterin Products
(Saproterin Dihydrochloride (generic Kuvan) | Javygtor | Zelvysia)
PDF, 185 KB
(Saproterin Dihydrochloride (generic Kuvan) | Javygtor | Zelvysia)
PDF, 185 KB
Savaysa
PDF, 173 KB
PDF, 173 KB
Savella
PDF, 153 KB
PDF, 153 KB
Serostim
PDF, 161 KB
PDF, 161 KB
Seysara
PDF, 146 KB
PDF, 146 KB
Siliq SQ
PDF, 173 KB
PDF, 173 KB
Simponi SQ (Pharmacy)
PDF, 178 KB
PDF, 178 KB
Sirturo
PDF, 158 KB
PDF, 158 KB
Skyclarys
PDF, 193 KB
PDF, 193 KB
Sodium Oxbate Drugs
(Lumryz, Sodium Oxbate Oral Solution, Xyrem, Xywav)
PDF, 231 KB
(Lumryz, Sodium Oxbate Oral Solution, Xyrem, Xywav)
PDF, 231 KB
Sodium Phenylbutyrate Drugs
(Sodium Phenylbutyrate, Buphenyl, Olpruva, Pheburane)
PDF, 156 KB
(Sodium Phenylbutyrate, Buphenyl, Olpruva, Pheburane)
PDF, 156 KB
Sohonos
PDF, 172 KB
PDF, 172 KB
Soliqua, Xultophy
PDF, 162 KB
PDF, 162 KB
Somatostatin Analog Drugs
(Bynfezia | lanreotide acetate ER | Mycapssa | octreotide injection | Palsonify | Sandostatin LAR Depot | Signafor | Signifor LAR | Somatuline Depot | Somavert)
PDF, 231 KB
(Bynfezia | lanreotide acetate ER | Mycapssa | octreotide injection | Palsonify | Sandostatin LAR Depot | Signafor | Signifor LAR | Somatuline Depot | Somavert)
PDF, 231 KB
Sotyktu
PDF, 170 KB
PDF, 170 KB
Spevigo SQ
PDF, 224 KB
PDF, 224 KB
Spravato
PDF, 182 KB
PDF, 182 KB
SQ Tocilizumab Products - Giant Cell Arteritis (GCA) (Pharmacy)
Actemra SQ | Tyenne SQ
PDF, 156 KB
Actemra SQ | Tyenne SQ
PDF, 156 KB
Strensiq
PDF, 204 KB
PDF, 204 KB
Sucraid
PDF, 167 KB
PDF, 167 KB
Sunlenca
PDF, 223 KB
PDF, 223 KB
Sunosi
PDF, 189 KB
PDF, 189 KB
Symdeko
PDF, 231 KB
PDF, 231 KB
Synagis
PDF, 889 KB
PDF, 889 KB
Syndros Oral Solution
PDF, 180 KB
PDF, 180 KB
Taltz SQ
PDF, 231 KB
PDF, 231 KB
Tarpeyo
PDF, 195 KB
PDF, 195 KB
Tasimelteon, Hetlioz
PDF, 200 KB
PDF, 200 KB
Tavalisse
PDF, 222 KB
PDF, 222 KB
Tavneos
PDF, 193 KB
PDF, 193 KB
Testosterone Replacement Therapy
(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution) (NON-PREFERRED - Androderm | Kyzatrex | Natesto | Vogelxo 1%)
PDF, 219 KB
(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution) (NON-PREFERRED - Androderm | Kyzatrex | Natesto | Vogelxo 1%)
PDF, 219 KB
Tetrabenazine, Xenazine
PDF, 148 KB
PDF, 148 KB
Tezspire (Pharmacy)
PDF, 244 KB
PDF, 244 KB
Tiglutik
PDF, 161 KB
PDF, 161 KB
Tiopronin Products
(Tiopronin (Thiola), tiopronin delayed-release (Thiola EC), venxxiva (Thiola))
PDF, 195 KB
(Tiopronin (Thiola), tiopronin delayed-release (Thiola EC), venxxiva (Thiola))
PDF, 195 KB
Tobi Podhaler
PDF, 165 KB
PDF, 165 KB
Tolvaptan (Samsca)
PDF, 165 KB
PDF, 165 KB
Topical Acne Drugs
(Preferred: adapalene (generic Differin) | treinoin cream (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel (generic Epiduo Forte) | Altreno lotion 0.05% | Aklief | Amzeeq | Azelex | clindamycin 1.2%/benzoyl peroxide 2.5% gel (generic Acanya) | dapsone gel 5% (generic Aczone) | erythromycin 3%/benzoyl 5% gel (generic Benzamycin) | tazarotene foam 0.1% (generic Fabior) | tretinoin gel 0.05% (generic Atralin) | Winlevi cream 1%)
PDF, 214 KB
(Preferred: adapalene (generic Differin) | treinoin cream (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel (generic Epiduo Forte) | Altreno lotion 0.05% | Aklief | Amzeeq | Azelex | clindamycin 1.2%/benzoyl peroxide 2.5% gel (generic Acanya) | dapsone gel 5% (generic Aczone) | erythromycin 3%/benzoyl 5% gel (generic Benzamycin) | tazarotene foam 0.1% (generic Fabior) | tretinoin gel 0.05% (generic Atralin) | Winlevi cream 1%)
PDF, 214 KB
Topical Antifungal Drugs
(luliconazole (Luzu), naftifine 2% cream, oxiconazole (Oxistat), sulconazole (Exelderm), tavaborole)
PDF, 169 KB
(luliconazole (Luzu), naftifine 2% cream, oxiconazole (Oxistat), sulconazole (Exelderm), tavaborole)
PDF, 169 KB
Topical Corticosteroid Drugs
PDF, 173 KB
PDF, 173 KB
Topical Immunomodulator Drugs
(Zyclara, Imiquimod 3.75% , Picato, Klisyri)
PDF, 175 KB
(Zyclara, Imiquimod 3.75% , Picato, Klisyri)
PDF, 175 KB
Topical Rosacea Drugs
(Brimonidine, Mirvaso, Rhofade, Ivermectin Cream, Soolantra, Zilxi)
PDF, 164 KB
(Brimonidine, Mirvaso, Rhofade, Ivermectin Cream, Soolantra, Zilxi)
PDF, 164 KB
Topical Zoryve Products
(Zoryve 0.05%, Zoryve 0.15% cream, Zoryve 0.3% cream, Zoryve topical foam, 0.3%)
PDF, 202 KB
(Zoryve 0.05%, Zoryve 0.15% cream, Zoryve 0.3% cream, Zoryve topical foam, 0.3%)
PDF, 202 KB
Transthyretin Stabilizers
(Attruby, Vyndamax, Vyndaqel)
PDF, 185 KB
(Attruby, Vyndamax, Vyndaqel)
PDF, 185 KB
Trikafta
PDF, 198 KB
PDF, 198 KB
Trimipramine
PDF, 153 KB
PDF, 153 KB
Tryngolza
PDF, 178 KB
PDF, 178 KB
Tryvio
PDF, 155 KB
PDF, 155 KB
Uloric
PDF, 132 KB
PDF, 132 KB
Upneeq
PDF, 207 KB
PDF, 207 KB
Ustekinumab Products - Crohn's Disease and Ulcerative Colitis
(Selarsdi | Yesintek)
PDF, 199 KB
(Selarsdi | Yesintek)
PDF, 199 KB
Ustekinumab Products - Psoriatic Arthritis and Plaque Psoriasis
(Selarsdi | Yesintek)
PDF, 203 KB
(Selarsdi | Yesintek)
PDF, 203 KB
Vabomere (Pharmacy)
PDF, 158 KB
PDF, 158 KB
Vanrafia
PDF, 200 KB
PDF, 200 KB
Vecamyl
PDF, 149 KB
PDF, 149 KB
Velsipity
PDF, 173 KB
PDF, 173 KB
Vemlidy
PDF, 175 KB
PDF, 175 KB
Verquvo
PDF, 158 KB
PDF, 158 KB
Vigabatrin Products
(Sabril, Vigadrone, vigabatrin, Vigafyde, Vigpoder)
PDF, 176 KB
(Sabril, Vigadrone, vigabatrin, Vigafyde, Vigpoder)
PDF, 176 KB
Vijoice
PDF, 189 KB
PDF, 189 KB
Vivjoa
PDF, 227 KB
PDF, 227 KB
Vowst
PDF, 195 KB
PDF, 195 KB
Voxzogo
PDF, 191 KB
PDF, 191 KB
Voydeya
PDF, 225 KB
PDF, 225 KB
Voyxact
PDF, 217 KB
PDF, 217 KB
Vtama
PDF, 195 KB
PDF, 195 KB
Vyalev (Pharmacy)
PDF, 161 KB
PDF, 161 KB
Vykat XR
PDF, 182 KB
PDF, 182 KB
Vyleesi
PDF, 154 KB
PDF, 154 KB
Wakix
PDF, 238 KB
PDF, 238 KB
Wayrilz
PDF, 194 KB
PDF, 194 KB
Winrevair
PDF, 274 KB
PDF, 274 KB
Xadago
PDF, 133 KB
PDF, 133 KB
Xdemvy
PDF, 155 KB
PDF, 155 KB
Xeljanz | Xeljanz XR
PDF, 217 KB
PDF, 217 KB
Xenleta Tablets
PDF, 138 KB
PDF, 138 KB
Xifaxan
PDF, 180 KB
PDF, 180 KB
Xolair (Pharmacy)
PDF, 588 KB
PDF, 588 KB
Xolremdi
PDF, 228 KB
PDF, 228 KB
Xphozah
PDF, 167 KB
PDF, 167 KB
Yorvipath
PDF, 195 KB
PDF, 195 KB
Zeposia
PDF, 177 KB
PDF, 177 KB
Zilbrysq
PDF, 204 KB
PDF, 204 KB
Zokinvy
PDF, 194 KB
PDF, 194 KB
Zolmitriptan (Zomig) Nasal Spray
PDF, 153 KB
PDF, 153 KB
Zontivity
PDF, 181 KB
PDF, 181 KB
Zorbtive
PDF, 186 KB
PDF, 186 KB
Ztalmy
PDF, 168 KB
PDF, 168 KB
Zurzuvae
PDF, 162 KB
PDF, 162 KB
Zyflo, Zileuton ER
PDF, 136 KB
PDF, 136 KB
Zymfentra
PDF, 197 KB
PDF, 197 KB
Excepción de medicamentos
Autorización previa
Compound Drugs
PDF, 139 KB
PDF, 139 KB
Farmacia y medicamentos con autorización previa - Medicare
Criterios de autorización de la Parte B
Medidas de calidad: HEDIS y estrellas
Proveedores especializados
Salud conductual
Cardiología
NCH Cardiology FAQs
PDF, 408 KB
PDF, 408 KB
Oncología
Oftalmología
EMI Ophthalmology CPT Code List
PDF, 583 KB
PDF, 583 KB