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Provider Forms

AvMed makes it easy to find the information you and your patients' need. Simply print and fill out one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.

Behavioral Health

• Primary Care Physician (PCP) - Behavioral Health Provider Communication Form

PDF , 42 KB Last Updated : 03/25/2025

PDF , 42 KB Last Updated : 03/25/2025

Claims and CPT Code

• Coordination of Benefits Claim Form

PDF , 15 KB Last Updated : 03/21/2025

PDF , 15 KB Last Updated : 03/21/2025

• Instruction on Billing Additional Codes

PDF , 526 KB Last Updated : 03/19/2025

PDF , 526 KB Last Updated : 03/19/2025

• Request for Claim Review

PDF , 214 KB Last Updated : 04/29/2026

PDF , 214 KB Last Updated : 04/29/2026

• Waiver of Liability

PDF , 8 KB Last Updated : 03/19/2025

PDF , 8 KB Last Updated : 03/19/2025

Continuation of Care

• Medicare Continuity of Care Notification Form

PDF , 166 KB Last Updated : 03/19/2025

PDF , 166 KB Last Updated : 03/19/2025

Contracting

• Credentialing Application

PDF , 278 KB Last Updated : 03/19/2025

PDF , 278 KB Last Updated : 03/19/2025

Member Related

• Appointment of Representative Form

PDF , 55 KB Last Updated : 03/26/2025

PDF , 55 KB Last Updated : 03/26/2025

• Appointment of Representative (Medicare Members)

PDF , 41 KB Last Updated : 03/19/2025

PDF , 41 KB Last Updated : 03/19/2025

• Standard Notice and Consent Documents Under the No Surprises Act

PDF , 217 KB Last Updated : 03/19/2025

PDF , 217 KB Last Updated : 03/19/2025

Prior Authorization and Hospital Admission Notification

Admission Notification

• Hospital Admission Emergent Urgent Direct Admissions Form

PDF , 192 KB Last Updated : 03/19/2025

PDF , 192 KB Last Updated : 03/19/2025

Prior Authorization

• Continuity of Care Authorization Form - Out of Network Providers

PDF , 142 KB Last Updated : 03/19/2025

PDF , 142 KB Last Updated : 03/19/2025

• Medical Prior Authorization Request Form

PDF , 254 KB Last Updated : 01/05/2026

PDF , 254 KB Last Updated : 01/05/2026

• New Member Transition of Service Form

PDF , 321 KB Last Updated : 01/05/2026

PDF , 321 KB Last Updated : 01/05/2026

Resources

• Inpatient Discharge Planning Resources

PDF , 61 KB Last Updated : 05/05/2026

PDF , 61 KB Last Updated : 05/05/2026

• No Authorization Required List Of Procedure Codes

PDF , 806 KB Last Updated : 03/19/2025

PDF , 806 KB Last Updated : 03/19/2025

• Notice of Medicare Non-Coverage Form

PDF , 911 KB Last Updated : 03/19/2025

PDF , 911 KB Last Updated : 03/19/2025

• Notice of Medicare Non-Coverage Form (Spanish)

PDF , 619 KB Last Updated : 03/19/2025

PDF , 619 KB Last Updated : 03/19/2025

• Prior Authorization Requirements

PDF , 758 KB Last Updated : 03/05/2025

PDF , 758 KB Last Updated : 03/05/2025

Prior Authorization Medical Drugs - Commercial

• Abecma (Medical)

PDF , 215 KB Last Updated : 04/02/2025

PDF , 215 KB Last Updated : 04/02/2025

• Abrysvo (Medical)

PDF , 147 KB Last Updated : 04/02/2025

PDF , 147 KB Last Updated : 04/02/2025

• Actemra IV for diagnosis of Cytokine Release Syndrome (CRS) (Medical)

PDF , 215 KB Last Updated : 04/02/2025

PDF , 215 KB Last Updated : 04/02/2025

• Actimmune (Medical)

PDF , 176 KB Last Updated : 04/02/2025

PDF , 176 KB Last Updated : 04/02/2025

• Adakveo (Medical)

PDF , 205 KB Last Updated : 04/02/2025

PDF , 205 KB Last Updated : 04/02/2025

• Adasuve (Medical)

PDF , 158 KB Last Updated : 01/14/2026

PDF , 158 KB Last Updated : 01/14/2026

• Adstiladrin (Medical)

PDF , 221 KB Last Updated : 04/02/2025

PDF , 221 KB Last Updated : 04/02/2025

• Aduhelm (Medical)

PDF , 353 KB Last Updated : 04/02/2025

PDF , 353 KB Last Updated : 04/02/2025

• Adzynma (Medical)

PDF , 264 KB Last Updated : 04/02/2025

PDF , 264 KB Last Updated : 04/02/2025

• Aldurazyme (Medical)

PDF , 220 KB Last Updated : 04/02/2025

PDF , 220 KB Last Updated : 04/02/2025

• Alhemo (Medical)

PDF , 214 KB Last Updated : 10/30/2025

PDF , 214 KB Last Updated : 10/30/2025

• Aliqopa IV (Medical)

PDF , 167 KB Last Updated : 04/02/2025

PDF , 167 KB Last Updated : 04/02/2025

• Alpha Proteinase Inhibitors (Medical)

PDF , 208 KB Last Updated : 04/02/2025

PDF , 208 KB Last Updated : 04/02/2025

• Amphotericin B Liposome (Medical)

PDF , 199 KB Last Updated : 01/14/2026

PDF , 199 KB Last Updated : 01/14/2026

• Amtagvi (Medical)

PDF , 217 KB Last Updated : 04/02/2025

PDF , 217 KB Last Updated : 04/02/2025

• Amvuttra (Medical)

PDF , 256 KB Last Updated : 01/14/2026

PDF , 256 KB Last Updated : 01/14/2026

• Aphexda (Medical)

PDF , 179 KB Last Updated : 04/02/2025

PDF , 179 KB Last Updated : 04/02/2025

• Aucatzyl (Medical)

PDF , 240 KB Last Updated : 07/01/2025

PDF , 240 KB Last Updated : 07/01/2025

• Azedra (Medical)

PDF , 257 KB Last Updated : 04/02/2025

PDF , 257 KB Last Updated : 04/02/2025

• Benlysta (Medical)

PDF , 259 KB Last Updated : 02/27/2026

PDF , 259 KB Last Updated : 02/27/2026

• Beqvez (Medical)

PDF , 276 KB Last Updated : 04/02/2025

PDF , 276 KB Last Updated : 04/02/2025

• Berinert IV (Medical)

PDF , 235 KB Last Updated : 04/30/2026

PDF , 235 KB Last Updated : 04/30/2026

• Besponsa IV (Medical)

PDF , 217 KB Last Updated : 04/02/2025

PDF , 217 KB Last Updated : 04/02/2025

• Beyfortus (Medical)

PDF , 205 KB Last Updated : 04/02/2025

PDF , 205 KB Last Updated : 04/02/2025

• Boruzu (Medical)

PDF , 206 KB Last Updated : 01/20/2026

PDF , 206 KB Last Updated : 01/20/2026

• Botox | Xeomin (Medical)

PDF , 201 KB Last Updated : 05/13/2026

PDF , 201 KB Last Updated : 05/13/2026

• Botox Injections-Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS) (Medical)

PDF , 171 KB Last Updated : 04/02/2025

PDF , 171 KB Last Updated : 04/02/2025

• Botox Injection-Type A (Chronic Migraine Headache Prophylaxis) (Medical)

PDF , 207 KB Last Updated : 04/02/2025

PDF , 207 KB Last Updated : 04/02/2025

• Botox Injection-Type A (Hyperhidrosis) (Medical)

PDF , 193 KB Last Updated : 04/02/2025

PDF , 193 KB Last Updated : 04/02/2025

• Breyanzi (Medical)

PDF , 221 KB Last Updated : 02/27/2026

PDF , 221 KB Last Updated : 02/27/2026

• Brineura IV (Medical)

PDF , 209 KB Last Updated : 04/02/2025

PDF , 209 KB Last Updated : 04/02/2025

• Briumvi (Medical)

PDF , 198 KB Last Updated : 04/02/2025

PDF , 198 KB Last Updated : 04/02/2025

• Brixadi│Sublocade (Medical)

PDF , 181 KB Last Updated : 04/02/2025

PDF , 181 KB Last Updated : 04/02/2025

• Cabenuva LAP (Medical)

PDF , 169 KB Last Updated : 04/02/2025

PDF , 169 KB Last Updated : 04/02/2025

• Carvykti (Medical)

PDF , 215 KB Last Updated : 04/02/2025

PDF , 215 KB Last Updated : 04/02/2025

• Casgevy - β - Thalassemia (Medical)

PDF , 277 KB Last Updated : 04/02/2025

PDF , 277 KB Last Updated : 04/02/2025

• Casgevy (Medical)

PDF , 264 KB Last Updated : 04/02/2025

PDF , 264 KB Last Updated : 04/02/2025

• Cimzia Lyophilized IV (Medical)

PDF , 199 KB Last Updated : 04/02/2025

PDF , 199 KB Last Updated : 04/02/2025

• Cinqair IV (Medical)

PDF , 175 KB Last Updated : 04/02/2025

PDF , 175 KB Last Updated : 04/02/2025

• Cosentyx IV (Medical)

PDF , 219 KB Last Updated : 04/02/2025

PDF , 219 KB Last Updated : 04/02/2025

• Cresemba (Medical)

PDF , 216 KB Last Updated : 04/02/2025

PDF , 216 KB Last Updated : 04/02/2025

• Crysvita Injection (Medical)

PDF , 218 KB Last Updated : 04/02/2025

PDF , 218 KB Last Updated : 04/02/2025

• Dalvance (Medical)

PDF , 191 KB Last Updated : 01/14/2026

PDF , 191 KB Last Updated : 01/14/2026

• Datroway (Medical)

PDF , 242 KB Last Updated : 10/30/2025

PDF , 242 KB Last Updated : 10/30/2025

• Daxxify (Medical)

PDF , 167 KB Last Updated : 04/02/2025

PDF , 167 KB Last Updated : 04/02/2025

• Denosumab Biosimilars - Oncology Indications (Medical)

(PREFERRED: Osenvelt | Wyost) (NON-PREFERRED: Aukelso | Bilprevda | Bomyntra | Xbryk | Xgeva | Xtrenbo)

PDF , 169 KB Last Updated : 05/13/2026

(PREFERRED: Osenvelt | Wyost) (NON-PREFERRED: Aukelso | Bilprevda | Bomyntra | Xbryk | Xgeva | Xtrenbo)

PDF , 169 KB Last Updated : 05/13/2026

• Denosumab Biosimilars - Osteoporosis Indications (Medical)

(PREFERRED: Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Enoby | Ospomyv | Prolia)

PDF , 168 KB Last Updated : 05/13/2026

(PREFERRED: Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Enoby | Ospomyv | Prolia)

PDF , 168 KB Last Updated : 05/13/2026

• Dextenza (Medical)

PDF , 204 KB Last Updated : 04/02/2025

PDF , 204 KB Last Updated : 04/02/2025

• Duchenne Muscular Dystrophy Medications (Medical)

PDF , 170 KB Last Updated : 04/02/2025

PDF , 170 KB Last Updated : 04/02/2025

• Durysta (Medical)

PDF , 175 KB Last Updated : 04/02/2025

PDF , 175 KB Last Updated : 04/02/2025

• Dysport (Botox Injections) (Medical) (Cosmetic indications Excluded)

PDF , 221 KB Last Updated : 04/02/2025

PDF , 221 KB Last Updated : 04/02/2025

• Eculizumab IV Products - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)

(Bkemv | Epysqli | Soliris)

PDF , 205 KB Last Updated : 01/20/2026

(Bkemv | Epysqli | Soliris)

PDF , 205 KB Last Updated : 01/20/2026

• Eculizumab IV Products - Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)

(Bkemv | Epysqli | Soliris)

PDF , 247 KB Last Updated : 01/20/2026

(Bkemv | Epysqli | Soliris)

PDF , 247 KB Last Updated : 01/20/2026

• Eculizumab Products IV - Generalized Myasthenia Gravis (gMG) (Medical)

(Bkemv | Epysqli | Soliris)

PDF , 235 KB Last Updated : 02/27/2026

(Bkemv | Epysqli | Soliris)

PDF , 235 KB Last Updated : 02/27/2026

• edaravone IV (Radicava IV) (Medical)

PDF , 233 KB Last Updated : 02/27/2026

PDF , 233 KB Last Updated : 02/27/2026

• Elaprase IV (Medical)

PDF , 232 KB Last Updated : 04/02/2025

PDF , 232 KB Last Updated : 04/02/2025

• Elevidys (Medical)

PDF , 189 KB Last Updated : 04/02/2025

PDF , 189 KB Last Updated : 04/02/2025

• Elfabrio IV (Medical)

PDF , 225 KB Last Updated : 04/02/2025

PDF , 225 KB Last Updated : 04/02/2025

• Emblaveo (Medical)

PDF , 191 KB Last Updated : 01/01/2026

PDF , 191 KB Last Updated : 01/01/2026

• Empaveli (Medical)

PDF , 241 KB Last Updated : 10/30/2025

PDF , 241 KB Last Updated : 10/30/2025

• Encelto (Medical)

PDF , 201 KB Last Updated : 01/20/2026

PDF , 201 KB Last Updated : 01/20/2026

• Enjaymo (Medical)

PDF , 249 KB Last Updated : 04/02/2025

PDF , 249 KB Last Updated : 04/02/2025

• Entyvio IV (Medical)

PDF , 191 KB Last Updated : 01/01/2026

PDF , 191 KB Last Updated : 01/01/2026

• Evenity (Medical)

PDF , 201 KB Last Updated : 04/02/2025

PDF , 201 KB Last Updated : 04/02/2025

• Evkeeza (Medical)

PDF , 209 KB Last Updated : 12/31/2025

PDF , 209 KB Last Updated : 12/31/2025

• Exdensur (Medical)

PDF , 210 KB Last Updated : 05/13/2026

PDF , 210 KB Last Updated : 05/13/2026

• Eylea - Retinopathy of Prematurity (ROP) (Medical)

PDF , 168 KB Last Updated : 04/02/2025

PDF , 168 KB Last Updated : 04/02/2025

• Fabrazyme IV (Medical)

PDF , 215 KB Last Updated : 04/02/2025

PDF , 215 KB Last Updated : 04/02/2025

• Factor IX Deficiency Therapy (Hemophilia B) (Medical)

(AlphaNine | Alprolix | BeneFIX | Idelvion | Ixinity | Profilnine | Rebinyn | Rixubis)

PDF , 373 KB Last Updated : 09/25/2025

(AlphaNine | Alprolix | BeneFIX | Idelvion | Ixinity | Profilnine | Rebinyn | Rixubis)

PDF , 373 KB Last Updated : 09/25/2025

• Factor VIIa (Bypassing Agents for Hemophilia A and B) (Medical)

(NovoSeven RT | Sevenfact)

PDF , 284 KB Last Updated : 09/25/2025

(NovoSeven RT | Sevenfact)

PDF , 284 KB Last Updated : 09/25/2025

• 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 Last Updated : 02/24/2026

(Advate | Adynovate | Afstyla | Alphanate | ALTUVIIIO | Eloctate | Esperoct | Hemofil M | Humate-P | Jivi | Koate | Kogenate | Kovaltry | Novoeight | Nuwiq | Obizur | Recominate | Wilate | Xyntha)

PDF , 403 KB Last Updated : 02/24/2026

• Fasenra (Medical)

PDF , 231 KB Last Updated : 09/07/2025

PDF , 231 KB Last Updated : 09/07/2025

• Feiba (Medical)

PDF , 273 KB Last Updated : 12/31/2025

PDF , 273 KB Last Updated : 12/31/2025

• Fetroja (Medical)

PDF , 177 KB Last Updated : 01/14/2026

PDF , 177 KB Last Updated : 01/14/2026

• Fuzeon (Medical)

PDF , 202 KB Last Updated : 01/14/2026

PDF , 202 KB Last Updated : 01/14/2026

• Gamifant – Hemophagocytic Lymphohistiocytosis (HLH)/Macrophage Activation Syndrome (MAS) (Medical)

PDF , 259 KB Last Updated : 10/21/2025

PDF , 259 KB Last Updated : 10/21/2025

• Gamifant – Primary Hemophagocytic Lymphohistiocytosis (HLH) (Medical)

PDF , 250 KB Last Updated : 10/21/2025

PDF , 250 KB Last Updated : 10/21/2025

• Gamifant IV (Medical)

PDF , 253 KB Last Updated : 04/02/2025

PDF , 253 KB Last Updated : 04/02/2025

• Gaucher Disease Drugs (Enzyme Replacement Therapy) (Medical)

Cerezyme | Elelyso | Vpriv

PDF , 230 KB Last Updated : 04/30/2026

Cerezyme | Elelyso | Vpriv

PDF , 230 KB Last Updated : 04/30/2026

• Gazyva - Lupus Nephritis (Medical)

PDF , 232 KB Last Updated : 03/30/2026

PDF , 232 KB Last Updated : 03/30/2026

• Givlaari (Medical)

PDF , 227 KB Last Updated : 04/02/2025

PDF , 227 KB Last Updated : 04/02/2025

• Gonadotropin-releasing Hormone Agonists (GnRH) (Medical)

PDF , 273 KB Last Updated : 10/30/2025

PDF , 273 KB Last Updated : 10/30/2025

• Hemgenix (Medical)

PDF , 260 KB Last Updated : 04/02/2025

PDF , 260 KB Last Updated : 04/02/2025

• Hemophilia Factors (IV) (Medical)

PDF , 166 KB Last Updated : 04/02/2025

PDF , 166 KB Last Updated : 04/02/2025

• 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 Last Updated : 03/10/2026

(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 Last Updated : 03/10/2026

• Hympavzi (Medical)

PDF , 217 KB Last Updated : 01/14/2026

PDF , 217 KB Last Updated : 01/14/2026

• Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors (Medical)

PDF , 201 KB Last Updated : 04/02/2025

PDF , 201 KB Last Updated : 04/02/2025

• Icatibant Products (Medical)

icatibant (Firazyr) | Sajazir

PDF , 195 KB Last Updated : 04/30/2026

icatibant (Firazyr) | Sajazir

PDF , 195 KB Last Updated : 04/30/2026

• iDose TR (Medical)

PDF , 176 KB Last Updated : 04/02/2025

PDF , 176 KB Last Updated : 04/02/2025

• Ilaris (sJIA | AOSD) (Medical) (Non-Preferred)

PDF , 280 KB Last Updated : 04/02/2025

PDF , 280 KB Last Updated : 04/02/2025

• Ilumya SQ (Medical)

PDF , 172 KB Last Updated : 04/02/2025

PDF , 172 KB Last Updated : 04/02/2025

• Imaavy (Medical)

PDF , 201 KB Last Updated : 03/10/2026

PDF , 201 KB Last Updated : 03/10/2026

• Imlygic (Medical)

PDF , 200 KB Last Updated : 04/02/2025

PDF , 200 KB Last Updated : 04/02/2025

• 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 , 238 KB Last Updated : 04/30/2026

(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Hyqvia | Panzyga)

PDF , 238 KB Last Updated : 04/30/2026

• 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 , 274 KB Last Updated : 05/13/2026

(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)

PDF , 274 KB Last Updated : 05/13/2026

• 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 Last Updated : 03/06/2026

(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)

PDF , 262 KB Last Updated : 03/06/2026

• 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 Last Updated : 01/14/2026

(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)

PDF , 232 KB Last Updated : 01/14/2026

• 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 , 238 KB Last Updated : 05/13/2026

(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gammaplex | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Alyglo | Asceniv | Panzyga | Yimmugo)

PDF , 238 KB Last Updated : 05/13/2026

• Immune Globulin SQ (IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)

(PREFERRED: Cutaquiq | Cuvitru | Gammagard | Gamunex-C | Hizentra | Xembify) (NON-PREFERRED: Hyqvia)

PDF , 250 KB Last Updated : 12/31/2025

(PREFERRED: Cutaquiq | Cuvitru | Gammagard | Gamunex-C | Hizentra | Xembify) (NON-PREFERRED: Hyqvia)

PDF , 250 KB Last Updated : 12/31/2025

• Infliximab Products (Medical)

(PREFERRED: Renflexis & unbranded Infliximab) (Non-Preferred: Avsola | Inflectra | Remicade| Zymfrentra)

PDF , 241 KB Last Updated : 04/02/2025

(PREFERRED: Renflexis & unbranded Infliximab) (Non-Preferred: Avsola | Inflectra | Remicade| Zymfrentra)

PDF , 241 KB Last Updated : 04/02/2025

• Intravitreal Compliement Inhibitors (Medical)

PDF , 215 KB Last Updated : 11/13/2025

PDF , 215 KB Last Updated : 11/13/2025

• Itvisma (Medical)

PDF , 228 KB Last Updated : 03/30/2026

PDF , 228 KB Last Updated : 03/30/2026

• IV Tocilizumab Products - Giant Cell Arteritis (GCA) (Medical)

(PREFERRED: Actemra IV, Tyenne IV) (NON-PREFERRED: Tofidence IV)

PDF , 189 KB Last Updated : 09/04/2025

(PREFERRED: Actemra IV, Tyenne IV) (NON-PREFERRED: Tofidence IV)

PDF , 189 KB Last Updated : 09/04/2025

• Kalbitor (Medical)

PDF , 211 KB Last Updated : 04/30/2026

PDF , 211 KB Last Updated : 04/30/2026

• Kanuma (Medical)

PDF , 216 KB Last Updated : 04/02/2025

PDF , 216 KB Last Updated : 04/02/2025

• Kepivance (Medical)

PDF , 211 KB Last Updated : 01/14/2026

PDF , 211 KB Last Updated : 01/14/2026

• Kimyrsa │Orbactiv (Medical)

PDF , 194 KB Last Updated : 01/14/2026

PDF , 194 KB Last Updated : 01/14/2026

• Kisunla (Medical)

PDF , 408 KB Last Updated : 12/31/2025

PDF , 408 KB Last Updated : 12/31/2025

• Korsuva (Medical)

PDF , 200 KB Last Updated : 04/02/2025

PDF , 200 KB Last Updated : 04/02/2025

• Krystexxa (Medical)

PDF , 252 KB Last Updated : 04/02/2025

PDF , 252 KB Last Updated : 04/02/2025

• Kymriah (Medical)

PDF , 249 KB Last Updated : 04/02/2025

PDF , 249 KB Last Updated : 04/02/2025

• Lamzede (Medical)

PDF , 179 KB Last Updated : 04/02/2025

PDF , 179 KB Last Updated : 04/02/2025

• Lantidra (Medical)

PDF , 202 KB Last Updated : 04/02/2025

PDF , 202 KB Last Updated : 04/02/2025

• Lemtrada IV (Medical)

PDF , 171 KB Last Updated : 04/02/2025

PDF , 171 KB Last Updated : 04/02/2025

• Lenmeldy (Medical)

PDF , 267 KB Last Updated : 07/01/2025

PDF , 267 KB Last Updated : 07/01/2025

• Leqembi (Medical)

PDF , 559 KB Last Updated : 12/31/2025

PDF , 559 KB Last Updated : 12/31/2025

• Leqvio (Medical)

PDF , 259 KB Last Updated : 04/02/2025

PDF , 259 KB Last Updated : 04/02/2025

• Lumizyme (Medical)

PDF , 196 KB Last Updated : 04/02/2025

PDF , 196 KB Last Updated : 04/02/2025

• Lutathera (Medical)

PDF , 246 KB Last Updated : 01/14/2026

PDF , 246 KB Last Updated : 01/14/2026

• Luxturna (Medical)

PDF , 170 KB Last Updated : 04/02/2025

PDF , 170 KB Last Updated : 04/02/2025

• Lyfgenia (Medical)

PDF , 264 KB Last Updated : 04/02/2025

PDF , 264 KB Last Updated : 04/02/2025

• 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 Last Updated : 03/10/2026

(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Eylea HD | Lucentis | Pavblu | Susvimo | Vabysmo)

PDF , 237 KB Last Updated : 03/10/2026

• Mepsevii IV (Medical)

PDF , 176 KB Last Updated : 04/02/2025

PDF , 176 KB Last Updated : 04/02/2025

• Mometasone Sinus Implants (Medical)

PDF , 170 KB Last Updated : 04/02/2025

PDF , 170 KB Last Updated : 04/02/2025

• Myobloc (Medical)

PDF , 167 KB Last Updated : 04/02/2025

PDF , 167 KB Last Updated : 04/02/2025

• Naglazyme (Medical)

PDF , 201 KB Last Updated : 04/02/2025

PDF , 201 KB Last Updated : 04/02/2025

• Nexviazyme | Pombiliti (Medical)

PDF , 259 KB Last Updated : 04/02/2025

PDF , 259 KB Last Updated : 04/02/2025

• Noninfectious Uveitis Drugs (Medical)

(Iluvien│Retisert│Yutiq)

PDF , 231 KB Last Updated : 01/14/2026

(Iluvien│Retisert│Yutiq)

PDF , 231 KB Last Updated : 01/14/2026

• Nplate (Medical)

PDF , 243 KB Last Updated : 12/31/2025

PDF , 243 KB Last Updated : 12/31/2025

• Nucala - Chronic Obstructive Pulmonary Disease (COPD) (Medical)

PDF , 227 KB Last Updated : 08/07/2025

PDF , 227 KB Last Updated : 08/07/2025

• Nucala - Chronic Rhinosinusitis with Nasal Polyps (CRSWNP) (Medical)

PDF , 220 KB Last Updated : 12/31/2025

PDF , 220 KB Last Updated : 12/31/2025

• Nucala - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Medical)

PDF , 219 KB Last Updated : 04/02/2025

PDF , 219 KB Last Updated : 04/02/2025

• Nucala - Hypereosinophilic Syndrome (HES) (Medical)

PDF , 214 KB Last Updated : 04/02/2025

PDF , 214 KB Last Updated : 04/02/2025

• Nucala - Severe Eosinophilic Asthma (SEA) (Medical)

PDF , 250 KB Last Updated : 08/07/2025

PDF , 250 KB Last Updated : 08/07/2025

• Nulibry (Medical)

PDF , 243 KB Last Updated : 04/02/2025

PDF , 243 KB Last Updated : 04/02/2025

• Nulojix (Medical)

PDF , 212 KB Last Updated : 04/02/2025

PDF , 212 KB Last Updated : 04/02/2025

• Nuzyra (Medical)

PDF , 183 KB Last Updated : 03/04/2026

PDF , 183 KB Last Updated : 03/04/2026

• Ocrevus | Ocrevus Zunovo (Medical)

PDF , 206 KB Last Updated : 04/02/2025

PDF , 206 KB Last Updated : 04/02/2025

• Omisirge (Medical)

PDF , 264 KB Last Updated : 02/27/2026

PDF , 264 KB Last Updated : 02/27/2026

• Onapgo (Medical)

PDF , 182 KB Last Updated : 01/01/2026

PDF , 182 KB Last Updated : 01/01/2026

• Onpattro IV (Medical)

PDF , 258 KB Last Updated : 01/14/2026

PDF , 258 KB Last Updated : 01/14/2026

• Ophthalmic Corticosteroid Injections (Medical)

PDF , 232 KB Last Updated : 04/02/2025

PDF , 232 KB Last Updated : 04/02/2025

• Orencia - Graft Versus Host Disease (GVHD) (Medical)

PDF , 189 KB Last Updated : 04/02/2025

PDF , 189 KB Last Updated : 04/02/2025

• Orencia IV (Infusion only) (Medical)

PDF , 148 KB Last Updated : 01/01/2026

PDF , 148 KB Last Updated : 01/01/2026

• Oxlumo | Rivfloza (Medical)

PDF , 212 KB Last Updated : 07/01/2025

PDF , 212 KB Last Updated : 07/01/2025

• Paclitaxel Protein-Bound (Medical) (Non-Preferred)

PDF , 205 KB Last Updated : 03/04/2026

PDF , 205 KB Last Updated : 03/04/2026

• Panhematin (Medical)

PDF , 184 KB Last Updated : 01/14/2026

PDF , 184 KB Last Updated : 01/14/2026

• Papzimeos (Medical)

PDF , 190 KB Last Updated : 05/13/2026

PDF , 190 KB Last Updated : 05/13/2026

• Parenteral Iron Products (Medical)

(PREFERRED: Feraheme (ESRD on Dialysis)│Ferrlecit│INFeD│ Venofer) (NON-PREFERRED: Feraheme (Non-ESRD)│Injectafer│Monoferric)

PDF , 159 KB Last Updated : 01/14/2026

(PREFERRED: Feraheme (ESRD on Dialysis)│Ferrlecit│INFeD│ Venofer) (NON-PREFERRED: Feraheme (Non-ESRD)│Injectafer│Monoferric)

PDF , 159 KB Last Updated : 01/14/2026

• Pemetrexed Injections (Medical)

PDF , 209 KB Last Updated : 10/08/2025

PDF , 209 KB Last Updated : 10/08/2025

• PiaSky-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)

PDF , 293 KB Last Updated : 04/02/2025

PDF , 293 KB Last Updated : 04/02/2025

• plerixafor (Mozobil) (Medical)

PDF , 218 KB Last Updated : 04/02/2025

PDF , 218 KB Last Updated : 04/02/2025

• Pluvicto (Medical)

PDF , 221 KB Last Updated : 04/02/2025

PDF , 221 KB Last Updated : 04/02/2025

• Prevymis IV (Medical)

PDF , 198 KB Last Updated : 04/02/2025

PDF , 198 KB Last Updated : 04/02/2025

• Prialt (Medical)

PDF , 142 KB Last Updated : 04/02/2025

PDF , 142 KB Last Updated : 04/02/2025

• Primaxin IV (Medical)

PDF , 187 KB Last Updated : 09/07/2025

PDF , 187 KB Last Updated : 09/07/2025

• Prophylaxis Hereditary Angioedema Drugs (Medical)

(PREFERRED: Cinryze | Haegarda | Takhzyro) (NON-PREFERRED: Andembry)

PDF , 240 KB Last Updated : 04/30/2026

(PREFERRED: Cinryze | Haegarda | Takhzyro) (NON-PREFERRED: Andembry)

PDF , 240 KB Last Updated : 04/30/2026

• Pulmonary Arterial Hypertension Drugs (Medical)

PDF , 246 KB Last Updated : 04/02/2025

PDF , 246 KB Last Updated : 04/02/2025

• Qalsody (Medical)

PDF , 253 KB Last Updated : 04/02/2025

PDF , 253 KB Last Updated : 04/02/2025

• Qfitlia (Medical)

PDF , 239 KB Last Updated : 01/20/2026

PDF , 239 KB Last Updated : 01/20/2026

• Qutenza (Medical)

PDF , 165 KB Last Updated : 01/14/2026

PDF , 165 KB Last Updated : 01/14/2026

• Reblozyl (Medical)

PDF , 249 KB Last Updated : 04/02/2025

PDF , 249 KB Last Updated : 04/02/2025

• Rebyota (Medical)

PDF , 207 KB Last Updated : 04/02/2025

PDF , 207 KB Last Updated : 04/02/2025

• Recarbrio (Medical)

PDF , 199 KB Last Updated : 04/30/2026

PDF , 199 KB Last Updated : 04/30/2026

• Rezzayo (Medical)

PDF , 192 KB Last Updated : 04/02/2025

PDF , 192 KB Last Updated : 04/02/2025

• Riabni | Rituxan IV | Ruxience | Truxima (Medical) (Non-Preferred)

PDF , 278 KB Last Updated : 12/31/2025

PDF , 278 KB Last Updated : 12/31/2025

• Rituxan Hycela IV (Medical)

PDF , 168 KB Last Updated : 04/02/2025

PDF , 168 KB Last Updated : 04/02/2025

• Roctavian (Medical)

PDF , 233 KB Last Updated : 04/02/2025

PDF , 233 KB Last Updated : 04/02/2025

• Ryoncil (Medical)

PDF , 216 KB Last Updated : 01/14/2026

PDF , 216 KB Last Updated : 01/14/2026

• Ryplazim (Medical)

PDF , 223 KB Last Updated : 04/02/2025

PDF , 223 KB Last Updated : 04/02/2025

• Rystiggo (Medical)

PDF , 182 KB Last Updated : 02/27/2026

PDF , 182 KB Last Updated : 02/27/2026

• Saphnelo (Medical)

PDF , 235 KB Last Updated : 04/02/2025

PDF , 235 KB Last Updated : 04/02/2025

• Scenesse (Medical)

PDF , 211 KB Last Updated : 04/02/2025

PDF , 211 KB Last Updated : 04/02/2025

• Simponi ARIA (Medical) (Non-Preferred)

PDF , 203 KB Last Updated : 02/28/2026

PDF , 203 KB Last Updated : 02/28/2026

• Simulect (Medical)

PDF , 172 KB Last Updated : 01/14/2026

PDF , 172 KB Last Updated : 01/14/2026

• Sivextro (Medical)

PDF , 185 KB Last Updated : 01/14/2026

PDF , 185 KB Last Updated : 01/14/2026

• Skysona (Medical)

PDF , 257 KB Last Updated : 01/02/2026

PDF , 257 KB Last Updated : 01/02/2026

• Soliris IV-Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)

PDF , 248 KB Last Updated : 07/01/2025

PDF , 248 KB Last Updated : 07/01/2025

• Somatostatin Analog Drugs (Medical)

PDF , 177 KB Last Updated : 01/01/2026

PDF , 177 KB Last Updated : 01/01/2026

• Spevigo (Medical)

PDF , 234 KB Last Updated : 04/02/2025

PDF , 234 KB Last Updated : 04/02/2025

• Spinraza (Medical)

PDF , 271 KB Last Updated : 04/02/2025

PDF , 271 KB Last Updated : 04/02/2025

• Sunlenca (Medical)

PDF , 232 KB Last Updated : 01/13/2026

PDF , 232 KB Last Updated : 01/13/2026

• Tecartus (Medical)

PDF , 223 KB Last Updated : 04/02/2025

PDF , 223 KB Last Updated : 04/02/2025

• Tecelra (Medical)

PDF , 234 KB Last Updated : 04/02/2025

PDF , 234 KB Last Updated : 04/02/2025

• Teflaro (Medical)

PDF , 181 KB Last Updated : 08/07/2025

PDF , 181 KB Last Updated : 08/07/2025

• Tegsedi SQ Injection (Medical)

PDF , 199 KB Last Updated : 04/02/2025

PDF , 199 KB Last Updated : 04/02/2025

• Tepezza (Medical)

PDF , 229 KB Last Updated : 04/30/2026

PDF , 229 KB Last Updated : 04/30/2026

• Testosterone Replacement Therapy Injectable (Medical)

(Aveed | Azmiro | TestoPel) Medication being provided by the physician's office

PDF , 253 KB Last Updated : 01/02/2026

(Aveed | Azmiro | TestoPel) Medication being provided by the physician's office

PDF , 253 KB Last Updated : 01/02/2026

• Tezspire (Medical)

PDF , 259 KB Last Updated : 12/31/2025

PDF , 259 KB Last Updated : 12/31/2025

• Tocilizumab products IV (Medical)

PDF , 245 KB Last Updated : 04/02/2025

PDF , 245 KB Last Updated : 04/02/2025

• Trogarzo IV (Medical)

PDF , 164 KB Last Updated : 04/02/2025

PDF , 164 KB Last Updated : 04/02/2025

• Tygacil (Medical)

PDF , 201 KB Last Updated : 02/13/2026

PDF , 201 KB Last Updated : 02/13/2026

• Tysabri IV (Medical)

PDF , 222 KB Last Updated : 04/02/2025

PDF , 222 KB Last Updated : 04/02/2025

• Tzield (Medical)

PDF , 252 KB Last Updated : 04/02/2025

PDF , 252 KB Last Updated : 04/02/2025

• Ultomiris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)

PDF , 258 KB Last Updated : 04/02/2025

PDF , 258 KB Last Updated : 04/02/2025

• Ultomiris IV - Generalized Myasthenia Gravis (gMG) (Medical)

PDF , 209 KB Last Updated : 03/10/2026

PDF , 209 KB Last Updated : 03/10/2026

• Ultomiris IV - Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)

PDF , 220 KB Last Updated : 04/02/2025

PDF , 220 KB Last Updated : 04/02/2025

• Ultomiris IV-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)

PDF , 217 KB Last Updated : 04/02/2025

PDF , 217 KB Last Updated : 04/02/2025

• Unituxin (Medical)

PDF , 213 KB Last Updated : 04/02/2025

PDF , 213 KB Last Updated : 04/02/2025

• Uplizna (Medical)

PDF , 219 KB Last Updated : 02/27/2026

PDF , 219 KB Last Updated : 02/27/2026

• Vabomere (Medical)

PDF , 160 KB Last Updated : 02/13/2026

PDF , 160 KB Last Updated : 02/13/2026

• Veopoz (Medical)

PDF , 218 KB Last Updated : 04/02/2025

PDF , 218 KB Last Updated : 04/02/2025

• Vibativ (Medical)

PDF , 185 KB Last Updated : 01/13/2026

PDF , 185 KB Last Updated : 01/13/2026

• Vimizim IV (Medical)

PDF , 215 KB Last Updated : 04/02/2025

PDF , 215 KB Last Updated : 04/02/2025

• Visudyne (Medical)

PDF , 187 KB Last Updated : 04/02/2025

PDF , 187 KB Last Updated : 04/02/2025

• Vyalev (Medical)

PDF , 175 KB Last Updated : 03/04/2026

PDF , 175 KB Last Updated : 03/04/2026

• Vyepti (Medical)

PDF , 226 KB Last Updated : 04/02/2025

PDF , 226 KB Last Updated : 04/02/2025

• Vyjuvek (Medical)

PDF , 222 KB Last Updated : 02/04/2026

PDF , 222 KB Last Updated : 02/04/2026

• Vyvgart | Vyvgart Hytrulo - Generalized Myasthenia Gravis (gMG) (Medical)

PDF , 194 KB Last Updated : 02/27/2026

PDF , 194 KB Last Updated : 02/27/2026

• Vyvgart | Vyvgart Hytrulo (Medical)

PDF , 218 KB Last Updated : 07/11/2025

PDF , 218 KB Last Updated : 07/11/2025

• Vyvgart Hytrulo - Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)(Medical)

PDF , 209 KB Last Updated : 01/20/2026

PDF , 209 KB Last Updated : 01/20/2026

• Xacduro (Medical)

PDF , 226 KB Last Updated : 04/02/2025

PDF , 226 KB Last Updated : 04/02/2025

• Xenleta (Medical)

PDF , 162 KB Last Updated : 04/02/2025

PDF , 162 KB Last Updated : 04/02/2025

• Xenpozyme (Medical)

PDF , 237 KB Last Updated : 04/02/2025

PDF , 237 KB Last Updated : 04/02/2025

• Xerava (Medical)

PDF , 176 KB Last Updated : 02/13/2026

PDF , 176 KB Last Updated : 02/13/2026

• Xiaflex (Medical)

PDF , 205 KB Last Updated : 04/02/2025

PDF , 205 KB Last Updated : 04/02/2025

• Xolair (Medical)

PDF , 637 KB Last Updated : 02/04/2026

PDF , 637 KB Last Updated : 02/04/2026

• Yartemlea (Medical)

PDF , 233 KB Last Updated : 04/30/2026

PDF , 233 KB Last Updated : 04/30/2026

• Ycanth (Medical)

PDF , 170 KB Last Updated : 04/02/2025

PDF , 170 KB Last Updated : 04/02/2025

• Yescarta (Medical)

PDF , 216 KB Last Updated : 04/30/2026

PDF , 216 KB Last Updated : 04/30/2026

• Zemdri (Medical)

PDF , 177 KB Last Updated : 02/13/2026

PDF , 177 KB Last Updated : 02/13/2026

• Zevaskyn (Medical)

PDF , 212 KB Last Updated : 01/02/2026

PDF , 212 KB Last Updated : 01/02/2026

• Zevtera (Medical)

PDF , 209 KB Last Updated : 12/31/2025

PDF , 209 KB Last Updated : 12/31/2025

• Zinplava (Medical)

PDF , 232 KB Last Updated : 04/02/2025

PDF , 232 KB Last Updated : 04/02/2025

• Zolgensma IV (Medical)

PDF , 282 KB Last Updated : 04/02/2025

PDF , 282 KB Last Updated : 04/02/2025

• Zulresso Injection (Medical)

PDF , 172 KB Last Updated : 04/02/2025

PDF , 172 KB Last Updated : 04/02/2025

• Zynteglo (Medical)

PDF , 231 KB Last Updated : 04/02/2025

PDF , 231 KB Last Updated : 04/02/2025

Prior Authorization Pharmacy Drugs - Commercial

• Abrysvo (Pharmacy)

(RSV Vaccine) for Active Immunization of Pregnancy

PDF , 122 KB Last Updated : 04/07/2025

(RSV Vaccine) for Active Immunization of Pregnancy

PDF , 122 KB Last Updated : 04/07/2025

• ACA Copay Waiver - Aspirin 81 mg

PDF , 141 KB Last Updated : 04/07/2025

PDF , 141 KB Last Updated : 04/07/2025

• ACA Copay Waiver - Breast Cancer Prevention Drugs

PDF , 143 KB Last Updated : 04/07/2025

PDF , 143 KB Last Updated : 04/07/2025

• ACA Copay Waiver - High Dose Statins

PDF , 166 KB Last Updated : 04/07/2025

PDF , 166 KB Last Updated : 04/07/2025

• Actemra SQ - Systemic Sclerosis-Associated Interstitial Lung Disease

PDF , 214 KB Last Updated : 04/07/2025

PDF , 214 KB Last Updated : 04/07/2025

• Actimmune SQ

PDF , 196 KB Last Updated : 04/07/2025

PDF , 196 KB Last Updated : 04/07/2025

• Adalimumab Preferred Products

(Self -Funded Commercial Group Preferreds: Cyltezo | Humira | Yuflyma) (Fully Insured Commercial Groups Preferreds: adalimumab-adbm | Simlandi)

PDF , 245 KB Last Updated : 01/01/2026

(Self -Funded Commercial Group Preferreds: Cyltezo | Humira | Yuflyma) (Fully Insured Commercial Groups Preferreds: adalimumab-adbm | Simlandi)

PDF , 245 KB Last Updated : 01/01/2026

• Adbry

PDF , 264 KB Last Updated : 04/07/2025

PDF , 264 KB Last Updated : 04/07/2025

• Addyi

PDF , 151 KB Last Updated : 02/27/2026

PDF , 151 KB Last Updated : 02/27/2026

• Adefovir Dipivoxil

(ADV, Generic Hepsera)

PDF , 194 KB Last Updated : 04/07/2025

(ADV, Generic Hepsera)

PDF , 194 KB Last Updated : 04/07/2025

• Afrezza

PDF , 156 KB Last Updated : 10/08/2025

PDF , 156 KB Last Updated : 10/08/2025

• Agamree | deflazacort (generic Emflaza) | Jaythari | Pyquvi

PDF , 202 KB Last Updated : 01/21/2026

PDF , 202 KB Last Updated : 01/21/2026

• Albuterol Inhalers

(Generic ProAir HFA, Generic Proventil HFA, Generic Ventolin HFA, Generic Xopenex, ProAir, Proventil HFA)

PDF , 137 KB Last Updated : 04/07/2025

(Generic ProAir HFA, Generic Proventil HFA, Generic Ventolin HFA, Generic Xopenex, ProAir, Proventil HFA)

PDF , 137 KB Last Updated : 04/07/2025

• Alhemo (Pharmacy)

PDF , 202 KB Last Updated : 10/30/2025

PDF , 202 KB Last Updated : 10/30/2025

• aliskiren (Tekturna) | Tekturna HCT

PDF , 199 KB Last Updated : 10/30/2025

PDF , 199 KB Last Updated : 10/30/2025

• Alosetron, Lotronex, Viberzi

PDF , 231 KB Last Updated : 04/07/2025

PDF , 231 KB Last Updated : 04/07/2025

• Alvaiz | eltrombopag (Promacta)

PDF , 230 KB Last Updated : 12/31/2025

PDF , 230 KB Last Updated : 12/31/2025

• Alyftrek

PDF , 220 KB Last Updated : 05/27/2026

PDF , 220 KB Last Updated : 05/27/2026

• Ancobon, Flucytosine

PDF , 152 KB Last Updated : 04/07/2025

PDF , 152 KB Last Updated : 04/07/2025

• Anticonvulsants, Antiepileptic Drugs, Antiseizure Drugs

PDF , 246 KB Last Updated : 04/30/2026

PDF , 246 KB Last Updated : 04/30/2026

• Antidepressant Drugs

(Fetzima, Trintellix, vilazodone, Viibryd)

PDF , 162 KB Last Updated : 04/07/2025

(Fetzima, Trintellix, vilazodone, Viibryd)

PDF , 162 KB Last Updated : 04/07/2025

• Antiparkinson Agents

carbidopa-levodopa ER (Rytary ABA) | Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone (Tasmar) | Rytary | Xadago

PDF , 220 KB Last Updated : 02/13/2026

carbidopa-levodopa ER (Rytary ABA) | Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone (Tasmar) | Rytary | Xadago

PDF , 220 KB Last Updated : 02/13/2026

• Antipsychotics (Children Ages 0 to 17)

PDF , 189 KB Last Updated : 10/08/2025

PDF , 189 KB Last Updated : 10/08/2025

• Anzupgo

PDF , 200 KB Last Updated : 10/30/2025

PDF , 200 KB Last Updated : 10/30/2025

• Apomorphine Products

(Apokyn | apomorphine hydrochloride | Onapgo)

PDF , 181 KB Last Updated : 12/31/2025

(Apokyn | apomorphine hydrochloride | Onapgo)

PDF , 181 KB Last Updated : 12/31/2025

• Aqneursa

PDF , 156 KB Last Updated : 04/07/2025

PDF , 156 KB Last Updated : 04/07/2025

• Aqvesme

PDF , 180 KB Last Updated : 04/30/2026

PDF , 180 KB Last Updated : 04/30/2026

• Arcalyst

PDF , 323 KB Last Updated : 04/07/2025

PDF , 323 KB Last Updated : 04/07/2025

• Arformoterol Nebulizer Solution

(Generic Brovana & ABA)

PDF , 135 KB Last Updated : 04/07/2025

(Generic Brovana & ABA)

PDF , 135 KB Last Updated : 04/07/2025

• Arikayce

PDF , 184 KB Last Updated : 04/07/2025

PDF , 184 KB Last Updated : 04/07/2025

• Atypical Antipsychotics

(asenapine (generic Saphris) | Caplyta | Cobenify | Fanapt | lurasidone (generic Latuda) | paliperidone (generic Invega) | Rexulti | Vraylar)

PDF , 174 KB Last Updated : 03/30/2026

(asenapine (generic Saphris) | Caplyta | Cobenify | Fanapt | lurasidone (generic Latuda) | paliperidone (generic Invega) | Rexulti | Vraylar)

PDF , 174 KB Last Updated : 03/30/2026

• Austedo

PDF , 165 KB Last Updated : 04/07/2025

PDF , 165 KB Last Updated : 04/07/2025

• Auvelity ER

PDF , 188 KB Last Updated : 04/07/2025

PDF , 188 KB Last Updated : 04/07/2025

• Auvi-Q Auto-Injector

PDF , 155 KB Last Updated : 04/07/2025

PDF , 155 KB Last Updated : 04/07/2025

• Benign Prostate Hyperplasia (BPH)

(Tadalafil 2.5 or 5 mg)

PDF , 152 KB Last Updated : 04/07/2025

(Tadalafil 2.5 or 5 mg)

PDF , 152 KB Last Updated : 04/07/2025

• Benlysta SQ (Pharmacy)

PDF , 284 KB Last Updated : 02/27/2026

PDF , 284 KB Last Updated : 02/27/2026

• Bevespi Aerosphere, Breztri, Duaklir Pressair

PDF , 177 KB Last Updated : 04/07/2025

PDF , 177 KB Last Updated : 04/07/2025

• Bimzelx

PDF , 187 KB Last Updated : 01/01/2026

PDF , 187 KB Last Updated : 01/01/2026

• Blujepa

PDF , 198 KB Last Updated : 03/30/2026

PDF , 198 KB Last Updated : 03/30/2026

• Botox - Chronic Migraine (Pharmacy)

PDF , 202 KB Last Updated : 05/13/2026

PDF , 202 KB Last Updated : 05/13/2026

• Botox - Hyperhidrosis (Pharmacy)

PDF , 188 KB Last Updated : 05/13/2026

PDF , 188 KB Last Updated : 05/13/2026

• Botox - Upper Limb Spasticity (ULS) & Lower Limb Spasticity (LLS) (Pharmacy)

PDF , 167 KB Last Updated : 05/13/2026

PDF , 167 KB Last Updated : 05/13/2026

• Botox | Xeomin (Pharmacy)

PDF , 197 KB Last Updated : 05/13/2026

PDF , 197 KB Last Updated : 05/13/2026

• Brexafemme

PDF , 185 KB Last Updated : 04/07/2025

PDF , 185 KB Last Updated : 04/07/2025

• Brinsupri

PDF , 215 KB Last Updated : 02/27/2026

PDF , 215 KB Last Updated : 02/27/2026

• Brixadi, Sublocade

PDF , 178 KB Last Updated : 04/07/2025

PDF , 178 KB Last Updated : 04/07/2025

• Bronchitol

PDF , 205 KB Last Updated : 04/07/2025

PDF , 205 KB Last Updated : 04/07/2025

• Butorphanol (Stadol) Nasal Spray

PDF , 150 KB Last Updated : 04/07/2025

PDF , 150 KB Last Updated : 04/07/2025

• Bylvay

PDF , 230 KB Last Updated : 04/07/2025

PDF , 230 KB Last Updated : 04/07/2025

• Cabenuva

PDF , 154 KB Last Updated : 04/07/2025

PDF , 154 KB Last Updated : 04/07/2025

• Cablivi

PDF , 224 KB Last Updated : 02/27/2026

PDF , 224 KB Last Updated : 02/27/2026

• candesartan (Atacand) | candesartan-HCTZ (Atacand HCT) | Edarbi | Edarbyclor | eprosartan

PDF , 213 KB Last Updated : 12/31/2025

PDF , 213 KB Last Updated : 12/31/2025

• Cardiac Myosin Inhibitors

Camzyos | Myqorzo

PDF , 183 KB Last Updated : 04/30/2026

Camzyos | Myqorzo

PDF , 183 KB Last Updated : 04/30/2026

• Carglumic Acid (Carbaglu)

PDF , 202 KB Last Updated : 04/07/2025

PDF , 202 KB Last Updated : 04/07/2025

• Central Nervous System (CNS) Stimulants - Age 19 and Above

PDF , 185 KB Last Updated : 01/01/2026

PDF , 185 KB Last Updated : 01/01/2026

• Central Nervous System (CNS) Stimulants - Binge Eating Disorder

(Vyvanse)

PDF , 189 KB Last Updated : 04/07/2025

(Vyvanse)

PDF , 189 KB Last Updated : 04/07/2025

• 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 Last Updated : 03/30/2026

(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 Last Updated : 03/30/2026

• Chenodal

PDF , 178 KB Last Updated : 04/07/2025

PDF , 178 KB Last Updated : 04/07/2025

• Cholbam

PDF , 197 KB Last Updated : 04/07/2025

PDF , 197 KB Last Updated : 04/07/2025

• Cibinqo

PDF , 193 KB Last Updated : 04/07/2025

PDF , 193 KB Last Updated : 04/07/2025

• Cimzia SQ

PDF , 226 KB Last Updated : 12/31/2025

PDF , 226 KB Last Updated : 12/31/2025

• Cinacalcet (Sensipar)

PDF , 203 KB Last Updated : 04/07/2025

PDF , 203 KB Last Updated : 04/07/2025

• Continuous Glucose Monitors (CGM)

(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)

PDF , 176 KB Last Updated : 05/01/2026

(PREFERRED: Dexcom | FreeStyle Libre 2 | FreeStyle Libre 3 | FreeStyle Libre 14 day ) (Non-Preferred: Eversense | Guardian)

PDF , 176 KB Last Updated : 05/01/2026

• Contraceptive Medical Exception Request Form

PDF , 156 KB Last Updated : 04/07/2025

PDF , 156 KB Last Updated : 04/07/2025

• Cosentyx SQ

PDF , 223 KB Last Updated : 01/01/2026

PDF , 223 KB Last Updated : 01/01/2026

• Crenessity

PDF , 246 KB Last Updated : 01/14/2026

PDF , 246 KB Last Updated : 01/14/2026

• Cresemba

PDF , 203 KB Last Updated : 04/07/2025

PDF , 203 KB Last Updated : 04/07/2025

• Crinone

PDF , 153 KB Last Updated : 04/07/2025

PDF , 153 KB Last Updated : 04/07/2025

• Ctexli

PDF , 185 KB Last Updated : 01/14/2026

PDF , 185 KB Last Updated : 01/14/2026

• Cuvrior, Syprine, Trientine

PDF , 182 KB Last Updated : 04/07/2025

PDF , 182 KB Last Updated : 04/07/2025

• Cystaran, Cystadrops

PDF , 187 KB Last Updated : 04/07/2025

PDF , 187 KB Last Updated : 04/07/2025

• Daybue | Daybue STIX

PDF , 232 KB Last Updated : 04/30/2026

PDF , 232 KB Last Updated : 04/30/2026

• Deferasirox, Exjade, Jadenu

PDF , 227 KB Last Updated : 04/07/2025

PDF , 227 KB Last Updated : 04/07/2025

• Deferiprone Tablets, Ferriprox, Ferriprox Solution

PDF , 222 KB Last Updated : 04/07/2025

PDF , 222 KB Last Updated : 04/07/2025

• Diacomit

PDF , 159 KB Last Updated : 04/07/2025

PDF , 159 KB Last Updated : 04/07/2025

• Dichlorphenamide (Keveyis)

PDF , 162 KB Last Updated : 04/07/2025

PDF , 162 KB Last Updated : 04/07/2025

• Dihydroergotamine Mesylate (D.H.E. 45), Dihydroergotamine Mesylate (Migranal)

PDF , 162 KB Last Updated : 04/07/2025

PDF , 162 KB Last Updated : 04/07/2025

• Dipetidyl Peptidase 4 (DPP4) Inhibitors

PDF , 165 KB Last Updated : 04/07/2025

PDF , 165 KB Last Updated : 04/07/2025

• Dojolvi

PDF , 232 KB Last Updated : 04/07/2025

PDF , 232 KB Last Updated : 04/07/2025

• Doptelet

PDF , 236 KB Last Updated : 12/31/2025

PDF , 236 KB Last Updated : 12/31/2025

• Doxylamine-Pyridoxine (Diclegis)

PDF , 148 KB Last Updated : 04/07/2025

PDF , 148 KB Last Updated : 04/07/2025

• Droxidopa (Northera)

PDF , 182 KB Last Updated : 04/07/2025

PDF , 182 KB Last Updated : 04/07/2025

• Duavee

PDF , 160 KB Last Updated : 04/07/2025

PDF , 160 KB Last Updated : 04/07/2025

• Duexis, Vimovo

PDF , 200 KB Last Updated : 04/07/2025

PDF , 200 KB Last Updated : 04/07/2025

• Duopa (Pharmacy)

PDF , 144 KB Last Updated : 04/07/2025

PDF , 144 KB Last Updated : 04/07/2025

• Dupixent

PDF , 322 KB Last Updated : 12/31/2025

PDF , 322 KB Last Updated : 12/31/2025

• Duvyzat

PDF , 196 KB Last Updated : 04/07/2025

PDF , 196 KB Last Updated : 04/07/2025

• Dysport (Pharmacy)

PDF , 219 KB Last Updated : 05/13/2026

PDF , 219 KB Last Updated : 05/13/2026

• Ebglyss

PDF , 219 KB Last Updated : 04/17/2026

PDF , 219 KB Last Updated : 04/17/2026

• Egrifta

PDF , 207 KB Last Updated : 10/30/2025

PDF , 207 KB Last Updated : 10/30/2025

• Ekterly

PDF , 216 KB Last Updated : 04/30/2026

PDF , 216 KB Last Updated : 04/30/2026

• Emflaza

PDF , 194 KB Last Updated : 04/07/2025

PDF , 194 KB Last Updated : 04/07/2025

• Empaveli (Pharmacy)

PDF , 236 KB Last Updated : 10/30/2025

PDF , 236 KB Last Updated : 10/30/2025

• Emsam

PDF , 147 KB Last Updated : 04/07/2025

PDF , 147 KB Last Updated : 04/07/2025

• Emverm

PDF , 196 KB Last Updated : 04/07/2025

PDF , 196 KB Last Updated : 04/07/2025

• Enbrel

PDF , 204 KB Last Updated : 04/07/2025

PDF , 204 KB Last Updated : 04/07/2025

• Enspryng

PDF , 146 KB Last Updated : 04/07/2025

PDF , 146 KB Last Updated : 04/07/2025

• Entyvio (Pharmacy)

PDF , 185 KB Last Updated : 01/28/2026

PDF , 185 KB Last Updated : 01/28/2026

• Eohilia

PDF , 181 KB Last Updated : 04/07/2025

PDF , 181 KB Last Updated : 04/07/2025

• Epidiolex

PDF , 184 KB Last Updated : 04/07/2025

PDF , 184 KB Last Updated : 04/07/2025

• Erythropoiesis Stimulating Agents (ESAs)

(Aranesp, Epogen, Mircera, Procrit, Retacrit)

PDF , 227 KB Last Updated : 04/07/2025

(Aranesp, Epogen, Mircera, Procrit, Retacrit)

PDF , 227 KB Last Updated : 04/07/2025

• Ethacrynic Acid (Edecrin)

PDF , 144 KB Last Updated : 04/07/2025

PDF , 144 KB Last Updated : 04/07/2025

• Eucrisa

PDF , 218 KB Last Updated : 04/07/2025

PDF , 218 KB Last Updated : 04/07/2025

• Evrysdi

PDF , 184 KB Last Updated : 04/07/2025

PDF , 184 KB Last Updated : 04/07/2025

• Exxua

PDF , 203 KB Last Updated : 04/07/2025

PDF , 203 KB Last Updated : 04/07/2025

• Ezetimibe-Simvastatin (Vytorin)

PDF , 155 KB Last Updated : 01/28/2026

PDF , 155 KB Last Updated : 01/28/2026

• Fabhalta

PDF , 264 KB Last Updated : 03/10/2026

PDF , 264 KB Last Updated : 03/10/2026

• Fasenra (Pharmacy)

PDF , 231 KB Last Updated : 09/07/2025

PDF , 231 KB Last Updated : 09/07/2025

• fidaxomicin (Dificid) | Dificid suspension

PDF , 216 KB Last Updated : 10/30/2025

PDF , 216 KB Last Updated : 10/30/2025

• Filspari

PDF , 208 KB Last Updated : 02/27/2026

PDF , 208 KB Last Updated : 02/27/2026

• Filsuvez

PDF , 194 KB Last Updated : 04/07/2025

PDF , 194 KB Last Updated : 04/07/2025

• Fintepla

PDF , 198 KB Last Updated : 04/07/2025

PDF , 198 KB Last Updated : 04/07/2025

• Firdapse

PDF , 170 KB Last Updated : 04/07/2025

PDF , 170 KB Last Updated : 04/07/2025

• Flector Patch

PDF , 141 KB Last Updated : 04/07/2025

PDF , 141 KB Last Updated : 04/07/2025

• Flucytosine

PDF , 148 KB Last Updated : 04/07/2025

PDF , 148 KB Last Updated : 04/07/2025

• Forteo, Tymlos, Teriparatide

PDF , 180 KB Last Updated : 04/07/2025

PDF , 180 KB Last Updated : 04/07/2025

• Forzinity

PDF , 162 KB Last Updated : 03/30/2026

PDF , 162 KB Last Updated : 03/30/2026

• Furoscix | Lasix Onyu

PDF , 172 KB Last Updated : 02/27/2026

PDF , 172 KB Last Updated : 02/27/2026

• Galafold

PDF , 170 KB Last Updated : 04/07/2025

PDF , 170 KB Last Updated : 04/07/2025

• Gastric Acid Suppression Drugs (Non-Preferred)

(Dexlansoprazole, Omeprazole/Sodium Bicarbonate, Voquezna)

PDF , 158 KB Last Updated : 04/07/2025

(Dexlansoprazole, Omeprazole/Sodium Bicarbonate, Voquezna)

PDF , 158 KB Last Updated : 04/07/2025

• Gastrointestinal Motility Drugs

(Ibsrela, Prucalopride (Motegrity), Relistor, Trulance, Zelnorm)

PDF , 176 KB Last Updated : 04/07/2025

(Ibsrela, Prucalopride (Motegrity), Relistor, Trulance, Zelnorm)

PDF , 176 KB Last Updated : 04/07/2025

• Gattex

PDF , 285 KB Last Updated : 04/07/2025

PDF , 285 KB Last Updated : 04/07/2025

• Gaucher Disease Drugs

(Cerdelga, Miglustat)

PDF , 228 KB Last Updated : 04/07/2025

(Cerdelga, Miglustat)

PDF , 228 KB Last Updated : 04/07/2025

• Glucagon Analogs

(GlucaGen HypoKit, Zegalogue)

PDF , 222 KB Last Updated : 01/01/2026

(GlucaGen HypoKit, Zegalogue)

PDF , 222 KB Last Updated : 01/01/2026

• Glucagon-Like Peptide (GLP-1) Receptor Agonists

(Bydureon Bcise, Exenatide (Byetta), Liraglutide (Victoza), Mounjaro, Ozempic, Rybelsus, Trulicity)

PDF , 170 KB Last Updated : 07/01/2025

(Bydureon Bcise, Exenatide (Byetta), Liraglutide (Victoza), Mounjaro, Ozempic, Rybelsus, Trulicity)

PDF , 170 KB Last Updated : 07/01/2025

• Glycerol phenylbutyrate (generic Ravicti)

PDF , 179 KB Last Updated : 01/12/2026

PDF , 179 KB Last Updated : 01/12/2026

• Glycopyrrolate (Cuvposa)

PDF , 186 KB Last Updated : 04/07/2025

PDF , 186 KB Last Updated : 04/07/2025

• 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 Last Updated : 01/14/2026

(PREFERRED: Eligard | Leuprolide | Lupron Depot | Lupron Depot-Ped | Trelstar | Zoladex) (NON-PREFERRED: (Fensolvi | Supprelin LA | Synarel | Triptodur)

PDF , 237 KB Last Updated : 01/14/2026

• Graft-Versus-Host Disease (GVHD) Drugs

(Jakafi, Imbruvica)

PDF , 215 KB Last Updated : 04/07/2025

(Jakafi, Imbruvica)

PDF , 215 KB Last Updated : 04/07/2025

• 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 Last Updated : 04/07/2025

(Granix, Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Leukine, Fulphila, Fylnetra, Neulasta, Nyvepria, Rolvedon, Ryzneuta, Stimufend, Udenyca, Ziextenzo)

PDF , 218 KB Last Updated : 04/07/2025

• Grastek, Oralair

PDF , 171 KB Last Updated : 04/07/2025

PDF , 171 KB Last Updated : 04/07/2025

• Hemangeol

PDF , 164 KB Last Updated : 04/07/2025

PDF , 164 KB Last Updated : 04/07/2025

• Hepatitis-C Antiviral (HCV) Drugs

(Preferred: Sofosbuvir/Elpatasvir, Ledipasvir/Sofobuvir, Mavyret)(Non-Preferred: Epclusa, Harvoni, Sovaldi, Viekira Pak, Vosevi, Zepatier)

PDF , 243 KB Last Updated : 04/07/2025

(Preferred: Sofosbuvir/Elpatasvir, Ledipasvir/Sofobuvir, Mavyret)(Non-Preferred: Epclusa, Harvoni, Sovaldi, Viekira Pak, Vosevi, Zepatier)

PDF , 243 KB Last Updated : 04/07/2025

• Human Chorionic Gonadotropin (hCG) - Pre-Pubertal Cryptorchidism

(Novarel, Pregnyl, Ovidrel, Chorionic Gonadotropin)

PDF , 197 KB Last Updated : 04/07/2025

(Novarel, Pregnyl, Ovidrel, Chorionic Gonadotropin)

PDF , 197 KB Last Updated : 04/07/2025

• Hympavzi (Pharmacy)

PDF , 208 KB Last Updated : 01/14/2026

PDF , 208 KB Last Updated : 01/14/2026

• Icatibant Products (Pharmacy)

icatibant (Firazyr) | Sajazir

PDF , 185 KB Last Updated : 04/30/2026

icatibant (Firazyr) | Sajazir

PDF , 185 KB Last Updated : 04/30/2026

• Icosapent Ethyl (Vascepa)

PDF , 200 KB Last Updated : 04/07/2025

PDF , 200 KB Last Updated : 04/07/2025

• Ilumya (Pharmacy)

PDF , 173 KB Last Updated : 01/01/2026

PDF , 173 KB Last Updated : 01/01/2026

• Imcivree

PDF , 199 KB Last Updated : 04/07/2025

PDF , 199 KB Last Updated : 04/07/2025

• Increlex

PDF , 176 KB Last Updated : 04/07/2025

PDF , 176 KB Last Updated : 04/07/2025

• Inflammatory Bowel Disease Drugs

(budesonide ER 9mg, Dipentum, Mesalamine DR 800mg)

PDF , 158 KB Last Updated : 04/07/2025

(budesonide ER 9mg, Dipentum, Mesalamine DR 800mg)

PDF , 158 KB Last Updated : 04/07/2025

• Ingrezza

PDF , 189 KB Last Updated : 04/07/2025

PDF , 189 KB Last Updated : 04/07/2025

• 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 Last Updated : 04/07/2025

(AirDuo Digihaler, AirDuo RespiClick, Budesonide-Formoterol, Dulera, Fluticasone-Salmeterol, Fluticasone Furoate-Vilanterol, Wixela Inhub)

PDF , 172 KB Last Updated : 04/07/2025

• Inhaled Corticosteroids (ICS) (Non-Preferred)

(Alvesco | ArmonAir Digihaler | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA | Pulmicort Flexhaler)

PDF , 162 KB Last Updated : 01/01/2026

(Alvesco | ArmonAir Digihaler | Flovent Diskus/HFA | fluticasone propionate Diskus/HFA | Pulmicort Flexhaler)

PDF , 162 KB Last Updated : 01/01/2026

• Inpefa

PDF , 141 KB Last Updated : 04/07/2025

PDF , 141 KB Last Updated : 04/07/2025

• Insomnia Drugs

(Belsomra, Dayvigo, doxepin, quazepam (Doral), Quviviq, ramelteon (Rozerem))

PDF , 161 KB Last Updated : 01/01/2026

(Belsomra, Dayvigo, doxepin, quazepam (Doral), Quviviq, ramelteon (Rozerem))

PDF , 161 KB Last Updated : 01/01/2026

• 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 Last Updated : 03/06/2026

(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 Last Updated : 03/06/2026

• Isturisa

PDF , 191 KB Last Updated : 01/14/2026

PDF , 191 KB Last Updated : 01/14/2026

• Ivermectin, Stromectol Tablets

PDF , 128 KB Last Updated : 04/07/2025

PDF , 128 KB Last Updated : 04/07/2025

• Jascayd

PDF , 226 KB Last Updated : 04/30/2026

PDF , 226 KB Last Updated : 04/30/2026

• Jesduvroq

PDF , 162 KB Last Updated : 04/07/2025

PDF , 162 KB Last Updated : 04/07/2025

• Joenja

PDF , 194 KB Last Updated : 04/07/2025

PDF , 194 KB Last Updated : 04/07/2025

• Juxtapid

PDF , 184 KB Last Updated : 04/07/2025

PDF , 184 KB Last Updated : 04/07/2025

• Jynarque

PDF , 267 KB Last Updated : 04/07/2025

PDF , 267 KB Last Updated : 04/07/2025

• Kalydeco

PDF , 172 KB Last Updated : 04/07/2025

PDF , 172 KB Last Updated : 04/07/2025

• Kebilidi

PDF , 221 KB Last Updated : 05/13/2026

PDF , 221 KB Last Updated : 05/13/2026

• Kerendia

PDF , 299 KB Last Updated : 01/01/2026

PDF , 299 KB Last Updated : 01/01/2026

• Kevzara

PDF , 168 KB Last Updated : 07/11/2025

PDF , 168 KB Last Updated : 07/11/2025

• Kineret

PDF , 252 KB Last Updated : 07/11/2025

PDF , 252 KB Last Updated : 07/11/2025

• Korlym

PDF , 168 KB Last Updated : 04/07/2025

PDF , 168 KB Last Updated : 04/07/2025

• Koselugo

PDF , 197 KB Last Updated : 04/07/2025

PDF , 197 KB Last Updated : 04/07/2025

• Lampit, Benznidazole

PDF , 237 KB Last Updated : 04/07/2025

PDF , 237 KB Last Updated : 04/07/2025

• Leqembi Iqlik

PDF , 550 KB Last Updated : 01/01/2026

PDF , 550 KB Last Updated : 01/01/2026

• L-glutamine (Endari)

PDF , 161 KB Last Updated : 04/07/2025

PDF , 161 KB Last Updated : 04/07/2025

• Libervant | Nayzilam | Valtoco

PDF , 163 KB Last Updated : 01/14/2026

PDF , 163 KB Last Updated : 01/14/2026

• Litfulo

PDF , 163 KB Last Updated : 04/07/2025

PDF , 163 KB Last Updated : 04/07/2025

• Livmarli

PDF , 234 KB Last Updated : 09/19/2025

PDF , 234 KB Last Updated : 09/19/2025

• Livtencity

PDF , 253 KB Last Updated : 04/07/2025

PDF , 253 KB Last Updated : 04/07/2025

• Lodoco

PDF , 169 KB Last Updated : 04/30/2026

PDF , 169 KB Last Updated : 04/30/2026

• Long-Acting Muscarinic Antagonist (LAMA) Inhalers

PDF , 174 KB Last Updated : 04/07/2025

PDF , 174 KB Last Updated : 04/07/2025

• Lupkynis

PDF , 198 KB Last Updated : 02/27/2026

PDF , 198 KB Last Updated : 02/27/2026

• Lynkuet | Veozah

PDF , 166 KB Last Updated : 02/27/2026

PDF , 166 KB Last Updated : 02/27/2026

• Marplan

PDF , 140 KB Last Updated : 04/08/2025

PDF , 140 KB Last Updated : 04/08/2025

• Metaxalone (generic Skelaxin)

PDF , 155 KB Last Updated : 04/08/2025

PDF , 155 KB Last Updated : 04/08/2025

• Metyrosine, Demser, Phenoxybenazmine, Dibenzyline

PDF , 162 KB Last Updated : 04/08/2025

PDF , 162 KB Last Updated : 04/08/2025

• Mifepristone (Mifeprex) 200mg Tablet

PDF , 149 KB Last Updated : 04/08/2025

PDF , 149 KB Last Updated : 04/08/2025

• Mifepristone (Mifeprex) 300mg Tablet

PDF , 169 KB Last Updated : 04/08/2025

PDF , 169 KB Last Updated : 04/08/2025

• Migraine Treatment - Injectable Calcitonin Gene-Related Peptide (CGRP) Antagonists

(Preferred: Aimovig, Emgality) (Non-Preferred: Ajovy)

PDF , 246 KB Last Updated : 05/13/2026

(Preferred: Aimovig, Emgality) (Non-Preferred: Ajovy)

PDF , 246 KB Last Updated : 05/13/2026

• Migraine Treatment - Non-injectable Drugs

(Preferred: Nurtec ODT, Qulipta) (Non-Preferred: Reyvow, Ubrelvy, Zavzpret)

PDF , 214 KB Last Updated : 04/08/2025

(Preferred: Nurtec ODT, Qulipta) (Non-Preferred: Reyvow, Ubrelvy, Zavzpret)

PDF , 214 KB Last Updated : 04/08/2025

• Miplyffa

PDF , 187 KB Last Updated : 04/08/2025

PDF , 187 KB Last Updated : 04/08/2025

• Mulpleta

PDF , 172 KB Last Updated : 04/08/2025

PDF , 172 KB Last Updated : 04/08/2025

• Multiple Sclerosis Drugs

(Avonex | Bafiertam | Betaseron | cladribine (Mavenclad) | Extavia | Kesimpta | Mayzent | Plegridy | Ponvory | Rebif | Vumerity | Zeposia)

PDF , 197 KB Last Updated : 05/13/2026

(Avonex | Bafiertam | Betaseron | cladribine (Mavenclad) | Extavia | Kesimpta | Mayzent | Plegridy | Ponvory | Rebif | Vumerity | Zeposia)

PDF , 197 KB Last Updated : 05/13/2026

• Myalept

PDF , 178 KB Last Updated : 04/08/2025

PDF , 178 KB Last Updated : 04/08/2025

• Myfembree, Oriahnn

PDF , 171 KB Last Updated : 05/13/2026

PDF , 171 KB Last Updated : 05/13/2026

• Myobloc (Pharmacy)

PDF , 161 KB Last Updated : 05/13/2026

PDF , 161 KB Last Updated : 05/13/2026

• Mytesi

PDF , 160 KB Last Updated : 04/08/2025

PDF , 160 KB Last Updated : 04/08/2025

• Nasal Corticosteroids

(Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)

PDF , 194 KB Last Updated : 01/13/2026

(Beconase AQ | flunisolide nasal spray | mometasone (Nasonex) | Omnaris | Qnasl | Xhance | Zetonna)

PDF , 194 KB Last Updated : 01/13/2026

• Natpara

PDF , 176 KB Last Updated : 04/08/2025

PDF , 176 KB Last Updated : 04/08/2025

• Nemluvio

PDF , 234 KB Last Updated : 01/01/2026

PDF , 234 KB Last Updated : 01/01/2026

• Neupro

PDF , 143 KB Last Updated : 04/08/2025

PDF , 143 KB Last Updated : 04/08/2025

• Nexletol | Nexlizet

PDF , 263 KB Last Updated : 04/30/2026

PDF , 263 KB Last Updated : 04/30/2026

• Nitazoxanide (Alinia)

PDF , 133 KB Last Updated : 04/08/2025

PDF , 133 KB Last Updated : 04/08/2025

• Nitisinone Products

Harliku | nitisinone | Nityr | Orfadin

PDF , 175 KB Last Updated : 10/30/2025

Harliku | nitisinone | Nityr | Orfadin

PDF , 175 KB Last Updated : 10/30/2025

• Nitroglycerin 0.4% ointment (generic Rectiv)

PDF , 161 KB Last Updated : 01/01/2026

PDF , 161 KB Last Updated : 01/01/2026

• Nocdurna

PDF , 156 KB Last Updated : 04/08/2025

PDF , 156 KB Last Updated : 04/08/2025

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (Oral)

PDF , 136 KB Last Updated : 01/01/2026

PDF , 136 KB Last Updated : 01/01/2026

• Nucala - Chronic Obstructive Pulmonary Disease (COPD) (Pharmacy)

PDF , 199 KB Last Updated : 08/07/2025

PDF , 199 KB Last Updated : 08/07/2025

• Nucala - Chronic Rhinosinusitis with Nasal Polyps (CRSWNP) (Pharmacy)

PDF , 189 KB Last Updated : 12/31/2025

PDF , 189 KB Last Updated : 12/31/2025

• Nucala - Severe Eosinophilic Asthma (SEA) (Pharmacy)

PDF , 240 KB Last Updated : 08/07/2025

PDF , 240 KB Last Updated : 08/07/2025

• Nucala SQ - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Pharmacy)

PDF , 220 KB Last Updated : 04/08/2025

PDF , 220 KB Last Updated : 04/08/2025

• Nucala SQ - Hypereosinophilic Syndome (HES)

PDF , 209 KB Last Updated : 04/08/2025

PDF , 209 KB Last Updated : 04/08/2025

• Nuedexta

PDF , 159 KB Last Updated : 04/08/2025

PDF , 159 KB Last Updated : 04/08/2025

• Nulibry

PDF , 233 KB Last Updated : 04/08/2025

PDF , 233 KB Last Updated : 04/08/2025

• Nuplazid

PDF , 179 KB Last Updated : 04/08/2025

PDF , 179 KB Last Updated : 04/08/2025

• Odactra House Dust Mite Allergen Extract

PDF , 169 KB Last Updated : 04/08/2025

PDF , 169 KB Last Updated : 04/08/2025

• OFEV

PDF , 252 KB Last Updated : 04/08/2025

PDF , 252 KB Last Updated : 04/08/2025

• Ohtuvayre

PDF , 195 KB Last Updated : 04/08/2025

PDF , 195 KB Last Updated : 04/08/2025

• Olumiant

PDF , 174 KB Last Updated : 07/11/2025

PDF , 174 KB Last Updated : 07/11/2025

• Omvoh

PDF , 230 KB Last Updated : 01/01/2026

PDF , 230 KB Last Updated : 01/01/2026

• Oncology Drugs (Pharmacy Benefit)

PDF , 186 KB Last Updated : 03/30/2026

PDF , 186 KB Last Updated : 03/30/2026

• Opfolda

PDF , 203 KB Last Updated : 04/08/2025

PDF , 203 KB Last Updated : 04/08/2025

• Ophthalmic Corticosteroid Injections (Medical)

(Ozurdex, Iluvien, Xipere)

PDF , 232 KB Last Updated : 04/08/2025

(Ozurdex, Iluvien, Xipere)

PDF , 232 KB Last Updated : 04/08/2025

• Ophthalmic Drugs - Antihistamines

(Alocril, Alomide, Bepotastine Besilate 1.5%, Zerviate)

PDF , 143 KB Last Updated : 01/01/2026

(Alocril, Alomide, Bepotastine Besilate 1.5%, Zerviate)

PDF , 143 KB Last Updated : 01/01/2026

• Ophthalmic Drugs - Dry Eye

(Cequa | Lacrisert | Miebo | Restasis Multidose | Tryptyr | Tyrvaya)

PDF , 160 KB Last Updated : 10/30/2025

(Cequa | Lacrisert | Miebo | Restasis Multidose | Tryptyr | Tyrvaya)

PDF , 160 KB Last Updated : 10/30/2025

• 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 Last Updated : 02/27/2026

(Betoptic-S | brimonidine 0.1% (Alphagan-P) | Omlonti | Rhopressa | Rocklatan | Simbrinza | tafluprost (Zioptan) | timolol (Betimol) | travoprost 0.004% (Travatan Z) | Vyzulta)

PDF , 145 KB Last Updated : 02/27/2026

• Opioids

PDF , 230 KB Last Updated : 04/30/2026

PDF , 230 KB Last Updated : 04/30/2026

• Opzelura

PDF , 147 KB Last Updated : 12/31/2025

PDF , 147 KB Last Updated : 12/31/2025

• Orencia SQ (Pharmacy)

PDF , 179 KB Last Updated : 01/01/2026

PDF , 179 KB Last Updated : 01/01/2026

• Orilissa

PDF , 168 KB Last Updated : 04/08/2025

PDF , 168 KB Last Updated : 04/08/2025

• Orkambi

PDF , 196 KB Last Updated : 04/08/2025

PDF , 196 KB Last Updated : 04/08/2025

• Orlynvah

PDF , 152 KB Last Updated : 10/30/2025

PDF , 152 KB Last Updated : 10/30/2025

• Osphena

PDF , 140 KB Last Updated : 04/08/2025

PDF , 140 KB Last Updated : 04/08/2025

• Otezla | Otezla XR

PDF , 220 KB Last Updated : 02/04/2026

PDF , 220 KB Last Updated : 02/04/2026

• Otrexup, Rasuvo, Reditrex

PDF , 135 KB Last Updated : 04/08/2025

PDF , 135 KB Last Updated : 04/08/2025

• Overactive Bladder Drugs

(fesoterodine (Toviaz), Gemtesa, mirabegron (Myrbetriq))

PDF , 165 KB Last Updated : 04/08/2025

(fesoterodine (Toviaz), Gemtesa, mirabegron (Myrbetriq))

PDF , 165 KB Last Updated : 04/08/2025

• Oxbryta

PDF , 206 KB Last Updated : 04/08/2025

PDF , 206 KB Last Updated : 04/08/2025

• Oxervate

PDF , 211 KB Last Updated : 04/08/2025

PDF , 211 KB Last Updated : 04/08/2025

• Oxlumo, Rivfloza (Pharmacy Benefit)

PDF , 205 KB Last Updated : 07/01/2025

PDF , 205 KB Last Updated : 07/01/2025

• Palforzia

PDF , 228 KB Last Updated : 04/08/2025

PDF , 228 KB Last Updated : 04/08/2025

• Palynziq Injection

PDF , 181 KB Last Updated : 04/08/2025

PDF , 181 KB Last Updated : 04/08/2025

• Pancreatic Enzymes

(Pancreaze, Pertzye, Viokace)

PDF , 155 KB Last Updated : 04/08/2025

(Pancreaze, Pertzye, Viokace)

PDF , 155 KB Last Updated : 04/08/2025

• Parathyroid Hormone Analogs

(teriparatide (Forteo), Tymlos, Teriparatide)

PDF , 176 KB Last Updated : 01/01/2026

(teriparatide (Forteo), Tymlos, Teriparatide)

PDF , 176 KB Last Updated : 01/01/2026

• Penciclovir (Denavir)

PDF , 149 KB Last Updated : 04/08/2025

PDF , 149 KB Last Updated : 04/08/2025

• Phosphate Binders

Ferric Citrate (Auryxia) | lanthanum chewable tablet (Fosrenol) | Velphoro

PDF , 156 KB Last Updated : 02/11/2026

Ferric Citrate (Auryxia) | lanthanum chewable tablet (Fosrenol) | Velphoro

PDF , 156 KB Last Updated : 02/11/2026

• Pimecrolimus (Elidel)

PDF , 128 KB Last Updated : 04/08/2025

PDF , 128 KB Last Updated : 04/08/2025

• Pirfenidone (Esbriet)

PDF , 158 KB Last Updated : 04/08/2025

PDF , 158 KB Last Updated : 04/08/2025

• Pitavastatin, Livalo, Zypitamag

PDF , 154 KB Last Updated : 04/08/2025

PDF , 154 KB Last Updated : 04/08/2025

• Pivya

PDF , 175 KB Last Updated : 04/30/2026

PDF , 175 KB Last Updated : 04/30/2026

• Posaconazole DR Tablets, Noxafil DR Tablets, Noxafil IR/DR suspension

PDF , 225 KB Last Updated : 04/08/2025

PDF , 225 KB Last Updated : 04/08/2025

• Potassium Binders

(Lokelma, Veltassa)

PDF , 172 KB Last Updated : 04/08/2025

(Lokelma, Veltassa)

PDF , 172 KB Last Updated : 04/08/2025

• Pradaxa

PDF , 196 KB Last Updated : 04/08/2025

PDF , 196 KB Last Updated : 04/08/2025

• Praluent | Repatha

PDF , 255 KB Last Updated : 02/12/2026

PDF , 255 KB Last Updated : 02/12/2026

• Pretomanid

PDF , 179 KB Last Updated : 04/08/2025

PDF , 179 KB Last Updated : 04/08/2025

• Prevymis (Pharmacy)

PDF , 178 KB Last Updated : 04/08/2025

PDF , 178 KB Last Updated : 04/08/2025

• Primary Biliary Cholangitis Drugs

Iqirvo | Livdelzi

PDF , 212 KB Last Updated : 10/30/2025

Iqirvo | Livdelzi

PDF , 212 KB Last Updated : 10/30/2025

• Procysbi

PDF , 168 KB Last Updated : 04/08/2025

PDF , 168 KB Last Updated : 04/08/2025

• Prophylaxis Hereditary Angioedema Drugs (Pharmacy)

(PREFERRED: Cinryze | Haegarda | Takhzyro) (NON-PREFERRED: Andembry | Dawnzera | Orladeyo)

PDF , 229 KB Last Updated : 04/30/2026

(PREFERRED: Cinryze | Haegarda | Takhzyro) (NON-PREFERRED: Andembry | Dawnzera | Orladeyo)

PDF , 229 KB Last Updated : 04/30/2026

• Pulmonary Arterial Hypertension (PAH) Drugs

PDF , 263 KB Last Updated : 10/30/2025

PDF , 263 KB Last Updated : 10/30/2025

• Pulmonary Hypertension associated with Interstitial Lung Disease (PH-ILD)

(Tyvaso)

PDF , 196 KB Last Updated : 04/08/2025

(Tyvaso)

PDF , 196 KB Last Updated : 04/08/2025

• Pulmozyme

PDF , 202 KB Last Updated : 04/08/2025

PDF , 202 KB Last Updated : 04/08/2025

• Pyrimethamine (Daraprim)

PDF , 227 KB Last Updated : 04/08/2025

PDF , 227 KB Last Updated : 04/08/2025

• Pyrukynd

PDF , 197 KB Last Updated : 04/08/2025

PDF , 197 KB Last Updated : 04/08/2025

• Qbrexza

PDF , 176 KB Last Updated : 04/08/2025

PDF , 176 KB Last Updated : 04/08/2025

• Qelbree

PDF , 158 KB Last Updated : 04/08/2025

PDF , 158 KB Last Updated : 04/08/2025

• Qfitlia (Pharmacy)

PDF , 205 KB Last Updated : 01/13/2026

PDF , 205 KB Last Updated : 01/13/2026

• Radicava ORS

PDF , 211 KB Last Updated : 02/27/2026

PDF , 211 KB Last Updated : 02/27/2026

• Ragwitek

PDF , 167 KB Last Updated : 04/08/2025

PDF , 167 KB Last Updated : 04/08/2025

• Rayaldee

PDF , 188 KB Last Updated : 04/08/2025

PDF , 188 KB Last Updated : 04/08/2025

• Recombinant Growth Hormone (rhGH)

(Preferred: Omnitrope, Norditropin)

(Non-Preferred: Genotropin, Humatrope, Ngenla, Nutropin, Nutropin AQ, Saizen, Sogroya, Skytrofa, Zomacton)

PDF , 181 KB Last Updated : 10/31/2025

(Preferred: Omnitrope, Norditropin)

(Non-Preferred: Genotropin, Humatrope, Ngenla, Nutropin, Nutropin AQ, Saizen, Sogroya, Skytrofa, Zomacton)

PDF , 181 KB Last Updated : 10/31/2025

• Recorlev

PDF , 206 KB Last Updated : 04/08/2025

PDF , 206 KB Last Updated : 04/08/2025

• Redemplo

PDF , 184 KB Last Updated : 03/10/2026

PDF , 184 KB Last Updated : 03/10/2026

• Relyvrio

PDF , 185 KB Last Updated : 04/08/2025

PDF , 185 KB Last Updated : 04/08/2025

• Repository Corticotropin Drugs - Infantile Spasms

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 171 KB Last Updated : 04/08/2025

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 171 KB Last Updated : 04/08/2025

• Repository Corticotropin Drugs - Myositis

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 200 KB Last Updated : 04/08/2025

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 200 KB Last Updated : 04/08/2025

• Repository Corticotropin Drugs - Nephrotic Syndrome

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 224 KB Last Updated : 04/08/2025

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 224 KB Last Updated : 04/08/2025

• Repository Corticotropin Drugs - Ocular Diseases

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 252 KB Last Updated : 04/08/2025

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 252 KB Last Updated : 04/08/2025

• Repository Corticotropin Drugs - Other Indications

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 201 KB Last Updated : 04/08/2025

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 201 KB Last Updated : 04/08/2025

• Repository Corticotropin Drugs - Sarcoidosis

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 172 KB Last Updated : 04/08/2025

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 172 KB Last Updated : 04/08/2025

• Repository Corticotropin Drugs - Systemic Lupus Erythematosus

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 225 KB Last Updated : 04/08/2025

(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)

PDF , 225 KB Last Updated : 04/08/2025

• Revcovi

PDF , 234 KB Last Updated : 04/08/2025

PDF , 234 KB Last Updated : 04/08/2025

• Rezdiffra

PDF , 192 KB Last Updated : 10/30/2025

PDF , 192 KB Last Updated : 10/30/2025

• Rezurock

PDF , 155 KB Last Updated : 04/08/2025

PDF , 155 KB Last Updated : 04/08/2025

• Rhapsido

PDF , 175 KB Last Updated : 01/01/2026

PDF , 175 KB Last Updated : 01/01/2026

• Rinvoq | Rinvoq LQ

PDF , 238 KB Last Updated : 02/27/2026

PDF , 238 KB Last Updated : 02/27/2026

• Roflumilast (Generic Daliresp)

PDF , 159 KB Last Updated : 04/08/2025

PDF , 159 KB Last Updated : 04/08/2025

• Ruconest (Pharmacy)

PDF , 206 KB Last Updated : 04/30/2026

PDF , 206 KB Last Updated : 04/30/2026

• Rukobia

PDF , 161 KB Last Updated : 04/08/2025

PDF , 161 KB Last Updated : 04/08/2025

• Saliva Substitutes

(Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx)

PDF , 160 KB Last Updated : 04/08/2025

(Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx)

PDF , 160 KB Last Updated : 04/08/2025

• Sapropterin Products

(Saproterin Dihydrochloride (generic Kuvan) | Javygtor | Zelvysia)

PDF , 185 KB Last Updated : 12/31/2025

(Saproterin Dihydrochloride (generic Kuvan) | Javygtor | Zelvysia)

PDF , 185 KB Last Updated : 12/31/2025

• Savaysa

PDF , 173 KB Last Updated : 04/08/2025

PDF , 173 KB Last Updated : 04/08/2025

• Savella

PDF , 153 KB Last Updated : 04/08/2025

PDF , 153 KB Last Updated : 04/08/2025

• Serostim

PDF , 161 KB Last Updated : 04/08/2025

PDF , 161 KB Last Updated : 04/08/2025

• Seysara

PDF , 146 KB Last Updated : 04/08/2025

PDF , 146 KB Last Updated : 04/08/2025

• Siliq SQ

PDF , 173 KB Last Updated : 01/01/2026

PDF , 173 KB Last Updated : 01/01/2026

• Simponi SQ (Pharmacy)

PDF , 178 KB Last Updated : 12/31/2025

PDF , 178 KB Last Updated : 12/31/2025

• Sirturo

PDF , 158 KB Last Updated : 10/30/2025

PDF , 158 KB Last Updated : 10/30/2025

• Skyclarys

PDF , 193 KB Last Updated : 04/08/2025

PDF , 193 KB Last Updated : 04/08/2025

• Skyrizi SQ - Crohn's Disease & Ulcerative Colitis

PDF , 172 KB Last Updated : 12/31/2025

PDF , 172 KB Last Updated : 12/31/2025

• Skyrizi SQ - Plaque Psoriasis & Psoriatic Arthritis

PDF , 142 KB Last Updated : 04/08/2025

PDF , 142 KB Last Updated : 04/08/2025

• Sodium Oxbate Drugs

(Lumryz, Sodium Oxbate Oral Solution, Xyrem, Xywav)

PDF , 232 KB Last Updated : 04/30/2026

(Lumryz, Sodium Oxbate Oral Solution, Xyrem, Xywav)

PDF , 232 KB Last Updated : 04/30/2026

• Sodium Phenylbutyrate Drugs

(Sodium Phenylbutyrate, Buphenyl, Olpruva, Pheburane)

PDF , 156 KB Last Updated : 04/08/2025

(Sodium Phenylbutyrate, Buphenyl, Olpruva, Pheburane)

PDF , 156 KB Last Updated : 04/08/2025

• Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors (Non-Preferred)

PDF , 158 KB Last Updated : 04/08/2025

PDF , 158 KB Last Updated : 04/08/2025

• Sohonos

PDF , 172 KB Last Updated : 04/08/2025

PDF , 172 KB Last Updated : 04/08/2025

• Soliqua, Xultophy

PDF , 162 KB Last Updated : 04/08/2025

PDF , 162 KB Last Updated : 04/08/2025

• Somatostatin Analog Drugs

(Bynfezia | lanreotide acetate ER | Mycapssa | octreotide injection | Palsonify | Sandostatin LAR Depot | Signafor | Signifor LAR | Somatuline Depot | Somavert)

PDF , 231 KB Last Updated : 01/12/2026

(Bynfezia | lanreotide acetate ER | Mycapssa | octreotide injection | Palsonify | Sandostatin LAR Depot | Signafor | Signifor LAR | Somatuline Depot | Somavert)

PDF , 231 KB Last Updated : 01/12/2026

• Sotyktu

PDF , 170 KB Last Updated : 04/08/2025

PDF , 170 KB Last Updated : 04/08/2025

• Spevigo SQ

PDF , 224 KB Last Updated : 10/30/2025

PDF , 224 KB Last Updated : 10/30/2025

• Spravato

PDF , 182 KB Last Updated : 01/01/2026

PDF , 182 KB Last Updated : 01/01/2026

• SQ Tocilizumab Products - Giant Cell Arteritis (GCA) (Pharmacy)

Actemra SQ | Tyenne SQ

PDF , 156 KB Last Updated : 09/04/2025

Actemra SQ | Tyenne SQ

PDF , 156 KB Last Updated : 09/04/2025

• SQ Tocilizumab Products - Other Indications (Actemra SQ, Tyenne SQ)

PDF , 206 KB Last Updated : 04/08/2025

PDF , 206 KB Last Updated : 04/08/2025

• Stendra, Vardenafil (Group Specific Benefit)

PDF , 147 KB Last Updated : 04/08/2025

PDF , 147 KB Last Updated : 04/08/2025

• Strensiq

PDF , 204 KB Last Updated : 04/08/2025

PDF , 204 KB Last Updated : 04/08/2025

• Sucraid

PDF , 167 KB Last Updated : 04/08/2025

PDF , 167 KB Last Updated : 04/08/2025

• Sunlenca

PDF , 223 KB Last Updated : 01/13/2026

PDF , 223 KB Last Updated : 01/13/2026

• Sunosi

PDF , 189 KB Last Updated : 09/22/2025

PDF , 189 KB Last Updated : 09/22/2025

• Symdeko

PDF , 231 KB Last Updated : 04/08/2025

PDF , 231 KB Last Updated : 04/08/2025

• Synagis

PDF , 889 KB Last Updated : 04/08/2025

PDF , 889 KB Last Updated : 04/08/2025

• Syndros Oral Solution

PDF , 180 KB Last Updated : 04/08/2025

PDF , 180 KB Last Updated : 04/08/2025

• Taltz SQ

PDF , 231 KB Last Updated : 04/08/2025

PDF , 231 KB Last Updated : 04/08/2025

• Tarpeyo

PDF , 195 KB Last Updated : 02/27/2026

PDF , 195 KB Last Updated : 02/27/2026

• Tasimelteon, Hetlioz

PDF , 200 KB Last Updated : 04/08/2025

PDF , 200 KB Last Updated : 04/08/2025

• Tavalisse

PDF , 222 KB Last Updated : 12/31/2025

PDF , 222 KB Last Updated : 12/31/2025

• Tavneos

PDF , 193 KB Last Updated : 04/08/2025

PDF , 193 KB Last Updated : 04/08/2025

• Testosterone Replacement Therapy

(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution) (NON-PREFERRED - Androderm | Kyzatrex | Natesto | Vogelxo 1%)

PDF , 219 KB Last Updated : 01/01/2026

(PREFERRED - testosterone gel 1%,1.62%, 2% | testosterone injections | testosterone solution) (NON-PREFERRED - Androderm | Kyzatrex | Natesto | Vogelxo 1%)

PDF , 219 KB Last Updated : 01/01/2026

• Tetrabenazine, Xenazine

PDF , 148 KB Last Updated : 04/08/2025

PDF , 148 KB Last Updated : 04/08/2025

• Tezspire (Pharmacy)

PDF , 244 KB Last Updated : 12/31/2025

PDF , 244 KB Last Updated : 12/31/2025

• Tiglutik

PDF , 161 KB Last Updated : 04/08/2025

PDF , 161 KB Last Updated : 04/08/2025

• Tiopronin Products

(Tiopronin (Thiola), tiopronin delayed-release (Thiola EC), venxxiva (Thiola))

PDF , 195 KB Last Updated : 04/08/2025

(Tiopronin (Thiola), tiopronin delayed-release (Thiola EC), venxxiva (Thiola))

PDF , 195 KB Last Updated : 04/08/2025

• Tobi Podhaler

PDF , 165 KB Last Updated : 04/08/2025

PDF , 165 KB Last Updated : 04/08/2025

• Tolvaptan (Samsca)

PDF , 165 KB Last Updated : 04/08/2025

PDF , 165 KB Last Updated : 04/08/2025

• 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 Last Updated : 07/01/2025

(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 Last Updated : 07/01/2025

• Topical Antibiotics Drugs

(Altabax, Xepi)

PDF , 133 KB Last Updated : 04/08/2025

(Altabax, Xepi)

PDF , 133 KB Last Updated : 04/08/2025

• Topical Antifungal Drugs

(luliconazole (Luzu), naftifine 2% cream, oxiconazole (Oxistat), sulconazole (Exelderm), tavaborole)

PDF , 169 KB Last Updated : 01/01/2026

(luliconazole (Luzu), naftifine 2% cream, oxiconazole (Oxistat), sulconazole (Exelderm), tavaborole)

PDF , 169 KB Last Updated : 01/01/2026

• Topical Corticosteroid Drugs

PDF , 173 KB Last Updated : 04/08/2025

PDF , 173 KB Last Updated : 04/08/2025

• Topical Immunomodulator Drugs

(Zyclara, Imiquimod 3.75% , Picato, Klisyri)

PDF , 175 KB Last Updated : 04/08/2025

(Zyclara, Imiquimod 3.75% , Picato, Klisyri)

PDF , 175 KB Last Updated : 04/08/2025

• Topical Psoriasis Drugs

(Vtama, Zoryve Cream)

PDF , 181 KB Last Updated : 04/08/2025

(Vtama, Zoryve Cream)

PDF , 181 KB Last Updated : 04/08/2025

• Topical Retinoids and Acne Drugs - Skin Conditions

PDF , 153 KB Last Updated : 04/08/2025

PDF , 153 KB Last Updated : 04/08/2025

• Topical Rosacea Drugs

(Brimonidine, Mirvaso, Rhofade, Ivermectin Cream, Soolantra, Zilxi)

PDF , 164 KB Last Updated : 01/01/2026

(Brimonidine, Mirvaso, Rhofade, Ivermectin Cream, Soolantra, Zilxi)

PDF , 164 KB Last Updated : 01/01/2026

• Topical Zoryve Products

(Zoryve 0.05%, Zoryve 0.15% cream, Zoryve 0.3% cream, Zoryve topical foam, 0.3%)

PDF , 202 KB Last Updated : 12/31/2025

(Zoryve 0.05%, Zoryve 0.15% cream, Zoryve 0.3% cream, Zoryve topical foam, 0.3%)

PDF , 202 KB Last Updated : 12/31/2025

• Transthyretin Stabilizers

(Attruby, Vyndamax, Vyndaqel)

PDF , 185 KB Last Updated : 04/08/2025

(Attruby, Vyndamax, Vyndaqel)

PDF , 185 KB Last Updated : 04/08/2025

• Tremfya - Crohn's disease & Ulcerative Colitis Diagnosis

PDF , 187 KB Last Updated : 12/31/2025

PDF , 187 KB Last Updated : 12/31/2025

• Tremfya - Plaque Psoriasis & Psoriatic Arthritis

PDF , 169 KB Last Updated : 12/31/2025

PDF , 169 KB Last Updated : 12/31/2025

• Trikafta

PDF , 198 KB Last Updated : 04/08/2025

PDF , 198 KB Last Updated : 04/08/2025

• Trimipramine

PDF , 153 KB Last Updated : 01/01/2026

PDF , 153 KB Last Updated : 01/01/2026

• Tryngolza

PDF , 178 KB Last Updated : 02/27/2026

PDF , 178 KB Last Updated : 02/27/2026

• Tryvio

PDF , 155 KB Last Updated : 04/08/2025

PDF , 155 KB Last Updated : 04/08/2025

• Uloric

PDF , 132 KB Last Updated : 04/08/2025

PDF , 132 KB Last Updated : 04/08/2025

• Upneeq

PDF , 207 KB Last Updated : 04/08/2025

PDF , 207 KB Last Updated : 04/08/2025

• Ustekinumab Products - Crohn's Disease and Ulcerative Colitis

(Selarsdi | Yesintek)

PDF , 199 KB Last Updated : 02/04/2026

(Selarsdi | Yesintek)

PDF , 199 KB Last Updated : 02/04/2026

• Ustekinumab Products - Psoriatic Arthritis and Plaque Psoriasis

(Selarsdi | Yesintek)

PDF , 203 KB Last Updated : 01/01/2026

(Selarsdi | Yesintek)

PDF , 203 KB Last Updated : 01/01/2026

• Vabomere (Pharmacy)

PDF , 158 KB Last Updated : 01/21/2026

PDF , 158 KB Last Updated : 01/21/2026

• Vanrafia

PDF , 200 KB Last Updated : 02/27/2026

PDF , 200 KB Last Updated : 02/27/2026

• Vecamyl

PDF , 149 KB Last Updated : 04/08/2025

PDF , 149 KB Last Updated : 04/08/2025

• Velsipity

PDF , 173 KB Last Updated : 01/01/2026

PDF , 173 KB Last Updated : 01/01/2026

• Vemlidy

PDF , 175 KB Last Updated : 04/08/2025

PDF , 175 KB Last Updated : 04/08/2025

• Verquvo

PDF , 158 KB Last Updated : 04/08/2025

PDF , 158 KB Last Updated : 04/08/2025

• Vigabatrin Products

(Sabril, Vigadrone, vigabatrin, Vigafyde, Vigpoder)

PDF , 176 KB Last Updated : 04/08/2025

(Sabril, Vigadrone, vigabatrin, Vigafyde, Vigpoder)

PDF , 176 KB Last Updated : 04/08/2025

• Vijoice

PDF , 189 KB Last Updated : 04/08/2025

PDF , 189 KB Last Updated : 04/08/2025

• Vivjoa

PDF , 227 KB Last Updated : 04/08/2025

PDF , 227 KB Last Updated : 04/08/2025

• Vowst

PDF , 195 KB Last Updated : 04/08/2025

PDF , 195 KB Last Updated : 04/08/2025

• Voxzogo

PDF , 191 KB Last Updated : 04/08/2025

PDF , 191 KB Last Updated : 04/08/2025

• Voydeya

PDF , 225 KB Last Updated : 04/08/2025

PDF , 225 KB Last Updated : 04/08/2025

• Voyxact

PDF , 217 KB Last Updated : 02/27/2026

PDF , 217 KB Last Updated : 02/27/2026

• Vtama

PDF , 195 KB Last Updated : 04/08/2025

PDF , 195 KB Last Updated : 04/08/2025

• Vyalev (Pharmacy)

PDF , 161 KB Last Updated : 01/20/2026

PDF , 161 KB Last Updated : 01/20/2026

• Vykat XR

PDF , 182 KB Last Updated : 02/13/2026

PDF , 182 KB Last Updated : 02/13/2026

• Vyleesi

PDF , 154 KB Last Updated : 04/08/2025

PDF , 154 KB Last Updated : 04/08/2025

• Vyvgart Hytrulo - Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)(Pharmacy)

PDF , 167 KB Last Updated : 01/20/2026

PDF , 167 KB Last Updated : 01/20/2026

• Vyvgart Hytrulo - Generalized Myasthenia Gravis (gMG) (Pharmacy)

PDF , 186 KB Last Updated : 02/27/2026

PDF , 186 KB Last Updated : 02/27/2026

• Wakix

PDF , 242 KB Last Updated : 04/30/2026

PDF , 242 KB Last Updated : 04/30/2026

• Wayrilz

PDF , 194 KB Last Updated : 01/12/2026

PDF , 194 KB Last Updated : 01/12/2026

• Wegovy - Cardiovascular Event Risk Reduction

PDF , 210 KB Last Updated : 04/08/2025

PDF , 210 KB Last Updated : 04/08/2025

• Wegovy - Metabolic Dysfunction–Associated Steatohepatitis (MASH) (Group Specific Benefit)

PDF , 206 KB Last Updated : 11/07/2025

PDF , 206 KB Last Updated : 11/07/2025

• Weight Management Drugs (Group Specific Benefit)

(benzphetamine 50mg | Contrave | diethylpropion IR/ER | liraglutide | phendimetrazine IR | phentermine HCL | phentermine hydrochloride USP (Lomaira) | phentermine/topiramate ER (Qsymia) | Wegovy | Xenical | Zepbound Pens)

PDF , 177 KB Last Updated : 04/30/2026

(benzphetamine 50mg | Contrave | diethylpropion IR/ER | liraglutide | phendimetrazine IR | phentermine HCL | phentermine hydrochloride USP (Lomaira) | phentermine/topiramate ER (Qsymia) | Wegovy | Xenical | Zepbound Pens)

PDF , 177 KB Last Updated : 04/30/2026

• Winrevair

PDF , 274 KB Last Updated : 04/08/2025

PDF , 274 KB Last Updated : 04/08/2025

• Xadago

PDF , 133 KB Last Updated : 04/08/2025

PDF , 133 KB Last Updated : 04/08/2025

• Xdemvy

PDF , 155 KB Last Updated : 04/08/2025

PDF , 155 KB Last Updated : 04/08/2025

• Xeljanz | Xeljanz XR

PDF , 217 KB Last Updated : 03/06/2026

PDF , 217 KB Last Updated : 03/06/2026

• Xenleta Tablets

PDF , 138 KB Last Updated : 04/08/2025

PDF , 138 KB Last Updated : 04/08/2025

• Xifaxan

PDF , 180 KB Last Updated : 04/08/2025

PDF , 180 KB Last Updated : 04/08/2025

• Xolair (Pharmacy)

PDF , 588 KB Last Updated : 02/04/2026

PDF , 588 KB Last Updated : 02/04/2026

• Xolremdi

PDF , 228 KB Last Updated : 04/08/2025

PDF , 228 KB Last Updated : 04/08/2025

• Xphozah

PDF , 167 KB Last Updated : 04/08/2025

PDF , 167 KB Last Updated : 04/08/2025

• Yorvipath

PDF , 195 KB Last Updated : 04/08/2025

PDF , 195 KB Last Updated : 04/08/2025

• Zepbound - Obstructive Sleep Apnea

PDF , 218 KB Last Updated : 09/22/2025

PDF , 218 KB Last Updated : 09/22/2025

• Zeposia

PDF , 177 KB Last Updated : 01/01/2026

PDF , 177 KB Last Updated : 01/01/2026

• Zilbrysq

PDF , 204 KB Last Updated : 02/27/2026

PDF , 204 KB Last Updated : 02/27/2026

• Zokinvy

PDF , 194 KB Last Updated : 04/08/2025

PDF , 194 KB Last Updated : 04/08/2025

• Zolmitriptan (Zomig) Nasal Spray

PDF , 153 KB Last Updated : 04/08/2025

PDF , 153 KB Last Updated : 04/08/2025

• Zontivity

PDF , 181 KB Last Updated : 04/08/2025

PDF , 181 KB Last Updated : 04/08/2025

• Zorbtive

PDF , 186 KB Last Updated : 04/08/2025

PDF , 186 KB Last Updated : 04/08/2025

• Ztalmy

PDF , 168 KB Last Updated : 04/08/2025

PDF , 168 KB Last Updated : 04/08/2025

• Zurzuvae

PDF , 162 KB Last Updated : 04/08/2025

PDF , 162 KB Last Updated : 04/08/2025

• Zycubo

PDF , 163 KB Last Updated : 04/30/2026

PDF , 163 KB Last Updated : 04/30/2026

• Zyflo, Zileuton ER

PDF , 136 KB Last Updated : 04/08/2025

PDF , 136 KB Last Updated : 04/08/2025

• Zymfentra

PDF , 197 KB Last Updated : 01/01/2026

PDF , 197 KB Last Updated : 01/01/2026

Medication Exception

• Maximum Daily Dosage Limit Exceptions Request Form

PDF , 135 KB Last Updated : 04/08/2025

PDF , 135 KB Last Updated : 04/08/2025

• Pharmacy Medical Necessity Request Form

PDF , 172 KB Last Updated : 04/08/2025

PDF , 172 KB Last Updated : 04/08/2025

Prior Authorization

• Compound Drugs

PDF , 139 KB Last Updated : 04/08/2025

PDF , 139 KB Last Updated : 04/08/2025

• New Member Transition of Service Form (Medical and Pharmacy)

PDF , 191 KB Last Updated : 04/08/2025

PDF , 191 KB Last Updated : 04/08/2025

Prior Authorization Pharmacy and Medical Drugs - Medicare

• Medical Drug Authorization Request Form

PDF , 192 KB Last Updated : 04/08/2025

PDF , 192 KB Last Updated : 04/08/2025

• Medicare Coverage Determination Request (Spanish)

PDF , 179 KB Last Updated : 04/08/2025

PDF , 179 KB Last Updated : 04/08/2025

Part B Authorization Criteria

• Medical Drug Authorization Request Form

PDF , 192 KB Last Updated : 04/08/2025

PDF , 192 KB Last Updated : 04/08/2025

Quality Measures - HEDIS & Stars

• Care Opportunity Report Provider Response Form

PDF , 117 KB Last Updated : 03/04/2025

PDF , 117 KB Last Updated : 03/04/2025

Specialty Providers

Behavioral Health

• Primary Care Physician (PCP) - Behavioral Health Provider Communication Form

PDF , 42 KB Last Updated : 03/25/2025

PDF , 42 KB Last Updated : 03/25/2025

Cardiology

• NCH Cardiology FAQs

PDF , 408 KB Last Updated : 04/02/2025

PDF , 408 KB Last Updated : 04/02/2025

• NCH Cardiology Prior Authorization Matrix

PDF , 180 KB Last Updated : 04/02/2025

PDF , 180 KB Last Updated : 04/02/2025

Oncology

• Medical Oncology & Hematology Prior Authorization Matrix

PDF , 284 KB Last Updated : 04/02/2025

PDF , 284 KB Last Updated : 04/02/2025

Ophthalmology

• EMI Ophthalmology CPT Code List

PDF , 583 KB Last Updated : 04/02/2025

PDF , 583 KB Last Updated : 04/02/2025

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