Clinical Payment Policies | Ambetter from Arizona Complete Health

 

Clinical & Payment Policies

Clinical Policies

Important Notice

The Clinical Policies do not constitute medical advice.  Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Clinical Policy Manual apply to health plan members. The health plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which health plan clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  In addition, the health plan may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual® criteria is payable by the health plan.   

The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine. The health plan reserves the right to amend the Policies without notice to providers or Members.

Policies specifically developed to assist the health plan in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other health plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

The Clinical Policy Manuals may be accessed through the links below.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Arizona Complete Health Payment Policy Manual apply with respect to Arizona Complete Health members. Policies in the Arizona Complete Health Payment Policy Manual may have either a Arizona Complete Health or a “Centene” heading.  In addition, Arizona Complete Health may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Arizona Complete Health.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Pharmacy Policies for Medicaid and Ambetter

POLICY TITLE POLICY NUMBER Last Review Date
Abaloparatide (Tymlos®) (PDF) CP.PMN.164 11/20
Abatacept (Orencia) (PDF) CP.PHAR.241 02/21
Abemaciclib (Verzenio) (PDF) CP.PHAR.355 11/20
AbobotulinumtoxinA (Dysport) (PDF) CP.PHAR.230 02/21
Acalabrutinib (Calquence®) (PDF) CP.PHAR.366 02/21
Acitretin (Soriatane®) (PDF) CP.PMN.40 08/20
Actimmune (PDF) CP.PHAR.52 02/21
Afatinib (Gilotrif) (PDF) CP.PHAR.298 05/20
Afinitor (PDF) CP.PHAR.63 02/21
Aflibercept (Eylea®) (PDF) CP.PHAR.184 02/21
Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) CP.PHAR.138 05/20
Aldurazyme (PDF) CP.PHAR.152 05/20
Alectinib (Alecensa) (PDF) CP.PHAR.369 05/20
Alemtuzumab (Lemtrada) (PDF) CP.PHAR.243 08/20
Alendronate (Binosto, Fosamax plus D) (PDF) CP.PMN.88 02/21
Alosetron (Lotronex) (PDF) CP.PMN.153 02/21
Amantadine ER (Gocovri) (PDF) CP.PMN.89 02/21
Ambrisentan (Letairis®) (PDF) CP.PHAR.190 02/21
Anakinra (Kineret) (PDF) CP.PHAR.244 02/21
Apalutamide (Erleada) (PDF) CP.PHAR.376 05/20
Apremilast (Otezla) (PDF) CP.PHAR.245 05/20
Aprepitant (Emend®) (PDF) CP.PMN.19 02/21
Aralast, Glassia, Prolastin-C, Zemaira (PDF) CP.PHAR.94 02/21
Armodafinil (Nuvigil) (PDF) CP.PMN.35 11/20
Asfotase alfa (Strensiq®) (PDF) CP.PHAR.328 11/20
Aspirin dipyridamole (Aggrenox®) (PDF) CP.PMN.20 02/21
Atezolizumab (Tecentrip®) (PDF) CP.PHAR.235 02/21
Avastin (PDF) CP.PHAR.93 11/20
Avelumab (Bacencio®) (PDF) CP.PHAR.333 02/21
Aztreonam (Cayston®) (PDF) CP.PHAR.209 02/21
Becaplermin (Regranex®) (PDF) CP.PMN.21 02/21
Belatacept (Nulojix®) (PDF) CP.PHAR.201 11/20
Belinostat (Beleodaq®) (PDF) CP.PHAR.311 11/20
Bendamustine (Bendeka®, Treanda®) (PDF) CP.PHAR.307 11/18
Benralizumab (Fasenra) (PDF) CP.PHAR.373 02/21
Benznidazole (PDF) CP.PMN.90 02/21
Betrixaban (Bevyxxa) (PDF) CP.PMN.114 11/19
Bevacizumab-awwb (Mvasi®) (PDF) CP.PHAR.356 11/17
Bezlotoxumab (Zinplava®) (PDF) CP.PHAR.300 02/21
Bosentan (Tracleer®) (PDF) CP.PHAR.191 02/21
Bosulif (PDF) CP.PHAR.105 05/20
Braftovi (PDF) CP.PHAR.127 08/18
Brand Name Override (PDF) CP.PMN.22 02/21
Brentuximab Vedotin (Adcetris®) (PDF) CP.PHAR.303 08/20
Brigatinib (Alunbrig) (PDF) CP.PHAR.342 05/20
Brodalumab (Siliq) (PDF) CP.PHAR.375 05/20
C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF) CP.PHAR.202 02/21
Cabazitaxel (Jevtana®) (PDF) CP.PHAR.316 05/20
Calcifediol (Rayaldee®) (PDF) CP.PMN.76 08/20
Canakinumab (Ilaris) (PDF) CP.PHAR.246 11/20
Caprelsa (PDF) CP.PHAR.80 02/21
Carbamazepine ER (Equetro) (PDF) CP.PMN.137 05/20
Carfilzomib (Kyprolis®) (PDF) CP.PHAR.309 11/18
Carglumic acid (Carbaglu®) (PDF) CP.PHAR.206 02/21
Celecoxib (Celebrex) (PDF) CP.PMN.122 05/20
Cerdelga (PDF) CP.PHAR.153 05/20
Cerezyme (PDF) CP.PHAR.154 05/20
Ceritinib (Zykadia) (PDF) CP.PHAR.349 05/20
Cerliponase alfa (Brineura) (PDF) CP.PHAR.338 08/20
Certolizumab (Cimzia) (PDF) CP.PHAR.247 02/21
Cetuximab (Erbitux®) (PDF) CP.PHAR.317 11/20
Ciclopirox (Penlac®) (PDF) CP.PMN.24 02/21
Clobazam (Onfi) (PDF) CP.PMN.54 11/20
Cobimetinib (Cotellic) (PDF) CP.PHAR.380 05/20
Colchicine (Colcrys) (PDF) CP.PMN.123 02/21
Copanlisib (Aliqopa®) (PDF) CP.PHAR.357 11/20
Cosyntropin (Cortrosyn®) (PDF) CP.PHAR.203 02/21
Crestor (PDF) CP.PST.20 11/17
Crisaborole (Eucrisa) (PDF) CP.PMN.110 05/20
Crysvita (PDF) CP.PHAR.11 11/20
Cyclosporine (Restasis) (PDF) CP.PMN.48 05/20
Cyramza (PDF) CP.PHAR.119 02/21
Cystagon, Procysbi (PDF) CP.PHAR.155 05/20
Cysteamine ophthalmic (Cystaran) (PDF) CP.PMN.130 05/20
Cytomegalovirus Immune Globulin (CytoGam) (PDF) CP.PHAR.277 08/20
Dabrafenib (Tafinlar) (PDF) CP.PHAR.239 05/20
Daclizumab (Zinbryta) (PDF) CP.PHAR.269 05/18
Dalfampridine (Ampyra) (PDF) CP.PHAR.248 05/20
Daratumumab (Darzalex®) (PDF) CP.PHAR.310 08/20
Daunorubicin/cytarabine (Vyxeos®) (PDF) CP.PHAR.352 11/20
Deflazacort (Emflaza®) (PDF) CP.PHAR.331 02/21
Delafloxacin (Baxdela) (PDF) CP.PMN.115 02/21
Desferal (PDF) CP.PHAR.146 08/20
Desmopressin acetate (DDAVP Injection®, Stimate®) (PDF) CP.PHAR.214 02/21
Deutetrabenazine (Austedo) (PDF) CP.PHAR.341 08/20
Dextromethorphan-Quinidine (Nuedexta) (PDF) CP.PMN.93 02/21
Dimethyl fumarate (Tecfidera) (PDF) CP.PHAR.249 08/20
Dolasetron (Anzemet) (PDF) CP.PMN.141 02/21
Dornase alfa (Pulmozyme®) (PDF) CP.PHAR.212 02/21
Dose Optimization (PDF)Doxycycline (Acticlate, Doryx, Oracea) (PDF) CP.PMN.13 11/20
Dronabinol (Marinol, Syndros) (PDF) CP.PMN.159 02/21
Droxidopa (Northera®) (PDF) CP.PMN.17 11/20
Dupilumab (Dupixent®) (PDF) CP.PHAR.336 02/21
Durvalumab (Imfinzi) (PDF) CP.PHAR.339 05/20
Dutasteride (Avodart) and dutasteride/tamsulosin (Jalyn) (PDF) CP.PMN.128 05/20
Ecallantide (Kalbitor®) (PDF) CP.PHAR.177 02/21
Efinaconazole (Jublia®) (PDF) CP.PMN.25 02/21
Egrifta (PDF) CP.PHAR.109 08/20
Elaprase (PDF) CP.PHAR.156 05/20
Elelyso (PDF) CP.PHAR.157 05/20
Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped (PDF) CP.PHAR.173 08/20
Elotuzumab (Empliciti®) (PDF) CP.PHAR.308 11/20
Eltrombopag (Promacta®) (PDF) CP.PHAR.180 02/21
Emicizumab-kxwh (Hemlibra®) (PDF) CP.PHAR.370 02/21
Enasidenib (Idhifa®) (PDF) CP.PHAR.363 11/20
Epidiolex (PDF) CP.PMN.164 11/20
Epoprostenol (Flolan®), Veletri®) (PDF) CP.PHAR.192 02/21
Eribulin Mesylate (Halaven®) (PDF) CP.PHAR.318 11/20
Erwina asparaginase (Erwinaze®) (PDF) CP.PHAR.301 02/21
Etelcalcetide (Parsabiv) (PDF) CP.PHAR.379 08/20
Eteplirsen (Exondys 51®) (PDF) CP.PHAR.288 02/21
Etidronate (Didronel) (PDF) CP.PMN.94 02/21
Exemestane Step Therapy (PDF) CP.PST.05 11/17
POLICY TITLE POLICY NUMBER Last Review Date
Febuxostat (Uloric) (PDF) CP.PMN.57 02/21
Feraheme (PDF) CP.PHAR.165 02/21
Ferric carboxymaltose (Injectafer®) (PDF) CP.PHAR.234 02/21
Ferriprox (PDF) CP.PHAR.147 08/20
Ferrlecit (PDF) CP.PHAR.166 02/21
Fingolimod (Gilenya) (PDF) CP.PHAR.251 08/20
Firmagon (PDF) CP.PHAR.170 11/20
Fluticasone propionate (Xhance) (PDF) CP.PMN.95 02/21
Fusilev (PDF) CP.PHAR.151 11/20
Fuzeon (PDF) CP.PHAR.41 08/20
Gablofen (PDF) CP.PHAR.149 11/20
Gattex (PDF) CP.PHAR.114 02/21
Gefitinib (Iressa®) (PDF) CP.PHAR.299 11/17
Gemtuzumab ozogamicin (Mylotarg®) (PDF) CP.PHAR.358 11/20
Glatiramer (Copaxone, Glatopa) (PDF) CP.PHAR.252 08/20
Gleevec (PDF) CP.PHAR.65 11/20
Glycerol phenylbutyrate (Ravicti®) (PDF) CP.PHAR.207 02/21
Golimumab (Simponi, Simponi Aria) (PDF) CP.PHAR.253 02/21
Granisetron (Sancuso®) (PDF) CP.PMN.74 02/21
Guselkumab (Tremfya) (PDF) CP.PHAR.364 11/20
H.P. Acthar Gel (PDF) CP.PHAR.168 02/21
Hemin (Panhematin®) (PDF) CP.PHAR.181 02/21
House dust mite allergen extract (Odactra®) (PDF) CP.PMN.111 08/20
Hycamtin (PDF) CP.PHAR.64 05/20
Ibalizumab-uiyk (Trogarzo) (PDF) CP.PHAR.378 05/20
Ibandronate Oral (Boniva) (PDF) CP.PMN.96 02/21
Ibandronate sodium (Boniva®) (PDF) CP.PHAR.189 02/21
Ibrance (PDF) CP.PHAR.125 11/20
Ibuprofen and Famotidine (Duexis) (PDF) CP.PMN.120 05/20
Icatibant (Firazyr®) (PDF) CP.PHAR.178 02/21
Iclusig (PDF) CP.PHAR.112 05/20
Iloprost (Ventavis®) (PDF) CP.PHAR.193 02/21
Imbruvica (PDF) CP.PHAR.126 02/21
Immunization Coverage (PDF) CP.PHAR.28 08/20
IncobotulinumtoxinA (Xeomin) (PDF) CP.PHAR.231 05/20
Increlex (PDF) CP.PHAR.150 08/20
Infliximab (Remicade, Inflectra, Renflexis) (PDF) CP.PHAR.254 02/21
Inlyta (PDF) CP.PHAR.100 02/21
Inotuzumab ozogamicin (Besponsa®) (PDF) CP.PHAR.359 11/20
Interferon beta-1a (Avonex, Rebif) (PDF) CP.PHAR.255 08/20
Interferon beta-1b (Betaseron, Extavia) (PDF) CP.PHAR.256 08/20
Ipilimumab (Yervoy®) (PDF) CP.PHAR.319 02/21
Iressa (PDF) CP.PHAR.68 05/20
Irinotecan Liposome (Onivyde®) (PDF) CP.PHAR.304 11/20
Isavuconazonium (Cresemba) (PDF) CP.PMN.154 05/20
Isotretinoin (PDF) CP.PMN.143 11/20
Itraconazole (Sporanox, Onmel) (PDF) CP.PMN.124 08/20
Ivabradine (Corlanor) (PDF) CP.PMN.70 02/21
Ivacaftor (Kalydeco®) (PDF) CP.PHAR.210 02/21
Ixazomib (Ninlaro®) (PDF) CP.PHAR.302 08/20
Ixekizumab (Taltz) (PDF) CP.PHAR.257 11/20
Jadenu (PDF) CP.PHAR.145 08/20
Jakafi (PDF) CP.PHAR.98 02/18
Jynarque (PDF) CP.PHAR.27 08/20
Kanuma (PDF) CP.PHAR.159 05/20
Korlym (PDF) CP.PHAR.101 02/21
Krystexxa (PDF) CP.PHAR.115 02/21
Kuvan (PDF) CP.PHAR.43 02/21
Lacosamide (Vimpat) (PDF) CP.PMN.155 08/20
Latanoprostene bunod (Vyzulta®) (PDF) CP.PMN.108 02/21
Lesinurad (Zurampic), lesinurad-allopurinol (Duzallo) (PDF) CP.PMN.150 02/21
Letermovir (Prevymis®) (PDF) CP.PHAR.367 02/21
L-glutamine (Endari) (PDF) CP.PMN.116 11/20
Lidocaine transdermal (Lidoderm®) (PDF) CP.PMN.08 08/20
Lifitegrast (Xiidra®) (PDF) CP.PMN.73 11/20
Linaclotide (Linzess®) (PDF) CP.PMN.71 11/20
Linezolid (Zyvox) (PDF) CP.PMN.27 02/21
Lomitapide (Juxtapid®) (PDF) CP.PHAR.283 02/21
Lubiprostone (Amitiza) (PDF) CP.PMN.142 11/20
Lumacaftor-ivacaftor (Orkambi®) (PDF) CP.PHAR.213 02/21
Lumizyme (PDF) CP.PHAR.160 05/20
Lutetium Lu 177 dotatate (Lutathera) (PDF) CP.PHAR.384 08/20
Macitentan (Opsumit®) (PDF) CP.PHAR.194 02/21
Makena (PDF) CP.PHAR.14 02/21
Mecamylamine (Vecamyl) (PDF) CP.PMN.136 05/20
Mechlorethamine (Valchlor) (PDF) CP.PHAR.381 08/20
Mepolizumab (Nucala) (PDF) CP.PHAR.200 02/21
Metformin hcl (Glumetza) (PDF) CP.PMN.72 02/21
Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) CP.PHAR.238 05/20
Midostaurin (Rydapt) (PDF) CP.PHAR.344 05/20
Milnacipran (Savella) (PDF) CP.PMN.125 05/20
Minocycline (Solodyn) (PDF) CP.PMN.80 11/20
Mipomersen (Kynamro®) (PDF) CP.PHAR.284 02/21
Mitoxantrone (Novantrone) (PDF) CP.PHAR.258 08/20
Mixed pollens allergen extract (Oralair®) (PDF) CP.PMN.85 08/20
Modafinil (Provigil) (PDF) CP.PMN.39 11/20
Nabilone (Cesamet) (PDF) CP.PMN.160 02/21
Naglazyme (PDF) CP.PHAR.174 11/20
Naldemedine (Symproic) (PDF) CP.PMN.112 11/20
Naloxone (Evzio) (PDF) CP.PMN.139 08/20
Naproxen and esomeprazole magnesium (Vimovo) (PDF) CP.PMN.117 05/20
Natalizumab (Tysabri) (PDF) CP.PHAR.259 08/20
Necitumumab (Portrazza®) (PDF) CP.PHAR.320 11/20
Neratinib (Nerlynx®) (PDF) CP.PHAR.365 11/20
Netarsudil (Rhopressa) (PDF) CP.PMN.118 05/20
Nexavar (PDF) CP.PHAR.69 05/20
Nintedanib (Ofev®) (PDF) CP.PHAR.259 08/20
POLICY TITLE POLICY NUMBER EFFECTIVE DATE
Obeticholic acid (Ocaliva®) (PDF) CP.PHAR.01  
Obinutuzumab (Gazyva®) (PDF) CP.PHAR.305 11/20
Ocrelizumab (Ocrevus) (PDF) CP.PHAR.335 08/20
Ofatumumab (Arzerra®) (PDF) CP.PHAR.306 02/21
Olaparib (Lynparza) (PDF) CP.PHAR.360 02/21
Olaratumab (Lartruvo®) (PDF) CP.PHAR.326 02/21
Omega-3-acid ethyl esters (Lovaza®) (PDF) CP.PMN.52 02/21
OnabotulinumtoxinA (Botox) (PDF) CP.PHAR.232 11/20
Ondansetron (Zuplenz) (PDF) CP.PMN.45 02/21
Opdivo (PDF) CP.PHAR.121 02/21
Osimertinib (Tagrisso®) (PDF) CP.PHAR.294 05/20
Oxymetazoline (Rhofade) (PDF) CP.PMN.86 05/18
Ozenoxacin (Xepi) (PDF) CP.PMN.119 05/20
Paclitaxel, protein bound (Abraxane) (PDF) CP.PHAR.176 05/20
Panitumumab (Vectibix®) (PDF) CP.PHAR.321 11/20
Panobinostat (Farydak) (PDF) CP.PHAR.382 08/20
Parathyroid hormone (Natpara) (PDF) CP.PHAR.282 02/21
Paricalcitol (Zemplar) (PDF) CP.PHAR.270 08/20
Pasireotide (Signifor LAR®) (PDF) CP.PHAR.332 11/20
Pegaptanib (Macugen®) (PDF) CP.PHAR.185 02/21
Pegaspargase (Oncaspar®) (PDF) CP.PHAR.353 11/20
Pegfilgrastim (Neulasta®) (PDF) CP.PHAR.296 02/21
Peginterferon beta-1a (Plegridy) (PDF) CP.PHAR.271 08/20
Pembrolizumab (Keytruda®) (PDF) CP.PHAR.322 08/20
Pemetrexed (Alimta®) (PDF) CP.PHAR.368 02/21
Perampanel (Fycompa) (PDF) CP.PMN.156 08/20
Perixafor (Mozobil®) (PDF) CP.PHAR.323 08/20
Pertuzumab (Perjeta) (PDF) CP.PHAR.227 05/20
Pimavanserin (Nuplazid) (PDF) CP.PMN.140 08/20
Pirfenidone (Esbriet®) (PDF) CP.PHAR.286 08/20
Plecanatide (Trulance) (PDF) CP.PMN.87 11/20
Pomalyst (PDF) CP.PHAR.116 0820
Pralatrexate (Folotyn®) (PDF) CP.PHAR.313 11/20
Praluent (PDF) CP.PHAR.124 02/21
Pramlintide (Symlin) (PDF) CP.PMN.129 02/21
Prasterone (Intrarosa) (PDF)Pregabalin (Lyrica) (PDF) CP.PMN.99 02/21
Prolia, Xgeva (PDF) CP.PHAR.58 02/21
Propranolol HCL solution (Hemangeol) (PDF) CP.PMN.58 05/20
Protein c concentrate, human (Ceprotin®) (PDF) CP.PHAR.330 02/21
Pyrimethamine (Daraprim®) (PDF) CP.PMN.44 08/20
QL of Diabetic Test Strips not receiving insulin (PDF) CP.PMN.151 02/21
Quantity Limit Overrides (PDF) CP.PMN.59 11/18
Quetiapine ER (Seroquel XR) (PDF) CP.PMN.64 02/21
Ranibizumab (Lucentis®) (PDF) CP.PHAR.186 02/21
Ranolazine (Ranexa®) (PDF) CP.PMN.34 02/21
Repatha (PDF) CP.PHAR.123 02/21
Reslizumab (Cinqair®) (PDF) CP.PHAR.223 02/21
Revlimid (PDF) CP.PHAR.71 11/20
Ribociclib (Kisqali®), ribociclib (Kisqali Femara®) (PDF) CP.PHAR.334 11/20
Rifapentine (Priftin®) (PDF) CP.PMN.05 02/21
Rifaximin (Xifaxan®) (PDF) CP.PMN.47 11/20
Rilonacept (Arcalyst) (PDF) CP.PHAR.266 05/20
RimabotulinumtoxinB (Myobloc) (PDF) CP.PHAR.233 05/20
Riociguat (Adempas®) (PDF) CP.PHAR.195 02/21
Risedronate (Actonel®, Atelvia®) (PDF) CP.PMN.100 02/21
Rituximab (Rituxan), Rituximab and hyaluronidase (Rituxan Hycela) (PDF) CP.PHAR.260 02/21
Rivastigmine (Exelon®) (PDF) CP.PHAR.101 02/21
Roflumilast (Daliresp®) (PDF) CP.PMN.46 08/20
Rolapitant (Varubi®) (PDF) CP.PMN.102 02/21
Romidepsin (Istodax®) (PDF) CP.PHAR.314 11/20
Romiplostim (Nplate®) (PDF) CP.PHAR.179 02/21
Rucaparib (Rucaparib®) (PDF) CP.PHAR.350 02/21
Rufinamide (Banzel) (PDF) CP.PMN.157 08/20
Sabril (PDF) CP.PHAR.169 08/20
Sacubitril-valsartan (Entresto) (PDF) CP.PMN.67 02/21
Safinamide (Xadago) (PDF) CP.PMN.113 02/21
Sandostatin (PDF) CP.PHAR.40 02/21
Sargramostim (Leukine®) (PDF) CP.PHAR.295 08/20
Sarilumab (Kevzara) (PDF) CP.PHAR.346 02/21
Secnidazole (Solosec®) (PDF) CP.PMN.103 02/21
Secukinumab (Cosentyx) (PDF) CP.PHAR.261 11/20
Selexipag (Uptravi®) (PDF) CP.PHAR.196 02/21
Sensipar (PDF) CP.PHAR.61 08/20
Short ragweed pollen allergen extract (Ragwitek®) (PDF) CP.PMN.83 08/20
Sildenafil (Revatio®) (PDF) CP.PHAR.197 02/21
Siltuximab (Sylvant®) (PDF) CP.PHAR.329 02/21
Sodium oxybate (Xyrem) (PDF) CP.PMN.42 11/20
Sodium phenylbutyrate (Buphenyl®) (PDF) CP.PHAR.208 02/21
Soliris (PDF) CP.PHAR.97 02/21
Sonidegib (Odomzo) (PDF) CP.PHAR.272 05/20
Sprycel (PDF) CP.PHAR.72 05/20
Step Therapy (PDF) CP.PST.01 02/21
Stivarga (PDF) CP.PHAR.107 05/20
Sutent (PDF) CP.PHAR.73 05/20
Suvorexant (Belsomra®) (PDF) CP.PMN.109 11/20
Sylatron (PDF) CP.PHAR.89 05/20
Synribo (PDF) CP.PHAR.108 05/20
Tadalafil (Adcirca®) (PDF) CP.PHAR.198 02/21
Tarceva (PDF) CP.PHAR.74 05/20
Targretin (PDF) CP.PHAR.75 05/20
Tasigna (PDF) CP.PHAR.76 05/20
Tasimelteon (Hetlioz®) (PDF) CP.PMN.104 02/21
Tavaborole (Kerydin®) (PDF) CP.PMN.105 02/21
Tavalisse (PDF) CP.PHAR.24 02/21
Tazarotene (Tazorac®) (PDF) CP.PMN.75 11/19
Tedizolid (Sivextro®) (PDF) CP.PMN.62 02/21
Telotristat ethyl (Xermelo) (PDF) CP.PHAR.337 05/20
Temodar (PDF) CP.PHAR.77 05/20
Temsirolimus (Torisel®) (PDF) CP.PHAR.324 11/20
Teriflunomide (Aubagio) (PDF) CP.PHAR.262 08/20
Tezacaftor/iv acafter; ivacaftor (Symdeko) (PDF) CP.PHAR.377 02/21
Thalomid (PDF) CP.PHAR.78 11/20
Thyrogen (PDF) CP.PHAR.95 08/20
Tildrakizumab-asmn (Ilumya) (PDF) CP.PHAR.386 05/20
Tiludronate (Skelid®) (PDF) CP.PMN.106 03/18
Timothy grass pollen allergen extract (Grastek®) (PDF) CP.PMN.84 08/20
Tocilizumab (Actemra) (PDF) CP.PHAR.263 02/21
Tofacitinib (Xeljanz, Xeljanz XR) (PDF) CP.PHAR.267 02/21
Topical Immunomodulators (PDF) CP.PMN.107 02/21
Toremifene (Fareston) (PDF) CP.PMN.126 05/20
Trabectedin (Yondelis®) (PDF) CP.PHAR.204 02/21
Trametinib (Mekinist) (PDF) CP.PHAR.240 05/20
Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF) CP.PHAR.228 05/20
Trifluridine_Tipiracil (Lonsurf) (PDF) CP.PHAR.383 08/20
Triptorelin pamoate (Trelstar®, Triptodur®) (PDF) CP.PHAR.175 11/20
Tykerb (PDF) CP.PHAR.79 11/20
Vantas, Supprelin LA (PDF) CP.PHAR.172 11/20
Vedolizumab (Entyvio) (PDF) CP.PHAR.265 05/20
Venofer (PDF) CP.PHAR.167 02/21
Verteporfin (Visudyne®) (PDF) CP.PHAR.187 02/21
Vestronidase alfa-vjbk (Mepsevii) (PDF) CP.PHAR.374 05/20
Vincristine sulfate liposome injection (Marqibo®) (PDF) CP.PHAR.315 11/20
Vismodegib (Erivedge) (PDF) CP.PHAR.273 05/20
Voretigene neparvovec-rzyl (Luxturna®) (PDF) CP.PHAR.372 02/21
Votrient (PDF) CP.PHAR.81 08/20
VPRIV (PDF) CP.PHAR.163 05/20
Xalkori (PDF) CP.PHAR.90 05/20
Xeloda (PDF) CP.PHAR.60 05/20
Xolair (PDF) CP.PHAR.01 02/21
Xtandi (PDF) CP.PHAR.106 02/21
Zelboraf (PDF) CP.PHAR.91 02/21
Ziv-aflibercept (Zaltrap®) (PDF) CP.PHAR.325 11/20
Zoladex (PDF) CP.PHAR.171 11/20
Zolinza (PDF) CP.PHAR.83 08/20
Zytiga (PDF) CP.PHAR.84 02/21