Clinical Pharmacy Policies

As a wholly owned subsidiary of Anthem, Inc. (Anthem), Empire BlueCross BlueShield Healthplus (Empire) adopted UniCare’s nationally recognized, evidence-based medical policies and clinical utilization management guidelines effective May 1, 2013. These policies are publicly available at Anthem’s UniCare subsidiary website.

The drug coverage policies below are based on medical necessity considerations subject to applicable benefits. The documents below assist with medical necessity coverage decisions, may include state-specific guidance regarding coverage and do not constitute medical advice. Benefit determination is based on the applicable contract language and/or state requirements.

These policies are not a guarantee of coverage. Contract language or state requirements will prevail when there are conflicts with any medication coverage policy. In all cases, Medicaid contracts or Centers for Medicare & Medicaid Services requirements supersede UniCare policy criteria.

If Empire does not manage the pharmacy benefit for your state, please reference the applicable pharmacy benefit manager’s website and/or manual.

As of May 1, 2014, the following policies were effective.

clinical-pharmacy-policies.js

 ‭(Hidden)‬ Clinical Pharmacy Policies

TitleName (for use in forms)
ActemraPHARM_ALL_Actemra.pdf
AdcetrisPHARM_ALL_Adcetris.pdf
AdempasPHARM_ALL_Adempas.pdf
AfinitorPHARM_ALL_Afinitor.pdf
AfrezzaPHARM_ALL_Afrezza.pdf
AlimtaPHARM_ALL_Alimta.pdf
AmpyraPHARM_ALL_Ampyra.pdf
AndrogensPHARM_ALL_Androgens.pdf
Antipsychotic Medications Age and Step TherapyPHARM_ALL_AntipsychoticMedications.pdf
AranespPHARM_ALL_Aranesp.pdf
ARBsPHARM_ALL_ARBs.pdf
ArixtraPHARM_ALL_Arixtra.pdf
ArzerraPHARM_ALL_Arzerra.pdf
AubagioPHARM_ALL_Aubagio.pdf
Auvi-QPHARM_ALL_Auvi-Q.pdf
AvastinPHARM_ALL_Avastin.pdf
BaracludePHARM_ALL_Baraclude.pdf
BeleodaqPHARM_ALL_Beleodaq.pdf
BenlystaPHARM_ALL_Benlysta.pdf
BosulifPHARM_ALL_Bosulif.pdf
Brand Ophthalmic AllergyPHARM_ALL_BrandOphthalmicAllergy.pdf
Burprenorphine-Naloxone - NY Policy PHARM_ALL_BuprenorphinewithNaloxone.pdf
Butorphanol Nasal SprayPHARM_ALL_ButorphanolNasalSpray.pdf
CaprelsaPHARM_ALL_Caprelsa.pdf
CesametPHARM_ALL_Cesamet.pdf
CimziaPHARM_ALL_Cimzia.pdf
CiproPHARM_ALL_Cipro.pdf
Clindamycin-Tretinoin Combination ProductsPHARM_ALL_ClindamycinTretinoinComboAgents.pdf
ColcrysPHARM_ALL_Colcrys.pdf
CometriqPHARM_ALL_Cometriq.pdf
CordaronePHARM_ALL_Cordarone.pdf
CosentyxPHARM_ALL_Cosentyx.pdf
CymbaltaPHARM_ALL_Cymbalta.pdf
CyramzaPHARM_ALL_Cyramza.pdf
DanazolPHARM_ALL_Danazol.pdf
DificidPHARM_ALL_Dificid.pdf
DuleraPHARM_ALL_Dulera.pdf
EgriftaPHARM_ALL_Egrifta.pdf
EnbrelPHARM_ALL_Enbrel.pdf
EntyvioPHARM_ALL_Entyvio.pdf
EpivirPHARM_ALL_Epivir.pdf
EraxisPHARM_ALL_Eraxis.pdf
ErbituxPHARM_ALL_Erbitux.pdf
ErivedgePHARM_ALL_Erivedge.pdf
EsbrietPHARM_ALL_Esbriet.pdf
EyleaPHARM_ALL_Eylea.pdf
FarydakPHARM_ALL_Farydak.pdf
ForteoPHARM_ALL_Forteo.pdf
Gaucher DiseasePHARM_ALL_GaucherDisease.pdf
GazyvaPHARM_ALL_Gazyva.pdf
GilenyaPHARM_ALL_Gilenya.pdf
GilotrifPHARM_ALL_Gilotrif.pdf
GleevecPHARM_ALL_Gleevec.pdf
GleostinePHARM_ALL_Gleostine.pdf
Gonadotropin Releasing Hormone Analogs (GnRH)PHARM_ALL_GnRH.pdf
GrastekPHARM_ALL_Grastek.pdf
Growth HormonePHARM_ALL_GrowthHormone.pdf
HalavenPHARM_ALL_Halaven.pdf
HarvoniPHARM_ALL_Harvoni.pdf
Hepatitis B InterferonPHARM_ALL_HepatitisBInterferon.pdf
HepseraPHARM_ALL_Hepsera.pdf
HetliozPHARM_ALL_Hetlioz.pdf
HP ActharPHARM_ALL_HPActhar.pdf
HumiraPHARM_ALL_Humira.pdf
IclusigPHARM_ALL_Iclusig.pdf
IlarisPHARM_ALL_Ilaris.pdf
ImbruvicaPHARM_ALL_Imbruvica.pdf
Immune GlobulinsPHARM_ALL_ImmuneGlobulin.pdf
IncrelexPHARM_ALL_Increlex.pdf
InlytaPHARM_ALL_Inlyta.pdf
JakafiPHARM_ALL_Jakafi.pdf
JuxtapidPHARM_ALL_Juxtapid.pdf
KadcylaPHARM_ALL_Kadcyla.pdf
KalydecoPHARM_ALL_Kalydeco.pdf
KineretPHARM_ALL_Kineret.pdf
KorlymPHARM_ALL_Korlym.pdf
KuvanPHARM_ALL_Kuvan.pdf
KynamroPHARM_ALL_Kynamro.pdf
KyprolisPHARM_ALL_Kyprolis.pdf
LetairisPHARM_ALL_Letairis.pdf
Low Molecular Weight HeparinsPHARM_ALL_LowMolecularWeightHeparins.pdf
LucentisPHARM_ALL_Lucentis.pdf
LyricaPHARM_ALL_Lyrica.pdf
MacugenPHARM_ALL_Macugen.pdf
MakenaPHARM_ALL_Makena.pdf
MarinolPHARM_ALL_Marinol.pdf
Mekinist (trametinib)PHARM_ALL_Mekinist.pdf
MethoxsalenPHARM_ALL_Methoxsalen.pdf
Migranal Nasal SprayPHARM_ALL_Migranal.pdf
MirceraPHARM_ALL_Mircera.pdf
MS AgentsPHARM_ALL_MSAgents.pdf
NaglazymePHARM_ALL_Naglazyme.pdf
Narc Analgesic ComboPHARM_ALL_NarcAnalgesicCombo.pdf
Narcotic DupPHARM_ALL_NarcoticDup.pdf
NeumegaPHARM_ALL_Neumega.pdf
NexavarPHARM_ALL_Nexavar.pdf
Non-Pegylated InterferonsPHARM_ALL_Non-PegylatedInterferons.pdf
NoxafilPHARM_ALL_Noxafil.pdf
NSAPHARM_ALL_NSA.pdf
NulojixPHARM_ALL_Nulojix.pdf
NuvigilPHARM_ALL_Nuvigil.pdf
OfevPHARM_ALL_Ofev.pdf
OlysioPHARM_ALL_Olysio.pdf
Omega-3 Fatty Acid Step TherapyPHARM_ALL_Omega3.pdf
OnychomycosisPHARM_ALL_Onychomycosis.pdf
OpsumitPHARM_ALL_Opsumit.pdf
OralairPHARM_ALL_Oralair.pdf
OrenciaPHARM_ALL_Orencia.pdf
OrenitramPHARM_ALL_Orenitram.pdf
OrlistatPHARM_ALL_Orlistat.pdf
OtezlaPHARM_ALL_Otezla.pdf
OxandrinPHARM_ALL_Oxandrin.pdf
OxycontinPHARM_ALL_Oxycontin.pdf
Pegylated InterferonsPHARM_ALL_PegylatedInterferons.pdf
PerjetaPHARM_ALL_Perjeta.pdf
PomalystPHARM_ALL_Pomalyst.pdf
Preferred PPIsPHARM_ALL_PPI.pdf
PradaxaPHARM_ALL_Pradaxa.pdf
PrialtPHARM_ALL_Prialt.pdf
Procrit and EpogenPHARM_ALL_ProcritandEpogen.pdf
ProliaPHARM_ALL_Prolia.pdf
PromactaPHARM_ALL_Promacta.pdf
Prostacyclins for PAHPHARM_ALL_ProstacyclinsforPAH.pdf
ProvengePHARM_ALL_Provenge.pdf
ProvigilPHARM_ALL_Provigil.pdf
PurixanPHARM_ALL_Purixan.pdf
QualaquinPHARM_ALL_Qualaquin.pdf
RagwitekPHARM_ALL_Ragwitek.pdf
RemicadePHARM_ALL_Remicade.pdf
RevlimidPHARM_ALL_Revlimid.pdf
RibavirinPHARM_ALL_Ribavirin.pdf
RituxanPHARM_ALL_Rituxan.pdf
RuconestPHARM_ALL_Ruconest.pdf
SavellaPHARM_ALL_Savella.pdf
SGLT2 Inhibitor Step TherapyPHARM_ALL_SGLT2InhibitorStepTherapy.pdf
SimponiPHARM_ALL_Simponi.pdf
SivextroPHARM_ALL_Sivextro.pdf
SolarazePHARM_ALL_Solaraze.pdf
SolirisPHARM_ALL_Soliris.pdf
SprycelPHARM_ALL_Sprycel.pdf
StelaraPHARM_ALL_Stelara.pdf
StivargaPHARM_ALL_Stivarga.pdf
SubutexPHARM_ALL_Subutex.pdf
SutentPHARM_ALL_Sutent.pdf
SylatronPHARM_ALL_Sylatron.pdf
SylvantPHARM_ALL_Sylvant.pdf
SynagisPHARM_ALL_Synagis.pdf
TadalafilPHARM_ALL_Tadalafil.pdf
TarcevaPHARM_ALL_Tarceva.pdf
TargretinPHARM_ALL_Targretin.pdf
TasignaPHARM_ALL_Tasigna.pdf
Tazarotene AgentsPHARM_ALL_TazaroteneAgents.pdf
TecfideraPHARM_ALL_Tecfidera.pdf
TemodarPHARM_ALL_Temodar.pdf
TestopelPHARM_ALL_Testopel.pdf
ThalomidPHARM_ALL_Thalomid.pdf
TracleerPHARM_ALL_Tracleer.pdf
TriptanPHARM_ALL_Triptan.pdf
TykerbPHARM_ALL_Tykerb.pdf
VancocinPHARM_ALL_Vancocin.pdf
VectibixPHARM_ALL_Vectibix.pdf
VictrelisPHARM_ALL_Victrelis.pdf
ViekiraPHARM_ALL_Viekira.pdf
VotrientPHARM_ALL_Votrient.pdf
XalkoriPHARM_ALL_Xalkori.pdf
XareltoPHARM_ALL_Xarelto.pdf
XeljanzPHARM_ALL_Xeljanz.pdf
XelodaPHARM_ALL_Xeloda.pdf
XgevaPHARM_ALL_Xgeva.pdf
XiaflexPHARM_ALL_Xiaflex.pdf
XifaxanPHARM_ALL_Xifaxan.pdf
XofigoPHARM_ALL_Xofigo.pdf
XolairPHARM_ALL_Xolair.pdf
XtandiPHARM_ALL_Xtandi.pdf
XyremPHARM_ALL_Xyrem.pdf
YervoyPHARM_ALL_Yervoy.pdf
ZaltrapPHARM_ALL_Zaltrap.pdf
ZavescaPHARM_ALL_Zavesca.pdf
ZelborafPHARM_ALL_Zelboraf.pdf
ZithromaxPHARM_ALL_Zithromax.pdf
Zoledronic AcidPHARM_ALL_ZoledronicAcid.pdf
ZolinzaPHARM_ALL_Zolinza.pdf
ZydeligPHARM_ALL_Zydelig.pdf
ZytigaPHARM_ALL_Zytiga.pdf
ZyvoxPHARM_ALL_Zyvox.pdf
IluvienPHARM_ALL_Iluvien.pdf
OzurdexPHARM_ALL_Ozurdex.pdf
StimatePHARM_ALL_Stimate.pdf
StribildPHARM_ALL_Stribild.pdf
TafinlarPHARM_ALL_Tafinlar.pdf
Diabetic Test StripsPHARM_ALL_DiabeticTestStrips.pdf
TysabriPHARM_ALL_Tysabri.pdf
LemtradaPHARM_ALL_Lemtrada.pdf
KrystexxaPHARM_ALL_Krystexxa.pdf
DihydroergotaminePHARM_ALL_Dihydroergotamine.pdf
ArcalystPHARM_ALL_Arcalyst.pdf
ElitekPHARM_ALL_Elitek.pdf
ErwinazePHARM_ALL_Erwinaze.pdf
FaslodexPHARM_ALL_Faslodex.pdf
KeytrudaPHARM_ALL_Keytruda.pdf
LotronexPHARM_ALL_Lotronex.pdf
NplatePHARM_ALL_Nplate.pdf
OncasparPHARM_ALL_Oncaspar.pdf
OxymorphonePHARM_ALL_Oxymorphone.pdf
Transdermal EstrogenPHARM_ALL_TransdermalEstrogen.pdf
VelcadePHARM_ALL_Velcade.pdf
ArgatrobanPHARM_ALL_Argatroban.pdf
CholbamPHARM_ALL_Cholbam.pdf
Colony Stimulating FactorsPHARM_ALL_ColonyStimulatingFactors.pdf
CresembaPHARM_ALL_Cresemba.pdf
DaklinzaPHARM_ALL_Daklinza.pdf
DPP4 Dipeptidyl Peptidase-4PHARM_ALL_DPP4.pdf
ExjadePHARM_ALL_Exjade.pdf
IBDPHARM_ALL_IBD.pdf
JadenuPHARM_ALL_Jadenu.pdf
Ketorolac AgentsPHARM_ALL_KetorolacAgents.pdf
Meglitinide Step TherapyPHARM_ALL_MeglitinideStepTherapy.pdf
Methotrexate Auto-Injector AgentsPHARM_ALL_MethotrexateAuto-InjectorAgents.pdf
NatparaPHARM_ALL_Natpara.pdf
Non-Preferred Long-Acting Opioid Analgesic Step TherapyPHARM_ALL_NPLong-ActingOpioids.pdf
Topical Corticosteroid - Low PotencyPHARM_ALL_NPLowPotencyTopicalCorticosteroidStepTherapy.pdf
NucalaPHARM_ALL_Nucala.pdf
OpdivoPHARM_ALL_Opdivo.pdf
OrkambiPHARM_ALL_Orkambi.pdf
PraluentPHARM_ALL_Praluent.pdf
ProcysbiPHARM_ALL_Procysbi.pdf
RexultiPHARM_ALL_Rexulti.pdf
RilutekPHARM_ALL_Rilutek.pdf
SigniforPHARM_ALL_Signifor.pdf
SovaldiPHARM_ALL_Sovaldi.pdf
StatinsPHARM_ALL_Statins.pdf
TechniviePHARM_ALL_Technivie.pdf
Topical CorticosteroidPHARM_ALL_TopicalCorticosteroid.pdf
TreandaPHARM_ALL_Treanda.pdf
ViberziPHARM_ALL_Viberzi.pdf
5 Alpha Reductase InhibitorsPHARM_ALL_5AlphaReduct.pdf
CotellicPHARM_ALL_Cotellic.pdf
Inhaled AgentsPHARM_ALL_Inhaled.pdf
Topical Corticosteroid - Medium PotencyPHARM_ALL_NPMedPotencyTopicalCorticosteroidStepTherapy.pdf
VytorinPHARM_ALL_Vytorin.pdf
ZepatierPHARM_ALL_Zepatier.pdf
ZetiaPHARM_ALL_Zetia.pdf
Alpha-1 Proteinase InhibitorsPHARM_ALL_Alpha-1ProteinaseInhibitors.pdf
Contraceptive ProductsPHARM_ALL_ContraceptiveProducts.pdf
BerinertPHARM_ALL_Berinert.pdf
CinryzePHARM_ALL_Cinryze.pdf
CorlanorPHARM_ALL_Corlanor.pdf
EvekeoPHARM_ALL_Evekeo.pdf
FirazyrPHARM_ALL_Firazyr.pdf
GattexPHARM_ALL_Gattex.pdf
IbrancePHARM_ALL_Ibrance.pdf
KalbitorPHARM_ALL_Kalbitor.pdf
KeveyisPHARM_ALL_Keveyis.pdf
SildenafilPHARM_ALL_Sildenafil.pdf
ADHD NarcolepsyPHARM_ALL_ADHDNarcolepsy.pdf
BlincytoPHARM_ALL_Blincyto.pdf
DaraprimPHARM_ALL_Daraprim.pdf
Emend InjectablePHARM_ALL_EmendInjectable.pdf
Emend OralPHARM_ALL_EmendOral.pdf
EntrestoPHARM_ALL_Entresto.pdf
GlyxambiPHARM_ALL_Glyxambi.pdf
Hyaluronan InjectionsPHARM_ALL_HyaluronanInjections.pdf
Isotretinoin AgentsPHARM_ALL_IsotretinoinAgents.pdf
Ivacaftor-LumacaftorPHARM_ALL_Ivacaftor-Lumacaftor.pdf
LenvimaPHARM_ALL_Lenvima.pdf
LinzessPHARM_ALL_Linzess.pdf
NinlaroPHARM_ALL_Ninlaro.pdf
Selected Weight Loss PHARM_ALL_SelectedWeightLoss.pdf
Smoking CessationPHARM_ALL_SmokingCessation.pdf
StratteraPHARM_ALL_Strattera.pdf
StrensiqPHARM_ALL_Strensiq.pdf
Thiazolidinedione Step TherapyPHARM_ALL_Thiazolidinediones.pdf
Transdermal FentanylPHARM_ALL_TransdermalFentanyl.pdf
VyvansePHARM_ALL_Vyvanse.pdf
ActimmunePHARM_ALL_Actimmune.pdf
AmitizaPHARM_ALL_Amitiza.pdf
AntiepilepticsPHARM_ALL_Antiepileptics.pdf
Botulinum ToxinPHARM_ALL_BotulinumToxin.pdf
Brand BupropionPHARM_ALL_BrandBupropion.pdf
Cosmetic Anti-AgingPHARM_ALL_CosmeticAnti-Aging.pdf
DuopaPHARM_ALL_Duopa.pdf
EloctatePHARM_ALL_Eloctate.pdf
HycamtinPHARM_ALL_Hycamtin.pdf
Injectable Triptan Agents Step TherapyPHARM_ALL_InjectableTriptansStepTherapy.pdf
IressaPHARM_ALL_Iressa.pdf
IstodaxPHARM_ALL_Istodax.pdf
LevaquinPHARM_ALL_Levaquin.pdf
LonsurfPHARM_ALL_Lonsurf.pdf
MitigarePHARM_ALL_Mitigare.pdf
MovantikPHARM_ALL_Movantik.pdf
Narcan Nasal SprayPHARM_ALL_Narcan.pdf
Nasal Triptan STPHARM_ALL_NasalTriptan.pdf
NilandronPHARM_ALL_Nilandron.pdf
Non-Preferred MinocyclinePHARM_ALL_NPMinocyclines.pdf
NuedextaPHARM_ALL_Nuedexta.pdf
OdomzoPHARM_ALL_Odomzo.pdf
Oral AntifungalsPHARM_ALL_OralAntifungals.pdf
OsphenaPHARM_ALL_Osphena.pdf
RelenzaPHARM_ALL_Relenza.pdf
RelistorPHARM_ALL_Relistor.pdf
TaltzPHARM_ALL_Taltz.pdf
TamifluPHARM_ALL_Tamiflu.pdf
ThiolaPHARM_ALL_Thiola.pdf
VarubiPHARM_ALL_Varubi.pdf
VidazaPHARM_ALL_Vidaza.pdf
ZyfloPHARM_ALL_Zyflo.pdf
ZykadiaPHARM_ALL_Zykadia.pdf
LumizymePHARM_ALL_Lumizyme.pdf
OndansetronPHARM_ALL_Ondansetron.pdf
TagrissoPHARM_ALL_Tagrisso.pdf
VfendPHARM_ALL_Vfend.pdf
DuexisPHARM_ALL_Duexis.pdf
HorizantPHARM_ALL_Horizant.pdf
OrfadinPHARM_ALL_Orfadin.pdf
RestasisPHARM_ALL_Restasis.pdf
TyzekaPHARM_ALL_Tyzeka.pdf
VimovoPHARM_ALL_Vimovo.pdf
AdapalenePHARM_ALL_Adapalene.pdf
OcalivaPHARM_ALL_Ocaliva.pdf
AggrenoxPHARM_ALL_Aggrenox.pdf
CabometyxPHARM_ALL_Cabometyx.pdf
Multisource Brand MSB AgentsPHARM_ALL_Multisource.pdf
Non-Preferred Agents for DementiaPHARM_ALL_NPAgentsforDementia.pdf
RanexaPHARM_ALL_Ranexa.pdf
ZontivityPHARM_ALL_Zontivity.pdf
Abilify MaintenaPHARM_ALL_Abilify.pdf
AristadaPHARM_ALL_Aristada.pdf
FuzeonPHARM_ALL_Fuzeon.pdf
Invega SustennaPHARM_ALL_InvegaSustena.pdf
Invega TrinzaPHARM_ALL_InvegaTrinza.pdf
DalirespPHARM_ALL_Daliresp.pdf
Non-Preferred Fluoroquinolone Otic AgentsPHARM_ALL_NPFluoroquinolone.pdf
VirazolePHARM_ALL_Virazole.pdf
XuridenPHARM_ALL_Xuriden.pdf
XtampzaPHARM_ALL_Xtampza.pdf
VimizimPHARM_ALL_Vimizim.pdf
VimizimPHARM_ALL_Namzaric.pdf
FabrazymePHARM_ALL_Fabrazyme.pdf
Doxorubicin Hydrochloride LiposomePHARM_ALL_DoxHydroLiposome.pdf
IrenkaPHARM_ALL_Irenka.pdf
IxempraPHARM_ALL_Ixempra.pdf
Non-Preferred Agents for Actinic KeratosisPHARM_ALL_NPAgentsforActinicKeratosis.pdf
Non-Preferred Short-Acting Beta-2 Agonist (SABA) Agents Step TherapyPHARM_ALL_NPSABAs.pdf
ValchlorPHARM_ALL_Valchlor.pdf
VenclextaPHARM_ALL_Venclexta.pdf
Breo ElliptaPHARM_ALL_BreoEllipta.pdf
Non-Preferred Inhaled CorticosteroidPHARM_ALL_NPInhaledCorticosteroids.pdf
AbraxanePHARM_ALL_Abraxane.pdf
AlecensaPHARM_ALL_Alecensa.pdf
Blood Glucose LancetsPHARM_ALL_BloodGlucoseLancets.pdf
Chelation TherapyPHARM_ALL_ChelationTherapy.pdf
EpclusaPHARM_ALL_Epclusa.pdf
Infliximab/Infliximab-dyybPHARM_ALL_InfliximabInfliximab-dyyb.pdf
PulmozymePHARM_ALL_Pulmozyme.pdf
ToriselPHARM_ALL_Torisel.pdf
ZyclaraPHARM_ALL_Zyclara.pdf
Dose OptimizationPHARM_ALL_DoseOptimization.pdf
DurlazaPHARM_ALL_Durlaza.pdf
KanumaPHARM_ALL_Kanuma.pdf
VistogardPHARM_ALL_Vistogard.pdf
ZurampicPHARM_ALL_Zurampic.pdf
DarzalexPHARM_ALL_Darzalex.pdf
EmplicitiPHARM_ALL_Empliciti.pdf
Enzyme Replacement Therapy for Gaucher DiseasePHARM_ALL_EnzymeRelpacementTherapyGaucher.pdf
Nucala / CinquairPHARM_ALL_NucalaCinquair.pdf
XiidraPHARM_ALL_Xiidra.pdf
Angiotensin Receptor Blocker (ARB) Agents Step TherapyPHARM_ALL_NPARBAgentsStepTherapy.pdf
Angiotensin Receptor (ARB)/Thiazide Diuretic Combination Agents Step TherapyPHARM_ALL_NPARBThiazide.pdf
NP LAMAPHARM_ALL_NPLAMAAgentsStepTherapy.pdf
NP LAMA LABAPHARM_ALL_NPLAMALABAStepTherapy.pdf
NP OABPHARM_ALL_NPOABStepTherapy.pdf
Phosphate BindersPHARM_ALL_PhosphateBinders.pdf
NP Topical Topical Fluorouracil AgentsPHARM_ALL_NPTopicalTopicalFluorouracilAgents.pdf
PicatoPHARM_ALL_Picato.pdf
ViekiraPak XR PHARM_ALL_ViekiraXR.pdf
Blood Glucose Test Strips and Monitors Step TherapyPHARM_ALL_BGStripsMonitors.pdf
CerdelgaPHARM_ALL_Cerdelga.pdf
ElaprasePHARM_ALL_Elaprase.pdf
Long-Acting Opioid AnalgesicsPHARM_ALL_LAOpioidAnalgesics.pdf
Mesnex TabletsPHARM_ALL_MesnexTablets.pdf
NuplazidPHARM_ALL_Nuplazid.pdf
ProbuphinePHARM_ALL_Probuphine.pdf
Regranex GelPHARM_ALL_RegranexGel.pdf
Triptan Quantity LimitPHARM_ALL_TriptanQuantityLimit.pdf
Triptans Duplicate TherapyPHARM_ALL_TriptansDuplicateTherapy.pdf
ZinbrytaPHARM_ALL_Zinbryta.pdf
Azelaic Acid AgentsPHARM_ALL_AzelaicAcidAgents.pdf
Narcotics Long Acting Duplicate TherapyPHARM_ALL_NarcoticsLongActingDuplicateTherapy.pdf
Narcotics Short Acting Duplicate TherapyPHARM_ALL_NarcoticsShortActingDuplicateTherapy.pdf
Non-Preferred Nasal CorticosteroidsPHARM_ALL_NPNasalCorticosteroids.pdf
Non-Preferred OpthalmicPHARM_ALL_NpOphthalmic.pdf
Non-Preferred Oral Triptans Step TherapyPHARM_ALL_NPOralTriptans.pdf
SoolantraPHARM_ALL_Soolantra.pdf
Zovirax topical AgentsPHARM_ALL_ZoviraxTopicalAgents.pdf
Injectable TriptansPHARM_ALL_InjectableTriptans.pdf
AldaraPHARM_ALL_Aldara.pdf
AldurazymePHARM_ALL_Aldurazyme.pdf
ArthrotecPHARM_ALL_Arthrotec.pdf
CetylevPHARM_ALL_Cetylev.pdf
Crofelemer PHARM_ALL_Crofelemer.pdf
Docetaxel PHARM_ALL_Docetaxel.pdf
Epiduo, Epiduo FortePHARM_ALL_Epiduo.pdf
Glatiramer acetatePHARM_ALL_Glatirame.pdf
GLP-1 Receptor Agonist Step TherapyPHARM_ALL_GLP1InsulinTherapy.pdf
LartruvoPHARM_ALL_Lartruvo.pdf
Noritate (metonidazole) CreamPHARM_ALL_MetonidazoleCream.pdf
NeuproPHARM_ALL_Neupro.pdf
Non-Preferred Anti-Parkinson AgentsPHARM_ALL_NPAnti-ParkinsonAgents.pdf
Non-Preferred Naloxone AgentsPHARM_ALL_NPNaloxoneAgents.pdf
Proton Pump InhibitorsPHARM_ALL_ProtonPumpInhibitors.pdf
RayaldeePHARM_ALL_Rayaldee.pdf
RayosPHARM_ALL_Rayos.pdf
Risperdal ConstaPHARM_ALL_RisperdalConsta.pdf
TasmarPHARM_ALL_Tasmar.pdf
Transmucosal Immediate Release Fentanyl (TIRF) Agents PHARM_ALL_TIRFAgents.pdf
Topical and Buccal Agents for Recurrent Herpes LabialisPHARM_ALL_TopicalBuccalAgentsfoRHerpesLabialis.pdf
UloricPHARM_ALL_Uloric.pdf
ZyprexaPHARM_ALL_Zyprexa.pdf
Brand EpiPen/EpiPen Jr.PHARM_ALL_BrandEpiPen.pdf
Calcitriol AgentsPHARM_ALL_CalcitriolAgents.pdf
HectorolPHARM_ALL_Hectorol.pdf
Non-Preferred Single Agent NSAID Step TherapyPHARM_ALL_NPSingleAgentNSAIDStepTherapy.pdf
Non-Preferred Topical Agents for External Anogenital Warts Step TherapyPHARM_ALL_NPTopicalAnogenitalWartsTherapy.pdf
SandostatinPHARM_ALL_Sandostatin.pdf
Signifor LARPHARM_ALL_SigniforLAR.pdf
Somatuline DepotPHARM_ALL_SomatulineDepot.pdf
SomavertPHARM_ALL_Somavert.pdf
ZemplarPHARM_ALL_Zemplar.pdf
Testosterone InjectablePHARM_ALL_TestosteroneInjectable.pdf
Non-Preferred Beta Blocker Step TherapyPHARM_ALL_NPBetaBlockerST.pdf
Non-Preferred Inflammatory Bowel Disease Step TherapyPHARM_ALL_NPInflammatoryBowelDiseaseST.pdf
Non-Formulary Prescription RequestPHARM_ALL_NonFormularyPrescriptionRequest.pdf
RepathaPHARM_ALL_Repatha.pdf
Short-Acting Opioid Analgesics for Acute Pain Duration of UsePHARM_ALL_SAOpioidAnalgesicsforAcutePain.pdf
Brand Azelastine Nasal Spray AgentsPHARM_ALL_BrandAzelastineNasalSprayAgents.pdf
EucrisaPHARM_ALL_Eucrisa.pdf
FusilevPHARM_ALL_Fusilev.pdf
Hepatitis B Oral Agents Duplicate TherapyPHARM_ALL_HepatitisBOralAgents.pdf
Inhaled Agents Duplicate TherapyPHARM_ALL_InhaledAgentsDuplicateTherapy.pdf
JevtanaPHARM_ALL_Jevtana.pdf
Metformin extended-releasePHARM_ALL_MetforminExtendedRelease.pdf
Non-Preferred Fenofibrate AgentsPHARM_ALL_NPFenofibrateAgents.pdf
Topical Corticosteroid - High PotencyPHARM_ALL_NPHighPotencyTopicalCorticosteroids.pdf
Non-Preferred Long-Acting InsulinPHARM_ALL_NPLongActingInsulin.pdf
Non-Preferred Ophthalmic NSAIDsPHARM_ALL_NPOphthalmicNSAIDs.pdf
Non-Preferred Sedative Hypnotic Agents for InsomniaPHARM_ALL_NPSedativeHypnoticAgentsForInsomnia.pdf
RiometPHARM_ALL_Riomet.pdf
RubracaPHARM_ALL_Rubraca.pdf
SensiparPHARM_ALL_Sensipar.pdf
SimvastatinPHARM_ALL_Simvastatin.pdf
TecentriqPHARM_ALL_Tecentriq.pdf
VemlidyPHARM_ALL_Vemlidy.pdf
Topical Corticosteroid - Very High PotencyPHARM_ALL_VeryHighPotencyTopicalCorticosteroids.pdf
ZinplavaPHARM_ALL_Zinplava.pdf
AczonePHARM_ALL_Aczone.pdf
AmjevitaPHARM_ALL_Amjevita.pdf
CarbagluPHARM_ALL_Carbaglu.pdf
Dronabinol agentsPHARM_ALL_DronabinolAgents.pdf
ErelziPHARM_ALL_Erelzi.pdf
Inflectra, RemicadePHARM_ALL_InflectraRemicade.pdf
Non-Preferred Skeletal Muscle Relaxants Step TherapyPHARM_ALL_NPSkeletalMuscleRelaxantsST.pdf
Non-Preferred Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)PHARM_ALL_NPSNRIs.pdf
Topical Anti-Infective-Benzoyl Peroxide ComboPHARM_ALL_NPTopicalAntiInfBenzoylPeroxideCombo.pdf
SamscaPHARM_ALL_Samsca.pdf
SantylPHARM_ALL_Sanytl.pdf
Antihemophilic and Clotting FactorsPHARM_ALL_AntihemophilicClottingFactors.pdf
Anzemet Quantity LimitPHARM_ALL_AnzemetQuantityLimit.pdf
Buprenorphine SL Tablets for Medication Assisted TreatmentPHARM_ALL_Buprenorphine.pdf
Dose Optimization Mental HealthPHARM_ALL_DoseOptimizationMentalHealth.pdf
Granisetron Agents Quantity LimitPHARM_ALL_GranisetronAgentsQuantityLimit.pdf
Non-Preferred Oral/Transdermal 5-HT3 Receptor AntagonistPHARM_ALL_NP5-HT3ReceptorAntagonist.pdf
Non-Preferred Pediculicides for Head LicePHARM_ALL_NPPediculicidesHeadLice.pdf
Non-Preferred Rapid Acting InsulinPHARM_ALL_NPRapidActingInsulin.pdf
OcrevusPHARM_ALL_Ocrevus.pdf
SpinrazaPHARM_ALL_Spinraza.pdf
XermeloPHARM_ALL_Xermelo.pdf
CyclosetPHARM_ALL_Cycloset.pdf
AustedoPHARM_ALL_Austedo.pdf
IngrezzaPHARM_ALL_Ingrezza.pdf
KisqualiPHARM_ALL_Kisqala.pdf
Non-Preferred Topical Agents for Cutaneous Fungal Infections Step TherapyPHARM_ALL_NonPreferredTopicalFungal.pdf
AbaloparotidePHARM_ALL_Abaloparotide.pdf
AlunbrigPHARM_ALL_Alunbrig.pdf
CycloserinePHARM_ALL_Cycloserine.pdf
Doxylamine and Pyridoxine AgentsPHARM_ALL_DoxylaminePyridoxineAgents.pdf
DupixentPHARM_ALL_Dupixent.pdf
EmflazaPHARM_ALL_Emflaza.pdf
EmsamPHARM_ALL_Emsam.pdf
GralisePHARM_ALL_Gralise.pdf
KevzaraPHARM_ALL_Kevzara.pdf
LacrisertPHARM_ALL_Lacrisert.pdf
Lidoderm (lidocaine) PatchPHARM_ALL_Lidoderm.pdf
RydaptPHARM_ALL_Rydapt.pdf
Self-Injected Epinephrine Agents Quantity LimitPHARM_ALL_SelfInjectedEpinephrineAgentsQLimit.pdf
SiliqPHARM_ALL_Siliq.pdf
SirturoPHARM_ALL_Sirturo.pdf
TrulancePHARM_ALL_Trulance.pdf
UptraviPHARM_ALL_Uptravi.pdf
VoseviPHARM_ALL_Vosevi.pdf
YospralaPHARM_ALL_Yosprala.pdf
MavyretPHARM_ALL_Mavyret.pdf
Inhaled Corticosteroid (ICS)/Long-Acting Beta-2 Agonist (LABA) Combination AgentsPHARM_ALL_ICSLABAAdvairAirDuoSymbicort.pdf
Topical OnychomycosisPHARM_ALL_TopicalOnychomycosis.pdf
Thiazolidinediones Duplicate TherapyPHARM_ALL_Thiazolidinedionesduptherapy.pdf
BrineuraPHARM_ALL_Brineura.pdf
ImfinziPHARM_ALL_Imfinzi.pdf
Opioid Analgesic ComboPHARM_ALL_OpioidAnalgesicComboQL.pdf
TymlosPHARM_ALL_Tymlos.pdf
ZejulaPHARM_ALL_Zejula.pdf
BavencioPHARM_ALL_Bavencio.pdf
CambiaPHARM_ALL_Cambia.pdf
EquetroPHARM_ALL_Equetro.pdf
Hydroxyprogesterone caproate injection PHARM_ALL_HydroxyprogCaproateInject.pdf
Noctiva Intranasal SprayPHARM_ALL_NoctivaIntranasalSpray.pdf
Non-Preferred Vaginal EstrogenPHARM_ALL_NPVaginalEstrogen.pdf
TremfyaPHARM_ALL_Tremfya.pdf
Doxycyclines-AcnePHARM_ALL_DoxycyclinesAcne.pdf
NortheraPHARM_ALL_Northera.pdf
Opioid Analgesic ComboPHARM_ALL_OpioidAnalgesicCombo.pdf
Non-Preferred CiprofloxacinPHARM_ALL_Non-PreferredCiprofloxacin.pdf
HaegardaPHARM_ALL_Haegarda.pdf
SGLT2- DPP4 Inhibitor CombinationPHARM_ALL_SGLT2DPP4InhibCombo.pdf