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Erythropoiesis Stimulating Agents PA Form 470-4098 111.58 KB |
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2022/04/28 |
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Anti-Fungal PA Form 470-4094 107.81 KB |
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2022/04/22 |
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Immunomodulators - Topical PA Form 470-5040 115.54 KB |
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2022/04/22 |
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Direct Oral Anticoagulants PA Form 470-5423 108.72 KB |
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2022/04/22 |
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Growth Hormone PA Form 470-4100 152.7 KB |
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2022/04/22 |
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Benzodiazepines PA Form 470-4117 137 KB |
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2022/04/22 |
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Modified Formulations PA Form 470-4705 107.88 KB |
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2022/04/22 |
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Apremilast (Otezla) PA Form 470-5293 102.72 KB |
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2022/04/22 |
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Topical Acne and Rosacea Products PA Form 470-5426 117.27 KB |
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2022/04/22 |
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Biologicals for Arthritis PA Form 470-4522 121.54 KB |
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2022/04/22 |
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Repository Corticotropin Injection PA Form 470-5172 99.58 KB |
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2022/04/22 |
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Selective Preventative Migraine Treatments PA Form 470-5554 119.75 KB |
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2022/04/22 |
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Nebivolol (Bystolic) PA Form 470-5099 128.97 KB |
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2022/04/22 |
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Janus Kinase Inhibitors PA Form 470-5175 115.78 KB |
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2022/04/22 |
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Deferasirox (Exjade) PA Form 470-5330 109.63 KB |
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2022/04/22 |
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Naloxone Nasal Spray PA Form 470-5461 101.14 KB |
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2022/04/22 |
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Select Non-Biologic Agents for Ulcerative Colitis PA Form 470-5683 100.63 KB |
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2022/04/22 |
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Proton Pump Inhibitors PA Form 470-4112 125.13 KB |
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2022/04/22 |
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Hepatitis C Treatments PA Form 470-5270 147.92 KB |
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2022/04/22 |
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Pulmonary Arterial Hypertension PA Form 470-4327 113.51 KB |
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2022/04/22 |
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Triheptanoin (Dojolvi) PA Form 470-5693 108.91 KB |
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2022/04/22 |
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Tasimelteon (Hetlioz) PA Form 470-5296 104.54 KB |
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2022/01/14 |
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Granulocyte Colony Stimulating Factor PA Form 470-4099 100.89 KB |
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2021/11/19 |
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Extended Release Formulation PA Form 470-4550 102.18 KB |
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2021/11/19 |
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Acute Migraine Treatments PA Form 470-4113 135.41 KB |
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2021/11/19 |
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Pirfenidone (Esbriet) & Nintedanib (Ofev) PA Form 470-5346 126.6 KB |
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2021/11/19 |
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Anti-Diabetic, Non-Insulin Agents PA Form 470-5259 115.53 KB |
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2021/11/19 |
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Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist, Oral PA Form 470-5578 116.56 KB |
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2021/11/19 |
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Vericiguat (Verquvo) PA Form 470-5685 103.93 KB |
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2021/11/19 |
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Viloxazine (Qelbree) PA Form 470-5684 102.12 KB |
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2021/11/19 |
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Omalizumab (Xolair) PA Form 470-4279 141.23 KB |
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2021/11/19 |
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CNS Stimulants and Atomoxetine PA Form 470-4116 136.79 KB |
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2021/11/19 |
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Antiemetic-5HT3 receptor Antogonists/Substance P Neurokinin Agents PA Form 470-4410 138.42 KB |
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2021/11/19 |
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Multiple Sclerosis Agents - Oral PA Form 470-5060 108.05 KB |
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2021/11/19 |
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Isotretinoin (Oral) PA Form 470-4101 115.9 KB |
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2021/08/05 |
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IL-5 Antagonists PA Form 470-5424 143.86 KB |
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2021/08/05 |
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Vesicular Monoamine Transporter (VMAT) 2 Inhibitors PA Form 470-5534 128.38 KB |
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2021/08/05 |
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Mannitol Inhalation Powder (Bronchitol) PA Form 470-5670 116.87 KB |
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2021/08/05 |
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Risdiplam (Evrysdi) PA Form 470-5671 118.6 KB |
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2021/08/05 |
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Binge Eating Disorder Agents PA Form 470-5336 112.95 KB |
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2021/08/05 |
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Nonsteroidal Anti-Inflammatory Drugs PA Form 470-4109 123.75 KB |
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2021/08/05 |
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Initial Days’ Supply Limit Override PA Form 470-5672 112.53 KB |
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2021/08/05 |
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Select Anticonvulsants PA Form 470-5591 107.03 KB |
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2021/08/05 |
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Satralizumab (Enspryng) PA Form 470-5652 133.04 KB |
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2021/05/20 |
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Methotrexate Injection PA Form 470-5294 108.48 KB |
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2021/04/16 |
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Eluxadoline (Viberzi) PA Form 470-5410 111.58 KB |
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2021/04/16 |
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Oral Constipation Agents PA Form 470-5174 113.97 KB |
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2021/04/16 |
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Topical Antifungals for Onychomycosis PA Form 470-5368 102.83 KB |
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2021/04/16 |
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Sapropterin (Kuvan) PA Form 470-5493 106.45 KB |
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2021/04/16 |
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Sodium Oxybate Products PA Form 470-5016 125.02 KB |
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2021/04/16 |
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Hematopoietics/Chronic ITP PA Form 470-4850 118.89 KB |
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2020/11/20 |
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Peanut (Arachis Hypogaea) Allergen Powder-dnfp (Palforzia) PA Form 470-5637 124.13 KB |
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2020/11/20 |
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Adenosine Triphosphate-Citrate Lyase Inhibitors PA Form 470-5636 125.92 KB |
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2020/11/20 |
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Biologicals for Axial Spondyloarthritis PA Form 470-4521 131.26 KB |
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2020/11/20 |
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Biologicals for Plaque Psoriasis PA Form 470-4524 117.68 KB |
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2020/11/20 |
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Cystic Fibrosis Agents, Oral PA Form 470-5627 118 KB |
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2020/11/20 |
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Voxelotor (Oxbryta) PA Form 470-5628 113.59 KB |
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2020/09/14 |
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Short Acting Opioids PA Form 470-4899 146.42 KB |
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2020/08/24 |
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Linezolid (Zyvox) PA Form 470-4275 121.62 KB |
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2020/08/24 |
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Ivabradine (Corlanor) PA Form 470-5409 110.23 KB |
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2020/08/24 |
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High Dose Opioids PA Form 470-5531 109.03 KB |
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2020/08/24 |
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Lidocaine Patch PA Form 470-4898 103.65 KB |
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2020/08/24 |
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Potassium Binders PA Form 470-5425 101.36 KB |
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2020/08/24 |
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Dupilumab (Dupixent) PA Form 470-5497 123.81 KB |
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2020/08/24 |
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Testosterone Products PA Form 470-5188 117.95 KB |
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2020/08/24 |
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Sedative/Hypnotic-Non_benzodiazepine PA Form 470-4328 110.04 KB |
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2020/08/24 |
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Pavilizumab PA Form 470-4110 24.68 KB |
Palivizumab (Synagis®) approval periods will begin November 1, 2021 and will be considered through March 31, 2022, and as medically necessary based on RSV prevalence. A maximum of five doses will be allowed per member per RSV season. No allowances will be made for a sixth dose, regardless of start date. Requests may be submitted beginning October 12, 2021 for a therapy start date of November 1, 2021. |
2020/06/11 |
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Muscle Relaxants PA Form 470-4105 124.14 KB |
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2019/11/26 |
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Non-Parenteral Vasopressin Derivatives PA 470-4107 106.99 KB |
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2019/11/26 |
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Dalfampridine (Ampyra) PA Form 470-5015 91.73 KB |
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2019/11/26 |
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Febuxostat (Uloric) PA Form 470-4849 79.07 KB |
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2019/11/26 |
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Antihistamines PA Form 470-4095 108.72 KB |
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2019/11/25 |
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PCSK9 Inhibitors PA Form 470-5399 449.71 KB |
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2019/11/25 |
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Aripiprazole Tablets with Sensor (Abilify MyCite) PA Form 470-5600 289.46 KB |
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2019/11/22 |
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Ospemifene (Osphena) PA Form 470-5601 283.96 KB |
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2019/11/22 |
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Lupron Depot - Adult PA Form 470-5435 28.97 KB |
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2019/08/26 |
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Long-Acting Opioids PA form 470-4409 33.97 KB |
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2019/05/21 |
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Miconazole-Zinc Oxide-White Petrolatum (Vusion) Ointment PA form 470-4655 24.6 KB |
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2019/04/30 |
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Biologicals for Inflammatory Bowel Disease PA Form 470-4523 28.62 KB |
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2019/04/30 |
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Nocturnal Polyuria Treatments PA Form 470-5577 36.37 KB |
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2019/04/30 |
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Lupron Depot - Pediatric PA Form 470-5434 65.21 KB |
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2018/11/20 |
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Letermovir (Prevymis) PA Form 470-5548 235.31 KB |
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2018/08/20 |
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Age Edit Override- Codeine or Tramadol PA Form 470-5507 231.46 KB |
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2018/02/22 |
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Antidepressant PA Form 470-5098 26.88 KB |
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2017/11/20 |
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Selected Brand Name Drug PA Form 470-5039 & 470-4119 43.17 KB |
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2017/08/24 |
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Lesinurad (Zurampic) PA Form 470-5491 68.3 KB |
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2017/08/23 |
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Deflazacort (Emflaza) PA Form 470-5489 25.98 KB |
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2017/08/23 |
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Crisaborole (Eucrisa) PA Form 470-5488 26.29 KB |
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2017/08/23 |
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GLP-1 Agonist/Basal Insulin Combinations PA Form 470-5490 24.77 KB |
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2017/08/23 |
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New to Market Drugs PA Form 470-5492 23.02 KB |
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2017/08/23 |
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Calcifediol (Rayaldee) PA Form 470-5487 24.57 KB |
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2017/08/23 |
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Fentanyl, Short Acting Products PA Form 470-4092 28.87 KB |
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2017/04/18 |
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Duplicate Therapy Edit Override PA Form 470-5460 174.36 KB |
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2017/02/07 |
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Concurrent IM/PO Antipsychotic PA Form 470-4594 23.68 KB |
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2017/02/07 |
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Biologicals for Hidradenitis Suppurativa PA Form 470-5408 179.68 KB |
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2016/06/22 |
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Rifaximin (Xifaxan) PA Form 470-5411 235.8 KB |
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2016/06/22 |
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Cholic Acid (Cholbam) PA Form 470-5391 280.27 KB |
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2016/03/08 |
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Alpha1-Proteinase Inhibitor Enzymes PA Form 470-5365 237 KB |
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2015/11/23 |
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Select Oncology Agents PA Form 470-5367 182.43 KB |
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2015/11/23 |
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Topical Corticosteroids PA Form 470-5347 22.21 KB |
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2015/08/27 |
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Dextromethorphan and Quinidine (Nuedexta™) PA Form 470-5084 30.17 KB |
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2015/06/04 |
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Oral Immunotherapy PA Form 470-5295 28.8 KB |
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2015/04/21 |
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Vorapaxar (Zontivity) PA Form 470-5331 23.4 KB |
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2015/04/17 |
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Korlym (mifepristone) PA Form 470-5141 19.78 KB |
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2013/01/16 |
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Ketorolac PA Form 470-4102 22.66 KB |
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2012/06/26 |
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Roflumilast (Daliresp™) PA Form 470-5085 56.57 KB |
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2011/12/28 |
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Fifteen Day Initial Prescription Supply Override PA Form 470-5038 14.22 KB |
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2011/07/11 |
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Vitamins Minerals and Multiple Vitamins PA Form 470-4115 13.95 KB |
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2011/06/16 |
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Non-Preferred Drug PA Form 470-4108 13.86 KB |
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2011/06/16 |
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Quantity Limit Override Form 470-4556 107.21 KB |
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2010/10/06 |
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Amylino Mimetic PA Form 470-4406 33.02 KB |
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2009/12/09 |
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Narcotic Agonist Antagonist Nasal Spray PA Form 470-4106 33.79 KB |
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2009/07/27 |
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Becaplermin (Regranex) PA Form 470-4276 24.3 KB |
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2008/09/05 |
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Miscellaneous PA Form 470-4104 16.18 KB |
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2007/12/26 |