Pharmacy Policy Criteria
Review ConnectiCare's preauthorization criteria on various prescription medications.
Please note, by downloading or viewing any of the criteria below, you have agreed to accept ConnectiCare’s preauthorization criteria user agreement.
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| 5HT3 Receptor Antagonists PA CCI | Download (PDF) |
| Abraxane (nab paclitaxel) | Download (PDF) |
| Absorica LD PA CCI | Download (PDF) |
| Absorica PA CCI | Download (PDF) |
| ACE-ARB ST CCI | Download (PDF) |
| Acitretin PA CCI | Download (PDF) |
| Acne Oral | Download (PDF) |
| Acne Topicals | Download (PDF) |
| Actemra SQ PA CCI | Download (PDF) |
| Acthar | Download (PDF) |
| Actimmune | Download (PDF) |
| Acyclovir Topical PA CCI | Download (PDF) |
| Adakveo (crizanlizumab) | Download (PDF) |
| Adcetris (brentuximab vedotin) | Download (PDF) |
| Adempas PA CCI | Download (PDF) |
| Adcirca PA CCI | Download (PDF) |
| ADHD PA CCI | Download (PDF) |
| Aemcolo PA CCI | Download (PDF) |
| Aemcolo QL CCI | Download (PDF) |
| Afrezza | Download (PDF) |
| Aimovig QL CCI | Download (PDF) |
| Aimovig | Download (PDF) |
| Ajovy PA CCI | Download (PDF) |
| Ajovy QL CCI | Download (PDF) |
| Aklief PA CCI | Download (PDF) |
| Alcortin PA CCI | Download (PDF) |
| Alecensa PA CCI | Download (PDF) |
| Alferon N | Download (PDF) |
| Alimta (pemetrexed) | Download (PDF) |
| Aliqopa (copanlisib) | Download (PDF) |
| Alkindi PA CCI | Download (PDF) |
| Alunbrig PA CCI | Download (PDF) |
| Alyq PA CCI | Download (PDF) |
| Amantadine ER PA CCI | Download (PDF) |
| Amitiza-Motegrity PA CCI | Download (PDF) |
| Amrix-Fexmid PA CCI | Download (PDF) |
| Annovera QL CCI | Download (PDF) |
| Anticoagulants | Download (PDF) |
| Antidepressants ST CCI | Download (PDF) |
| Antihistamines PA CCI | Download (PDF) |
| Antimalarials PA CCI | Download (PDF) |
| Apadaz QL CCI | Download (PDF) |
| Aplenzin-Forfivo XL PA CCI | Download (PDF) |
| Aptiom PA CCI | Download (PDF) |
| Arazlo PA CCI | Download (PDF) |
| Arikayce QL | Download (PDF) |
| Arikayce | Download (PDF) |
| Arranon (nelarabine) | Download (PDF) |
| Arzerra | Download (PDF) |
| Asparlas (calaspargase pegol-mknl) | Download (PDF) |
| Aspirin Products PA CCI | Download (PDF) |
| Atypicals | Download (PDF) |
| Aubagio PA CCI | Download (PDF) |
| Auryxia PA CCI | Download (PDF) |
| Austedo PA CCI | Download (PDF) |
| Auvi Q-Symjepi | Download (PDF) |
| Avastin (bevacizumab) and Biosimilars (Mvasi and Zirabev) | Download (PDF) |
| Avonex PA CCI | Download (PDF) |
| Ayvakit PA CCI | Download (PDF) |
| Ayvakit QL CCI | Download (PDF) |
| Azedra (iobenguane I-131) | Download (PDF) |
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| Bafiertam PA CCI | Download (PDF) |
| Barfiertam QL CCI | Download (PDF) |
| Balversa PA | Download (PDF) |
| Baqsimi QL CCI | Download (PDF) |
| Bavencio | Download (PDF) |
| Baxdela PA CCI | Download (PDF) |
| BCG | Download (PDF) |
| Belbuca PA CCI | Download (PDF) |
| Beleodaq (belinosat) | Download (PDF) |
| Belsomra PA CCI | Download (PDF) |
| Benlysta SQ | Download (PDF) |
| Benznidazole PA CCI | Download (PDF) |
| Besponsa | Download (PDF) |
| Betaseron PA CCI | Download (PDF) |
| Blenrep (belantamab mafodotin-blmf) | Download (PDF) |
| Blincyto (blinatumomab) | Download (PDF) |
| Bone Modifying Agents (Aredia Zometa Xgeva Prolia) | Download (PDF) |
| Bosulif PA CCI | Download (PDF) |
| Bowel Preparation PA CCI | Download (PDF) |
| BPH_Silodosin ST CCI | Download (PDF) |
| Braftovi QL | Download (PDF) |
| Braftovi | Download (PDF) |
| Breast Cancer Primary Prevention | Download (PDF) |
| Breztri Aerosphere PA CCI | Download (PDF) |
| Breztri Aerosphere QL CCI | Download (PDF) |
| Briviact PA CCI | Download (PDF) |
| Bronchitol PA CCI | Download (PDF) |
| Brukinsa PA CCI | Download (PDF) |
| Brukinsa QL CCI | Download (PDF) |
| Bunavail CCI Exchange PA | Download (PDF) |
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| Cablivi (caplacizumab-yhdp) | Download (PDF) |
| Cabometyx PA CCI | Download (PDF) |
| Calquence | Download (PDF) |
| Cambia PA CCI | Download (PDF) |
| Campath (alemtuzumab) | Download (PDF) |
| Caplyta PA CCI | Download (PDF) |
| Caplyta QL CCI | Download (PDF) |
| Carbinoxamine PA CCI | Download (PDF) |
| Carvedilol ER PA CCI | Download (PDF) |
| Cayston PA CCI | Download (PDF) |
| Cequa QL | Download (PDF) |
| Cequa.pdf | Download (PDF) |
| Cerdelga PA CCI | Download (PDF) |
| Cesamet PA CCI | Download (PDF) |
| Chenodal | Download (PDF) |
| Chlorzoxazone PA CCI | Download (PDF) |
| Cholbam PA CCI | Download (PDF) |
| Cholinesterase Inhibitors PA CCI | Download (PDF) |
| Cimzia PA CCI | Download (PDF) |
| Cinacalcet (Sensipar) PA CCI | Download (PDF) |
| Clobazam PA CCI | Download (PDF) |
| Clolar (clofarabine) | Download (PDF) |
| Cometriq PA CCI | Download (PDF) |
| Conjupri PA CCI | Download (PDF) |
| Consensi PA CCI | Download (PDF) |
| Consensi QL CCI | Download (PDF) |
| Copiktra QL | Download (PDF) |
| Copiktra | Download (PDF) |
| Corlanor | Download (PDF) |
| Cosela (trilaciclib) | Download (PDF) |
| Cosentyx PA CCI | Download (PDF) |
| Cotellic PA CCI | Download (PDF) |
| Cresemba PA CCI | Download (PDF) |
| Cuvposa PA CCI | Download (PDF) |
| Cyramza (ramucirumab) | Download (PDF) |
| Cystadrops-Cystaran PA CCI | Download (PDF) |
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| Dalfampridine PA CCI | Download (PDF) |
| Danyelza (naxitamab-gqgk) | Download (PDF) |
| Dapsone Topical PA CCI | Download (PDF) |
| Darzalex and Darzalex Faspro (daratumumab) | Download (PDF) |
| Daurismo QL | Download (PDF) |
| Daurismo | Download (PDF) |
| Dayvigo PA CCI | Download (PD |
| Dayvigo QL CCI | Download (PDF) |
| Delstrigo QL | Download (PDF) |
| Dexamethasone Packs PA CCI | Download (PDF) |
| Dexcom QL | Download (PDF) |
| Diabetic Oral Medications CCI | Download (PDF) |
| Diabetic Test Strips | Download (PDF) |
| Diacomit PA CCI | Download (PDF) |
| Diacomit QL CCI | Download (PDF) |
| Dificid PA CCI | Download (PDF) |
| Dihydroergotamine spray PA CCI | Download (PDF) |
| Doptelet QL | Download (PDF) |
| Doptelet.pdf | Download (PDF) |
| Dovato QL.pdf | Download (PDF) |
| Doxepin Creams PA CCI | Download (PDF) |
| Doxil or Lipodox | Download (PDF) |
| Drizalma Sprinkle PA CCI | Download (PDF) |
| Dronabinol PA CCI | Download (PDF) |
| Duaklir Pressair PA CCI | Download (PDF) |
| Duexis PA CCI | Download (PDF) |
| Dojolvi PA CCI | Download (PDF) |
| Duobrii QL CCI | Download (PDF) |
| Dupixent PA CCI | Download (PDF) |
| Dymista PA CCI | Download (PDF) |
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| Ecoza Luzu CCI PA | Download (PDF) |
| Egrifta | Download (PDF) |
| Eletriptan PA CCI | Download (PDF) |
| Elliot's B | Download (PDF) |
| Elzonris (tagraxofusp) | Download (PDF) |
| Emend Cinvanti and Varubi | Download (PDF) |
| Emflaza | Download (PDF) |
| Emgality PA CCI | Download (PDF) |
| Emgality QL CCI. | Download (PDF) |
| Empliciti | Download (PDF) |
| Emsam PA CCI | Download (PDF) |
| Enbrel PA CCI | Download (PDF) |
| Endari PA CCI | Download (PDF) |
| Endari QL | Download (PDF) |
| Enhertu (fam-trastuzumab deruxtecan-nxki) | Download (PDF) |
| Enspryng PA CCI | Download (PDF) |
| Epidiolex CCI | Download (PDF) |
| Epoprostenol PA CCI | Download (PDF) |
| Equetro PA CCI | Download (PDF) |
| Erbitux (cetuximab) | Download (PDF) |
| Erectile Dysfunction | Download (PDF) |
| Erivedge (vismodegib) | Download (PDF) |
| Erleada PA CCI | Download (PDF) |
| Erwinaze and Rylaze (asparaginase Erwinia chrysanthemi and recombinantrywn) | Download (PDF) |
| Erythropoiesis Stimulating Agents (Aranesp, Epogen, Procrit, Retacrit) | Download (PDF) |
| Esbriet | Download (PDF) |
| Eucrisa PA CCI | Download (PDF) |
| Evekeo | Download (PDF) |
| Evekeo-ODT | Download (PDF) |
| Evrysdi PA CCI | Download (PDF) |
| Exelderm PA CCI | Download (PDF) |
| Extavia PA CCI | Download (PDF) |
| Eysuvis PA CCI | Download (PDF) |
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| Farydak PA CCI | Download (PDF) |
| Faslodex | Download (PDF) |
| Febuxostat ST CCI | Download (PDF) |
| Fenofibrates Brand ST CCI | Download (PDF) |
| Fenofibrates Brand PA CCI | Download (PDF) |
| Fentanyls | Download (PDF) |
| Fertility PA CCI | Download (PDF) |
| Fintepla PA CCI | Download (PDF) |
| Firdapse - Ruzurgi PA CCI | Download (PDF) |
| Firdapse QL CCI | Download (PDF) |
| Flector | Download (PDF) |
| Folotyn | Download (PDF) |
| Fotivda PA CCI | Download (PDF) |
| Freedom Calcium Channel Blockers PA CCI | Download (PDF) |
| Freedom Contraceptives PA CCI | Download (PDF) |
| FREEDOM Lachydrin | Download (PDF) |
| Freestyle Libre QL | Download (PDF) |
| Fusilev | Download (PDF) |
| Fuzeon PA CCI | Download (PDF) |
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| Galafold QL | Download (PDF) |
| Galafold | Download (PDF) |
| Gamifant (emapalumab-lzsg) | Download (PDF) |
| Gavreto PA CCI | Download (PDF) |
| Gavreto QL CCI | Download (PDF) |
| Gazyva | Download (PDF) |
| Generic Oncology | Download (PDF) |
| Gilenya PA CCI | Download (PDF) |
| Gimoti PA CCI | Download (PDF) |
| Glaucoma ST CCI | Download (PDF) |
| Gloperba PA CCI | Download (PDF) |
| GLP-2 Analog | Download (PDF) |
| Glucagon Products PA CCI | Download (PDF) |
| Gluten Intolerance PA CCI | Download (PDF) |
| Glycopyrrolate | Download (PDF) |
| Gralise PA CCI | Download (PDF) |
| Grastek PA CCI | Download (PDF) |
| Growth Hormone PA CCI | Download (PDF) |
| Gvoke QL CCI | Download (PDF) |
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| Halaven | Download (PDF) |
| Hepatitis C | Download (PDF) |
| Hemady PA CCI | Download (PDF) |
| Horizant PA CCI | Download (PDF) |
| Humira PA CCI | Download (PDF) |
| Hycamtin PA CCI | Download (PDF) |
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| Iclusig PA CCI | Download (PDF) |
| Imbruvica | Download (PDF) |
| Imcivree PA CCI | Download (PDF) |
| Imfinzi | Download (PDF) |
| Imlygic | Download (PDF) |
| Impavido PA CCI | Download (PDF) |
| Inbrija PA CCI | Download (PDF) |
| Inbrija QL CCI | Download (PDF) |
| Increlex PA CCI | Download (PDF) |
| Ingrezza PA CCI | Download (PDF) |
| Inlyta | Download (PDF) |
| Inqovi PA CCI | Download (PDF) |
| Inqovi QL CCI | Download (PDF) |
| Inrebic PA CCI | Download (PDF) |
| Inrebic QL CCI | Download (PDF) |
| Insulins PA CCI | Download (PDF) |
| Intravenous Immune Globulin (Aceniv, Panzyga, Bivigam, Carimune, Cuvitru, Gammagard, Gammaplex, Gamunex, Hiqvia, Gammaked, Octagam, Privigen) | Download (PDF) |
| Intron-A | Download (PDF) |
| Iressa (gefitinib) | Download (PDF) |
| Iron Chelators PA CCI | Download (PDF) |
| Istodax | Download (PDF) |
| Isturisa PA CCI | Download (PDF) |
| IVIG-Subcutaneous | Download (PDF) |
| Ixempra | Download (PDF) |
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| Jakafi | Download (PDF) |
| Jatenzo PA CCI | Download (PDF) |
| Jatenzo QL CCI | Download (PDF) |
| Jelmyto (mitomycin for pyelocalyceal instillation) | Download (PDF) |
| Jemperli (dostarlimab-gxly) | Download (PDF) |
| Jevtana | Download (PDF) |
| Jublia PA CCI | Download (PDF) |
| Juxtapid | Download (PDF) |
| Jynarque QL | Download (PDF) |
| Jynarque PA CCI | Download (PDF) |
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| Kadcyla | Download (PDF) |
| Kalydeco | Download (PDF) |
| Katerzia PA CCI | Download (PDF) |
| Kerydin PA CCI | Download (PDF) |
| Kesimpta PA CCI | Download (PDF) |
| Ketoprofen PA CCI | Download (PDF) |
| Keveyis PA CCI | Download (PDF) |
| Kevzara | Download (PDF) |
| Keytruda (pembrolizumab) | Download (PDF) |
| Kineret | Download (PDF) |
| Klisyri CCI PA | Download (PDF) |
| Korlym PA CCI | Download (PDF) |
| Koselugo PA CCI | Download (PDF) |
| Kuvan | Download (PDF) |
| Kynamro | Download (PDF) |
| Kynmobi PA CCI | Download (PDF) |
| Kyprolis (carfilzomib) | Download (PDF) |
| L back to top |
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| Lactulose | Download (PDF) |
| Lampit PA CCI | Download (PDF) |
| Letairis PA CCI | Download (PDF) |
| LHRH (Agonists and antagonist) | Download (PDF) |
| Libtayo (cemiplimab-rwlc) | Download (PDF) |
| Lidocaines | Download (PDF) |
| Lokelma | Download (PDF) |
| Long Acting Hydrocodones | Download (PDF) |
| Long Acting Opioids | Download (PDF) |
| Long-acting muscarinic antagonist CCI Exchange PA | Download (PDF) |
| Long-Acting Muscarinic Antagonist-Long-Acting Beta-Agonist Combo PA CCI | Download (PDF) |
| Lonsurf PA CCI | Download (PDF) |
| Lorbrena | Download (PDF) |
| Lucemyra QL | Download (PDF) |
| Lucemyra | Download (PDF) |
| Lumoxiti | Download (PDF) |
| Lupkynis PA CCI | Download (PDF) |
| Lynparza PA CCI | Download (PDF) |
| Lyrica | Download (PDF) |
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| Margenza (margetuximab-cmkb) | Download (PDF) |
| Marqibo (vincristine liposome) | Download (PDF) |
| Matulane PA CCI | Download (PDF) |
| Mavenclad PA CCI | Download (PDF) |
| Mayzent PA CCI | Download (PDF) |
| Medical Exception Policy | Download (PDF) |
| Mekinist | Download (PDF) |
| Mektovi QL | Download (PDF) |
| Mektovi | Download (PDF) |
| Mepron | Download (PDF) |
| Metformin (Liquids) PA CCI | Download (PDF) |
| Metformin Extended Release (Osmotic & Gastric Retention) PA CCI | Download (PDF) |
| Methotrexates | Download (PDF) |
| Metoprolol HCTZ | Download (PDF) |
| Metyrosine PA CCI | Download (PDF) |
| Minocycline topical foam PA CCI | Download (PDF) |
| Morphines | Download (PDF) |
| Monjuvi (tafasitamab-cxix) | Download (PDF) |
| Mulpleta QL | Download (PDF) |
| Mulpleta | Download (PDF) |
| Myalept PA CCI | Download (PDF) |
| Mycapssa PA CCI | Download (PDF) |
| Myeloid Growth Factors (Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Udenyca and Zarxio) | Download (PDF) |
| Mylotarg | Download (PDF) |
| Mytesi | Download (PDF) |
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| Naproxen ER PA CCI | Download (PDF) |
| Nasal Steroids | Download (PDF) |
| Natpara | Download (PDF) |
| Nayzilam PA CCI | Download (PDF) |
| Nayzilam QL CCI | Download (PDF) |
| Needlephobia | Download (PDF) |
| Nexletol and Nexlizet PA CCI | Download (PDF) |
| Nexletol QL CCI | Download (PDF) |
| Nexlizet QL CCI | Download (PDF) |
| Nilutamide PA CCI | Download (PDF) |
| Nitisinone PA CCI | Download (PDF) |
| Nocdurna QL | Download (PDF) |
| Noctiva QL | Download (PDF) |
| Noctiva-Nocdurna | Download (PDF) |
| Non-Preferred GLP1 PA CCI | Download (PDF) |
| Northera PA CCI | Download (PDF) |
| Nourianz PA CCI | Download (PDF) |
| Noxafil (posaconazole) PA CCI | Download (PDF) |
| Nplate | Download (PDF) |
| NSAID | Download (PDF) |
| Nubeqa PA CCI | Download (PDF) |
| Nubeqa QL CCI | Download (PDF) |
| Nuedexta PA CCI | Download (PDF) |
| Nuedexta QL CCI | Download (PDF) |
| Nuplazid PA CCI | Download (PDF) |
| Nurtec ODT PA CCI | Download (PDF) |
| Nurtec ODT QL CCI | Download (PDF) |
| Nuvigil PA CCI | Download (PDF) |
| Nuzyra PA CCI | Download (PDF) |
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| Ocaliva PA CCI | Download (PDF) |
| Odactra | Download (PDF) |
| Ofev PA CCI | Download (PDF) |
| Off Label | Download (PDF) |
| Olumiant QL | Download (PDF) |
| Olumiant | Download (PDF) |
| Omega 3's | Download (PDF) |
| Oncology | Download (PDF) |
| Oncospar (pegaspargase) | Download (PDF) |
| Ongentys PA CCI | Download (PDF) |
| Ongentys QL CCI | Download (PDF) |
| Onivyde (irinotecan liposome) | Download (PDF) |
| Onmel | Download (PDF) |
| Onureg PA CCI | Download (PDF) |
| Onureg QL CCI | Download (PDF) |
| Opdivo (nivolumab) | Download (PDF) |
| Ophthalmic Anti-Allergy ST CCI | Download (PDF) |
| Ophthalmic Glaucoma PA CCI | Download (PDF) |
| Ophthalmic NSAIDs ST CCI | Download (PDF) |
| Ophthalmic Steroid ST CCI | Download (PDF) |
| Opioids MME CCI | Download (PDF) |
| Opsumit PA CCI | Download (PDF) |
| Oracea | Download (PDF) |
| Oral Contraceptives | Download (PDF) |
| Oralair | Download (PDF) |
| Oravig | Download (PDF) |
| Orencia IV Medical PA CCI | Download (PDF) |
| Orencia PA CCI | Download (PDF) |
| Orenitram PA CCI | Download (PDF) |
| Orgovyx PA CCI | Download (PDF) |
| Oriahnn PA CCI | Download (PDF) |
| Orilissa | Download (PDF) |
| Orkambi QL | Download (PDF) |
| Orkambi | Download (PDF) |
| Orladeyo PA CCI | Download (PDF) |
| Ortikos PA CCI | Download (PDF) |
| Oseni (alogliptin benzoate-pioglitazone hydrochloride) PA CCI | Download (PDF) |
| Otezla PA CCI | Download (PDF) |
| Ovace Plus | Download (PDF) |
| Overactive Bladder ST CCI | Download (PDF) |
| Oxandrin PA CCI | Download (PDF) |
| Oxbryta PA CCI | Download (PDF) |
| Oxbryta QL CCI | Download (PDF) |
| Oxervate CCI PA | Download (PDF) |
| Oxervate QL CCI | Download (PDF) |
| Oxiconazole cream PA CCI | Download (PDF) |
| Oxtellar XR | Download (PDF) |
| Oxycodones | Download (PDF) |
| P back to top |
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| Padcev (enfortumab vedotin-ejfv) | Download (PDF) |
| Palforzia PA CCI | Download (PDF) |
| Palynziq | Download (PDF) |
| Pancreatic Enzymes ST CCI | Download (PDF) |
| Panretin PA CCI | Download (PDF) |
| Pantoprazole Suspension PA CCI | Download (PDF) |
| Patanase | Download (PDF) |
| Pegasys-PegIntron | Download (PDF) |
| Pemazyre PA CCI | Download (PDF) |
| Pemazyre QL CCI | Download (PDF) |
| Penicillamine PA CCI | Download (PDF) |
| Pennsaid | Download (PDF) |
| Pepaxto (melphalan flufenamide) | Download (PDF) |
| Perjeta (pertuzumab) and Phesgo | Download (PDF) |
| Phenoxybenzamine PA CCI | Download (PDF) |
| Phosphate Binder ST CCI | Download (PDF) |
| Photofrin (porfimer) | Download (PDF) |
| Pifeltro QL | Download (PDF) |
| Piqray PA CCI | Download (PDF) |
| Piqray QL CCI | Download (PDF) |
| Plegridy PA CCI | Download (PDF) |
| Polivy (polatuzumab vedotin) | Download (PDF) |
| Pomalyst CCI PA Policy | Download (PDF) |
| Ponvory PA CCI | Download (PDF) |
| Poteligeo | Download (PDF) |
| PPI's | Download (PDF) |
| Praluent | Download (PDF) |
| Preferred GLP1 ST CCI | Download (PDF) |
| Prestalia PA CCI | Download (PDF) |
| Pretomanid PA CCI | Download (PDF) |
| Prevymis | Download (PDF) |
| Prialt | Download (PDF) |
| Procysbi | Download (PDF) |
| Promacta | Download (PDF) |
| Provenge | Download (PDF) |
| Provigil | Download (PDF) |
| Psoriasis Topicals CCI | Download (PDF) |
| Pyrimethamine | Download (PDF) |
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| Qbrelis--Epaned | Download (PDF) |
| Qbrexa QL | Download (PDF) |
| Qbrexza | Download (PDF) |
| Qdolo PA CCI | Download (PDF) |
| Qelbree QL CCI | Download (PDF) |
| Qinlock PA CCI | Download (PDF) |
| Qinlock QL CCI | Download (PDF) |
| QL Policy | Download (PDF) |
| Qtern PA CCI | Download (PDF) |
| Qtern QL | Download (PDF) |
| Qualaquin PA CCI | Download (PDF) |
| Qudexy-Trokendi | Download (PDF) |
| R back to top |
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|---|---|
| Ragwitek | Download (PDF) |
| Ravicti | Download (PDF) |
| Rayaldee PA CCI | Download (PDF) |
| Rayos | Download (PDF) |
| Rebif PA CCI | Download (PDF) |
| Reblozyl (luspatercept-aamt) | Download (PDF) |
| Regranex PA CCI | Download (PDF) |
| Relistor | Download (PDF) |
| Reltone ST CCI | Download (PDF) |
| Remodulin PA CCI | Download (PDF) |
| Repatha | Download (PDF) |
| Retevmo PA CCI | Download (PDF) |
| Retevmo QL CCI | Download (PDF) |
| Revatio PA CCI | Download (PDF) |
| Revlimid | Download (PDF) |
| Rexulti | Download (PDF) |
| Reyvow PA CCI | Download (PDF) |
| Reyvow QL CCI | Download (PDF) |
| Rhopressa_Rocklatan PA CCI | Download (PDF) |
| Rinvoq PA CCI | Download (PDF) |
| Rinvoq QL CCI | Download (PDF) |
| Rituximab Products (Riabni, Rituxan Hyclea, Ruxience, Truxima) | Download (PDF) |
| Rosacea Topicals | Download (PDF) |
| Roszet PA CCI | Download (PDF) |
| Rozlytrek PA CCI | Download (PDF) |
| Rozlytrek QL CCI | Download (PDF) |
| Rubraca CCI PA | Download (PDF) |
| Rukobia QL CCI | Download (PDF) |
| Ruzurgi QL CCI | Download (PDF) |
| Rybelsus QL CCI | Download (PDF) |
| Rydapt | Download (PDF) |
| S back to top |
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|---|---|
| Sarclisa (isatuximab-irfc) | Download (PDF) |
| Secuado PA CCI | Download (PDF) |
| Secuado QL CCI | Download (PDF) |
| Sedative Hypnotics ST CCI | Download (PDF) |
| Semglee PA CCI | Download (PDF) |
| Short Acting Bronchodilators PA CCI | Download (PDF) |
| Short Acting Opioids | Download (PDF) |
| Signifor PA CCI | Download (PDF) |
| Siklos PA CCI | Download (PDF) |
| Silenor PA CCI | Download (PDF) |
| Siliq | Download (PDF) |
| Simponi PA CCI | Download (PDF) |
| Sirturo PA CCI | Download (PDF) |
| Sitavig | Download (PDF) |
| Sivextro PA CCI | Download (PDF) |
| Skyrizi PA CCI | Download (PDF) |
| Skyrizi QL CCI | Download (PDF) |
| Sodium Phenylbutyrate PA CCI | Download (PDF) |
| Soliqua PA CCI | Download (PDF) |
| Solodyn (minocycline extended release) PA CCI | Download (PDF) |
| Soliris (eculizumab) | Download (PDF) |
| Solosec | Download (PDF) |
| Somatostatin Analog (Sandostatin and Somatuline) | Download (PDF) |
| Somavert | Download (PDF) |
| Sprix | Download (PDF) |
| Stadol-QL | Download (PDF) |
| Statin Step | Download (PDF) |
| Steglujan PA CCI | Download (PDF) |
| Stelara PA CCI | Download (PDF) |
| Steroid Beta Agonist Combo Inhalers PA CCI | Download (PDF) |
| Steroid Inhalers PA CCI | Download (PDF) |
| Strensiq PA CCI | Download (PDF) |
| Sucraid PA CCI | Download (PDF) |
| Sumatriptan_Naproxen(Treximet) PA CCI | Download (PDF) |
| Sumatriptans | Download (PDF) |
| Sumavel Dose Pro PA CCI | Download (PDF) |
| Sunosi PA CCI | Download (PDF) |
| Sylatron PA CCI | Download (PDF) |
| Sylvant (siltuximab) | Download (PDF) |
| Symapzan | Download (PDF) |
| Symdeko QL | Download (PDF) |
| Symdeko | Download (PDF) |
| SymlinPen PA CCI | Download (PDF) |
| Sympazan PA CCI | Download (PDF) |
| Synarel PA CCI | Download (PDF) |
| Syndros PA CCI | Download (PDF) |
| Synribo (omacetaxine) | Download (PDF) |
| T back to top |
Download (PDF) |
|---|---|
| Tabrecta PA CCI | Download (PDF) |
| Tabrecta QL CCI | Download (PDF) |
| Tafamidis PA CCI | Download (PDF) |
| Tafinlar | Download (PDF) |
| Tagrisso | Download (PDF) |
| Taltz PA CCI | Download (PDF) |
| Talzenna QL | Download (PDF) |
| Talzenna | Download (PDF) |
| Targretin Gel PA | Download (PDF) |
| Targretin Oral Capsules PA | Download (PDF) |
| Tasigna | Download (PDF) |
| Tavalisse | Download (PDF) |
| Tazverik PA CCI | Download (PDF) |
| Tazverik QL CCI | Download (PDF) |
| Tecartus (brexucabtagene autoleucel) | Download (PDF) |
| Tecentriq | Download (PDF) |
| Tecfidera PA CCI | Download (PDF) |
| Tepadina (thiotepa) | Download (PDF) |
| Testosterones | Download (PDF) |
| Tetrabenazine PA CCI | Download (PDF) |
| Thyrogen | Download (PDF) |
| Tibsovo QL | Download (PDF) |
| Tibsovo | Download (PDF) |
| Tiglutik QL | Download (PDF) |
| Tiglutik | Download (PDF) |
| Tirosint-SOL | Download (PDF) |
| Tivicay QL CCI | Download (PDF) |
| Tobramycin PA CCI | Download (PDF) |
| Tolsura PA CCI | Download (PDF) |
| Tolsura QL CCI | Download (PDF) |
| Topical Antibiotic PA CCI | Download (PDF) |
| Topical Steroids PA CCI | Download (PDF) |
| Torisel (temsirolimus) | Download (PDF) |
| Tosymra QL CCI | Download (PDF) |
| Tracleer PA CCI | Download (PDF) |
| Tramadol Biphasic | Download (PDF) |
| Trastuzumab Products and Phesgo (pertuzumab trastuzumab and hyaluronidase-zzxf) Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera | Download (PDF) |
| Treanda_Bendeka_Belrapzo | Download (PDF) |
| Trelstar PA CCI | Download (PDF) |
| Tremfya | Download (PDF) |
| Tretin-X | Download (PDF) |
| Tretinoin PA CCI | Download (PDF) |
| Trientine PA CCI | Download (PDF) |
| Trikafta PA CCI | Download (PDF) |
| Trikafta QL CCI | Download (PDF) |
| Trintellix PA CCI | Download (PDF) |
| Triptan Nasal Sprays PA CCI | Download (PDF) |
| Triptans QL | Download (PDF) |
| Trisenox (arsenic trioxide) | Download (PDF) |
| Trodelvy (sacituzumab govitecan-hziy) | Download (PDF) |
| Tudorza | Download (PDF) |
| Tukysa PA CCI | Download (PDF) |
| Tukysa QL CCI | Download (PDF) |
| Turalio PA CCI | Download (PDF) |
| Turalio QL CCI | Download (PDF) |
| Tuzistra XR PA CCI. | Download (PDF) |
| Tykerb | Download (PDF) |
| Tyvaso PA CCI | Download (PDF) |
| U back to top |
Download (PDF) |
|---|---|
| Ubrelvy PA CCI | Download (PDF) |
| Ubrelvy QL CCI | Download (PDF) |
| Uceris Rectal Foam PA CCI | Download (PDF) |
| Ulcerative Colitis ST CCI | Download (PDF) |
| Ultomiris (ravulizumab) | Download (PDF) |
| Unituxin (dinutuximab) | Download (PDF) |
| Upneeq PA CCI | Download (PDF) |
| Uptravi PA CCI | Download (PDF) |
| Utopic | Download (PDF) |
| V back to top |
Download (PDF) |
|---|---|
| Valchlor PA CCI | Download (PDF) |
| Valstar (valrubicin) | Download (PDF) |
| Valtoco PA CCI | Download (PDF) |
| Vectibix (panitumumab) | Download (PDF) |
| Velcade (bortezomib) | Download (PDF) |
| Veltassa | Download (PDF) |
| Vemlidy PA CCI | Download (PDF) |
| Ventavis PA CCI | Download (PDF) |
| Verquvo PA CCI | Download (PDF) |
| Vimovo PA CCI | Download (PDF) |
| Vitamin D2 Analogs PA CCI | Download (PDF) |
| Vitrakvi QL | Download (PDF) |
| Vitrakvi | Download (PDF) |
| Vizimpro QL | Download (PDF) |
| Vizimpro | Download (PDF) |
| Voraxaze | Download (PDF) |
| Vumerity PA CCI | Download (PDF) |
| Vusion | Download (PDF) |
| Vyndaqel QL CCI | Download (PDF) |
| Vyxeos | Download (PDF) |
| W back to top |
Download (PDF) |
|---|---|
| Wakix PA CCI | Download (PDF) |
| Wellbutrin XL QL CCI | Download (PDF) |
| X back to top |
Download (PDF) |
|---|---|
| Xadago | Download (PDF) |
| Xcopri PA CCI | Download (PDF) |
| Xeljanz | Download (PDF) |
| Xenleta PA CCI | Download (PDF) |
| Xenleta QL CCI | Download (PDF) |
| Xerese PA CCI | Download (PDF) |
| Xermelo | Download (PDF) |
| Xhance ST CCI | Download (PDF) |
| Xifaxan PA CCI | Download (PDF) |
| Xofluza QL CCI | Download (PDF) |
| Xolair | Download (PDF) |
| Xospata QL | Download (PDF) |
| Xospata | Download (PDF) |
| Xpovio PA CCI | Download (PDF) |
| Xtandi PA CCI | Download (PDF) |
| Xuriden PA CCI | Download (PDF) |
| Xyrem | Download (PDF) |
| Xywav PA CCI | Download (PDF) |
| Y back to top |
Download (PDF) |
|---|---|
| Yervoy (ipilimumab) | Download (PDF) |
| Yondelis (trabectedin) | Download (PDF) |
| Yonsa | Download (PDF) |
| Z back to top |
Download (PDF) |
|---|---|
| Zaltrap (ziv-aflibercept) | Download (PDF) |
| Zavesca | Download (PDF) |
| Zejula PA CCI | Download (PDF) |
| Zelboraf PA CCI | Download (PDF) |
| Zelnorm PA CCI | Download (PDF) |
| Zeposia PA CCI | Download (PDF) |
| Zepzelca (lurbinectedin) | Download (PDF) |
| Zokinvy PA CCI | Download (PDF) |
| Zolinza (vorinostat) | Download (PDF) |
| Zolpidem | Download (PDF) |
| Zontivity PA CCI | Download (PDF) |
| Zortress | Download (PDF) |
| Zurampic--Duzallo | Download (PDF) |
| Zyflo PA CCI | Download (PDF) |
| Zynlonta (loncastuzimab tesirine-lpyl) | Download (PDF) |
