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Browse alphabetically to medications listed in
the Medication Policy:
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Browse policies by brand name:
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Policy Name |
Revised |
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| A |
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| | Abilify®, aripiprazole
| 02/01/2013 |
| | Abstral®, fentanyl sublingual tablets
| 11/01/2012 |
| | Aciphex®, rabeprazole
| 02/01/2013 |
| | Actemra®, tocilizumab
| 02/01/2013 |
| | Actiq®, fentanyl citrate oral transmucosal lozenges
| 11/01/2012 |
| | Actos®, pioglitazone - containing medications (Actos, ACTOplus Met®, Duetact™)
| 05/25/2012 |
| | Adcetris™, brentuximab
| 12/01/2012 |
| | Adcirca®, tadalafil 20 mg
| 07/13/2012 |
| | Afinitor®, everolimus
| 07/01/2012 |
| | Alimta®, pemetrexed
| 04/01/2013 |
| | Alsuma®, sumatriptan
| 02/01/2013 |
| | Ambien CR®, zolpidem MR
| 05/25/2012 |
| | Ampyra™, dalfampridine
| 12/01/2012 |
| | Amturnide™, alisksartan-containing medications (Tekturna®, Tekturna HCT®, Tekamlo™, Valturna®)
| 04/01/2013 |
| | Androderm®, testosterone replacement therapy products
| 04/01/2013 |
| | Arcalyst®, rilonacept
| 07/13/2012 |
| | Arzerra™, ofatumumab
| 02/01/2013 |
| | Atacand®/Atacand® HCT, candesartan-containing medications (Atacand, Atacand® HCT)
| 04/01/2013 |
| | Atralin®, tretinoin topical
| 07/13/2012 |
| | Aubagio®, teriflunomid
| 12/01/2012 |
| | Avandamet®, rosiglitazone/metformin
| 05/25/2012 |
| | Avandaryl®, rosiglitazone/glimepiride
| 05/25/2012 |
| | Avandia®, rosiglitazone-containing Medications (Avandia®, Avandamet®, Avandaryl®)
| 05/25/2012 |
| | Avastin®, bevacizumab
| 11/01/2012 |
| | Avita®, tretinoin topical
| 07/13/2012 |
| | Axert®, almotriptan
| 02/01/2013 |
| | Axiron®, testosterone replacement therapy products
| 04/01/2013 |
| | AZOR®, olmesartan-containing medications (Benicar®, Benicar HCT®, Tribensor™)
| 04/01/2013 |
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| B |
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| | Beconase AQ®, beclomethasone nasal
| 04/01/2013 |
| | Benicar®/Benicar HCT®, olmesartan-containing medications (Benicar, Benicar HCT®, AZOR®, Tribenzor™)
| 04/01/2013 |
| | Benlysta®, belimumab
| 05/25/2012 |
| | Betaseron®, interferon beta-1b
| 12/01/2012 |
| | Bosulif®, bosutinib
| 02/01/2013 |
| | Botox®, onabotulinumtoxinA Injection
| 03/16/2012 |
| | Bydureon®, exenatide
| 06/01/2012 |
| | Byetta®, exenatide
| 06/01/2012 |
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| C |
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| | Caprelsa®, vandetanib
| 08/01/2012 |
| | Carimune NF (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Celebrex®, celecoxib
| 12/01/2012 |
| | Cerezyme®, imiglucerase
| 08/01/2012 |
| | Cialis®, tadalafil
| 07/13/2012 |
| | Cimzia®, certolizumab pegol
| 02/01/2013 |
| | Cinryze™, C1 inhibitor (human)
| 12/01/2012 |
| | Cometriq™, cabozantinib
| 02/01/2013 |
| | Compounded Medications
| 02/01/2013 |
| | Contraceptives for Medical Conditions, Self-administered
| 04/01/2013 |
| | Crestor®, rosuvastatin
| 04/01/2013 |
| | Cymbalta®, duloxetine
| 05/25/2012 |
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| D |
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| | Dexilant®, dexlansoprazole
| 02/01/2013 |
| | Diabetic Test Supply: Abbott Blood Glucose Meters and Testing Strips; (Including, but not limited to FreeStyle Lite, FreeStyle Freedom Lite, and Precision Xtra)
| 12/01/2012 |
| | Diabetic Test Supply: LifeScan (OneTouch) Blood Glucose Meters and Testing Strips (including, but not limited to OneTouch Ultra, OneTouch Select, OneTouch SureStep, and OneTouch FastTake)
| 12/01/2012 |
| | Diabetic Test Supply: Roche Blood Glucose Meters and Testing Strips (including, but not limited to Accu-Chek)
| 12/01/2012 |
| | Diovan®/Diovan HCT®, valsartan-containing medications (Diovan, Diovan HCT®, Exforge®, Exforge HCT®)
| 04/01/2013 |
| | Doryx®, doxycycline hyclate
| 04/01/2013 |
| | Doxil®, doxorubicin liposomal Injection
| 04/01/2013 |
| | Dymista®, fluticasone propionate with azelastine nasal spray
| 04/01/2013 |
| | Dysport®, abobotulinumtoxinA Injection
| 03/16/2012 |
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| E |
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| | Edarbi™, azilsartan
| 04/01/2013 |
| | Edarbyclor™, azilsartan
| 04/01/2013 |
| | Edluar®, zolpidem sublingual tablets
| 05/25/2012 |
| | Egrifta™, tesamorelin
| 02/01/2013 |
| | Elelyso™ taliglucerase alfa
| 08/01/2012 |
| | Enbrel®, etanercept
| 02/01/2013 |
| | Erbitux®, cetuximab
| 11/01/2012 |
| | Erivedge™, vismodegib
| 04/01/2013 |
| | Erwinaze®, erwinia chrysanthemi
| 02/01/2013 |
| | Euflexxa®, (1% sodium hyaluronate)
| 05/25/2012 |
| | Exforge®/Exforge HCT®, valsartan-containing medications (Diovan, Diovan HCT®, Exforge®, Exforge HCT®, Valturna®)
| 04/01/2013 |
| | Extavia®, interferon beta-1b
| 12/01/2012 |
| | Eylea™, aflibercept
| 05/25/2012 |
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| | Fanapt®, iloperidone
| 02/01/2013 |
| | Fentora®, fentanyl citrate buccal tablet
| 11/01/2012 |
| | Firazyr®, icatibant
| 12/01/2012 |
| | Flebogamma® DIF (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Flector®, diclofenac topical patch
| 02/01/2013 |
| | Folotyn™, pralatrexate
| 02/01/2013 |
| | Forteo®, teriparatide
| 07/13/2012 |
| | Fortesta®, testosterone replacement therapy products
| 04/01/2013 |
| | Frova®, frovatriptan
| 02/01/2013 |
| | Fycompa®, perampanel
| 04/01/2013 |
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| G |
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| | Gammagard® (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Gammagard S/D®, (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Gammaplex®, (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Gamunex® (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Gel-One® (sodium hyaluronate)
| 06/01/2012 |
| | Genotropin®, somatropin
| 12/01/2012 |
| | Geodon®, ziprasidone
| 02/01/2013 |
| | Gilenya™, fingolimod
| 12/01/2012 |
| | Gleevec®, imatinib mesylate
| 02/01/2013 |
| | Growth Hormone
| 12/01/2012 |
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| H |
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| | Halaven™, eribulin
| 02/01/2013 |
| | Hizentra™ (SQ preparation) (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Humatrope®, somatropin
| 12/01/2012 |
| | Humira®, adalimumab
| 04/01/2013 |
| | Hyalgan®, (sodium hyaluronate)
| 05/25/2012 |
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| I |
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| | Iclusig®, ponatinib
| 04/01/2013 |
| | Ilaris®, canakinumab
| 07/13/2012 |
| | Imitrex®, sumatriptan
| 02/01/2013 |
| | Imitrex® Injectable, sumatriptan
| 02/01/2013 |
| | Immune Globulin Replacement Therapy (IVIG, SQ)
| 05/25/2012 |
| | Incivek™, telaprevir
| 11/01/2012 |
| | Increlex®, mecasermin
| 02/01/2013 |
| | Inlyta®, axitinib
| 04/01/2013 |
| | Intermezzo®, zolpidem sublingual tablets
| 05/25/2012 |
| | Invega®, paliperidone
| 02/01/2013 |
| | Istodax®, romidepsin
| 02/01/2013 |
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| J |
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| | Jakafi™, ruxolitinib
| 02/01/2013 |
| | Januvia®, sitagliptin-Containing Medications (Januvia, Janumet®)
| 05/25/2012 |
| | Jetrea®, ocriplasmin
| 04/01/2013 |
| | Jevtana®, cabazitaxel
| 02/01/2013 |
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| K |
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| | Kalydeco™, ivacaftor
| 04/01/2013 |
| | Kazano®, alogliptan-containing medications (Nesina®, Oseni®)
| 04/01/2013 |
| | Kineret®, anakinra
| 04/01/2013 |
| | Kombiglyze XR®, saxagliptin-containing medications (Onglyza®, Kombiglyze®)
| 05/25/2012 |
| | Korlym™, mifepristone
| 08/01/2012 |
| | Krystexxa™, pegloticase
| 04/01/2013 |
| | Kyprolis™, carfilzomib
| 04/01/2013 |
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| L |
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| | Latuda®, lurasidone
| 02/01/2013 |
| | Lazanda™, fentanyl nasal spray
| 11/01/2012 |
| | Letairis®, ambrisentan
| 07/13/2012 |
| | Levitra®, vardenafil
| 07/13/2012 |
| | Livalo®, pitavastatin
| 04/01/2013 |
| | Lucentis®, ranibizumab
| 05/25/2012 |
| | Lunesta®, eszopiclone
| 05/25/2012 |
| | Lyrica®, pregabalin
| 08/01/2012 |
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| M |
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| | Macugen®, pegaptanib
| 05/25/2012 |
| | Makena™, hydroxyprogesterone caproate
| 11/01/2012 |
| | Marqibo®, vincristine sulfate liposome injection
| 11/01/2012 |
| | Maxalt®, Maxalt MLt®, rizatriptan
| 02/01/2013 |
| | Maximum Drug Dosage
| 04/01/2013 |
| | Medical Exception Criteria for Closed Pharmacy Benefit Designs
| 11/01/2012 |
| | Medical Exception Criteria for Tiered Benefit Designs with Tier Copay Exceptions
| 12/01/2012 |
| | Medication Policy Manual Introduction
| 02/01/2013 |
| | Micardis®/Micardis HCT®, telmisartan-containing medications (Micardis, Micardis HCT®, Twynsta®))
| 04/01/2013 |
| | Mirena®, Skyla™, levonorgestrel-containing Intrauterine System (LNG-IUS) for Medical Conditions
| 04/01/2013 |
| | Myobloc®, rimabotulinumtoxin B
| 04/01/2013 |
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| N |
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| | Nasonex®, mometasone nasal
| 04/01/2013 |
| | Nesina®, alogliptan-containing medications (Kazano®, Oseni®)
| 04/01/2013 |
| | Nexavar®, sorafenib
| 02/01/2013 |
| | Nexium®, esomeprazole
| 02/01/2013 |
| | Norditropin®, somatropin
| 12/01/2012 |
| | Nplate®, romiplostim
| 06/01/2012 |
| | Nutropin®, somatropin
| 12/01/2012 |
| | Nutropin AQ®, somatropin
| 12/01/2012 |
| | Nuvigil®, armodafinil
| 11/01/2012 |
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| O |
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| | Octagam® (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Off-Label Use of FDA Approved Drugs
| 02/01/2013 |
| | Omnaris™, ciclesonide nasal
| 04/01/2013 |
| | Omnitrope®, somatropin
| 12/01/2012 |
| | Onglyza®, saxagliptin-containing medications (Kombiglyze®)
| 05/25/2012 |
| | Onsolis™, fentanyl buccal soluble film
| 11/01/2012 |
| | Opana® ER, oxymorphone, Extended-Release
| 11/01/2012 |
| | Opioids for Chronic Non-Cancer Pain
| 11/01/2012 |
| | Orencia®, abatacept
| 06/01/2012 |
| | Orthovisc®, (high molecular weight hyaluronan)
| 05/25/2012 |
| | Oseni®, alogliptan-containing medications (Kazano®, Nesina®)
| 04/01/2013 |
| | OxyContin®, oxycodone CR
| 11/01/2012 |
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| P |
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| | Pegasys®, peginterferon alfa-2a
| 11/01/2012 |
| | PEG-Intron®, peginterferon alfa-2b
| 11/01/2012 |
| | Pennsaid®, diclofenac topical solution
| 02/01/2013 |
| | Perjeta™, pertuzumab
| 04/01/2013 |
| | Pomalyst®, pomalidomide
| 04/01/2013 |
| | Prevacid®, lansoprazol
| 02/01/2013 |
| | Pristiq™, desvenlafaxine
| 05/25/2012 |
| | Privigen® (Immune Globulin Replacement Therapy)
| 05/25/2012 |
| | Prolia™, denosumab
| 07/13/2012 |
| | Promacta®, eltrombopag
| 06/01/2012 |
| | Provenge®, sipuleucel-T
| 02/01/2013 |
| | Provigil®, modafinil
| 11/01/2012 |
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| Q |
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| | QNasl™ , beclomethasone nasal
| 06/01/2012 |
| | Qualaquin®, quinine
| 12/01/2012 |
| | Qutenza®, capsaicin 8% patch
| 07/13/2012 |
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| R |
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| | Reclast®, Zometa®, zoledronic acid
| 07/13/2012 |
| | Relenza®, zanamivir
| 07/13/2012 |
| | Relistor®, methylnaltrexone
| 11/01/2012 |
| | Relpax®, eletriptan
| 02/01/2013 |
| | Remicade®, infliximab
| 04/01/2013 |
| | Remodulin®, treprostinil injectable
| 07/13/2012 |
| | Renova®, tretinoin topical
| 07/13/2012 |
| | Retin A®, tretinoin topical
| 07/13/2012 |
| | Retin A Micro®, tretinoin topical
| 12/01/2012 |
| | Revatio®, sildenafil 20mg
| 12/01/2012 |
| | Revlimid®, lenalidomide
| 11/01/2012 |
| | Rhinocort Aqua®, budesonide nasal
| 11/01/2012 |
| | Rituxan®, rituximab
| 04/01/2013 |
| | Rozerem™, ramelteon
| 05/25/2012 |
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| S |
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| | Saizen®, somatropin
| 12/01/2012 |
| | Saphris®, asenapine
| 02/01/2013 |
| | Savella™, milnacipran
| 05/25/2012 |
| | Self-administered Contraceptives for Medical Conditions
| 04/01/2013 |
| | Self-Administered Injectables
| 02/01/2013 |
| | Serostim®, somatropin
| 12/01/2012 |
| | Serostim LQ®, somatropin
| 12/01/2012 |
| | Simponi®, golimumab
| 12/01/2013 |
| | Skyla™, Mirena®, levonorgestrel-containing intrauterine system (LNG-IUS) for Medical Conditions
| 04/01/2013 |
| | Solodyn®, minocycline HCI
| 04/01/2013 |
| | Sprix®, ketorolac nasal spray
| 02/01/2013 |
| | Sprycel®, dasatinib
| 02/01/2013 |
| | Staxyn®, vardenafil
| 07/13/2012 |
| | Stelara™, ustekinumab
| 02/01/2013 |
| | Stendra™, avanafil
| 04/01/2013 |
| | Stivarga®, regorafenib
| 12/01/2012 |
| | Striant®, testosterone replacement therapy products (Androderm®, Axiron®, Fortesta®, Testin Gel®)
| 04/01/2013 |
| | Subsys™, fentanyl sublingual spray
| 11/01/2012 |
| | Sumavel™, DosePro™, sumatriptan
| 02/01/2013 |
| | Supartz®, (sodium hyaluronate)
| 05/25/2012 |
| | Sutent®, sunitinib
| 02/01/2013 |
| | Sylatron™, peginterferon alfa-2b
| 07/13/2012 |
| | Synagis®, palivizumab, respiratory syncytial virus immune prophylaxis
| 08/01/2012 |
| | Synribo™, omacetaxine mepesuccinate
| 02/01/2013 |
| | Synvisc®/Synvisc-One® (hylan G-F 20)
| 05/25/2012 |
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| | Tamiflu®, oseltamivir
| 07/13/2012 |
| | Tarceva®, erlotinib
| 07/01/2012 |
| | Tasigna®, nilotinib
| 02/01/2013 |
| | Tekamlo™, alisksartan-containing medications (Tekturna®, Tekturna HCT®, Valturna®, Amturnide™)
| 04/01/2013 |
| | Tekturna®/Tekturna HCT®, alisksartan-containing medications (Tekturna, Tekturna HCT®, Valturna®, Amturnide™, Tekamlo™)
| 04/01/2013 |
| | Testosterone replacement therapy products (Axiron®, Fortesta®, Testim Gel®, Androderm®, Striant®)
| 04/01/2013 |
| | Testim Gel®, testosterone replacement therapy products (Axiron®, Fortesta®, Testim Gel®, Androderm®, Striant®)
| 04/01/2013 |
| | Tev-Tropin®, somatropin
| 12/01/2012 |
| | Teveten®/Teveten HCT®, eprosartan-containing medications (Teveten, Teveten HCT®)
| 04/01/2013 |
| | Tracleer®, bosentan
| 07/13/2012 |
| | Tradjenta®, linagliptin
| 05/25/2012 |
| | Tretin-X®, tretinoin topical
| 07/13/2012 |
| | Treximet™, sumatriptan/naproxen
| 02/01/2013 |
| | TRIBENZOR™, olmesartan-containing medications (Benicar®, Benicare HCT®, AZOR®)
| 04/01/2013 |
| | Twynsta®, telmisartan-containing medications (Micardis®, Micardis HCT®)
| 04/01/2014 |
| | Tykerb®, lapatinib
| 11/01/2012 |
| | Tysabri®, natalizumab
| 12/01/2012 |
| | Tyvaso®, treprostinil inhalation
| 07/13/2012 |
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| | Valturna®, alisksartan-containing medications (Tekturna, Tekturna HCT®, Valturna®)
| 04/01/2013 |
| | Valturna®, valsartan-containing medications (Diovan, Diovan HCT®, Exforge®, Exforge HCT®, Valturna®)
| 04/01/2013 |
| | Velcade®, bortezomib
| 11/01/2012 |
| | Ventavis®, iloprost inhalation
| 07/13/2012 |
| | Veramyst®, fluticasone furoatenasal
| 04/01/2013 |
| | Viagra®, sildenafil
| 12/01/2012 |
| | Victoza®, liraglutide
| 05/25/2012 |
| | Victrelis™, boceprevir
| 11/01/2012 |
| | Viibryd™, vilazodone
| 05/25/2012 |
| | Vimovo™, esomeprazole-containing medications
| 02/01/2013 |
| | Votrient™, pazopanib
| 02/01/2013 |
| | VPRIV™, velaglucerase alfa
| 08/01/2012 |
| | Vytorin®, simvastatin/ezetimibe
| 04/01/2013 |
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| | Xalkori®, crizotinib
| 12/01/2012 |
| | Xeljanz™, tofacitinib
| 02/01/2013 |
| | Xenazine®, tetrabenazine
| 04/01/2013 |
| | Xeomin®, incobotulinumtoxinA Injection
| 03/16/2012 |
| | Xgeva™, denosumab
| 07/13/2012 |
| | Xolair®, omalizumab
| 07/13/2012 |
| | Xtandi®, enzalutamide
| 11/01/2012 |
| | Xyrem®, sodium oxybate
| 11/01/2012 |
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| Y |
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| | Yervoy™, ipilimumab
| 09/01/2012 |
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| | Zaltrap®, ziv-aflibercept
| 11/01/2012 |
| | Zavesca®, miglustat
| 03/02/2012 |
| | Zelboraf™, vemurafenib
| 12/01/2012 |
| | Zetonna™, ciclesonide nasal
| 04/01/2013 |
| | Zolinza™, vorinostat
| 02/01/2013 |
| | ZolpiMist®, zolpidem
| 05/25/2012 |
| | Zometa®, Reclast®, zoledronic acid
| 07/13/2012 |
| | Zomig®, Zomig ZMT®, zolmitriptan
| 02/01/2013 |
| | Zorbtive®, somatropin
| 12/01/2012 |
| | Zytiga™, abiraterone
| 02/01/2013 |
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Comments from physicians and other health care practitioners regarding TRG medication policies are welcome. If you are a physician and have a question or comment regarding a medical policy, please contact the medical policy staff through our secure form.
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