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Browse policies by brand name | Browse
policies by generic name | View
recent medication policy updates (PDF) | View
past medication policy updates
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Policy Name |
Revised |
| A |
|
| |
abatacept,
Orencia® |
11/14/2008 |
| |
adalimumab,
Humira® |
11/14/2008 |
| |
alefacept,
Amevive® |
11/14/2008 |
| |
almotriptan,
Axert® |
11/14/2008 |
| |
almotriptan,
Axert®, effective December 1, 2009 |
10/28/2009 |
| |
amphetamine-dextroamphetamine ER capsules |
05/08/2009 |
| |
anakinra, Kineret® |
11/14/2008 |
| |
Antineoplaston
Cancer Therapy |
03/18/2008 |
| |
aprepitant, Emend® |
01/09/2009 |
| |
armodafinil, Nuvigil® |
07/17/2009 |
| |
atorvastatin,
Lipitor® |
04/07/2009 |
| B |
|
| |
beclomethasone nasal,
Beconase AQ® |
04/07/2009 |
| |
bortezomib, Velcade® Effective date February 1, 2010 |
09/11/2009 |
| |
botulinum
toxin Type A, Botox® |
04/07/2009 |
| |
botulinum
toxin Type B, MyoBloc® |
04/07/2009 |
| |
budesonide nasal, Rhinocort Aqua® |
04/07/2009 |
| C |
|
| |
C1 inhibitor (human), Cinryze™ |
03/13/2009 |
| |
canakinumab, Illaris® |
07/17/2009 |
| |
celecoxib, Celebrex® |
11/14/2008 |
| |
certolizumab
pegol, Cimzia® |
07/17/2009 |
| |
cetuximab, Erbitux® Effective date February 1, 2010 |
09/11/2009 |
| |
ciclesonide nasal,
Omnaris™ |
04/07/2009 |
| |
ciclopirox,
Penlac® |
07/17/2009 |
| |
Compounded
Medications |
07/18/2008 |
| D |
|
| |
darbepoetin, Aranesp® |
05/09/2008 |
| |
dasatinib, Sprycel® |
11/14/2008 |
| |
desvenlafaxine,
Pristiq™ |
05/08/2009 |
| |
dexlansoprazole, Kapidex™ |
09/11/2009 |
| |
dolasetron,
Anzemet ® |
11/14/2008 |
| |
duloxetine,
Cymbalta® |
05/08/2009 |
| E |
|
| |
efalizumab,
Raptiva® |
11/14/2008 |
| |
eletriptan,
Relpax® |
11/14/2008 |
| |
eletriptan,
Relpax®, effective December 1, 2009 |
10/28/2009 |
| |
eltrombopag,
Promacta® |
05/08/2009 |
| |
epoetin alfa,
Epogen®, Procrit® |
05/09/2008 |
| |
erlotinib,
Tarceva® |
07/17/2009 |
| |
escitalopram,
Lexapro® |
05/08/2009 |
| |
esomeprazole, Nexium® |
09/11/2009 |
| |
eszopiclone,
Lunesta® |
05/08/2009 |
| |
etanercept,
Enbrel® |
11/14/2008 |
| |
everolimus, Afinitor® |
05/08/2009 |
| |
exenatide,
Byetta® |
05/08/2009 |
| F |
|
| |
fentanyl
buccal tablet, Fentora® |
09/11/2009 |
| |
fentanyl
buccal soluble film, Onsolis™ |
09/11/2009 |
| |
fentanyl
citrate oral transmucosal lozenges, Actiq® |
09/11/2009 |
| |
fluticasone furoate nasal, Veramyst® |
04/07/2009 |
| |
fluvoxamine
extended-release capsules, Luvox® CR |
05/08/2009 |
| |
frovatriptan, Frova® |
11/14/2008 |
| |
frovatriptan, Frova®, effective December 1, 2009 |
10/28/2009 |
| G |
|
| |
golimumab, Simponil® |
08/12/2009 |
| |
granisetron, Kytril® |
11/14/2008 |
| |
granisetron topical patches, Sancuso® |
11/14/2008 |
| |
Growth
Hormone |
07/17/2009 |
| I |
|
| |
ibandronate
injection,
Boniva® |
07/17/2009 |
| |
ibandronate
oral,
Boniva® |
07/17/2009 |
| |
imatinib
mesylate, Gleevec® |
11/14/2008 |
| |
imiglucerase,
Cerezyme® |
01/09/2009 |
| |
infliximab,
Remicade® |
05/08/2009 |
| |
interferon
alfacon-1, Infergen® |
05/08/2009 |
| |
interferon
beta-1b, Betaseron® |
09/11/2009 |
| |
itraconazole
oral, Sporanox® |
07/17/2009 |
| |
Immune
Globulin Replacement Therapy (IVIG, SQ) (Baygam®,
Carimune NF®,
Flebogamma®, Gamastan®,
Gammagard S/D®, Gamunex®,
Iveegam®, Octagam®,
Polygam S/D®,
Privigen®, Vivaglobin® |
05/08/2009 |
| L |
|
| |
lansoprazole,
Prevacid® |
09/11/2009 |
| |
lapatinib,
Tykerb® |
09/11/2009 |
| |
lenalidomide,
Revlimid® |
07/17/2009 |
| |
Lvonorgestrel-containing
Intrauterine System (LNG-IUS)
for Medical Conditions, Mirena® |
04/07/2009 |
| M |
|
| |
mecasermin,
Increlex® |
01/09/2009 |
| |
Medication Policy Manual Introduction |
09/11/2009 |
| |
methylnaltrexone,
Relistor® |
09/11/2009 |
| |
miglustat,
Zavesca® |
01/09/2009 |
| |
milnacipran,
Savella™ |
05/08/2009 |
| |
modafinil,
Provigil® |
07/17/2009 |
| |
mometasone,
Nasal® |
04/07/2009 |
| N |
|
| |
naratriptan,
Amerge® |
11/14/2008 |
| |
naratriptan,
Amerge®, effective December 1, 2009 |
10/28/2009 |
| |
natalizumab,
Tysabri® |
09/11/2009 |
| |
nilotinib,
Tasigna® |
11/14/2008 |
| |
Non-Formulary
Medications, Medical Exception Criteria for Closed
Pharmacy Benefit Designs |
01/09/2009 |
| |
Non-Preferred
Medications, Medical Exception Criteria for Tiered
Benefit Designs with Tier Copay Exceptions |
01/09/2009 |
| O |
|
| |
Off-Label
Use of FDA Approved Medications |
09/11/2009 |
| |
omalizumab,
Xolair® |
07/17/2009 |
| |
ondansetron,
Zofran® |
11/14/2008 |
| |
Opioids
for Chronic Non-Cancer Pain |
11/14/2008 |
| |
oseltamivir, Tamiflu® |
05/08/2009 |
| |
oxycodone,
Controlled Release, OxyContin® |
11/14/2008 |
| |
oxymorphone,
Extended-Release, Opana® ER |
11/14/2008 |
| P |
|
| |
palivizumab,
Synagis® respiratory
syncytial virus prophylaxis) |
09/11/2009 |
| |
palivizumab,
Synagis® respiratory
syncytial virus prophylaxis), Effective January 15, 2010 |
11/05/2009 |
| |
palonosetron,
Aloxi® |
11/14/2008 |
| |
pantoprazole,
Protonix® |
09/11/2009 |
| |
peginterferon
alfa-2a, Pegasys® |
05/08/2009 |
| |
peginterferon
alfa-2b, PEG-Intron® |
05/08/2009 |
| |
pioglitazone,
Actos® |
05/08/2009 |
| |
pioglitazone/glimepiride,
Duetact™ |
05/09/2008 |
| |
pioglitazone/metformin,
ACTOplus met® |
05/09/2008 |
| |
pitavastatin, Livalo® |
09/11/2009 |
| |
pramlintide,
Symlin® |
05/08/2009 |
| |
pregabalin, Lyrica® |
01/09/2009 |
| R |
|
| |
rabeprazole,
Aciphex® |
09/11/2009 |
| |
ramelteon,
Rozerem™ |
05/08/2009 |
| |
respiratory
syncytial virus prophylaxis, Synagis® |
03/15/2007 |
| |
rilonacept,
Arcalyst® |
07/17/2009 |
| |
risedronate,
Actonel®-Containing Medications (Actonel®,
Actonel with Calcium®) |
07/17/2009 |
| |
rizatriptan,
Maxalt®, Maxalt MLT® |
11/14/2008 |
| |
rizatriptan,
Maxalt®, Maxalt MLT®, effective December 1, 2009 |
10/28/2009 |
| |
romiplostim,
Nplate® |
11/14/2008 |
| |
rosiglitazone,
Avandia® |
05/08/2009 |
| |
rosiglitizone/glimepiride,
Avandaryl® |
05/09/2008 |
| |
rosiglitizone/metformin,
Avandamet® |
05/09/2008 |
| |
rosuvastatin,
Crestor® |
04/07/2009 |
| S |
|
| |
saxagliptin, Onglyza® |
09/11/2009 |
| |
sapropterin
dihydrochloride, Kuvan™ |
04/07/2009 |
| |
Self-Administered
Contraceptives for Medical Conditions |
04/07/2009 |
| |
Self-Adminsitered
Injectables |
09/11/2009 |
| |
sildenafil
20 mg, Revatio® |
07/17/2009 |
| |
sildenafil,
Viagra® |
07/17/2009 |
| |
simvastatin/ezetimibe,
Vytorin® |
08/12/2009 |
| |
sitagliptin-Containing
Medications (Januvia®,
Janumet®) |
05/08/2009 |
| |
sodium
oxybate, Xyrem® |
09/11/2009 |
| |
somatropin,
Accretropin®, Genotropin®, Humatrope®,
Norditropin®,
Nutropin®, Nutropin AQ®,
Omnitrope®, Saizen®, Serostim®, Serostim
LQ®, Tev-Tropin®,
Zorbtive® |
07/18/2008 |
| |
sorafenib,
Nexavar® |
04/07/2009 |
| |
sumatriptan,
Imitrex® |
11/14/2008 |
| |
sumatriptan,
Imitrex®, effective December 1, 2009 |
10/28/2009 |
| |
sumatriptan,
Sumavel™ DosePro™, effective December 1, 2009 |
10/28/2009 |
| |
sumatriptan/naproxen,
Treximet™ |
11/14/2008 |
| |
sumatriptan/naproxen,
Treximet™, effective December 1, 2009 |
10/28/2009 |
| |
sunitinib,
Sutent® |
04/07/2009 |
| T |
|
| |
tadalafil,
Adcirca™ |
07/17/2009 |
| |
tadalafil,
Cialis® |
07/17/2009 |
| |
terbinafine
oral, Lamisil® |
07/17/2009 |
| |
teriparatide,
Forteo® |
07/17/2009 |
| |
tetrabenazine,
Xenazine® |
04/07/2009 |
| |
topical tretinoin (Altinac®,
Atralin®, Avita®, Renova®, Retin A®,
Retin A Micro®, Solage®) |
07/17/2009 |
| |
triamcinolone nasal,
AllerNaze™ |
04/07/2009 |
| |
triamcinolone nasal,
Nasacort AQ® |
04/07/2009 |
| V |
|
| |
vardenafil,
Levitra® |
07/17/2009 |
| |
venlafaxine
extended-release capsules, Effexor XR® |
09/11/2009 |
| |
vorinostat,
Zolinza® |
04/07/2009 |
| Z |
|
| |
zaleplon,
Sonata® |
05/08/2009 |
| |
zanamivir,
Relenza® |
05/08/2009 |
| |
zoledronic acid,
Reclast® |
07/17/2009 |
| |
zolmitriptan,
Zomig®, Zomig ZMT® |
11/14/2008 |
| |
zolmitriptan,
Zomig®, Zomig ZMT®, effective December 1, 2009 |
10/28/2009 |
| |
zolpidem
MR, Ambien CR® |
05/08/2009 |
| |
zolpidem,
Ambien® |
05/08/2009 |
| |
zolpidem,
Edluar® |
05/08/2009 |
| |
zolpidem,
ZolpiMist® |
05/08/2009 |
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