 |
|
|
|
Browse alphabetically to medications listed in
the Medication Policy:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
Browse policies by generic name:
|
|
Policy Name |
Revised |
|
|
|
|
|
|
| A |
|
|
|
| | abatacept, Orencia®
| 06/01/2012 |
| | abiraterone, Zytiga™
| 02/01/2013 |
| | abobotulinumtoxinA, Dysport®
| 04/01/2012 |
| | adalimumab, Humira®
| 04/01/2013 |
| | ado-trasuzumab emtansine, Kadcyla™
| 06/01/2013 |
| | aflibercept, Eylea™
| 05/25/2012 |
| | aliskiren-containing medications (Tekturna, Tekturna HCT®, Valturna®, Amturnide™, Tekamlo™)
| 04/01/2013 |
| | almotriptan, Axert®
| 02/01/2013 |
| | alogliptin-containing medications (Nesina®, Kazano®, Oseni®)
| 04/01/2013 |
| | ambrisentan, Letairis®
| 07/13/2012 |
| | amphetamine-dexroamphetamine ER
| 06/01/2013 |
| | anakinra, Kineret®
| 04/01/2013 |
| | aripiprazole, Abilify®
| 02/01/2013 |
| | armodafinil, Nuvigil®
| 11/01/2012 |
| | asenapine, Saphris®
| 02/01/2013 |
| | atorvastatin/ezetinibe, Liptruzet™
| 06/01/2013 |
| | avanafil, Stendra™
| 08/01/2012 |
| | axitinib, Inlyta®
| 07/01/2012 |
| | azilsartan-containing medications (Edarbi™, Edarbyclor™)
| 04/01/2013 |
|
|
| B |
|
|
|
| | beclomethasone nasal, Beconase AQ®, QNasal™
| 04/01/2013 |
| | belimumab, Benlysta®
| 05/25/2012 |
| | bevacizumab, Avastin®
| 11/01/2012 |
| | boceprevir, Victrelis™
| 11/01/2012 |
| | bortezomib, Velcade®
| 11/01/2012 |
| | bosentan, Tracleer®
| 07/13/2012 |
| | bosutinib, Bosulif®
| 02/01/2013 |
| | botulinum toxic Type B, MyoBloc®
| 04/01/2013 |
| | brentuximab, Adcetris™
| 12/01/2012 |
| | budesonide nasal, Rhinocort Aqua®
| 04/01/2013 |
|
|
| C |
|
|
|
| | C1 inhibitor (human), Cinryze™
| 12/01/2012 |
| | cabazitaxel, Jevtana®
| 02/01/2013 |
| | cabozantinib, Cometriq™
| 02/01/2013 |
| | canagliflozin, Invokana™
| 06/01/2013 |
| | canakinumab, Ilaris®
| 07/13/2012 |
| | candesartan-containing medications (Atacand, Atacand® HCT), Atacand®
| 04/01/2013 |
| | capsaicin 8% patch, Qutenza®
| 07/13/2012 |
| | carfilzomib, Kyprolis™
| 04/01/2013 |
| | celecoxib, Celebrex®
| 12/01/2012 |
| | certolizumab pegol, Cimzia®
| 02/01/2013 |
| | cetuximab, Erbitux®
| 11/01/2012 |
| | ciclesonide nasal, Omnaris®, Zetonna™
| 04/01/2013 |
| | Compounded Medications
| 02/01/2013 |
| | Contraceptives for Medical Conditions, Self-administered
| 04/01/2013 |
| | crizotinib, Xalkori®
| 12/01/2012 |
|
|
| D |
|
|
|
| | dalfampridine, Ampyra™
| 12/01/2012 |
| | dasatinib, Sprycel®
| 07/01/2012 |
| | denosumab, Prolia™, Xgeva™
| 07/13/2012 |
| | desvenlafaxine, Pristiq™
| 05/25/2012 |
| | dexlansoprazole, Dexilant®
| 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 |
| | diclofenac topical patch (Flector®, Pennsaid®)
| 02/01/2013 |
| | dimethyl fumarate, Tecfidera™
| 06/01/2013 |
| | doxorubicin liposomal injection, Doxil®
| 04/01/2013 |
| | doxycycline hyclate, Doryx®
| 04/01/2013 |
| | duloxetine, Cymbalta®
| 05/25/2012 |
|
|
| E |
|
|
|
| | eletriptan, Relpax®
| 02/01/2013 |
| | eltrombopag, Promacta®
| 06/01/2012 |
| | enzalutamide, Xtandi®
| 11/01/2012 |
| | eprosartan-containing medications (Teveten®, Teveten HCT®)
| 04/01/2013 |
| | eribulin, Halaven™
| 02/01/2013 |
| | erlotinib, Tarceva®
| 07/01/2012 |
| | erwina chrysanthemi, Erwinaze®
| 02/01/2013 |
| | esomeprazole-containing medications, Nexium®, Vimovo™
| 02/01/2013 |
| | eszopiclone, Lunesta®
| 05/25/2012 |
| | etanercept, Enbrel®
| 02/01/2013 |
| | everolimus, Afinitor®
| 07/01/2012 |
| | exenatide-containing medications, Bydureon®, Byetta®
| 06/01/2012 |
|
|
| F |
|
|
|
| | fentanyl buccal soluble film, Onsolis™
| 11/01/2012 |
| | fentanyl buccal tablet, Fentora®
| 11/01/2012 |
| | fentanyl citrate oral transmucosal lozenges, Actiq®
| 11/01/2012 |
| | fentanyl nasal spray, Lazanda™
| 11/01/2012 |
| | fentanyl sublingual spray, Subsys®
| 11/01/2012 |
| | fentanyl sublingual tablets, Abstral®
| 11/01/2012 |
| | fingolimod, Gilenya™
| 12/01/2012 |
| | fluticasone furoate nasal, Veramyst®
| 04/01/2013 |
| | fluticasone propionate with azelastine nasal, Dymista™
| 04/01/2013 |
| | frovatriptan, Frova®
| 02/01/2013 |
|
|
| G |
|
|
|
| | golimumab, Simponi®
| 02/01/2013 |
| | Growth Hormone
| 12/01/2012 |
|
|
| H |
|
|
|
| | high molecular weight hyaluronan, Orthovisc®
| 05/25/2012 |
| | hydroxyprogesterone caproate, Makena™
| 11/01/2012 |
| | hylan G-F-20, Synvisc®/Synvisc-One®
| 05/25/2012 |
|
|
| I |
|
|
|
| | icatibant, Firazyr®
| 12/01/2012 |
| | iloperidone, Fanapt®
| 02/01/2013 |
| | iloprost inhalation, Ventavis®
| 07/13/2012 |
| | imatinib mesylate, Gleevec®
| 02/01/2013 |
| | imiglucerase, Cerezyme®
| 07/13/2012 |
| | incobotulinumtoxinA, Xeomin®
| 03/16/2012 |
| | infliximab, Remicade®
| 04/01/2013 |
| | interferon beta-1b, Betaseron®, Extavia®
| 12/01/2012 |
| | ipilimumab, Yervoy™
| 09/01/2012 |
| | Immune Globulin Replacement Therapy(IVIG, SQ), (Carimune NF®, Flebogamma® DIF, Gammagard®, Gammagard S/D®, Gammaplex®, Gamunex®, Hizentra™(SQ preparation), Octagam®, Privigen®)
| 05/25/2012 |
| | ivacaftor, Kalydeco™
| 04/01/2013 |
|
|
| L |
|
|
|
| | lansoprazole, Prevacid®
| 02/01/2013 |
| | lapatinib, Tykerb®
| 11/01/2012 |
| | lenalidomide, Revlimid®
| 11/01/2012 |
| | levonorgestrel-containing Intrauterine System (LNG-IUS) for Medical Conditions, Mirena®, Skyla
| 04/01/2013 |
| | linagliptin,Tradjenta®
| 05/25/2012 |
| | liraglutide, Victoza®
| 05/25/2012 |
| | lomitapide, Juxtapid™
| 06/01/2013 |
| | lurasidone, Latuda®
| 02/01/2013 |
|
|
| M |
|
|
|
| | Maximum Drug Dosage
| 04/01/2013 |
| | mecasermin, Increlex®
| 02/01/2013 |
| | Medical Exception Criteria for Closed Pharmacy Benefit Designs
| 12/01/2012 |
| | Medical Exception Criteria for Tiered Benefit Designswith Tier Copay Exceptions
| 12/01/2012 |
| | Medication Policy Manual Introduction
| 02/01/2013 |
| | methylnaltrexone, Relistor®
| 11/01/2012 |
| | mifepristone, Korlym™
| 08/13/2012 |
| | miglustat, Zavesca®
| 03/02/2012 |
| | milnacipran, Savella™
| 05/25/2012 |
| | minocycline HCI, Solodyn®
| 04/01/2013 |
| | mipomersen, Kynamro™
| 06/01/2013 |
| | modafinil, Provigil®
| 11/01/2012 |
| | mometasone nasal, Nasonex®
| 04/01/2013 |
|
|
| N |
|
|
|
| | natalizumab, Tysabri®
| 12/01/2012 |
| | nilotinib, Tasigna®
| 02/01/2013 |
|
|
| O |
|
| | ocriplasmin, Jetrea®
| 04/01/2013 |
| | ofatumumab, Arzerra™
| 02/01/2013 |
| | Off-Label Use of FDA Approved Medications
| 02/01/2013 |
| | olmesartan-containing medicaitons (Benicar, Benicar HTC®, AZOR®, Tribenzor™)
| 04/01/2013 |
| | omacetaxine mepesuccinate, Synribo™
| 02/01/2013 |
| | omalizumab, Xolair®
| 07/13/2012 |
| | onabotulinumtoxinA, Botox®
| 03/16/2012 |
| | Opioids for Chronic Non-Cancer Pain
| 11/01/2012 |
| | oseltamivir, Tamiflu®
| 07/13/2012 |
| | oxycodone, Controlled Release, OxyContin®
| 11/01/2012 |
| | oxymorphone, Extended-Release, Opana® ER
| 11/01/2012 |
|
|
| P |
|
|
|
| | paliperidone, Invega®
| 02/01/2013 |
| | palivizumab, Synagis® (respiratory syncytial virus prophylaxis)
| 08/01/2012 |
| | pasireotide, Signifor®
| 06/01/2013 |
| | pazopanib, Votrient™
| 02/01/2013 |
| | pegaptanib, Macugen®
| 05/25/2012 |
| | peginterferon alfa-2a, Pegasys®
| 11/01/2012 |
| | peginterferon alfa-2b, PEG-Intron®
| 11/01/2012 |
| | peginterferon alfa-2b, Sylatron™
| 07/13/2012 |
| | pegloticase, Krystexxa™
| 04/01/2013 |
| | pemetrexed, Alimta®
| 04/01/2013 |
| | perampanel, Fycompa®
| 04/01/2013 |
| | pitavastatin, Livalo®
| 04/01/2013 |
| | pomalidomide, Pomalyst®
| 04/01/2013 |
| | pralatrexate, Folotyn™
| 02/01/2013 |
| | pregabalin, Lyrica®
| 08/01/2012 |
|
|
| Q |
|
|
|
| | quinine, Qualaquin®
| 12/01/2012 |
|
|
| R |
|
|
|
| | rabeprazole, Aciphe®
| 02/01/2013 |
| | ramelteon, Rozerem™
| 05/25/2012 |
| | ranibizumab, Lucentis®
| 05/25/2012 |
| | regorafenib, Stivarga®
| 12/01/2012 |
| | respiratory syncytial virus prophylaxis, Synagis®
| 08/01/2012 |
| | rilonacept, Arcalyst®
| 07/13/2012 |
| | rimabotulinumtoxin B, MyoBloc®
| 04/01/2013 |
| | risedronate & Actonel with Calcium risedronate with calcium), Actonel®
| 07/13/2012 |
| | rituximab, Rituxan®
| 04/01/2013 |
| | rizatriptan, Maxalt®, Maxalt MLT®
| 02/01/2013 |
| | romidepsin, Istodax®
| 02/01/2013 |
| | romiplostim, Nplate®
| 06/01/2012 |
| | rosiglitazone, Avandia®
| 05/25/2012 |
| | rosiglitizone/glimepiride, Avandaryl®
| 05/25/2012 |
| | rosiglitizone/metformin, Avandamet®
| 05/25/2012 |
| | rosuvastatin, Crestor®
| 04/01/2013 |
| | ruxolitinib, Jakafi™
| 02/01/2013 |
|
|
| S |
|
|
|
| | saxagliptin, containing medications (Onglyza, Kombiglyze XR®)
| 05/25/2012 |
| | Self-Administered Contraceptives for Medical Conditions
| 04/01/2013 |
| | Self-Adminsitered Injectables
| 02/01/2013 |
| | sildenafil 20 mg, Revatio®
| 12/01/2012 |
| | sildenafil, Viagra®
| 12/01/2012 |
| | simvastatin/ezetimibe, Vytorin®
| 04/01/2013 |
| | sipuleucel-T, Provenge®
| 02/01/2013 |
| | sitagliptin-Containing Medications (Januvia®, Janumet®, Janumet XR®, Juvisync®)
| 05/25/2012 |
| | 1% sodium hyaluronate, Euflexxa®
| 05/25/2012 |
| | sodium hyaluronate, Gel-One®
| 06/01/2012 |
| | sodium hyaluronate, Hyalgan®
| 05/25/2012 |
| | sodium hyaluronate, Supartz®
| 05/25/2012 |
| | sodium oxybate, Xyrem®
| 11/01/2012 |
| | somatropin, Genotropin®, Humatrope®, Norditropin®, Nutropin®, Nutropin AQ®, Omnitrope®, Saizen®, Serostim®, Serostim LQ®, Tev-Tropin®, Zorbtive®
| 12/01/2012 |
| | sorafenib, Nexavar®
| 07/01/2012 |
| | sumatriptan, Alsuma®
| 02/01/2013 |
| | sumatriptan, Imitrex®
| 02/01/2013 |
| | sumatriptan, Imitrex® Injectable
| 02/01/2013 |
| | sumatriptan, Sumavel™, DosePro™
| 02/01/2013 |
| | sumatriptan/naproxen, Treximet™
| 02/01/2013 |
| | sunitinib, Sutent®
| 07/01/2012 |
|
|
| T |
|
|
|
| | tadalafil, Adcirca®
| 07/13/2012 |
| | tadalafil, Cialis®
| 07/13/2012 |
| | taliglucerase alfa, Elelyso™
| 08/01/2012 |
| | teduglutide, Gattex®
| 06/01/2013 |
| | telaprevir, Incivek™
| 11/01/2012 |
| | telmisartan-containing medications(Micardis, Micardis HCT®), Micardis®
| 04/01/2013 |
| | teriflunomide, Aubagio®
| 12/01/2012 |
| | teriparatide, Forteo®
| 07/13/2012 |
| | tesamorelin, Egrifta™
| 02/01/2013 |
| | Testosterone replacement therapy products (Axiron®, Fortesta®, Testim Gel®, Androderm®, Striant®)
| 04/01/2013 |
| | tetrabenazine, Xenazine®
| 04/01/2013 |
| | tocilizumab, Actemra®
| 02/01/2013 |
| | tofacitinib, Xeljanz®
| 02/01/2013 |
| | treprostinil inhalation, Tyvaso®
| 07/13/2012 |
| | treprostinil injectable, Remodulin®
| 07/13/2012 |
| | tretinoin, topical (Atralin®, Avita®, Renova®, Retin A®, Retin A Micro®, Tretin-X®)
| 07/13/2012 |
|
|
| U |
|
|
|
| | ustekinumab, Stelara™
| 02/01/2013 |
|
|
| V |
|
|
|
| | valsartan-containing medications(Diovan®, Diovan HCT®, Exforge®, Exforge HCT®,)
| 04/01/2013 |
| | vandetanib, Caprelsa®
| 08/01/2012 |
| | vardenafil, Levitra®, Staxyn®
| 07/13/2012 |
| | velaglucerase, VPRIV™
| 08/01/2012 |
| | vemurafenib, Zelboraf™
| 12/01/2012 |
| | vilazodone, Viibryd™
| 05/25/2012 |
| | vincristine sulfate liposome, Marqibo®
| 11/01/2012 |
| | vismodegib, Erivedge™
| 04/01/2013 |
| | vorinostat, Zolinza®
| 02/01/2013 |
|
|
| Z |
|
|
|
| | zanamivir, Relenza®
| 07/13/2012 |
| | ziv-aflibercept, Zaltrap®
| 11/01/2012 |
| | ziprasidone, Geodon®
| 02/01/2013 |
| | zoledronic acid, Reclast®
| 07/13/2012 |
| | zoledronic acid, Zometa®
| 07/13/2012 |
| | zolmitriptan, Zomig®/Zomig-ZMT®
| 02/01/2013 |
| | zolpidem MR, Ambien CR®
| 05/25/2012 |
| | zolpidem sublingual, Edluar®
| 05/25/2012 |
| | zolpidem sublingual, Intermezzo®
| 05/25/2012 |
| | zolpidem, ZolpiMist®
| 05/25/2012 |
| |
|
|
| |
|
|
| |
|
|
|
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.
|
|
|
|
