Formularios de autorización de fármacos recetados – Planes de Medicaid
Formularios de excepción especial e información de farmacias de Medicaid
Quantity Limit Exception Request
PDF, 175 KB
PDF, 175 KB
Pharmacy Benefit Oncology Medications
PDF, 208 KB
PDF, 208 KB
Formularios de autorización de fármacos 2024
Abilify Mycite (Non-Preferred)
PDF, 200 KB
PDF, 200 KB
Abrysvo (Pharmacy)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 122 KB
Absorica
PDF, 147 KB
PDF, 147 KB
Actemra | Tyenne SQ (Non-Preferred)
PDF, 215 KB
PDF, 215 KB
Actimmune SQ (Pharmacy benefit)
PDF, 169 KB
PDF, 169 KB
ADHD/Stimulant Medications
(See PA Form for Age Criteria)PDF, 174 KB
(See PA Form for Age Criteria)PDF, 174 KB
Albenza | Emverm
PDF, 189 KB
PDF, 189 KB
Allzital
PDF, 173 KB
PDF, 173 KB
Alvaiz | eltrombopag (Promacta)
PDF, 233 KB
PDF, 233 KB
Alyftrek
PDF, 205 KB
PDF, 205 KB
Anti-Allergen, Orals
(Non-Preferred - Grastek | Odactra | Oralair | Ragwitek)PDF, 156 KB
(Non-Preferred - Grastek | Odactra | Oralair | Ragwitek)PDF, 156 KB
Antibiotics - Inhaled
(PREFERRED- Bethkis 300 mg/4mL (QL, AG) | Kitabis Pak 300mg/5mL (QL, AG) | Tobi Podhaler (QL, AG, SE) | tobramycin inhalation neb solution (QL, AG)) (Non-preferred - Arikayce (QL, PA) | Cayston (QL, AG) | Tobi inhalation neb solution (QL,AG) | tobramycin inhalation (QL, AG) | tobramycin PaK (QL, AG))
PDF, 164 KB
(PREFERRED- Bethkis 300 mg/4mL (QL, AG) | Kitabis Pak 300mg/5mL (QL, AG) | Tobi Podhaler (QL, AG, SE) | tobramycin inhalation neb solution (QL, AG)) (Non-preferred - Arikayce (QL, PA) | Cayston (QL, AG) | Tobi inhalation neb solution (QL,AG) | tobramycin inhalation (QL, AG) | tobramycin PaK (QL, AG))
PDF, 164 KB
Antidepressants
PDF, 171 KB
PDF, 171 KB
Antiemetic-Antivertigo Drugs
(PREFERRED- Diclegis (doxylamine succinate/ vitamin B6) | ondansetron ODT tab/soln | meclizine | metoclopramide tab/soln | prochlorperazine tab | promethazine (AG) (members over 2 yrs of age) | Dronabinol cap | (All Non-Preferred Drugs require PA)
PDF, 174 KB
(PREFERRED- Diclegis (doxylamine succinate/ vitamin B6) | ondansetron ODT tab/soln | meclizine | metoclopramide tab/soln | prochlorperazine tab | promethazine (AG) (members over 2 yrs of age) | Dronabinol cap | (All Non-Preferred Drugs require PA)
PDF, 174 KB
Antifungals - Oral (Non-Preferred)
PDF, 151 KB
PDF, 151 KB
Anti-Migraine Drugs
(PREFERRED: Aimovig | Ajovy | Emgality Pen & Syringe (120mg) | Nurtec ODT | Ubrelvy | Qulipta) (Non-Preferred: Emgality Syringe (100mg) | Vyepti | Zavzpret)
PDF, 206 KB
(PREFERRED: Aimovig | Ajovy | Emgality Pen & Syringe (120mg) | Nurtec ODT | Ubrelvy | Qulipta) (Non-Preferred: Emgality Syringe (100mg) | Vyepti | Zavzpret)
PDF, 206 KB
Antiparkinson Agents
Carbidopa-levodopa ER | Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone | Rytary | Xadago
PDF, 215 KB
Carbidopa-levodopa ER | Crexont | Inbrija | Lodosyn | Neupro | Nourianz | Ongentys | tolcapone | Rytary | Xadago
PDF, 215 KB
Apomorphine Products
(Apokyn | apomorphine hydrochloride)
PDF, 168 KB
(Apokyn | apomorphine hydrochloride)
PDF, 168 KB
Aqneursa
PDF, 156 KB
PDF, 156 KB
Aqvesme
PDF, 181 KB
PDF, 181 KB
Arcalyst (Non-Preferred)
PDF, 198 KB
PDF, 198 KB
Arikayce
PDF, 214 KB
PDF, 214 KB
Atypical Antipsychotics
(Non-Preferred) (Abilify | Abilify Mycite | aripiprazole ODT/solution | asenapine | Bysanti | Caplyta | clozapine ODT | Clozaril | Cobenfy | Fanapt | FazaClo | Geodon | Invega | Latuda | Lybalvi | Nuplazid | olanzapine/fluoxetine | Opipza | quetiapine ER | Rexulti | Risperdal | Saphris | Secuado Patch | Seroquel | Seroquel XR | Versacloz | Zyprexa)
PDF, 172 KB
(Non-Preferred) (Abilify | Abilify Mycite | aripiprazole ODT/solution | asenapine | Bysanti | Caplyta | clozapine ODT | Clozaril | Cobenfy | Fanapt | FazaClo | Geodon | Invega | Latuda | Lybalvi | Nuplazid | olanzapine/fluoxetine | Opipza | quetiapine ER | Rexulti | Risperdal | Saphris | Secuado Patch | Seroquel | Seroquel XR | Versacloz | Zyprexa)
PDF, 172 KB
Atypical Antipsychotics Injectables (Non-Preferred)
Rykindo IM injection | risperidone ER injection vial | Zyprexa Relprevv IM injection
PDF, 156 KB
Rykindo IM injection | risperidone ER injection vial | Zyprexa Relprevv IM injection
PDF, 156 KB
Benlysta SQ (Pharmacy benefit)
PDF, 279 KB
PDF, 279 KB
Bimzelx (Non-Preferred)
PDF, 165 KB
PDF, 165 KB
Blujepa│Orlynvah
PDF, 239 KB
PDF, 239 KB
Botox - Other Indications (Pharmacy)
PDF, 200 KB
PDF, 200 KB
Brinsupri
PDF, 210 KB
PDF, 210 KB
Briumvi (Pharmacy)
PDF, 215 KB
PDF, 215 KB
Bronchitol
PDF, 157 KB
PDF, 157 KB
Bylvay
PDF, 146 KB
PDF, 146 KB
Cablivi
PDF, 218 KB
PDF, 218 KB
candesartan
PDF, 201 KB
PDF, 201 KB
Cardamyst
PDF, 176 KB
PDF, 176 KB
carglumic acid (Carbaglu)
PDF, 201 KB
PDF, 201 KB
Cephalosporins (Oral)
PDF, 190 KB
PDF, 190 KB
Chenodal
PDF, 177 KB
PDF, 177 KB
Cibinqo (Non-Preferred)
PDF, 180 KB
PDF, 180 KB
Cimzia SQ (Pharmacy benefit)
PDF, 192 KB
PDF, 192 KB
Cinqair (Pharmacy)
PDF, 213 KB
PDF, 213 KB
Continuous Glucose Monitors (CGM)
(PREFERRED: Dexcom G6 | Dexcom G7 | FreeStyle Libre 14 day | FreeStyle Libre 2 | FreeStyle Libre 3) (Non-Preferred: Eversense | Guardian 3 | Guardian 4 | Minimed Instinct | Simplera | Symplera)
PDF, 171 KB
(PREFERRED: Dexcom G6 | Dexcom G7 | FreeStyle Libre 14 day | FreeStyle Libre 2 | FreeStyle Libre 3) (Non-Preferred: Eversense | Guardian 3 | Guardian 4 | Minimed Instinct | Simplera | Symplera)
PDF, 171 KB
Cosentyx SQ (Pharmacy)
PDF, 209 KB
PDF, 209 KB
Crenessity
PDF, 246 KB
PDF, 246 KB
Ctexli
PDF, 186 KB
PDF, 186 KB
Cuvrior | Syprine | trientine
PDF, 209 KB
PDF, 209 KB
Cystaran | Cystadrops
PDF, 182 KB
PDF, 182 KB
dalfampridine ER | Ampyra
PDF, 190 KB
PDF, 190 KB
Daybue | Daybue STIX
PDF, 232 KB
PDF, 232 KB
Denosumab Biosimilars - Osteoporosis Indications (Pharmacy)
(PREFERRED: Enoby | Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Ospomyv | Osvyrti | Prolia)
PDF, 226 KB
(PREFERRED: Enoby | Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Ospomyv | Osvyrti | Prolia)
PDF, 226 KB
dichlorphenamide (Keveyis)
PDF, 162 KB
PDF, 162 KB
Dojolvi
PDF, 229 KB
PDF, 229 KB
Doptelet
PDF, 206 KB
PDF, 206 KB
droxidopa (Northera)
PDF, 151 KB
PDF, 151 KB
Duchenne Muscular Dystrophy (Pharmacy)
(Preferred: Emflaza) (Non-Preferred: Agamree | Amodndy-45 | deflazacort | Duvyzat | Exondys-51 | Jaythari | Pyquvi |Viltepso | Vyondys-53)
PDF, 160 KB
(Preferred: Emflaza) (Non-Preferred: Agamree | Amodndy-45 | deflazacort | Duvyzat | Exondys-51 | Jaythari | Pyquvi |Viltepso | Vyondys-53)
PDF, 160 KB
Duopa (Pharmacy)
PDF, 161 KB
PDF, 161 KB
Dupixent
PDF, 224 KB
PDF, 224 KB
Ebglyss
PDF, 158 KB
PDF, 158 KB
Egrifta
PDF, 207 KB
PDF, 207 KB
Empaveli (Pharmacy)
PDF, 236 KB
PDF, 236 KB
Enstilar Foam (Non-Preferred)
PDF, 171 KB
PDF, 171 KB
Entresto Sprinkle
PDF, 139 KB
PDF, 139 KB
Entyvio (Pharmacy)
PDF, 169 KB
PDF, 169 KB
Eohilia
PDF, 180 KB
PDF, 180 KB
Epidiolex CV (Preferred)
PDF, 190 KB
PDF, 190 KB
ethacrynic acid (Edecrin)
PDF, 147 KB
PDF, 147 KB
Evrysdi
PDF, 200 KB
PDF, 200 KB
Exdensur (Pharmacy)
PDF, 212 KB
PDF, 212 KB
Fabhalta
PDF, 265 KB
PDF, 265 KB
Fasenra (Pharmacy)
PDF, 232 KB
PDF, 232 KB
Filspari
PDF, 241 KB
PDF, 241 KB
Filsuvez
PDF, 195 KB
PDF, 195 KB
Fintepla
PDF, 136 KB
PDF, 136 KB
Firdapse
PDF, 171 KB
PDF, 171 KB
Forzinity
PDF, 166 KB
PDF, 166 KB
Furoscix │ Lasix Onyu
PDF, 162 KB
PDF, 162 KB
Galafold
PDF, 169 KB
PDF, 169 KB
Gastrointestinal (GI) Antibiotics
(PREFERRED- metronidazole tab | vancomycin cap | vancomycin for Recon oral kit) (Non-Preferred drugs require PA) - Aemcolo | Alinia/ nitazoxanide | Dificid | fidaxomicin │Firvanq | Flagyl/ ER | Likmez | metronidazole 125mg | metronidazole cap | neomycin | paromomycin | Solosec | Tindamax | tinidazole | Vancocin | Vowst)
PDF, 184 KB
(PREFERRED- metronidazole tab | vancomycin cap | vancomycin for Recon oral kit) (Non-Preferred drugs require PA) - Aemcolo | Alinia/ nitazoxanide | Dificid | fidaxomicin │Firvanq | Flagyl/ ER | Likmez | metronidazole 125mg | metronidazole cap | neomycin | paromomycin | Solosec | Tindamax | tinidazole | Vancocin | Vowst)
PDF, 184 KB
Gastrointestinal (GI) Chronic Motility Drugs
(PREFERRED - lubiprostone | Linzess | Movantik) (Non-Preferred - alosetron | Amitiza | Ibsrela | Lotronex | Motegrity | prucalopride | Symproic | Viberzi)
PDF, 204 KB
(PREFERRED - lubiprostone | Linzess | Movantik) (Non-Preferred - alosetron | Amitiza | Ibsrela | Lotronex | Motegrity | prucalopride | Symproic | Viberzi)
PDF, 204 KB
Gattex Injection
PDF, 259 KB
PDF, 259 KB
Gaucher Disease Drugs (Substrate Reduction Therapy) (Pharmacy)
(Cerdelga | Miglustat)
PDF, 210 KB
(Cerdelga | Miglustat)
PDF, 210 KB
Gocovri ER | Osmolex ER
PDF, 197 KB
PDF, 197 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Pharmacy)
(PREFERRED: Camveci | Eligard | Leuprolide Depot | Lupron Depot | Lupron Depot-Ped | Lutrate Depot | Supprelin LA | Trelstar | Vantas) (Non-Preferred: Eligard (1-month) | Fensolvi | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Synarel | Trelstar (1-month) | Triptodur | Zoladex)
PDF, 223 KB
(PREFERRED: Camveci | Eligard | Leuprolide Depot | Lupron Depot | Lupron Depot-Ped | Lutrate Depot | Supprelin LA | Trelstar | Vantas) (Non-Preferred: Eligard (1-month) | Fensolvi | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Synarel | Trelstar (1-month) | Triptodur | Zoladex)
PDF, 223 KB
Graft-Versus-Host Disease (GVHD) Drugs
(Jakafi | Imbruvica)
PDF, 201 KB
(Jakafi | Imbruvica)
PDF, 201 KB
Granulocyte Colony-Stimulating Factors (G-CSF)(GM-CSF) (Pharmacy)
Short-acting G-CSFs: (PREFERRED: Neupogen) (Non-Preferred: Filkri | Granix | Nivestym | Nypozi | Releuko | Zarxio) Long-acting G-CSFs: (PREFERRED: Fulphilia) (Non-Preferred: Fylnetra | Neulasta | Nyvepria | Rolvedon | Ryzneuta | Udenyca | Udenyca Onbody | Zieztenzo) CM-CSFs: (Leukine)
PDF, 173 KB
Short-acting G-CSFs: (PREFERRED: Neupogen) (Non-Preferred: Filkri | Granix | Nivestym | Nypozi | Releuko | Zarxio) Long-acting G-CSFs: (PREFERRED: Fulphilia) (Non-Preferred: Fylnetra | Neulasta | Nyvepria | Rolvedon | Ryzneuta | Udenyca | Udenyca Onbody | Zieztenzo) CM-CSFs: (Leukine)
PDF, 173 KB
Growth Hormone (rhGH)
(PREFERRED - Genotropin | Norditropin FlexPro) (Non-Preferred: Humatrope | Ngenla | Nutropin AQ NuSpin | Omnitrope | Serostim | Skytrofa | Sogroya | Zomacton)
PDF, 201 KB
(PREFERRED - Genotropin | Norditropin FlexPro) (Non-Preferred: Humatrope | Ngenla | Nutropin AQ NuSpin | Omnitrope | Serostim | Skytrofa | Sogroya | Zomacton)
PDF, 201 KB
Hemangeol (Non-Preferred)
PDF, 149 KB
PDF, 149 KB
Hepatitis-C Antiviral Drugs (Non-Preferred)
(Non-Preferred) (Epclusa | Harvoni | Incivek | interferon | ledipasvir/sofosuvir (generic Harvoni) | Olysio | Pegasys | sofosbuvir/velpatasvir | Sovaldi | Technivie | Viekira Pak | Viekira XR | Vosevi | Zepatier)
PDF, 169 KB
(Non-Preferred) (Epclusa | Harvoni | Incivek | interferon | ledipasvir/sofosuvir (generic Harvoni) | Olysio | Pegasys | sofosbuvir/velpatasvir | Sovaldi | Technivie | Viekira Pak | Viekira XR | Vosevi | Zepatier)
PDF, 169 KB
Hereditary Angioedema (HAE)
(PREFERRED Drugs with Quantity Limits - Berinert | Cinryze | icatibant | Kalibitor | Sajazir) (Non-Preferred Drugs with Quantity Limits - Andembry | Dawnzera | Ekterly | Firazyr | Haegarda | Orladeyo | Ruconest |Takhzyro)
PDF, 171 KB
(PREFERRED Drugs with Quantity Limits - Berinert | Cinryze | icatibant | Kalibitor | Sajazir) (Non-Preferred Drugs with Quantity Limits - Andembry | Dawnzera | Ekterly | Firazyr | Haegarda | Orladeyo | Ruconest |Takhzyro)
PDF, 171 KB
Hyaluronate Acids (Pharmacy)
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 229 KB
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 229 KB
Hyftor
PDF, 186 KB
PDF, 186 KB
Icotyde (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Ilaris (sJIA | AOSD | TRAPS | HIDS/MKD | FMF diseases | CAPS) (Pharmacy))
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA), Adult Onset Still's Disease (AOSD), Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF), Cryopyrin-Associated Periodic Syndromes (CAPS), and gout flares
PDF, 239 KB
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA), Adult Onset Still's Disease (AOSD), Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF), Cryopyrin-Associated Periodic Syndromes (CAPS), and gout flares
PDF, 239 KB
Immunomodulators Atopic Dermatitis
(PREFERRED: Adbry | Dupixent | Ebglyss | Eucrisa | pimecrolimus | tacrolimus | Vtama) (Non-Preferred: Anzupgo | Cibinqo | Nemluvio | Opzelura | Protopic | Zoryve)
PDF, 183 KB
(PREFERRED: Adbry | Dupixent | Ebglyss | Eucrisa | pimecrolimus | tacrolimus | Vtama) (Non-Preferred: Anzupgo | Cibinqo | Nemluvio | Opzelura | Protopic | Zoryve)
PDF, 183 KB
Increlex
PDF, 177 KB
PDF, 177 KB
Incretin Mimetic Drugs (Diabetic GLP-1 receptor agonists)
(PREFERRED: Trulicity | Victoza) (Non-Preferred: exenatide (generic Bydureon Bcise) | liraglutide (generic Victoza) | Mounjaro | Ozempic | Rybelsus | Soliqua 100/33 | Tanzeum | Xultophy)
PDF, 165 KB
(PREFERRED: Trulicity | Victoza) (Non-Preferred: exenatide (generic Bydureon Bcise) | liraglutide (generic Victoza) | Mounjaro | Ozempic | Rybelsus | Soliqua 100/33 | Tanzeum | Xultophy)
PDF, 165 KB
Infliximab Category (Pharmacy)
(Non-Preferred: Avsola | Inflectra | Infliximab (unbranded Remicade) | Remicade | Renflexis | Zymfentra) (Pharmacy)
PDF, 195 KB
(Non-Preferred: Avsola | Inflectra | Infliximab (unbranded Remicade) | Remicade | Renflexis | Zymfentra) (Pharmacy)
PDF, 195 KB
Inpefa
PDF, 133 KB
PDF, 133 KB
Insulins (Non-Preferred)
(Admelog | Afrezza | Apidra | Fiasp | Humalog | Humalog Kwikpen | Lyumjev | Merilog | Novolog | Novolin R | Novolin N | insulin degludec | insulin glargine SoloStar/Max SoloStar | Rezvoglar Kwikpen)
PDF, 174 KB
(Admelog | Afrezza | Apidra | Fiasp | Humalog | Humalog Kwikpen | Lyumjev | Merilog | Novolog | Novolin R | Novolin N | insulin degludec | insulin glargine SoloStar/Max SoloStar | Rezvoglar Kwikpen)
PDF, 174 KB
Isturisa
PDF, 196 KB
PDF, 196 KB
Ivabradine | Corlanor
PDF, 184 KB
PDF, 184 KB
Jascayd
PDF, 227 KB
PDF, 227 KB
Joenja
PDF, 195 KB
PDF, 195 KB
Journavx
PDF, 159 KB
PDF, 159 KB
Juxtapid
PDF, 160 KB
PDF, 160 KB
Jylamvo
PDF, 155 KB
PDF, 155 KB
Jynarque
PDF, 166 KB
PDF, 166 KB
Kalydeco
PDF, 180 KB
PDF, 180 KB
Kerendia
PDF, 300 KB
PDF, 300 KB
Kevzara Injection (Non-Preferred)
PDF, 143 KB
PDF, 143 KB
Kineret (Non-Preferred)
PDF, 158 KB
PDF, 158 KB
Korlym
PDF, 167 KB
PDF, 167 KB
Kristalose
PDF, 134 KB
PDF, 134 KB
Kygevvi
PDF, 217 KB
PDF, 217 KB
Lampit | benznidazole
PDF, 211 KB
PDF, 211 KB
Leqembi Iqlik
PDF, 547 KB
PDF, 547 KB
Libtayo
PDF, 163 KB
PDF, 163 KB
Lipotropics - Other (Non-Preferred)
(Leqvio | Praluent | Repatha)
PDF, 218 KB
(Leqvio | Praluent | Repatha)
PDF, 218 KB
Livmarli
PDF, 204 KB
PDF, 204 KB
Livtencity
PDF, 179 KB
PDF, 179 KB
Lodoco
PDF, 170 KB
PDF, 170 KB
Lucemyra
PDF, 153 KB
PDF, 153 KB
Lupkynis
PDF, 194 KB
PDF, 194 KB
Lynkuet | Veozah
PDF, 183 KB
PDF, 183 KB
Lyrica Solution (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Macrolides & Ketolides (Oral)
(PREFERRED-azithromycin pack, susp, tab | clarithromycin tab, susp | erythromycin ethylsuccinate 200mg susp | erythromycin base tab DR | erythromycin stearate) (Non-Preferred: Biaxin tab | Clarithromycin ER | Eryped 200 & 400 susp | Ery-tab | E.E.S. 400 tab | E.E.S 200 susp │ Erythrocin Stearate | erythromycin base tab | erthromycin ethylsuccinate 400 mg tab (generic E.E.S. 400) | erthyromycin base cap DR | PCE | Zithromax pac/tab/susp | ZMAX susp)
PDF, 163 KB
(PREFERRED-azithromycin pack, susp, tab | clarithromycin tab, susp | erythromycin ethylsuccinate 200mg susp | erythromycin base tab DR | erythromycin stearate) (Non-Preferred: Biaxin tab | Clarithromycin ER | Eryped 200 & 400 susp | Ery-tab | E.E.S. 400 tab | E.E.S 200 susp │ Erythrocin Stearate | erythromycin base tab | erthromycin ethylsuccinate 400 mg tab (generic E.E.S. 400) | erthyromycin base cap DR | PCE | Zithromax pac/tab/susp | ZMAX susp)
PDF, 163 KB
Methadone
PDF, 207 KB
PDF, 207 KB
mifepristone 300 mg
PDF, 169 KB
PDF, 169 KB
Miplyffa
PDF, 187 KB
PDF, 187 KB
Movement Disorders Medications
(PREFERRED: Austedo | Austedo XR | Austedo Xr titration pack | Ingrezza | Ingrezza Initiation Pack | tetrabenazine (generic Xenazine) | Ingrezza Sprinkle | Non-Preferred: Xenazine)
PDF, 166 KB
(PREFERRED: Austedo | Austedo XR | Austedo Xr titration pack | Ingrezza | Ingrezza Initiation Pack | tetrabenazine (generic Xenazine) | Ingrezza Sprinkle | Non-Preferred: Xenazine)
PDF, 166 KB
Mulpleta
PDF, 166 KB
PDF, 166 KB
Multiple Sclerosis Drugs
(PREFERRED - Avonex | Avonex Adm Pack | Copaxone (20mg syringe) | dalfampridine ER (generic Ampyra) | dimethyl fumarate (generic Tecfidera) | fingolimod (generic Gilenya) | Kesimpta | teriflunomide (generic Aubagio)) (Non-Preferred - Ampyra | Aubagio | Bafiertam | Betaseron | Briumvi | Copaxone (40mg syringe) | Extavia Kit | Gilenya | glatiramer 20mg syringe | Glatopa | Mavenclad | Mayzent | Ocrevus | Ocrevus Zunovo | Plegridy | Ponvory | Rebif SQ | Rebif Redidose Pen | Tascenso ODT | Tecfidera | Tysabri | Tyruko | Vumerity | Zeposia)
PDF, 261 KB
(PREFERRED - Avonex | Avonex Adm Pack | Copaxone (20mg syringe) | dalfampridine ER (generic Ampyra) | dimethyl fumarate (generic Tecfidera) | fingolimod (generic Gilenya) | Kesimpta | teriflunomide (generic Aubagio)) (Non-Preferred - Ampyra | Aubagio | Bafiertam | Betaseron | Briumvi | Copaxone (40mg syringe) | Extavia Kit | Gilenya | glatiramer 20mg syringe | Glatopa | Mavenclad | Mayzent | Ocrevus | Ocrevus Zunovo | Plegridy | Ponvory | Rebif SQ | Rebif Redidose Pen | Tascenso ODT | Tecfidera | Tysabri | Tyruko | Vumerity | Zeposia)
PDF, 261 KB
Myalept
PDF, 178 KB
PDF, 178 KB
Myfembree | Oriahnn
PDF, 171 KB
PDF, 171 KB
Mytesi (formerly Fulyzaq)
PDF, 154 KB
PDF, 154 KB
Narcolepsy Medications
(PREFERRED: armodafinil | modafinil | Sunosi) (Non-Preferred: Nuvigil | Provigil | Wakix
PDF, 206 KB
(PREFERRED: armodafinil | modafinil | Sunosi) (Non-Preferred: Nuvigil | Provigil | Wakix
PDF, 206 KB
Nayzilam
PDF, 151 KB
PDF, 151 KB
Nemluvio
PDF, 167 KB
PDF, 167 KB
Nexletol | Nexlizet (Non-Preferred)
PDF, 223 KB
PDF, 223 KB
Nitisinone Products
Harliku | nitisinone | Nityr | Orfadin
PDF, 175 KB
Harliku | nitisinone | Nityr | Orfadin
PDF, 175 KB
Nocdurna sublingual tablets
PDF, 160 KB
PDF, 160 KB
Non-Preferred Adalimumab Products (Pharmacy)
Abrilada | adalimumab-aacf | adalimumab-aaty | adalimumab-adaz | adalimumab-adbm | adalimumab-fkjp | adalimumab-ryvk | Amjevita | Cyltezo | Hulio | Humira | Hyrimoz | Idacio | Simlandi | Yuflyma | Yusimry
PDF, 211 KB
Abrilada | adalimumab-aacf | adalimumab-aaty | adalimumab-adaz | adalimumab-adbm | adalimumab-fkjp | adalimumab-ryvk | Amjevita | Cyltezo | Hulio | Humira | Hyrimoz | Idacio | Simlandi | Yuflyma | Yusimry
PDF, 211 KB
Non-Preferred Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Celebrex | Vyscoxa
PDF, 137 KB
Celebrex | Vyscoxa
PDF, 137 KB
Non-Preferred Ustekinumab Product (Pharmacy)
(PREFERRED: Pyzchiva syringe/vial | Starjemza) (Non-Preferred: Imuldosa | Otulfi | Pyzchiva Auto-Injector | Selarsdi | Stelara | Steqeyma | ustekinumab [generic Stelara] | ustekinumab-aekn [generic Stelara] | ustekinumab-ttwe [generic Pyzchiva] | Wezlana | Yesintek)
PDF, 226 KB
(PREFERRED: Pyzchiva syringe/vial | Starjemza) (Non-Preferred: Imuldosa | Otulfi | Pyzchiva Auto-Injector | Selarsdi | Stelara | Steqeyma | ustekinumab [generic Stelara] | ustekinumab-aekn [generic Stelara] | ustekinumab-ttwe [generic Pyzchiva] | Wezlana | Yesintek)
PDF, 226 KB
Nuedexta
PDF, 134 KB
PDF, 134 KB
Nulibry IV (Pharmacy)
PDF, 238 KB
PDF, 238 KB
Ocrevus | Ocrevus Zunovo (Pharmacy)
PDF, 217 KB
PDF, 217 KB
Ohtuvayre
PDF, 191 KB
PDF, 191 KB
Olumiant
PDF, 156 KB
PDF, 156 KB
Omega- 3 Fatty Acid Agents
icosapent ethyl | Lovaza | Omega-3 acid ethyl esters | Omega-3 OTC
PDF, 186 KB
icosapent ethyl | Lovaza | Omega-3 acid ethyl esters | Omega-3 OTC
PDF, 186 KB
Omvoh
PDF, 171 KB
PDF, 171 KB
Onapgo (Pharmacy)
PDF, 170 KB
PDF, 170 KB
Opfolda
PDF, 203 KB
PDF, 203 KB
Ophthalmic Immunomodulator Drugs
(PREFERRED: Restasis | Xiidra) (Non-Preferred: Cequa | Eysuvis | cyclosporine | Miebo | Restasis Multidose | Tryptyr | Tyrvaya | Verkazia)
PDF, 143 KB
(PREFERRED: Restasis | Xiidra) (Non-Preferred: Cequa | Eysuvis | cyclosporine | Miebo | Restasis Multidose | Tryptyr | Tyrvaya | Verkazia)
PDF, 143 KB
Opzelura (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Oral Buprenorphine Products
PDF, 180 KB
PDF, 180 KB
Oravig
PDF, 126 KB
PDF, 126 KB
Orencia SQ (Pharmacy)
PDF, 196 KB
PDF, 196 KB
Orilissa
PDF, 162 KB
PDF, 162 KB
Orkambi
PDF, 220 KB
PDF, 220 KB
Otezla | Otezla XR
PDF, 195 KB
PDF, 195 KB
Otrexup (Non-Preferred)
PDF, 132 KB
PDF, 132 KB
Oxervate
PDF, 205 KB
PDF, 205 KB
Oxlumo (Pharmacy)
PDF, 164 KB
PDF, 164 KB
Palforzia
PDF, 241 KB
PDF, 241 KB
Palynziq
PDF, 157 KB
PDF, 157 KB
Pancreatic Enzymes
(PREFERRED - Creon | Viokace) (Non-Preferred - Pertzye | Zenpep)
PDF, 153 KB
(PREFERRED - Creon | Viokace) (Non-Preferred - Pertzye | Zenpep)
PDF, 153 KB
Panretin
PDF, 162 KB
PDF, 162 KB
Phosphodiesterase 5 Inhibitors (PDE-5)
(PREFERRED - Alyq | sildenafil tab/suspension | tadalafil tab) (Non-Preferred - Adcirca | Liqrev | Opsynvi | Revatio | Tadliq)
PDF, 183 KB
(PREFERRED - Alyq | sildenafil tab/suspension | tadalafil tab) (Non-Preferred - Adcirca | Liqrev | Opsynvi | Revatio | Tadliq)
PDF, 183 KB
Pivya
PDF, 175 KB
PDF, 175 KB
Platelet Inhibitors
(PREFERRED: clopidogrel | dipyridamole | prasugrel (generic Effient) | ticagrelor (generic Brilinta)) (Non-Preferred: ASA/dypyridamole | ASA/omeprazole (generic Yosprala) | Brilinta | Effient | Plavix | Yosprala | Zontivity)
PDF, 171 KB
(PREFERRED: clopidogrel | dipyridamole | prasugrel (generic Effient) | ticagrelor (generic Brilinta)) (Non-Preferred: ASA/dypyridamole | ASA/omeprazole (generic Yosprala) | Brilinta | Effient | Plavix | Yosprala | Zontivity)
PDF, 171 KB
Preferred Cytokine and CAM antagonists (Pharmacy)
adalimumab-adbm [Humira biosimilar] | Enbrel | Hadlima [Humira biosimilar | Pyzchiva [Stelara biosimilar] | Starjemza
PDF, 230 KB
adalimumab-adbm [Humira biosimilar] | Enbrel | Hadlima [Humira biosimilar | Pyzchiva [Stelara biosimilar] | Starjemza
PDF, 230 KB
Pretomanid
PDF, 175 KB
PDF, 175 KB
Prevymis tablets (Pharmacy)
PDF, 178 KB
PDF, 178 KB
Procysbi
PDF, 167 KB
PDF, 167 KB
Proton Pump Inhibitors (PPI) Drugs
(PREFERRED PPIs - omeprazole Rx | pantoprazole tablets | pantoprazole suspension | Protonix suspension- no PA required for short-term use, less than 90 days) (NON-PREFERRED: Aciphex DR | dexlansoprazole DR | Dexilant | esomeprazole/magnesium | esomeprazole strontium | lansoprazole | Konvomep | Nexium | omeprazole OTC | omeprazole magnesium OTC | omeprazole/sodium bicarbonate | Prevacid RX/OTC/Solutab | Prilosec RX/suspension | Protonix | rabeprazole DR)
PDF, 199 KB
(PREFERRED PPIs - omeprazole Rx | pantoprazole tablets | pantoprazole suspension | Protonix suspension- no PA required for short-term use, less than 90 days) (NON-PREFERRED: Aciphex DR | dexlansoprazole DR | Dexilant | esomeprazole/magnesium | esomeprazole strontium | lansoprazole | Konvomep | Nexium | omeprazole OTC | omeprazole magnesium OTC | omeprazole/sodium bicarbonate | Prevacid RX/OTC/Solutab | Prilosec RX/suspension | Protonix | rabeprazole DR)
PDF, 199 KB
Pulmozyme inhalation solution
PDF, 206 KB
PDF, 206 KB
pyrimethamine (Daraprim)
PDF, 161 KB
PDF, 161 KB
Pyrukynd
PDF, 159 KB
PDF, 159 KB
Quinolones (Oral)
(PREFERRED-ciprofloxacin susp, tab | levofloxacin tab - does not require PA) (Non-Preferred-Baxdela IV | Cipro IR, XR, susp | ciprofloxacin ER | Noroxin | ofloxacin | Levaquin tab, susp | levofloxacin susp | moxifloxacin)
PDF, 188 KB
(PREFERRED-ciprofloxacin susp, tab | levofloxacin tab - does not require PA) (Non-Preferred-Baxdela IV | Cipro IR, XR, susp | ciprofloxacin ER | Noroxin | ofloxacin | Levaquin tab, susp | levofloxacin susp | moxifloxacin)
PDF, 188 KB
Radicava ORS
PDF, 211 KB
PDF, 211 KB
Rasuvo (Non-Preferred)
PDF, 129 KB
PDF, 129 KB
Rayaldee
PDF, 160 KB
PDF, 160 KB
Redemplo
PDF, 142 KB
PDF, 142 KB
Relyvrio
PDF, 185 KB
PDF, 185 KB
Rezdiffra
PDF, 194 KB
PDF, 194 KB
Rezurock
PDF, 158 KB
PDF, 158 KB
Rhapsido
PDF, 176 KB
PDF, 176 KB
Ridaura | Auranofin
PDF, 160 KB
PDF, 160 KB
Rinvoq | Rinvoq LQ
PDF, 212 KB
PDF, 212 KB
Rivfloza (Pharmacy)
PDF, 170 KB
PDF, 170 KB
Saphnelo (Pharmacy)
PDF, 209 KB
PDF, 209 KB
Sapropterin Products
Javygtor | sapropterin dihydrochloride (Kuvan) | Zelvysia
PDF, 186 KB
Javygtor | sapropterin dihydrochloride (Kuvan) | Zelvysia
PDF, 186 KB
Savaysa (Non-Preferred)
PDF, 164 KB
PDF, 164 KB
Sephience
PDF, 216 KB
PDF, 216 KB
Sernivo Spray (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Sickle Cell Drugs
(PREFERRED - Droxia | Endari | Siklos) (Non-Preferred - Adakveo IV | L-glutamine (generic Endari) | Xromi)
PDF, 191 KB
(PREFERRED - Droxia | Endari | Siklos) (Non-Preferred - Adakveo IV | L-glutamine (generic Endari) | Xromi)
PDF, 191 KB
Simponi SQ (Pharmacy benefit)
PDF, 204 KB
PDF, 204 KB
Sirturo
PDF, 158 KB
PDF, 158 KB
Sivextro tablets (Pharmacy benefit)
PDF, 162 KB
PDF, 162 KB
Skyclarys
PDF, 183 KB
PDF, 183 KB
Skyrizi
PDF, 217 KB
PDF, 217 KB
Sodium Oxybate Products
(Lumryz | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 233 KB
(Lumryz | Sodium Oxybate oral solution | Xyrem IR oral solution | Xywav low sodium IR oral solution)
PDF, 233 KB
Sodium Phenylbutyrate Products
(sodium phenylbutyrate | Pheburane | Olpruva)
PDF, 144 KB
(sodium phenylbutyrate | Pheburane | Olpruva)
PDF, 144 KB
Sohonos
PDF, 173 KB
PDF, 173 KB
Soma (Non-Preferred)
PDF, 160 KB
PDF, 160 KB
Somatostatin Analogs (Pharmacy)
(Bynfezia | lanreotide acetate ER | Mycapssa | octreotide injection | Palsonify | Sandostatin LAR Depot | Signafor | Signifor LAR | Somatuline Depot | Somavert)
PDF, 248 KB
(Bynfezia | lanreotide acetate ER | Mycapssa | octreotide injection | Palsonify | Sandostatin LAR Depot | Signafor | Signifor LAR | Somatuline Depot | Somavert)
PDF, 248 KB
Sotyktu
PDF, 189 KB
PDF, 189 KB
Spevigo (Pharmacy)
PDF, 162 KB
PDF, 162 KB
Spravato (Pharmacy)
PDF, 183 KB
PDF, 183 KB
Strensiq
PDF, 156 KB
PDF, 156 KB
Sucraid
PDF, 182 KB
PDF, 182 KB
Symdeko
PDF, 200 KB
PDF, 200 KB
SymLin | SymLinPen (Non-Preferred)
PDF, 154 KB
PDF, 154 KB
Taltz SQ (Pharmacy) (Non-Preferred)
PDF, 212 KB
PDF, 212 KB
Tavalisse
PDF, 215 KB
PDF, 215 KB
Tezspire (Pharmacy)
PDF, 216 KB
PDF, 216 KB
tiopronin products
tiopronin (Thiola) | tiopronin delayed-release tablets (Thiola EC) | venxxiva
PDF, 191 KB
tiopronin (Thiola) | tiopronin delayed-release tablets (Thiola EC) | venxxiva
PDF, 191 KB
tolvaptan (Samsca)
PDF, 154 KB
PDF, 154 KB
Topical Immunomodulators
(Zyclara 2.5% Pump | Zyclara 3.75% Packets/Pump | imiquimod 3.75% packets/pump | Picato | Klisyri )
PDF, 160 KB
(Zyclara 2.5% Pump | Zyclara 3.75% Packets/Pump | imiquimod 3.75% packets/pump | Picato | Klisyri )
PDF, 160 KB
Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
(PREFERRED-diclofenac sodium 1% gel) (Non-Preferred: diclofenac 1.5% topical solution | diclofenac 2% topical solution gel | diclofenac epolamine 1.3% patch | diclofenac 3% gel | Diclogen Kit | Flector patch | Licart patch | Lixofen 1.5% Kit | Pennsaid topical solution packet and pump | Voltaren 1% gel | Xrylix Kit)
PDF, 143 KB
(PREFERRED-diclofenac sodium 1% gel) (Non-Preferred: diclofenac 1.5% topical solution | diclofenac 2% topical solution gel | diclofenac epolamine 1.3% patch | diclofenac 3% gel | Diclogen Kit | Flector patch | Licart patch | Lixofen 1.5% Kit | Pennsaid topical solution packet and pump | Voltaren 1% gel | Xrylix Kit)
PDF, 143 KB
Toujeo Solostar
PDF, 140 KB
PDF, 140 KB
Transthyretin Stabilizers
Attruby | Vyndamax | Vyndaqel
PDF, 161 KB
Attruby | Vyndamax | Vyndaqel
PDF, 161 KB
Tremfya Injection (Pharmacy)
PDF, 232 KB
PDF, 232 KB
Trexall (Non-Preferred)
PDF, 151 KB
PDF, 151 KB
Trikafta
PDF, 197 KB
PDF, 197 KB
Tryngolza
PDF, 143 KB
PDF, 143 KB
Tryvio
PDF, 161 KB
PDF, 161 KB
Tysabri and Biosimilars (Pharmacy)
Tysabri IV | Tyruko IV
PDF, 290 KB
Tysabri IV | Tyruko IV
PDF, 290 KB
Ulesfia Lotion
PDF, 162 KB
PDF, 162 KB
Uplizna (Pharmacy)
PDF, 237 KB
PDF, 237 KB
Upneeq opthalmic solution 01%
PDF, 201 KB
PDF, 201 KB
Vanrafia
PDF, 200 KB
PDF, 200 KB
Velsipity
PDF, 155 KB
PDF, 155 KB
Vemlidy (Non-Preferred)
PDF, 150 KB
PDF, 150 KB
Verquvo
PDF, 207 KB
PDF, 207 KB
Vijoice
PDF, 189 KB
PDF, 189 KB
Vivjoa
PDF, 205 KB
PDF, 205 KB
Vowst
PDF, 171 KB
PDF, 171 KB
Voxzogo │ Yuviwel
PDF, 231 KB
PDF, 231 KB
Voydeya
PDF, 225 KB
PDF, 225 KB
Voyxact
PDF, 217 KB
PDF, 217 KB
Vraylar For Major Depressive Disorder
PDF, 188 KB
PDF, 188 KB
Vyalev (Pharmacy)
PDF, 162 KB
PDF, 162 KB
Vyepti IV (Pharmacy)
PDF, 216 KB
PDF, 216 KB
Vykat XR
PDF, 186 KB
PDF, 186 KB
Vyvanse Binge Eating Disorder (BED)
PDF, 161 KB
PDF, 161 KB
Wainua
PDF, 135 KB
PDF, 135 KB
Wayrilz
PDF, 196 KB
PDF, 196 KB
Weight Loss Management
(PREFERRED - benzphetamine | diethylpropion IR and ER | orlistat | phendimetrazine IR and ER | phentermine 15mg, 30mg, 37.5mg | Xenical) (Non-Preferred - Foundayo | Imcivree | liraglutide | Lomaira | phentermine/topiramate ER | Saxenda | Wegovy | Zepbound)
PDF, 223 KB
(PREFERRED - benzphetamine | diethylpropion IR and ER | orlistat | phendimetrazine IR and ER | phentermine 15mg, 30mg, 37.5mg | Xenical) (Non-Preferred - Foundayo | Imcivree | liraglutide | Lomaira | phentermine/topiramate ER | Saxenda | Wegovy | Zepbound)
PDF, 223 KB
Winrevair
PDF, 268 KB
PDF, 268 KB
Xatmep (Non-Preferred)
PDF, 160 KB
PDF, 160 KB
Xdemvy
PDF, 156 KB
PDF, 156 KB
Xenleta
PDF, 141 KB
PDF, 141 KB
Xolair (Pharmacy)
PDF, 1 MB
PDF, 1 MB
Xolremdi
PDF, 228 KB
PDF, 228 KB
Yorvipath
PDF, 196 KB
PDF, 196 KB
Yupelri
PDF, 153 KB
PDF, 153 KB
Zelsuvmi
PDF, 153 KB
PDF, 153 KB
Zepbound - Obstructive Sleep Apnea
PDF, 236 KB
PDF, 236 KB
Zilbrysq
PDF, 205 KB
PDF, 205 KB
Zokinvy
PDF, 226 KB
PDF, 226 KB
Zontivity (Non-Preferred)
PDF, 172 KB
PDF, 172 KB
Ztalmy
PDF, 136 KB
PDF, 136 KB
Zurzuvae
PDF, 162 KB
PDF, 162 KB
Zycubo
PDF, 164 KB
PDF, 164 KB
Zymfentra
PDF, 203 KB
PDF, 203 KB
Zyvox
PDF, 162 KB
PDF, 162 KB
Fármacos de beneficios médicos 2024
Abecma (Medical)
PDF, 210 KB
PDF, 210 KB
Abrysvo (Medical)
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 162 KB
(RSV Vaccine) for Active Immunization of Pregnancy
PDF, 162 KB
Actimmune (Medical)
PDF, 152 KB
PDF, 152 KB
Adakveo (Medical)
PDF, 213 KB
PDF, 213 KB
Adasuve (Medical)
PDF, 177 KB
PDF, 177 KB
Adzynma (Medical)
PDF, 256 KB
PDF, 256 KB
Aldurazyme IV (Medical)
PDF, 248 KB
PDF, 248 KB
Alpha Protein Inhibitors (Medical)
(Aralast NP | Glassia | Prolastin-C | Zemaira)PDF, 208 KB
(Aralast NP | Glassia | Prolastin-C | Zemaira)PDF, 208 KB
Amphotericin B Liposome (Medical)
PDF, 208 KB
PDF, 208 KB
Amvuttra (Medical)
PDF, 255 KB
PDF, 255 KB
Aphexda (Medical)
PDF, 186 KB
PDF, 186 KB
Aucatzyl (Medical)
PDF, 239 KB
PDF, 239 KB
Avlayah (Medical)
PDF, 257 KB
PDF, 257 KB
Beqvez (Medical)
PDF, 280 KB
PDF, 280 KB
Beyfortus (Medical)
PDF, 205 KB
PDF, 205 KB
Boruzu (Medical) (Non-Preferred)
PDF, 208 KB
PDF, 208 KB
Botox | Xeomin (Medical)
Botulinum Toxin Injections, Type A (Botox | Xeomin)PDF, 205 KB
Botulinum Toxin Injections, Type A (Botox | Xeomin)PDF, 205 KB
Botox Injections (Type A) - Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS) (Medical)
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 146 KB
Botulinum Toxin Injections, Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS))
PDF, 146 KB
Botox Injection-Type A (Chronic Migraine Headache Prophylaxis) (Medical)
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)PDF, 202 KB
Botulinum Toxin Injections, Type A (Chronic Migraine Headache Prophylaxis)PDF, 202 KB
Botox Injection-Type A (Hyperhidrosis) (Medical)
Botulinum Toxin Injections, Type A (Hyperhidrosis)PDF, 193 KB
Botulinum Toxin Injections, Type A (Hyperhidrosis)PDF, 193 KB
Breyanzi (Medical)
PDF, 215 KB
PDF, 215 KB
Brineura (Medical)
PDF, 196 KB
PDF, 196 KB
Briumvi (Medical)
PDF, 222 KB
PDF, 222 KB
Carvykti (Medical)
PDF, 214 KB
PDF, 214 KB
Casgevy - β-Thalassemia (Medical)
PDF, 237 KB
PDF, 237 KB
Casgevy (Medical)
PDF, 182 KB
PDF, 182 KB
Cerezyme (Medical)
PDF, 204 KB
PDF, 204 KB
Cimzia (Medical)
PDF, 188 KB
PDF, 188 KB
Contepo (Medical)
PDF, 178 KB
PDF, 178 KB
Cosentyx IV (Medical)
PDF, 169 KB
PDF, 169 KB
Cresemba (Medical)
PDF, 192 KB
PDF, 192 KB
Crysvita (Medical)
PDF, 217 KB
PDF, 217 KB
Dalvance (Medical)
PDF, 192 KB
PDF, 192 KB
Datroway (Medical)
PDF, 241 KB
PDF, 241 KB
Daxxify (Medical)
PDF, 171 KB
PDF, 171 KB
Denosumab Biosimilars - Oncology (Medical)
(PREFERRED: Osenvelt | Wyost | Xtrenbo) (NON-PREFERRED: Aukelso | Bilprevda |Bomyntra | Jubereq | Xgeva | Xbryk)
PDF, 171 KB
(PREFERRED: Osenvelt | Wyost | Xtrenbo) (NON-PREFERRED: Aukelso | Bilprevda |Bomyntra | Jubereq | Xgeva | Xbryk)
PDF, 171 KB
Denosumab Biosimilars - Oncology Indications (Pharmacy)
(PREFERRED: Osenvelt | Wyost│Xtrenbo) (NON-PREFERRED: Aukelso | Bilprevda | Bomyntra | Jubereq | Xbryk | Xgeva)
PDF, 183 KB
(PREFERRED: Osenvelt | Wyost│Xtrenbo) (NON-PREFERRED: Aukelso | Bilprevda | Bomyntra | Jubereq | Xbryk | Xgeva)
PDF, 183 KB
Denosumab Biosimilars - Osteoporosis Indications (Medical)
(PREFERRED: Enoby | Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Ospomyv | Osvyrti | Prolia)
PDF, 226 KB
(PREFERRED: Enoby | Jubbonti | Stoboclo) (NON-PREFERRED: Bildyos | Bosaya | Conexxence | Ospomyv | Osvyrti | Prolia)
PDF, 226 KB
Dextenza (Medical)
PDF, 192 KB
PDF, 192 KB
Duchenne Muscular Dystrophy (DMD) Medications (Medical)
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 161 KB
(Amondys 45 | Exondys 51 | Viltepso | Vyondys 53)
PDF, 161 KB
Duopa (Medical)
PDF, 174 KB
PDF, 174 KB
Durysta (Medical)
PDF, 169 KB
PDF, 169 KB
Dysport (Medical)
Botulinum Toxin Injections, Type A (Dysport)PDF, 218 KB
Botulinum Toxin Injections, Type A (Dysport)PDF, 218 KB
Eculizumab IV Products - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
(Bkemv | Epysqli | Soliris)
PDF, 203 KB
(Bkemv | Epysqli | Soliris)
PDF, 203 KB
Eculizumab IV Products - Generalized Myasthenia Gravis (gMG) (Medical)
(Bkemv | Epysqli | Soliris)
PDF, 227 KB
(Bkemv | Epysqli | Soliris)
PDF, 227 KB
Eculizumab IV Products - Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)
(Epysqli | Soliris)
PDF, 242 KB
(Epysqli | Soliris)
PDF, 242 KB
Eculizumab IV Products - Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
(Bkemv | Epysqli | Soliris)
PDF, 215 KB
(Bkemv | Epysqli | Soliris)
PDF, 215 KB
edaravone IV (Radicava IV) (Medical)
PDF, 226 KB
PDF, 226 KB
Elelyso IV (Medical)
PDF, 171 KB
PDF, 171 KB
Elevidys (Medical)
PDF, 185 KB
PDF, 185 KB
Elfabrio IV (Medical)
PDF, 210 KB
PDF, 210 KB
Emblaveo (Medical)
PDF, 189 KB
PDF, 189 KB
Empaveli (Medical)
PDF, 239 KB
PDF, 239 KB
Encelto (Medical)
PDF, 192 KB
PDF, 192 KB
Enflonsia (Medical)
PDF, 161 KB
PDF, 161 KB
Enjaymo (Medical)
PDF, 248 KB
PDF, 248 KB
Entyvio IV (Medical)
PDF, 165 KB
PDF, 165 KB
Epioxa (Medical)
PDF, 199 KB
PDF, 199 KB
Evenity (Medical)
PDF, 201 KB
PDF, 201 KB
Evkeeza (Medical)
PDF, 208 KB
PDF, 208 KB
Exdensur (Medical)
PDF, 215 KB
PDF, 215 KB
Eylea - Retinopathy of Prematurity (ROP) (Medical)
Retinopathy of Prematurity (ROP)PDF, 167 KB
Retinopathy of Prematurity (ROP)PDF, 167 KB
Fasenra SQ (Medical)
PDF, 255 KB
PDF, 255 KB
Fetroja IV (Medical)
PDF, 178 KB
PDF, 178 KB
Fuzeon (Medical)
PDF, 204 KB
PDF, 204 KB
Gazyva - Lupus Nephritis (Medical)
PDF, 225 KB
PDF, 225 KB
Givlaari (Medical)
PDF, 226 KB
PDF, 226 KB
Gonadotropin-releasing Hormone Agonists (GnRH) (Medical)
(PREFERRED: Camcevi | Eligard (3-month, 4-month, 6-month) | Lupron Depot (3-month, 4-month, 6-month)) | Lupron Depot-Ped (3-month, 6-month) | Trelstar (3-month) | Supprelin LA | Vantas) (Non-Preferred: Eligard (1-month) | Fensolvi | leuprolide acetate | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Trelstar (1-month) |Triptodur (6-months) | Vabrinty | Zoladex)
PDF, 255 KB
(PREFERRED: Camcevi | Eligard (3-month, 4-month, 6-month) | Lupron Depot (3-month, 4-month, 6-month)) | Lupron Depot-Ped (3-month, 6-month) | Trelstar (3-month) | Supprelin LA | Vantas) (Non-Preferred: Eligard (1-month) | Fensolvi | leuprolide acetate | Lupron Depot (1-month) | Lupron Depot-Ped (1-month) | Trelstar (1-month) |Triptodur (6-months) | Vabrinty | Zoladex)
PDF, 255 KB
Hemgenix (Medical)
PDF, 245 KB
PDF, 245 KB
Hyaluronate Acids (Medical)
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Hymovis One | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 241 KB
(PREFERRED - Euflexxa | Synvisc | Synvisc-One) (Non-Preferred - Durolane | Gel-One | Gel-Syn | Genvisc 850 | Hyalgan | Hymovis | Hymovis One | Monovisc | Orthovisc | Supartz/FX | SynoJoynt | Triluron | TriVisc | Visco-3)
PDF, 241 KB
Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors (Medical)
Jesduvroq | Vafseo
PDF, 201 KB
Jesduvroq | Vafseo
PDF, 201 KB
iDose TR (Medical)
PDF, 169 KB
PDF, 169 KB
Ilaris (sJIA | AOSD | TRAPS | HIDS/MKD | FMF diseases | CAPS) (Medical)
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA), AdultOnset Still's Disease (AOSD) , Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF), Cryopyrin-Associated Periodic Syndromes (CAPS), and gout flares
PDF, 249 KB
This form is applicable for the following diagnoses: System Juvenile Idiopathic Arthritis (sJIA), AdultOnset Still's Disease (AOSD) , Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS), Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD), Familial Mediterranean Fever (FMF), Cryopyrin-Associated Periodic Syndromes (CAPS), and gout flares
PDF, 249 KB
Ilumya (Medical)
PDF, 172 KB
PDF, 172 KB
Imaavy (Medical)
PDF, 200 KB
PDF, 200 KB
Immune Globulin Intravenous (IVIG) (immunodeficiency) Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Hyqvia | Panzyga)
PDF, 238 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Hyqvia | Panzyga)
PDF, 238 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Disorders) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 272 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 272 KB
Immune Globulin Intravenous (IVIG) (Miscellaneous Sjögren’s Syndrome Neuropathies) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 267 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammagard Liquid | Gammagard S/D | Gammaked | Gamunex-C | Octagam | Privigen) (NON-PREFERRED: Panzyga)
PDF, 267 KB
Immune Globulin Intravenous (IVIG) (Multifocal Motor Neuropathy (MMN)) (Medical)
(PREFERRED: Bivigam | Gammaked | Flebogamma DIF | Gamunex-C | Gammagard Liquid | Octagam | Gammagard S/D | Privigen) (NON-PREFERRED: Panzyga)
PDF, 230 KB
(PREFERRED: Bivigam | Gammaked | Flebogamma DIF | Gamunex-C | Gammagard Liquid | Octagam | Gammagard S/D | Privigen) (NON-PREFERRED: Panzyga)
PDF, 230 KB
Immune Globulin Intravenous(IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)
(PREFERRED: Bivigam | Flebogamma DIF | Gammaked | Gamaplex | Gammagard Liquid | Gamunex-C | Gammagard S/D | Octagam | Privigen) (NON-PREFERRED: Alyglo | Asceniv | Panzyga | Yimmugo)
PDF, 211 KB
(PREFERRED: Bivigam | Flebogamma DIF | Gammaked | Gamaplex | Gammagard Liquid | Gamunex-C | Gammagard S/D | Octagam | Privigen) (NON-PREFERRED: Alyglo | Asceniv | Panzyga | Yimmugo)
PDF, 211 KB
Immune Globulin SQ (IVIG) (Primary Immunodeficiency Disorder) (Medical)
(PREFERRED: Cutaquiq | Cuvitru | Gammagard | Gamunex-C | Hizentra | Xembify) (NON-PREFERRED: Hyqvia)
PDF, 249 KB
(PREFERRED: Cutaquiq | Cuvitru | Gammagard | Gamunex-C | Hizentra | Xembify) (NON-PREFERRED: Hyqvia)
PDF, 249 KB
Infliximab Category (Medical)
(Non-Preferred: Avsola | Inflectra | Infliximab (unbranded Remicade) | Remicade | Renflexis | Zymfentra) (Medical)
PDF, 197 KB
(Non-Preferred: Avsola | Inflectra | Infliximab (unbranded Remicade) | Remicade | Renflexis | Zymfentra) (Medical)
PDF, 197 KB
Intravitreal Complement Inhibitors (Medical)
(Izervay | Syfovre)
PDF, 214 KB
(Izervay | Syfovre)
PDF, 214 KB
Itvisma (Medical)
PDF, 240 KB
PDF, 240 KB
Kebilidi (Medical)
PDF, 220 KB
PDF, 220 KB
Kepivance (Medical)
PDF, 213 KB
PDF, 213 KB
Kimyrsa | Orbactiv (Medical)
PDF, 191 KB
PDF, 191 KB
Kisunla (Medical)
PDF, 406 KB
PDF, 406 KB
Korsuva (Medical)
PDF, 197 KB
PDF, 197 KB
Krystexxa (Medical)
PDF, 242 KB
PDF, 242 KB
Kymriah (Medical)
PDF, 249 KB
PDF, 249 KB
Lamzede (Medical)
PDF, 184 KB
PDF, 184 KB
Lantidra (Medical)
PDF, 198 KB
PDF, 198 KB
Lemtrada (Medical)
PDF, 169 KB
PDF, 169 KB
Lenmeldy (Medical)
PDF, 255 KB
PDF, 255 KB
Leqembi IV (Medical)
PDF, 557 KB
PDF, 557 KB
Leqvio (Medical)
PDF, 238 KB
PDF, 238 KB
Loargys (Medical)
PDF, 197 KB
PDF, 197 KB
Lumizyme (Medical)
PDF, 194 KB
PDF, 194 KB
Luxturna (Medical)
(Drug should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in performing intraocular surgery)PDF, 210 KB
(Drug should ONLY be administered in a surgical suite under controlled aseptic conditions by a surgeon experienced in performing intraocular surgery)PDF, 210 KB
Lyfgenia (Medical)
PDF, 183 KB
PDF, 183 KB
Macular Degeneration Drugs (Medical)
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Eylea HD | Lucentis | Pavblu | Susvimo | Vabysmo)
PDF, 235 KB
(PREFERRED: Avastin | bevacizumab 1.25mg/0.05mL) (Non-Preferred: Beovu | Byooviz | Cimerli | Eylea | Eylea HD | Lucentis | Pavblu | Susvimo | Vabysmo)
PDF, 235 KB
Mepsevii IV (Medical)
PDF, 195 KB
PDF, 195 KB
Mozobil (Medical)
PDF, 215 KB
PDF, 215 KB
Myobloc (Medical)
Botulinum Toxin Injections, Type B (Myobloc)PDF, 172 KB
Botulinum Toxin Injections, Type B (Myobloc)PDF, 172 KB
Nexviazyme | Pombiliti (Medical)
PDF, 263 KB
PDF, 263 KB
Niktimvo (Medical)
PDF, 214 KB
PDF, 214 KB
Noninfectious Uveitis (NIU) Drugs (Medical)
(Iluvien| Retisert | Yutiq)
PDF, 237 KB
(Iluvien| Retisert | Yutiq)
PDF, 237 KB
Non-Preferred tocilizumab products IV (Medical)
Actemra | Avtozma | Tofidence | Tyenne
PDF, 177 KB
Actemra | Avtozma | Tofidence | Tyenne
PDF, 177 KB
Non-Preferred Vykoura & levoleucovorin Products – Oncology Indications (Medical)
(Non-Preferred: levoleucovorin (generic Fusilev) │ Khapzory │ Vykoura)
PDF, 217 KB
(Non-Preferred: levoleucovorin (generic Fusilev) │ Khapzory │ Vykoura)
PDF, 217 KB
Nplate (Medical)
PDF, 221 KB
PDF, 221 KB
Nulibry IV (Medical)
PDF, 242 KB
PDF, 242 KB
Nulojix (Medical)
PDF, 210 KB
PDF, 210 KB
Nuzyra IV (Medical)
PDF, 181 KB
PDF, 181 KB
Ocrevus | Ocrevus Zunovo (Medical)
PDF, 218 KB
PDF, 218 KB
Omisirge (Medical)
PDF, 263 KB
PDF, 263 KB
Onapgo (Medical)
PDF, 193 KB
PDF, 193 KB
Onpattro (Medical)
PDF, 256 KB
PDF, 256 KB
Ophthalmic Corticosteroid Injections (Medical)
(Ozurdex | Iluvien | Xipere)PDF, 230 KB
(Ozurdex | Iluvien | Xipere)PDF, 230 KB
Orencia IV Graft Versus Host Disease (GVHD) (Medical)
(Infusion Only)PDF, 199 KB
(Infusion Only)PDF, 199 KB
Oxlumo (Medical)
PDF, 170 KB
PDF, 170 KB
Panhematin (Medical)
PDF, 186 KB
PDF, 186 KB
Papzimeos (Medical)
PDF, 188 KB
PDF, 188 KB
Parenteral Iron Products (Medical)
(Non-Preferred) Feraheme | Injectafer | MonoferricPDF, 150 KB
(Non-Preferred) Feraheme | Injectafer | MonoferricPDF, 150 KB
Pemetrexed Injections (Medical)
PDF, 210 KB
PDF, 210 KB
Prevymis IV (Infusion) (Medical)
PDF, 195 KB
PDF, 195 KB
Prialt (Medical)
PDF, 141 KB
PDF, 141 KB
Primaxin IV (Medical)
PDF, 185 KB
PDF, 185 KB
Pulmonary Arterial Hypertension IV Drugs (Medical)
Phosphodiesterase Type-5 Inhibitors (sildenafil IV (Revatio)); Prostacyclin Pathway Agents - Analogues and Receptor Agonist (epoprostenol IV (Flolan) | epoprostenol IV (Veletri) | treprostinil IV (Remodulin) | Uptravi IV)PDF, 261 KB
Phosphodiesterase Type-5 Inhibitors (sildenafil IV (Revatio)); Prostacyclin Pathway Agents - Analogues and Receptor Agonist (epoprostenol IV (Flolan) | epoprostenol IV (Veletri) | treprostinil IV (Remodulin) | Uptravi IV)PDF, 261 KB
Qalsody (Medical)
PDF, 246 KB
PDF, 246 KB
Qutenza (Medical)
PDF, 142 KB
PDF, 142 KB
Reblozyl (Medical)
PDF, 255 KB
PDF, 255 KB
Rebyota (Medical)
PDF, 194 KB
PDF, 194 KB
Recarbrio (Medical)
PDF, 197 KB
PDF, 197 KB
Rezzayo IV (Medical)
PDF, 190 KB
PDF, 190 KB
Rivfloza (Medical)
PDF, 199 KB
PDF, 199 KB
Roctavian (Medical)
PDF, 191 KB
PDF, 191 KB
Ryoncil (Medical)
PDF, 210 KB
PDF, 210 KB
Ryplazim (Medical)
PDF, 233 KB
PDF, 233 KB
Rystiggo (Medical)
PDF, 182 KB
PDF, 182 KB
Saphnelo IV (Medical)
PDF, 189 KB
PDF, 189 KB
Scenesse Implant (Medical)
PDF, 210 KB
PDF, 210 KB
Simulect IV (Medical)
PDF, 173 KB
PDF, 173 KB
Sinuva Sinus Implant (Medical)
PDF, 200 KB
PDF, 200 KB
Sivextro (Medical)
PDF, 190 KB
PDF, 190 KB
Skysona (Medical)
PDF, 244 KB
PDF, 244 KB
Somatostatin Analog Drugs (Medical)
PREFERRED (lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection); NON-PREFERRED (Somatuline Depot)
PDF, 202 KB
PREFERRED (lanreotide acetate ER SQ injection | octreotide injection | Sandostatin injection | Signifor LAR SQ injection); NON-PREFERRED (Somatuline Depot)
PDF, 202 KB
Spevigo (Medical)
PDF, 211 KB
PDF, 211 KB
Spinraza (Medical)
PDF, 225 KB
PDF, 225 KB
Tecartus IV (Medical)
PDF, 240 KB
PDF, 240 KB
Tecelra (Medical)
PDF, 237 KB
PDF, 237 KB
Teflaro IV (Medical)
PDF, 179 KB
PDF, 179 KB
Tepezza (Medical)
PDF, 227 KB
PDF, 227 KB
Testosterone Replacement Therapy Injectable (Medical)
(PREFERRED: testosterone cypionate | testosterone enanthate) (NON-PREFERRED: Aveed | Azmiro | Testopel)
PDF, 215 KB
(PREFERRED: testosterone cypionate | testosterone enanthate) (NON-PREFERRED: Aveed | Azmiro | Testopel)
PDF, 215 KB
Tezspire (Medical)
PDF, 249 KB
PDF, 249 KB
Trogarzo IV (Medical)
Medication being provided by the physician's officePDF, 179 KB
Medication being provided by the physician's officePDF, 179 KB
Tygacil (Medical)
PDF, 202 KB
PDF, 202 KB
Tysabri and Biosimilars (Medical)
Tysabri IV | Tyruko IV
PDF, 290 KB
Tysabri IV | Tyruko IV
PDF, 290 KB
Tzield (Medical)
PDF, 239 KB
PDF, 239 KB
Unituxin (Medical)
PDF, 211 KB
PDF, 211 KB
Uplizna (Medical)
PDF, 270 KB
PDF, 270 KB
Vabomere (Medical)
PDF, 160 KB
PDF, 160 KB
Veopoz (Medical)
PDF, 218 KB
PDF, 218 KB
Vibativ (Medical)
PDF, 181 KB
PDF, 181 KB
Vimizim IV (Medical)
IV Infusion Performed at Sentara Infusion Centers ONLYPDF, 213 KB
IV Infusion Performed at Sentara Infusion Centers ONLYPDF, 213 KB
Visudyne (Medical)
PDF, 202 KB
PDF, 202 KB
Vpriv (Medical)
PDF, 204 KB
PDF, 204 KB
Vyalev (Medical)
PDF, 169 KB
PDF, 169 KB
Vyepti IV (Medical)
PDF, 231 KB
PDF, 231 KB
Vyjuvek (Medical)
PDF, 219 KB
PDF, 219 KB
Vykoura in Cerebral Folate Transport Deficiency (CFTD) (Medical)
(Non-Preferred: Vykoura )
PDF, 224 KB
(Non-Preferred: Vykoura )
PDF, 224 KB
Waskyra (Medical)
PDF, 264 KB
PDF, 264 KB
Xacduro (Medical)
PDF, 225 KB
PDF, 225 KB
Xenleta IV (Medical)
PDF, 167 KB
PDF, 167 KB
Xenpozyme (Medical)
PDF, 210 KB
PDF, 210 KB
Xerava IV (Medical)
PDF, 177 KB
PDF, 177 KB
Xiaflex (Medical)
PDF, 198 KB
PDF, 198 KB
Xolair (Medical)
PDF, 1 MB
PDF, 1 MB
Yartemlea (Medical)
PDF, 231 KB
PDF, 231 KB
Ycanth (Medical)
PDF, 167 KB
PDF, 167 KB
Yescarta (Medical)
PDF, 216 KB
PDF, 216 KB
Zemdri IV (Medical)
PDF, 177 KB
PDF, 177 KB
Zevaskyn (Medical)
PDF, 211 KB
PDF, 211 KB
Zevtera (Medical)
PDF, 203 KB
PDF, 203 KB
Zinplava (Medical)
PDF, 248 KB
PDF, 248 KB
Zolgensma IV (Medical)
PDF, 216 KB
PDF, 216 KB
Zynteglo (Medical)
PDF, 233 KB
PDF, 233 KB