Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the PA Health & Wellness Clinical Policy Manual apply to PA Health & Wellness members. Policies in the PA Health & Wellness Clinical Policy Manual may have either a PA Health & Wellness or a “Centene” heading.  PA Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health & Wellness clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling PA Health & Wellness. In addition, PA Health & Wellness may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by PA Health & Wellness.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z

Acupuncture (PDF) 

Effective Date: 01/18 

Intestinal and Multivisceral Transplant (PDF) 

Effective Date: 01/18 

Radial Head Implant (PDF) Effective Date: 01/18 

Allergy Testing and Therapy (PDF) 

Effective Date: 04/18 

Intensity-modulated Radiotherapy (PDF) 

Effective Date: 01/18 

Reduction Mammoplasty and Gynecomastia Surgery (PDF) 

Effective Date: 01/18 

Allogenic Hematopoietic Cell Transplants for Sickle Cell (PDF) 

Effective Date: 01/18 

Injections and Radiofrequency Neurotomy for Pain Management (PDF) 

Effective Date: 01/18 

Stereotactic Body Radiation Therapy (PDF) 

Effective Date: 01/18 

Ambulatory Surgery Center Optimization (PDF) 

Effective Date: 03/18 

Laser Therapy for Skin Conditions (PDF) 

Effective Date: 01/18 

Spinal Cord Stimulation (PDF) 

Effective Date: 01/18 

Balloon Sinus Ostial Dilation for Treatment of Chronic Sinusitis (PDF) 

Effective Date: 01/18 

Low-Frequency Ultrasound Therapy for Wound Management (PDF) 

Effective Date: 05/18 

Testing for Rupture of Fetal Membranes (PDF) 

Effective Date: 05/18

Bariatric Surgery (PDF) 

Effective Date: 01/18 

Lysis of Epidural Lesions (PDF) 

Effective Date: 01/18 

Ultrasound in Pregnancy (PDF) 

Effective Date: 04/18 

Biofeedback (PDF) 

Effective Date: 01/18 

Non-Myeloablative Allogeneic Stem Cell Transplants (PDF) 

Effective Date: 01/18 

Urinary Incontinence Devices and Treatments (PDF) 

Effective Date: 01/18 

Cardiac Biomarker Testing (PDF) 

Effective Date: 05/18 

Medical Necessity Guidelines (PDF) 

Effective Date: 01/18 

Urodynamic Testing (PDF) 

Effective Date: 05/18 

Carrier Screening in Pregnancy (PDF) 

Effective Date: 01/18 

Multiple Sleep Latency Testing (PDF) 

Effective Date: 01/18 

Vagus Nerve Stimulation (PDF) 

Effective Date: 01/18 

Cell-free Fetal DNA Testing (PDF) 

Effective Date: 01/18 

Obstetrical Home Care Programs (PDF) 

Effective Date: 01/18 

Ventricular Assist Devices (PDF) 

Effective Date: 01/18

Clinical Trials (PDF) 

Effective Date: 01/18 

Optic Nerve Decompression Surgery (PDF) 

Effective Date: 01/18 

Ventriculectomy and Cardiomyoplasty (PDF) 

Effective Date: 01/18 

Cochlear Implant Replacements (PDF) 

Effective Date: 01/18 

Outpatient Testing for Drugs of Abuse (PDF) 

Effective Date: 01/18 

 

Cosmetic and Reconstructive Surgery (PDF) 

Effective Date: 01/18 

Pancreas Transplantation (PDF) 

Effective Date: 01/18 

 

Dental Anesthesia (PDF) 

Effective Date: 01/18 

Panniculectomy (PDF) 

Effective Date: 01/18 

 

Digital EEG Spike Analysis (PDF) 

Effective Date: 05/18 

Pediatric Heart Transplant (PDF) 

Effective Date: 01/18 

 

Disc Decompression Procedures (PDF) 

Effective Date: 01/18 

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) 

Effective Date: 01/18 

 

Discography (PDF) 

Effective Date: 01/18 

Proton and Neutron Beam Therapy (PDF) 

Effective Date: 01/18 

 

DME and O&P Criteria (PDF) 

Effective Date: 01/18 

   

Donor Lymphocyte Infusion (PDF) 

Effective Date: 01/18 

   

EEG in the Evaluation of Headache (PDF) 

Effective Date: 05/18 

   

Electric Tumor Treating Fields (Optune) (PDF) 

Effective Date: 01/18 

   

Endometrial Ablation (PDF) 

Effective Date: 05/18 

   

EpiFix Wound Treatment (PDF) 

Effective Date: 03/18 

   

Essure Removal (PDF) 

Effective Date: 01/18 

   

Fecal Incontinence Treatments (PDF) 

Effective Date: 01/18 

   

Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF) 

Effective Date: 01/18 

   

Functional MRI (PDF) 

Effective Date: 01/18 

   

Gastric Electrical Stimulation (PDF) 

Effective Date: 01/18 

   

Gender Confirmation Surgery (PDF) 

Effective Date: 01/18 

   

Heart-Lung Transplant (PDF) 

Effective Date: 01/18 

   

Helicobacter Pylori Serology Testing (PDF) 

Effective Date: 05/18 

   

Holter Monitors (PDF) 

Effective Date: 05/18 

   

Home Sleep Testing (PDF) 

Effective Date: 01/18 

   

Homocysteine Testing (PDF) 

Effective Date: 08/16 

   

Hospice Services (PDF) 

Effective Date: 01/18 

   

Hyperemesis Gravidarum Treatment (PDF) 

Effective Date: 01/18 

   
 
A - H   I - Q  R - Z

Abaloparatide (Tymlos) (PDF) 

Effective Date: 07/17 

Ibandronate Sodium (Boniva) (PDF) 

Effective Date: 03/17 

Ranolazine (Ranexa) (PDF) 

Effective Date: 01/18

Abiraterone (Zytiga) (PDF) 

Effective Date: 01/18 

Icatibant (Firazyr) (PDF) 

Effective Date: 01/18 

Ranibizumab (Lucentis) (PDF) 

Effective Date: 01/18 

AbobotulinumtoxinA (Dysport) (PDF) 

Effective Date: 01/18 

IncobotulinumtoxinA (Xeomin)(PDF) 

Effective Date: 01/18 

Ramucirumab (Cyramza) (PDF) 

Effective Date: 01/18 

Adalimumab (Humira) (PDF) 

Effective Date: 01/18 

Interferon beta-1b (Betaseron, Extavia) (PDF) 

Effective Date: 01/18 

Regorafenib (Stivarga) (PDF) 

Effective Date: 01/18 

Ado-Trastuzumab (Kadcyla) (PDF) 

Effective Date: 01/18 

Iloprost (Ventavis) (PDF) 

Effective Date: 01/18 

Repository Corticotropin Injection (H.P. Acthar Gel) (PDF) 

Effective Date: 01/18 

Agalsidase Beta (Fabrazyme) (PDF) 

Effective Date: 01/18 

Infliximab (Remicade, Inflectra, Renflexis) (PDF) 

Effective Date: 01/18 

Reslizumab (Cinqair) (PDF) 

Effective Date: 01/18 

Afatinib (Gilotrif) (PDF) 

Effective Date: 01/18 

Inhaled Combination Long-acting Anticholinergic & Beta-2-agonist Agents (PDF) 

Effective Date: 01/18 

Ribociclib (Kisqali) (PDF) 

Effective Date: 01/18 

Aflibercept (Eylea) (PDF) 

Effective Date: 01/18 

Interferon beta-1a (Avonex, Rebif) (PDF) 

Effective Date: 01/18 

Rifaximin (Xifaxan) (PDF) 

Effective Date: 01/18 

Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF) 

Effective Date: 03/18 

Interferon Gamma-1b (Actimmune) (PDF)

Effective Date 01/18 

Rilonacept (Arcalyst) (PDF) 

Effective Date: 01/18 

Alemtuzumab (Lemtrada) (PDF) 

Effective Date: 01/18 

Imatinib (Gleevec) (PDF) 

Effective Date: 06/11 

RimabotulinumtoxinB (Myobloc)(PDF) 

Effective Date: 01/18 

Alglucosidase Alfa (Lumizyme) (PDF) 

Effective Date: 01/18 

Immune Globulins (PDF) 

Effective Date: 01/18 

Riociguat (Adempas) (PDF) 

Effective Date: 01/18 

Alirocumab (Praluent) (PDF) 

Effective Date: 01/18 

Ipilimumab (Yervoy) (PDF) 

Effective Date: 01/18 


Rituximab (Rituxan) (PDF) 


Effective Date: 01/18 

Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia,Prolastin-C, Zemaira) (PDF) 

Effective Date: 01/18 

Irinotecan Liposome Injection (Onivyde) (PDF) 

Effective Date: 01/18 

 

Rivastigmine (Exelon) (PDF) 

Effective Date: 01/18 

Anakinra (Kineret) (PDF) 

Effective Date: 01/18 

Isotretinoin (Claravis, Absorica, Myorisan, Zenatane) (PDF) 

Effective Date: 01/18 

Romidepsin (Istodax) (PDF) 

Effective Date: 01/18 

Anti-Allergy Ophthalmics (PDF) 

Effective Date: 01/18 

Iron Sucrose (Venofer) (PDF) 

Effective Date: 01/18 

Roflumilast (Daliresp) (PDF) 

Effective Date: 01/18 

Anti-Inhibitor Coagulant Complex (Human - Feiba) (PDF) 

Effective Date: 01/18 

Ivabradine (Corlanor) (PDF) 

Effective Date: 01/18 

Romiplostim (Nplate) (PDF) 

Effective Date: 01/18 

Antipsychotics (PDF) 

Effective Date: 01/18 

Ivacaftor (Kalydeco) (PDF) 

Effective Date: 01/18 

Rucaparib (Rubraca) (PDF) 

Effective Date : 01/18 

Ambrisentan (Letairis) (PDF) 

Effective Date: 03/16 

Ixazomib (Ninlaro) (PDF) 

Effective Date: 01/18 

Ruxolitinib (Jakafi) (PDF) 

Effective Date: 01/18 

Apalutamide (Erleada) (PDF) 

Effective Date: 03/18 

Ixekizumab (Taltz) (PDF) 

Effective Date: 01/18 

Sacubitril-Valsartan (Entresto) (PDF) 

Effective Date: 01/18 

Apremilast (Otezla) (PDF) 

Effective Date: 08/16 

Lapatinib (Tykerb) (PDF) 

Effective Date: 01/18 

Sapropterin Dihydrochloride (Kuvan) (PDF) 

Effective Date: 01/18 

Armodafinil (Nuvigil) (PDF) 

Effective Date: 01/18 

Ledipasvir/Sofosbuvir (Harvoni) (PDF) 

Effective Date: 08/17 

Sargramostim (Leukine) (PDF) 

Effective Date: 01/18 

Asfotase Alfa (Strensiq) (PDF) 

Effective Date: 01/18 

Lenalidomide (Revlimid) (PDF) 

Effective Date: 01/18 

Sebelipase Alfa (Kanuma) (PDF) 

Effective Date: 01/18 

Atezolizumab (Tecentriq) (PDF) 

Effective Date: 01/18 

Lidocaine transdermal (Lidoderm) (PDF) 

Effective Date: 09/06 

Secukinumab (Cosentyx) (PDF) 

Effective Date: 01/18 

Atomoxetine (Strattera) (PDF) 

Effective Date: 01/18 

Lifitegrast (Xiidra) (PDF) 

Effective Date: 01/18 

Selexipag (Uptravi) (PDF) 

Effective Date: 01/18 

Axitinib (Inlyta) (PDF) 

Effective Date: 01/18 

Lindane Shampoo (PDF) 

Effective Date: 01/18 

Short Acting Narcotic Analgesics (PDF) 

Effective Date: 08/18 

Avelumab (Bavencio) (PDF) 

Effective Date: 01/18 

Linezolid (Zyvox) (PDF) 

Effective Date: 01/18 

Sildenafil (Revatio) (PDF)

Effective Date: 01/18 

Aztreonam (Cayston) (PDF) 

Effective Date: 01/18 

Lomitapide (Juxtapid) (PDF) 

Effective Date: 01/18 

Siltuximab (Sylvant) (PDF) 

Effective Date: 01/18 

Belatacept (Nulojix) (PDF) 

Effective Date: 01/18 

Lisdexamfetamine (Vyvanse) (PDF) 

Effective Date: 1/18 

Simeprevir (Olysio) (PDF) 

Effective Date: 01/18 

Belinostat (Beleodaq) (PDF) 

Effective Date: 01/18 

Nafarelin Acetate (Synarel) (PDF) 

Effective Date: 01/18 

Sipuleucel-T (Provenge) (PDF) 

Effective Date: 01/18 

Belimumab (Benlysta) (PDF) 

Effective Date: 01/18 

Naltrexone (Vivitrol) (PDF) 

Effective Date: 01/18 

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF) 

Effective Date: 01/18 

Bendamustine (Bendeka, Treanda) (PDF) 

Effective Date: 01/18 

Natalizumab (Tysabri) (PDF) 

Effective Date: 01/18 

Sodium phenylbutyrate (Buphenyl) (PDF) 

Effective Date: 01/18

Bevacizumab (Avastin) (PDF) 

Effective Date: 01/18 

Nilotinib (Tasigna) (PDF) 

Effective Date: 01/18 

Sodium Oxybate (Xyrem) (PDF) 

Effective Date: 01/18 

Bexarotene (Targretin) Capsules (PDF) 

Effective Date: 09/11 

Nintedanib (Ofev) (PDF) 

Effective Date: 01/18 

Sofosbuvir (Sovaldi) (PDF) 

Effective Date: 01/18 

Bezlotoxumab (Zinplava) (PDF) 

Effective Date: 01/18 

Nivolumab (Opdivo) (PDF) 

Effective Date: 01/18 

Sofosbuvir/Velpatasvir (Epclusa) (PDF) 

Effective Date: 01/18 

Blinatumomab (Blincyto) (PDF) 

Effective Date: 01/18 

Macitentan (Opsumit) (PDF)  

Effective Date: 01/18 

Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF) 

Effective Date 01/18 

Bosentan (Tracleer) (PDF) 

Effective Date: 01/18 

Mecasermin (Increlex) (PDF)

Effective Date: 01/18 

Sonidegib (Odomzo) (PDF) 

Effective Date: 01/18 

Bosutinib (Bosulif) (PDF) 

Effective Date: 01/18 

Mepolizumab (Nucala) (PDF) 

Effective Date: 01/18 

Sorafenib (Nexavar) (PDF) 

Effective Date: 01/18 

Brand Name Override (PDF) 

Effective Date: 09/06 

Mesalamine Oral Therapy (PDF) 

Effective Date: 01/18 

Taliglucerase Alfa (Elelyso) (PDF) 

Effective Date: 01/18 

Brentuximab Vedotin (Adcetris) (PDF) 

Effective Date: 01/18

Metformin ER (Glumetza) (PDF) 

Effective Date: 01/18 

Tazarotene (Tazorac) (PDF) 

Effective Date: 01/18 

Brigatinib (Alunbrig) (PDF) 

Effective Date: 01/18 

Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF) 

Effective Date: 01/18 

Teduglutide (Gattex) (PDF) 

Effective Date: 01/18 

Buprenorphine (Subutex) (PDF) 

Effective Date: 01/18

Mifepristone (Korlym) (PDF) 

Effective Date: 01/18 

Temsirolimus (Torisel) (PDF) 

Effective Date: 01/18 

Buprenorphine HCL (Probuphine Implant) (PDF) 

Effective Date: 01/18 

Miglustat (Zavesca) (PDF) 

Effective Date: 01/18 

Teriflunomide (Aubagio) (PDF) 

Effective Date: 01/18

Buprenorphine-Naloxone (Suboxone, Bunavail, Zubsolv) (PDF) 

Effective Date: 01/18 

Minocycline (Solodyn) and Microspheres (Arestin) (PDF) 

Effective Date: 01/18 

Teriparatide (Forteo) (PDF) 

Effective Date: 01/18

C1 Esterase Inhibitors (Berinert, Cinryze, Ruconest) (PDF) 

Effective Date: 01/18 

Mipomersen (Kynamro) (PDF) 

Effective Date: 01/18 

Tesamorelin (Egrifta) (PDF) 

Effective Date: 01/18 

Cabazitaxel (Jevtana) (PDF) 

Effective Date: 01/18 

Modafinil (Provigil) (PDF) 

Effective Date: 01/18 

Thalidomide (Thalomid) (PDF) 

Effective Date: 09/11

Cabozantinib (Cometriq, Cabometyx) (PDF) 

Effective Date: 06/13 

Obeticholic acid (Ocaliva) (PDF) 

Effective Date: 01/18 

Thyrotropin alfa (Thyrogen)(PDF) 

Effective Date: 01/18 

Canakinumab (Ilaris) (PDF) 

Effective Date: 01/18 

Obinutuzumab (Gazyva) (PDF) 

Effective Date: 01/18 

Tocilizumab (Actemra) (PDF) 

Effective Date: 01/18 

Capecitabine (Xeloda) (PDF)

Effective Date: 01/18 

 

Octreotide Acetate (Sandostatin Injection, Sandostatin LAR Depot) (PDF)

Effective Date: 01/18

Tofacitinib (Xeljanz/Xeljanz XR) (PDF) 

Effective Date: 01/18 

Carbamazepine ER (Equetro) (PDF) 

Effective Date: 03/18 

Off-Label Use (PDF) 

Effective Date: 01/18 

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) 

Effective Date: 01/18 

Carglumic acid (Carbaglu) (PDF) 

Effective Date: 01/18 

Olaratumab (Lartruvo) (PDF) 

Effective Date: 01/18 

Trabectedin (Yondelis) (PDF) 

Effective Date: 01/18 

Celecoxib (Celebrex) (PDF) 

Effective Date: 01/18 

OnabotulinumtoxinA (Botox) (PDF) 

Effective Date: 01/18 

Trametinib (Mekinist) (PDF) 

Effective Date: 01/18 

Cerliponasa alfa (Brineura) (PDF) 

Effective Date: 01/18 

Omacetaxine (Synribo) (PDF) 

Effective Date: 01/18 

Triptorelin Pamoate (Trelstar) (PDF) 

Effective Date: 01/18 

Certolizumab (Cimzia) (PDF) 

Effective Date: 01/18 

Ombitasvir/Paritaprevir/Ritonavir (Technivie) (PDF) 

Effective Date: 01/18 

Velaglucerase Alfa (VPRIV) (PDF) 

Effective Date: 01/18 

Cetuximab (Erbitux) (PDF) 

Effective Date: 01/18 

Omalizumab (Xolair) (PDF) 

Effective Date: 01/18 

Vemurafenib (Zelboraf) (PDF) 

Effective Date: 01/18

Cinacalcet (Sensipar) (PDF) 

Effective Date: 01/18 

Omega-3-Acid Ethyl Esters (Lovaza) (PDF) 

Effective Date: 01/18 

Vilazodone (Viibryd) (PDF) 

Effective Date: 01/18 

Clobazam (Onfi) (PDF) 

Effective Date: 01/18 

Oral Antiemetics (5-HT3 Antagonists) (PDF) 

Effective Date: 01/18 

Vincristine Sulfate Liposome Injection (Marqibo) (PDF) 

Effective Date: 01/18 

Colchicine (Colcrys) (PDF) 

Effective Date: 01/18 

Oral Bisphosphonates (PDF) 

Effective Date: 01/18 

 

Collagenase Clostridium Histolyticum (Xiaflex) (PDF) 

Effective Date: 01/18 

Ozenoxacin (Xepi) (PDF) 

Effective Date: 01/18 

 

Cosyntropin (Cortrosyn) (PDF) 

Effective Date: 01/18 

Palbociclib (Ibrance) (PDA) 

Effective Date: 01/18

 

Crizotinib (Xalkori) (PDF) 

Effective Date: 01/18

Palivizumab (Synagis) (PDF) 

Effective Date: 01/18 

 

Cyclosporine (Restasis) (PDF) 

Effective Date: 04/18 

Peginterferon Alfa-2b (PegIntron, Sylatron) (PDF) 

Effective Date: 01/18 

 

Dabigatran (Pradaxa) (PDF) 

Effective Date: 01/18 

Pertuzumab (Perjeta) (PDF) 

Effective Date: 01/18 

 

Daclatasvir (Daklinza) (PDF) 

Effective Date: 08/17 

 

Pimavanserin (Nuplazid) (PDF) 

Effective Date: 01/18 

 

Daclizumab (Zinbryta) (PDF) 

Effective Date: 01/18 

Pirfenidone (Esbriet) (PDF) 

Effective Date: 01/18 

 

Dalfampridine (Ampyra) (PDF) 

Effective Date: 01/18

Ponatinib (Iclusig) (PDF) 

Effective Date: 01/18

 

Dalteparin (Fragmin) (PDF) 

Effective Date: 01/18 

Pralatrexate (Folotyn) (PDF) 

Effective Date: 01/18 

 

Daratumumab (Darzalex) (PDF) 

Effective Date: 01/18 

Pramlintide (Symlin) (PDF) 

Effective Date: 01/18 

 

Darbepoetin alfa (Aranesp) (PDF) 

Effective Date: 01/18 

Protein C Concentrate, Human (Ceprotin) (PDF) 

Effective Date: 01/18 

 

Dasabuvir, Ombitasvir, Paritaprevir, Ritonavir (Viekira XR, Viekira Pak) (PDF) 

Effective Date: 01/18

Pyrimethamine (Daraprim) (PDF) 

Effective Date: 01/18 

 

Deferoxamine (Desferal) (PDF) 

Effective Date: 01/18 

 

 

Deflazacort (Emflaza) (PDF) 

Effective Date: 01/18 

   

Degarelix Acetate (Firmagon) (PDF) 

Effective Date: 01/18 

   

Denosumab (Prolia, Xgeva) (PDF) 

Effective Date: 01/18 

   

Desmopressin Acetate (DDAVP Injection) (PDF) 

Effective Date: 01/18 

   

Deutetrabenazine (Austedo) (PDF) 

Effective Date: 01/18 

   

Dexmethylphenidate ER (Focalin XR) (PDF) 

Effective Date: 01/18 

   

Dimethyl fumarate (Tecfidera) (PDF) 

Effective Date: 01/18 

   

Dornase Alfa (Pulmozyme) (PDF) 

Effective Date: 01/18 

   

Doxycline (Doryx, Oracea) (PDF) 

Effective Date: 01/18

   

Droxidopa (Northera™) (PDF) 

Effective Date: 01/18 

   

Dupilumab (Dupixent) (PDF) 

Effective Date: 01/18 

   

Ecallantide (Kalbitor) (PDF) 

Effective Date: 01/18 

   

Eculizumab (Soliris) (PDF) 

Effective Date: 01/18 

   

Edaravone (Radicava) (PDF) 

Effective Date: 01/18

   

Elbasvir/Grazoprevir (Zepatier) (PDF) 

Effective Date: 01/18 

   

Elosulfase Alfa (Vimizim) (PDF) 

Effective Date: 01/18 

   

Elotuzumab (Empliciti) (PDF) 

Effective Date: 01/18 

   

Eltrombopag (Promacta) (PDF) 

Effective Date: 01/18 

   

Enfuvirtide (Fuzeon) (PDF) 

Effective Date: 01/18

   

Enzalutamide (Xtandi) (PDF) 

Effective Date: 01/18 

 

 

Epinephrine (EpiPen and EpiPen Jr) (PDF) 

Effective Date: 01/18 

   

Epoetin alfa (Epogen and Procrit) (PDF) 

Effective Date: 01/18 

   

Epoprostenol Sodium (Flolan, Veletri) (PDF) 

Effective Date: 01/18 

   

Eribulin Mesylate (Halaven) (PDF) 

Effective Date: 1/18 

   

Erwinia Asparaginase (Erwinaze) (PDF) 

Effective Date: 01/18 

   

Etanercept (Enbrel) (PDF) 

Effective Date: 01/18 

   

Eteplirsen (PDF) 

Effective Date: 01/18 

   

Everolimus (Afinitor, Afinitor Disperz) (PDF) 

Effective Date: 01/18 

   

Evolocumab (Repatha) (PDF) 

Effective Date: 01/18 

   

Exemestane (Aromasin) (PDF) 

Effective Date: 01/18

   

Ezetimibe (Zetia) (PDF) 

Effective Date: 01/18 

   

Factor IX Complex (Human - Bebulin, Profilnine) (PDF) 

Effective Date: 01/18 

   

Factor IX (Human - AlphaNine SD, Mononine; Recombinant - Alprolix, BeneFIX, Ixinity, Rixubis) (PDF) 

Effective Date: 01/18 

   

Factor XIII (Human - Corifact) (PDF) 

Effective Date: 01/18 

   

Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF) 

Effective Date: 01/18 

   

Factor VIII (Human, Recombinant) (PDF) 

Effective Date: 01/18 

   

Factor VIIa (Recombinant - NovoSeven RT) (PDF) 

Effective Date: 01/18 

   

Febuxostat (Uloric) (PDF) 

Effective Date: 01/18 

   

Ferric Carboxymaltose (Injectafer) (PDF) 

Effective Date: 01/18 

   

Ferric Gluconate (Ferrlecit) (PDF) 

Effective Date: 01/18 

   

Ferumoxytol (Feraheme) (PDF) 

Effective Date: 01/18 

   

Filgrastim, Filgrastim-sndz, Tbo-filgrastim (PDF) 

Effective Date: 01/18

   

Fluticasone/Salmeterol (Advair Diskus, Advair HFA) (PDF) 

Effective Date: 01/18

   

Fingolimod (Gilenya) (PDF) 

Effective Date: 01/18 

   

Galsulfase (Naglazyme) (PDF) 

Effective Date: 01/18 

   

Gefitinib (Iressa) (PDF) 

Effective Date: 01/18 

   

Glatiramer Acetate (Copaxone, Glatopa) (PDF) 

Effective Date: 01/18 

   

Glecaprevir/Pibrentasvir (Mavyret) (PDF) 

Effective Date: 01/18 

   

Global Biopharm Criteria (PDF) 

Effective Date: 01/18 

   

Glucagon-like peptide-1 receptor agonists for type 2 diabetes (PDF) 

Effective Date: 01/18 

   

Glycerol phenylbutyrate (Ravicti) (PDF) 

Effective Date: 01/18 

   

Golimumab (Simponi, Simponi Aria) (PDF) 

Effective Date: 01/18 

   

Goserelin Acetate (Zoladex) (PDF) 

Effective Date: 01/18 

   

Granisetron (Sancuso) (PDF) 

Effective Date: 01/18

   

Hemin (Panhematin) (PDF) 

Effective Date: 01/18 

   

Histrelin Acetate (Vantas, Supprelin LA) (PDF) 

Effective Date: 01/18 

   

Hyaluronate Derivatives (PDF) 

Effective Date: 01/18 

   

Hydroxyprogesterone Caproate (Makena/compound) (PDF)

Effective Date: 01/18