Policies & Criteria
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 Health Net Clinical Policy Manual apply to Health Net members. Policies in the Health Net Clinical Policy Manual may have either a Health Net or a “Centene” heading. Health Net utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Health Net 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 Health Net. In addition, Health Net 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 Health Net.
If you have any questions regarding these policies, please contact Provider Services 1-888-802-7001 (Commercial) or 1-888-445-8913 (Medicare) and ask to be directed to the Medical Management department.
For Medicare information, please visit our Medicare Prior Authorization website.
Pharmacy Criteria
Health Net’s goal is to offer the right drug coverage to our members. Health Net covers prescription and some over the counter drugs when they are ordered by a licensed prescriber. The pharmacy program does not cover all drugs. Some drugs need prior approval and some have a limit on the amount of drug that can be given.
Clinical policies are one set of guidelines used to assist in administering health plan benefits. 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.
The Pharmacy and Therapeutics (P&T) Committee is comprised of doctors and pharmacists. Together we work to offer drugs used to treat many conditions and illnesses. All clinical policies are reviewed annually by the P&T Committee, which meets quarterly. Approved criteria and revisions made by the P&T Committee go into effect the first day of the month the start of the following quarter. All medications newly approved by the FDA (Food and Drug Administration) require prior approval until reviewed by our P&T Committee.
All policies found in the Health Net Clinical Policy Manual apply to Health Net members. Policies in the Health Net Clinical Policy Manual may have either a Health Net or a “Centene” heading.
If you have any questions regarding these policies, please contact Provider Services and ask to be directed to the Pharmacy department.
Commercial Pharmacy Criteria
Anti-Inflammatory Agents
- Biologic and Non-biologic DMARDs; CP.CPA.194 (PDF)
- Canakinumab (Ilaris); CP.PHAR.246 (PDF)
- Celecoxib (Celebrex, Elyxyb); CP.PMN.122 (PDF)
- Diclofenac potassium (Cambia, Flector, Licart, Pennsaid, Solaraze, Zipsor, Zorvolex); CP.PCH.28 (PDF)
- Ibuprofen-famotidine (Duexis); CP.PMN.120 (PDF)
- Ketorolac nasal spray (Sprix); CP.PMN.282 (PDF)
- Meloxicam (Vivlodex); CP.CPA.296 (PDF)
- Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep, Jylamvo); CP.PHAR.134 (PDF)
- Nabumatone Double-Strength (Relafen DS); CP.PMN.287 (PDF)
- Naproxen and esomeprazole magnesium (Vimovo); CP.PMN.117 (PDF)
- Rilonacept (Arcalyst); CP.PHAR.266 (PDF)
Opioid Agents
- Age Limit Override (Codeine, Tramadol, Hydrocodone); CP.PMN.138 (PDF)
- Buprenorphine (Sublocade, Brixadi); CP.PHAR.289 (PDF)
- Buprenorphine (Subutex); CP.PMN.82 (PDF)
- Buprenorphine-naloxone (Suboxone, Zubsolve); CP.PMN.81 (PDF)
- Fentanyl IR (Actiq, Fentora, Lazanda, Subsys); CP.PMN.127 (PDF)
Amebicides
Amnoglycosides
- Amikacin (Arikayce); CP.PHAR.401 (PDF)
- Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler); CP.PHAR.211 (PDF)
Antifungals
- Efinaconazole (Jublia); CP.PMN.25 (PDF)
- Isavuconazonium sulfate (Cresemba); CP.PMN.154 (PDF)
- Itraconazole (Sporanox, Tolsura); CP.PMN.124 (PDF)
- Luliconazole (Luzu); CP.PMN.166 (PDF)
- Tavaborole (Kerydin); CP.PMN.105 (PDF)
Antihelmintics
Anti-Infective Agents - Misc.
- Chloramphenicol Sodium Succinate; CP.PHAR.388 (PDF)
- Ciprofloxacin/Fluocinolone (Otovel); CP.PMN.249 (PDF)
- Daptomycin (Cubicin, Cubicin RF, Dapzura RT); CP.PHAR.351 (PDF)
- Lefamulin acetate (Xenleta); CP.PMN.219 (PDF)
- Linezolid (Zyvox); CP.PMN.27 (PDF)
- Nifurtimox (Lampit); CP.PMN.256 (PDF)
- Rifamvcin (Aemcolo); CP.PNM.196 (PDF)
- Rifaximin (Xifaxan); CP.PMN.47 (PDF)
- Tedizolid (Sivextro); CP.PMN.62 (PDF)
- Vancomycin (Firvanq, Vancocin); CP.CPA.166 (PDF)
Antimalarials
Antimycobacterial Agents
- Bedaquiline (Sirturo): CP.PMN.212 (PDF)
- Pretomanid; CP.PMN.222 (PDF)
- Rifabutin (Mycobutin); CP.PMN.223 (PDF)
Antivirals
- Acyclovir (Sitavig); CP.PMN.210 (PDF)
- Bolaxavir marboxil (Xofluza); CP.PMN.185 (PDF)
- Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva); CP.PHAR.573 (PDF)
- Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira Pak); CP.CPA.288 (PDF)
- Elbasvir-Grazoprevir (Zepatier); CP.CPA.284 (PDF)
- Emtricitabine/Tenofovir Alafenamide (Descovy); CP.PMN.235 (PDF)
- Enfuvirtide (Fuzeon); CP.PHAR.41 (PDF)
- Fostemsavir (Rukobia); CP.PHAR.516 (PDF)
- Glecaprevir-Pibrentasvir (Mavyret); CP.CPA.285 (PDF)
- Ibalizumab-uiyk (Trogarzo); CP. PHAR.378 (PDF)
- Ledipasvir-Sofosbuvir (Harvoni); CP.CPA.175 (PDF)
- Lenacapavir (Sunlenca); CP.PHAR.622 (PDF)
- Letermovir (Prevymis); CP.PHAR.367 (PDF)
- Maribavir (Livtencity); CP.PMN.271 (PDF)
- Nirmatrelvir-Ritonavir (Paxlovid); CP.PMN.288 (PDF)
- Peginterferon alfa-2a (Pegasys); CP.PHAR.89 (PDF)
- Ribavirin (Rebetol, Ribasphere); CP.PHAR.141 (PDF)
- Sofosbuvir (Sovaldi); CP.CPA.176 (PDF)
- Sofosbuvir/Velpatasvir (Epclusa); CP.CPA.286 (PDF)
- Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi); CP.CPA.290 (PDF)
- Tenofovir alafenamide fumarate (Vemlidy); CP.PMN.268 (PDF)
- Valganciclovir (Valcyte); CP.PCH.06 (PDF)
Fluoroqunolones
Passive Immunizing and Treatment Agents
- Bezlotoxumab (Zinplava); CP.PHAR.300 (PDF)
- Cytomegalovirus Immune Globulin (CytoGam); CP.PHAR.277
- Immune Globulin (Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF, GamaSTAN SD, Gammagard Liquid, Gammagard S/D; Gammaked; Gammaplex, Gamunex-C, Hizentra, HyQvia, Octagam, Panzyga, Privigen, Xembify); CP.PHAR.103 (PDF)
- Nirsevimab (Beyfortus); CP.PHAR.614 (PDF)
- Palivizumab (Synagis); CP.PHAR.16 (PDF)
Tetracyclines
Alkylating Agents
- Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta); CP.PHAR.307 (PDF)
- Lomustine (Gleostine); CP.PHAR.507 (PDF)
- Lurbinectedin (Zepzelca); CP.PHAR.500 (PDF)
- Melphalan (Hepzato); CP.PHAR.653 (PDF)
- Melphalan flufenamide (Pepaxto); CP.PHAR.535 (PDF)
- Prednisone delayed-release (Rayos); CP.CPA.273 (PDF)
- Trabectedin (Yondelis); CP.PHAR.204 (PDF)
Antimetabolites
- Azacitidine (Onureg, Vidaza); CP.PHAR.387 (PDF)
- Pemetrexed (Alimta, Pemfexy); CP.PHAR.368 (PDF)
- Pralatrexate (Folotyn); CP.PHAR.313 (PDF)
- Mercaptopurine (Purixan); CP.PHAR.447 (PDF)
Antineoplastic – Angiogenesis Inhibitors
- Bevacizumab (Alymsys; Avastin, Avzivi, Mvasi, Vegzelma, Zirabev); CP.PHAR.93 (PDF)
- Fruquintinib (Fruzaqla); CP.PHAR.666 (PDF)
- Ramucirumab (Cyramza); CP.PHAR.119 (PDF)
- Ziv-aflibercept (Zaltrap); CP.PHAR.325 (PDF)
Antineoplastic – Anti-HER2 Agents
Antineoplastic – Antibodies
- Ado-Trastuzumab Emtansine (Kadcyla); CP.PHAR.229 (PDF)
- Amivantamab-vmjw (Rybrevant); CP.PHAR.544 (PDF)
- Atezolizumab (Tecentriq); CP.PHAR.235 (PDF)
- Avelumab (Bavencio); CP.PHAR.333 (PDF)
- Belantamab mafodotin (Blenrep); CP.PHAR.469 (PDF)
- Blinatumomab (Blincyto); CP.PHAR.312 (PDF)
- Brentuximab vedotin (Adcetris); CP.PHAR.303 (PDF)
- Cemiplimab-rwlc (Libtayo); CP.PHAR.397 (PDF)
- Cetuximab (Erbitux); CP.PHAR.317 (PDF)
- Cosibelimab-Ipdl (Unloxcyt); CP.PHAR.711 (PDF)
- Daratumumab (Darzalex); CP.PHAR.310 (PDF)
- Dostarlimab-gxly (Jermerli); CP.PHAR.540 (PDF)
- Durvalumab (Imfinzi): CP.PHAR.339 (PDF)
- Elranatamab-bcmm (Elrexfio); CP.PHAR.652 (PDF)
- Elotozumab (Empliciti); CP.PHAR.308 (PDF)
- Enfortumab Vedotin-ejfv (Padcev); CP.PHAR.455 (PDF)
- Epcoritamab-bysp (Epkinly); CP.PHAR.634 (PDF)
- Fam-trastuzumb deruxtecan-nxki (Enhertu); CP.PHAR.456 (PDF)
- Gemtuzumab ozogamicin (Mylotarg); CP.PHAR.358 (PDF)
- Glofitamab-gxbm (Columvi); CP.PHAR.636 (PDF)
- Inotuzumab Ozogamicin (Besponsa); CP.PHAR.359 (PDF)
- Ipilimumab (Yervoy); CP.PHAR.319 (PDF)
- Isatuximab-irfc (Sarclisa); CP.PHAR.482 (PDF)
- Loncastuximab tesirine-Ipyl (Zynlonta); CP.PHAR.539 (PDF)
- Mirvetuximab soravtansine-gynx (Elahere); CP.PHAR.617 (PDF)
- Mogamulizumab-kpkc (Poteligeo); CP.PHAR.139 (PDF)
- Mosunetuzumab-axgb (Lunsumio); CP.PHAR.618 (PDF)
- Moxetumomab pasudotox-tdfk (Lumoxiti); CP.PHAR.398 (PDF)
- Naxitamab-gqgk (Danyelza); CP.PHAR.523 (PDF)
- Nivolumab (Opdivo); CP.PHAR.121 (PDF)
- Ofatumumab (Arzerra, Kesimpta); CP.PHAR.306 (PDF)
- Panitumumab (Vectibix); CP.PHAR.321 (PDF)
- Pembrolizumab (Keytruda); CP.PHAR.322 (PDF)
- Pertuzumab (Perjeta); CP.PHAR.227 (PDF)
- Polatuzumab vedotin-piiq (Polivy); CP.PHAR.433 (PDF)
- retifanlimab-dlwr (Zynyz); CP.PHAR.629 (PDF)
- Rituximab (Rituxan and biosimilars); CP.PHAR.260 (PDF)
- Sacituzumab govitecan (Trodelvy); CP.PHAR.475 (PDF)
- Tafasitamab-cxix (Monjuvi); CP.PHAR.508 (PDF)
- Tarlatamab-dlle (Imdelltra); CP.PHAR.685 (PDF)
- Talquetamab-tgvs (Talvey); CP.PHAR.649 (PDF)
- Tebentafusp-tebn (Kimmtrak); CP.PHAR.575 (PDF)
- Teclistamab-cqyv (Tecvayli); CP.PHAR.611 (PDF)
- Tislelizumab-jsgr (Tevimbra); CP.PHAR.687 (PDF)
- Tisotumab vedotin-tftv (Tivdak); CP.PHAR.561 (PDF)
- Toripalimab (Loqtorzi); CP.PHAR.668 (PDF)
- Trastuzumab (Herceptin); Trastuzumab-dkst (Ogivri); Trastuzumab-dttb (Ontruzant); Trastuzumab-qyyp (Trazimera); Trastuzumab-anns (Kanjinti); Trastuzumab-pkrb (Herzuma); CP.PHAR.228 (PDF)
- Tremelimumab-actl (Imjudo); CP.PHAR.612 (PDF)
- Zanubrutinib (Brukinsa); CP.PHAR.467 (PDF)
- Zenocutuzumab-zbco (Bizengri); CP.PHAR.713 (PDF)
Antineoplastic – BCL-2 Inhibitors
Antineoplastic – Cellular Immunotherapy
- Axicabtagene ciloleucel (Yescarta); CP.PHAR.362 (PDF)
- Bresucabtagene autoleucel (Tecartus); CP.PHAR.472 (PDF)
- Ciltacabtagene Autoleucel (Carvykti); CP.PHAR.533 (PDF)
- Idecabtagene Vicleucel (Abecma); CP.PHAR.481 (PDF)
- Lifileucel (Amtagvi); CP.PHAR.598 (PDF)
- Lisocabtagene maraleucel (Breyanzi); CP.PHAR.483 (PDF)
- Obecabtagene Autoleucel (Aucatzyl); CP.PHAR.675 (PDF)
- Sipuleucel-T (Provenge); CP.PHAR.120 (PDF)
- Tisagenlecleucel (Kymriah); CP.PHAR.361 (PDF)
Antineoplastic – Hedgehog Pathway Inhibitors
- Glasdegib (Daurismo); CP.PHAR.413 (PDF)
- Sonidegib (Odomzo); CP.PHAR.272 (PDF)
- Vismodegib (Erivedge); CP.PHAR.273 (PDF)
Antineoplastic – Hormonal and Related Agents
- Abiraterone (Yonsa, Zytiga); CP.PHAR.84 (PDF)
- Apalutamide (Erleada); CP.PCH.45 (PDF)
- Darolutamide (Nubeqa); CP.PHAR.435 (PDF)
- Degarelix (Firmagon); CP.PHAR.170 (PDF)
- Elacestrant (Orserdu); CP.PHAR.623 (PDF)
- Enzalutamide (Xtandi); CP.PHAR.106 (PDF)
- Fulvestrant (Faslodex); CP.PHAR.424 (PDF)
- Histrelin (Vantas, Supprelin LA); CP.PHAR.172 (PDF)
- Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi, Camcevi); CP.PCH.53. (PDF)
- Niraparib and Abiraterone (Akeega); CP.PHAR.645 (PDF)
- Relugolix (Orgovyx)), relugolix-estradiol-norethindrone (Myfembree); CP.PHAR.529 (PDF)
- Triptorelin pamoate (Trelstar, Triptodur); CP.PHAR.175 (PDF)
Antineoplastic – Hypoxia-Inducible Factor Inhibitors
Antineoplastic – Immunomodulators
Antineoplastic - Menin Inhibitors
Antineoplastic – Kinase Inhibitor
Antineoplastic Antibiotics
- Mitomycin for Pyelocalyceal Solution (Jelmyto); CP.PHAR.495 (PDF)
- Mitoxantrone; CP.PHAR.258 (PDF)
- Valrubicin (Valstar); CP.PHAR.439 (PDF)
Antineoplastic Combinations
- Afamitresgene Autoleucel (Tecelra); CP.PHAR.678 (PDF)
- Daratumumab-Haluronidase-fihj (Darzalex Faspro); CP.PHAR.310 (PDF)
- Daunorubicin/Cytarabine (Vyxeos); CP.PHAR.352 (PDF)
- Decitabine-Cedazuridine (Inqovi); CP.PHAR.479 (PDF)
- Nivolumab/Relatlimab (Opdualag); CP.PHAR.588 (PDF)
- Obinutuzumab (Gazyva); CP.PHAR.305 (PDF)
- Pertuzumab-trastuzumab-hyaluronidse-zzxf (Phesgo); CP.PHAR.501 (PDF)
- Rituximab/Hyaluronidase (Rituxan Hycela); CP.PHAR.260 (PDF)
- Trastuzumab/hyaluonidase-oysk (Heceptin Hylecta); CP.PHAR.228 (PDF)
- Trifluridine-tipiracil (Lonsurf); CP.PHAR.383 (PDF)
Antineoplastic Enzyme Inhibitors
- Abemaciclib (Verzenio); CP.PHAR.355 (PDF)
- Acalabrutinib (Calquence); CP.PHAR.366 (PDF)
- Adagrasib (Krazati); CP.PHAR.605 (PDF)
- Afatinib (Gilotrif); CP.PHAR.298 (PDF)
- Alectinib (Alecensa); CP.PHAR.369 (PDF)
- Alpelisib (Piqray, Vijoice); CP.PHAR.430 (PDF)
- Asciminib (Scemblix); CP.PHAR.565 (PDF)
- Avapritinib (Ayvakit); CP.PHAR.454 (PDF)
- Axitinib (Inlyta); CP.PHAR.100 (PDF)
- Binimetinib (Mektovi); CP.PHAR.50 (PDF)
- Bortezomib (Velcade); CP.PHAR.410 (PDF)
- Brigatinib (Alunbrig); CP.PHAR.342 (PDF)
- Bosutinib (Bosulif); CP.PHAR.105 (PDF)
- Cabozantinib (Cabometyx, Cometriq); CP.PHAR.111 (PDF)
- Capivasertib (Truqap); CP.PHAR.663 (PDF)
- Capmatinib (Tabrecta); CP.PHAR.494 (PDF)
- Carfilzomib (Kyprolis); CP.PHAR.309 (PDF)
- Ceritinib (Zykadia); CP.PHAR.349 (PDF)
- Cobimetinib (Cotellic); CP.PHAR.380 (PDF)
- Copanlisib (Aliqopa); CP.PHAR.357 (PDF)
- Crizotinib (Xalkori); CP.PHAR.90 (PDF)
- Dabrafenib (Tafinlar); CP.PHAR.239 (PDF)
- Dacomitinib (Vizimpro); CP.PHAR.399 (PDF)
- Dasatinib (Sprycel, Phyrago); CP.PHAR.72 (PDF)
- Duvelisib (Copiktra); CP.PHAR.400 (PDF)
- Enasidenib (Idhifa); CP.PHAR.363 (PDF)
- Encorafenib (Braftovi); CP.PHAR.127 (PDF)
- Ensartinib (Ensacove); CP.PHAR.712 (PDF)
- Entrectinib (Rozlytrek); CP.PHAR.441 (PDF)
- Erdafitinib (Balversa); CP.PHAR.423 (PDF)
- Erlotinib (Tarceva); CP.PHAR.74 (PDF)
- Everolimus (Afinitor, Afinitor Disperz, Zortress); CP.PHAR.63 (PDF)
- Fedratinib (Inrebic); CP.PHAR.442 (PDF)
- Futibatinib (Lytgobi); CP.PHAR.604 (PDF)
- Gefitinib (Iressa); CP.PHAR.68 (PDF)
- Gilteritinib (Xospata); CP.PHAR.412 (PDF)
- Ibrutinib (Imbruvica); CP.PHAR.126 (PDF)
- Idelalisib (Zydelig); CP.PHAR.133 (PDF)
- Imetelstat (Rytelo); CP.PHAR.690 (PDF)
- Imatinib mesylate (Gleevec); CP.PHAR.65 (PDF)
- Inavolisib (Itovebi); CP.PHAR.702 (PDF)
- Infigratinib (Truseltiq); CP.PHAR.547 (PDF)
- Ivosidenib (Tibsovo); CP.PHAR.137 (PDF)
- Ixazomib (Ninlaro); CP.PHAR.302 (PDF)
- Lapatinib (Tykerb); CP.PHAR.79 (PDF)
- Larotrectinib (Vitrakvi); CP.PHAR.414 (PDF)
- Lenvatinib (Lenvima); CP.PHAR.138 (PDF)
- Lorlatinib (Lorbrena); CP.PHAR.406 (PDF)
- Midostaurin (Rydapt); CP.PHAR.344 (PDF)
- Momelotinib (Ojjaara); CP.PHAR.654 (PDF)
- Neratinib (Nerlynx); CP.PHAR.365 (PDF)
- Nilotinib (Tasigna); CP.PHAR.76 (PDF)
- Niraparib (Zejula); CP.PHAR.408 (PDF)
- Nirogacestat (Ogsiveo); CP.PHAR.671 (PDF)
- Olaparib (Lynparza); CP.PHAR.360 (PDF)
- Olutasidenib (Rezlidhia); CP.PHAR.615 (PDF)
- Osimertinib (Tagrisso); CP.PHAR.294 (PDF)
- Pacritinib (Vonjo); CP.PHAR.583 (PDF)
- Palbociclib (Ibrance); CP.PHAR.125 (PDF)
- Pazopanib (Votrient); CP.PHAR.81 (PDF)
- Pemigatinib (Pemazyre); CP.PHAR.496 (PDF)
- Pexidartinib (Turalio); CP.PHAR.436 (PDF)
- Pirtobrutinib (Jaypirca); CP.PHAR.620 (PDF)
- Ponatinib (Iclusig); CP.PHAR.112 (PDF)
- Pralsetinib (Gavreto); CP.PHAR.514 (PDF)
- Quizartinib (Vanflyta); CP.PHAR.646 (PDF)
- Regorafenib (Stivarga); CP.PHAR.107 (PDF)
- Repotrectinib (Augtyro); CP.PHAR.667 (PDF)
- Ribociclib (Kisqali, Kisqali Femara); CP.PHAR.334 (PDF)
- Ripretinib (Qinlock); CP.PHAR.502 (PDF)
- Romidepsin (Istodax); CP.PHAR.314 (PDF)
- Rucaparib (Rubraca); CP.PHAR.350 (PDF)
- Ruxolitinib (Jakafi, Opzelura); CP.PHAR.98 (PDF)
- Selpercatinib (Retevmo); CP.PHAR.478 (PDF)
- Selumetinib (Koselugo); CP.PHAR.464 (PDF)
- Sirolimus Protein-Bound Particles (Fyarro), Topical Gel, (Hyftor); CP.PHAR.574 (PDF)
- Sorafenib (Nexavar); CP.PHAR.69 (PDF)
- Sotorasib (Lumakras); CP.PHAR.549 (PDF)
- Sunitinib (Sutent); CP.PHAR.73 (PDF)
- Talazoparib (Talzenna); CP.PHAR.409 (PDF)
- Tazemetostat (Tazverik); CP.PHAR.452 (PDF)
- Tepotinib (Tepmetko); CP.PHAR.530 (PDF)
- Tivozanib (Fotivda); CP.PHAR.538 (PDF)
- Tovorafenib (Ojemda); CP.PHAR.686 (PDF)
- Trametinib (Mekinist); CP.PHAR.240 (PDF)
- Tucatinib (Tukysa); CP.PHAR.497 (PDF)
- Umbralisib (Ukoniq); CP.PHAR.531 (PDF)
- Vandetanib (Caprelsa); CP.PHAR.80 (PDF)
- Vemurafenib (Zelboraf); CP.PHAR.91 (PDF)
- Vorasidenib (Voranigo); CP.PHAR.699 (PDF)
- Vorinostat (Zolinza); CP.PHAR.83 (PDF)
Antineoplastic Enzymes
- Erwinia Asparaginase (Rylaze); CP.PHAR.301 (PDF)
- Pegaspargase (Oncaspar); Calaspargase pegol-mknl (Asparlas) CP.PHAR.353 (PDF)
Antineoplastic Radiopharmaceuticals
- Iobenguane I 131 (Azedra); CP.PHAR.459 (PDF)
- Lutetium Lu 177 dotatate (Lutathera); CP.PHAR.384 (PDF)
- Lutetium Lu 177 vipivotide tetraxetan (Pluvicto); CP.PHAR.582 (PDF)
Antineoplastics Misc.
- Bexarotene (Targretin Capsules, Gel); CP.PHAR.75 (PDF)
- Denileukin Diftitox-cxdl (Lymphir); CP.PHAR.693 (PDF)
- Interferon Gamma- 1b (Actimmune); CP.PHAR.52 (PDF)
- Nadofaragene firadenovec (Adstiladrin); CP.PHAR.461 (PDF)
- Nogapendekin alfa inbakicept-pmln (Anktiva); CP.PHAR.684 (PDF)
- Omacetaxine (Synribo); CP.PHAR.108 (PDF)
- Ropeginterferon alfa-2b-njft (BESREMi); CP.PHAR.570 (PDF)
Chemotherapy Rescue/Antidote Agents
- Dextazoxane (Totect); CP.PHAR.418 (PDF)
- Eflornithine (Iwilfin); CP.PHAR.670 (PDF)
- Levoleucovorin (Fusilev; Khapzorv); CP.PHAR.151 (PDF)
- Leucovorin Injection; CP.PHAR.393 (PDF)
- Sodium thiosulfate (Pedmark); CP.PHAR.610 (PDF)
Antineoplastic XPO1 Inhibitors
Mitotic Inhibitors
- Eribulin Mesylate (Halaven); CP.PHAR.318 (PDF)
- Paclitaxel Protein-Bound Particles (Abraxane); CP.PHAR.176 (PDF)
Oncolytic Viral Agents
Topoisomerase I Inhibitors
Antianginal Agents
Antihyperlipidemics
- Alirocumab (Praluent); CP.PHAR.124 (PDF)
- Bempedoic acid (Nexletol); bempedoic acid-ezetimibe (Nexlizet); CP.PMN.237 (PDF)
- Evinacumab-dgnb (Evkeeza); CP.PHAR.511 (PDF)
- Evolocumab (Repatha); CP.CPA.269 (PDF)
- Icosapent ethyl (Vascepa); CP.CPA.357 (PDF)
- Inclisiran (Leqvio); CP.PHAR.568 (PDF)
- Lomitapide (Juxtapid); CP.PHAR.283 (PDF)
Antihypertensives
Beta Blockers
Cardiovascular Agents – Misc.
- Ambrisentan (Letairis); CP.PHAR.190 (PDF)
- Amlodipine-Atorvastatin (Caduet); CP.PMN.176 (PDF)
- Bosentan (Tracleer); CP.PHAR.191 (PDF)
- Epoprostenol (Flolan, Veletri); CP.PHAR.192 (PDF)
- Iloprost (Ventavis); CP.PHAR.193 (PDF)
- Ivabradine (Corlanor); CP.PMN.70 (PDF)
- Macitentan (Opsumit); CP.PHAR.194 (PDF)
- Mavacamten (Camzyos); CP.PMN.272 (PDF)
- Riociguat (Adempas); CP.PHAR.195 (PDF)
- Sacubitril/valsartan (Entresto); CP.PCH.52 (PDF)
- Selexipag (Uptravi); CP.PHAR.196 (PDF)
- Sildenafil (Revatio, liqrev); CP.PHAR.197 (PDF)
- Sotatercept (Winrevair); CP.PHAR.657 (PDF)
- Tadalafil (Adcirca, Alyq, Tadliq); CP.PHAR.198 (PDF)
- Tafamidis (Vyndaquel, Vyndamax); CP.PHAR.432 (PDF)
- Treprostinil (Orenitram, Remodulin, Tyvaso); CP.PHAR.199 (PDF)
Vasopressors
Allergenic Extracts/Biologicals Misc.
- Dust mite mixed allergen extracat (Odactra); CP.PMN.111 (PDF)
- Mixed pollens allergen extract (Oralair); CP.PMN.85 (PDF)
- Peanut allergen powder (Palforzia); CP.PMN.220 (PDF)
- Ragweed pollen (Ragwitek); CP.PMN.83 (PDF)
- Timothy grass pollen (Grastek); CP.PMN.84 (PDF)
Antihistamines – Non-Sedating
Cough/Cold/Allergy Combinations
Nasal Steroids
- Abrocitinib (Cibinqo); CP.PHAR.578 (PDF)
- Adapalene/Benzoyl peroxide (Epiduo Forte); CP.CPA.337 (PDF)
- Afamelanotide (Scenesse); CP.PHAR.444 (PDF)
- Allogeneic cultured keratinocytes and dermal fibroblasts (StrataGraft); CP.PHAR.562 (PDF)
- Berdazimer (Zelsuvmi); CP.PMN.293 (PDF)
- Betamethasone dipropionate (Sernivo); CP.PMN.182 (PDF)
- Biologic and Non-biologic DMARDs; CP.CPA.194 (PDF)
- Birch Triterpenes (Filsuvez); CP.PHAR.669 (PDF)
- Calcipotriene/betamethasone (Enstilar); CP.PMN.181 (PDF)
- Ciclopirox (Penlac); CP.PMN.24 (PDF)
- Clascoterone (Winlevi); CP.PMN.257 (PDF)
- Clindamycin/benzoyl peroxide (Acanya, Onexton); CP.CPA.133 (PDF)
- Crisaborole (Eucrisa); CP.PMN.110 (PDF)
- Dapsone (Aczone); CP.PCH.32 (PDF)
- DaxibotulinumtoxinA-lanm (Daxxify); CP.PHAR.651 (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea); CP.PMN.79 (PDF)
- Dupilumab (Dupixent); CP.CPA.360 (PDF)
- Fluorouracil (Tolak); CP.PMN.165 (PDF)
- Glycopyrronium Tosylate (Qbrexza); CP.PMN.177 (PDF)
- Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate); CP.PMN.180 (PDF)
- Halobetasol-Tazarotene (Duobrii); CP.PMN.208 (PDF)
- Isotretinoin (Absorica, Absorica LD, Amnesteem , Claravis, Myorisan, Zenatane); CP.PMN.143 (PDF)
- Ivermectin (Soolantra); CP.CPA.155 (PDF)
- Lidocaine Transdermal (Lidoderm, ZTlido); CP.PMN.08 (PDF)
- Mechlorethamine (Valchlor); CP.PHAR.381 (PDF)
- Minocycline Micronized Foam (Amzeeq); CP.PMN.242 (PDF)
- Nemolizumab-ito (Nemluvio); CP.PHAR.703 (PDF)
- Neomycin/Fluocinolone (Neo-Synalar Kit); CP.PMN.167 (PDF)
- Oxymetazoline (Rhofade, Upneeq); CP.PMN.86 (PDF)
- Ozenoxacin (Xepi); CP.PMN.119 (PDF)
- Spesolimab-sbzo (Spevigo); CP.PHAR.606 (PDF)
- Tapinarof (Vtama); CP.PMN.283 (PDF)
- Tazarotene (Arazlo, Fabior, Tazorac); CP.PMN.244 (PDF)
- Topical Immunomodulators; CP.PMN.107 (PDF)
- Tralokinumab-ldrm (Adbry); CP.PHAR.577 (PDF)
- Trifarotene (Aklief); CP.PMN.225 (PDF)
Adrenal Steroid Inhibitors
Aldosterone Receptor Antagonists
Androgens/Anabolic
Antidiabetics
- Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists; CP.CPA.16 (PDF)
- Insulin glargine (Basaglar, Rezvoglar, Semglee); CP.CPA.228 (PDF)
- Insulin glulisine (Apidra); CP.CPA.224 (PDF)
- Metformin ER (Glumetza, Fortamet); CP.PMN.72 (PDF)
- Non-Preferred Dipeptidyl Peptidase-4 (DPP-4) Inhibitors; CP.CPA.343 (PDF)
- Pramlintide (Symlin); CP.PMN.129 (PDF)
- Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors; CP.CPA.347 (PDF)
- Teplizumab-mzwv (Tzield); CP.PHAR.492 (PDF)
Bone Density Regulators
- Abaloparatide (Tymlos); CP.PHAR.345 (PDF)
- Alendronate (Binosto, Fosamax plus D); CP.PMN.88 (PDF)
- Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost); CP.PHAR.58 (PDF)
- Ibandronate injection (Boniva); CP.PHAR.189 (PDF)
- Parathyroid hormone (Natpara); CP.PHAR.282 (PDF)
- Risedronate (Actonel, Atelvia); CP.PMN.100 (PDF)
- Romosozumab-aqqg (Evenity); CP.PHAR.428 (PDF)
- Teriparatide (Forteo, Bonsity); CP.PHAR.188 (PDF)
- Zoledronic Acid (Reclast); CP.PHAR.59 (PDF)
Corticosteroids
- Budesonide (Tarpeyo); CP.PHAR.572 (PDF)
- Budesonide (Echills, Uceris); CP.PMN.294 (PDF)
- Deflazacort (Emflaza); CP.PHAR.331 (PDF)
- Triamcinolone ER Injection (Zilretta); CP.PHAR.371 (PDF)
- Vamorolone (Agamree); CP.PHAR.659 (PDF)
Corticotropin
Corticotropin-Releasing Factor Receptor Antagonists
Fertility Regulators
GNRH/LHRH Antagonists
Growth Hormone Receptor Antagonists
Growth Hormone Releasing Hormones (GHRH)
- Tesamorelin (Egrifta); CP.PHAR.109 (PDF)
- Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd); OR.CP.CPA.353 (PDF)
Growth Hormones
Hormone Receptor Modulators
Insulin-Like Growth Factors (Somatomedins)
Insulin-Like Growth Factor Receptor Inhibitors
Menopausal Symptoms Suppressants
Metabolic Modifiers
- Agalsidase beta (Fabrazyme); CP.PHAR.158 (PDF)
- Alglucosidase alfa (Lumizyme); CP.PHAR.160 (PDF)
- Asfotase alfa (Strensiq); CP.PHAR.328 (PDF)
- Avalglucosidase Alfa-ngpt (Nexviazyme); CP.PHAR.521 (PDF)
- Betaine (Cystadane); CP.PHAR.143 (PDF)
- Burosumab-twza (Crysvita); CP.PHAR.11 (PDF)
- Calcifediol (Rayaldee); CP.PMN.76 (PDF)
- Carglumic acid (Carbaglu); CP.PHAR.206 (PDF)
- Cerliponase alfa (Brineura); CP.PHAR.338 (PDF)
- Cinacalcet (Sensipar); CP.PHAR.61 (PDF)
- Cipaglucosidase Alfa-atga + Miglustat (Pombiliti + Opfolda); CP.PHAR.567 (PDF)
- Eladocagene Exuparvovec-tneq (Kebilidi); CP.PHAR.595 (PDF)
- Elapegademse-lvlr (Revcovi); CP.PHAR.419 (PDF)
- Elosulfase alfa (Vimizim); CP.PHAR.162 (PDF)
- Fosdenopterin (Nulibry); CP.PHAR.471 (PDF)
- Galsulfase (Naglazyme); CP.PHAR.161 (PDF)
- Glycerol phenylbutyrate (Ravicti); CP.PHAR.207 (PDF)
- Idursulfase (Elaprase); CP.PHAR.156 (PDF)
- Laronidase (Aldurazyme); CP.PHAR.152 (PDF)
- Metreleptin (Myalept); CP.PHAR.425 (PDF)
- Migalastat (Galafold); CP.PHAR.394 (PDF)
- Nitisinone (Orfadin, Nityr); CP.PHAR.132 (PDF)
- Olezarsen (Tryngolza); CP.PHAR.689 (PDF)
- Olipudase alfa-rpcp (Xenpozyme); CP.PHAR.586 (PDF)
- Palopegteriparatide (Yorvipath); CP.PHAR.696 (PDF)
- Pegunigalsidase alfa (Elfabrio); CP.PHAR.512 (PDF)
- Pegvaliase-pqpz (Palynziq); CP.PHAR.140 (PDF)
- Paricalcitol (Zemplar); CP.PHAR.270 (PDF)
- Sapropterin (Kuvan); CP.PHAR.43 (PDF)
- Sebelipase alfa (Kanuma); CP.PHAR.159 (PDF)
- Sodium phenylbutyrate (Buphenyl, Pheburane, Olpruva); CP.PHAR.208 (PDF)
- Velmanase Alfa-tycv (Lamzede); CP.PHAR.601 (PDF)
- Vestronidase alfa-vjbk (Mepsevii); CP.PHAR.374 (PDF)
Natriuretic Peptides
Posterior Pituitary Hormones
Progesterone Receptor Antagonists
Progestins
- Hydroxyprogesterone caproate (Makena); CP.PHAR.14 (PDF)
- Progesterone (Crinone, Endometrin); CP.PMN.243 (PDF)
Somatostatic Agents
- Lanreotide (Somatuline Depot and Unbranded); CP.PHAR.391 (PDF)
- Octreotide Acetate (Sandostatin, Sandostatin LAR, Bynfezia, Mycapssa); CP.PHAR.40 (PDF)
- Pasireotide (Signifor LAR, Singifor); CP.PHAR.332 (PDF)
Vasopressin Receptor Antagonists
Anti-Diarrheal/Probiotic Agents
Antiemetics
- Amisulpride (Barhemsys); CP.PMN.236 (PDF)
- Dolasetron (Anzemet); CP.PMN.141 (PDF)
- Dronabinol (Marinol, Syndros); CP.PMN.159 (PDF)
- Granisetron (Sancuso, Sustol); CP.PMN.74 (PDF)
- Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV); CP.PMN.158 (PDF)
Digestive Aids
Diuretics
Gastrointestinal Agents – Misc.
- Alosetron (Lotronex); CP.PMN.153 (PDF)
- Biologic and Non-biologic DMARDs; CP.CPA.194 (PDF)
- Chenodiol (Chenodal); CP.PMN.239 (PDF)
- Cholic Acid (Cholbam); CP.PHAR.390 (PDF)
- Dalfampridine (Ampyra); CP.PHAR.248 (PDF)
- Elafibranor (Iqirvo); CP.PHAR.688 (PDF)
- Eluxadoline (Viberzi); CP.PMN.170 (PDF)
- Fecal microbiota, live-jslm (Rebyota); CP.PHAR.613 (PDF)
- Fecal microbiota spores, live-brpk (Vowst); CP.PHAR.632 (PDF)
- Linaclotide (Linzess); CP.PMN.71 (PDF)
- Lubiprostone (Amitiza); CP.PMN.142 (PDF)
- Maralixibar (Livmarli); CP.PHAR.543 (PDF)
- Methylnaltrexone (Relistor); CP.PMN.169 (PDF)
- Metoclopramide (Gimoti); CP.PMN.252 (PDF)
- Naldemedine (Symproic); CP.PMN.112 (PDF)
- Non-Calcium Phosphate Binders; CP.PMN.04 (PDF)
- Obeticholic acid (Ocaliva); CP.PHAR.287 (PDF)
- Odevixibat (Bylvay); CP.PHAR.528 (PDF)
- Plecanatide (Trulance); CP.PMN.87 (PDF)
- Prucalopride (Motegrity): CP.PMN.194 (PDF)
- Resmetirom (Rezdiffra); CP.PHAR.647 (PDF)
- Seladelpar (Livdelzi); CP.PHAR.698 (PDF)
- Teduglutide (Gattex); CP.PHAR.114 (PDF)
- Telotristat ethyl (Xermelo); CP.PHAR.337 (PDF)
- Tenapanor (Ibsrela, Xphozah); CP.PMN.224 (PDF)
Genitourinary Agents – Misc.
- Cysteamine oral (Cystagon, Procysbi); CP.PHAR.155 (PDF)
- Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn); CP.PMN.128 (PDF)
- Lumasiran (Oxlumo); CP.PHAR.473 (PDF)
- Nedosiran (Rivfloza); CP.PHAR.619 (PDF)
- Pentosan polysulfate sodium (Elmiron); CP.PMN.276 (PDF)
- Sparsentan (Filspari); CP.PHAR.631 (PDF)
- Tiopronin Delayed-Release (Thiola EC); CP.PCH.50 (PDF)
Gout Agents
Impotence Agents
- Alprostadil (Caverject, Edex, Muse); CP.CPA.02 (PDF)
- Avanafil (Stendra); CP.CPA.323 (PDF)
- Sildenafil for ED (Viagra); CP.PCH.07 (PDF)
- Tadalafil (Cialis); CP.PMN.132 (PDF)
- Vardenafil (Levitra, Staxyn); CP.CPA.324 (PDF)
Laxatives
- Colonoscopy Preparation Products (GoLytely, Colyte, MoviPrep, OsmoPrep, Plenvu, Preopik, Clenpiq, Nulytely, Suprep); CP.PCH.43 (PDF)
Ulcer Drugs/Anti-Spasmodies/Anticholinergies
- Proton Pump Inhibitors (rabeprazole (AcipHex®, AcipHex® Sprinkle), dexlansoprazole (Dexilant®), esomeprazole strontium (ES), esomeprazole (Nexium®, Nexium® 24HR, Nexium® 24HR ClearMinisTM), omeprazole (Prilosec® Packets), lansoprazole (Prevacid® SoluTabsTM), omeprazole/sodium bicarbonate (Zegerid®, Zegerid® OTC)); CP.CPA.209 (PDF)
- Ulcer Therapy Products; CP.PMN.277 (PDF)
Urinary Antispasmotics
Vaginal Products
Anticoagulants
- Dalteparin (Fragmin); CP.PHAR.225 (PDF)
- Enoxaparin (Lovenox); CP.PHAR.224 (PDF)
- Fondaparinux (Arixtra); CP.PHAR.226 (PDF)
Hematological Agents – Misc.
- Adzynma (ADAMTS13, Recombinant-krhn); CP.PHAR.635 (PDF)
- Anti-inhibitor Coagulant Complex, Human; (Feiba); CP.PHAR.217 (PDF)
- Antithrombin III (ATryn, Thrombate III); CP.PHAR.564 (PDF)
- Avacopan (Tavneos); CP.PHAR.515 (PDF)
- Berotralstat (Orladeyo); CP.PHAR.485 (PDF)
- C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest); CP.PHAR.202 (PDF)
- Caplacizumab-yhdp (Cablivi); CP.PHAR.416 (PDF)
- Concizumab-mtci (Alhemo); CP.PHAR.625 (PDF)
- Crovalimab-akkz (PiaSky); CP.PHAR.664 (PDF)
- Danicopan (Voydeya); CP.PHAR.665 (PDF)
- Ecallantide (Kalbitor); CP.PHAR.177 (PDF)
- Eculizumab (Soliris), Eculizumab-aeeb (Bkemv), Eculizumab-aagh (Epysqli); CP.PHAR.97 (PDF)
- Emicizumab-kxwh (Hemlibra); CP.PHAR.370 (PDF)
- Etranacogene Dezaparvovec (Hemgenix); CP.PHAR.580 (PDF)
- Factor IX Complex, Human (Profilnine); CP.PHAR.219 (PDF)
- Factor IX Human, recombinant; CP.PHAR.218 (PDF)
- Factor VIIa, Recombinant (NovoSeven RT, SevenFact); CP.PHAR.220 (PDF)
- Factor VIII - Human, recombinant; CP.PHAR.215 (PDF)
- Factor VIII- von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate); CP.PHAR.216 (PDF)
- Factor XIII, Human; (Corifact); CP.PHAR.221 (PDF)
- Factor XIII A-Subunit, Recombinant (Tretten); CP.PHAR.222 (PDF)
- Fibrinogen concentrate (human) (Fibryga, RiaSTAP); CP.PHAR.526 (PDF)
- Fidanacogene Elaparvovec-dzkt (Beqvez); CP.PHAR.643 (PDF)
- Fostamatinib (Tavalisse); CP.PHAR.24 (PDF)
- Givosiran (Givlaari); CP.PHAR.457 (PDF)
- Hemin (Panhematin); CP.PHAR.181 (PDF)
- Icatibant (Firazyr); CP.PHAR.178 (PDF)
- Iptacopan (Fabhalta); CP.PHAR.656 (PDF)
- Lanadelumab-fylo (Takhzyro); CP.PHAR.396 (PDF)
- Marstacimab-hncq (Hympavzi); CP.PHAR.674 (PDF)
- Mitapivat (Pyrukynd); CP.PHAR.558 (PDF)
- Plasminogen, human-tvmh (Ryplazim); CP.PHAR.513 (PDF)
- Pozelimab (Veopoz); CP.PHAR.626 (PDF)
- Pegcetacoplan (Empaveli, Syfovre); CP.PHAR.524 (PDF)
- Protein C Concentrate Human (Ceprotin); CP.PHAR.330 (PDF)
- Ravulizumab-cwvz (Ultomiris); CP.PHAR.415 (PDF)
- Sutimlimab-jome (Enjaymo); CP.PHAR.503 (PDF)
- Valoctocogene Roxaparvovec-rvox (Roctavian); CP.PHAR.466 (PDF)
- Zilucoplan (Zilbrysq); CP.PHAR.616 (PDF)
Hematopoietic Agents
- Avatrombopag (Doptelet); CP.PHAR.130 (PDF)
- Betibeglogene autotemcel (Zynteglo); CP.PHAR.545 (PDF)
- Crizanlizumab-tmca (Adakveo); CP.PHAR.449 (PDF)
- Daprodustat (Jesduvroq); CP.PHAR.628 (PDF)
- Darbepoetin alfa (Aranesp); CP.PHAR.236 (PDF)
- Eliglustat (Cerdelga); CP.PHAR.153 (PDF)
- Eltrombopag (Alvaiz, Promacta); CP.PHAR.180 (PDF)
- Epoetin Alfa (Epogen, Procrit); Epoetin alfa-ebpx (Retacrit); CP.PHAR.237 (PDF)
- Exagamglogene Autotemcel (Casgevy); CP.PHAR.603 (PDF)
- Ferric Carboxymaltose (Injectafer); CP.PHAR.234 (PDF)
- Ferric Derisomaltose (Monoferric); CP.PHAR.480 (PDF)
- Ferric maltol (Accrufer); CP.PMN.213 (PDF)
- Ferric Pyrophosphate Citrate (Triferic); CP.PHAR.624 (PDF)
- Ferumoxytol (Feraheme); CP.PHAR.165 (PDF)
- Filgrastim (Neupogen and biosimilars); CP.PHAR.297 (PDF)
- Hydroxyurea (Siklos, Xromi); CP.PMN.193 (PDF)
- Imiglucerase (Cerezyme); CP.PHAR.154 (PDF)
- L-glutamine (Endari); CP.PMN.116 (PDF)
- Lovotibeglogene Autotemcel (Lyfgenia); CP.PHAR.627 (PDF)
- Luspatercept-aamt (Reblozyl); CP.PHAR.450 (PDF)
- Lusutrombopag (Mulpleta); CP.PHAR.407 (PDF)
- Mavorixafor (Xolremdi);CP.PHAR.679 (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera); CP.PHAR.238 (PDF)
- Miglustat (Zavesca); CP.PHAR.164 (PDF)
- Motixafortide (Aphexda); CP.PHAR.655 (PDF)
- Pegfilgrastim and Biosimilars (Neulasta, Fulphila, Udenyca, Ziextenzo, Nyvepria, Fylnetra, Eflapegrastim, Efbemalenograstim; CP.PHAR.296 (PDF)
- Plerixafor (Mozobil); CP.PHAR.323 (PDF)
- Romiplostim (Nplate); CP.PHAR.179 (PDF)
- Sargramostim (Leukine); CP.PHAR.295 (PDF)
- Taliglucerase alfa (Elelyso); CP.PHAR.157 (PDF)
- Velaglucerase alfa (VPRIV); CP.PHAR.163 (PDF)
- Voxelotor (Oxbyta); CP.PHAR.451 (PDF)
Anesthetics - Misc.
Antidotes and Specific Antagonists
- Deferasirox (Exjade, Jadenu); CP.PHAR.145 (PDF)
- Deferiprone (Ferriprox); CP.PHAR.147 (PDF)
- Deferoxamine (Desferal); CP.PHAR.146 (PDF)
- Nalmefene (Opvee); CP.PHAR.638 (PDF)
- Naltrxone (Vivotrol); CP.PHAR.96 (PDF)
Chelating Agents
Diabetic Supplies
- Continuous Glucose Monitors; CP.CPA.355 (PDF)
- Insulin Delivery Systems (V-Go, Omnipod); CP.PHAR.534 (PDF)
Diagnostic Products
Enzymes
Immunomodulators
- Axatilimab-csfr (Niktimvo); CP.PHAR.691 (PDF)
- Lenalidomide (Revlimid); CP.PHAR.71 (PDF)
- Leniolisib (Joenja); CP.PHAR.597 (PDF)
- Thalidomide (Thalomid); CP.PHAR.78 (PDF)
- Rozanolixizumab-noli (Rystiggo); CP.PHAR.648 (PDF)
Immunosuppressive Agents
- Antithymocyte Globulin (Atgam, Thymoglobulin); CP.PHAR.506 (PDF)
- Belatacept (Nulojix); CP.PHAR.201 (PDF)
- Belumosudil (Rezurock); CP.PHAR.552 (PDF)
- Emapalumab-lzsg (Gamifant); CP.PHAR.402 (PDF)
- Inebilizumb-cdon (Uplinza); CP.PHAR.458 (PDF)
- Satralizaumab-mwge (Enspryng); CP.PHAR.463 (PDF)
- Voclosporin (Lupkynis); CP.PHAR.504 (PDF)
Lipids
Potassium Removing Agents
- Patiromer sorbitex calcium (Veltassa); CP.PMN.205 (PDF)
- Sodium zirconium cyclosilicate (Lokelma); CP.PMN.163 (PDF)
Progeria Treatment Agents
Other Misc. Drugs
Systemic Lupus Erythematosus Agents
Tissue Products
Wound Care Products
ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants
- Armodafinil (Nuvigil); CP.PMN.35 (PDF)
- Benzphetamine; CP.CPA.326 (PDF)
- Bupropion-Naltrexone (Contrave); CP.PCH.12 (PDF)
- CNS Stimulants; CP.PMN.92 (PDF)
- Diethylpropion (Tenuate, Tenuate Dospan); CP.CPA.328 (PDF)
- Liraglutide (Saxenda); CP.CPA.332 (PDF)
- Orlistat (Xenical); CP.CPA.335 (PDF)
- Phendimetrazine; CP.PCH.47 (PDF)
- Phentermine (Adipex-P, Lomaira); CP.PCH.13 (PDF)
- Phentermine-Topiramate (Qsymia); CP.CPA.336 (PDF)
- Pitolisant (Wakix); CP.PMN.221 (PDF)
- Semaglutide (Wegovy); OR.CP.CPA.352 (PDF)
- Setmelanotide (Imcivree); CP.PHAR.491 (PDF)
- Solriamfetol (Sunosi); CP.PMN.209 (PDF)
- Tirzepatide (Zepbound); CP.CPA.359 (PDF)
- Viloxazine (Qelbree); CP.PMN.264 (PDF)
Anticonvulsants
- Brivaracetam (Briviact); CP.PMN.297 (PDF)
- Cannabidiol (Epidiolex); CP.PMN.164 (PDF)
- Cenobamate (Xcopri); CP.PMN.231 (PDF)
- Clobazam (Onfi, Sympazan); CP.PMN.54 (PDF)
- Diazepam nasal spray (Valtoco); CP.PMN.216 (PDF)
- Fenfluramine (Fintepla); CP.PMN.246 (PDF)
- Ganaxolone (Ztalmy); CP.PMN.278 (PDF)
- Lamotrigine (Lamictal ODT, Lamictal XR); CP.CPA.97 (PDF)
- Midazolam (Nayzilam); CP.PMN.211 (PDF)
- Perampanel (Fycompa); CP.PMN.156 (PDF)
- Pregabalin (Lyrica); CP.PMN.33 (PDF)
- Topiramate ER (Qudexy XR, Trokendi XR); CP.PMN.281 (PDF)
Anti-Depressants
- Brexanolone (Zulresso); CP.PHAR.417 (PDF)
- Dextromethorphan-bupropion (Auvelity); CP.PMN.284 (PDF)
- Esketamine (Spravato); CP.PMN.199 (PDF)
- Zuranolone (Zurzuvae); CP.PHAR.650 (PDF)
Anti-Myasthenic/Cholinergic Agents
Antiparkinson and Related Therapy Agents
- Amantadine ER (Gocovri, Osmolex ER); CP.PMN.89 (PDF)
- Apomorphine (Apokyn); CP.PHAR.488 (PDF)
- Carbidopa-Levodopa ER Capsules (Rytary), Enteral Suspension (Duopa), IR Tablets (Dhivy); CP.PMN.238 (PDF)
- Istradefylline (Nourianz); CP.PMN.217 (PDF)
- Levodopa Inhalation Powder (Inbrija); CP.PMN.267 (PDF)
- Opicapone (Ongentys); CP.PMN.245 (PDF)
- Safinamide (Xadago); CP.PMN.113 (PDF)
Antipsychotics/Antimanic Agents
- Aripiprazole Orally Disintegrating Tablet, Oral Film (Opipza); CP.PMN.300 (PDF)
- Asimtufii, Aristada, Aristada Initio); CP.PHAR.290 (PDF)
- Asenapine (Saphris, Secuado); CP.PMN.15 (PDF)
- Brexpiprazole (Rexulti); CP.PMN.68 (PDF)
- Carbarnazepine ER (Equetro); CP.PMN.137 (PDF)
- Cariprazine (Vraylar); CP.PMN.91 (PDF)
- Iloperidone (Fanapt); CP.PMN.32 (PDF)
- Lumateperone (Caplyta); CP.PMN.232 (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv); CP.PHAR.292 (PDF)
- Olanzapine-samidorpham (Lybalyi); CP.PMN.265 (PDF)
- Paliperidone Long-Acting Injections (Invega Hafyera, Invega Sustenna, Invega Trinza); CP.PHAR.291 (PDF)
- Pimavanserin (Nuplazid); CP.PMN.140 (PDF)
- Quetiapine ER (Seroquel XR); CP.PMN.64 (PDF)
- Risperidone Long-Acting Injections (Perseris, Risperdal Consta, Rykindo, Uzedy); CP.PHAR.293 (PDF)
- Xanomeline/Trospium Chloride (Cobenfy); CP.PMN.299 (PDF)
Hypnotics/Sedatives/Sleep Disorder Agents
- Doxepin (Silenor); CP.PMN.175 (PDF)
- Ramelteon (Rozerem); CP.PMN.173 (PDF)
- Suvorexant (Belsomra); CP.CPA.200 (PDF)
- Tasimelteon (Hetlioz); CP.PMN.104 (PDF)
- Zolpidem (Edluar, Zolpimist); CP.PMN.172 (PDF)
Migraine Products
- Atogepant (Qulipta); CP.PHAR.566 (PDF)
- Triptans (naratriptan (Amerge®), almotriptan (Axert®), frovatriptan (Frova®), sumatriptan (Imitrex®, Tosymra™), rizatriptan (Maxalt®/Maxalt-MLT®), eletriptan (Relpax®), sumatriptan/naproxen (Treximet®), zolmitriptan (Zomig®/Zomig® ZMT), Imitrex® injection, Onzetra™ Xsail™, Sumavel™ Dosepro™, and Zembrace™ SymTouch™)); CP.CPA.217 (PDF)
- Diclofenac potassium (Cambia); CP.PCH.28 (PDF)
- Erenumab-aaoe (Aimovig); CP.CPA.349 (PDF)
- Eptinezumab-jjmr (Vyepti); CP.CPA.345 (PDF)
- Fremanezumab-vfrm (Ajovy); CP.CPA.346 (PDF)
- Galcanezumba-gnln (Emgality); CP.CPA.344 (PDF)
- Lasmiditan (Reyvow); CP.PMN.218 (PDF)
- Rimegepant (Nurtec ODT); CP.PHAR.490 (PDF)
- Zavegepant (Zavzpret); CP.PHAR.630 (PDF)
Psychotherapeutic and Neurological Agents – Misc.
- Aducanumab (Aduhelm); CP.CPA.356 (PDF)
- Alemtuzumab (Lemtrada); CP.PHAR.243 (PDF)
- Atidarsagene autotemcel (Lenmeldy); CP.PHAR.602 (PDF)
- Bremelanotide (Vyleesi); CP.PHAR.434 (PDF)
- Cladribine (Mavenclad); CP.PHAR.422 (PDF)
- Deutetrabenazine (Austedo); CP.PCH.42 (PDF)
- Dextromethorphan-Quinidine (Nuedexta); CP.PMN.93 (PDF)
- Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), Monomethyl Fumerate (Bafiertam); CP.PHAR.249 (PDF)
- Elivaldogene Autotemcel (Skysona); CP.PHAR.556 (PDF)
- Eplontersen (Wainua); CP.PHAR.633 (PDF)
- Fingolimod (Gilenya, Tascenso ODT); CP.PCH.38 (PDF)
- Flibanserin (Addyi); CP.PHAR.446 (PDF)
- Gabapentin ER (Gralise, Horizant); CP.PMN.240 (PDF)
- Glatiramer (Copaxone, Glatopa); CP.CPA.252 (PDF)
- Interferon beta-1a (Avonex, Rebif); CP.PHAR.255 (PDF)
- Interferon beta-1b (Betaseron, Extavia); CP.PCH.46 (PDF)
- Inotersen (Tegsedi); CP.PHAR.405 (PDF)
- Lecanemab-irmb (Leqembi); CP.PHAR.596 (PDF)
- Levacetylleucine (Aqneursa); CP.PHAR.682 (PDF)
- Lofexidine (Lucemyra); CP.PMN.152 (PDF)
- Memantine (Namenda XR, Namzaric); CP.PCH.30 (PDF)
- Milnacipran (Savella); CP.PMN.125 (PDF)
- Natalizumab (Tysabri) Natalizumab-sztn (Tyruko); CP.PHAR.259 (PDF)
- Ocrelizumab (Ocrevus); CP.PHAR.335 (PDF)
- Ozanimod (Zeposia); CP.PHAR.462 (PDF)
- Patisiran (Onpatrro); CP.PHAR.395 (PDF)
- Peginterferon beta-1a (Plegridy); CP.PHAR.271 (PDF)
- Ponesimod (Ponvoy); CP.PHAR.537 (PDF)
- Siponimod fumarate (Mayzent); CP.PHAR.427 (PDF)
- Sodium Oxybate (Xyrem, Lumryz) and Calcium, Magnesium, Potassium, Sodium Oxybate (Xywav); CP.PMN.42 (PDF)
- Stiripentol (Diacomit); CP.PMN.184 (PDF)
- Teriflunomide (Aubagio); CP.PCH.40 (PDF)
- Tetrabenazine (Xenazine); CP.PHAR.92
- Ublituximab-xiiy (Briumvi); CP.PHAR.621 (PDF)
- Valbenazine (Ingrezza); CP.PCH.48 (PDF)
- Vutrisiran (Amvuttra); CP.PHAR.550 (PDF)
- AbobotulinumtoxinA (Dysport); CP.PHAR.230 (PDF)
- Casimersen (Amondys 45); CP.PHAR.470 (PDF)
- Delandistrogene Moxeparvovec-rokl (Elevidys); CP.PHAR.593 (PDF)
- Edaravone (Radicava); CP.PHAR.343 (PDF)
- Eteplirsen (Exondys 51); CP.PHAR.288 (PDF)
- Givinostat (Duvyzat); CP.PHAR.644 (PDF)
- Golodirsen (Vyondys 53); CP.PHAR.453 (PDF)
- IncobotulinumtoxinA (Xeomin); CP.PHAR.231 (PDF)
- Omaveloxolone (Skyclarys); CP.PHAR.590 (PDF)
- OnabotulinumtoxinA (Botox); CP.PHAR.232 (PDF)
- Onasemnogene abeparvovec-xioi (Zolgensma); CP.PHAR.421 (PDF)
- Nusinersen (Spinraza); CP.PHAR.327 (PDF)
- RimabotulinumtoxinB (Myobloc); CP.PHAR.233 (PDF)
- Risdiplam; CP.PHAR.477 (PDF)
- Sodium Phenylbutyrate-Taurursodiol (Relyvrio); CP.PHAR.584 (PDF)
- Tofersen (Qalsody); CP.PHAR.591 (PDF)
- Trofinetide (Daybue); CP.PHAR.600 (PDF)
- Viltolarsen (Viltepso): CP.PHAR.484 (PDF)
- Aflibercept (Eylea and biosimilars); CP.PHAR.184 (PDF)
- Avacincaptad pegol (Izervay); CP.PHAR.641 (PDF)
- Bimatoprost (Durysta); CP.PHAR.486 (PDF)
- Brimonidine (Mirvaso); CP.PMN.192 (PDF)
- Brolucizumab (Beovu); CP.PHAR.445 (PDF)
- Cenegermin-bkbj (Oxervate); CP.PMN.186 (PDF)
- Corticosteroids for ophthalmic injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq); CP.PHAR.385 (PDF)
- Cyclosporine ophthalmic emulsion (Cequa, Restasis, Verkazia, Vevye, Klarity-C); CP.PMN.48 (PDF)
- Cysteamine ophthalmic (Cystaran, Cystadrops); CP.PMN.130 (PDF)
- Faricimab (Vabysmo); CP.PHAR.581 (PDF)
- Glaucoma Agents (Omlonti, Rhopressa, Rocklatan, Vyzulta); CP.PMN.286 (PDF)
- Lifitegrast (Xiidra); CP.PMN.73 (PDF)
- Lotilaner (Xdemvy); CP.PMN.291 (PDF)
- Loteprednol etabonate (Eysuvis); CP.PMN.260 (PDF)
- Ophthalmic Riboflavin (Photrexa, Photrexa Viscous); CP.PHAR.536 (PDF)
- Oxymetazoline (Rhofade, Upneeq); CP.PMN.86 (PDF)
- Perfluorohexyloctane (Miebo); CP.PMN.290 (PDF)
- Pilocarpine (Qlosi, Vuity); CP.PMN.270 (PDF)
- Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo); CP.PHAR.186 (PDF)
- Travoprost (iDose TR); CP.PHAR.672 (PDF)
- Varenicline (Tyrvaya); CP.PMN.273 (PDF)
- Verteporfin (Visudyne); CP.PHAR.187 (PDF)
- Voretigene neparvovec-rzyl (Luxturna); CP.PHAR.372 (PDF)
Antiasthmatic and Bronchodilator Agents
- Benralizumab (Fasenra); CP.PHAR.373 (PDF)
- Inhaled Agents for Asthma and COPD; CP.CPA.350 (PDF)
- Mepolizumab (Nucala); CP.PHAR.200 (PDF)
- Omalizumab (Xolair); CP.PCH.49 (PDF)
- Reslizumab (Cinqair); CP.PHAR.223 (PDF)
- Roflumilast (Daliresp, Zoryve); CP.PMN.46 (PDF)
- Tezepelumab (Tezspire); CP.PHAR.576 (PDF)
Respiratory Agents – Misc.
- Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira); CP.PHAR.94 (PDF)
- Dornase alfa (Pulmozyme); CP.PHAR.212 (PDF)
- Elexacaftor-ivacaaftor-tezacaftor (Trikafta); CP.PHAR.440 (PDF)
- Ivacaftor (Kalydeco); CP.PHAR.210 (PDF)
- Lumacaftor-ivacaftor (Orkambi); CP.PHAR.213 (PDF)
- Mannitol (Bronchitol); CP.PHAR.518 (PDF)
- Nintedanib esylate (Ofev); CP.PCH.54 (PDF)
- Pirfenidone (Esbriet); CP.PHAR.286 (PDF)
- Tezacaftlor-Ivacaflor (Symdeko); CP.PHAR.377 (PDF)
Medicare Pharmacy Criteria
For the most up-to-date information, please visit the prior authorization, step therapy and quantity limits page.
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Health Net Payment Policy Manual apply with respect to Health Net members. Policies in the Health Net Payment Policy Manual may have either a Health Net or a “Centene” heading. In addition, Health Net may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Health Net.
If you have any questions regarding these policies, please contact Provider Services and ask to be directed to the Medical Management department.
Policy Number | Policy Title |
---|---|
CP.MP.157 | 25-hydroxyvitamin D Testing in Children and Adolescents (PDF) |
30 Day Readmission (PDF) (Effective February 15, 2022) | |
3-day Payment Window (PDF) | |
CP.MP.100 | Allergy Testing and Therapy (PDF) |
CP.MP.110 | Bronchial Thermoplasty (PDF) |
CP.MP.156 | Cardiac Biomarker Testing (PDF) |
CP.MP.105 | Digital EEG Spike Analysis (PDF) |
CP.MP.125 | DNA Analysis of Stool to Screen for Colorectal Cancer (PDF) (Effective April 01, 2021) |
CP.MP.155 | EEG in the Evaluation of Headache (PDF) |
CP.MP.106 | Endometrial Ablation (PDF) |
CC.PI.04 | Equian for Clean Claims Reviews (PDF) |
CP.VP.26 | Extended Ophthalmoscopy (PDF) |
OC.UM.CP.0043 | External Ocular Photography (PDF) (Effective July 01, 2021) |
CP.VP.28 | Fluorescein Angiography (PDF) |
CP.VP.29 | Fundus Photography (PDF) |
CP.VP.31 | Gonioscopy (PDF) |
CP.MP.153 | Helicobacter Pylori Serology Testing (PDF) |
CP.MP.113 | Holter Monitors (PDF) |
CP.MP.121 | Homocysteine Testing (PDF) (Effective April 01, 2021) |
CC.PP.007 | Lab Quantity Limits (PDF) (Effective January 15, 2021) |
CP.MP.123 | Laser Therapy for Skin Conditions (PDF) |
CC.PP.053 | Leveling of ED Services (PDF) (Effective Date: October 01, 2019) |
CP.MP.139 | Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy (PDF) |
CP.MP.152 | Measurement of Serum 1,25-dihydroxyvitamin D (PDF) |
CC.PP.065 | Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF) |
CC.PP.061 | Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) |
CC.MP.50 | Outpatient Testing for Drugs of Abuse (PDF) (Effective October 01, 2020) |
CC.PP.063 | Place of Service Mismatch (PDF) |
CC.PP.067 | Renal Hemodialysis (PDF) (Effective January 15, 2021) |
CP.PP.050 | Robotic Surgery (PDF) (Effective January 15, 2021) |
CP.VP.14 | Scanning Computerized Ophthalmic Diagnostic Imaging (PDF) |
CC.PP.073 | Sepsis Diagnosis (PDF) |
CC.PP.145 | Severe Malnutrition (PDF) |
CC.PP.206 | Skilled Nursing Facility Leveling (PDF) |
CC.PP.035 | Sleep Studies POS (PDF) (Effective January 15, 2021) |
CC.PP.049 | Status "P" Bundled Services (PDF) (Effective Date: October 01, 2019) |
CP.MP.149 | Testing for Rupture of Fetal Membranes (PDF) (Effective April 01, 2021) |
CP.MP.97 | Testing for Select Genitourinary Conditions (PDF) |
CP.MP.154 | Thyroid Hormones and Insulin Testing in Pediatrics (PDF) |
CP.MP.38 | Ultrasound in Pregnancy (PDF) |
CC.PP.056 | Urine Specimen Validity Testing (PDF) |
CP.MP.98 | Urodynamic Testing (PDF) |
CP.VP.63 | Visual Field Testing (PDF) |
CC.PP.502 | Wheelchair Accessories (PDF) (Effective July 01, 2021) |
CP.MP.99 | Wheelchair Seating (PDF) |
Policy Number | Policy Title |
---|---|
CC.PP.011 (PDF) | Code Editing Overview (Effective February 15, 2020) |
30 Day Readmission (Effective February 15, 2022) | |
3-day Payment Window | |
OC.UM.CP.0029 (PDF) | Fundus Photography (Effective May 15, 2021) |
OC.UM.CP.0063 (PDF) | Visual Field Testing (Effective May 15, 2021) |
Equian for Clean Claims Reviews | |
CC.PP.053 (PDF) | Leveling of ED Services (Effective October 01, 2019) |
Non-obstetrical Pelvic and Transvaginal Ultrasounds | |
Place of Service Mismatch | |
CC.PP.007 (PDF) | Lab Quantity Limits (Effective Janaury 15, 2021) |
CC.PP.067 (PDF) | Renal Hemodialysis (Effective January 15, 2021) |
CC.PP.065 (PDF) | Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (Effective October 01, 2020) |
CC.PP.070 (PDF) | 340B Drug Payment Reduction (Effective July 01, 2021) |
CP.MP.208 (PDF) | Outpatient Testing for Drugs of Abuse: Presumptive Frequency Edits (Effective July 01, 2021) |
CC.PP.035 (PDF) | Sleep Studies POS (Effective January 15, 2021) |
CC.PP.073 (PDF) | Sepsis Diagnosis Effective: February 17, 2025 |
CC.PP.145 (PDF) | Severe Malnutrition Effective: February 17, 2025 |
MC.CP.MP.106 (PDF) | Endometrial Ablation Effective: February 17, 2025 |