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Políticas clínicas y de pago
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 Buckeye Health Plan Clinical Policy Manual apply to Buckeye Health Plan members. Policies in the Buckeye Health Plan Clinical Policy Manual may have either a Buckeye Health Plan or a “Centene” heading. Buckeye Health Plan utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Buckeye Health Plan 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 Buckeye Health Plan. In addition, Buckeye Health Plan 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 Buckeye Health Plan.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 72 Hour Emergency Supply Of Medication (OH.PHAR.01) (PDF)
- Abaloparatide (Tymlos®) (CP.PHAR.345) (PDF)
- Abatacept (Orencia®) (CP.PHAR.241) (PDF)
- Abemaciclib (Verzenio™) (CP.PHAR.355) (PDF)
- Abiraterone (Zytiga) (CP.PHAR.84) (PDF)
- AbobotulinumtoxinA (Dysport®) (CP.PHAR.230) (PDF)
- Acalabrutinib (Calquence®) (CP.PHAR.366) (PDF)
- ACEI and ARB Duplicate Therapy (CP.PMN.61) (PDF)
- Acitretin (Soriatane) (CP.PMN.40) (PDF)
- Adalimumab (Humira®) (CP.PHAR.242) (PDF)
- Ado-Trastuzumab Emtansine (Kadcyla®) (CP.PHAR.229) (PDF)
- Afatinib (Gilotrif®) (CP.PHAR.298) (PDF)
- Aflibercept (Eylea®) (CP.PHAR.184) (PDF)
- Agalsidase beta (Fabrazyme®) (CP.PHAR.158) (PDF)
- Age Limit Override (Codeine, Tramadol, Hydrocodone) (CP.PMN.138) (PDF)
- Alectinib (Alecensa®) (CP.PHAR.369) (PDF)
- Alemtuzumab (Lemtrada) (CP.PHAR.243) (PDF)
- Alglucosidase alfa (Lumizyme®) (CP.PHAR.160) (PDF)
- Alirocumab (Praluent) (CP.PHAR.124) (PDF)
- Alpha-1 Proteinase Inhibitors (CP.PHAR.94) (PDF)
- Alzheimer's Agents (OH.PHAR.PPA.33) (PDF)
- Ambrisentan (Letairis®) (CP.PHAR.190) (PDF)
- Anakinra (Kineret®) (CP.PHAR.244) (PDF)
- Analgesic Agents - NSAIDs (OH.PHAR.PPA.21) (PDF)
- Analgesic Agents - Gout (OH.PHAR.PPA.22) (PDF)
- Androgens (OH.PHAR.PPA.48) (PDF)
- Angina, Hypertension and Heart Failure (PDF)
- Antiobiotics - Cephalosporins (OH.PHAR.PPA.65) (PDF)
- Antibiotics - Inhaled (OH.PHAR.PPA.68) (PDF)
- Antibiotics - Macrolides (OH.PHAR.PPA.66) (PDF)
- Antibiotics - Quinolones (OH.PHAR.PPA.67) (PDF)
- Antibiotics - Tetracyclines (OH.PHAR.PPA.69) (PDF)
- Anticonvulsant Agents (OH.PHAR.PPA.35) (PDF)
- Antidepressant Agents (OH.PHAR.PPA.36) (PDF)
- Anti-Emetics (OH.PHAR.PPA.55) (PDF)
- Antifungals for Onychomycosis and Systemic Infections (OH.PHAR.PPA.70) (PDF)
- Anti-inhibitor Coagulant Complex (Feiba®) (CP.PHAR.217) (PDF)
- Anti-migraine Agents (OH.PHAR.PPA.34) (PDF)
- Antivirals - Hepatitis C Agents (OH.PHAR.PPA.71) (PDF)
- Antivirals - Herpes (OH.PHAR.PPA.72) (PDF)
- Antivirals - HIV (OH.PHAR.PPA.73) (PDF)
- Apalutamide (Erleada™) (CP.PHAR.376) (PDF)
- Appropriate Use and Safety Pharmacy Edits (IN.CP.PMN.01) (PDF)
- Approval of Brand-Name Override (OH.PHAR.02) (PDF)
- Apremilast (Otezla®) (CP.PHAR.245) (PDF)
- Asfotase Alfa (Strensiq®) (CP.PHAR.328) (PDF)
- Aspirin-dipyridamole (Aggrenox®) (CP.PMN.20) (PDF)
- Atezolizumab (Tecentriq®) (CP.PHAR.235) (PDF)
- Attention Deficit Hyperactivity Disorder Agents (OH.PHAR.PPA.38) (PDF)
- Atypical Antipsychotic Agents (OH.PHAR.PPA.37) (PDF)
- Avelumab (Bavencio®) (CP.PHAR.333) (PDF)
- Axicabtagene Ciloleucel (Yescarta) (CP.PHAR.362) (PDF)
- Axitinib (Inlyta®) (CP.PHAR.100) (PDF)
- Aztreonam (Cayston®) (CP.PHAR.209) (PDF)
- Baricitinib (Olumiant) (CP.PHAR.135) (PDF)
- Becaplermin (Regranex®) (CP.PMN.21) (PDF)
- Belatacept (Nulojix®) (CP.PHAR.201) (PDF)
- Belimumab (Benlysta) (CP.PHAR.88) (PDF)
- Belinostat (Beleodaq®) (CP.PHAR.311) (PDF)
- Bendamustine (Bendeka®, Treanda®) (CP.PHAR.307) (PDF)
- Benign Prostatic Hyperplasia Agents V2 (OH.PHAR.PPA.61) (PDF)
- Benralizumab (FasenraTM) (CP.PHAR.373) (PDF)
- Benzinadazole (CP.PMN.90) (PDF)
- Betrixaban (Bevyxxa®) (CP.PMN.114) (PDF)
- Bevacizumab (Avastin®) (CP.PHAR.93) (PDF)
- Bevacizumab-awwb (Mvasi®) (CP.PHAR.356) (PDF)
- Bexarotene (Targretin®) (CP.PHAR.75) (PDF)
- Bezlotoxumab (Zinplava®) (CP.PHAR.300) (PDF)
- Binimetinib (Mektovi®) (CP.PHAR.50) (PDF)
- Blinatumomab (Blincyto) (CP.PHAR.312) (PDF)
- Blood Formation, Coagulation and Thrombosis Agents: Hematopoietic Agents (OH.PHAR.PPA.24) (PDF)
- Blood Formation, Coagulation and Thrombosis Agents: Colony Stimulating Factors (OH.PHAR.PPA.25) (PDF)
- Blood Formation, Coagulation and Thrombosis Agents: Hemophilia Factors (OH.PHAR.PPA.26) (PDF)
- Blood Formation, Coagulation and Thrombosis Agents: Heparin-Related Preparations (OH.PHAR.PPA.27) (PDF)
- Blood Formation, Coagulation and Thrombosis Agents: Oral Anticoagulants and Antiplatelet Agents (OH.PHAR.PPA.28) (PDF)
- Bosentan (Tracleer®) (CP.PHAR.191) (PDF)
- Bosutinib (Bosulif®) (CP.PHAR.105) (PDF)
- Brand Name Override (CP.PMN.22) (PDF)
- Brentuximab Vedotin (Adcetris) (CP.PHAR.303) (PDF)
- Brigatinib (AlunbrigTM) (CP.PHAR.342) (PDF)
- Brimonidine (Mirvaso®), Oxymetazoline (Rhofade™) (CP.PMN.86) (PDF)
- Brodalumab (Siliq™) (CP.PHAR.375) (PDF)
- Buprenorphine (Probuphine®, Sublocade®) (CP.PHAR.289) (PDF)
- Bupropion/naltrexone (Contrave®) (CP.PMN.133) (PDF)
- Burosumab-twza (Crysvita) (CP.PHAR.11) (PDF)
- Cabazitaxel (Jevtana®) (CP.PHAR.316) (PDF)
- Cabozantinib (Cabometyx, Cometriq) (CP.PHAR.111) (PDF)
- Calcifediol (Rayaldee®) (CP.PMN.76) (PDF)
- Canakinumab (Ilaris®) (CP.PHAR.246) (PDF)
- Capecitabine (Xeloda®) (CP.PHAR.60) (PDF)
- Cardiovascular Agents: Angina, Hypertension & Heart Failure (OH.PHAR.PPA.29) (PDF)
- Cardiovascular Agents: Antiarrhythmics (OH.PHAR.PPA.30) (PDF)
- Cardiovascular Agents: Lipotropics (OH.PHAR.PPA.31) (PDF)
- Cardiovascular Agents: Pulmonary Arterial Hypertension (OH.PHAR.PPA.32) (PDF)
- Carfilzomib (Kyprolis®) (CP.PHAR.309) (PDF)
- Carglumic acid (Carbaglu®) (CP.PHAR.206) (PDF)
- Central Nervous System (CNS) Agents - Movement Disorders (PDF)
- Ceritinib (Zykadia®) (CP.PHAR.349) (PDF)
- Cerliponase alfa (Brineura) (CP.PHAR.338) (PDF)
- Certolizumab (Cimzia) (CP.PHAR.247) (PDF)
- Cetuximab (Erbitux®) (CP.PHAR.317) (PDF)
- Cinacalcet (Sensipar) (CP.PHAR.61) (PDF)
- Cobimetinib (Cotellic) (CP.PHAR.380) (PDF)
- Collagenase Clostridium Histolyticum (Xiaflex®) (CP.PHAR.82) (PDF)
- Coordinated Services Program (CSP) (OH.PHAR.20) (PDF)
- Copanlisib (Aliqopa®) (CP.PHAR.357) (PDF)
- Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert) (CP.PHAR.385) (PDF)
- Corticotropin (H.P. Acthar) (CP.PHAR.168) (PDF)
- Cosyntropin (Cortrosyn®) (CP.PHAR.203) (PDF)
- Crizanlizumab-tmca (Adakveo) (CP.PHAR.449) (PDF)
- Crizotinib (Xalkori®) (CP.PHAR.90) (PDF)
- Cysteamine ophthalmic (Cystaran™) (CP.PMN.130) (PDF)
- Cysteamine oral bitartrate (Cystagon®, Procysbi®) (CP.PHAR.155) (PDF)
- Cytomegalovirus Immune Globulin (CytoGam) (CP.PHAR.277) (PDF)
- Dabrafenib (Tafinlar) (CP.PHAR.239) (PDF)
- Daclizumab (Zinbryta™) (CP.PHAR.269) (PDF)
- Dalfampridine (Ampyra) (CP.PHAR.248) (PDF)
- Dalteparin (Fragmin®) (CP.PHAR.225) (PDF)
- Daptomycin (Cubicin Cubicin RF) (CP.PHAR.351) (PDF)
- Daratumumab (Darzalex) (CP.PHAR.310) (PDF)
- Darbepoetin alfa (Aranesp®) (CP.PHAR.236) (PDF)
- Dasatinib (Sprycel®) (CP.PHAR.72) (PDF)
- Daunorubicin/Cytarabine (Vyxeos®) (CP.PHAR.352) (PDF)
- Deferasirox (Exjade, Jadenu) (CP.PHAR.145) (PDF)
- Deferiprone (Ferriprox) (CP.PHAR.147) (PDF)
- Deferoxamine (Desferal) (CP.PHAR.146) (PDF)
- Deflazacort (Emflaza®) (CP.PHAR.331) (PDF)
- Degarelix Acetate (Firmagon®) (CP.PHAR.170) (PDF)
- Denosumab (Prolia, Xgeva) (CP.PHAR.58) (PDF)
- Desmopressin (DDAVP®, Stimate®) (CP.PHAR.214) (PDF)
- Deutetrabenazine (Austedo®) (CP.PHAR.341) (PDF)
- Dextromethorphan-Quinidine (Nuedexta®) (CP.PMN.93) (PDF)
- Diabetes-Insulin (OH.PHAR.PPA.49) (PDF)
- Diabetes-Non-Insulin (OH.PHAR.50) (PDF)
- Dimethyl fumarate (Tecfidera®) (CP.PHAR.249) (PDF)
- Dornase alfa (Pulmozyme®) (CP.PHAR.212) (PDF)
- Dose Optimization (CP.PMN.13) (PDF)
- Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (CP.PMN.79) (PDF)
- DPP-4 inhibitors (CP.PST.18) (PDF)
- Dronabinol (Marinol, Syndros) (CP.PMN.159) (PDF)
- Droxidopa (Northera®) (CP.PMN.17) (PDF)
- Drug Recall Notification (OH.PHAR.03) (PDF)
- Drug Utilization Review (OH.PHAR.04) (PDF)
- Dupilumab (Dupixent®) V7 (OH.PHAR.PPA.94) (PDF)
- Durvalumab (Imfinzi®) (CP.PHAR.339) (PDF)
- Ecallantide (Kalbitor®) (CP.PHAR.177) (PDF)
- Eculizumab (Soliris®) (CP.PHAR.97) (PDF)
- Edaravone (Radicava™) (CP.PHAR.343) (PDF)
- Electrolyte Depleter Agents (OH.PHAR.PPA.62) (PDF)
- Elexacaftor-ivacaftor-tezacaftor (Trikafta) (CP.PHAR.440) (PDF)
- Eliglustat (Cerdelga®) (CP.PHAR.153) (PDF)
- Elosulfase alfa (Vimizim®) (CP.PHAR.162) (PDF)
- Elotuzumab (Empliciti®) (CP.PHAR.308) (PDF)
- Eltrombopag (Promacta®) (CP.PHAR.180) (PDF)
- Emicizumab-rzyl (Hemlibra) (CP.PHAR.370) (PDF)
- Enasidenib (Idhifa®) (CP.PHAR.363) (PDF)
- Encorafenib (Braftovi™) (CP.PHAR.127) (PDF)
- Endocrine Agents - Diabetes Hypoglycemia treatements Version 1 (PDF)
- Endocrine Agents - Growth Hormone (OH.PHAR.PPA.53) (PDF)
- Endocrine Agents - Uterine Fibroids (PDF)
- Endocrine Agents - Endometriosis (PDF)
- Enfuvirtide (Fuzeon) (CP.PHAR.41) (PDF)
- Enzalutamide (Xtandi) (CP.PHAR.106) (PDF)
- Epinephrine (EpiPen and EpiPen Jr) Quanity Limit Override (CP.PMN.144) (PDF)
- Epoetin Alfa (Epogen and Procrit) (CP.PHAR.237) (PDF)
- Epoprostenol (Flolan®, Veletri®) (CP.PHAR.192) (PDF)
- Erenumab-aaoe (Aimovig) (CP.PHAR.128) (PDF)
- Eribulin Mesylate (Halaven®) (CP.PHAR.318) (PDF)
- Erlotinib (Tarceva®) (CP.PHAR.74) (PDF)
- Erwinia Asparaginase (Erwinaze®) (CP.PHAR.301) (PDF)
- Esoteric Agents (OH.PHAR.PPA.51) (PDF)
- Etanercept (Enbrel) (CP.PHAR.250) (PDF)
- Etelcalcetide (Parsabiv) (CP.PHAR.379) (PDF)
- Eteplirsen (Exondys 51®) (CP.PHAR.288) (PDF)
- Everolimus (Afinitor, Afinitor Disperz) (CP.PHAR.63) (PDF)
- Evolocumab (Repatha) (CP.PHAR.123) (PDF)
- Exemestane (Aromasin®) (CP.PST.05) (PDF)
- Factor IX Complex Human (CP.PHAR.219) (PDF)
- Factor IX_Human Recombinant (CP.PHAR.218) (PDF)
- Factor VIIa Recombinant (NovoSeven® RT) (CP.PHAR.220) (PDF)
- Factor VIII (CP.PHAR.215) (PDF)
- Factor VIII-von Willebrand_Human (CP.PHAR.216) (PDF)
- Factor XIII Human (Corifact®) (CP.PHAR.221) (PDF)
- Factor XIIIa_Recombinant (Tretten®) (CP.PHAR.222) (PDF)
- Ferric Carboxymaltose (Injectafer®) (CP.PHAR.234.) (PDF)
- Ferric Gluconate (Ferrlecit®) (CP.PHAR.166) (PDF)
- Ferumoxytol (Feraheme®) (CP.PHAR.165) (PDF)
- Fibromyalgia Agents (OH.PHAR.PPA.39) (PDF)
- Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo-filgrastim (Granix) (CP.PHAR.297) (PDF)
- Fingolimod (Gilenya®) (CP.PHAR.251) (PDF)
- Fondaparinux (Arixtra®) (CP.PHAR.226) (PDF)
- Fostamatinib (Tavalisse) (CP.PHAR.24) (PDF)
- Galsulfase (Naglazyme®) (CP.PHAR.161) (PDF)
- Gefitinib (Iressa®) (CP.PHAR.68) (PDF)
- Gefitinib (Iressa®) (CP.PHAR.299) (PDF)
- Gemtuzumab ozogamicin (Mylotarg®) (CP.PHAR.358) (PDF)
- Glatiramer (Copaxone®, Glatopa®) (CP.PHAR.252) (PDF)
- GLP-1 receptor agonists (CP.PST.14) (PDF)
- Glycerol phenylbutyrate (Ravicti®) (CP.PHAR.207) (PDF)
- Golimumab (Simponi®, Simponi Aria®) (CP.PHAR.253) (PDF)
- Goserelin Acetate (Zoladex®) (CP.PHAR.171) (PDF)
- Guselkumab (Tremfya®) (CP.PHAR.364) (PDF)
- Halobetasol-Tazarotene (Duobrii) (CP.PMN.208) (PDF)
- Hemophilia Factors
- Hemin (Panhematin®) (CP.PHAR.181) (PDF)
- Histrelin Acetate (Vantas®, Supprelin LA®) (CP.PHAR.172) (PDF)
- House dust mite allergen extract (Odactra®) (CP.PMN.111) (PDF)
- Hyaluronate Derivatives (CP.PHAR.05) (PDF)
- Hydroxyprogesterone caproate (Makena®) (CP.PHAR.14) (PDF)
- Ibalizumab-uiyk (Trogarzo™) (CP.PHAR.378) (PDF)
- Ibandronate injection (Boniva®) (CP.PHAR.189) (PDF)
- Ibrutinib (Imbruvica) (CP.PHAR.126) (PDF)
- Icatibant (Firazyr®) (CP.PHAR.178) (PDF)
- Idursulfase (Elaprase®) (CP.PHAR.156) (PDF)
- Ifaximin (Xifaxan®) (CP.PMN.47) (PDF)
- Iloprost (Ventavis®) (CP.PHAR.193) (PDF)
- Imatinib mesylate (Gleevec®) (CP.PHAR.65) (PDF)
- Imiglucerase (Cerezyme®) (CP.PHAR.154) (PDF)
- Immune Globulins (CP.PHAR.103) (PDF)
- Immunization Coverage (CP.PHAR.28) (PDF)
- Immunomodulator Agents for Systemic Inflammatory Disease (OH.PHAR.PPA.64) (PDF)
- IncobotulinumtoxinA (Xeomin®) (CP.PHAR.231) (PDF)
- Indacaterol (Arcapta Neohaler) (CP.PMN.203) (PDF)
- Infectious Disease Agents - Antibiotics-Tetracyclines V6 (PDF)
- Infectious Disease Agents - Antiviruals-Hepatitis C Agents (PDF)
- Infectious Disease Agents - Antibiotics-Macrolides v6 (PDF)
- Infectious Disease Agents - Antivirals - HIV V6 (PDF)
- Infliximab (Remicade®, Inflectra®, Renflexis™) (CP.PHAR.254) (PDF)
- Inotuzumab ozogamicin (Besponsa®) (CP.PHAR.359) (PDF)
- Interferon beta-1a (Avonex®, Rebif®) (CP.PHAR.255) (PDF)
- Interferon beta-1b (Betaseron®, Extavia®) (CP.PHAR.256) (PDF)
- Interferon Gamma- 1b (Actimmune®) (CP.PHAR.52) (PDF)
- Intra baclofen (Gablofen®) (CP.PHAR.149) (PDF)
- Ipilimumab (Yervoy) (CP.PHAR.319) (PDF)
- Irinotecan Liposome (Onivyde®) (CP.PHAR.304) (PDF)
- Iron Sucrose (Venofer®) (CP.PHAR.167) (PDF)
- Irritable Bowel Syndrome (IBS) - Selected GI (OH.PHAR.PPA.56) (PDF)
- Isotretinoin (Claravis, Absorica, Myorisan, Zenatane) (CP.PMN.143) (PDF)
- Ivacaftor (Kalydeco®) (CP.PHAR.210) (PDF)
- Ixazomib (Ninlaro) (CP.PHAR.302) (PDF)
- Ixekizumab (Taltz®) (CP.PHAR.257) (PDF)
- Lapatinib (Tykerb®) (CP.PHAR.79) (PDF)
- Laronidase (Aldurazyme®) (CP.PHAR.152) (PDF)
- Lenalidomide (Revlimid®) (CP.PHAR.71) (PDF)
- Letermovir (Prevymis®) (CP.PHAR.367) (PDF)
- Leuprolide Acetate (Eligard®, Lupaneta Pack®, Lupron Depot®, Lupron Depot-Ped®) (CP.PHAR.173) (PDF)
- Levoleucovorin (Fusilev®) (CP.PHAR.151) (PDF)
- L-glutamine (Endari®) (CP.PMN.116) (PDF)
- Lindane Shampoo (CP.PMN.09) (PDF)
- Linezolid (Zyvox®) (CP.PMN.27) (PDF)
- Lomitapide (Juxtapid) (CP.PHAR.283) (PDF)
- Lost, Stolen, Spilled or Broken Medication (OH.PHAR.05) (PDF)
- Lorcaserin (Belviq®, Belviq XR®) (CP.PCH.03) (PDF)
- Lumacaftor-ivacaftor (Orkambi®) (CP.PHAR.213) (PDF)
- Luspatercept-aamt (Reblozyl) (CP.PHAR.450) (PDF)
- Lutetium Lu 177 dotatate (Lutathera) (CP.PHAR.384) (PDF)
- Macitentan (Opsumit®) (CP.PHAR.194) (PDF)
- Mecamylamine (Vecamyl®) (CP.PMN.136) (PDF)
- Mecasermin (Increlex) (CP.PHAR.150) (PDF)
- Mechlorethamine (Valchlor) (CP.PHAR.381) (PDF)
- Medicaid Pharmacy Appeals (OH.PHAR.21) (PDF)
- Medication Assisted Treatment of Opioid Addiction (OH.PHAR.PPA.40) (PDF)
- Mepolizumab (Nucala) (CP.PHAR.200) (PDF)
- Mesalamine Oral Therapy (CP.PST.08) (PDF)
- Methadone for Management of Pain (IN.CP.PMN.02) (PDF)
- Methoxy polyethylene glycol-epoetin beta (Mircera®) (CP.PHAR.238) (PDF)
- Midostaurin (Rydapt) (CP.PHAR.344) (PDF)
- Mifepristone (Korlym®) (CP.PHAR.101) (PDF)
- Miglustat (Zavesca®) (CP.PHAR.164) (PDF)
- Mipomersen (Kynamro) (CP.PHAR.284) (PDF)
- Mitoxantrone (Novantrone®) (CP.PHAR.258) (PDF)
- Multiple Sclerosis (OH.PHAR.PPA.41) (PDF)
- Nabilone (Cesamet) (CP.PMN.160) (PDF)
- Nafarelin Acetate (Synarel®) (CP.PHAR.174) (PDF)
- Naloxone (Evzio) (CP.PMN.139) (PDF)
- Naltrexone (Vivitrol®) (CP.PHAR.96) (PDF)
- Natalizumab (Tysabri®) (CP.PHAR.259) (PDF)
- Necitumumab (Portrazza®) (CP.PHAR.320) (PDF)
- Neratinib (Nerlynx®) (CP.PHAR.365) (PDF)
- Netarsudil (Rhopressa®) (CP.PMN.118) (PDF)
- Netupitant;palonosetron (Akynzeo) (CP.PMN.158) (PDF)
- Neurophathic Pain (OH.PHAR.PPA.42) (PDF)
- Nilotinib (Tasigna®) (CP.PHAR.76) (PDF)
- Nintedanib (Ofev) (CP.PHAR.285) (PDF)
- Nivolumab (Opdivo) (CP.PHAR.121) (PDF)
- No Coverage Criteria/Off-Label Use Policy (CP.PMN.53) (PDF)
- Nusinersen (Spinraza) (CP.PHAR.327) (PDF)
- Obeticholic acid (Ocaliva) (CP.PHAR.287) (PDF)
- Obinutuzumab (Gazyva®) (CP.PHAR.305) (PDF)
- Ocrelizumab (OcrevusTM) (CP.PHAR.335) (PDF)
- Octreotide Acetate (Sandostatin®, Sandostatin LAR Depot®) (CP.PHAR.40) (PDF)
- Ofatumumab (Arzerra®) (CP.PHAR.306) (PDF)
- Olaparib (Lynparza) (CP.PHAR.360) (PDF)
- Olaratumab (Lartruvo®) (CP.PHAR.326) (PDF)
- Omacetaxine (Synribo®) (CP.PHAR.108) (PDF)
- Omalizumab (Xolair®) (CP.PHAR.01) (PDF)
- Omega-3-Acid Ethyl Esters (Lovaza®) (CP.PMN.52) (PDF)
- Omnipod Insulin Pump (OH.PHAR.PPA.19) (PDF)
- OnabotulinumtoxinA (Botox) (CP.PHAR.232) (PDF)
- Opioid Analgesics (OH.PHAR.PPA.23) (PDF)
- Opioid-Induced Constipaction (OH.PHAR.PPA.57) (PDF)
- Opioid Rx Limits (OH.PHAR.PPA.02) (PDF)
- Ophthalmic Agents: Antibiotic and Antibiotic Steroid Combination Drops and Ointments (OH.PHAR.PPA.74) (PDF)
- Ophthalmic Agents: Antihistamines and Mast Cell Stabilizers (OH.PHAR.PPA.75) (PDF)
- Ophthalmic Agents: Dry Eye Treatments (OH.PHAR.PPA.76) (PDF)
- Ophthalmic Agents: Glaucoma Agents (OH.PHAR.PPA.77) (PDF)
- Ophthalmic Agents: NSAIDS (OH.PHAR.PPA.78) (PDF)
- Ophthalmic Steroids (PDF)
- Oral Antiemetics (5-HT3 Antagonists) (CP.PMN.11) (PDF)
- Osimertinib (Tagrisso) (CP.PHAR.294) (PDF)
- Osteoporosis-Bone Ossification Enhancers (OH.PHAR.PPA.54) (PDF)
- Otic Agents: Antibacterial and Antibacterial Steroid Combinations (OH.PHAR.PPA.79) (PDF)
- Ozenoxacin (Xepi) (CP.PMN.119) (PDF)
- Paclitaxel, protein-bound (Abraxane®) (CP.PHAR.176) (PDF)
- Palbociclib (Ibrance®) (CP.PHAR.125) (PDF)
- Palivizumab (Synagis®) (CP.PHAR.16) (PDF)
- Pancreatic Enzymes (OH.PHAR.PPA.58) (PDF)
- Panitumumab (Vectibix®) (CP.PHAR.321) (PDF)
- Panobinostat (Farydak) (CP.PHAR.382) (PDF)
- Parathyroid hormone (Natpara) (CP.PHAR.282) (PDF)
- Paricalcitol Injection (Zemplar) (CP.PHAR.270) (PDF)
- Parkinson's Agent (OH.PHAR.PPA.43) (PDF)
- Pasireotide (Signifor LAR®) (CP.PHAR.332) (PDF)
- Pazopanib (Votrient®) (CP.PHAR.81) (PDF)
- PBM Inquiry for Additional Information During PA/MN Review Process (OH.PHAR.06) (PDF)
- Pegaptanib (Macugen®) (CP.PHAR.185) (PDF)
- Pegaspargase (Oncaspar®) (CP.PHAR.353) (PDF)
- Pegfilgrastim (Neulasta) (CP.PHAR.296) (PDF)
- Peginterferon Alfa-2b (PegIntron, Sylatron) (CP.PHAR.89) (PDF)
- Peginterferon beta-1a (Plegridy®) (CP.PHAR.271) (PDF)
- Pegloticase (Krystexxa®) (CP.PHAR.115) (PDF)
- Pembrolizumab (Keytruda®) (CP.PHAR.322) (PDF)
- Pemetrexed (Alimta®) (CP.PHAR.368) (PDF)
- Pertuzumab (Perjeta®) (CP.PHAR.227) (PDF)
- Pharmaceutical Management (OH.PHAR.07) (PDF)
- Pharmaceutical Transition for New Members (OH.PHAR.50) (PDF)
- Pharmacy and Therapeutics Committee (OH.PHAR.13) (PDF)
- Pharmacy and Therapeutics Committee Member Documentation and Tracking (OH.PHAR.16) (PDF)
- Pharmacy and Therapeutics Committee Members Confidentiality Statement (OH.PHAR.17) (PDF)
- Pharmacy Compounds (OH.PHAR.PPA.03) (PDF)
- Pharmacy Prior Authorization and Medical Necessity Criteria (OH.PHAR.08) (PDF)
- Pharmacy Program (OH.PHAR.09) (PDF)
- Phentermine (Adipex-P ®, LomairaTM) (CP.PMN.135) (PDF)
- Pimecrolimus (Elidel®) (CP.PMN.98) (PDF)
- Pirfenidone (Esbriet) (CP.PHAR.286) (PDF)
- Plerixafor (Mozobil) (CP.PHAR.323) (PDF)
- Pomalidomide (Pomalyst®) (CP.PHAR.116) (PDF)
- Ponatinib (Iclusig®) (CP.PHAR.112) (PDF)
- Pralatrexate (Folotyn®) (CP.PHAR.313) (PDF)
- Prasterone (Intrarosa®) (CP.PMN.99) (PDF)
- Preferred Drug List (OH.PHAR.10) (PDF)
- Propranolol HCl oral solution (Hemangeol®) (CP.PMN.58) (PDF)
- Protein C Concentrate Human (Ceprotin®) (CP.PHAR.330) (PDF)
- Proton Pump Inhibitors (OH.PHAR.PPA.59) (PDF)
- Provider Requests for Pharmacy Profiles (OH.PHAR.11) (PDF)
- Pyrimethamine (Daraprin®) (CP.PMN.44) (PDF)
- QL of Diabetic Test Strips not receiving insulin (CP.PMN.151) (PDF)
- Quantity Limit Override (CP.PMN.59) (PDF)
- Ramucirumab (Cyramza®) (CP.PHAR.119) (PDF)
- Ranibizumab (Lucentis®) (CP.PHAR.186) (PDF)
- Regorafenib (Stivarga®) (CP.PHAR.107) (PDF)
- Request for Medically Necessary Drug not on the PDL (CP.PMN.16) (PDF)
- Reslizumab (Cinqair®) (CP.PHAR.223) (PDF)
- Respiratory Agents: Antihistamines - Second Generation (OH.PHAR.PPA.80) (PDF)
- Respiratory Agents: Beta-Adrenergic Agonists - Inhaled, Short Acting (OH.PHAR.PPA.81) (PDF)
- Respiratory Agents: Beta-Adrenergic Agonists - Inhaled, Long Acting (OH.PHAR.PPA.82) (PDF)
- Respiratory Agents: Chronic Obstructive Pulmonary Disease (OH.PHAR.PPA.83) (PDF)
- Respiratory Agents: Epinephrine Auto-Injectors (OH.PHAR.PPA.84) (PDF)
- Respiratory Agents: Glucocorticoids - Inhaled (OH.PHAR.PPA.85) (PDF)
- Respiratory Agents: Hereditary Angioedema (OH.PHAR.PPA.86) (PDF)
- Respiratory Agents: Leukotriene Receptor Modifiers and Inhibitors (OH.PHAR.PPA.87) (PDF)
- Respiratory Agents: Monoclonal Antibiotics-Anti-IL Anti-IgE (PDF)
- Respiratory Agents: Nasal Preparations (OH.PHAR.PPA.88) (PDF)
- Restless Leg Syndrom (OH.PHAR.PPA.44) (PDF)
- Ribociclib (Kisqali®, Kisqali Femara®) (CP.PHAR.334) (PDF)
- Rifamycin (Aemcolo) (CP.PMN.196) (PDF)
- Rifapentine (Priftin®) (CP.PMN.05) (PDF)
- Rilonacept (Arcalyst®) (CP.PHAR.266) (PDF)
- RimabotulinumtoxinB (Myobloc®) (CP.PHAR.233) (PDF)
- Riociguat (Adempas®) (CP.PHAR.195) (PDF)
- Risankizumab-rzaa (Skyrizi) (CP.PHAR.426) (PDF)
- Rituximab (Rituxan®), Rituximab and hyaluronidase (Rituxan Hycela™) (CP.PHAR.260) (PDF)
- Romidepsin (Istodax®) (CP.PHAR.314) (PDF)
- Romiplostim (Nplate®) (CP.PHAR.179) (PDF)
- Rucaparib (Rubraca®) (CP.PHAR.350) (PDF)
- Ruxolitinib (Jakafi®) (CP.PHAR.98) (PDF)
- Sapropterin (Kuvan®) (CP.PHAR.43) (PDF)
- Sargramostim (Leukine) (CP.PHAR.295) (PDF)
- Sarilumab (Kevzara®) (CP.PHAR.346) (PDF)
- Sebelipase alfa (Kanuma®) (CP.PHAR.159) (PDF)
- Secnidazole (Solosec®) (CP.PMN.103) (PDF)
- Secukinumab (Cosentyx®) (CP.PHAR.261) (PDF)
- Sedative Hypnotic, Non-Barbiturate Agents (OH.PHAR.PPA.45) (PDF)
- Selinexor (Xpovio) (CP.PHAR.431) (PDF)
- Selexipag (Uptravi®) (CP.PHAR.196) (PDF)
- Short Ragweed Pollen Allergen Extract (Ragwitek) (CP.PMN.83) (PDF)
- Sildenafil (Revatio®) (CP.PHAR.197) (PDF)
- Siltuximab (Sylvant®) (CP.PHAR.329) (PDF)
- Sipuleucel-T (Provenge®) (CP.PHAR.120) (PDF)
- Skeletal Muscle Relaxants, Non-Benzodiazepine (OH.PHAR.PPA.46) (PDF)
- Sodium phenylbutyrate (Buphenyl®) (CP.PHAR.208) (PDF)
- Solriamfetol (Sunosi) (CP.PMN.209) (PDF)
- Somatropin (Human Growth Hormone) (CP.PHAR.55) (PDF)
- Sonidegib (Odomzo®) (CP.PHAR.272) (PDF)
- Sorafenib (Nexavar®) (CP.PHAR.69) (PDF)
- Specialty Pharmacy Program (OH.PHAR.12) (PDF)
- SSRI SNRI Duplicate Thearapy (CP.PMN.60) (PDF)
- Step Therapy (CP.PST.01) (PDF)
- Sunitinib (Sutent®) (CP.PHAR.73) (PDF)
- Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract (Oralair) (CP.PMN.85) (PDF)
- Tadalafil (Adcirca®) (CP.PHAR.198) (PDF)
- Taliglucerase alfa (Elelyso®) (CP.PHAR.157) (PDF)
- Tasimelteon (Hetlioz®) (CP.PMN.104) (PDF)
- Tedizolid (Sivextro®) (CP.PMN.62) (PDF)
- Teduglutide (Gattex) (CP.PHAR.114) (PDF)
- Telotristat ethyl (Xermelo™) (CP.PHAR.337) (PDF)
- Temozolomide (Temodar®) (CP.PHAR.77) (PDF)
- Temsirolimus (Torisel®) (CP.PHAR.324) (PDF)
- Teriflunomide (Aubagio®) (CP.PHAR.262) (PDF)
- Teriparatide (Forteo®) (CP.PHAR.188) (PDF)
- Tesamorelin (Egrifta) (CP.PHAR.109) (PDF)
- Testosterone Pellet (Testopel®) (CP.PHAR.354) (PDF)
- Tetrabenazine (Xenazine®) (CP.PHAR.92) (PDF)
- Tezacaftor/iv acafter; ivacaftor (Symdeko™ ) (CP.PHAR.377) (PDF)
- Thalidomide (Thalomid) (CP.PHAR.78) (PDF)
- Thyrotropin Alfa (Thyrogen) (CP.PHAR.95) (PDF)
- Tildrakizumab-asmn (Ilumya) (CP.PHAR.386) (PDF)
- Tiludronate (Skelid®) (CP.PMN.106) (PDF)
- Timothy Grass Pollen Allergen Extract (Grastek) (CP.PMN.84) (PDF)
- Tisagenlecleucel (Kymriah®) (CP.PHAR.361) (PDF)
- Tobramycin (CP.PHAR.211) (PDF)
- Tocilizumab (Actemra®) (CP.PHAR.263) (PDF)
- Tofacitinib (Xeljanz®, Xeljanz® XR) (CP.PHAR.267) (PDF)
- Tolvaptan (Jynarque) (CP.PHAR.27) (PDF)
- Topical Agents: Acne Preparations (OH.PHAR.PPA.89) (PDF)
- Topical Agents: Anti-Fungals (OH.PHAR.PPA.90) (PDF)
- Topical Agents: Anti-Parasitics (OH.PHAR.PPA.91) (PDF)
- Topical Agents: Corticosteroids (OH.PHAR.PPA.92) (PDF)
- Topical Agents: Immunomodulators (OH.PHAR.PPA.93) (PDF)
- Topotecan (Hycamtin®) (CP.PHAR.64) (PDF)
- Toremifene (Fareston®) (CP.PMN.126) (PDF)
- Trametinib (Mekinist) (CP.PHAR.240) (PDF)
- Trastuzumab (Herceptin®), Trastuzumab-dkst (Ogivri®) (CP.PHAR.228) (PDF)
- Treprostinil (Orenitram®, Remodulin®, Tyvaso®) (CP.PHAR.199) (PDF)
- Triamcinolone ER Injection (Zilretta) (CP.PHAR.371) (PDF)
- Trifluridine_Tipiracil (Lonsurf) (CP.PHAR.383) (PDF)
- Triptorelin Pamoate (Trelstar®, Triptodur®) (CP.PHAR.175) (PDF)
- Ulcerative Colitis Agent (OH.PHAR.PPA.60) (PDF)
- Upadacitinib (Rinvoq) (CP.PHAR.443) (PDF)
- Urinary Antispasmodic Agents V2 (OH.PHAR.PPA.63) (PDF)
- Ustekinumab (Stelara®) (CP.PHAR.264) (PDF)
- Vacation Overrides (OH.PHAR.17) (PDF)
- Valbenazine (Ingrezza™) (CP.PHAR.340) (PDF)
- Vandetanib (Caprelsa®) (CP.PHAR.80) (PDF)
- Vedolizumab (Entyvio®) (CP.PHAR.265) (PDF)
- Velaglucerase alfa (VPRIV®) (CP.PHAR.163) (PDF)
- Vemurafenib (Zelboraf®) (CP.PHAR.91) (PDF)
- Verteporfin (Visudyne®) (CP.PHAR.187) (PDF)
- Vestronidase alfa-vjbk (Mepsevii™) (CP.PHAR.374) (PDF)
- Vigabatrin (Sabril) (CP.PHAR.169) (PDF)
- Vincristine Sulfate Liposome Injection (Marqibo®) (CP.PHAR.315) (PDF)
- Vismodegib (Erivedge®) (CP.PHAR.273) (PDF)
- Voretigene Neparvovec-rzyl (Luxturna) (CP.PHAR.372) (PDF)
- Vorinostat (Zolinza®) (CP.PHAR.83) (PDF)
- Voxelotor (Oxbryta) (CP.PHAR.451) (PDF)
- Ziv-aflibercept (Zaltrap®) (CP.PHAR.325) (PDF)
- Zoledronic Acid (Reclast®, Zometa®) (CP.PHAR.59) (PDF)
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