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Content with Policies & Guidelines Draft Self-Administered Drug Policies .
Genotropin, Humatrope, Ngenla, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Skytrofa, Sogroya, Zomacton, Zorbtive
Adcirca, Adempas, Letairis, Liqrev, Opsumit, Orenitram, Revatio, Tadliq, Tracleer, Tyvaso, Tyvaso DPI, Uptravi, Ventavis
Acticlate, Doxycycline monohydrate, Doryx, Doryx MPC, doxycycline hyclate, Monodox, Oracea, Vibramycin, Minocin, Minocycline ER capsule, Minocycline ER tablet, Minolira, Solodyn, Ximino, Seysara,...
almotriptan, Amerge® , Frova® Tablets, Imitrex®, Sumatriptan Injection, Imitrex®, Sumatriptan (sumatriptan) Nasal Spray, Imitrex® (sumatriptan) Tablets, Maxalt® (rizatriptan) MLT Tablets, Maxalt®...
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Coverage Exception Program Summary
Policy Number: PH-91087
POLICY REVIEW CYCLE
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Aplenzin, Auvelity, Celexa, Cymbalta, Desvenlafaxine ER, Drizalma Sprinkle, duloxetine delayed release, Effexor, Effexor XR, Escitalopram, Fetzima, Fluoxetine, Forfivo XL, Khedezla,...
Adipex-P, Benzphetamine, Contrave, Diethylpropion, Lomaira, Phendimetrazine, Phentermine, Qsymia, Saxenda, Wegovy, Xenical Qsymia™ (phentermine/topiramate), Regimex™ (benzphetamine)a, Saxenda®...