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8/14/2025 1:58 PM 86424 1.1.22-Non-Formulary-Quantity-Limit.pdf
8/14/2025 1:58 PM 488333 2022-ADD-File-NDCs.xlsx
8/14/2025 1:58 PM 103906 2022_EOB_MMP_010122.pdf
8/14/2025 1:58 PM 282487 Acamprosate-Calcium-REG-PA-1975-A-11-2020.docx
8/14/2025 1:58 PM 432162 Acamprosate-Calcium-REG-PA-1975-A-11-2020.pdf
8/14/2025 1:58 PM 29864 Actimmune-2375-A-SGM-P2020.pdf
8/14/2025 1:58 PM 136812 Adapalene-PA-351-A-08-2021.pdf
8/14/2025 1:58 PM 139316 Alpha1-Proteinase-Inhibitors-1877-A-SGM-P2021.pdf
8/14/2025 1:58 PM 155179 ambrisentan-Letairis-1646-A-SGM-P2021.pdf
8/14/2025 1:58 PM 434348 Anadrol-50-PA-1087-A-12-2020.pdf
8/14/2025 1:58 PM 128477 Apokyn-Kynmobi-2258-A-SGM-P2020.pdf
8/14/2025 1:58 PM 49275 Arcalyst-1800-A-SGM-P2021a.pdf
8/14/2025 1:58 PM 18365 Aubagio-1808-A-SGM-P2021.pdf
8/14/2025 1:58 PM 18876 Avonex-1837-A-SGM-P2021.pdf
8/14/2025 1:58 PM 31649 azacitidine-Vidaza-2280-A-SGM-P2021-1.pdf
8/14/2025 1:58 PM 31649 azacitidine-Vidaza-2280-A-SGM-P2021.pdf
8/14/2025 1:58 PM 203624 Banzel-PA-863-A-496-A-06-2021.pdf
8/14/2025 1:58 PM 29229 Betaseron-Extavia-1840-A-SGM-P2021.pdf
8/14/2025 1:58 PM 155312 bosentan-Tracleer-1649-A-SGM-P2021.pdf
8/14/2025 1:58 PM 136511 BPH-Cialis-2.5mg-5mg-PA-with-Limit-865-C-05-2021-v2.pdf
8/14/2025 1:58 PM 33476 Cabometyx-2212-A-SGM-P2021a-.pdf
8/14/2025 1:58 PM 38589 Carbaglu-2122-A-SGM-P2021.pdf
8/14/2025 1:58 PM 18951 Cayston-1880-A-SGM-P2021.pdf
8/14/2025 1:58 PM 130200 Cetrotide-Ganirelix-1912-A-1913-A-SGM-P2021.pdf
8/14/2025 1:58 PM 103481 Childrens-Care-Services-Benefit-Coverage-Summary-9.24.12-to-11.30.21.pdf
8/14/2025 1:58 PM 577832 Childrens-Care-Services-Payment-Policy-12.01.21-1.pdf
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8/14/2025 1:58 PM 577832 Childrens-Care-Services-Payment-Policy-12.01.21through-12.02.21.pdf
8/14/2025 1:58 PM 602234 Childrens-Care-Services-Payment-Policy-12.03-v2.pdf
8/14/2025 1:58 PM 602218 Childrens-Care-Services-Payment-Policy-rev-12.03.21.pdf
8/14/2025 1:58 PM 441379 Chiropractic-Services-Payment-Policy-12.01.21.pdf
8/14/2025 1:58 PM 976344 CMP_M_VWF_Vonvendi_20211202-1.pdf
8/14/2025 1:58 PM 823664 CMP_M_Xiaflex_2021118.pdf
8/14/2025 1:58 PM 429636 Complementary-and-Alternative-Medicine-CAM-Payment-Policy-12.01.21.pdf
8/14/2025 1:58 PM 31254 Copaxone-Glatopa-1841-A-SGM-P2021.pdf
8/14/2025 1:58 PM 590509 COVID-19-Vaccine-Payment-Policy-Eff.-09.27.21-through-11.12.21-replaced-with-Imm-and-Vacc-11.12.2021.pdf
8/14/2025 1:58 PM 296061 Cuprimine-Depen-Syprine-PA-3079-A-04-2021.pdf
8/14/2025 1:58 PM 140909 Cystadane-2988-A-SGM-P2021a.pdf
8/14/2025 1:58 PM 203522 Daliresp-PA-646-A-11-2020.pdf
8/14/2025 1:58 PM 402692 Daraprim-PA-REG-3404-A-12-2020.pdf
8/14/2025 1:58 PM 32323 decitabine-Dacogen-2288-A-SGM-P2021.pdf
8/14/2025 1:58 PM 151049 Dibenzyline-PA-with-Limit-3673-C-04-2021.pdf
8/14/2025 1:58 PM 135647 Dificid-PA-REG-2753-A-11-2020.pdf
8/14/2025 1:58 PM 16865 dimethyl-fumarate-Tecfidera-1845-A-SGM-P2021.pdf
8/14/2025 1:58 PM 126137 Dipentum-PA-2967-A-07-2021.pdf
8/14/2025 1:58 PM 26352 Dofetilide-Tikosyn-1873-A-SGM-P2021.pdf
8/14/2025 1:58 PM 138128 Eligard-1966-A-SGM-P2021.pdf
8/14/2025 1:58 PM 127043 Emsam-PA-REG-2823-A-03-2021.pdf
8/14/2025 1:58 PM 230123 Epclusa-2137-A-2676-A-SGM-P2020a.pdf
8/14/2025 1:58 PM 138706 Esbriet-1881-A-SGM-P2021.pdf
8/14/2025 1:58 PM 263509 everolimus-Afinitor-Products-2021-A-SGM-P2021.pdf
8/14/2025 1:58 PM 245623 Exchange-1.1.22-NOC.pdf
8/14/2025 1:58 PM 261978 Exelon-PA-85-A-509-A-05-2021.pdf
8/14/2025 1:58 PM 14820 Farydak-2231-A-SGM-P2020.pdf
8/14/2025 1:58 PM 142805 Follitropins-1914-A-1915-A-SGM-P2021-1.pdf
8/14/2025 1:58 PM 142805 Follitropins-1914-A-1915-A-SGM-P2021.pdf
8/14/2025 1:58 PM 31401 fulvestrant-Faslodex-2903-A-SGM-P2021.pdf
8/14/2025 1:58 PM 17624 Fuzeon-3099-A-SGM-P2021.pdf
8/14/2025 1:58 PM 16683 Gilenya-1842-A-SGM-P2021.pdf
8/14/2025 1:58 PM 248895 Growth-Hormone-Without-ISS-1742-A-SGM-P2021.pdf
8/14/2025 1:58 PM 165941 Harvoni-2134-A-2677-A-SGM-P2020a.pdf
8/14/2025 1:58 PM 139006 hCG-1925-A-1926-A-SGM-P2021.pdf
8/14/2025 1:58 PM 434491 High-Risk-Medications-HRM-Long-List-PA-with-Age-698-B-01-2021-v2.pdf
8/14/2025 1:58 PM 447926 imatinib-Gleevec-2172-A-SGM-P2021.pdf
8/14/2025 1:58 PM 543398 Immunization-and-Vaccine-Payment-Policy-12.01.21.pdf
8/14/2025 1:58 PM 343253 In-Lieu-of-Services-Payment-Policy-07.16.20-to-09.28.21.pdf
8/14/2025 1:58 PM 528978 In-Lieu-of-Services-Payment-Policy-09.29.21-to-11.30.21.pdf
8/14/2025 1:58 PM 65597 In-Lieu-of-Services-Payment-Policy-11.02.21.docx
8/14/2025 1:58 PM 426864 In-Lieu-of-Services-Payment-Policy-12.01.21-2.pdf
8/14/2025 1:58 PM 417115 In-Lieu-of-Services-Payment-Policy-eff-12.01.2021.html
8/14/2025 1:58 PM 220279 Inbrija-2860-A-SGM-P2020.pdf
8/14/2025 1:58 PM 148830 Increlex-1740-A-SGM-P2021.pdf
8/14/2025 1:58 PM 150855 Intron-A-1703-A-SGM-P2021.pdf
8/14/2025 1:58 PM 268893 Itraconazole-Sporanox-Capsules-PA-REG-2825-A-03-2021.pdf
8/14/2025 1:58 PM 143407 Itraconazole-Sporanox-Oral-Solution-PA-210-A-03-2021.pdf
8/14/2025 1:58 PM 117248 JCode-Listing-1Q2021.xls
8/14/2025 1:58 PM 80384 JCode-Listing-2Q2021.xls
8/14/2025 1:58 PM 76800 JCode-Listing-3Q2021.xls
8/14/2025 1:58 PM 74752 JCode-Listing-4Q2020.xls
8/14/2025 1:58 PM 324881 Jublia-PA-with-Limit-1160-C-12-2020.pdf
8/14/2025 1:58 PM 554487 Keytruda-1889-A-SGM-P2020d.pdf
8/14/2025 1:58 PM 34807 Kuvan-2012-A-SGM-P2021.pdf
8/14/2025 1:58 PM 85073 Lidoderm-ZTLido-PA-with-Limit-125-C-09-2020.pdf
8/14/2025 1:58 PM 160722 Lotronex-PA-129-A-690-A-09-2020-1.pdf
8/14/2025 1:58 PM 160722 Lotronex-PA-129-A-690-A-09-2020.pdf
8/14/2025 1:58 PM 18498 Lupaneta-Pack-1994-A-SGM-P2021.pdf
8/14/2025 1:58 PM 283752 Mammography-Screening-09.01.13-to-11.30.21.pdf
8/14/2025 1:58 PM 824868 Mammography-Screening-Payment-Policy-10.21.21.docx
8/14/2025 1:58 PM 462792 Mammography-Screening-Payment-Policy-12.01.21-1.pdf
8/14/2025 1:58 PM 68949 Medicaid-NOC-1.1.22.pdf
8/14/2025 1:58 PM 74047 Medicaid_Breast_Cancer_Risk_Reduction_20211202.pdf
8/14/2025 1:58 PM 86046 Medicaid_Ivermectin_20210914.pdf
8/14/2025 1:58 PM 77040 Medicaid_Pharmacy_-Benefit_Only_20211014.pdf
8/14/2025 1:58 PM 78711 Medicaid_Pharmacy_-Benefit_Only_20211231.pdf
8/14/2025 1:58 PM 253239 Medicaid_Preferred_Drug_-Therapy-Global-Policy.20201123a.pdf
8/14/2025 1:58 PM 418224 Mitoxantrone-1662-A-SGM-P2021.pdf
8/14/2025 1:58 PM 556618 ModernHealthcareNamesElizabethMcClaine_Top25-EmergingLeader2021_FINAL.pdf
8/14/2025 1:58 PM 304089 Multaq-PA-532-A-05-2021.pdf
8/14/2025 1:58 PM 255391 Namenda-PA-with-Age-511-B-05-2021-1.pdf
8/14/2025 1:58 PM 255391 Namenda-PA-with-Age-511-B-05-2021.pdf
8/14/2025 1:58 PM 210151 Neulasta-and-pegfilgrastim-biosimilars-1931-A-SGM-P2020.pdf
8/14/2025 1:58 PM 232055 Neupogen-and-filgrastim-biosimilars-1930-A-SGM-P2020.pdf
8/14/2025 1:58 PM 824429 NHP-BeWell-FallWinter2021-ENG_508.pdf
8/14/2025 1:58 PM 651837 NHP-BeWell-FallWinter2021-SPN_508.pdf
8/14/2025 1:58 PM 765566 NHP-HealthyYou-Fall2021-Eng_508.pdf
8/14/2025 1:58 PM 713537 NHP-HealthyYou-Fall2021-SPN_508.pdf
8/14/2025 1:58 PM 224857 Noxafil-PA-REG-3405-A-03-2021-v3.pdf
8/14/2025 1:58 PM 343955 Nuvigil-PA-with-Limit-534-C-04-2021-1.pdf
8/14/2025 1:58 PM 343955 Nuvigil-PA-with-Limit-534-C-04-2021.pdf
8/14/2025 1:58 PM 207552 Onfi-Sympazan-PA-871-A-718-A-06-2021.pdf
8/14/2025 1:58 PM 154487 Opsumit-1647-A-SGM-P2021.pdf
8/14/2025 1:58 PM 580241 Oral-Intranasal-Fentanyl-Products-PA-with-Limit-288-C-01-2021-v2.pdf
8/14/2025 1:58 PM 155820 Oral-surgery-07.25.11-to-11.30.21.pdf
8/14/2025 1:58 PM 495572 Oral-Surgery-Payment-Policy-12.01.21-1.pdf
8/14/2025 1:58 PM 155062 Orenitram-1643-A-SGM-P2021.pdf
8/14/2025 1:58 PM 261380 Oxandrolone-PA-15-A-320-A-12-2020.pdf
8/14/2025 1:58 PM 138039 Pancrelipase-PA-3134-A-09-2020.pdf
8/14/2025 1:58 PM 140310 PCSK9i-2574-A-SGM-P2021.pdf
8/14/2025 1:58 PM 157412 Peg-Intron-3805-A-MDC-2021.pdf
8/14/2025 1:58 PM 144667 Pegasys-2139-A-SGM-P2021.pdf
8/14/2025 1:58 PM 33614 phenylbutyrate-Buphenyl-2121-A-SGM-P2021.pdf
8/14/2025 1:58 PM 18557 Plegridy-1844-A-SGM-P2021.pdf
8/14/2025 1:58 PM 188285 Prolia-2026-A-SGM-P2020.pdf
8/14/2025 1:58 PM 281829 Provigil-PA-with-Limit-178-C-REG-2814-C-04-2021.pdf
8/14/2025 1:58 PM 29502 Rebif-1839-A-SGM-P2021.pdf
8/14/2025 1:58 PM 255271 Regranex-PA-with-Limit-186-C-04-2021.pdf
8/14/2025 1:58 PM 208594 Reminder_Claim-Processing-Updates-for-1.1-PCC-Final-v3.pdf
8/14/2025 1:58 PM 135349 Ribavirin-2140-A-SGM-P2020.pdf
8/14/2025 1:58 PM 136940 Rosacea-Products-PA-1486-A-BOG-4915-A-09-2021.pdf
8/14/2025 1:58 PM 17418 Samsca-2181-A-SGM-P2021.pdf
8/14/2025 1:58 PM 428066 SCIG-2043-A-SGM-P2020.pdf
8/14/2025 1:58 PM 252416 sildenafil-Revatio-1651-A-SGM-P2021.pdf
8/14/2025 1:58 PM 299490 Sirturo-PA-923-A-03-2021.pdf
8/14/2025 1:58 PM 133138 Somavert-2097-A-SGM-P2021.pdf
8/14/2025 1:58 PM 194362 Sovaldi-2141-A-2680-A-SGM-P2020a-1.pdf
8/14/2025 1:58 PM 194362 Sovaldi-2141-A-2680-A-SGM-P2020a.pdf
8/14/2025 1:58 PM 376465 Step_Therapy_12.30.21.pdf
8/14/2025 1:58 PM 156379 Supprelin-LA-1973-A-SGM-P2021a.pdf
8/14/2025 1:58 PM 52371 Sutent-2022-A-SGM-P2021.pdf
8/14/2025 1:58 PM 256128 Synarel-2984-A-3157-A-3158-A-Supplemental-Specialty-PA-P2021a.pdf
8/14/2025 1:58 PM 246759 Tadalafil-Products-1640-A-SGM-P2021.pdf
8/14/2025 1:58 PM 175632 Taltz-2013-A-SGM-P2021.pdf
8/14/2025 1:58 PM 246420 Tazorac-PA-REG-2815-A-04-2021-1.pdf
8/14/2025 1:58 PM 246420 Tazorac-PA-REG-2815-A-04-2021.pdf
8/14/2025 1:58 PM 563824 Telemedicine-Services-Payment-Policy-04.13.20-to-05.06.20.pdf
8/14/2025 1:58 PM 587231 Telemedicine-Services-Payment-Policy-05.07.20-to-12.31.21.pdf
8/14/2025 1:58 PM 1629315 Telemedicine-Services-Payment-Policy-rev12.15-eff-01.01.22.pdf
8/14/2025 1:58 PM 1599922 Telemedicine-Telephone-Services-Payment-Policy-eff-01.01.22-1.pdf
8/14/2025 1:58 PM 34892 temozolomide-Temodar-1665-A-SGM-P2021.pdf
8/14/2025 1:58 PM 401027 Temporary-COVID-19-Telemedicine-Telephone-only-Services-03.18.20-to-03.30.20.pdf
8/14/2025 1:58 PM 377745 Temporary-COVID-19-Telemedicine-Telephone-only-Services-03.31.20-to-04.12.20.pdf
8/14/2025 1:58 PM 380329 Temporary-COVID-19-Telemedicine-Telephone-only-Services-04.13.20-to-05.06.20.pdf
8/14/2025 1:58 PM 384154 Temporary-COVID-19-Telemedicine-Telephone-only-Services-05.07.20-to-06.03.20.pdf
8/14/2025 1:58 PM 388236 Temporary-COVID-19-Telemedicine-Telephone-only-Services-06.04.20-to-07.12.20.pdf
8/14/2025 1:58 PM 387086 Temporary-COVID-19-Telemedicine-Telephone-only-Services-07.13.20-to-07.16.20.pdf
8/14/2025 1:58 PM 387809 Temporary-COVID-19-Telemedicine-Telephone-only-Services-07.17.20-to-07.26.20.pdf
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8/14/2025 1:58 PM 440560 Temporary-COVID-19-Telemedicine.Telephone-only-Services-07.27.20-through-5.10.2021.pdf
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8/14/2025 1:58 PM 394340 Temporary-COVID-19-TelemedicineTelephone-only-Preventive-Medicine-Services-03.18.20-to-07.12.20.pdf
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