| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-001 |
Acne Vulgaris and Rosacea |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-002 |
Alpha-1-Proteinase-Inhibitors |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-003 |
Ankylosing Spondylitis Retail Drugs |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-004 |
Anthelmintics |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-006 |
Brand Antiemetics for Chemotherapy Induced Nausea and Vomiting |
August 22, 2022 |
July 22, 2022 |
July 22, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-007 |
Antineoplastics - Retail |
September 01, 2021 |
August 18, 2021 |
August 18, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-008 |
Aranesp |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-009 |
Eucrisa |
October 01, 2022 |
September 19, 2022 |
September 19, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-011 |
Basal Insulin |
June 01, 2023 |
May 19, 2023 |
May 19, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-012 |
Retail Biosimilar Policy |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-013 |
Brand Name Medications |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-014 |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Agents |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-015 |
Clostridium Difficile |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-016 |
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist for Migraine Prevention |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-017 |
Constipation Medications |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-019 |
Crohn's Disease: Retail Drugs |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-022 |
Dupixent for Asthma, Eosinophilic Esophagitis, or Prurigo Nodularis |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-024 |
Epidiolex |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-026 |
Gonadotropin Releasing Hormone (GnRH) Agonists and Antagonists |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-027 |
Growth Hormones - Adult |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-028 |
Growth Hormones - Child |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-030 |
Hepatitis C Direct Acting Antivirals |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-031 |
Hereditary Angioedema |
February 01, 2021 |
January 27, 2021 |
January 27, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-032 |
Hidradenitis Suppurativa - Retail Medications |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-033 |
Hyperkalemia- Commercial & Individual |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-034 |
Irritable Bowel Syndrome with Diarrhea (IBS-D) |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-035 |
IL5 Receptor Antagonist for Asthma |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-036 |
Increlex |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-039 |
Interstitial Cystitis |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-041 |
Juvenile Idiopathic Arthritis |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-043 |
Long Acting Tacrolimus |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-044 |
Multiple Sclerosis Agents |
November 01, 2022 |
August 24 , 2022 |
August 24, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-045 |
Pulmozyme |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-047 |
Neupro |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-049 |
Off Label Use |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-050 |
Opioid Dependence Agents |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-051 |
Opioids - Chronic |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-052 |
Acute Opioid Use Policy |
September 01, 2022 |
August 24, 2022 |
August 24, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-054 |
Osteoporosis Medications |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-056 |
Pharmacy Prior Authorization and Medical Necessity Policy |
March 08, 2024 |
March 05, 2024 |
March 05, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-057 |
Phosphodiesterase Type 5 (PDE-5) Inhibitor |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-058 |
Phenylbutyrates |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-059 |
Phenylketonuria (PKU) |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-060 |
Promacta |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-061 |
Psoriasis: Retail Drugs |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-062 |
Psoriatic Arthritis |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-063 |
Pulmonary Arterial Hypertension |
September 01, 2021 |
August 18, 2021 |
August 18, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-065 |
Rheumatoid Arthritis |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-066 |
Sandostation LAR |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-067 |
Savella |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-068 |
Ocaliva |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-069 |
Spravato |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-070 |
Subcutaneous Methotrexate |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-071 |
Brand Statins |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-074 |
Topiramate ER Sprinkle Capsules |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-075 |
Ulcerative Colitis: Retail Drugs |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-077 |
VMAT-2 Inhibitors |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-078 |
Xifaxan- Commercial & Individual |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-079 |
Xolair |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-080 |
Pancreatic Enzymes |
December 01, 2022 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-081 |
Benlysta |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-082 |
Iron Chelation Therapy |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-082 |
Iron Chelation Therapy |
October 01, 2022 |
September 19, 2022 |
September 19, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-083 |
Nuedexta |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-084 |
Ruzurgi- Firdapse |
November 01, 2021 |
October 13, 2021 |
October 13, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-086 |
XHANCE |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-087 |
Yupelri |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-088 |
Acute Migraine Medications |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-089 |
Parkinson's Agents |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-090 |
Vascepa |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-091 |
OFEV®, pirfenidone |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-091 |
Idiopathic Pulmonary Fibrosis |
January 1, 2022 |
December 13, 2021 |
December 13, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-094 |
Cablivi |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-098 |
Cuvposa |
August 10, 2020 |
August 19, 2020 |
August 19, 2021 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-099 |
Nexletol and Nexlizet |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-100 |
Prevymis |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-101 |
Humira for Uveitis |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-103 |
Pharmacy Continuity of Care |
May 22, 2023 |
May 18, 2023 |
May 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-104 |
Cystadrops and Cystaran for Ocular Cystinosis |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-105 |
Isturisa |
January 1, 2022 |
December 13, 2021 |
December 13, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-107 |
Sunosi |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-108 |
Continuous Glucose Monitor (CGM) Retail Pharmacy |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-109 |
Signifor |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-110 |
Hemophilia and Blood Products |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-111 |
Descovy |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-112 |
Dojolvi |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-113 |
Nerlynx- Commercial & Individual |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-114 |
Rocklatan and Rhopressa |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-115 |
Step Therapy |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-117 |
Evrysdi |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-125 |
Wakix |
February 1, 2022 |
January 19, 2022 |
January 19, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-126 |
Bylvay |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-127 |
Livtencity |
February 1, 2022 |
January 19, 2022 |
January 19, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-128 |
Oxervate |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-130 |
Leqvio |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-131 |
Rezurock- Commercial & Individual |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-135 |
Atopic Dermatitis: Biologics/JAK Inhibitors- Commercial & Individual |
January 01, 2023 |
October 26, 2022 |
October 26, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-141 |
Opzelura |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-142 |
Non-Radiographic Axial Spondyloarthritis (nrx-SpA) |
February 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-144 |
Nucala- Commercial & Individual |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-146 |
Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-147 |
Zoryve |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-148 |
Mounjaro and GLP-1s |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-149 |
Heavily Treated HIV |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual & Commercial |
pharm-150 |
Hormone Therapy for Gender Dysphoria (UT Members Only) |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-153 |
Posaconazole |
June 01, 2023 |
May 19, 2023 |
May 19, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-154 |
Beyfortus |
October 07, 2023 |
October 03, 2023 |
October 03, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-158 |
Zurzuvae |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-001 |
Acne Vulgaris and Rosacea |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-hu-002 |
Alpha-1-Proteinase-Inhibitors |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-HU-003 |
Ankylosing Spondylitis Retail & Medical Drugs |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-HU-004 |
Anthelmintics |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-008 |
Aranesp |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-011 |
Basal Insulin |
January 01, 2024 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-012 |
Retail Basal Insulin |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| Healthy U |
pharm-hu-013 |
Brand Name Medications |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-014 |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Agents |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-HU-015 |
Clostridium Difficile |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-016 |
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists for Migraine Prevention |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-HU-017 |
Constipation Medications |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-HU-019 |
Crohn's Disease Retail & Medical Drugs |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-HU-022 |
Dupixent for Asthma, Eosinophilic Esophagitis, or Prurigo Nodularis |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-026 |
Gonadotropin Releasing Hormone Agonists and Antagonists – Healthy U |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| Healthy U |
pharm-HU-027 |
Growth Hormones: Adult |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-028 |
Growth Hormone - Child |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-HU-030 |
Hepatitis C Direct Acting Antivirals |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-031 |
Hereditary Angioedema |
December 1, 2024 |
November 08, 2023 |
November 08, 2024 |
| Healthy U |
pharm-HU-032 |
Hidradenitis Suppurativa Retail Medications |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-033 |
Hyperkalemia- Healthy U |
March 1, 2023 |
February 17, 2023 |
February 17, 2024 |
| Healthy U |
pharm-hu-034 |
Irritable Bowel Syndrome with Diarrhea (IBS-D) |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-hu-035 |
IL5 Receptor Antagonist for Asthma |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| Healthy U |
pharm-hu-036 |
Increlex |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-039 |
Interstitial Cystitis |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-HU-041 |
Juvenile Idiopathic Arthritis Retail & Medical Drugs |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-HU-044 |
Multiple Sclerosis Agents |
November 01, 2022 |
August 24, 2022 |
August 24, 2023 |
| Healthy U |
pharm-hu-045 |
Pulmozyme |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| Healthy U |
pharm-hu-047 |
Neupro |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-049 |
Off Label Use |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-051 |
Opioids - Chronic |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-052 |
Acute Opioid Use Policy |
September 01, 2022 |
August 24, 2022 |
August 24, 2023 |
| Healthy U |
pharm-HU-054 |
Osteoporosis Medications |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-056 |
Pharmacy Prior Authorization and Medical Necessity Policy |
March 08, 2024 |
March 05, 2024 |
March 05, 2025 |
| Healthy U |
pharm-hu-058 |
Phenylbutyrates |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| Healthy U |
pharm-hu-059 |
Phenylketonuria (PKU) |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-060 |
Promacta |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-HU-061 |
Psoriasis Retail & Medical Drugs |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-hu-062 |
Psoriatic Arthritis - Psoriatic Arthritis Retail & Medical Drugs |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-063 |
Pulmonary Hypertension (PH) Medications |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| Healthy U |
pharm-HU-065 |
Rheumatoid Arthritis Retail & Medical Drugs |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-066 |
Sandostatin LAR |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-067 |
Savella |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-068 |
Ocaliva |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| Healthy U |
pharm-hu-069 |
Spravato - Healthy U |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| Healthy U |
pharm-hu-070 |
Subcutaneous Methotrexate |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| Healthy U |
pharm-hu-071 |
Brand Statins |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-HU-073 |
Synagis |
October 07, 2023 |
October 03, 2023 |
October 03, 2024 |
| Healthy U |
pharm-HU-075 |
Ulcerative Colitis Retail & Medical Drugs |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-hu-077 |
VMAT - 2 Inhibitors |
June 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| Healthy U |
pharm-hu-078 |
Xifaxan |
March 1, 2023 |
February 17, 2023 |
February 17, 2024 |
| Healthy U |
pharm-hu-079 |
Xolair |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-hu-080 |
Pancreatic Enzymes |
December 01, 2022 |
November 21, 2022 |
November 21, 2023 |
| Healthy U |
pharm-HU-081 |
Benlysta |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-HU-082 |
Iron Chelation Therapy |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-083 |
Nuedexta |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-HU-086 |
Xhance |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-hu-087 |
Yupelri |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-088 |
Acute Migraine |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-089 |
Parkinson's Agents |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-090 |
Icosapent Ethyl |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| Healthy U |
pharm-hu-091 |
OFEV®, pirfenidone |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-094 |
Cablivi |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-099 |
Nexletol & Nexlizet |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-100 |
Prevymis |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-101 |
Humira for Uveitis |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-103 |
Pharmacy Continuity of Care |
March 22, 2023 |
March 18, 2023 |
March 18, 2024 |
| Healthy U |
pharm-hu-104 |
Cystadrops and Cystaran for Ocular Cystinosis |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-105 |
Istursia |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-107 |
Sunosi |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-108 |
Continuous Glucose Monitor (CGM) Retail Pharmacy |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-109 |
Signifor |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-HU-111 |
Descovy |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-112 |
Dojolvi |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-113 |
Nerlynx |
March 1, 2023 |
February 17, 2023 |
February 17, 2024 |
| Healthy U |
pharm-hu-115 |
Step Therapy |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| Healthy U |
pharm-hu-117 |
Evrysdi |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-118 |
Lupkynis |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-119 |
Cabenuva & Vocabria |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-127 |
Livtencity |
February 1, 2022 |
January 19, 2022 |
January 19, 2023 |
| Healthy U |
pharm-hu-128 |
Oxervate |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-HU-130 |
Leqvio |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-HU-131 |
Rezurock |
March 1, 2023 |
February 17, 2023 |
February 17, 2024 |
| Healthy U |
pharm-HU-132 |
Tavneous |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-134 |
Apretude |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-135 |
Brand Name Atopic Dermatitis Agents |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-142 |
Non-Radiographic Axial Spondyloarthritis (nrx-SpA) Retail & Medical Drugs |
September 01, 2022 |
August 24, 2022 |
August 24, 2023 |
| Healthy U |
pharm-hu-144 |
Nuucala |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-145 |
Hyftor |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-146 |
Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-147 |
Zoryve |
May 01, 2023 |
April 19, 2023 |
April 19, 2024 |
| Healthy U |
pharm-hu-148 |
Mounjaro and GLP-1s |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-149 |
Heavily Treated HIV |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-150 |
Hormone Therapy for Gender Dysphoria |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| Healthy U |
pharm-hu-152 |
Radicava |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-153 |
Posaconazole- Healthy U |
June 01, 2023 |
May 19, 2023 |
May 19, 2024 |
| Healthy U |
pharm-hu-156 |
Opzelura For Treatment Of Nonsegmental Vitiligo |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| Healthy U |
pharm-hu-157 |
Tezspire |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| Healthy U |
pharm-hu-159 |
Kevzara for Polymyalgia Rheumatica |
February 01, 2024 |
January 17, 2024 |
January 17, 2025 |
| Healthy U |
pharm-hu-m002 |
Intravenous Iron Therapy |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-m003 |
Kymriah |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| Healthy U |
pharm-HU-M004 |
Lutathera |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| Healthy U |
pharm-hu-m005 |
Ophthalmic Injections |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-HU-M006 |
Branded Denosumab Products (Prolia, Xgeva) |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-m007 |
Spinraza |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| Healthy U |
pharm-HU-M008 |
Testopel |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-M009 |
Yescarta |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| Healthy U |
pharm-HU-M010 |
Zilretta |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| Healthy U |
pharm-hu-m011 |
Xiaflex |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| Healthy U |
pharm-hu-m012 |
Zolgensma |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| Healthy U |
pharm-hu-m013 |
Soliris Ultomiris- Healthy U |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-m014 |
Brineura |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-M016 |
Tepezza |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| Healthy U |
pharm-hu-M027 |
Neuromyelitis Optica Spectrum Disorder (NMOSD) |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-M028 |
Akynzeo IV |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| Healthy U |
pharm-hu-m029 |
Krystexxa |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| Healthy U |
pharm-hu-m030 |
Medical Biosimilar Products |
August 01, 2022 |
May 18, 2022 |
May 18, 2023 |
| Healthy U |
pharm-hu-m031 |
Tecartus |
May 19, 2023 |
April 19, 2024 |
April 19, 2024 |
| Healthy U |
pharm-hu-M032 |
Vyepti |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-M033 |
Abecma |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-M034 |
Breyanzi |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-M035 |
Primary Hyperoxaluria Type 1 |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-m036 |
Ketamine |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| Healthy U |
pharm-hu-m037 |
Saphnelo |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| Healthy U |
pharm-HU-M039 |
Carvykti |
May 01, 2023 |
April 19, 2023 |
April 19, 2024 |
| Healthy U |
pharm-hu-m042 |
Zynteglo |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| Healthy U |
pharm-hu-m043 |
Lunsumio |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| Healthy U |
pharm-hu-m044 |
Tzield |
June 01, 2023 |
May 17, 2023 |
May 17, 2024 |
| Healthy U |
pharm-hu-m045 |
NPlate |
June 01, 2023 |
May 19, 2023 |
May 19, 2024 |
| Healthy U |
pharm-hu-m046 |
Myasthenia Gravis |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U |
pharm-hu-m047 |
Leqembi |
December 01, 2023 |
November 08, 2023 |
November 08, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m001 |
Hyaluronic Acid |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m002 |
Intravenous Iron Therapy |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m003 |
Kymriah |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m004 |
Lutathera |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m005 |
Ophthalmic Inhibitors- Commercial & Individual |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m005 |
Ophthalmic Inhibitors |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m006 |
Branded Denosumab Products (Prolia, Xgeva) |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m007 |
Spinraza |
June 01, 2024 |
May 22, 2024 |
May 22, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m008 |
Testopel |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m009 |
Yescarta |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m010 |
Zilretta |
July 01, 2022 |
June 21, 2022 |
June 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m011 |
Xiaflex- Commercial & Individual |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m012 |
Zolgensma |
November 01, 2022 |
October 26, 2022 |
October 26, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m013 |
Soliris Ultomiris- Mountain Health CO-OP, Commercial & Individual |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m014 |
Brineura |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m016 |
Tepezza |
October 01, 2023 |
September 13, 2023 |
September 13, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m017 |
Antineoplastics - Medical Infused Drugs |
September 01, 2021 |
August 18, 2021 |
August 18, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m018 |
Ankylosing Spondylitis- Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m019 |
Crohn’s Disease - Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m020 |
Hidradenitis Supperativa- Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m021 |
Juvenile Idiopathic Arthritis - Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m022 |
Psoriasis- Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m023 |
Psoriatic Arthritis- Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m024 |
Rheumatoid Arthritis-Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m025 |
Ulcerative Colitis - Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-M026 |
Place of Service for Pharmaceutical Infusions |
September 01, 2021 |
August 18, 2021 |
August 18, 2022 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m027 |
Neuromyelitis Optica Spectrum Disorder |
June 1, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m028 |
Akynzeo |
August 01, 2023 |
July 31, 2023 |
July 31, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m029 |
Krystexxa |
July 01, 2023 |
June 28, 2023 |
June 28, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-M030 |
Medical Biosimilar Products |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m031 |
Tecartus |
November 01, 2020 |
October 28, 2020 |
October 28, 2021 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m032 |
Vyepti |
June 1, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m033 |
Abecma |
June 1, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m034 |
Breyanzi |
June 1, 2022 |
May 18, 2022 |
May 18, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m035 |
Primary Hyperoxaluria Type 1 |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m036 |
Ketamine |
October 01, 2022 |
September 19, 2022 |
September 19, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m037 |
Saphnelo- Commercial & Individual |
March 01, 2023 |
February 17, 2023 |
February 17, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-M039 |
Carvykti |
April 01, 2022 |
March 16, 2022 |
March 16, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m041 |
Non-Radiographic Axial Spondyloarthritis (nrx-SpA) - Medical Infused Drugs |
January 01, 2023 |
November 21, 2022 |
November 21, 2023 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-M042 |
Zynteglo |
February 01, 2023 |
January 18, 2023 |
January 18, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m043 |
Lunsumio |
April 01, 2023 |
March 15, 2023 |
March 15, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m045 |
Nplate |
June 01, 2023 |
May 19, 2023 |
May 19, 2024 |
| UUHP Individual Commercial & Mountain Health CO-OP |
pharm-m046 |
Myasthenia Gravis |
April 01, 2024 |
March 27, 2024 |
March 27, 2025 |
| Healthy U CHIP |
PHARM-CHIP-001 |
Acne Vulgaris And Rosacea |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-002 |
Alpha-1-Proteinase-Inhibitors |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-003 |
Ankylosing Spondylitis Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-004 |
Anthelmintics |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-006 |
Antiemetics For Chemotherapy Induced Nausea And Vomiting |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-007 |
Antineoplastics - Retail |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-008 |
Aranesp |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-011 |
Basal Insulin |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-012 |
Retail Biosimilar Policy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-013 |
Brand Name Medications |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-014 |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Agents |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-015 |
Clostridium Difficile |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-016 |
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist For Migraine Prevention |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-017 |
Constipation Medications |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-019 |
Crohn's Disease Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-022 |
Dupixent For Asthma, Eosinophilic Esophagitis, Or Prurigo Nodularis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-024 |
Epidiolex |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-026 |
Gonadotropin Releasing Hormone Agonists And Antagonists |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-027 |
Growth Hormones: Adult |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-028 |
Growth Hormones: Child |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-030 |
Hepatitis C Direct Acting Antivirals |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-031 |
Hereditary Angioedema |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-032 |
Hidradenitis Suppurativa Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-033 |
Hyperkalemia |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-034 |
Irritable Bowel Syndrome With Diarrhea (IBS-D) |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-035 |
IL5 Receptor Antagonist For Asthma |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-036 |
Increlex |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-038 |
Chronic Insomina Medications |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-039 |
Interstitial Cystitis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-041 |
Juvenile Idiopathic Arthritis Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-043 |
Long Acting Tacrolimus |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-044 |
Multiple Sclerosis Agents |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-045 |
Pulmozyme |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-047 |
Neupro |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-049 |
Off Label Policy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-050 |
Opoid Dependance Agents |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-051 |
Chronic Opioid Medications |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-052 |
Acute Opioid Use |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-54 |
Osteoporosis Medications |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-056 |
Prior Authorization And Medical Necessity Policy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-058 |
Phenylbutyrates |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-059 |
Phenylketonuria (PKU) |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-060 |
Promacta |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-061 |
Psoriasis Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-062 |
Psoriatic Arthritis - Psoriatic Arthritis Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-063 |
Pulmonary Hypertension (PH) Medications |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-065 |
Rheumatoid Arthritis Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-066 |
Sandostatin LAR |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-067 |
Savella |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-068 |
Ocaliva |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-069 |
Spravato |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-070 |
Subcutaneous Methotrexate |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-071 |
Brand Statins |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-073 |
Synagis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-074 |
Topiramate ER Sprinkle Capsules |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-075 |
Ulcerative Colitis Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-078 |
Xifaxan |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-079 |
Xolair |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-080 |
Pancreatic Enzymes |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-081 |
Benlysta |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-082 |
Iron Chelation Therapy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-083 |
Nuedexta |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-086 |
Xhance |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-087 |
Yupelri |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-088 |
Acute Migraine |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-089 |
Parkinson's Agents |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-090 |
Icosapent Ethyl |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-091 |
OFEV®, Pirfenidone |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-094 |
Cablivi |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-099 |
Nexletol & Nexlizet |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-100 |
Prevymis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-101 |
Adalimumab for Uveitis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-103 |
Pharmacy Continuity of Care |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-104 |
Cystadrops And Cystaran For Ocular Cystinosis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-105 |
Istursia |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-107 |
Sunosi |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-108 |
Continuous Glucose Monitor (CGM) Retail Pharmacy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-109 |
Signifor |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-110 |
Hemophilia |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-111 |
Descovy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-112 |
Dojolvi |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-113 |
Nerlynx |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-115 |
Step Therapy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-117 |
Evrysdi |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-118 |
Lupkynis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-119 |
Cabenuva & Vocabria |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-127 |
Livtencity |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-128 |
Oxervate |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-130 |
Leqvio |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-131 |
Rezurock |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-132 |
Tavneous |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-134 |
Apretude |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-135 |
Brand Name Atopic Dermatitis Agents |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-142 |
Non-Radiographic Axial Spondyloarthritis (Nrx-SpA) Retail & Medical Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-144 |
Nuucala |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-145 |
Hyftor |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-146 |
Nasal Polyposis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-147 |
Zoryve |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-148 |
Mounjaro and GLP-1s |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-149 |
Heavily Treated HIV |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-150 |
Hormone Therapy For Gender Dysphoria |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-151 |
Formulary Exceptions |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-152 |
Radicava |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-153 |
Posaconazole |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-154 |
Beyfortus |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-156 |
Opzelura For Treatment Of Nonsegmental Vitiligo |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-157 |
Tezspire |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-158 |
Zurzuvae |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-159 |
Kevzara For Polymyalgia Rheumatica |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M002 |
Intravenous Iron Therapy |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M003 |
Kymriah |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M004 |
Lutathera |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M005 |
Ophthalmic Injections |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M006 |
Branded Denosumab Products (Prolia, Xgeva) |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M007 |
Spinraza |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M008 |
Testopel |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M011 |
Xiaflex |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M012 |
Zolgensma |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M013 |
Soliris, Ultomiris |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M014 |
Brineura |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M016 |
Tepezza |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M017 |
Antineoplastics - Medical Infused Drugs |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M026 |
Place of Service for Pharmaceutical Infusions |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M027 |
Neuromyelitis Optica Spectrum Disorder (NMOSD) |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M028 |
Akynzeo IV |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M029 |
Krystexxa |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M030 |
Medical Biosimilar Products |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M032 |
Vyepti |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M035 |
Primary Hyperoxaluria Type 1 |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M036 |
Ketamine |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M037 |
Saphnelo |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M042 |
Zynteglo |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M043 |
Lunsumio |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M044 |
Tzield |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M045 |
NPlate |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M046 |
Myasthenia Gravis |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |
| Healthy U CHIP |
PHARM-CHIP-M047 |
Leqembi |
July 01, 2024 |
July 01, 2024 |
July 01, 2025 |