● glyburide DiaBeta, Micronase, ● glyburide/metformin Glucovance ● metformin Glucophage Insulin Detemir Levemir Insulin Detemir Soln Pen-injector Levemor Flextouch Insulin Glargine Lantus Insulin Glargine Soln Pen-Injector Lantus Solostar Insulin Aspart Novolog Insulin Aspart Soln Cartridge Novolog Penfill Insulin Aspart Soln Pen-injector Novolog Flexpen Insulin Lispro Humalog Insulin Lispro Soln Pen-injector Humalog Junior Kwikpen Insulin Lispro Soln Pen-injector Humalog Kwikpen Insulin NPH (Human) (Isophane) Inj Humulin N Insulin NPH (Human) (Isophane) Inj Novolin N Insulin NPH (人)(异物架)涉及笔记本novolin n flexpen胰岛素NPH和常规涉及PEN-INJ(70-30)HUMULIN 70/30 KWIKPEN胰岛素NPH Isophane&常规人Inj(70-30)笔入(70-30)Novolog Mix 70/30 Prefl
eTanercept parcipateus ind;依那耐皮下溶液预填充注射器; Etanercept皮下溶液自动注射器; Etanercept皮下溶液墨盒
氢可酮 - 对乙酰氨基酚Soln PO 108 mg/5ml-2.5 mg/5ml,217 mg/10ml-5 mg/10ml,325 mg/15ml- 7.5 mg/15ml
抗糖尿病层1- acarbose tab(previv)β阻滞剂1- acebutolol cap(Acebutolol Cap(e e e epiv)镇痛药 - 阿片类药物2 QL乙酰氨基酚/咖啡因/咖啡因/咖啡因/二氢可源性drocoseine tabs/for for 20或for for 20或for for 20或for for 20或for 20年龄; 90 days) ANALGESICS - OPIOID Tier 1 QL acetaminophen/codeine tab (TYLENOL/CODEINE equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days) MIGRAINE PRODUCTS Tier 1 - acetaminophen/isometheptene/dichloral cap (MIDRIN equiv) MIGRAINE PRODUCTS Tier 2 - ACETAMINOPHEN/ISOMETHEPTENE/DICHLORAL CAP DIURETICS Tier 1 - acetazolamide ER cap (DIAMOX SEQUEL equiv) DIURETICS Tier 1 - acetazolamide tab OTIC AGENTS Tier 1 - acetic acid otic soln (VOSOL equiv) OTIC AGENTS Tier 1 - ACETIC ACID/ALUMINUM ACETATE OTIC SOLN COUGH/COLD/ALLERGY第1层 - 乙酰半胱氨酸溶液(Mucomyst Equiv)皮肤病学层2型抗凝集素帽(Soriatane Equiv)(阶梯疗法)需要对Adapalene,Adapalene/Adapalene/Adapalene/Benzoyl过氧化物或维美替诺蛋白)进行试验。Tier 2专业LD-PA ACTHAR HP凝胶ING(仅通过Accredo 800-803-2523或Walgreens 888-347-3416)内分泌和代谢剂 - Misc。Tier 2专业LD-PA Acthar Inj 80unit(仅通过认证800-803-2523或Walgreens 888-347-3416)咳嗽/冷/冷/过敏2 Ql actier 2 ql actier液体液体(Ql = 1200ml/30天) Acuvail Ophth Soln抗病毒药层1-阿塞克洛维尔帽(Zovirax equiv)皮肤病学系列2- acyclovir Cream(Zovirax equiv)
703448001 HAVRIX JUNIOR S/DOSE 0.5ML 甲型肝炎疫苗注射 720 EL 单位/0.5ML 700513001 AVAXIM PREF SYR 80 0.5ML 甲型肝炎疫苗注射 80 单位/0.5ML 873179005 HEPACCINE-B PAED SINGLE D 乙型肝炎疫苗注射 3 MCG/ML 701658001 HEBERBIOVAC HB SGL D 0.5ML 乙型肝炎疫苗 (重组) SUSP 10 MCG/0.5M 700356001 ENGERIX-B PAED MONODOSE 乙型肝炎疫苗 (重组) 10 MCG/0.5ML 700210001 ENGERIX-B 新单剂量 20MCG 乙肝疫苗 (重组) 20 MCG/ML 701659001 HEBERBIOVAC HB SGL D 1ML PA 乙肝疫苗 (重组) 20 MCG/ML 713048002 EUVAX B 小瓶 20MCG/ML 乙肝疫苗 (重组) 20 MCG/ML 715349001 EUVAX B 小瓶 20MCG/ML 乙肝疫苗 (重组) 20 MCG/ML 700210002 ENGERIX-B 新单剂量 20MCG 1 乙肝疫苗 (重组) 20 MCG/ML 713048001 EUVAX B VIAL 20MCG/ML 疫苗 乙肝疫苗(重组) 20 MCG/ML 722290001 MEASBIO 多剂量粉剂 VIAL 麻疹病毒疫苗(INJ) 3002554002 麻疹疫苗 CIPLA VIAL POW 麻疹病毒疫苗(INJ) 3002554001 麻疹疫苗 CIPLA VIAL POW 麻疹病毒疫苗(INJ) 823678008 OPV-MERIEUX 10 剂量脊髓灰质炎病毒疫苗,口服活疫苗溶液 823686019 OPV-MERIEUX 20 剂量脊髓灰质炎病毒疫苗,口服活疫苗溶液841307016 OPV-MERIEUX 10 剂量塑料脊髓灰质炎疫苗,活口服溶液
阿扎那韦 (REYATAZ)* 阿扎那韦/考比司他 (EVOTAZ) 比克替拉韦/恩曲他滨/替诺福韦 (BIKTARVY) 卡博特韦/利匹韦林 (CABENUVA/VOCABRIA) PA 考比司他 (TYBOST) 达芦那韦 (PREZISTA) ST2 达芦那韦/考比司他 (PREZCOBIX) 达芦那韦/考比司他/替诺福韦/恩曲他滨 (SYMTUZA) 地拉韦定 (RESCRIPTOR) 地达诺辛 (VIDEX EC*, VIDEX soln) 多替拉韦/利匹韦林 (JULUCA) 多替拉韦/拉米夫定 (DOVATO) 多拉韦林 (PIFELTRO) 多拉韦林/拉米夫定/替诺福韦 (DELSTRIGO) 依法韦仑 (SUSTIVA) 依法韦仑/恩曲他滨/替诺福韦(ATRIPLA)* Efavirenz/lamivudine/tenofovir (SYMFI, SYMFI LO) Elvitegravir/Cobicistat/Emtricitabine/Tenofovir (STRIBILD, GENVOYA) ST1 Emtricitabine (EMTRIVA, EMTRIVA soln*) Emtricitabine/tenofovir (TRUVADA, DESCOVY) Emtricitabine/rilpivirine/tenofovir (COMPLERA) Enfuvirtide (FUZEON), QL Etravirine (INTELENCE) Fosamprenavir (LEXIVA) Fostemsavir (RUKOBIA) Ibalizumab (TROGARZO) PA Indinavir (CRIXIVAN) Lamivudine (EPIVIR)* Lamivudine/tenofovir (CIMDUO) Lamivudine/zidovudine (COMBIVIR)* Lencapavir (SUNLENCA) PA Lopinavir/Ritonavir (KALETRA) 马拉维若 (SELZENTRY) 奈非那韦 (VIRACEPT) 奈韦拉平 (VIRAMUNE)* 雷替拉韦 (ISENTRESS) 利匹韦林 (EDURANT) 利匹韦林/恩曲他滨/替诺福韦 (ODEFSEY) 利托那韦 (NORVIR) ST1 沙奎那韦 (INVIRASE) ST2 司他夫定 (ZERIT)* 替诺福韦 (VIREAD、VEMLIDY)* 替拉那韦 (APTIVUS)、ST2 齐多夫定 (RETROVIR)*
塞来昔布 QL 酮咯酸片 QL Anaprex ® 酮洛芬 1% 双氯芬酸凝胶 QL 美洛昔康片 Celebrex ® QL 酮咯酸鼻喷雾剂 PA 双氯芬酸 50mg 片 萘丁美酮 Daypro ® 甲氯芬那酸 双氯芬酸片 DR 萘普生片(处方药和非处方药) 双氯芬酸胶囊 PA 甲芬那酸 双氯芬酸片 ER Pennsaid ® PA 双氯芬酸小袋 PA 美洛昔康悬浮液和胶囊 PA, QL 布洛芬(处方药和非处方药) 舒林酸 双氯芬酸贴剂 PA, QL Mobic ® 吲哚美辛 双氯芬酸钾 25mg 片 PA Motrin ® 吲哚美辛 ER 双氯芬酸钾 50mg 片 Nalfon ® 双氯芬酸钠片 Naprelan ® 双氯芬酸溶液 PA Naprosyn ® EC-Naprosyn ® 萘普生混悬剂 Elyxyb ® PA, QL 萘普生钠 ER 依托度酸 萘普生 CR 依托度酸 ER 奥沙普秦 Feldene ® 吡罗昔康 非诺洛芬 Relafen DS ® Flector ® PA, QL Sprix ® PA, QL 氟比洛芬 托美汀 Licart ® Toradol ® QL Lofena ® PA Zipsor® Zorvolex® PA
当前审查日期:01/14/2025不需要PA第一代Divalproex片/er Divalproex撒上Ethosuximide felbamate felbamate schytoin capsule/悬浮甲氧二酰胺苯二酰胺苯二甲阵阵态chew tab chehytoin ext to ext capsule ext Capsule(gen egytek)胶囊/悬浮剂DiLantin咀嚼片Felbatol甲莫林苯酚苯甲蛋白胶囊/糖浆第二代LACOSAMIDE溶液lamotrigine单位剂量soln briviact lacosamide lacosamide lacotrigine lamotrigine xr Levetiracetam er Fycompa topiramate片剂/撒布Rufinamide悬浮液/XR * Zonisamide rufinamide片剂lamictal/odt/odt/xr/ds tiagabine tiagabine libervant topim topim topim er motpolotate er topolotpoly xr vig vigabatrin vig qudexim vig qudim vigim vig qudim aptrAd sprrad sprrict sprrict s sababatrilin s sababatrilin s sababatrilin sababatrilin平板电脑/洒水 * banzel trokendi xr vigafyde解决方案nr
当前审查日期:01/14/2025不需要PA第一代Divalproex片/er Divalproex撒上Ethosuximide felbamate felbamate schytoin capsule/悬浮甲氧二酰胺苯二酰胺苯二甲阵阵态chew tab chehytoin ext to ext capsule ext Capsule(gen egytek)胶囊/悬浮剂DiLantin咀嚼片Felbatol甲莫林苯酚苯甲蛋白胶囊/糖浆第二代LACOSAMIDE溶液lamotrigine单位剂量soln briviact lacosamide lacosamide lacotrigine lamotrigine xr Levetiracetam er Fycompa topiramate片剂/撒布Rufinamide悬浮液/XR * Zonisamide rufinamide片剂lamictal/odt/odt/xr/ds tiagabine tiagabine libervant topim topim topim er motpolotate er topolotpoly xr vig vigabatrin vig qudexim vig qudim vigim vig qudim aptrAd sprrad sprrict sprrict s sababatrilin s sababatrilin s sababatrilin sababatrilin平板电脑/洒水 * banzel trokendi xr vigafyde解决方案nr
MSCI USA INDEX 新增 删除 4D MOLECULAR 908 DEVICES AFFIRM HOLDINGS A AECOM ALTA EQUIPMENT GROUP ALTO INGREDIENTS INC ARDELYX AMMO ARHAUS A AXON ENTERPRISE BIOHAVEN BARK BLUE BIRD (US) BEACHBODY COMPANY A BLUEGREEN VAC HLD BIOVENTUS COMPASS THERAPEUTICS CARDLYTICS CYMABAY THERAPEUTICS CELULARITY DISTRIBUTION SOLN GRP CONTAINER STORE GROUP EVERQUOTE A EASTMAN KODAK F&G ANNUITIES & LIFE EDGIO FTAI AVIATION F45 TRAINING HOLDINGS HASHICORP A GENEDX HOLDINGS A IVANHOE ELECTRIC GENERATION BIO JANUX THERAPEUTICS GOSSAMER BIO LINCOLN NATIONAL CORP GRACO LUMEN TECHNOLOGIES GREENLIGHT BIOSCIENCES OIL STATES INTERNATIONAL HELIOGEN POSEIDA THERAPEUTICS HONEST COMPANY PRIME MEDICINE HUMACYTE A SATIXFY COMMUNICATIONS INDUSTRIAL LOGIS PPTYS SENTINELONE INC A INNOVID A SIGHT SCIENCES INOTIV SYMBOTIC A LANDS' END TIPTREE LORDSTON MOTORS CORP A VIKING THERAPEUTICS MARKFORGED HOLDING WESTERN UNION MEIRAGTX HOLDINGS ZYMEWORKS (US) NEXTNAV ZYNEX NKARTA OCUGEN OPTIMIZERX PLAYTIKA HOLDING CORP QUANTUM-SI A RELIANCE STEEL & ALUM SARCOS TECH & ROBO CORP SKILLSOFT A SKILLZ 纹身厨师 TORO CO TUPPERWARE BRANDS 联合治疗公司 VERA THERAPEUTICS A WW INTERNATIONAL Y MABS THERAPEUTICS