| Effective Date | Policy Name | Reviewed Date |
| 6/16/2021 |
Abecma® (idecabtagene vicleucel)
| 8/19/2026 |
| 6/16/2021 |
Abecma® (idecabtagene vicleucel)
| 8/19/2026 |
| 1/1/2023 |
Abecma® (idecabtagene vicleucel)
| 8/19/2026 |
| 7/1/2024 |
Abecma® (idecabtagene vicleucel)
| 8/19/2026 |
| 1/1/2026 |
Abilify MyCite (aripiprazole tablets with sensor)
| 5/20/2026 |
| 1/1/2023 |
Abraxane (nab- paclitaxel)
| 9/17/2025 |
| 1/1/2023 |
Abraxane (nab-paclitaxel)
| 9/17/2025 |
| 11/1/2025 |
Abraxane (nab-paclitaxel)
| 9/17/2025 |
| 7/27/2022 |
Abuse Deterrent Oxycodone tablets (RoxyBond,Oxaydo, generics)
| 6/18/2025 |
| 1/1/2021 |
Acitretin
| 7/15/2026 |
| 1/1/2025 |
Actimmune® (interferon gamma-1b)
| 8/19/2026 |
| 1/1/2022 |
Actinic Keratosis Agents
| 11/19/2025 |
| 1/1/2026 |
Adakveo (crizanlizumab-tmca)
| 3/18/2026 |
| 1/1/2026 |
Adbry® (tralokinumab-ldrm)
| 5/20/2026 |
| 9/1/2011 |
Adcetris® (brentuximab vedotin)
| 4/15/2026 |
| 7/1/2026 |
Adcetris® (brentuximab vedotin)
| 4/15/2026 |
| 7/1/2026 |
Adcetris® (brentuximab vedotin)
| 4/15/2026 |
| 1/1/2026 |
Adempas® (riociguat)
| 5/20/2026 |
| 1/1/2024 |
Adlarity® (donepezil transdermal)
| 11/19/2025 |
| 9/4/2023 |
Adstiladrin (nadofaragene firadenovec-vncg)
| 6/17/2026 |
| 1/19/2024 |
Adstiladrin (nadofaragene firadenovec-vncg)
| 6/17/2026 |
| 12/15/2021 |
Aduhelm® (aducanumab-avwa)
| 11/19/2025 |
| 4/27/2022 |
Aduhelm® (aducanumab-avwa)
| 11/19/2025 |
| 4/24/2024 |
Adzynma (ADAMTS13, Recombinant-krhn)
| 7/15/2026 |
| 2/1/2026 |
Adzynma (ADAMTS13, recombinant-krhn)
| 7/15/2026 |
| 1/1/2024 |
Aemcolo™ (rifamycin)
| 1/21/2026 |
| 1/1/2026 |
Afinitor/Afinitor Disperz (everolimus)
| 2/18/2026 |
| 1/1/2025 |
Aflibercept Products
| 8/19/2026 |
| 8/26/2026 |
Aflibercept Products
| 8/19/2026 |
| 1/1/2023 |
Aflibercept Products (Eylea®, Eylea® HD, Pavblu™)
| 1/21/2026 |
| 3/1/2026 |
Aflibercept Products (Eylea®, Eylea® HD, Pavblu™)
| 1/21/2026 |
| 8/26/2026 |
Aflibercept Products (Yesafili™)
| 8/19/2026 |
| 12/31/2014 |
Afrezza® (insulin human) Inhalation Powder
| 10/15/2025 |
| 5/22/2024 |
Agamree® (vamorolone)
| 3/18/2026 |
| 1/1/2026 |
Akeega (niraparib and abiraterone acetate)
| 2/18/2026 |
| 1/1/2026 |
Akynzeo (fosnetupitant-palonosetron/netupitant- palonosetron)
| 6/17/2026 |
| 1/1/2013 |
Aldurazyme® (laronidase)
| 5/20/2026 |
| 1/1/2026 |
Alecensa (alectinib)
| 2/18/2026 |
| 4/23/2025 |
Alhemo® subcutaneous pen injector
| 2/18/2026 |
| 12/20/2017 |
Aliqopa™ (copanlisib)
| 7/15/2026 |
| 1/1/2026 |
Allergy Ophthalmics
| 8/20/2025 |
| 1/1/2026 |
Allergy Ophthalmics
| 6/17/2026 |
| 1/1/2026 |
Alpha-1 Proteinase Inhibitors (Aralast NP®, Glassia®, Prolastin-C®)
| 6/17/2026 |
| 1/1/2026 |
Alpha-1 Proteinase Inhibitors (Aralast NP®, Glassia®, Prolastin-C®, Zemaira®)
| 6/17/2026 |
| 1/1/2026 |
Alpha-1 Proteinase Inhibitors (Aralast NP®, Glassia®, Prolastin-C®, Zemaira®)
| 6/17/2026 |
| 1/1/2026 |
Alpha-1 Proteinase Inhibitors (Aralast NP®, Glassia®, Prolastin-C®, Zemaira®)
| 6/17/2026 |
| 1/1/2025 |
Alphagan® P (brimonidine)
| 3/18/2026 |
| 2/26/2025 |
Alternate nilotinib products (Danziten, Cavhanza, nilotinib tartrate-Cipla)
| 7/16/2026 |
| 1/1/2026 |
Alunbrig (brigatinib)
| 2/18/2026 |
| 8/28/2024 |
Alvaiz™ (eltrombopag choline) tablet
| 4/15/2026 |
| 1/1/2024 |
Amitiza® (lubiprostone)
| 11/19/2025 |
| 8/18/2021 |
Amivantamab Products (Rybrevant, Rybrevant Faspro)
| 1/21/2026 |
| 7/23/2025 |
Amivantamab Products (Rybrevant, Rybrevant Faspro)
| 1/21/2026 |
| 9/1/2025 |
Amivantamab Products (Rybrevant, Rybrevant Faspro)
| 1/21/2026 |
| 9/1/2025 |
Amivantamab Products (Rybrevant, Rybrevant Faspro)
| 1/21/2026 |
| 6/16/2021 |
Amondys 45 (casimersen)
| 12/10/2025 |
| 1/1/2020 |
Ampyra® (dalfampridine)
| 9/17/2025 |
| 5/28/2025 |
Amvuttra™ (vutrisiran)
| 3/18/2026 |
| 7/1/2025 |
Amvuttra™ (vutrisiran)
| 3/18/2026 |
| 7/23/2025 |
Amzeeq® (minocycline) Topical Foam
| 7/15/2026 |
| 7/23/2025 |
Andembry ® (garadacimab-gxii)
| 7/15/2026 |
| 1/1/2023 |
Angiotensin Blocking Agents
| 7/15/2026 |
| 6/26/2024 |
Anktiva (nogapendekin alfa inbakicept-pmln)
| 3/18/2026 |
| 6/1/2026 |
Anktiva (nogapendekin alfa inbakicept-pmln)
| 3/18/2026 |
| 6/1/2026 |
Anktiva (nogapendekin alfa inbakicept-pmln)
| 3/18/2026 |
| 1/1/2022 |
Anticholinergic Polypharmacy Agents
| 5/7/2026 |
| 10/1/2025 |
Anticholinergic Polypharmacy Agents - Louisiana Medicaid
| 9/11/2025 |
| 1/1/2019 |
Antipsychotic Utilization Program
| 6/4/2026 |
| 10/1/2025 |
Antipsychotic Utilization Program
| 7/24/2025 |
| 12/17/2025 |
Anzupgo® (delgocitinib)
| 12/10/2025 |
| 1/1/2026 |
Apokyn® (apomorphine)
| 1/21/2026 |
| 1/1/2024 |
Aptiom® (eslicarbazepine acetate)
| 3/18/2026 |
| 3/26/2025 |
Aqneursa™ (levacetylleucine)
| 2/18/2026 |
| 3/25/2026 |
Aqvesme (mitapivat) tablet
| 3/18/2026 |
| 1/1/2025 |
Aranesp® (darbepoetin alfa)
| 7/15/2026 |
| 4/3/2008 |
Arcalyst® (rilonacept)
| 12/10/2025 |
| 1/1/2020 |
Arikayce® (liposomal amikacin for inhalation)
| 7/15/2026 |
| 12/11/2019 |
Asparlas™ (calaspargase pegol-mknl)
| 7/15/2026 |
| 12/1/2025 |
Asparlas™ (calaspargase pegol-mknl)
| 7/15/2026 |
| 12/1/2025 |
Asparlas™ (calaspargase pegol-mknl)
| 7/15/2026 |
| 12/1/2025 |
Asparlas™ (calaspargase pegol-mknl)
| 7/15/2026 |
| 1/1/2026 |
Asthma Interleukin Inhibitors (Cinqair®, Nucala™, Fasenra®)
| 7/15/2026 |
| 1/1/2025 |
Atezolizumab products (Tecentriq, Tecentriq Hybreza)
| 7/15/2026 |
| 12/1/2025 |
Atezolizumab products (Tecentriq, Tecentriq Hybreza)
| 12/10/2025 |
| 12/1/2025 |
Atezolizumab products (Tecentriq, Tecentriq Hybreza)
| 12/10/2025 |
| 12/1/2025 |
Atezolizumab products (Tecentriq, Tecentriq Hybreza)
| 12/10/2025 |
| 1/1/2024 |
Atgam (antithymocyte immune globulin, equine)
| 6/17/2026 |
| 2/26/2025 |
Attruby™ (acoramidis)
| 3/18/2026 |
| 12/18/2024 |
Aucatzyl (obecabtagene autoleucel)
| 8/19/2026 |
| 2/28/2024 |
Augtyro (repotrectinib)
| 4/15/2026 |
| 1/1/2023 |
Auryxia® (ferric citrate)
| 2/21/2024 |
| 1/1/2022 |
Austedo® & Austedo® XR (deutetrabenazine)
| 6/17/2026 |
| 1/1/2026 |
Auvelity™ (dextromethorphan and bupropion)
| 5/20/2026 |
| 1/1/2025 |
Aveed® (testosterone undecanoate)
| 4/15/2026 |
| 5/27/2026 |
Avlayah™ (tividenofusp alfa-eknm) solution
| 5/20/2026 |
| 8/1/2026 |
Avlayah™ (tividenofusp alfa-eknm) solution
| 5/20/2026 |
| 8/1/2026 |
Avlayah™ (tividenofusp alfa-eknm) solution
| 5/20/2026 |
| 7/23/2025 |
Avmapki (avutometinib)-Fakzynja (defactinib) Co-Pack
| 5/20/2026 |
| 1/1/2026 |
Ayvakit (avapritinib)
| 3/18/2026 |
| 10/17/2018 |
Azedra® (iobenguane I 131)
| 12/10/2025 |
| 1/1/2025 |
Azopt® (brinzolamide ophthalmic suspension)
| 3/18/2026 |