| Effective Date | Policy Name | Reviewed Date |
| 1/1/2013 |
Naglazyme® (galsulfase)
| 3/18/2026 |
| 1/1/2026 |
Namzaric (memantine-donepezil ER)
| 8/20/2025 |
| 1/1/2026 |
Namzaric (memantine-donepezil ER)
| 8/19/2026 |
| 11/27/2024 |
Neffy® (epinephrine nasal spray)
| 8/19/2026 |
| 1/1/2026 |
Nemluvio® (nemolizumab-ilto)
| 8/19/2026 |
| 6/24/2026 |
Nereus (tradipitant) capsule
| 6/17/2026 |
| 1/1/2021 |
Nerlynx (neratinib)
| 12/11/2025 |
| 1/1/2026 |
Nexavar (sorafenib)
| 3/18/2026 |
| 10/26/2022 |
Nexiclon™ XR (clonidine ER) tablet
| 9/17/2025 |
| 10/20/2021 |
Nexviazyme™ (avalglucosidase alfa-ngpt) Injection
| 5/20/2026 |
| 5/27/2026 |
Nexviazyme™ (avalglucosidase alfa-ngpt) Injection
| 5/20/2026 |
| 5/28/2025 |
Niktimvo™ (axatilimab-csfr)
| 4/15/2026 |
| 7/1/2026 |
Niktimvo™ (axatilimab-csfr)
| 4/15/2026 |
| 1/1/2026 |
Nilotinib products (Tasigna, nilotinib)
| 4/15/2026 |
| 1/1/2022 |
Ninlaro® (ixazomib)
| 12/11/2025 |
| 1/1/2025 |
Nivolumab products (Opdivo, Opdivo Qvantig)
| 6/17/2026 |
| 9/1/2026 |
Nivolumab products (Opdivo, Opdivo Qvantig)
| 6/17/2026 |
| 9/1/2026 |
Nivolumab products (Opdivo, Opdivo Qvantig)
| 6/17/2026 |
| 9/1/2026 |
Nivolumab products (Opdivo, Opdivo Qvantig)
| 6/17/2026 |
| 6/3/2020 |
Non-FDA Approved Medications
| 1/21/2026 |
| 10/1/2025 |
Non-FDA Approved Medications
| 9/18/2025 |
| 10/1/2025 |
Non-FDA Approved Medications
| 1/21/2026 |
| 1/1/2019 |
Non-Formulary Exceptions
| 6/16/2026 |
| 1/1/2026 |
Non-preferred adalimumab products
| 6/17/2026 |
| 1/1/2024 |
Non-Preferred Continuous Glucose Monitoring Systems
| 8/19/2026 |
| 7/1/2024 |
Non-Preferred Exceptions
| 7/24/2025 |
| 1/1/2020 |
Non-Preferred Exceptions
| 6/4/2026 |
| 1/1/2026 |
Non-Preferred Filgrastim Products
| 1/21/2026 |
| 1/1/2026 |
Non-Preferred Filgrastim Products: Neupogen, Nypozi, Releuko, Filkri
| 1/21/2026 |
| 1/1/2026 |
Non-Preferred GLP-1 Agonists and GLP-1/GIP Agonists
| 6/17/2026 |
| 1/1/2024 |
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq)
| 5/20/2026 |
| 1/1/2024 |
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq), Remicade (infliximab), unbranded Infliximab
| 6/17/2026 |
| 7/1/2024 |
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq), Remicade (infliximab), unbranded Infliximab
| 6/17/2026 |
| 1/1/2026 |
Non-Preferred Multiple Sclerosis Injectable Products
| 6/18/2025 |
| 1/1/2026 |
Non-Preferred Multiple Sclerosis Injectable Products
| 4/15/2026 |
| 1/1/2026 |
Non-Preferred Oral Multiple Sclerosis Products
| 6/18/2025 |
| 1/1/2026 |
Non-Preferred Oral Multiple Sclerosis Products
| 4/15/2026 |
| 1/1/2026 |
Non-Preferred Pegfilgrastim Products
| 2/18/2026 |
| 1/1/2026 |
Non-Preferred Pegfilgrastim Products
| 2/18/2026 |
| 1/1/2026 |
Non-preferred Pegfilgrastim Products: Fylnetra, Nyvepria, Stimufend, Ziextenzo
| 2/18/2026 |
| 1/1/2025 |
Non-Preferred Testosterone Products
| 4/15/2026 |
| 1/1/2026 |
Non-preferred Ustekinumab Products
| 5/20/2026 |
| 1/1/2026 |
Nonsteroidal Anti-Inflammatory Drug Products
| 7/15/2026 |
| 1/1/2018 |
Northera® (droxidopa)
| 11/19/2025 |
| 1/1/2022 |
Nourianz™ (istradefylline)
| 11/19/2025 |
| 1/1/2014 |
Novarel®, Pregnyl® (human chorionic gonadotropin)
| 5/20/2026 |
| 1/20/2017 |
NovoSeven RT and SevenFact (Recombinant Activated Factor VIIa)
| 4/15/2026 |
| 1/1/2025 |
Noxafil® (posaconazole)
| 9/17/2025 |
| 1/1/2021 |
Nplate® (romiplostim)
| 7/15/2026 |
| 1/1/2026 |
Nubeqa (darolutamide)
| 8/19/2026 |
| 1/1/2026 |
Nucynta IR (tapentadol) tablet
| 3/18/2026 |
| 1/1/2022 |
Nuedexta® (dextromethorphan and quinidine)
| 3/18/2026 |
| 8/26/2026 |
Nufymco™ (ranibizumab-leyk)
| 8/19/2026 |
| 6/16/2021 |
Nulibry™ (fosdenopterin)
| 8/19/2026 |
| 1/1/2026 |
Nulibry™ (fosdenopterin)
| 8/19/2026 |
| 1/1/2021 |
Nuplazid® (pimavanserin)
| 2/18/2026 |
| 1/1/2025 |
Nurtec® ODT (rimegepant)
| 4/15/2026 |
| 1/1/2024 |
Nurtec™ ODT (rimegepant)
| 3/20/2024 |
| 1/1/2018 |
Nuvigil® (armodafinil)
| 11/19/2025 |