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  • Analgesics
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  • Anti-Addiction/Substance Abuse Treatment Agents
  • Antibacterials
  • Anticonvulsants
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  • Antimycobacterials
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  • Antipsychotics
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  • Anxiolytics
  • Bipolar Agents
  • Blood Glucose Regulators
  • Blood Products/Modifiers/Volume Expanders
  • Cardiovascular Agents
  • Central Nervous System Agents
  • Dental And Oral Agents
  • Dermatological Agents
  • Electrolytes/Minerals/Metals/Vitamins
  • Gastrointestinal Agents
  • Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment
  • Genitourinary Agents
  • Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
  • Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
  • Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
  • Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
  • Hormonal Agents, Suppressant (Pituitary)
  • Hormonal Agents, Suppressant (Thyroid)
  • Immunological Agents
  • Inflammatory Bowel Disease Agents
  • Metabolic Bone Disease Agents
  • Miscellaneous
  • Ophthalmic Agents
  • Otic Agents
  • Respiratory Tract Agents
  • Skeletal Muscle Relaxants
  • Sleep Disorder Agents
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Formulary Id: 20548, 20550
Formulary Effective Date: 12/01/2020
Updated:
11/2020
CMS Approval Date:
11/24/2020
CMS Version:
17

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