| Guideline | Drug Name |
|---|---|
| Hemophilia B Gene Therapies - PA, NF | Beqvez (fidanacogene elaparvovec-dzkt), Hemgenix (etranacogene dezaparvovec-drlb) |
| Hereditary Angioedema Agents (HAE) Quantity Limit Override | Berinert (C1 esterase inhibitor [Human]), Firazyr (icatibant), Kalbitor (ecallantide), Ruconest (C1 esterase inhibitor [Recombinant]), Sajazir (icatibant) |
| Hereditary Angioedema Agents - PA, NF | Berinert (C1 esterase inhibitor [Human]), Cinryze (C1 esterase inhibitor [Human]), Firazyr (icatibant), Haegarda (C1 esterase inhibitor [Human]), Kalbitor (ecallantide), Orladeyo (berotralstat), Ruconest (C1 esterase inhibitor [Recombinant]), Sajazir (icatibant), Takhzyro (lanadelumab-flyo) |
| Hetlioz, Hetlioz LQ (tasimelteon) - PA, NF | Hetlioz (tasimelteon) capsule, Hetlioz LQ (tasimelteon) suspension |
| High Cost, Low Value Non-Formulary Program | ABSORICA, ABSORICA LD, ACZONE, ADAPALENE, ANUSOL-HC, ARAZLO, ATOPADERM, AZESCO, BENSAL HP, CABTREO, CHLORZOXAZONE, COXANTO, DICLOFENAC EPOLAMINE, DORYX, DORYX MPC, DOXEPIN HYDROCHLORIDE, DUEXIS, EPICERAM, FENOPROFEN CALCIUM, FLECTOR, FLUOVIX, FLUOVIX PLUS, FOLIC-K, GENICIN VITA-S, IBUPROFEN/FAMOTIDINE, INDERAL XL, INNOPRAN XL, KAMDOY, KELARX, LICART, LIDOCAINE AND TETRACAINE CREAM, LIDOCAINE/TETRACAINE, NAPROSYN, NAPROXEN/ESOMEPRAZOLE MAGNESIUM, ORACEA, ORTHO DF, OXAPROZIN, PENNSAID, PLIAGLIS, POKONZA, PREGENNA, PRODIGEN, PROMETHAZINE HYDROCHLORIDE, PROMETHAZINE HYDROCHLORIDE PLAIN, PROMETHAZINE VC, PRUDOXIN, RAYOS, RELAFEN DS, SAJAZIR, SITAVIG, SPRIX, TOLSURA, VIMOVO, WINLEVI, XERESE, XHANCE, YOSPRALA, ZIPSOR, ZONALON, ZORVOLEX, ZTLIDO, ZYCLARA, ZYCLARA PUMP, ZYFLO |
| High Dollar/Claim Dollar | Claim, Dollar, High |
| High-Cost Brand with Generics Program | |
| Horizant (gabapentin enacarbil) | Horizant (gabapentin enacarbil) |
| Human Chorionic Gonadotropin (hCG) | Novarel (chorionic gonadotropin), Pregnyl (chorionic gonadotropin), Ovidrel (chorionic gonadotropin) PreFilled Syringe |
| Hyaluronic Acid Derivatives - PA, NF | Durolane/Euflexxa/Hyalgan/Sodium Hyaluronate/Supartz FX/Gelsyn-3/Genvisc 850/Triluron/TriVisc/Visco-3 (sodium hyaluronate), Gel-One (cross-linked hyaluronate), Monovisc/Orthovisc/Hymovis (hyaluronan), Synvisc/Synvisc-One (hylan), Synojoynt |
| Hyftor (sirolimus) topical gel | Hyftor (sirolimus) topical gel |
| Hympavzi (marstacimab-hncq) | Hympavzi (marstacimab-hncq) |
| Ibrance (palbociclib) | Ibrance (palbociclib) |
| IBS - Diarrhea | Lotronex (alosetron hydrochloride), Viberzi (eluxadoline) |
| Ibsrela (tenapanor) - PA, NF | Ibsrela (tenapanor) |
| Iclusig (ponatinib) | Iclusig (ponatinib) |
| Idhifa (enasidenib) | Idhifa (enasidenib) |
| iDose TR (travoprost intracameral implant) | iDose TR (travoprost intracameral implant) |
| Igalmi (dexmedetomidine) | Igalmi (dexmedetomidine) |
| Ilaris (canakinumab injection) | Ilaris (canakinumab injection) |
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