01.05.03 |
Restricted Use
|
 |
Adalimumab Amgevita®, Humira®, Imraldi® |
10.01.03 |
Restricted Use
|
 |
Adalimumab Amgevita®, Humira®, Imraldi® |
13.05.03 |
Restricted Use
|
 |
Adalimumab Amgevita®,Humira®, Imraldi® |
04.09.03 |
Restricted Use
|
 |
Botulinum Toxin Dysport®, Botox®, Neurobloc®, |
04.07.04.02 |
Restricted Use
|
 |
Botulinum Toxin Type A botox® |
08.01.05 |
Restricted Use
|
 |
Brentuximab vedotin Adcetris® |
10.01.03 |
Restricted Use
|
 |
Certolizumab Pegol Cimzia® |
06.01.06 |
Restricted Use
|
 |
Continuous Glucose Monitoring (CGM) System |
10.01.03 |
Restricted Use
|
 |
Etanercept Enbrel®,Benepali® |
13.05.03 |
Restricted Use
|
 |
Etanercept Enbrel®, Benepali® |
06.01.06 |
Restricted Use
|
 |
Flash Glucose Scanning (FGS) System Freestyle Libre® |
01.05.03 |
Restricted Use
|
 |
Infliximab Flixabi®, Inflectra® |
10.01.03 |
Restricted Use
|
 |
Infliximab Remsima®, Inflectra®, Remicade®, Flixabi® |
13.05.03 |
Restricted Use
|
 |
Infliximab Remsima®, Inflectra®,Remicade® Flixabi® |
10.01.03 |
Restricted Use
|
 |
Rituximab (rheumatology) MabThera®, Truxima® |