Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
B
- Beovu (brolucizumab)
- Beovu (brolucizumab)
- Botox (onabotulinumtoxinA) - Archived 01/01/2025
- Botox (onabotulinumtoxinA) - Archived on 04/01/2024
- Botox (onabotulinumtoxinA) - Archived on 1/13/2023
- Breyanzi (lisocabtagene maraleucel)
- Brineura (cerliponase alfa)
- Brineura (cerliponase alfa) - Archived on 1/13/2023
C
D
E
F
G
I
K
L
M
- Macrilen (macimorelin) - Archived on 04/01/2024
- Macrilen (macimorelin) - Archived on 08/16/2024
- Macugen (pegaptanib)
- Macugen (pegaptanib) - Archived on 09/10/2024
- Medical Necessity – Off Label - Archived on 10/01/2024
- Medical Necessity for DAW - Archived on 10/01/2024
- Medical Necessity for Non-Formulary Medications - Archived on 10/01/2024
- Myobloc (rimabotulinumtoxinB)
- Myobloc (rimabotulinumtoxinB) - Archived on 1/13/2023
O
P
Q
R
- Reblozyl (luspatercept-aamt) - Archived on 07/01/2024
- Retisert (fluocinolone acetonide) - Archived on 04/01/2024
- Rituxan (rituximab) - Archived on 1/13/2023
- Rituxumab (Rituxan*, Truxima, Ruxience, Riabni) - Archived on 04/01/2024
- Rivfloza (nedosiran) - Archived on 10/01/2024
- Ruzurgi (amifampridine) - Archived on 09/10/2024
S
T
U
V
- Vabysmo (faricimab-svoa) - Archived on 04/01/2024
- Visudyne (verteporfin) - Archived on 04/01/2024
- Vyepti (eptinezumab-jjmr) - Archived on 10/01/2024
- Vyvgart (efgartigimod alfa-fcab) - Archived on 1/13/2023
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) - Archived on 01/01/2025