Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
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A
- Abatacept (Orencia) Injection
- Actemra (tocilizumab)
- Actemra (tocilizumab)
- Aimovig (erenumab-aooe)
- Aimovig (erenumab-aooe)
- Ajovy (fremanezumab-vfrm)
- Alpha 1-Proteinase Inhibitor Injection
- Alunbrig (brigatinib)
- Amevive (alefacept)
- Ampyra (dalfampridine)
- Anakinra (Kineret) Injection
- Antihemophilic Agents
- Asthma and COPD Management
- Aubagio (teriflunomide)
- Austedo (deutetrabenazine)
- Austedo (deutetrabenazine)
- Avonex (interferon beta-1a)
B
C
- Calcium Regulators (Reclast, Zometa, Boniva, Prolia, Forteo, Xgeva)
- Calquence
- Cholesterol Lowering Agents for Homozygous Familial Hypercholesterolemia
- Cimzia (certolizumab pegol)
- Cimzia (certolizumab pegol)
- Cinryze (C1 esterase inhibitor (human))
- Copaxone (glatiramer acetate)
- Cosentyx (secukinumab)
- Crysvita (burosumab-twza)
- Cystic Fibrosis
- Cytomegalovirus Immune Globulin Intravenous (Cytogam)
D
E
- Emflaza (deflazacort)
- Emgality (galcanezumab-gnlm)
- Enbrel (etanercept)
- Entyvio (vedolizumab)
- Enzyme Replacement Therapy and Agents
- Epclusa (sofosbuvir/velpatasvir)
- Epclusa (sofosbuvir/velpatasvir)
- Euflexxa (sodium hyaluronate)
- Exondys 51 (eteplirsen)
- Exondys 51 (eteplirsen)
- Extavia (interferon beta-1b)
F
G
H
- Haegarda (C1 inhibitor (human))
- Harvoni (ledipasvir/sofosbuvir)
- Harvoni (ledipasvir/sofosbuvir)
- Hematopoietic Growth Factors
- Hematopoietic Growth Factors
- Hemophilic Agents
- Hemophilic Agents
- Hepatitis C - Oral
- Hereditary Angioedema and Pharmacotherapy
- Hereditary Angioedema and Pharmacotherapy
- Humira (adalimumab)
- Hyalgan (sodium hyaluronate)
- Hyaluronic Acid Derivative Injection
- Hymovis (sodium hyaluronate)
- Hyperlipidemia Management Policy
I
- Ibrance (palbociclib)
- Idiopathic Pulmonary Fibrosis
- Ilaris (canakinumab)
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Ilumya (tildrakizumab-asmn)
- Imfinzi (durvalumab)
- Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
- Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
- Immune Globulin (IVIG)
- Immune globulin (IVIG)
- Inflammatory Bowel Disease: Biological Therapies
- Ingrezza (valbenazine)
- Ingrezza (valbenazine)
K
L
M
- Mavyret (glecaprevir and pibrentasvir)
- Mavyret (glecaprevir and pibrentasvir)
- Medical Necessity for Physician Dispense as Written (DAW) Requests
- Medication Assisted Therapy (buprenorphine containing agents)
- Medication Assisted Therapy (MAT) for Suboxone
- Monovisc (sodium hyaluronate)
- Multiple Sclerosis Therapy Class
N
O
P
- Parenteral Calcium Regulators - pamidronate (Aredia), zoledronic acid (Reclast and Zometa), ibandronate (Boniva), denosumab (Prolia and Xgeva), teriparatide (Forteo)
- Pegylated and Non-Pegylated Interferon
- Plegridy (peginterferon beta-1a)
- Promacta (eltrombopag)
- Proton Pump Inhibitors (PPIs)
- Provenge
- Psoriasis: Biological Therapies
- Pulmonary Arterial Hypertension
R
S
- Seizure Disorders (Repository Corticotropin Injection (H.P. Acthar Gel) and Vigabatrin (Sabril) Oral Solution and Tablets)
- Short Bowel Syndrome (Gattex, Zorbtive)
- Siliq (brodalumab)
- Simponi (golimumab)
- Simponi Aria (golimumab)
- Simponi Aria (golimumab)
- Somatropin Injection
- Sovaldi (sofosbuvir)
- Sovaldi (sofosbuvir)
- Sovaldi (sofosbuvir)
- Spinraza (nusinersen)
- Spinraza (nusinersen)
- Stelara (ustekinumab)
- Sublocade (buprenorphine extended-release) injection, for subcutaneous use
- Supartz FX (sodium hyaluronate)
- Synagis (palivizumab)
- Synagis (palivizumab)
- Synagis (palivizumab)
- Synvisc (sodium hyaluronate)
- Synvisc-One (sodium hyaluronate)