Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Acthar Gel
- Adakveo - Archived on 07/01/2024
- Adalimumab (Amjevita, Humira) - Archived 06/30/2023
- Adbry - Archived on 04/01/2024
- Adbry (tralokinumab-ldrm) - Archived on 07/01/2024
- Aimovig - Archived on 06/19/2023
- Aimovig (erenumab-aooe) -Archived on 08/23/2023
- Ajovy - Archived 7/28/2023
- Aldurazyme - Archived on 07/01/2024
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin C, Zemaira [human]) - Archived 01/01/2024
- Amvuttra
- Apretude
- Apretude (cabotegravir extended-release) - Archived 01/01/2024
- Aranesp - Archived 04/17/23
- Austedo
- Austedo (deutetrabenazine) - Archived on 04/01/2024
B
C
- Cablivi - Archived 01/01/2024
- Cerdelga
- Cibinqo - Archived 07/01/2023
- Cibinqo (abrocitinib) - Archived on 04/01/2024
- Cimzia - Archived on 04/17/2023
- Cinqair - Archived on 04/01/2024
- Continuous Glucose Monitors, Long Term
- Continuous Monitors, Long Term (FreeStyle Libre, Dexcom, Guardian, Eversense)
- Cortrophin Gel (corticotropin)
- Cosentyx - Archived on 04/01/2024
- Cysteamine - Archived 01/01/2024
D
E
- Egrifta - Archived on 04/01/2024
- Elaprase - Archived on 07/01/2024
- Emflaza - Archived on 04/01/2024
- Emgality - Archived on 06/19/2023
- Empaveli - Archived 01/01/2024
- Empaveli (pegcetacoplan) - Archived on 04/01/2024
- Enbrel - Archived on 04/01/2024
- Endothelin Receptor Antagonists for PAH
- Enjaymo
- Enspryng - Archived 01/01/2024
- Entyvio - Archived on 04/01/2024
- Enzyme replacement for Gaucher disease
- ENZYME REPLACEMENT THERAPY (ERT) FOR GAUCHER DISEASE: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa) - Archived 01/01/2024
- Epclusa - Archived on 04/01/2024
- Epogen - Archived on 05/02/23
- Evenity - Archived on 07/01/2023
- Evkeeza
- Eylea
- Eylea (aflibercept) - Archived on 04/01/2024
F
G
H
I
- Ilaris - Archived on 04/01/2024
- Ilumya - Archived on 04/17/2023
- Iluvien - Archived on 04/01/2024
- Imcivree - Archived on 07/01/2024
- Immune globulin
- Immune globulin (IVIG and SCIG): Intravenous (IVIG) - Archived on 07/01/2024
- Increlex - Archived on 04/01/2024
- Infliximab - Archived on 07/01/2024
- Ingrezza - Archived on 04/01/2024
- Injectable Prostacyclins for PAH
- IV Iron Products - Archived 01/01/2024
J
K
L
- Leqembi (lecanemab) - Archived 01/01/2024
- Leqvio - Archived 01/01/2024
- Livmarli
- Livtencity
- Long Term Continuous Glucose Monitors - Archived 06/14/2023
- Long Term Continuous Glucose Monitors - Archived on 8/22/2023
- Lucentis
- Lumizyme - Archived 04/17/23
- Lumizyme (alglucosidase alfa) - Archived on 04/01/2024
- Lupkynis - Archived on 07/01/2024
M
- Macrilen - Archived 04/17/23
- Macrilen (macimorelin) - Archived on 04/01/2024
- Macugen - Archived on 02/21/2024
- Makena - Archived on 04/20/23
- Mayzent - Archived 04/17/23
- Medical Necessity – Off Label - Archived on 07/20/2023
- Medical Necessity for DAW - Archived on 07/20/2023
- Medical Necessity for Medical Benefit Medications - Archived on 07/20/2023
- Medical Necessity for Non-Formulary Medications - Archived on 07/20/2023
- Mepsevii - Archived on 07/01/2024
- Mulpleta - Archived 07/01/2023
- Multi-ingredient Compound Policy - Archived on 07/20/2023
- Myalept - Archived on 04/01/2024
- Myobloc - Archived on 04/01/2024
N
O
- Olumiant - Archived on 02/21/2024
- Olumiant (baricitinib) - Archived 01/01/2024
- Onpattro
- Oral Prostacyclins for PAH
- Orencia - Archived on 04/01/2024
- Orencia (abatacept) - Archived on 04/01/2024
- Orfadin - Archived on 05/02/23
- Orkambi - Archived 04/17/23
- Oxbryta - Archived on 07/01/2024
- Oxlumo - Archived 04/17/23
- Oxlumo (lumasiran) - Archived on 04/01/2024
- Oxlumo (lumasiran) - Archived on 07/01/2024
- Ozurdex - Archived on 04/01/2024
P
Q
R
- Radicava - Archived 04/17/23
- Ravicti - Archived 07/01/2023
- Reblozyl - Archived 04/17/23
- Reblozyl (luspatercept-aamt) - Archived on 07/01/2024
- Rebyota (fecal microbiota, live - jslm)
- Relistor - Archived on 07/01/2024
- Repatha - Archived 01/01/2024
- Retisert - Archived on 04/01/2024
- Rinvoq - Archived 07/01/2023
- Rinvoq (upadacitinib) - Archived 10/01/2023
- Rinvoq (upadacitinib) - Archived on 04/01/2024
- Rituximab - Archived 07/01/2023
- Rivfloza (nedosiran) - Archived on 07/01/2024
- Rukobia - Archived on 07/01/2024
S
- Saphnelo - Archived on 07/01/2024
- Scenesse - Archived 04/17/23
- Serostim (somatropin) - Archived on 04/01/2024
- Short Term Continuous Glucose Monitoring (Professional CGM)
- Short-acting Somatropin - Archived 01/01/2024
- Short-Acting Somatropin Injections for Growth Hormone Deficiency - Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton - Archived on 07/01/2024
- Short-Acting Somatropin Injections for Growth Hormone Deficiency - Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton - Archived on 04/01/2024
- Siliq - Archived on 04/17/2023
- Simponi - Archived on 04/17/2023
- Skytrofa - Archived 01/01/2024
- Sogroya - Archived 01/01/2024
- Soliris - Archived 01/01/2024
- Soluble Guanylate Cyclase Stimulator for PAH
- Spravato - Archived on 08/23/2023
- Sublocade - Archived 01/01/2024
- Suboxone and Zubsolv - Archived on 10/06/2023
- Sunlenca (lenacapavir) - Archived on 07/01/2024
- Susvimo
- Synagis (palivizumab) - Archived on 11/01/2023
T
- Takhzyro - Archived on 07/01/2023
- Taltz - Archived on 04/17/2023
- Tarpeyo - Archived on 07/01/2024
- Tavalisse - Archived on 07/01/2023
- Tegsedi - Archived on 07/01/2024
- Tepezza
- Tezspire
- Trastuzumab - Archived on 04/01/2024
- Trikafta
- Trogarzo - Archived on 07/01/2023
- Trogarzo (ibalizumab-uiyk) - Archived on 07/01/2024
- Tymlos - Archived on 07/01/2023
- Tysabri - Archived on 04/01/2024