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
- Daklinza - Archived on 09/10/2024
- Dispense as Written (DAW) Policy - Archived on 10/1/2024
- Dojolvi
- Doptelet - Archived 07/01/2023
- Dupixent - Archived 04/17/23
- Dupixent - Archived on 10/1/2024
- Dupixent (dupilumab) - Archived on 07/01/2024
- Durysta - Archived on 07/01/2024
- Durysta - Archived on 08/16/2024
- Dysprot - Archived on 04/01/2024
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
- Emgality (galcanezumab-gnlm) - Archived on 10/1/2024
- Empaveli - Archived 01/01/2024
- Empaveli (pegcetacoplan) - Archived on 04/01/2024
- Enbrel - Archived on 04/01/2024
- Endothelin Receptor Antagonists for PAH
- Endothelin Receptor Antagonists for Pulmonary Arterial Hypertension: Letairis (ambrisentan), Opsumit (macitentan), Tracleer (bosentan) - Archived on 10/1/2024
- Enjaymo
- Enspryng - Archived 01/01/2024
- Enspryng (satralizumab-mwge) - Archived on 10/01/2024
- Entyvio - Archived on 04/01/2024
- Entyvio (vedolizumab) - Archived on 10/01/2024
- 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
- Epclusa (Sofosbuvir/velpatasvir) - Archived on 10/01/2024
- Epogen - Archived on 05/02/23
- Evenity - Archived on 07/01/2023
- Evenity (romosozumab-aqqg) - Archived on 10/01/2024
- Evkeeza
- Evkeeza (evinacumab-dgnb) - Archived on 10/01/2024
- Eylea
- Eylea (aflibercept) - Archived on 04/01/2024
F
- Fabrazyme - Archived 04/17/23
- Fasenra - Archived on 04/01/2024
- Fasenra (benralizumab) - Archived on 10/01/2024
- Fensolvi - Archived on 10/01/2024
- Fingolimod (Gilenya, Tascenso ODT)
- Firdapse - Archived 04/17/23
- Forteo (teriparatide) - Archived on 07/01/2023
- Forteo (teriparatide) - Archived on 10/01/2024
G
H
I
- Ilaris - Archived on 04/01/2024
- Ilumya - Archived on 04/17/2023
- Iluvien - Archived on 04/01/2024
- Imbruvica (ibrutinib) - Archived on 10/01/2024
- 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
- Inhaled Prostacyclins for PAH - Archived on 10/01/2024
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost) - Archived on 10/01/2024
- Injectable Prostacyclins for PAH
- Injectable Prostacyclins for Pulmonary Arterial Hypertension: Flolan/Veletri (epoprostenol), Remodulin (treprostinil), Uptravi (selexipag) - Archived on 10/01/2024
- Interferons for Multiple Sclerosis: Avonex (interferon beta-1a), Betaseron (interferon beta-1b), Extavia (interferon beta-1b), Plegridy (peginterferon beta-1a), Rebif (interferon beta-1a) - Archived on 08/16/2024
- IV Iron Products - Archived 01/01/2024
- IV Iron Products - Archived on 10/1/2024
J
K
L
- Lamzede (velmanase alfa-tycv) - Archived on 10/01/2024
- Leqembi (lecanemab) - Archived 01/01/2024
- Leqvio - Archived 01/01/2024
- Leqvio (inclisiran) - Archived on 10/01/2024
- Livmarli
- Livmarli (maralixibat) - Archived on 10/01/2024
- 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
- Lupron and Lupaneta Pack - Archived on 10/01/2024
- Luxturna - Archived on 10/01/2024
- Lyfgenia - Archived on 10/01/2024
M
- Macrilen - Archived 04/17/23
- Macrilen (macimorelin) - Archived on 04/01/2024
- Macrilen (macimorelin) - Archived on 08/16/2024
- Macugen - Archived on 02/21/2024
- Macugen (pegaptanib) - Archived 09/10/2024
- Makena - Archived on 04/20/23
- Mavyret - Archived on 10/01/2024
- Mayzent - Archived 04/17/23
- Medical Benefit Medications - Archived on 10/01/2024
- 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
- Multi-ingredient Compound Policy - Archived on 10/01/2024
- Myalept - Archived on 04/01/2024
- Myfembree - Archived on 10/01/2024
- Myobloc - Archived on 04/01/2024
N
O
- Off Label Medication Requests - Archived on 10/01/2024
- Olumiant - Archived on 02/21/2024
- Olumiant (baricitinib) - Archived 01/01/2024
- Onpattro
- Oral Prostacyclins for PAH
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets) - Archived on 10/01/2024
- Orencia - Archived on 04/01/2024
- Orencia (abatacept) - Archived on 04/01/2024
- Orencia (abatacept) - Archived on 10/01/2024
- Orfadin - Archived on 05/02/23
- Oriahnn - Archived on 10/01/2024
- Orilissa - Archived on 10/01/2024
- Orkambi - Archived 04/17/23
- Otezla - Archived on 10/01/2024
- Oxbryta - Archived on 07/01/2024
- Oxervate - Archived on 10/01/2024
- Oxlumo - Archived 04/17/23
- Oxlumo - Archived on 10/01/2024
- Oxlumo (lumasiran) - Archived on 04/01/2024
- Oxlumo (lumasiran) - Archived on 07/01/2024
- Ozurdex - Archived on 04/01/2024
P
- Palforzia - Archived on 10/01/2024
- Panhematin (hemin for injection) - Archived on 07/01/2024
- Pegfilgrastim - Archived on 10/01/2024
- Personal Continuous Glucose Monitors - Archived on 11/15/2023
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq/Tadliq (tadalafil), Liqrev/Revatio (sildenafil) - Archived on 10/01/2024
- Phosphodiesterase Type 5 Inhibitors for PAH - Archived on 10/01/2024
- Ponvory - Archived 04/17/23
- Praluent - Archived 01/01/2024
- Praluent (alirocumab) - Archived on 10/01/2024
- Prevymis - Archived 01/01/2024
- Prolia - Archived on 10/01/2024
- Promacta - Archived 07/01/2023
- Pyrukynd - Archived on 10/01/2024
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
- Relyvrio (sodium phenylbutyrate/ taurursodiol) - Archived 11/15/2024
- Repatha - Archived 01/01/2024
- Repatha (evolocumab) - Archived on 10/01/2024
- Retisert - Archived on 04/01/2024
- Rezurock - Archived on 10/01/2024
- Rinvoq - Archived 07/01/2023
- Rinvoq (upadacitinib) - Archived 10/01/2023
- Rinvoq (upadacitinib) - Archived on 04/01/2024
- Rituximab - Archived 07/01/2023
- Rivfloza - Archived on 10/01/2024
- Rivfloza (nedosiran) - Archived on 07/01/2024
- Roctavian (valoctocogene roxaparvovec) - Archived on 10/01/2024
- Rukobia - Archived on 07/01/2024
- Ruzurgi - Archived on 09/10/2024
- Ryplazim - Archived on 10/01/2024
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
- Skyrizi - Archived on 10/01/2024
- Skytrofa - Archived 01/01/2024
- Sogroya - Archived 01/01/2024
- Soliris - Archived 01/01/2024
- Soliris (eculizumab) - Archived on 10/01/2024
- Soluble Guanylate Cyclase Stimulator for PAH
- Spevigo (spesolimab-sbzo) - Archived on 10/01/2024
- 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
- Supprelin LA - Archived on 10/01/2024
- Susvimo
- Synagis (palivizumab) - Archived on 10/01/2024
- 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
- Tremfya - Archived on 10/01/2024
- Trikafta
- Triptodur - Archived on 10/01/2024
- Trogarzo - Archived on 07/01/2023
- Trogarzo (ibalizumab-uiyk) - Archived on 07/01/2024
- Tymlos - Archived on 07/01/2023
- Tymlos (abaloparatide) - Archived on 10/01/2024
- Tysabri - Archived on 04/01/2024