Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
- 2018 Archived Pharmacy Policies
- 2019 Archived Pharmacy Policies
- 11/13/2019 Update
- 11/27/2019 Update ( A–I | J–Z)
- 2021 Archived Pharmacy Policies
#
A
- Abatacept (Orencia) Injection
- Abecma (idecabtagene vicleucel) - Archived 9/30/2022
- Actemra (tocilizumab)
- Actemra (tocilizumab) - Archived 7/1/2022
- Acthar Gel - Archived on 10/1/2024
- Acthar Gel (repository corticotropin injection) - Archived 12/31/2022
- Actimmune (Interferon gamma-1b)
- Adagen (pegademase bovine) injection
- Adakveo (crizanlizumab-tmca) - Archived 7/1/2022
- Adakveo (crizanlizumab-tmca) - Archived on 07/01/2024
- Adalimumab (Amjevita, Humira) - Archived 06/30/2023
- Adbry (tralokinumab-ldrm)
- Adbry (tralokinumab-ldrm) - Archived on 04/01/2024
- Adbry (tralokinumab-ldrm) - Archived on 07/01/2024
- Adcirca (tadalafil)
- Adempas (riociguat)
- Aduhelm (aducanumab-avwa) - Archived 7/1/2022
- AFINITOR (everolimus)
- Aimovig (erenumab-aooe) - Archived 08/23/2023
- Aimovig (erenumab-aooe) - Archived 9/30/2022
- Aimovig (erenumab-aooe) - Archived on 06/19/2023
- Ajovy (fremanezumab-vfrm) - Archived 01/17/2023
- Ajovy (fremanezumab-vfrm) - Archived 9/30/2022
- ALDURAZYME (laronidase)
- Aldurazyme (laronidase) - Archived on 07/01/2024
- Alpha 1-Proteinase Inhibitor Injection
- Alpha1-Proteinase Inhibitors
- Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin C, Zemaira [human]) - Archived 01/01/2024
- Amevive (alefacept)
- Amondys 45 (casimersen) - Archived 7/1/2022
- Ampyra (dalfampridine)
- Anakinra (Kineret) Injection
- APOKYN (apomorphine)
- Apretude (cabotegravir extended-release) - Archived 01/01/2024
- Apretude (cabotegravir extended-release) - Archived 04/24/23
- Apretude (cabotegravir extended-release) - Archived on 10/01/2023
- ARANESP (darbepoetin alfa)
- Aranesp (darbepoetin alfa) - Archived on 4/1/23
- ARCALYST (rilonacept)
- Arcalyst (Rilonacept) - Archived 7/1/2022
- ARZERRA (ofatumumab)
- Asthma and COPD Management
- AUBAGIO (teriflunomide)
- Aubagio (teriflunomide) - Archived on 12/31/2022
- Austedo (deutetrabenazine)
- Austedo (deutetrabenazine) - Archived 04/01/2024
- Austedo (deutetrabenazine) - Archived on 10/01/2023
- Autoimmune Diseases: Biologic Therapies
- Autoimmune Diseases: Biologic Therapies
- Avonex (interferon beta-1a) archived on 1/1/23
B
- Bafiertam (monomethyl fumarate) - Archived on 12/31/2022
- Belimumab (Benlysta)
- Benlysta - Archived on 07/01/2024
- BENLYSTA (belimumab)
- Benlysta (belimumab) - Archived 9/30/2022
- Beovu (brolucizumab) - Archived on 12/31/2022
- Berinert (C1 esterase inhibitor (human)) - Archived on 12/31/2022
- Betaseron (interferon beta-1b) archived on 1/1/23
- Bethkis (tobramycin inhalation solution)
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev) - Archived 10/1/2022
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev) Archived 01/01/2023
- Beyfortus (nirsevimab) - Archived 01/01/2024
- Beyfortus (nirsevimab) - Archived on 10/1/2024
- Biologic and other Ophthalmologic Agents
- Biologic Cholesterol Agents
- Bleeding Disorder Agents - Archived on 4/1/23
- BOSULIF (bosutinib)
- BOTOX (onabotulinumtoxinA)
- Botox (onabotulinumtoxinA) - Archived 04/24/2024
- Botox (onabotulinumtoxinA) - Archived 7/1/2022
- Botulinum Toxin Injection
- Botulinum Toxin Injection
- Breyanzi (lisocabtagene maraleucel) - Archived on 12/31/2022
- Brineura (cerliponase alfa) - Archived 7/1/2022
- Brineura (cerliponase alfa) - Archived on 10/1/2024
- Bunavail (buprenorphine and naloxone) buccal film Archived on 09/14/2022
- BUPHENYL (sodium phenylbutyrate)
- Bylvay (odevixibat) - Archived 01/01/2024
C
- Cabenuva (cabotegravir/rilpivirine) - Archived on 9/30/2022
- Cablivi (caplacizumab-yhdp) - Archived 01/01/2024
- Calcium Regulators (Reclast, Zometa, Boniva, Prolia, Forteo, Xgeva)
- CAPRELSA (vandetanib)
- CARBAGLU (carglumic acid)
- CAYSTON (aztreonam for inhalation solution)
- Cayston (aztreonam inhalation solution) - Archived 9/30/2022
- CERDELGA (eliglustat)
- Cerdelga (eliglustat) - Archived 10/01/2023
- CEREZYME (imiglucerase)
- Cholesterol Lowering Agents for Homozygous Familial Hypercholesterolemia
- Cibinqo (abrocitinib) - Archived on 04/01/2024
- Cibinqo (abrocitinib) - Archived on 07/01/2023
- CIMZIA (certolizumab pegol)
- Cimzia (certolizumab pegol) - Archived 04/17/23
- Cimzia (certolizumab pegol) - Archived 7/1/2022
- Cinqair (reslizumab) - Archived 04/24/2024
- Cinqair (reslizumab) - Archived 7/1/2022
- Cinryze (C1 esterase inhibitor (human)) - Archived on 12/31/2022
- Colony Stimulating Factors
- COMETRIQ (cabozantinib)
- Continuous Glucose Monitors - Archived on 7/1/22
- Continuous Glucose Monitors, Long Term - Archived 10/01/2023
- Continuous Monitors, Long Term (FreeStyle Libre, Dexcom, Guardian, Eversense)
- COPAXONE (glatiramer acetate)
- Cortrophin Gel (corticotropin) - Archived on 10/01/2023
- COSENTYX (secukinumab)
- Cosentyx (secukinumab)
- Cosentyx (secukinumab) - Archived 04/01/2024
- Crysvita (burosumab-twza) - Archived 9/30/2022
- CYSTAGON (cysteamine bitartrate)
- CYSTARAN (cysteamine ophthalmic solution)
- Cystic Fibrosis
- Cystic Fibrosis
- Cytomegalovirus Immune Globulin Intravenous (Cytogam)
- Cytomegalovirus Immune Globulin Intravenous (Cytogam)
D
- DACOGEN (decitabine)
- Daklinza (daclatasvir) - Archived 09/10/2024
- Desmopressin Acetate (Stimate) Nasal Spray
- Diacomit (stiripentol) - Archived 9/30/2022
- Diacomit (stiripentol) - Archived on 4/1/23
- Dispense as Written (DAW) Policy - Archived on 10/1/2024
- Dispense as Written (DAW) Requests
- Dojolvi (triheptanoin) - Archived on 10/01/2023
- Doptelet (avatrombopag) - Archived on 07/01/2023
- Dupixent - Archived on 04/01/2024
- Dupixent - Archived on 4/1/23
- Dupixent (dupilumab) - Archived on 07/01/2024
- Dupixent (dupilumab) - Archived on 10/1/2024
- Dupixent (dupilumab) - Archived on 12/31/2022
- Durolane (sodium hyaluronate) - Archived on 10/1/22
- Durysta (bimatoprost intracameral implant) - Archived 7/1/2022
- Durysta (bimatoprost intracameral implant) - Archived on 07/01/2024
- Durysta (bimatoprost intracameral implant) - Archived on 08/16/2024
- Dysport (abobotulinumtoxinA) - Archived 7/1/2022
- Dysport (abobotulinumtoxinA) - Archived on 04/01/2024
E
- Egrifta SV (tesamorelin) - Archived 04/01/2024
- ELAPRASE (idursulfase)
- Elaprase (idursulfase) - Archived on 07/01/2024
- ELELYSO (taliglucerase alfa)
- ELIGARD (leuprolide acetate)
- Emflaza (deflazacort) - Archived 7/1/2022
- Emflaza (deflazacort) - Archived on 04/01/2024
- Emgality - Archived on 06/19/2023
- Emgality (galcanezumab-gnlm) - Archived 9/30/2022
- Emgality (galcanezumab-gnlm) - Archived on 10/1/2024
- Emgality (galcanezumab-gnlm) - Archived on 12/31/2022
- Empaveli (pegcetacoplan) - Archived 01/01/2024
- Empaveli (pegcetacoplan) - Archived on 04/01/2024
- ENBREL (etanercept)
- Enbrel (etanercept) - Archived 04/01/2024
- Enbrel (etanercept) - Archived 7/1/2022
- Endothelin Receptor Antagonists for Pulmonary Arterial Hypertension: Letairis (ambrisentan), Opsumit (macitentan), Tracleer (bosentan) - Archived 10/01/2023
- Endothelin Receptor Antagonists for Pulmonary Arterial Hypertension: Letairis (ambrisentan), Opsumit (macitentan), Tracleer (bosentan) - Archived on 10/1/2024
- Enspryng (satralizumab-mwge) - Archived 01/01/2024
- Enspryng (satralizumab-mwge) - Archived on 10/1/2024
- Entyvio - Archived on 04/01/2024
- Entyvio (vedolizumab) - Archived on 10/1/2024
- Entyvio (vedolizumab) - Archived on 12/31/2022
- Enzyme Replacement Therapy
- Enzyme Replacement Therapy (ERT) for Gaucher Disease: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa) - Archived 01/01/2024
- ENZYME REPLACEMENT THERAPY (ERT) FOR GAUCHER DISEASE: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa) - Archived 10/01/2023
- Enzyme Replacement Therapy and Agents
- Epclusa (Sofosbuvir/velpatasvir) - Archived 7/1/2022
- Epclusa (Sofosbuvir/velpatasvir) - Archived on 04/01/2024
- Epclusa (Sofosbuvir/velpatasvir) - Archived on 10/1/2024
- Epidiolex (cannabidiol) - Archived 9/30/2022
- Epogen (epoetin alfa) - Archived 07/20/2023
- EPOGEN, PROCRIT (epoetin alfa)
- Epoprostenol for injection (generic)
- ERBITUX (cetuximab)
- ERIVEDGE (vismodegib)
- Esbriet (pirfenidone) - Archived 9/30/2022
- Euflexxa (sodium hyaluronate) - Archived on 10/1/22
- Evenity (romosozumab-aqqg) - Archived 9/30/2022
- Evenity (romosozumab-aqqg) - Archived on 07/01/2023
- Evenity (romosozumab-aqqg) - Archived on 10/1/2024
- Evkeeza (evinacumab-dgnb) - Archived 10/01/2023
- Evkeeza (evinacumab-dgnb) - Archived 7/1/2022
- Evkeeza (evinacumab-dgnb) - Archived on 10/1/2024
- Evrysdi (risdiplam) - Archived on 12/31/2022
- EXJADE (deferasirox; tablets for suspension)
- Exondys 51 (eteplirsen) - Archived 7/1/2022
- Extavia (interferon beta-1b) archived on 1/1/23
- Eylea (aflibercept) - Archived 10/01/2023
- Eylea (aflibercept) - Archived on 04/01/2024
F
- FABRAZYME (agalsidase beta)
- Fabrazyme (agalsidase beta) - Archived on 4/1/23
- FARYDAK (panobinostat)
- Fasenra (benralizumab) - Archived 7/1/2022
- Fasenra (benralizumab) - Archived on 04/01/2024
- Fasenra (benralizumab) - Archived on 10/1/2024
- Fensolvi (leuprolide acetate) - Archived on 12/31/2022
- FERRIPROX (deferiprone)
- Fingolimod (Gilenya, Tascenso ODT) - Archived 10/01/2023
- Fintepla (fenfluramine) - Archived 9/30/2022
- FIRAZYR (icatibant)
- Firazyr (icatibant) - Archived on 12/31/2022
- Firdapse (amifampridine) - Archived 7/1/2022
- Firdapse (amifampridine) - Archived on 4/1/23
- Firmagon (degarelix)
- Forteo - Archived on 07/01/2023
- FORTEO (teriparatide)
- Forteo (teriparatide) - Archived 9/30/2022
- Forteo (teriparatide) - Archived on 10/1/2024
- Forteo (teriparatide) - Archived on 4/1/23
- Fulphila (pegfilgrastim-jmdb)
G
- Galafold (migalastat) - Archived on 4/1/23
- Gamifant (emapalumab-lzsg) - Archived 04/24/2024
- Gattex (teduglutide) - Archived 01/01/2024
- GAZYVA (obinutuzumab)
- Gel-One (sodium hyaluronate) - Archived on 10/1/22
- Gelsyn-3 (sodium hyaluronate) - Archived on 10/1/22
- Gender–Affirming Hormone Therapy - Archived 9/30/2022
- GENOTROPIN (somatropin)
- GenVisc 850 (sodium hyaluronate) - Archived 02/07/2023
- GILENYA (fingolimod)
- Gilenya (fingolimod) - Archived on 04/01/2023
- Givlaari (givosiran) - Archived on 07/01/2023
- Givlaari (givosiran) - Archived on 07/01/2024
- GLEEVEC (imatinib mesylate)
- Granix (tbo-filgrastim) - Archived on 09/14/2022
H
- Haegarda (C1 esterase inhibitor (human)) - Archived on 12/31/2022
- Harvoni (ledipasvir/sofosbuvir) - Archived 7/1/2022
- Hematopoietic Growth Factors
- Hematopoietic Growth Factors
- Hemegenix (etranacogene dezaparvovec) - Archived on 10/1/2024
- Hemophilia and Other Clotting Disorders - Archived on 07/01/2024
- Hemophilia And Other Clotting Disorders (setmelanotide) - Archived on 10/1/2024
- Hepatitis C - Oral
- Hepatitis C - Oral
- Hereditary Angioedema and Pharmacotherapy
- Hereditary Angioedema and Pharmacotherapy
- HETLIOZ (tasimelteon)
- Home Infusion Therapy
- HUMIRA (adalimumab)
- Humira (adalimumab) - Archived 04/17/23
- Humira (adalimumab) - Archived 7/1/2022
- Humira (adalimumab) - Archived on 7/1/22
- Hyalgan (sodium hyaluronate) - Archived on 10/1/22
- Hyaluronic Acid Derivative Injection
- Hyaluronic Acid Derivative Injection
- Hyaluronic Acid Viscosupplements - Archived on 4/1/23
- HYCAMTIN CAPSULES (topotecan)
- Hymovis (sodium hyaluronate) - Archived on 10/1/22
- Hyperlipidemia Management Policy
I
- IBRANCE (palbociclib)
- ICLUSIG (ponatinib)
- Idiopathic Pulmonary Fibrosis
- Idiopathic Pulmonary Fibrosis
- Ilaris (canakinumab) - Archived 04/01/2024
- Ilaris (canakinumab) - Archived 7/1/2022
- Ilumya (tildrakizumab-asmn)
- Ilumya (tildrakizumab-asmn) - Archived 04/17/23
- Iluvien (fluocinolone acetonide) - Archived 04/24/2024
- Imbruvica - Archived on 10/1/2024
- IMBRUVICA (ibrutinib)
- Imbruvica (ibrutinib) - Archived on 4/1/23
- Imcivree - Archived on 07/01/2024
- Imcivree (setmelanotide) - Archived on 12/31/2022
- Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
- Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
- Immune globulin (IVIG and SCIG) - Archived on 08/26/2024
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Asceniv, Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen Subcutaneous (SCIG): Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify) - Archived on 07/01/2024
- Immune Globulin (IVIG, IGIV, or IMIG or SCIG)
- Immune Globulin (IVIG, IGIV, or IMIG or SCIG)
- INCRELEX (mecasermin)
- Increlex (mecasermin) - Archived 04/01/2024
- Inflammatory Bowel Disease: Biological Therapies
- Inflammatory Bowel Disease: Biological Therapies
- Inflectra (infliximab-dyyb)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis) - Archived 10/1/2022
- Infliximab (Avsola, Inflectra, Remicade, Renflexis) - Archived on 07/01/2024
- Ingrezza (valbenazine) - Archived 9/30/2022
- Ingrezza (valbenazine) - Archived on 04/01/2024
- Inhaled Prostacyclins for PAH - Archived 10/01/2023
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost) - Archived on 10/1/2024
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost) - Archived on 12/31/2022
- Injectable Prostacyclins for Pulmonary Arterial Hypertension: Flolan/Veletri (epoprostenol), Remodulin (treprostinil), Uptravi (selexipag) - Archived 10/01/2023
- Injectable Prostacyclins for Pulmonary Arterial Hypertension: Flolan/Veletri (epoprostenol), Remodulin (treprostinil), Uptravi (selexipag) - Archived on 10/1/2024
- Injectable somatostatin analogs (First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline depot (lanreotide) - Archived 9/30/2022
- Injectable somatostatin analogs (First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline depot (lanreotide), Bynfezia Pen (octreotide)
- INLYTA (axitinib)
- 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
- Intravenous Iron Products - Archived 01/01/2024
- INTRON A (interferon alfa-2b)
- Isturisa (osilodrostat) - Archived 9/30/2022
- IV Iron Products - Archived on 10/1/2024
J
- JAKAFI (ruxolitinib)
- Jakafi (ruxolitinib) - Archived on 10/1/2024
- Jesduvroq (daprodustat) - Archived on 10/1/2024
- Joenja (leniolisib) - Archived on 10/1/2024
- Juxtapid (lomitapide) - Archived 10/01/2023
- Juxtapid (lomitapide) - Archived 7/1/2022
- Juxtapid (lomitapide) - Archived on 10/1/2024
- Jynarque (tolvaptan) - Archived 04/01/2024
K
- KADCYLA (ado-trastuzumab)
- Kalbitor (ecallantide) - Archived on 12/31/2022
- KALYDECO (ivacaftor)
- Kalydeco (ivacaftor) - Archived 10/01/2023
- Kalydeco (ivacaftor) - Archived 9/30/2022
- Kanuma (sebelipase alfa) - Archived 7/1/2022
- Kanuma (sebelipase alfa) - Archived on 10/1/2024
- Kesimpta (ofatumumab) - Archived on 12/31/2022
- Kevzara (sarilumab) - Archived 04/17/23
- Kevzara (sarilumab) - Archived 10/01/2023
- Kevzara (sarilumab) - Archived 7/1/2022
- KEYTRUDA (pembrolizumab)
- Kineret (anakinra) - Archived 04/17/23
- Kineret (anakinra) - Archived 7/1/2022
- KINERET® (anakinra)
- Kitabis Pak (tobramycin inhalation solution) - Archived 9/30/2022
- Korlym (mifepristone) - Archived 9/30/2022
- Korsuva (difelikefalin) - Archived 9/30/2022
- Korsuva (difelikefalin) - Archived on 08/16/2024
- Koselugo (selumetinib) - Archived on 04/01/2024
- Krystexxa (pegloticase) - Archived on 12/31/2022
- KUVAN (sapropterin dihydrochloride)
- Kuvan (sapropterin) - Archived on 4/1/23
- Kymriah (tisagenlecleucel) - Archived on 12/31/2022
L
- Lamzede (velmanase alfa-tycv) - Archived on 10/1/2024
- Lemtrada (alemtuzumab) - Archived on 12/31/2022
- LENVIMA (lenvatinib)
- Leqembi (lecanemab) - Archived 01/01/2024
- Leqvio (inclisiran) - Archived 01/01/2024
- Leqvio (inclisiran) - Archived on 10/1/2024
- Letairis (ambrisentan)
- LEUKINE (sargramostim)
- Leukine (sargramostim) - Archived on 09/14/2022
- Leuprolide acetate injection
- Livmarli (maralixibat) - Archived 10/01/2023
- Livmarli (maralixibat) - Archived on 10/1/2024
- Livtencity (maribavir) - Archived 10/01/2023
- Long Term Continuous Glucose Monitors - Archived on 07/10/2023
- Long Term Continuous Glucose Monitors - Archived on 8/22/2023
- Lumizyme - Archived on 04/01/2024
- Lumizyme (alglucosidase alfa) - Archived on 4/1/23
- LUPANETA
- Lupaneta Pack (leuprolide acetate, norethindrone acetate) - Archived on 09/14/2022
- Lupkynis - Archived on 07/01/2024
- Lupkynis (voclosporin) - Archived on 12/31/2022
- Lupron DEPOT
- Lupron DEPOT
- Lupron Depot and Lupron Depot-PED (leuprolide acetate) - Archived on 10/1/2024
- LUPRON DEPOT Endometriosis
- LUPRON DEPOT PED
- LUPRON DEPOT Prostate
- Luxturna (voretigene neparvovec-rzyl) - Archived on 10/1/2024
- Luxturna (voretigene neparvovec-rzyl) intraocular suspension for subretinal injection - Archived 7/1/2022
- Lyfgenia (lovotibeglogene autotemcel) - Archived on 10/1/2024
- LYNPARZA (olaparib)
M
- MACI (autologous cultured chondrocytes) - Archived 9/30/2022
- Macrilen (macimorelin) - Archived on 08/16/2024
- Macrilen - Archived on 04/01/2024
- Macrilen (macimorelin) - Archived on 4/1/23
- Macugen (pegaptanib) - Archived 09/10/2024
- Macugen (pegaptanib) - Archived 10/01/2023
- Makena (hydroxyprogesterone caproate) - Archived on 04/20/23
- Mavenclad (cladribine) - Archived on 12/31/2022
- Mavyret (glecaprevir and pibrentasvir) - Archived 7/1/2022
- Mavyret (glecaprevir and pibrentasvir) - Archived on 10/1/2024
- Mayzent (siponimod) - Archived on 4/1/23
- Medical Benefit Medications - Archived on 10/1/2024
- Medical Necessity – Off Label - Archived 07/20/2023
- Medical Necessity for DAW - Archived 07/20/2023
- Medical Necessity for Medical Benefit Medications - Archived 07/20/2023
- Medical Necessity for Non-Formulary Medications - Archived 07/20/2023
- Medication Assisted Therapy (MAT) for Suboxone
- MEKINIST (trametinib)
- MENOPUR (menotropins for injection)
- Mepsevii (vestronidase alfa-vjbk) - Archived on 07/01/2024
- Mitoxantrone
- Monovisc (sodium hyaluronate) - Archived on 10/1/22
- MOZOBIL (plerixafor)
- Mulpleta (lusutrombopag) - Archived on 07/01/2023
- Multi-ingredient Compound Policy - Archived 07/20/2023
- Multi-ingredient Compound Policy - Archived on 10/1/2024
- Multiple Sclerosis Therapy Class
- Multiple Sclerosis Therapy Class
- MYALEPT (metreleptin)
- Myalept (metreleptin) - Archived on 04/01/2024
- Mycapssa (octreotide) - Archived 9/30/2022
- Myfembree - Archived on 10/1/2024
- Myfembree (relugolix, estradiol, and norethindrone acetate) - Archived on 12/31/2022
- Myobloc (rimabotulinumtoxinB) - Archived 7/1/2022
- Myobloc (rimabotulinumtoxinB) - Archived on 04/01/2024
N
- NAGLAZYME (galsulfase)
- Naglazyme (galsulfase) - Archived on 07/01/2024
- NEULASTA (pegfilgrastim)
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
- NEUPOGEN (filgrastim)
- NEXAVAR (sorafenib)
- Nexviazyme (avalglucosidase alfa-ngp) - Archived 9/30/2022
- Nexviazyme (avalglucosidase alfa-ngp) - Archived on 04/01/2024
- Noctiva (desmopressin acetate) intranasal 0.83 mcg/0.1 mL and 1.66 mcg/0.1 mL-archived on 12/13/22
- Non-Formulary Medications - Archived on 10/1/2024
- Novantrone (mitoxantrone) - Archived on 12/31/2022
- NOVAREL (chorionic gonadotropin)
- NPlate (romiplostim) - Archived on 07/01/2023
- Nucala - Archived on 04/01/2024
- Nucala (mepolizumab) - Archived on 4/1/23
- Nulibry (fosdenopterin) - Archived 10/01/2023
- NUPLAZID (pimavanserin)
O
- Ocrevus (ocrelizumab) - Archived on 12/31/2022
- Ofev (nintedanib) - Archived 9/30/2022
- Off Label Medication Requests - Archived on 10/1/2024
- Off-Label Use Consideration and Excluded Indications
- Olumiant - Archived 04/17/23
- Olumiant (baricitinib)
- Olumiant (baricitinib) - Archived 01/01/2024
- Olumiant (baricitinib) - Archived 7/1/2022
- ONCASPAR (pegaspargase)
- Onpattro (patisiran) - Archived 10/01/2023
- Onpattro (patisiran) - Archived on 12/31/2022
- Opsumit (macitentan)
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets) - Archived 10/01/2023
- Oral Prostacyclins for Pulmonary Arterial Hypertension: Orenitram (treprostinil extended-release), Uptravi (selexipag tablets) - Archived on 10/1/2024
- ORENCIA (abatacept)
- Orencia (abatacept) - Archived 04/17/23
- Orencia (abatacept) - Archived 7/1/2022
- Orencia (abatacept) - Archived on 04/01/2024
- Orencia (abatacept) - Archived on 10/1/2024
- Orenitram (treprostinil)
- ORFADIN (nitisinone)
- Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix) - Archived on 10/1/2024
- Orilissa - Archived on 10/1/2024
- Orilissa (elagolix) - Archived on 12/31/2022
- ORKAMBI (lumacaftor/ivacaftor)
- Orkambi (lumacaftor/ivacaftor) - Archived 9/30/2022
- Orkambi (lumacaftor/ivacaftor) - Archived on 4/1/23
- Orladeyo (berotralstat) - Archived on 12/31/2022
- Orthovisc (sodium hyaluronate) - Archived on 10/1/22
- OTEZLA (apremilast)
- Otezla (apremilast) - Archived 7/1/2022
- Otezla (apremilast) - Archived on 10/1/2024
- Oxbryta (voxelotor) - Archived 7/1/2022
- Oxbryta (voxelotor) - Archived on 07/01/2024
- Oxervate (cenegermin-bkbj) - Archived 7/1/2022
- Oxervate (cenegermin-bkbj) - Archived on 10/1/2024
- Oxlumo - Archived on 04/01/2024
- Oxlumo (lumasiran) - Archived 9/30/2022
- Oxlumo (lumasiran) - Archived on 07/01/2024
- Oxlumo (lumasiran) - Archived on 10/1/2024
- Oxlumo (lumasiran) - Archived on 4/1/23
- Ozurdex (dexamethasone) - Archived 04/24/2024
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder- dnfp] - Archived on 10/1/2024
- Palivizumab (Synagis)
- Palivizumab (Synagis)
- Palynziq (pegvaliase-pqpz) - Archived on 4/1/23
- Panhematin (hemin for injection) - Archived on 07/01/2024
- Parenteral Calcium Regulators - pamidronate (Aredia), zoledronic acid (Reclast and Zometa), ibandronate (Boniva), denosumab (Prolia and Xgeva), teriparatide (Forteo)
- Pegasys (peginterferon alfa-2a) - Archived on 12/31/2022
- Pegfilgrastim (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo) - Archived 10/1/2022
- Pegfilgrastim (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo) - Archived on 10/1/2024
- Pegylated and Non-Pegylated Interferon
- Pegylated and Non-Pegylated Interferon
- Personal Continuous Glucose Monitors - Archived on 11/15/2023
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq (tadalafil), Revatio (sildenafil) - Archived 10/01/2023
- Phosphodiesterase Type 5 Inhibitors (PDE-5 Inhibitors) for Pulmonary Arterial Hypertension: Adcirca/Alyq/Tadliq (tadalafil), Liqrev/Revatio (sildenafil) - Archived on 10/1/2024
- PLEGRIDY (peginterferon beta-1a)
- Plegridy (peginterferon beta-1a) archived on 1/1/23
- POMALYST (pomalidomide)
- Ponvory (ponesimod) - Archived on 4/1/23
- PRALUENT (alirocumab)
- Praluent (alirocumab) - Archived 01/01/2024
- Praluent (alirocumab) - Archived 7/1/2022
- Praluent (alirocumab) - Archived on 10/1/2024
- Prevymis (letermovir) - Archived 01/01/2024
- Probuphine (buprenorphine subdermal implant) - Archived on 09/14/2022
- Procrit (epoetin alfa) - Archived 07/20/2023
- Procysbi and Cystagon (cysteamine bitartrate); Cystaran and Cystadrops (cysteamine hydrochloride solution) - Archived 01/01/2024
- PROLIA (denosumab)
- Prolia (denosumab) - Archived 9/30/2022
- Prolia (denosumab) - Archived on 10/1/2024
- PROMACTA (eltrombopag)
- Promacta (eltrombopag) - Archived on 07/01/2023
- Proton Pump Inhibitors (PPIs)
- Psoriasis: Biological Therapies
- Psoriasis: Biological Therapies
- Pulmonary Arterial Hypertension
- Pulmonary Arterial Hypertension
- Pulmozyme (dornase alfa inhalation solution) - Archived 9/30/2022
- Pyrukynd (mitapivat) - Archived on 10/1/2024
Q
R
- Radicava (edaravone injection) - Archived on 4/1/23
- Ravicti (glycerol phenylbuytyrate) - Archived on 07/01/2023
- REBIF (interferon beta-1a)
- Rebif (interferon beta-1a) archived on 1/1/23
- Reblozyl - Archived on 07/01/2024
- Reblozyl (luspatercept-aamt) - Archived on 4/1/23
- Rebyota (fecal microbiota, live - jslm) - Archived 10/01/2023
- Relistor (methylnaltrexone) - Archived on 07/01/2024
- REMICADE (infliximab)
- Remicade (infliximab)
- Remicade (infliximab) - Archived 7/1/2022
- Remodulin (treprostinil injection)
- Renflexis (infliximab-abda)
- REPATHA (evolocumab)
- Repatha (evolocumab) - Archived 01/01/2024
- Repatha (evolocumab) - Archived 7/1/2022
- Repatha (evolocumab) - Archived on 10/1/2024
- Retacrit (epoetin alfa-epbx) - Archived 07/20/2023
- Retisert (fluocinolone acetonide) - Archived on 04/01/2024
- Revatio (sildenafil)
- REVLIMID (lenalidomide)
- Rezurock (belumosudil) - Archived on 10/1/2024
- Rheumatoid Arthritis, Inflammatory Bowel Disease, Psoriasis and Psoriatic Arthritis: Biological Therapies
- Rinvoq (upadacitinib)
- Rinvoq (upadacitinib) - Archived 10/01/2023
- Rinvoq (upadacitinib) - Archived 7/1/2022
- Rinvoq (upadacitinib) - Archived on 04/01/2024
- Rinvoq (upadacitinib) - Archived on 07/01/2023
- Rituxan (Rituximab)
- Rituxan (rituximab)
- RITUXAN (rituximab)
- Rituxan (rituximab)
- Rituxan (rituximab) - Archived 7/1/2022
- RITUXAN (rituximab) Oncology
- RITUXAN HYCELA (rituximab and hyaluronidase human)
- Rituximab - Archived on 07/01/2023
- Rituximab (Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima) - Archived 10/1/2022
- Rituximab (Rituxan, Ruxience, Truxima) - Archived on 12/31/2022
- Rivfloza (nedosiran) - Archived on 07/01/2024
- Rivfloza (nedosiran) - Archived on 10/1/2024
- Roctavian (valoctocogene roxaparvovec) - Archived on 10/1/2024
- Ruconest (C1 esterase inhibitor (recombinant)) - Archived on 12/31/2022
- Rukobia (fostemsavir) - Archived 9/30/2022
- Rukobia (fostemsavir) - Archived on 07/01/2024
- Ruzurgi (amifampridine) - Archived on 09/10/2024
- RYDAPT (midostaurin)
- Ryplazim (plasminogen, human-tvmh) - Archived on 10/1/2024
S
- SABRIL (vigabatrin)
- SANDOSTATIN (octreotide acetate injection)
- Saphnelo - Archived on 07/01/2024
- Saphnelo (anifrolumab-fnia) - Archived on 12/31/2022
- Scenesse (Afamelanotide) - Archived on 4/1/23
- Seizure Disorders
- Seizure Disorders (Repository Corticotropin Injection (H.P. Acthar Gel) and Vigabatrin (Sabril) Oral Solution and Tablets)
- SENSIPAR (cinacalcet)
- Serostim (somatropin) - Archived 04/01/2024
- Short Bowel Syndrome (Gattex, Zorbitive)
- Short Bowel Syndrome (Gattex, Zorbtive)
- Short Term Continuous Glucose Monitoring (Professional CGM)
- 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 01/01/2024
- Short-Acting Somatropin Injections for Growth Hormone Deficiency - Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton - Archived on 04/01/2024
- SIGNIFOR (pasireotide)
- SIGNIFOR LAR (pasireotide injectable suspension)
- Siliq (brodalumab)
- Siliq (brodalumab) - Archived 04/17/23
- SIMPONI (golimumab)
- Simponi (golimumab) - Archived 04/17/23
- SIMPONI ARIA (golimumab)
- Simponi Aria (golimumab) - Archived 7/1/2022
- Skyrizi - Archived on 10/1/2024
- Skyrizi (risankizumab-rzaa)
- Skyrizi (risankizumab-rzaa) - Archived 7/1/2022
- Skyrizi (risankizumab-rzaa) archived on 1/1/23
- Skytrofa (lonapegsomatropin) - Archvied 01/01/2024
- Sogroya (somapacitan-beco) - Archived 01/01/2024
- Soliris (eculizumab) - Archived 01/01/2024
- Soliris (eculizumab) - Archived on 10/1/2024
- Soluble Guanylate Cyclase (sGC) Stimulator for Pulmonary Arterial Hypertension: Adempas (riociguat) - Archived 10/01/2023
- SOMATULINE DEPOT (lanreotide)
- SOMAVERT (pegvisomant)
- Spevigo (spesolimab-sbzo) - Archived on 10/1/2024
- Spinraza (nusinersen) - Archived on 12/31/2022
- Spravato (esketamine) - Archived on 08/23/2023
- SPRYCEL (dasatinib)
- STELARA (ustekinumab)
- Stelara (ustekinumab)
- Stelara (ustekinumab) - Archived 7/1/2022
- Stelara (ustekinumab) archived on 1/1/23
- STIVARGA (regorafenib)
- Strensiq (asfotase alfa) - Archived 9/30/2022
- Sublocade - Archived 01/01/2024
- Sublocade (buprenorphine extended-release) injection, for subcutaneous use - Archived on 12/31/2022
- Suboxone (buprenorphine and naloxone sublingual film), Zubsolv (buprenorphine and naloxone sublingual tablets) - Archived on 04/13/23
- Suboxone (buprenorphine and naloxone) sublingual film, for sublingual or buccal use archived on 1/1/23
- Sunlenca (lenacapavir) - Archived on 07/01/2024
- Supartz FX (sodium hyaluronate) - Archived on 10/1/22
- Supprelin LA (histrelin acetate) - Archived on 10/1/2024
- Susvimo (ranibizumab) - Archived 10/01/2023
- SUTENT (sunitinib)
- Symdeko (tezacaftor/ivacaftor) - Archived 9/30/2022
- Synagis (palivizumab) - Archived on 10/1/2024
- Synagis (palivizumab) - Archived on 11/01/2023
- Synagis (palivizumab) - Archived on 12/31/2022
- Synagis (palivizumab) - Archived on 9/20/2022
- SYNRIBO (omacetaxine mepesuccinate)
- Synvisc-One (sodium hyaluronate) - Archived on 10/1/22
T
- TAFINLAR (dabrafenib)
- Takhzyro - Archived on 07/01/2023
- Takhzyro (lanadelumab-flyo) - Archived on 12/31/2022
- Taltz (ixekizumab)
- Taltz (ixekizumab) - Archived 04/17/23
- Taltz (ixekizumab) - Archived 7/1/2022
- TARCEVA (erlotinib)
- Targretin (bexarotene) capsules
- Tarpeyo (budesonide) - Archived on 07/01/2024
- Tavalisse (fostamatinib disodium hexahydrate) - Archived on 07/01/2023
- Tecartus (Brexucabtagene Autoleucel) - Archived 7/1/2022
- TECFIDERA (dimethyl fumarate)
- Tecfidera (dimethyl fumarate) - Archived on 12/31/2022
- Tegsedi - Archived on 07/01/2024
- Tegsedi (inotersen) - Archived on 12/31/2022
- Temodar temozolomide
- Tepezza (teprotumumab-trbw) - Archived 10/01/2023
- Tepezza (teprotumumab-trbw) - Archived 7/1/2022
- Tezspire (tezepelumab-eeko) - Archived 10/01/2023
- THALOMID (thalidomide)
- TIKOSYN (dofetilide)
- Tobi (tobramycin inhalation solution), Tobi Podhaler - Archived 9/30/2022
- tobramycin inhalation solution (TOBI)
- Tocilizumab (Actemra)
- TORISEL (temsirolimus)
- Tracleer (bosentan)
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) - Archived 04/01/2024
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) - Archived 10/1/2022
- TRELSTAR (triptorelin pamoate)
- Tremfya (guselkumab) - Archived 7/1/2022
- Tremfya (guselkumab) - Archived on 04/12/23
- Tremfya (guselkumab) - Archived on 10/1/2024
- Tremfya (guselkumab) - Archived on 7/1/22
- Trikafta (elexacaftor, tezacaftor and ivacaftor tablets; ivacaftor tablets) - Archived 10/01/2023
- Trikafta (elexacaftor, tezacaftor and ivacaftor tablets; ivacaftor tablets) - Archived 9/30/2022
- Triptodur (triptorelin) - Archived on 10/1/2024
- Trogarzo (ibalizumab-uiyk) - Archived on 07/01/2024
- Trogarzo (ibalizumab-uiyk) - Archived 9/30/2022
- Trogarzo (ibalizumab-uiyk) - Archived on 07/01/2023
- TYKERB (lapatinib)
- Tymlos (abaloparatide) - Archived on 07/01/2023
- Tymlos (abaloparatide) - Archived on 10/1/2024
- Tysabri - Archived on 04/01/2024
- TYSABRI (natalizumab)
- Tysabri (natalizumab) - Archived on 12/31/2022
- Tysabri (Natalizumab) for Treatment of Crohn's Disease
- Tyvaso (treprostinil)
U
- Udenyca (pegfilgrastim-cbqv)
- Ultomiris - Archived 01/01/2024
- Ultomiris (ravulizumab-cwvz) - Archived 9/30/2022
- Ultomiris (ravulizumab-cwvz) - Archived on 10/1/2024
- Ultomiris (ravulizumab-cwvz) - Archived on 12/31/2022
- Uplizna (inebilizumab-cdon) - Archived 01/01/2024
- Uplizna (inebilizumab-cdon) - Archived on 10/1/2024
- Uptravi (selexipag)
V
- Vabysmo (faricimab-svoa) - Archived 10/01/2023
- Vabysmo (faricimab-svoa) - Archived on 04/01/2024
- Varubi (rolapitant) - Archived on 8/24/2022
- VENCLEXTA (venetoclax)
- Ventavis (iloprost)
- VIDAZA (azacitidine) azacitidine (generic)
- Vigabatrin (generic for Sabril), Vigadrone - Archived on 12/31/2022
- Viltepso (viltolarsen) - Archived 7/1/2022
- Vimizim (elosulfase alfa) - Archived on 07/01/2024
- Visudyne (verteporfin) - Archived 04/01/2024
- VIVITROL (naltrexone)
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir) - Archived 7/1/2022
- VOTRIENT (pazopanib)
- VOXZOGO (vosoritide) - Archived on 04/01/2024
- VPRIV (velaglucerase alfa)
- Vumerity (diroximel fumarate) - Archived on 12/31/2022
- Vyepti (eptinezumab-jjmr) - Archived 01/01/2024
- Vyepti (eptinezumab-jjmr) - Archived 9/30/2022
- Vyepti (eptinezumab-jjmr) - Archived on 10/1/2024
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis) - Archived on 12/31/2022
- Vyondys 53 (golodirsen) - Archived 7/1/2022
- Vyvgart (efgartigimod alfa-fcab) - Archived 01/01/2024
W
X
- XALKORI (crizotinib)
- XELJANZ (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib) - Archived 04/17/23
- Xeljanz/Xeljanz XR (tofacitinib) - Archived 7/1/2022
- XELODA (capecitabine)
- XENAZINE (tetrabenazine)
- Xenleta (lefamulin) - Archived on 08/16/2024
- Xenpozyme (olipudase alfa-rpcp) - Archived on 10/1/2024
- XEOMIN (incobotulinumtoxinA)
- Xeomin (incobotulinumtoxinA) - Archived 04/24/2024
- Xeomin (incobotulinumtoxinA) - Archived 7/1/2022
- XGEVA (denosumab)
- Xgeva (denosumab) - Archived 9/30/2022
- Xipere (triamcinolone) - Archived on 04/01/2024
- Xolair (omalizumab) - Archived 7/1/2022
- Xolair (omalizumab) - Archived on 10/1/2024
- Xolair Nucala
- Xolair/Nucala/Cinqair
- Xyrem (sodium oxybate) and Xywav (calcium, magnesium, potassium, and sodium oxybates) - Archived 10/01/2023
Y
Z
- ZALTRAP (ziv-aflibercept)
- ZAVESCA (miglustat)
- Zavesca (miglustat) - Archived 10/01/2023
- ZELBORAF (vemurafenib)
- Zepatier (grazoprevir/elbasvir) - Archived 7/1/2022
- Zeposia (ozanimod)
- Zeposia (ozanimod) - Archived 04/17/23
- ZOLADEX (goserelin acetate)
- Zoladex (goserelin acetate) - Archived on 10/1/2024
- Zolgensma (onasemnogene abeparvovec-xioi) - Archived on 12/31/2022
- ZOLINZA (vorinostat)
- ZOMETA (zoledronic acid)
- ZORBTIVE (somatropin)
- Zubsolv (buprenorphine and naloxone) sublingual tablets for sublingual administration archived on 1/1/23
- Zulresso (brexanolone) - Archived 9/30/2022
- Zulresso (brexanolone) - Archived on 07/01/2024
- Zulresso (brexanolone) - Archived on 07/01/2024
- ZYDELIG (idelalisib)
- ZYKADIA (ceritinib)
- Zynteglo (betibeglogene autotemcel) - Archived on 07/01/2024
- ZYTIGA (abiraterone)