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
- Benlysta (belimumab) - Archived on 02/27/2026
- Beovu (brolucizumab)
- Beovu (brolucizumab)
- Beovu (brolucizumab) - Archived on 04/01/2025
- Beqvez (fidanacogene elaparvovec-dzkt) - Archived on 10/01/2025
- Berinert (C1 esterase inhibitor (human)) - Archived on 02/27/2026
- Bleeding Disorder Agents - Archived on 02/27/2026
- Botox (onabotulinumtoxinA) - Archived 01/01/2025
- Botox (onabotulinumtoxinA) - Archived 04/01/2025
- Botox (onabotulinumtoxinA) - Archived on 02/27/2026
- Botox (onabotulinumtoxinA) - Archived on 04/01/2024
- Botox (onabotulinumtoxinA) - Archived on 1/13/2023
- Breyanzi (lisocabtagene maraleucel)
- Breyanzi (lisocabtagene maraleucel) - Archived on 02/27/2026
- Breyanzi (lisocabtagene maraleucel) - Archived on 07/01/2025
- Brineura (cerliponase alfa)
- Brineura (cerliponase alfa) - Archived on 02/27/2026
- Brineura (cerliponase alfa) - Archived on 1/13/2023
- Briumvi (ublituximab-xiiy) - Archived on 02/27/2026
C
- Cabenuva (cabotegravir/rilpivirine)
- Cabenuva (cabotegravir/rilpivirine) - Archived on 02/27/2026
- Carvykti (ciltacabtagene autoleucel) - Archived on 02/27/2026
- Casgevy (exagamglogene autotemcel) - Archived on 01/12/2026
- Cinqair (reslizumab) - Archived on 04/01/2024
- Cinryze (C1 esterase inhibitor (human)) - Archived on 02/27/2026
- Continuous Glucose Monitors
- Continuous Glucose Monitors - Archived on 02/27/2026
- COVID-19 Vaccination - Archived on 11/24/2025
- Crysvita (burosumab-twza) - Archived on 02/27/2026
D
- Darzalex Faspro (daratumumab and hyaluronidase-fihj) - Archived on 02/27/2026
- Darzalex Faspro (daratumumab and hyaluronidase-fihj) - Archived on 04/01/2025
- Daxxify (DaxibotulinumtoxinA-lanm) - Archived on 04/01/2025
- Durysta (bimatoprost intracameral implant)
- Durysta (bimatoprost intracameral implant) - Archived on 08/16/2024
- Durysta (bimatoprost intracameral implant) - Archived on 1/13/2023
- Dysport (abobotulinumtoxinA)
- Dysport (abobotulinumtoxinA) - Archived on 04/01/2025
- Dysport (abobotulinumtoxinA) - Archived on 1/13/2023
E
- Elaprase (idursulfase) - Archived on 02/27/2026
- Elevidys (delandistrogene moxeparvovec-rokl) - Archived on 01/01/2025
- Elevidys (delandistrogene moxeparvovec-rokl) - Archived on 01/01/2026
- Elevidys (delandistrogene moxeparvovecrokl) - Archived on 02/27/2026
- Entyvio (vedolizumab)
- Entyvio (vedolizumab) - Archived on 02/27/2026
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa-iwxj) - Archived on 10/01/2025
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfaiwxj) - Archived on 02/27/2026
- ENZYME REPLACEMENT THERAPY (ERT) FOR GAUCHER DISEASE: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa) - Archived on 02/27/2026
- Epidiolex (cannabidiol) - Archived on 01/14/2025
- Euflexxa (sodium hyaluronate) - Archived on 02/27/2026
- Evkeeza (evinacumab-dgnb)
- Evkeeza (evinacumab-dgnb) - Archived on 1/13/2023
- Exondys 51 (eteplirsen) - Archived on 02/27/2026
- Eylea (aflibercept)
- Eylea (aflibercept) - Archived on 04/01/2024
- Eylea and Eylea HD (aflibercept) - Archived on 04/01/2025
F
G
- Gamifant (emapalumab-lzsg) - Archived on 01/01/2026
- Gamifant (emapalumab-lzsg) - Archived on 02/27/2026
- Gamifant (emapalumab-lzsg) - Archived on 04/01/2024
- Gel-One (sodium hyaluronate) - Archived on 02/27/2026
- Gelsyn-3 (sodium hyaluronate) - Archived on 02/27/2026
- GenVisc 850 (sodium hyaluronate) - Archived on 02/27/2026
- Givlaari (givosiran)
- Givlaari (givosiran) - Archived on 02/27/2026
- Givlaari (givosiran) - Archived on 07/01/2024
H
I
- Iluvien (fluocinolone acetonide) - Archived on 02/27/2026
- Iluvien (fluocinolone acetonide) - Archived on 04/01/2024
- Iluvien (fluocinolone acetonide) - Archived on 10/01/2025
- Injectable somatostatin analogs (First generation) - Archived on 02/27/2026
- IV Iron Products - Archived on 02/27/2026
- Izervay (avacincaptad pegol) - Archived on 02/27/2026
- Izervay (avacincaptad pegol) - Archived on 10/01/2025
K
- Kalbitor (ecallantide)
- Kalbitor (ecallantide) - Archived 01/01/2026
- Kanuma (sebelipase alfa)
- Kanuma (sebelipase alfa) - Archived on 1/13/2023
- Kisunla (donanemab) - Archived 01/01/2026
- Krystexxa (pegloticase)
- Krystexxa (pegloticase) - Archived on 02/27/2026
- Krystexxa (pegloticase) - Archived on 07/01/2025
- Kymriah (tisagenlecleucel) - Archived on 02/27/2026
- Kymriah (tisagenlecleucel) - Archived on 07/01/2025
L
- Lamzede (velmanase alfa-tycv) - Archived on 10/01/2024
- Lemtrada (alemtuzumab) - Archived 01/01/2026
- Lemtrada (alemtuzumab) - Archived on 02/27/2026
- Lenmeldy (atidarsagene autotemcel) - Archived on 02/27/2026
- Leqembi (lecanemab) - Archived on 02/27/2026
- Leqembi (lecanemab) - Archived on 07/01/2025
- Leqvio (inclisiran) - Archived on 02/27/2026
- Leqvio (inclisiran) - Archived on 1/13/2023
- Lucentis (ranibizumab) - Archived on 02/27/2026
- Lumizyme (alglucosidase alfa) - Archived on 02/27/2026
- Lumizyme (alglucosidase alfa) - Archived on 04/01/2024
- Luxturna (voretigene neparvovec-rzyl) - Archived on 1/13/2023
- Lyfgenia (lovotibeglogene autotemcel) - Archived on 01/12/2026
- Lyfgenia (lovotibeglogene autotemcel) - Archived on 10/01/2024
M
- MACI (autologous cultured chondrocytes) - Archived on 07/01/2025
- Macrilen (macimorelin) - Archived on 04/01/2024
- Macrilen (macimorelin) - Archived on 08/16/2024
- Macugen (pegaptanib)
- Macugen (pegaptanib) - Archived on 09/10/2024
- Medical Benefit Medications - Archived on 10/01/2025
- Medical Necessity - Off Label - Archived on 10/01/2025
- Medical Necessity – Off Label - Archived on 10/01/2024
- Medical Necessity for DAW - Archived on 07/01/2025
- Medical Necessity for DAW - Archived on 10/01/2024
- Medical Necessity for Non-Formulary Medications - Archived on 10/01/2024
- Multi-ingredient Compound Policy - Archived on 10/01/2025
- Myobloc (rimabotulinumtoxinB)
- Myobloc (rimabotulinumtoxinB) - Archived on 06/11/2025
- Myobloc (rimabotulinumtoxinB) - Archived on 1/13/2023
N
- Naglazyme (galsulfase) - Archived on 02/27/2026
- Nexviazyme (avalglucosidase alfa-ngp) - Archived on 02/27/2026
- Niktimvo (axatilimab) - Archived on 02/27/2026
- Niktimvo (axatilimab) - Archived on 07/01/2025
- Novantrone (mitoxantrone) - Archived 01/01/2026
- NPlate (romiplostim) - Archived 01/01/2026
- NPlate (romiplostim) - Archived on 02/27/2026
O
- Ocrevus (ocrelizumab) - Archived on 02/27/2026
- Onpattro (patisiran) - Archived on 10/01/2025
- Oxlumo (lumasiran) - Archived 01/01/2026
- Oxlumo (lumasiran) - Archived on 02/27/2026
- Oxlumo (lumasiran) - Archived on 04/01/2024
- Oxlumo (lumasiran) - Archived on 07/01/2024
- Oxlumo (lumasiran) - Archived on 10/01/2024
- Ozurdex (dexamethasone) - Archived on 01/01/2025
- Ozurdex (dexamethasone) - Archived on 02/27/2026
- Ozurdex (dexamethasone) - Archived on 04/01/2024
- Ozurdex (dexamethasone) - Archived on 10/01/2025
P
Q
R
- Radicava (edaravone injection); Radicava ORS (edaravone oral suspension) - Archived on 02/27/2026
- Ranibizumab (Lucentis, Byooviz, Cimerli) - Archived on 04/01/2025
- Ranibizumab (Lucentis, Byooviz, Cimerli) - Archived on 02/27/2026
- Reblozyl (luspatercept-aamt) - Archived on 07/01/2024
- Retisert (fluocinolone acetonide) - Archived on 02/27/2026
- Retisert (fluocinolone acetonide) - Archived on 04/01/2024
- Retisert (fluocinolone acetonide) - Archived on 10/01/2025
- Rituxan (rituximab) - Archived on 1/13/2023
- Rituximab (Rituxan, Truxima, Ruxience, Riabni) - Archived on 02/27/2026
- Rituximab (Rituxan, Truxima, Ruxience, Riabni) - Archived on 04/01/2025
- Rituxumab (Rituxan*, Truxima, Ruxience, Riabni) - Archived on 04/01/2024
- Rivfloza (nedosiran) - Archived on 10/01/2024
- Ruconest (C1 esterase inhibitor (recombinant)) - Archived on 02/27/2026
- Ruzurgi (amifampridine) - Archived on 09/10/2024
- Rystiggo (rozanolixizumab-noli) - Archived on 02/27/2026
- Rystiggo (rozanolixizumab-noli) - Archived on 10/01/2025
S
- Saphnelo (anifrolumab-fnia)
- Saphnelo (anifrolumab-fnia) - Archived on 02/27/2026
- Saphnelo (anifrolumab-fnia) - Archived on 07/01/2024
- Scenesse (Afamelanotide) - Archived on 01/01/2025
- Signifor, Signifor LAR (pasireotide) - Archived on 02/27/2026
- Skysona (elivaldogene autotemcel) - Archived on 04/01/2025
- Soliris (eculizumab) - Archived on 10/01/2024
- Soliris (eculizumab) - Archived on 10/01/2025
- Spevigo (spesolimab-sbzo) - Archived on 02/27/2026
- Spinraza (nusinersen) - Archived on 02/27/2026
- Spravato (esketamine) - Archived on 02/21/2024
- Spravato (esketamine) - Archived on 03/13/2025
- Strensiq (asfotase alfa) - Archived on 02/27/2026
- Susvimo (ranibizumab)
- Susvimo (ranibizumab) - Archived on 04/01/2025
- Susvimo (ranibizumab) - Archived on 10/01/2025
- Syfovre (pegcetacoplan) - Archived on 02/27/2026
- Syfovre (pegcetacoplan) - Archived on 10/01/2025
- Sylvant (siltuximab) - Archived on 02/27/2026
- Synagis (palivizumab) - Archived on 08/15/2025
T
- Tecartus (brexucabtagene autoleucel) - Archived on 02/27/2026
- Tecartus (Brexucabtagene Autoleucel) - Archived on 1/13/2023
- Tepezza (teprotumumab-trbw) - Archived on 02/27/2026
- Tepezza (teprotumumab-trbw) - Archived on 1/13/2023
- Tezspire (tezepelumab-eeko) archived on 1/1/23
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) - Archived on 02/27/2026
- Trogarzo (ibalizumab-uiyk) - Archived on 07/01/2024
- Tzield (teplizumab-mzwv) - Archived on 02/27/2026
- Tzield (teplizumab-mzwv) - Archived on 07/01/2025
U
- Ultomiris (ravulizumab-cwvz) - Archived on 02/27/2026
- Ultomiris (ravulizumab-cwvz) - Archived on 10/01/2024
- Ultomiris (ravulizumab-cwvz) - Archived on 10/01/2025
- Uplizna (inebilizumab-cdon) - Archived on 02/27/2026
- Uplizna (inebilizumab-cdon) - Archived on 10/01/2024
- Uplizna (inebilizumab-cdon) - Archived on 10/01/2025
V
- Vabysmo (faricimab-svoa) - Archived on 02/27/2026
- Vabysmo (faricimab-svoa) - Archived on 04/01/2024
- Vabysmo (faricimab-svoa) - Archived on 04/01/2025
- Vimizim (elosulfase alfa) - Archived on 02/27/2026
- Visudyne (verteporfin) - Archived on 04/01/2024
- Vyepti (eptinezumab-jjmr) - Archived on 02/27/2026
- 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
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) - Archived on 02/27/2026
X
- Xenpozyme (olipudase alfa-rpcp) - Archived on 10/01/2024
- Xeomin (incobotulinumtoxinA) - Archived on 02/27/2026
- Xeomin (incobotulinumtoxinA) - Archived on 04/01/2025
- Xeomin (incobotulinumtoxinA) - Archived on 1/13/2023
- Xipere (triamcinolone) - Archived on 04/01/2024
- Xipere (triamcinolone) - Archived on 10/01/2025