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
- Beovu (brolucizumab)
- Beovu (brolucizumab)
- Beovu (brolucizumab) - Archived on 04/01/2025
- Botox (onabotulinumtoxinA) - Archived 01/01/2025
- Botox (onabotulinumtoxinA) - Archived 04/01/2025
- Botox (onabotulinumtoxinA) - Archived on 04/01/2024
- Botox (onabotulinumtoxinA) - Archived on 1/13/2023
- Breyanzi (lisocabtagene maraleucel)
- Breyanzi (lisocabtagene maraleucel) - Archived on 07/01/2025
- Brineura (cerliponase alfa)
- Brineura (cerliponase alfa) - Archived on 1/13/2023
C
D
- 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
- Elevidys (delandistrogene moxeparvovec-rokl) - Archived on 01/01/2025
- Entyvio (vedolizumab)
- Epidiolex (cannabidiol) - Archived on 01/14/2025
- Evkeeza (evinacumab-dgnb)
- Evkeeza (evinacumab-dgnb) - Archived on 1/13/2023
- Eylea (aflibercept)
- Eylea (aflibercept) - Archived on 04/01/2024
- Eylea and Eylea HD (aflibercept) - Archived on 04/01/2025
F
G
H
I
K
L
- Lamzede (velmanase alfa-tycv) - Archived on 10/01/2024
- Leqembi (lecanemab) - Archived on 07/01/2025
- Leqvio (inclisiran) - Archived on 1/13/2023
- Lumizyme (alglucosidase alfa) - Archived on 04/01/2024
- Luxturna (voretigene neparvovec-rzyl) - Archived on 1/13/2023
- 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 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
- Myobloc (rimabotulinumtoxinB)
- Myobloc (rimabotulinumtoxinB) - Archived on 06/11/2025
- Myobloc (rimabotulinumtoxinB) - Archived on 1/13/2023
N
O
P
Q
R
- Ranibizumab (Lucentis, Byooviz, Cimerli) - Archived on 04/01/2025
- Reblozyl (luspatercept-aamt) - Archived on 07/01/2024
- Retisert (fluocinolone acetonide) - Archived on 04/01/2024
- Rituxan (rituximab) - Archived on 1/13/2023
- 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
- Ruzurgi (amifampridine) - Archived on 09/10/2024
S
- Saphnelo (anifrolumab-fnia)
- Saphnelo (anifrolumab-fnia) - Archived on 07/01/2024
- Scenesse (Afamelanotide) - Archived on 01/01/2025
- Skysona (elivaldogene autotemcel) - Archived on 04/01/2025
- Soliris (eculizumab) - Archived on 10/01/2024
- Spravato (esketamine) - Archived on 02/21/2024
- Spravato (esketamine) - Archived on 03/13/2025
- Susvimo (ranibizumab)
- Susvimo (ranibizumab) - Archived on 04/01/2025
T
U
V
- Vabysmo (faricimab-svoa) - Archived on 04/01/2024
- Vabysmo (faricimab-svoa) - Archived on 04/01/2025
- Visudyne (verteporfin) - Archived on 04/01/2024
- 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