Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Adzynma (ADAMT S13, recombinant-krhn) - Archived on 11/01/2026
- Adzynma (ADAMTS13, recombinant-krhn) Archived on 06/30/2026
- Aflibercept (Eylea, Eylea HD, Pavblu) - Archived on 11/01/2026
- Aflibercept (Eylea, Eylea HD, Pavblu) Archived on 06/30/2026
- Aldurazyme (laronidase) - Archived on 09/30/2026
- Aldurazyme (laronidase) - Archived on 11/01/2026
- Alpha1-Proteinase Inhibitor (Aralast NP, Glassia, Prolastin C, Zemaira [human]) - Archived on 11/01/2026
- Amondys 45 (casimersen) - Archived on 11/01/2026
- Amvuttra (vutrisiran) - Archived on 11/01/2026
- Avlayah (tividenofusp alfa-eknm) - Archived on 11/01/2026
B
C
- Cabenuva (cabotegravir/rilpivirine) - Archived on 11/01/2026
- Cinqair (reslizumab) - Archived on 11/01/2026
- Cortrophin Gel (corticotropin) - Archived on 11/01/2026
- Crysvita (burosumab-twza) - Archived on 11/01/2026
- Cytogam (cytomegalovirus immune globulin ) - Archived on 11/01/2026
- Cytogam (cytomegalovirus immune globulin) Archived on 06/30/2026
D
E
- Elaprase (idursulfase) - Archived on 09/30/2026
- Elaprase (idursulfase) - Archived on 11/01/2026
- Elevidys (delandistrogene moxeparvovec-rokl) - Archived on 11/01/2026
- Enjaymo (sutimlimab) - Archived on 11/01/2026
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfaiwxj) - Archived on 11/01/2026
- Enzyme Replacement Therapy (ERT) for Gaucher Disease: Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), Vpriv (velaglucerase alfa) - Archived on 11/01/2026
- Evenity (romosozumab-aqqg) - Archived on 11/01/2026
- Evkeeza (evinacumab-dgnb) - Archived on 04/01/2026
- Evkeeza (evinacumab-dgnb) - Archived on 11/01/2026
- Exdensur (depemokimab-ulaa) - Archived on 11/01/2026
- Exondys 51 (eteplirsen) - Archived on 11/01/2026
G
H
I
- Ilaris (canakinumab) - Archived on 11/01/2026
- Iluvien (fluocinolone acetonide) - Archived on 11/01/2026
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gamunex-C, Panzyga, Privigen, Yimmugo Subcutaneous (SCIG): Hizentra, HyQvia, Xembify - Archived on 11/01/2026
- Itvisma (onasemnogene abeparvovec-brve) - Archived on 11/01/2026
- Izervay (avacincaptad pegol) - Archived on 11/01/2026
K
L
- Lamzede (velmanase alfa-tycv) - Archived on 11/01/2026
- Lemtrada (alemtuzumab) - Archived on 11/01/2026
- Lenmeldy (atidarsagene autotemcel) - Archived on 11/01/2026
- Leqembi (lecanemab) - Archived on 04/01/2026
- Leqembi (lecanemab) - Archived on 11/01/2026
- Leqvio (inclisiran) - Archived on 04/01/2026
- Leqvio (inclisiran) - Archived on 11/01/2026
- Lumizyme (alglucosidase alfa) - Archived on 11/01/2026
- Lupkynis (voclosporin) - Archived on 11/01/2026
- Luxturna (voretigene neparvovec-rzyl) - Archived on 11/01/2026
M
- MACI (autologous cultured chondrocytes) - Archived on 11/01/2026
- Macrilen (macimorelin) - Archived on 11/01/2026
- Medical Benefit Medications - Archived on 11/01/2026
- Medical Benefit Medications Archived on 06/30/2026
- Medical Necessity for Multi-Source Brands - Archived on 11/01/2026
- Medical Necessity Off Label
- Mepsevii (vestronidase alfa-vjbk) - Archived on 09/30/2026
- Mepsevii (vestronidase alfa-vjbk) - Archived on 11/01/2026
- Multi-ingredient Compound Policy - Archived on 11/01/2026
N
- Naglazyme (galsulfase) - Archived on 09/30/2026
- Naglazyme (galsulfase) - Archived on 11/01/2026
- Natalizumab (Tysabri, Tyruko) - Archived on 11/01/2026
- Nexviazyme (avalglucosidase alfa-ngp) - Archived on 11/01/2026
- Niktimvo (axatilimab) - Archived on 11/01/2026
- Novantrone (mitoxantrone) - Archived on 11/01/2026
- NPlate (romiplostim) - Archived on 11/01/2026
- Nulibry (fosdenopterin) - Archived on 11/01/2026
- Nulibry (fosdenopterin) Archived on 06/30/2026
O
- Ocrevus (ocrelizumab) and Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) - Archived on 11/01/2026
- Omvoh (mirikizumab-mrkz) - Archived on 11/01/2026
- Oncology Regimens - Archived on 11/01/2026
- Oncology Regimens Archived on 06/30/2026
- Onpattro (patisiran) - Archived on 11/01/2026
- Oxlumo (lumasiran) - Archived on 11/01/2026
- Ozurdex (dexamethasone) - Archived on 11/01/2026
P
- Panhematin (hemin for injection) - Archived on 11/01/2026
- Papzimeos (imadenovec-drba) - Archived on 11/01/2026
- PiaSky (crovalimab-akkz) - Archived on 11/01/2026
- Pombiliti (cipaglucosidase alfa-atga) and Opfolda (miglustat) - Archived on 11/01/2026
- Prevymis (letermovir) - Archived on 11/01/2026
- Prolia (denosumab) - Archived on 11/01/2026
Q
R
- Ranibizumab (Lucentis, Byooviz, Cimerli) - Archived on 11/01/2026
- Reblozyl (luspatercept-aamt) - Archived on 06/30/2026
- Reblozyl (luspatercept-aamt) - Archived on 11/01/2026
- Rebyota (fecal microbiota, live - jslm) - Archived on 11/01/2026
- Retisert (fluocinolone acetonide) - Archived on 11/01/2026
- Rituximab (Rituxan, Truxima, Ruxience, Riabni) - Archived on 06/30/2026
- Rituximab (Rituxan, Truxima, Ruxience, Riabni) - Archived on 11/01/2026
- Rivfloza (nedosiran) - Archived on 11/01/2026
- Roctavian (valoctocogene roxaparvovec) - Archived on 11/01/2026
- Ryplazim (plasminogen, human-tvmh) - Archived on 11/01/2026
- Rystiggo (rozanolixizumab-noli) - Archived on 11/01/2026
S
- Saphnelo (anifrolumab-fnia) - Archived on 04/01/2026
- Saphnelo (anifrolumab-fnia) - Archived on 11/01/2026
- Scenesse (afamelanotide) - Archived on 11/01/2026
- Skyrizi (risankizumab-rzaa) - Archived on 11/01/2026
- Skysona (elivaldogene autotemcel) - Archived on 11/01/2026
- Soliris (eculizumab) - Archived on 11/01/2026
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide) - Archived on 11/01/2026
- Spevigo (spesolimab-sbzo) - Archived on 11/01/2026
- Spinraza (nusinersen) - Archived on 06/30/2026
- Spinraza (nusinersen) - Archived on 11/01/2026
- Spravato (esketamine) - Archived on 11/01/2026
- Standard Medical Billing Guidance - Archived on 11/01/2026
- Sunlenca (lenacapavir) - Archived on 11/01/2026
- Supprelin LA (histrelin acetate) - Archived on 11/01/2026
- Susvimo (ranibizumab) - Archived on 11/01/2026
- Syfovre (pegcetacoplan) - Archived on 11/01/2026
T
- Tepezza (teprotumumab-trbw) - Archived on 11/01/2026
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) - Archived on 06/30/2026
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) - Archived on 11/01/2026
- Triptodur (triptorelin) - Archived on 11/01/2026
- Trogarzo (ibalizumab-uiyk) - Archived on 11/01/2026
- Tysabri (natalizumab) - Archived on 04/01/2026
- Tysabri (natalizumab) - Archived on 09/30/2026
- Tzield (teplizumab-mzwv) - Archived on 11/01/2026
U
V
- Vabysmo (faricimab-svoa) - Archived on 11/01/2026
- Veopoz (Pozelimab) - Archived on 11/01/2026
- Viltepso (viltolarsen) - Archived on 11/01/2026
- Vimizim (elosulfase alfa) - Archived on 09/30/2026
- Vimizim (elosulfase alfa) - Archived on 11/01/2026
- Visudyne (verteporfin) - Archived on 11/01/2026
- Vyepti (eptinezumab-jjmr) - Archived on 11/01/2026
- Vyjuvek (beremagene geperpavec-svdt) - Archived on 11/01/2026
- Vyondys 53 (golodirsen) - Archived on 11/01/2026
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) - Archived on 11/01/2026