Archived Pharmacy Policies
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A
- Abecma (idecabtagene vicleucel) - Archived 10/1/2022
- Actemra (tocilizumab) - Archived on 7/1/2022
- Acthar Gel (repository corticotropin injection)-archived on 1/1/23
- Adakveo (crizanlizumab-tmca) - Archived on 7/1/2022
- Adalimumab (Amjevita, Humira) - Archived 06/30/2023
- Aduhelm (aducanumab-avwa) - Archived on 7/1/2022
- Aimovig (erenumab-aooe)
- Aimovig (erenumab-aooe) - Archived 08/23/2023
- Aimovig (erenumab-aooe) - Archived 10/1/2022
- Aimovig (erenumab-aooe) - Archived on 06/19/2023
- Ajovy (fremanezumab-vfrm) - Archived 01/17/2023
- Ajovy (fremanezumab-vfrm) - Archived 10/1/2022
- Amevive (alefacept)
- Amondys 45 (casimersen) - Archived on 7/1/2022
- Apretude (cabotegravir extended-release) - Archived 07/01/2023
- Aralast NP, Glassia, Prolastin C, Zemaira (alpha1- proteinase inhibitor [human])
- Aralast NP, Glassia, Prolastin C, Zemaira (alpha1- proteinase inhibitor [human])
- Aranesp (darbepoetin alfa) - Archived on 4/1/23
- Arcalyst (Rilonacept) - Archived on 7/1/2022
- Aubagio (teriflunomide)-archived on 1/1/23
- Austedo (deutetrabenazine) - Archived 10/1/2022
- Avonex (interferon beta-1a) archived on 1/1/23
B
- Bafiertam (monomethyl fumarate)-archived on 1/1/23
- Benlysta (belimumab)-archived on 1/1/23
- Beovu (brolucizumab)
- Beovu (brolucizumab)-archived on 1/1/23
- Berinert (C1 esterase inhibitor (human))-archived on 1/1/23
- Betaseron (interferon beta-1b) archived on 1/1/23
- Bethkis (tobramycin inhalation solution) - Archived 10/1/2022
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev) - Archived 10/1/2022
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev) Archived 01/01/2023
- Bleeding Disorder Agents - Archived on 4/1/23
- Botox (onabotulinumtoxinA)
- Botox (onabotulinumtoxinA) - Archived on 7/1/2022
- Breyanzi (lisocabtagene maraleucel) archived on 1/1/23
- Brineura (cerliponase alfa) - Archived on 7/1/2022
- Bunavail (buprenorphine and naloxone) buccal film Archived on 09/14/2022
C
- Cabenuva (cabotegravir/rilpivirine)
- Cabenuva (cabotegravir/rilpivirine) - Archived 10/1/2022
- Cayston (aztreonam inhalation solution) - Archived 10/1/2022
- Cibinqo (abrocitinib) - Archived on 07/01/2023
- Cimzia (certolizumab pegol) - Archived 04/17/23
- Cimzia (certolizumab pegol) - Archived on 7/1/2022
- Cinqair (reslizumab) - Archived on 7/1/2022
- Cinryze (C1 esterase inhibitor (human)) archived on 1/1/23
- Continuous Glucose Monitors - Archived on 7/1/22
- Cosentyx (secukinumab)
- Cosentyx (secukinumab)
- Crysvita (burosumab-twza) - Archived 10/1/2022
D
- Dalfampridine (generic for Ampyra)
- Dalfampridine (generic for Ampyra)-archived on 1/1/23
- Diacomit (stiripentol) - Archived 10/1/2022
- Diacomit (stiripentol) - Archived on 4/1/23
- Doptelet (avatrombopag) - Archived on 07/01/2023
- Dupixent (dupilumab)
- Dupixent (dupilumab) - Archived on 4/1/23
- Dupixent (dupilumab) archived on 1/1/23
- Durolane (sodium hyaluronate) - Archived on 10/1/22
- Durysta (bimatoprost intracameral implant) - Archived on 7/1/2022
- Dysport (abobotulinumtoxinA)
- Dysport (abobotulinumtoxinA) - Archived on 7/1/2022
E
- Emflaza (deflazacort) - Archived on 7/1/2022
- Emgality (galcanezumab-gnlm)
- Emgality (galcanezumab-gnlm) - Archived 10/1/2022
- Emgality (galcanezumab-gnlm) - Archived on 06/19/2023
- Emgality (galcanezumab-gnlm) archived on 1/1/23
- Enbrel (etanercept) - Archived on 7/1/2022
- Entyvio (vedolizumab) archived on 1/1/23
- Epclusa (Sofosbuvir/velpatasvir) - Archived on 7/1/2022
- Epidiolex (cannabidiol) - Archived 10/1/2022
- Epogen (epoetin alfa) - Archived 07/20/2023
- Esbriet (pirfenidone) - Archived 10/1/2022
- Euflexxa (sodium hyaluronate) - Archived on 10/1/22
- Evenity (romosozumab-aqqg) - Archived 10/1/2022
- Evenity (romosozumab-aqqg) - Archived on 07/01/2023
- Evkeeza (evinacumab-dgnb) - Archived on 7/1/2022
- Evrysdi (risdiplam) archived on 1/1/23
- Exondys 51 (eteplirsen) - Archived on 7/1/2022
- Extavia (interferon beta-1b) archived on 1/1/23
F
- Fabrazyme (agalsidase beta) - Archived on 4/1/23
- Fasenra (benralizumab) - Archived on 7/1/2022
- Fensolvi (leuprolide acetate) archived on 1/1/23
- Fintepla (fenfluramine) - Archived 10/1/2022
- Firazyr (icatibant) archived on 1/1/23
- Firdapse (amifampridine) - Archived on 4/1/23
- Firdapse (amifampridine) - Archived on 7/1/2022
- Forteo - Archived on 07/01/2023
- Forteo (teriparatide) - Archived 10/1/2022
- Forteo (teriparatide) - Archived on 4/1/23
- Fulphila (pegfilgrastim-jmdb)
G
- Galafold (migalastat)
- Galafold (migalastat) - Archived on 4/1/23
- Gel-One (sodium hyaluronate) - Archived on 10/1/22
- Gelsyn-3 (sodium hyaluronate) - Archived on 10/1/22
- Gender–Affirming Hormone Therapy - Archived 10/1/2022
- 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
- Granix (tbo-filgrastim) - Archived on 09/14/2022
H
- Haegarda (C1 esterase inhibitor (human)) archived on 1/1/23
- Harvoni (ledipasvir/sofosbuvir) - Archived on 7/1/2022
- Humatrope (somatropin)
- Humira (adalimumab)
- Humira (adalimumab) - Archived 04/17/23
- Humira (adalimumab) - Archived on 7/1/2022
- Humira (adalimumab) - Archived on 7/1/22
- Hyalgan (sodium hyaluronate) - Archived on 10/1/22
- Hyaluronic Acid Viscosupplements - Archived on 4/1/23
- Hymovis (sodium hyaluronate) - Archived on 10/1/22
I
- Ilaris (canakinumab)
- Ilaris (canakinumab) - Archived on 7/1/2022
- Ilumya (tildrakizumab-asmn)
- Imbruvica (ibrutinib) - Archived on 4/1/23
- Imcivree (setmelanotide) archived on 1/1/23
- Inflectra (infliximab-dyyb)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis) - Archived 10/1/2022
- Ingrezza (valbenazine) - Archived 10/1/2022
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost) archived on 1/1/23
- Injectable somatostatin analogs (First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline depot (lanreotide), Bynfezia Pen (octreotide)
- Isturisa (osilodrostat) - Archived 10/1/2022
J
K
- Kalbitor (ecallantide) archived on 1/1/23
- Kalydeco (ivacaftor) - Archived 10/1/2022
- Kanuma (sebelipase alfa) - Archived on 7/1/2022
- Kesimpta (ofatumumab) archived on 1/1/23
- Kevzara (sarilumab) - Archived 04/17/23
- Kevzara (sarilumab) - Archived on 7/1/2022
- Kineret (anakinra)
- Kineret (anakinra) - Archived 04/17/23
- Kineret (anakinra) - Archived on 7/1/2022
- Kitabis Pak (tobramycin inhalation solution) - Archived 10/1/2022
- Korlym (mifepristone) - Archived 10/1/2022
- Korsuva (difelikefalin) - Archived 10/1/2022
- Krystexxa (pegloticase) archived on 1/1/23
- Kuvan (sapropterin) - Archived on 4/1/23
- Kymriah (tisagenlecleucel) archived on 1/1/23
L
- Lemtrada (alemtuzumab) archived on 1/1/23
- Leukine (sargramostim) - Archived on 09/14/2022
- Long Term Continuous Glucose Monitors - Archived on 07/10/2023
- Long Term Continuous Glucose Monitors - Archived on 8/22/2023
- Lumizyme (alglucosidase alfa) - Archived on 4/1/23
- Lupaneta Pack (leuprolide acetate, norethindrone acetate) - Archived on 09/14/2022
- Lupkynis (voclosporin) archived on 1/1/23
- Luxturna (voretigene neparvovec-rzyl) intraocular suspension for subretinal injection - Archived on 7/1/2022
M
- MACI (autologous cultured chondrocytes) - Archived 10/1/2022
- Macrilen (macimorelin) - Archived on 4/1/23
- Makena (hydroxyprogesterone caproate) - Archived on 04/20/23
- Mavenclad (cladribine) archived on 1/1/23
- Mavyret (glecaprevir and pibrentasvir) - Archived on 7/1/2022
- Mayzent (siponimod)
- Mayzent (siponimod) - Archived on 4/1/23
- 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
- Mepsevii (vestronidase alfa-vjbk)
- Monovisc (sodium hyaluronate) - Archived on 10/1/22
- Mulpleta (lusutrombopag) - Archived on 07/01/2023
- Multi-ingredient Compound Policy - Archived 07/20/2023
- Mycapssa (octreotide) - Archived 10/1/2022
- Myfembree (relugolix, estradiol, and norethindrone acetate) archived on 1/1/23
- Myobloc (rimabotulinumtoxinB)
- Myobloc (rimabotulinumtoxinB) - Archived on 7/1/2022
N
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
- Nexviazyme (avalglucosidase alfa-ngp) - Archived 10/1/2022
- Noctiva (desmopressin acetate) intranasal 0.83 mcg/0.1 mL and 1.66 mcg/0.1 mL-archived on 12/13/22
- Norditropin (somatropin)
- Novantrone (mitoxantrone) archived on 1/1/23
- NPlate (romiplostim)
- NPlate (romiplostim) - Archived on 07/01/2023
- Nucala (mepolizumab) - Archived on 4/1/23
- Nutropin AQ (somatropin)
O
- Ocrevus (ocrelizumab)
- Ocrevus (ocrelizumab) archived on 1/1/23
- Ofev (nintedanib) - Archived 10/1/2022
- Olumiant (baricitinib)
- Olumiant (baricitinib) - Archived 04/17/23
- Olumiant (baricitinib) - Archived on 7/1/2022
- Olumiant (baricitinib) archived on 1/1/23
- Omnitrope (somatropin) cartridge 5 mg/1.5 mL and 10 mg/1.5 mL, Omnitrope (somatropin) for injection 5.8 mg/vial
- Onpattro (patisiran) archived on 1/1/23
- Orencia (abatacept) - Archived 04/17/23
- Orencia (abatacept) - Archived on 7/1/2022
- Orilissa (elagolix) archived on 1/1/23
- Orkambi (lumacaftor/ivacaftor) - Archived 10/1/2022
- Orkambi (lumacaftor/ivacaftor) - Archived on 4/1/23
- Orladeyo (berotralstat) archived on 1/1/23
- Orthovisc (sodium hyaluronate) - Archived on 10/1/22
- Otezla (apremilast) - Archived on 7/1/2022
- Oxbryta (voxelotor) - Archived on 7/1/2022
- Oxervate (cenegermin-bkbj) - Archived on 7/1/2022
- Oxlumo (lumasiran) - Archived 10/1/2022
- Oxlumo (lumasiran) - Archived on 4/1/23
P
- Palynziq (pegvaliase-pqpz) - Archived on 4/1/23
- Pegasys (peginterferon alfa-2a) archived on 1/1/23
- Pegfilgrastim (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo) - Archived 10/1/2022
- Plegridy (peginterferon beta-1a)
- Plegridy (peginterferon beta-1a) archived on 1/1/23
- Ponvory (ponesimod)
- Ponvory (ponesimod) - Archived on 4/1/23
- Praluent (alirocumab) - Archived on 7/1/2022
- Probuphine (buprenorphine subdermal implant) - Archived on 09/14/2022
- Procrit (epoetin alfa) - Archived 07/20/2023
- Prolia (denosumab) - Archived 10/1/2022
- Promacta (eltrombopag) - Archived on 07/01/2023
- Pulmozyme (dornase alfa inhalation solution) - Archived 10/1/2022
R
- Radicava (edaravone injection) - Archived on 4/1/23
- Ravicti (glycerol phenylbuytyrate) - Archived on 07/01/2023
- Rebif (interferon beta-1a) archived on 1/1/23
- Reblozyl (luspatercept-aamt) - Archived on 4/1/23
- Remicade (infliximab)
- Remicade (infliximab) - Archived on 7/1/2022
- Renflexis (infliximab-abda)
- Repatha (evolocumab) - Archived on 04/13/23
- Retacrit (epoetin alfa-epbx) - Archived 07/20/2023
- Rinvoq (upadacitinib)
- Rinvoq (upadacitinib)
- Rinvoq (upadacitinib) - Archived on 07/01/2023
- Rinvoq (upadacitinib) - Archived on 7/1/2022
- Rituxan (rituximab)
- Rituxan (rituximab) - Archived on 7/1/2022
- Rituximab (Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima) - Archived 10/1/2022
- Rituximab (Rituxan, Ruxience, Truxima) - Archived on 07/01/2023
- Rituximab (Rituxan, Ruxience, Truxima) archived on 1/1/23
- Ruconest (C1 esterase inhibitor (recombinant)) archived on 1/1/23
- Rukobia (fostemsavir) - Archived 10/1/2022
S
- Saphnelo (anifrolumab-fnia) archived on 1/1/23
- Scenesse (Afamelanotide) - Archived on 4/1/23
- Siliq (brodalumab)
- Siliq (brodalumab) - Archived 04/17/23
- Simponi (golimumab) - Archived 04/17/23
- Simponi Aria (golimumab) - Archived on 7/1/2022
- Skyrizi (risankizumab-rzaa)
- Skyrizi (risankizumab-rzaa) - Archived on 7/1/2022
- Skyrizi (risankizumab-rzaa) archived on 1/1/23
- Sofosbuvir/velpatasvir (generic for Epclusa) - Archived on 11/18/2022
- Soliris (eculizumab)
- Somatostatin Analogs - Archived 10/1/2022
- Spinraza (nusinersen) archived on 1/1/23
- Spravato (esketamine) - Archived on 08/23/2023
- Stelara (ustekinumab)
- Stelara (ustekinumab)
- Stelara (ustekinumab) - Archived on 7/1/2022
- Stelara (ustekinumab) archived on 1/1/23
- Strensiq (asfotase alfa) - Archived on 9/30/2022
- Sublocade (buprenorphine extended-release) injection, for subcutaneous use archived on 1/1/23
- 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
- Supartz FX (sodium hyaluronate) - Archived on 10/1/22
- Symdeko (tezacaftor/ivacaftor) - Archived on 9/30/2022
- Synagis (palivizumab)
- Synagis (palivizumab) - Archived on 9/20/2022
- Synvisc-One (sodium hyaluronate)
- Synvisc-One (sodium hyaluronate) - Archived on 10/1/22
T
- Takhzyro (lanadelumab-flyo) - Archived on 07/01/2023
- Takhzyro (lanadelumab-flyo) archived on 1/1/23
- Taltz (ixekizumab)
- Taltz (ixekizumab) - Archived 04/17/23
- Taltz (ixekizumab) - Archived on 7/1/2022
- Tavalisse (fostamatinib disodium hexahydrate) - Archived on 07/01/2023
- Tecartus (Brexucabtagene Autoleucel) - Archived on 7/1/2022
- Tecfidera (dimethyl fumarate) archived on 1/1/23
- Tegsedi (inotersen) archived on 1/1/23
- Tepezza (teprotumumab-trbw) - Archived on 7/1/2022
- Tobi (tobramycin inhalation solution), Tobi Podhaler - Archived 10/1/2022
- Trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) - Archived 10/1/2022
- Tremfya (guselkumab)
- Tremfya (guselkumab) - Archived on 04/12/23
- Tremfya (guselkumab) - Archived on 7/1/2022
- Tremfya (guselkumab) - Archived on 7/1/22
- Trikafta (elexacaftor, tezacaftor and ivacaftor tablets; ivacaftor tablets) - Archived 10/1/2022
- Trogarzo (ibalizumab-uiyk) - Archived 10/1/2022
- Trogarzo (ibalizumab-uiyk) - Archived on 07/01/2023
- Tymlos (abaloparatide) - Archived on 07/01/2023
- Tysabri (natalizumab) archived on 1/1/23
U
V
- Varubi (rolapitant) - Archived on 8/24/2022
- Vigabatrin (generic for Sabril), Vigadrone archived on 1/1/23
- Viltepso (viltolarsen) - Archived on 7/1/2022
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir) - Archived on 7/1/2022
- Vumerity (diroximel fumarate) archived on 1/1/23
- Vyepti (eptinezumab-jjmr) - Archived 10/1/2022
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis) archived on 1/1/23
- Vyondys 53 (golodirsen) - Archived on 7/1/2022
X
- Xeljanz/Xeljanz XR (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib) - Archived 04/17/23
- Xeljanz/Xeljanz XR (tofacitinib) - Archived on 7/1/2022
- Xeomin (incobotulinumtoxinA)
- Xeomin (incobotulinumtoxinA) - Archived on 7/1/2022
- Xgeva (denosumab) - Archived 10/1/2022
- Xolair (omalizumab) - Archived on 7/1/2022
Y
Z
- Zarxio (filgrastim-sndz) - Archived on 04/13/23
- Zavesca (miglustat)
- Zepatier (grazoprevir/elbasvir) - Archived on 7/1/2022
- Zeposia (ozanimod)
- Zolgensma (onasemnogene abeparvovec-xioi) archived on 1/1/23
- Zubsolv (buprenorphine and naloxone) sublingual tablets for sublingual administration archived on 1/1/23
- Zulresso (brexanolone) - Archived 07/20/2023
- Zulresso (brexanolone) - Archived 10/1/2022