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
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A
- Abatacept (Orencia) Injection
- Abecma (idecabtagene vicleucel) - Archived 9/30/2022
- Actemra (tocilizumab)
- Actemra (tocilizumab) - Archived 7/1/2022
- Acthar Gel (repository corticotropin injection) - Archived 12/31/2022
- Actimmune (Interferon gamma-1b)
- Adagen (pegademase bovine) injection
- Adakveo (crizanlizumab-tmca) - Archived 7/1/2022
- Adbry (tralokinumab-ldrm)
- Adcirca (tadalafil)
- Adempas (riociguat)
- Aduhelm (aducanumab-avwa) - Archived 7/1/2022
- AFINITOR (everolimus)
- Aimovig (erenumab-aooe) - Archived 9/30/2022
- Ajovy (fremanezumab-vfrm) - Archived 01/17/2023
- Ajovy (fremanezumab-vfrm) - Archived 9/30/2022
- ALDURAZYME (laronidase)
- Alpha 1-Proteinase Inhibitor Injection
- Alpha1-Proteinase Inhibitors
- Amevive (alefacept)
- Amondys 45 (casimersen) - Archived 7/1/2022
- Ampyra (dalfampridine)
- Anakinra (Kineret) Injection
- APOKYN (apomorphine)
- ARANESP (darbepoetin alfa)
- 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)
- 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 (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
- Biologic and other Ophthalmologic Agents
- Biologic Cholesterol Agents
- BOSULIF (bosutinib)
- BOTOX (onabotulinumtoxinA)
- 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
- Bunavail (buprenorphine and naloxone) buccal film Archived on 09/14/2022
- BUPHENYL (sodium phenylbutyrate)
C
- Cabenuva (cabotegravir/rilpivirine) - Archived on 9/30/2022
- 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)
- CEREZYME (imiglucerase)
- Cholesterol Lowering Agents for Homozygous Familial Hypercholesterolemia
- CIMZIA (certolizumab pegol)
- Cimzia (certolizumab pegol) - Archived 7/1/2022
- 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
- COPAXONE (glatiramer acetate)
- COSENTYX (secukinumab)
- Cosentyx (secukinumab)
- 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)
- Desmopressin Acetate (Stimate) Nasal Spray
- Diacomit (stiripentol) - Archived 9/30/2022
- Dispense as Written (DAW) Requests
- Dispense as Written (DAW) Requests
- Dupixent (dupilumab) - Archived on 12/31/2022
- Durolane (sodium hyaluronate) - Archived on 10/1/22
- Durysta (bimatoprost intracameral implant) - Archived 7/1/2022
- Dysport (abobotulinumtoxinA) - Archived 7/1/2022
E
- ELAPRASE (idursulfase)
- ELELYSO (taliglucerase alfa)
- ELIGARD (leuprolide acetate)
- Emflaza (deflazacort) - Archived 7/1/2022
- Emgality (galcanezumab-gnlm) - Archived 9/30/2022
- Emgality (galcanezumab-gnlm) - Archived on 12/31/2022
- ENBREL (etanercept)
- Enbrel (etanercept) - Archived 7/1/2022
- Entyvio (vedolizumab) - Archived on 12/31/2022
- Enzyme Replacement Therapy
- Enzyme Replacement Therapy and Agents
- Epclusa (Sofosbuvir/velpatasvir) - Archived 7/1/2022
- Epidiolex (cannabidiol) - Archived 9/30/2022
- 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
- Evkeeza (evinacumab-dgnb) - Archived 7/1/2022
- 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
F
- FABRAZYME (agalsidase beta)
- FARYDAK (panobinostat)
- Fasenra (benralizumab) - Archived 7/1/2022
- Fensolvi (leuprolide acetate) - Archived on 12/31/2022
- FERRIPROX (deferiprone)
- Fintepla (fenfluramine) - Archived 9/30/2022
- FIRAZYR (icatibant)
- Firazyr (icatibant) - Archived on 12/31/2022
- Firdapse (amifampridine) - Archived 7/1/2022
- Firmagon (degarelix)
- FORTEO (teriparatide)
- Forteo (teriparatide) - Archived 9/30/2022
- Fulphila (pegfilgrastim-jmdb)
G
- 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)
- GILENYA (fingolimod)
- 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
- Hepatitis C - Oral
- Hepatitis C - Oral
- Hereditary Angioedema and Pharmacotherapy
- Hereditary Angioedema and Pharmacotherapy
- HETLIOZ (tasimelteon)
- Home Infusion Therapy
- HUMIRA (adalimumab)
- 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
- 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 7/1/2022
- Ilumya (tildrakizumab-asmn)
- IMBRUVICA (ibrutinib)
- Imcivree (setmelanotide) - Archived on 12/31/2022
- Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
- Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
- Immune Globulin (IVIG, IGIV, or IMIG or SCIG)
- Immune Globulin (IVIG, IGIV, or IMIG or SCIG)
- INCRELEX (mecasermin)
- Inflammatory Bowel Disease: Biological Therapies
- Inflammatory Bowel Disease: Biological Therapies
- Inflectra (infliximab-dyyb)
- Infliximab (Avsola, Inflectra, Remicade, Renflexis) - Archived 10/1/2022
- Ingrezza (valbenazine) - Archived 9/30/2022
- Inhaled Prostacyclins for Pulmonary Arterial Hypertension: Tyvaso (treprostinil), Ventavis (iloprost) - Archived on 12/31/2022
- 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)
- INTRON A (interferon alfa-2b)
- Isturisa (osilodrostat) - Archived 9/30/2022
J
K
- KADCYLA (ado-trastuzumab)
- Kalbitor (ecallantide) - Archived on 12/31/2022
- KALYDECO (ivacaftor)
- Kalydeco (ivacaftor) - Archived 9/30/2022
- Kanuma (sebelipase alfa) - Archived 7/1/2022
- Kesimpta (ofatumumab) - Archived on 12/31/2022
- Kevzara (sarilumab) - Archived 7/1/2022
- KEYTRUDA (pembrolizumab)
- 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
- Krystexxa (pegloticase) - Archived on 12/31/2022
- KUVAN (sapropterin dihydrochloride)
- Kymriah (tisagenlecleucel) - Archived on 12/31/2022
L
- Lemtrada (alemtuzumab) - Archived on 12/31/2022
- LENVIMA (lenvatinib)
- Letairis (ambrisentan)
- LEUKINE (sargramostim)
- Leukine (sargramostim) - Archived on 09/14/2022
- Leuprolide acetate injection
- LUPANETA
- Lupaneta Pack (leuprolide acetate, norethindrone acetate) - Archived on 09/14/2022
- Lupkynis (voclosporin) - Archived on 12/31/2022
- Lupron DEPOT
- Lupron DEPOT
- LUPRON DEPOT Endometriosis
- LUPRON DEPOT PED
- LUPRON DEPOT Prostate
- Luxturna (voretigene neparvovec-rzyl) intraocular suspension for subretinal injection - Archived 7/1/2022
- LYNPARZA (olaparib)
M
- MACI (autologous cultured chondrocytes) - Archived 9/30/2022
- Mavenclad (cladribine) - Archived on 12/31/2022
- Mavyret (glecaprevir and pibrentasvir) - Archived 7/1/2022
- Medication Assisted Therapy (MAT) for Suboxone
- MEKINIST (trametinib)
- MENOPUR (menotropins for injection)
- Mitoxantrone
- Monovisc (sodium hyaluronate) - Archived on 10/1/22
- MOZOBIL (plerixafor)
- Multi-ingredient Compound Policy
- Multiple Sclerosis Therapy Class
- Multiple Sclerosis Therapy Class
- MYALEPT (metreleptin)
- Mycapssa (octreotide) - Archived 9/30/2022
- Myfembree (relugolix, estradiol, and norethindrone acetate) - Archived on 12/31/2022
- Myobloc (rimabotulinumtoxinB) - Archived 7/1/2022
N
- NAGLAZYME (galsulfase)
- NEULASTA (pegfilgrastim)
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
- NEUPOGEN (filgrastim)
- NEXAVAR (sorafenib)
- Nexviazyme (avalglucosidase alfa-ngp) - Archived 9/30/2022
- Noctiva (desmopressin acetate) intranasal 0.83 mcg/0.1 mL and 1.66 mcg/0.1 mL-archived on 12/13/22
- Novantrone (mitoxantrone) - Archived on 12/31/2022
- NOVAREL (chorionic gonadotropin)
- NUPLAZID (pimavanserin)
O
- ocrevus (ocrelizumab)
- Ocrevus (ocrelizumab) - Archived on 12/31/2022
- Ofev (nintedanib) - Archived 9/30/2022
- Off-Label Use Consideration and Excluded Indications
- Olumiant (baricitinib)
- Olumiant (baricitinib) - Archived 7/1/2022
- Olumiant (baricitinib) archived on 1/1/23
- ONCASPAR (pegaspargase)
- Onpattro (patisiran) - Archived on 12/31/2022
- Opsumit (macitentan)
- ORENCIA (abatacept)
- Orencia (abatacept) - Archived 7/1/2022
- Orenitram (treprostinil)
- ORFADIN (nitisinone)
- Orilissa (elagolix) - Archived on 12/31/2022
- ORKAMBI (lumacaftor/ivacaftor)
- Orkambi (lumacaftor/ivacaftor) - Archived 9/30/2022
- Orladeyo (berotralstat) - Archived on 12/31/2022
- Orthovisc (sodium hyaluronate) - Archived on 10/1/22
- OTEZLA (apremilast)
- Otezla (apremilast) - Archived 7/1/2022
- Oxbryta (voxelotor) - Archived 7/1/2022
- Oxervate (cenegermin-bkbj) - Archived 7/1/2022
- Oxlumo (lumasiran) - Archived 9/30/2022
P
- Palivizumab (Synagis)
- Palivizumab (Synagis)
- 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
- Pegylated and Non-Pegylated Interferon
- Pegylated and Non-Pegylated Interferon
- PLEGRIDY (peginterferon beta-1a)
- Plegridy (peginterferon beta-1a) archived on 1/1/23
- POMALYST (pomalidomide)
- PRALUENT (alirocumab)
- Praluent (alirocumab) - Archived 7/1/2022
- Probuphine (buprenorphine subdermal implant) - Archived on 09/14/2022
- PROLIA (denosumab)
- Prolia (denosumab) - Archived 9/30/2022
- PROMACTA (eltrombopag)
- 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
R
- REBIF (interferon beta-1a)
- Rebif (interferon beta-1a) archived on 1/1/23
- REMICADE (infliximab)
- Remicade (infliximab)
- Remicade (infliximab) - Archived 7/1/2022
- Remodulin (treprostinil injection)
- Renflexis (infliximab-abda)
- REPATHA (evolocumab)
- Repatha (evolocumab) - Archived 7/1/2022
- Revatio (sildenafil)
- REVLIMID (lenalidomide)
- Rheumatoid Arthritis, Inflammatory Bowel Disease, Psoriasis and Psoriatic Arthritis: Biological Therapies
- Rinvoq (upadacitinib)
- Rinvoq (upadacitinib) - Archived 7/1/2022
- Rituxan (Rituximab)
- Rituxan (rituximab)
- RITUXAN (rituximab)
- Rituxan (rituximab)
- Rituxan (rituximab) - Archived 7/1/2022
- RITUXAN (rituximab) Oncology
- RITUXAN HYCELA (rituximab and hyaluronidase human)
- Rituximab (Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima) - Archived 10/1/2022
- Rituximab (Rituxan, Ruxience, Truxima) - Archived on 12/31/2022
- Ruconest (C1 esterase inhibitor (recombinant)) - Archived on 12/31/2022
- Rukobia (fostemsavir) - Archived 9/30/2022
- RYDAPT (midostaurin)
S
- SABRIL (vigabatrin)
- SANDOSTATIN (octreotide acetate injection)
- Saphnelo (anifrolumab-fnia) - Archived on 12/31/2022
- Seizure Disorders
- Seizure Disorders (Repository Corticotropin Injection (H.P. Acthar Gel) and Vigabatrin (Sabril) Oral Solution and Tablets)
- SENSIPAR (cinacalcet)
- Short Bowel Syndrome (Gattex, Zorbitive)
- Short Bowel Syndrome (Gattex, Zorbtive)
- SIGNIFOR (pasireotide)
- SIGNIFOR LAR (pasireotide injectable suspension)
- Siliq (brodalumab)
- SIMPONI (golimumab)
- SIMPONI ARIA (golimumab)
- Simponi Aria (golimumab) - Archived 7/1/2022
- Skyrizi (risankizumab-rzaa)
- Skyrizi (risankizumab-rzaa) - Archived 7/1/2022
- Skyrizi (risankizumab-rzaa) archived on 1/1/23
- Somatropin Injection
- Somatropin Injection
- SOMATULINE DEPOT (lanreotide)
- SOMAVERT (pegvisomant)
- Spinraza (nusinersen) - Archived on 12/31/2022
- 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 (buprenorphine extended-release) injection, for subcutaneous use - Archived on 12/31/2022
- 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
- SUTENT (sunitinib)
- Symdeko (tezacaftor/ivacaftor) - Archived 9/30/2022
- 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 (lanadelumab-flyo) - Archived on 12/31/2022
- Taltz (ixekizumab)
- Taltz (ixekizumab) - Archived 7/1/2022
- TARCEVA (erlotinib)
- Targretin (bexarotene) capsules
- Tecartus (Brexucabtagene Autoleucel) - Archived 7/1/2022
- TECFIDERA (dimethyl fumarate)
- Tecfidera (dimethyl fumarate) - Archived on 12/31/2022
- Tegsedi (inotersen) - Archived on 12/31/2022
- Temodar temozolomide
- Tepezza (teprotumumab-trbw) - Archived 7/1/2022
- 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 10/1/2022
- TRELSTAR (triptorelin pamoate)
- Tremfya (guselkumab) - Archived 7/1/2022
- Tremfya (guselkumab) - Archived on 7/1/22
- Trikafta (elexacaftor, tezacaftor and ivacaftor tablets; ivacaftor tablets) - Archived 9/30/2022
- Trogarzo (ibalizumab-uiyk) - Archived 9/30/2022
- TYKERB (lapatinib)
- TYSABRI (natalizumab)
- Tysabri (natalizumab) - Archived on 12/31/2022
- Tysabri (Natalizumab) for Treatment of Crohn's Disease
- Tyvaso (treprostinil)
U
V
- 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
- VIVITROL (naltrexone)
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir) - Archived 7/1/2022
- VOTRIENT (pazopanib)
- VPRIV (velaglucerase alfa)
- Vumerity (diroximel fumarate) - Archived on 12/31/2022
- Vyepti (eptinezumab-jjmr) - Archived 9/30/2022
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis) - Archived on 12/31/2022
- Vyondys 53 (golodirsen) - Archived 7/1/2022
W
X
- XALKORI (crizotinib)
- XELJANZ (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib) - Archived 7/1/2022
- XELODA (capecitabine)
- XENAZINE (tetrabenazine)
- XEOMIN (incobotulinumtoxinA)
- Xeomin (incobotulinumtoxinA) - Archived 7/1/2022
- XGEVA (denosumab)
- Xgeva (denosumab) - Archived 9/30/2022
- Xolair (omalizumab) - Archived 7/1/2022
- Xolair Nucala
- Xolair/Nucala/Cinqair
Y
Z
- ZALTRAP (ziv-aflibercept)
- ZAVESCA (miglustat)
- ZELBORAF (vemurafenib)
- Zepatier (grazoprevir/elbasvir) - Archived 7/1/2022
- Zeposia (ozanimod)
- ZOLADEX (goserelin acetate)
- 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
- ZYDELIG (idelalisib)
- ZYKADIA (ceritinib)
- ZYTIGA (abiraterone)