Archived Pharmacy Policies
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A
- Actemra (tocilizumab)
- Actemra (tocilizumab)
- Actemra (tocilizumab)
- Actemra (tocilizumab)
- Actemra (tocilizumab)
- Actemra (tocilizumab) - Archived on 10/1/2022
- Adakveo (crizanlizumab-tmca)
- Adakveo (crizanlizumab-tmca)
- Aimovig (erenumab-aooe) archived on 01/09/23
- Aimovig (erenumab-aooe)
- Aimovig (erenumab-aooe)
- Aimovig (erenumab-aooe)
- Aimovig (erenumab-aooe)
- Aimovig (erenumab-aooe) Archived on 01/01/2023
- Ajovy (fremanezumab-vfrm)
- Ajovy (fremanezumab-vfrm)
- Ajovy (fremanezumab-vfrm)
- Alpha 1-Proteinase Inhibitor Injection
- Alpha-1 Proteinase Inhibitors
- Alunbrig (brigatinib)
- Amevive (alefacept)
- Amevive (alefacept)
- Ampyra (dalfampridin) archived on 1/1/23
- Ampyra (dalfampridine)
- Antihemophilic agents
- Antihemophilic Agents
- Antihemophilic Agents
- Apretude (cabotegravir extended-release) - Archived 04/24/23
- Aranesp (darbepoetin alfa)
- Aranesp (darbepoetin alfa)
- Aubagio (teriflunomide)
- Austedo (deutetrabenazine)
- Austedo (deutetrabenazine)
- Autoimmune Diseases: Biologic Therapies
- Avonex (interferon beta-1a)
- Avonex (interferon beta-1a) archived on 1/1/23
B
- Bafiertam (monomethyl fumarate) archived on 1/1/23
- Bavencio (avelumab)
- Bavencio (avelumab)
- Benlysta (belimumab)
- Benlysta (belimumab)
- Benlysta (belimumab)
- Benlysta (belimumab)
- Beovu (brolucizumab)
- Beovu (brolucizumab) archived on 1/1/23
- Berinert (C1 Esterase Inhibitor (Human))
- Berinert (C1 Esterase Inhibitor (Human))
- Betaseron (interferon beta-1b)
- Betaseron (interferon beta-1b) archived on 1/1/23
- Bethkis (tobramycin inhalation solution)
- Bethkis (tobramycin inhalation solution) - Archived on 10/1/2022
- Biologic and other Ophthalmologic Agents
- Biologic Cholesterol Agents
- Boniva (ibandronate) injection
- Botox (onabotulinumtoxinA)
- Botox (onabotulinumtoxinA)
- Botox (onabotulinumtoxinA)
- Botox (onabotulinumtoxinA)
- Botox (onabotulinumtoxinA)
- Botox (onabotulinumtoxinA) - Archived on 7/1/2022
- Botulinum Toxin Injection
- Brineura (cerliponase alfa)
- Brineura (cerliponase alfa) - Archived on 7/1/2022
- Bronchitol (mannitol) - Archived on 10/1/2022
- Bunavail (buprenorphine and naloxone) buccal film
- Bunavail (buprenorphine and naloxone) buccal film
- Bunavail (buprenorphine and naloxone) buccal film Archived on 09/14/2022
C
- Cabenuva (cabotegravir/rilpivirine)
- Calcium Regulators (Reclast, Zometa, Boniva, Prolia, Forteo, Xgeva)
- Calquence (acalabrutinib)
- Cayston (aztreonam inhalation solution)
- Cayston (aztreonam inhalation solution) - Archived on 10/1/2022
- Cimzia (certolizumab pegol)
- Cimzia (certolizumab pegol)
- Cimzia (certolizumab pegol)
- Cimzia (certolizumab pegol)
- Cimzia (certolizumab pegol)
- Cinqair (reslizumab)
- Cinryze (C1 esterase inhibitor (human))
- Cinryze (C1 esterase inhibitor (human))
- Cinryze (C1 esterase inhibitor (human))
- Cinryze (C1 esterase inhibitor (human)) - Archived on 01/01/2023
- Colony Stimulating Factors
- Continuity of Care
- Copaxone (glatiramer acetate)
- Cosentyx (secukinumab)
- Cosentyx (secukinumab)
- Cosentyx (secukinumab)
- Cosentyx (secukinumab)
- Crysvita (burosumab-twza)
- Crysvita (burosumab-twza)
- Crysvita (burosumab-twza)
- Cystic Fibrosis
D
- Diacomit (stiripentol)
- Diacomit (stiripentol) - Archived on 09/14/2022
- Dispense as Written (DAW) Requests
- Dispense as Written (DAW) Requests
- Doptelet (avatrombopag)
- Dupixent (dupilumab)
- Dupixent (dupilumab)
- Dupixent (dupilumab)
- Dupixent (dupilumab)
- Dupixent (dupilumab)
- Dupixent (dupilumab) archived on 01/09/23
- Dupixent (dupilumab) archived on 1/1/23
- Durolane (sodium hyaluronate)
- 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)
- Emflaza (deflazacort)
- Emflaza (deflazacort)
- Emgality (galcanezumab-gnlm)
- Emgality (galcanezumab-gnlm)
- Emgality (galcanezumab-gnlm) Archived on 01/01/2023
- Enbrel (etanercept)
- Enbrel (etanercept)
- Enbrel (etanercept)
- Entyvio (vedolizumab)
- Entyvio (vedolizumab)
- Entyvio (vedolizumab)
- Entyvio (vedolizumab) archived on 1/1/23
- Epidiolex (cannabidiol)
- Epidiolex (cannabidiol) - Archived on 09/14/2022
- Epogen (epoetin alfa)
- Epogen (epoetin alfa)
- Esbriet (pirfenidone) - Archived on 10/1/2022
- Euflexxa (sodium hyaluronate)
- Euflexxa (sodium hyaluronate) - Archived on 10/1/22
- Evenity (romosozumab-aqqg)
- Evenity (romosozumab-aqqg) - Archived on 10/1/2022
- Evkeeza (evinacumab-dgnb) - Archived on 7/1/2022
- Exondys 51 (eteplirsen)
- Extavia (interferon beta-1b)
- Extavia (interferon beta-1b) archived on 1/1/23
F
- Fabrazyme (agalsidase beta) Archived - 04/01/23
- Fasenra (benralizumab)
- Fasenra (benralizumab)
- Fasenra (benralizumab)
- Fintepla (fenfluramine) - Archived on 09/14/2022
- Firazyr (icatibant)
- Firazyr (icatibant)
- Firazyr (icatibant) archived on 1/1/23
- Firdapse (amifampridine)
- Firdapse (amifampridine) - Archived on 7/1/2022
- Forteo (teriparatide) - Archived on 10/1/2022
- Fulphila (pegfilgrastim-jmdb)
G
- Galafold (migalastat)
- Galafold (migalastat) Archived - 04/01/23
- Gel-One (sodium hyaluronate)
- Gel-One (sodium hyaluronate) - Archived on 10/1/22
- Gelsyn-3 (sodium hyaluronate)
- Gelsyn-3 (sodium hyaluronate) - Archived on 10/1/22
- Genotropin (somatropin)
- GenVisc 850 (sodium hyaluronate)
- GenVisc 850 (sodium hyaluronate) - Archived on 10/1/22
- Gilenya (fingolimod)
- Gilenya (fingolimod)
- Glatopa (glatiramer acetate)
- Granix (tbo-filgrastim)
- Granix (tbo-filgrastim) - Archived on 09/14/2022
H
- H.P. Acthar Gel (repository corticotropin injection)
- Haegarda (C1 esterase inhibitor (human)) archived on 1/1/23
- Haegarda (C1 inhibitor (human))
- Haegarda (C1 inhibitor (human))
- Haegarda (C1 inhibitor (human))
- Hematopoietic Growth Factors
- Hemophilic Agents
- Hereditary Angioedema and Pharmacotherapy
- Home Infusion Therapy
- Humatrope (somatropin)
- Humira (adalimumab)
- Humira (adalimumab)
- Humira (adalimumab)
- Humira (adalimumab)
- Hyalgan (sodium hyaluronate)
- Hyalgan (sodium hyaluronate) - Archived on 10/1/22
- Hyaluronic Acid Derivative Injection
- Hyaluronic Acid Viscosupplements - Archived 04/01/23
- Hydroxyprogesterone caproate
- Hymovis (sodium hyaluronate)
- Hymovis (sodium hyaluronate) - Archived on 10/1/22
I
- Ibrance (palbociclib)
- Idiopathic Pulmonary Fibrosis
- Ilaris (canakinumab)
- Ilaris (canakinumab)
- Ilaris (canakinumab)
- Ilaris (canakinumab)
- Ilumya (tildrakizumab-asmn)
- Ilumya (tildrakizumab-asmn)
- Imbruvica (ibrutinib) Archived - 04/01/23
- Imfinzi (durvalumab)
- Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
- Immune globulin
- Immune globulin (IVIG)
- Immune globulin (IVIG)
- Immune globulin (IVIG)
- Inflammatory Bowel Disease: Biological Therapies
- Inflectra (infliximab-dyyb)
- Ingrezza (valbenazine)
- Ingrezza (valbenazine)
- Ingrezza (valbenazine)
- Isturisa (osilodrostat) - Archived on 10/1/2022
J
K
- Kalbitor (ecallantide)
- Kalbitor (ecallantide)
- Kalbitor (ecallantide) archived on 1/1/23
- Kalydeco (ivacaftor)
- Kanuma (sebelipase alfa) - Archived on 7/1/2022
- Kesimpta (ofatumumab) archived on 1/1/23
- Kevzara (sarilumab)
- Kevzara (sarilumab)
- Kevzara (sarilumab)
- Keytruda (pembrolizumab)
- Kineret (anakinra)
- Kineret (anakinra)
- Kineret (anakinra)
- Kisqali (ribociclib)
- Kitabis Pak (tobramycin inhalation solution)
- Kitabis Pak (tobramycin inhalation solution) - Archived on 10/1/2022
- Korlym (mifepristone) - Archived on 10/1/2022
- Korsuva (difelikefalin) - Archived on 10/1/2022
- Krystexxa (pegloticase) archived on 1/1/23
- Kuvan (sapropterin) Archived - 04/01/23
- Kymriah (tisagenlecleucel)
- Kymriah (tisagenlecleucel)
- Kyriah (tisagenlecleucel)
L
- Lemtrada (alemtuzumab)
- Lemtrada (alemtuzumab)
- Lemtrada (alemtuzumab) archived on 1/1/23
- Leukine (sargramostim)
- Leukine (sargramostim)
- Leukine (sargramostim) - Archived on 09/14/2022
- Lumizyme (alglucosidase alfa) Archived - 04/01/23
- Lupkynis (voclosporin) archived on 1/1/23
- Lupron Depot and Lupron Depot-PED (leuprolide acetate)
- Luxturna (voretigene neparvovec-rzyl) intraocular suspension for subretinal injection
M
- MACI (autologous cultured chondrocytes) - Archived on 10/1/2022
- Macrilen (macimorelin) Archived - 04/01/23
- Makena (hydroxyprogesterone caproate)
- Mavenclad (cladribine) archived on 1/1/23
- Mayzent (siponimod)
- Medical Necessity for Physician Dispense as Written (DAW) Requests
- Medication Assisted Therapy (buprenorphine containing agents)
- Mepsevii (vestronidase alfa-vjbk)
- Mepsevii (vestronidase alfa-vjbk)
- Monovisc (sodium hyaluronate)
- Monovisc (sodium hyaluronate) - Archived on 10/1/22
- Multi-ingredient Compound Policy
- Multiple Sclerosis
- Mycapssa (octreotide) - Archived on 10/1/2022
- Myfembree (relugolix, estradiol, and norethindrone acetate) archived on 1/1/23
- Myobloc (rimabotulinumtoxinB)
- Myobloc (rimabotulinumtoxinB)
- Myobloc (rimabotulinumtoxinB)
- Myobloc (rimabotulinumtoxinB) - Archived on 7/1/2022
N
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector)
- Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim on-body injector) - Archived on 9/14/2022
- Neupogen (filgrastim)
- Neupogen (filgrastim)
- Neupogen (filgrastim)
- Nexviazyme (avalglucosidase alfa-ngp) - Archived on 10/1/2022
- Noctiva (desmopressin acetate) intranasal-archived on 12/13/22
- Norditropin (somatropin)
- Novantrone (mitoxantrone)
- Novantrone (mitoxantrone) archived on 1/1/23
- Nucala (mepolizumab)
- Nucala (mepolizumab)
- Nucala (mepolizumab)
- Nucala (mepolizumab)
- Nutropin AQ (somatropin)
O
- Ocrevus (ocrelizumab)
- Ocrevus (ocrelizumab)
- Ocrevus (ocrelizumab) archived on 1/1/23
- Ofev (nintedanib) - Archived on 10/1/2022
- Olumiant (baricitinib)
- Olumiant (baricitinib)
- Olumiant (baricitinib)
- Olumiant (baricitinib) archived on 1/1/23
- Omnitrope (somatropin)
- Omnitrope (somatropin)
- Oncology Medications
- Onpattro (patisiran)
- Orencia (abatacept)
- Orencia (abatacept)
- Orencia (abatacept)
- Orencia (abatacept) - Archived on 7/1/2022
- Orilissa (elagolix)
- Orilissa (elagolix)
- Orilissa (elagolix) archived on 1/1/23
- Orkambi (lumacaftor/ivacaftor)
- Orladeyo (berotralstat) archived on 1/1/23
- Orthovisc (sodium hyaluronate)
- Orthovisc (sodium hyaluronate) - Archived on 10/1/22
- Otezla (apremilast)
- Otezla (apremilast)
- Otezla (apremilast)
- Otezla (apremilast)
- Otezla (apremilast) - Archived on 7/1/2022
- Oxervate (cenegermin-bkbj)
- Oxervate (cenegermin-bkbj) - Archived on 7/1/2022
- Oxlumo (lumasiran) - Archived on 9/14/2022
- Oxlumo (lumasiran) Archived - 04/01/23
P
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]
- Palynziq (pegvaliase-pqpz)
- Palynziq (pegvaliase-pqpz) Archived - 04/01/23
- Pegylated and Non-Pegylated Interferon
- Plegridy (peginterferon beta-1a)
- Plegridy (peginterferon beta-1a) archived on 1/1/23
- Ponvory (ponesimod)
- Praluent (alirocumab)
- Praluent (alirocumab)
- Probuphine (buprenorphine subdermal implant) - Archived on 09/14/2022
- Procrit (epoetin alfa)
- Procrit (epoetin alfa)
- Prolia (denosumab)
- Prolia (denosumab) - Archived on 10/1/2022
- Provenge (sipuleucel-T)
- Psoriasis Biological Therapies
- Pulmonary Arterial Hypertension
- Pulmozyme (dornase alfa inhalation solution)
- Pulmozyme (dornase alfa inhalation solution)
- Pulmozyme (dornase alfa inhalation solution) - Archived on 10/1/2022
Q
R
- Radicava (edaravone injection)
- Radicava (edaravone injection) Archived - 04/01/23
- Rebif (interferon beta-1a)
- Rebif (interferon beta-1a) archived on 1/1/23
- Reblozyl (luspatercept-aamt)
- Remicade (infliximab)
- Remicade (infliximab)
- Remicade (infliximab)
- Renflexis (infliximab-abda)
- Repatha (evolocumab)
- Repatha (evolocumab)
- Repatha (evolocumab)
- Rinvoq (upadacitinib)
- Rinvoq (upadacitinib) - Archived on 10/1/2022
- Rituxan (rituximab)
- Rituxan (rituximab)
- Rituxan (rituximab)
- Rituxan (rituximab) - Archived on 7/1/2022
- Rituxan (rituximab) archived on 1/1/23
- Ruconest (C1 esterase inhibitor (rabbit-derived))
- Ruconest (C1 esterase inhibitor (rabbit-derived))
- Ruconest (C1 esterase inhibitor (recombinant)) archived on 1/1/23
- Ruzurgi (amifampridine)
- Rydapt (midostaurin)
S
- Sabril (vigabatrin)
- Saizen (somatropin)
- Saphnelo (anifrolumab-fnia) archived on 1/1/23
- Scenesse (Afamelanotide)
- Scenesse (Afamelanotide) Archived - 04/01/23
- Seizure Disorders (H.P. Acthar Gel (repository corticotropin injection) and Sabril (vigabatrin) oral solution and tablets)
- Short Bowel Syndrome (Gattex, Zorbtive)
- Signifor, Signifor LAR (pasireotide) - Archived on 10/1/2022
- Siliq (brodalumab)
- Siliq (brodalumab)
- Siliq (brodalumab)
- Simponi (golimumab)
- Simponi (golimumab)
- Simponi Aria (golimumab)
- Simponi Aria (golimumab)
- Simponi Aria (golimumab)
- Skyrizi (risankizumab-rzaa)
- Skyrizi (risankizumab-rzaa) archived on 1/1/23
- Soliris (eculizumab)
- Soliris (eculizumab)
- Soliris (eculizumab)
- Soliris (eculizumab)
- Soliris (eculizumab)
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide)
- Somatropin Injection
- Somatuline depot (lanreotide), Bynfezia Pen (octreotide)
- Somavert (pegvisomant) - Archived on 10/1/2022
- Spinraza (nusinersen)
- Stelara (ustekinumab)
- Stelara (ustekinumab)
- Stelara (ustekinumab)
- Stelara (ustekinumab)
- Stelara (ustekinumab) archived on 1/1/23
- Strensiq (asfotase alfa)
- Sublocade (buprenorphine extended-release) injection
- Suboxone (buprenorphine and naloxone)
- Supartz FX (sodium hyaluronate)
- Supartz FX (sodium hyaluronate) - Archived on 10/1/22
- Synagis (palivizumab)
- Synagis (palivizumab)
- Synagis (palivizumab)
- Synagis (palivizumab)
- Synagis (palivizumab)
- Synagis (palivizumab) - Archived on 9/20/2022
- Synagis (palivizumab) archived on 1/1/23
- Synvisc (sodium hyaluronate)
- Synvisc (sodium hyaluronate) - Archived on 10/1/22
- Synvisc-One (sodium hyaluronate)
- Synvisc-One (sodium hyaluronate) - Archived on 10/1/22
T
- Takhzyro (lanadelumab-flyo)
- Takhzyro (lanadelumab-flyo) archived on 1/1/23
- Taltz (ixekizumab)
- Taltz (ixekizumab)
- Taltz (ixekizumab)
- Tecentriq (atezolizumab)
- Tecfidera (dimethyl fumarate)
- Tegsedi (inotersen)
- Tepezza (teprotumumab-trbw)
- Tepezza (teprotumumab-trbw) - Archived on 7/1/2022
- Tobi (tobramycin inhalation solution)
- Tobi (tobramycin inhalation solution), Tobi Podhaler - Archived on 10/1/2022
- Tremfya (guselkumab)
- Tremfya (guselkumab)
- Tremfya (guselkumab)
- Triptodur (triptorelin)
- Tymlos (abaloparatide) - Archived on 10/1/2022
- Tysabri (natalizumab)
- Tysabri (natalizumab)
- Tysabri (natalizumab)
- Tysabri (natalizumab) archived on 1/1/23
U
V
X
- Xeljanz/Xeljanz XR (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib)
- Xeljanz/Xeljanz XR (tofacitinib)
- Xenleta (lefamulin) - Archived on 10/1/2022
- Xeomin (incobotulinumtoxinA)
- Xeomin (incobotulinumtoxinA)
- Xeomin (incobotulinumtoxinA)
- Xeomin (incobotulinumtoxinA)
- Xeomin (incobotulinumtoxinA) - Archived on 7/1/2022
- Xermelo (telotristat ethyl) - Archived on 10/1/2022
- Xolair (omalizumab) inmed
- Xolair/Nucala/Cinqair
Y
Z
- Zarxio (filgrastim-sndz) - Archived on 9/14/2022
- Zavesca (miglustat)
- Zejula (niraparib)
- Zeposia (ozanimod)
- Zinbryta (daclizumab)
- Zomacton (somatropin)
- Zubsolv (buprenorphine and naloxone)
- Zubsolv (buprenorphine and naloxone) sublingual tablets for sublingual administration
- Zubsolv (buprenorphine and naloxone) sublingual tablets for sublingual administration archived on 1/1/23
- Zulresso (brexanolone) - Archived 04/12/23
- Zulresso (brexanolone) - Archived on 10/1/2022