Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Aldurazyme (laronidase) - Archived on 07/01/2026
- Alpha1-Proteinase Inhibitor (Aralast NP, Glassia, Prolastin C, Zemaira [human]) - Archived 10/31/2026
- Amvuttra (vutrisiran) - Archived on 10/01/2025
- Andembry (garadacimab-gxii) - Archived on 02/01/2026
- Apretude (cabotegravir extended-release) - Archived on 01/01/2026
- Apretude (cabotegravir extended-release) - Archived on 10/01/2025
- Aqvesme (mitapivat) - Archived 10/31/2026
B
C
D
E
- Elaprase (idursulfase) - Archived 10/31/2026
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfaiwxj) - Archived on 10/01/2025
- Esbriet (pirfenidone) - Archived 04/30/2026
- Esbriet (pirfenidone) - Archived on 06/30/2025
- Exdensur (depemokimab-ulaa) - Archived on 10/23/2026
- Eylea and Eylea HD (aflibercept) - Archived on 06/30/2025
- Eylea and Eylea HD (aflibercept) - Archived on 07/01/2026
F
G
H
I
- Iluvien (fluocinolone acetonide) - Archived on 10/01/2025
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen Subcutaneous (SCIG): Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify - Archived 04/30/2026
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Yimmugo, Gammagard Liquid ERC Subcutaneous (SCIG): Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify - Archived 10/31/2026
- Iqirvo (elafibranor) - Archived 10/31/2026
- Izervay (avacincaptad pegol) - Archived on 10/01/2025
K
L
M
- MACI (autologous cultured chondrocytes) - Archived on 06/30/2025
- Mepsevii (vestronidase alfa-vjbk) - Archived 10/31/2026
- Multi-ingredient Compound Policy - Archived on 10/01/2025
- Mycapssa (octreotide) - Archived 10/31/2026
- Mycapssa (octreotide) - Archived on 10/01/2025
- Myobloc (rimabotulinumtoxinB) - Archived on 06/30/2025
N
- Naglazyme (galsulfase) - Archived 10/31/2026
- Nemluvio (nemolizumab-ilto) - Archived on 02/01/2026
- Nitisinone (Orfadin and Nityr) - Archived 04/30/2026
- Nitisinone (Orfadin and Nityr) - Archived on 06/30/2025
- Novantrone (mitoxantrone) - Archived 04/30/2026
- NPlate (romiplostim) - Archived 04/30/2026
- Nulibry (fosdenopterin) - Archived on 07/01/2026
O
- Ofev (nintedanib) - Archived 04/30/2026
- Ofev (nintedanib) - Archived on 06/30/2025
- Oncology Regimens - Archived 10/31/2026
- Onpattro (patisiran) - Archived on 10/01/2025
- Orladeyo (berotralstat) - Archived on 02/01/2026
- Oxlumo (lumasiran) - Archived 04/30/2026
- Ozurdex (dexamethasone) - Archived on 10/01/2025
P
Q
R
- Radicava (edaravone injection); Radicava ORS (edaravone oral suspension) - Archived on 01/01/2026
- Ranibizumab (Lucentis, Byooviz, Cimerli) - Archived on 06/30/2025
- Retisert (fluocinolone acetonide) - Archived on 10/01/2025
- Revcovi (elapegademase-lvlr) - Archived on 06/30/2025
- Rituximab (Rituxan, Truxima, Ruxience, Riabni) - Archived on 06/30/2025
- Rituximab (Rituxan, Truxima, Ruxience, Riabni) - Archived on 07/01/2026
- Rivfloza (nedosiran) - Archived on 10/15/2025
- Ruconest (C1 esterase inhibitor (recombinant)) - Archived 04/30/2026
- Rystiggo (rozanolixizumab-noli) - Archived on 10/01/2025
S
T
- Takhzyro (lanadelumab-flyo) - Archived on 02/01/2026
- Tarpeyo (budesonide) - Archived on 06/30/2025
- Tavalisse (fostamatinib disodium hexahydrate) - Archived on 01/01/2026
- Tavneos (avacopan) - Archived on 06/30/2025
- Tegsedi (inotersen) - Archived on 06/30/2025
- Tegsedi (inotersen) - Archived on 07/01/2025
- Turalio (pexidartinib) - Archived on 10/01/2025
U
V
- Vabysmo (faricimab-svoa) - Archived on 06/30/2025
- Vanrafia (atrasentan) - Archived on 10/31/2025
- Vimizim (elosulfase alfa) - Archived 10/31/2026
- Vykat XR (diazoxide choline) - Archived on 02/01/2026
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) - Archived 10/31/2026
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) - Archived on 10/01/2025