Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
B
- Benlysta (belimumab) - Archived on 03/10/2025
- Beovu (brolucizumab) - Archived on 04/01/2025
- Beqvez (fidanacogene elaparvovec-dzkt) - Archived on 10/01/2025
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev)- Archived on 04/01/2025
- Beyfortus (nirsevimab) - Archived on 05/19/2025
- Bimzelx (bimekizumab-bkzx) - Archived on 04/01/2025
- Bleeding Disorder Agents - Archived on 03/10/2025
- Botox (onabotulinumtoxinA) - Archived on 04/01/2025
- Breyanzi (lisocabtagene maraleucel) - Archived on 07/04/25
- Briumvi (ublituximab-xiiy)- Archived on 04/01/2025
- Buprenorphine extended-release (Sublocade, Brixadi) - Archived on 10/01/2025
C
- Carbaglu (carglumic acid) - Archived on 07/01/2025
- Carvykti (ciltacabtagene autoleucel) - Archived on 07/04/25
- Cayston (aztreonam inhalation solution) - Archived on 07/01/2025
- Cerdelga (eliglustat) - Archived on 10/01/2025
- Cimzia (certolizumab pegol) - Archived on 07/04/25
- Cuvrior (trientine tetrahydrochloride) - Archived on 07/01/2025
D
- Dalfampridine (generic for Ampyra) - Archived on 10/01/2025
- Darzalex Faspro (daratumumab and hyaluronidase-fihj)- Archived on 04/01/2025
- Daxxify (DaxibotulinumtoxinA-lanm) - Archived on 04/01/2025
- Diacomit (stiripentol) - Archived on 07/01/2025
- Dispense as Written (DAW) Policy - Archived on 07/14/2025
- Dupixent (dupilumab) - Archived on 10/01/2025
- Durysta (bimatoprost intracameral implant) - Archived on 07/04/25
- Dysport (abobotulinumtoxinA) - Archived on 04/01/2025
E
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa-iwxj) - Archived on 10/01/2025
- Epclusa (Sofosbuvir/velpatasvir) - Archived on 04/30/2025
- Epidiolex (cannabidiol) - Archived on 07/01/2025
- Epoetin alfa (Epogen, Procrit, Retacrit) - Archived on 10/01/2025
- Eylea and Eylea HD (aflibercept) - Archived on 04/01/2025
- Eylea and Eylea HD (aflibercept) - Archived on 05/01/2025
F
G
H
- Harvoni (ledipasvir/sofosbuvir) - Archived on 10/01/2025
- Hemophilia and Other Clotting Disorders - Archived on 07/04/25
- Hemophilia and Other Clotting Disorders - Archived on 10/01/2025
- Hetlioz and Hetlioz LQ (tasimelteon) - Archived on 10/01/2025
- Hyaluronic Acid Viscosupplements - Archived on 04/01/2025
I
J
K
L
- Leqembi (lecanemab) - Archived on 07/04/25
- Leqselvi (deuruxolitinib) - Archived on 07/04/25
- Livmarli (maralixibat)- Archived on 10/01/2025
- Lost, Stolen, Damaged, Vacation and School Supply of Medication - Archived on 10/01/2025
- Lucentis (ranibizumab) - Archived on 03/10/2025
- Luxturna (voretigene neparvovec-rzyl) - Archvied on 04/01/2025
M
- MACI (autologous cultured chondrocytes) - Archived on 07/04/25
- Makena (hydroxyprogesterone caproate) - Archived on 03/10/2025
- Mavyret (glecaprevir and pibrentasvir) - Archived on 07/04/25
- Mavyret (glecaprevir and pibrentasvir) - Archived on 10/01/2025
- Medical Benefit Medications
- Medical Benefit Medications - Archived on 10/01/2025
- Medical Necessity for Non-Formulary Medications - Archived on 04/01/2025
- Mircera (methoxy polyethylene glycol-epoetin beta) - Archived on 10/01/2025
- Multi-Ingredient Compound Policy - Archived on 10/01/2025
- Mycapssa (octreotide) - Archived on 10/01/2025
- Myobloc (rimabotulinumtoxinB) - Archived on 04/01/2025
N
O
P
R
- Ranibizumab (Lucentis, Byooviz, Cimerli) - Archived on 04/01/2025
- Ravicti (glycerol phenylbuytyrate) - Archived on 07/01/2025
- Retisert (fluocinolone acetonide) - Archived on 10/01/2025
- Rinvoq, Rinvoq LQ (upadacitinib) - Archived on 08/13/2025
- Rituximab (Rituxan*, Truxima, Ruxience, Riabni) - Archived on 04/01/2025
- Rystiggo (rozanolixizumab-noli) - Archived on 10/01/2025
S
- Signifor, Signifor LAR (pasireotide) - Archived on 10/01/2025
- Skysona (elivaldogene autotemcel)- Archived on 04/01/2025
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva) - Archived on 07/01/2025
- Sofosbuvir/Velpatasvir (Epclusa) - Archived on 10/01/2025
- Soliris (eculizumab) - Archived on 10/01/2025
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide) - Archived on 07/01/2025
- Somavert (pegvisomant) - Archived on 10/01/2025
- Sovaldi (sofosbuvir) - Archived on 10/01/2025
- Spravato (esketamine) - Archived on 07/01/2025
- Susvimo (ranibizumab) - Archived on 04/01/2025
- Susvimo (ranibizumab) - Archived on 10/01/2025
- Syfovre (pegcetacoplan) - Archived on 10/01/2025
- Symdeko (tezacaftor/ivacaftor) - Archived on 07/01/2025
- Synagis (palivizumab) - Archived on 10/01/2025
T
- Tecartus (Brexucabtagene Autoleucel) - Archived on 07/01/2025
- Tobi, Tobi Podhaler (tobramycin inhalation solution) - Archived on 07/01/2025
- Tocilizumab (Actemra, Tyenne, Tofidence) - Archived on 10/01/2025
- Tremfya (guselkumab) - Archived on 6/18/2025
- Trikafta (elexacaftor, tezacaftor and ivacaftor; ivacaftor) - Archived on 07/01/2025
- Turalio (pexidartinib) - Archived on 10/01/2025
- Tysabri (natalizumab)- Archived on 04/01/2025
- Tzield (teplizumab-mzwv) - Archived on 07/01/2025
U
V
- Vabysmo (faricimab-svoa)- Archived on 04/01/2025
- Vafseo (vadadustat) - Archived on 10/01/2025
- Vosevi (sofosbuvir/velpatasvir/voxilaprevir) - Archived on 10/01/2025
- Vyjuvek (beremagene geperpavec-svdt ) - Archived on 10/01/2025
- Vyndaqel (tafamidis meglumine) and Vyndamax (tafamidis) - Archived on 07/01/2025
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) - Archived on 10/01/2025