Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
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- 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 on 01/01/2025)
- Immune globulin (IVIG and SCIG): Intravenous (IVIG): Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Yimmugo Subcutaneous (SCIG): Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify - Archived on 01/01/2026
- 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 on 04/01/2026
- Infliximab (Avsola, Inflectra, Remicade, Renflexis) - Archived on 01/01/2026
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- Medical Benefit Medications - Archived 06/30/2026
- Medical Benefit Medications - Archived on 10/01/2025
- Medical Necessity – Non-Formulary Off Label - Archived on 10/01/2025
- Medical Necessity for Non-Formulary DAW - Archived on 07/01/2025
- Medical Necessity for Non-Formulary Medications - Archived 06/30/2026