Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
A
- Adstiladrin® (nadofaragene firadenovec-vncg intravesical suspension – Ferring) - Archived on 03/24/2026
- Advate® (Antihemophilic Factor intravenous infusion – Baxalta/Takeda) - Archived on 03/23/2026
- Adynovate® (Antihemophilic Factor PEGylated intravenous infusion – Baxalta/Takeda) - Archived on 03/23/2026
- Afstyla® (Antihemophilic Factor single chain intravenous infusion – CSL Behring) - Archived on 03/23/2026
- Alphanate (Antihemophilic Factor/von Willebrand Factor Complex [human] intravenous infusion – Grifols) - Archived on 03/23/2026
- AlphaNine SD (Coagulation Factor IX [plasma-derived] intravenous infusion – Grifols) - Archived on 03/19/2026
- Alprolix® (Coagulation Factor IX [recombinant] Fc fusion protein intravenous infusion – Bioverativ/Sanofi) - Archived on 03/19/2026
- Altuviiio™ (antihemophilic factor [recombinant] Fc-VWF-XTEN fusion protein-ehtl intravenous infusion − Bioverativ/Sanofi) - Archived on 03/19/2026
- Amondys 45™ (casimersen intravenous infusion – Sarepta) - Archived on 03/24/2026
- Amtagvi™ (lifileucel intravenous infusion – Iovance Biotherapeutics) - Archived on 03/24/2026
- Anktiva® (nogapendekin alfa inbakicept-pmln intravesical solution – ImmunityBio) - Archived on 03/24/2026
B
C
D
E
- Eloctate® (Antihemophilic Factor Fc fusion protein intravenous infusion – Bioverativ/Sanofi) - Archived on 03/23/2026
- Esperoct® (Antihemophilic factor glycopegylated intravenous infusion – Novo Nordisk) - Archived on 03/23/2026
- Euflexxa® (sodium hyaluronate injection – Ferring) - Archived on 03/24/2026
- Evusheld™ (tixagevimab intramuscular injection and cilgavimab intramuscular injection − AstraZeneca) - Archived on 03/18/2026
G
- Gel-One® (sodium hyaluronate injection – Seikagaku/Zimmer) - Archived on 03/24/2026
- Gelsyn-3™ (sodium hyaluronate injection – Bioventus) - Archived on 03/24/2026
- GenVisc® 850 (sodium hyaluronate injection – OrthogenRx) - Archived on 03/24/2026
- Grafapex™ (treosulfan intravenous infusion – Medexus) - Archived on 03/24/2026
H
- Hemgenix® (etranacogene dezaparvovec-drlb intravenous infusion − CSL Behring and uniQure) - Archived on 03/23/2026
- Hemofil M (Antihemophilic Factor intravenous infusion – Baxalta/Takeda) - Archived on 03/23/2026
- Humate-P (Antihemophilic Factor/von Willebrand Factor Complex intravenous infusion – CSL Behring) - Archived on 03/23/2026
- Hyalgan (sodium hyaluronate injection − Fidia/Sanofi) - Archived on 03/24/2026
- Hymovis (high molecular weight viscoelastic hyaluronan injection – Fidia) - Archived on 03/24/2026
I
- Idelvion (Coagulation Factor IX [recombinant] albumin fusion protein intravenous infusion – CSL Behring) - Archived on 03/19/2026
- Ilaris® (canakinumab subcutaneous injection – Novartis) - Archived on 03/24/2026
- Ixinity (Coagulation Factor IX [recombinant] intravenous infusion – Medexus) - Archived on 03/19/2026
J
K
- Kimmtrak® (tebentafusp-tebn intravenous infusion – Immunocore) - Archived on 03/24/2026
- Koāte (Antihemophilic Factor intravenous infusion – Grifols/Kedrion Biopharma) - Archived on 03/23/2026
- Kogenate® FS (Antihemophilic Factor intravenous infusion – Bayer HealthCare) - Archived on 03/23/2026
- Kovaltry® (Antihemophilic Factor intravenous infusion – Bayer HealthCare) - Archived on 03/23/2026
L
M
N
O
P
R
- Rebinyn® (Coagulation Factor IX [recombinant] glycoPEGylated intravenous infusion – NovoNordisk) - Archived on 03/19/2026
- Recombinate® (Antihemophilic Factor intravenous infusion – Baxalta/Takeda) - Archived on 03/23/2026
- Riabni™ (rituximab-arrx intravenous infusion – Amgen) - Archived on 03/24/2026
- Rituxan Hycela® (rituximab and hyaluronidase human subcutaneous injection – Biogen and Genentech/Roche) - Archived on 03/24/2026
- Rituxan® (rituximab intravenous infusion − Genentech) - Archived on 03/24/2026
- Rixubis® (Coagulation Factor IX [recombinant] intravenous infusion – Baxalta/Takeda) - Archived on 03/19/2026
- Ruxience® (rituximab-pvvr intravenous infusion – Pfizer) - Archived on 03/24/2026
S
- Sandostatin® LAR Depot (octreotide acetate intramuscular injection – Novartis, generic) - Archived on 03/24/2026
- Sodium hyaluronate 1% injection – Teva - Archived on 03/24/2026
- Supartz FX™ (sodium hyaluronate injection − Seikagaku/Bioventus) - Archived on 03/24/2026
- SynoJoynt™ (sodium hyaluronate injection − Arthrex) - Archived on 03/24/2026
- Synvisc (hylan G-F 20 sodium hyaluronate injection – Genzyme/Sanofi), Synvisc-One® (hylan G-F 20 sodium hyaluronate injection – Genzyme/Sanofi) - Archived on 03/24/2026
T
- Tepezza™ (teprotumumab intravenous infusion – Horizon) - Archived on 03/24/2026
- Triluron™ (sodium hyaluronate injection – Fidia) - Archived on 03/24/2026
- TriVisc™ (sodium hyaluronate injection – OrthogenRx) - Archived on 03/24/2026
- Truxima® (rituximab-abbs intravenous infusion – Celltrion/Teva) - Archived on 03/24/2026