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 11/15/2024
- Beovu (brolucizumab) - Archived on 04/01/2025
- Bethkis (tobramycin inhalation solution) - Archived on 07/01/2025
- Bevacizumab (Alymsys, Avastin, Mvasi, Zirabev) - Archived on 04/01/2025
- Beyfortus (nirsevimab) - Archived on 05/19/2025
- Bimzelx (bimekizumab-bkzx) - Archived on 03/03/2025
- Bimzelx (bimekizumab-bkzx) - Archived on 04/01/2025
- Bleeding Disorder Agents - Archived on 03/07/2025
- Botox (onabotulinumtoxinA) - Archived on 04/01/2025
- Botox (onabotulinumtoxinA) - Archived on 11/15/2024
- Breyanzi (lisocabtagene maraleucel) - Archived on 07/01/2025
- Brineura (cerliponase alfa) - Archived on 11/15/2024
- Briumvi (ublituximab-xiiy) - Archived on 04/01/2025
- Briumvi (ublituximab-xiiy) - Archived on 11/15/2024
- Bronchitol (mannitol) - Archived on 07/01/2025
C
- Carbaglu (carglumic acid) - Archived on 07/01/2025
- Carvykti (ciltacabtagene autoleucel) - Archived on 07/01/2025
- Cayston (aztreonam inhalation solution) - Archived on 07/01/2025
- Cimzia (certolizumab pegol) - Archived on 07/01/2025
- Cimzia (certolizumab pegol) - Archived on 11/15/2024
- Cuvrior (trientine tetrahydrochloride) - Archived on 07/01/2025
D
- Daklinza (daclatasvir) - Archived on 03/07/2025
- 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
- Dupixent (dupilumab) - Archived on 04/01/2025
- Durysta (bimatoprost intracameral implant) - Archived on 07/04/25
- Dysport (abobotulinumtoxinA) - Archived on 04/01/2025
E
F
- Fabhalta (iptacopan) - Archived on 04/01/2025
- Fasenra (benralizumab) - Archived on 04/01/2025
- Filgrastim (Neupogen, Zarxio, Nivestym, Releuko) - Archived on 11/15/2024
- Filspari (sparsentan)- Archived on 04/01/2025
- Fintepla (fenfluramine) - Archived on 07/01/2025
- Firdapse (amifampridine)- Archived on 04/01/2025
G
H
I
- Ilumya (tildrakizumab-asmn) - Archived on 04/01/2025
- Imcivree (setmelanotide - Archived on 07/01/2025
- 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 on 11/15/2024
- Infliximab (Avsola, Inflectra, Remicade, Renflexis, Zymfentra) - Archived on 11/15/2024
- IV Iron Products - Archived on 03/07/2025
J
K
L
M
N
O
- Ocrevus (ocrelizumab) - Archived on 04/01/2025
- Ocrevus (ocrelizumab) - Archived on 11/15/2024
- Ofev (nintedanib) - Archived on 04/01/2025
- Omvoh (mirikizumab-mrkz) - Archived on 07/01/2025
- Omvoh (mirikizumab-mrkz) - Archived on 11/15/2024
- Oncology Regimens - Archived on 04/01/2025
- Orencia (abatacept) - Archived on 11/15/2024
- Orfadin (nitisinone) - Archived on 07/04/25
- Orkambi (lumacaftor/ivacaftor) - Archived on 07/01/2025
- Oxbryta (voxelotor) - Archived on 07/01/2025
- Ozurdex (dexamethasone) - Archived on 11/15/2024
P
R
- Ranibizumab (Lucentis, Byooviz, Cimerli) - Archived on 04/01/2025
- Ravicti (glycerol phenylbuytyrate) - Archived on 07/01/2025
- Relyvrio (sodium phenylbutyrate/ taurursodiol) - Archived on 03/07/2025
- Remicade (infliximab) - Archived on 03/07/2025
- Retacrit (epoetin alfa-epbx) - Archived on 03/07/2025
- Rituxan (rituximab) - Archived on 03/07/2025
- Rituximab (Rituxan*, Truxima, Ruxience, Riabni) - Archived on 04/01/2025
S
- Scenesse (Afamelanotide) - Archived on 11/15/2024
- Siliq (brodalumab) - Archived on 04/01/2025
- Simponi (golimumab) - Archived on 11/15/2024
- Simponi Aria (golimumab) - Archived on 11/15/2024
- Skysona (elivaldogene autotemcel) - Archived on 04/01/2025
- Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva) - Archived on 07/01/2025
- Soluble Guanylate Cyclase Stimulator for Pulmonary Arterial Hypertension: Adempas (riociguat) - Archived on 03/07/2025
- Somatostatin analogs (Injectable; First generation): Sandostatin (octreotide), Sandostatin LAR (octreotide), Somatuline Depot (lanreotide), Bynfezia Pen (octreotide) - Archived on 07/01/2025
- Spravato (esketamine) - Archived on 07/01/2025
- Spravato (esketamine) - Archived on 11/15/2024
- Stelara (ustekinumab) - Archived on 11/15/2024
- Subutex (buprenorphine) - Archived on 07/04/25
- Susvimo (ranibizumab) - Archived on 04/01/2025
- Symdeko (tezacaftor/ivacaftor) - Archived on 07/01/2025
T
- Tarpeyo (budesonide) - Archive on 04/01/2025
- Tavneos (avacopan) - Archive on 04/01/2025
- Tecartus (Brexucabtagene Autoleucel) - Archived on 07/01/2025
- Tegsedi (inotersen) - Archived on 07/01/2025
- Tobi, Tobi Podhaler (tobramycin inhalation solution) - Archived on 07/01/2025
- Tremfya (guselkumab) - Archived on 6/18/2025
- Trikafta (elexacaftor, tezacaftor and ivacaftor; ivacaftor) - Archived on 07/01/2025
- Tysabri (natalizumab) - Archived on 04/01/2025
- Tzield (teplizumab-mzwv) - Archived on 07/01/2025
V
- Vabysmo (faricimab-svoa) - Archive on 04/01/2025
- Vigabatrin (generic for Sabril), Vigadrone - Archive on 04/01/2025
- Vijoice (alpelisib) - Archived 04/01/2025
- 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 11/15/2024
X
- Xenleta (lefamulin) - Archived on 01/31/2025
- Xeomin (incobotulinumtoxinA)- Archived 04/01/2025
- Xermelo (telotristat ethyl) - Archived on 07/01/2025
- Xgeva (denosumab) - Archived on 11/15/2024
- Xolair (omalizumab) - Archived on 11/15/2024
- Xyrem (sodium oxybate), Lumryz (sodium oxybate extended release) and Xywav (calcium, magnesium, potassium, and sodium oxybates)- Archived 04/01/2025