Pharmacy Policy

The policy bulletins on this website were developed to assist participating providers in administering and understanding the provisions of benefits.

To access a policy, select the corresponding link below:

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Policy Name
PDF iconAbatacept (Orencia) subcutaneous
PDF iconAdalimumab (Humira®)
PDF iconAge Edits for Pharmaceuticals Covered Under the Pharmacy Benefit
PDF iconAnakinra (Kineret®)
PDF iconAndrogens
PDF iconAntidepressant policy
PDF iconApixiban (Eliquis)
PDF iconArmodafinil (Nuvigil®)
PDF iconAztreonam (Cayston®)
PDF iconBedaquiline (Sirturo®)
PDF iconBuprenorphine and Naloxone (Suboxone® Zubsolv®) and Buprenorphine (Subutex®)
PDF iconCalcipotriene and betamethasone dipropionate (Taclonex®/Taclonex Scalp®)
PDF iconCarglumic Acid (Carbaglu)
PDF iconCelecoxib (Celebrex)
PDF iconCertolizumab (Cimzia®) Prefilled Syringe
PDF iconChorionic gonadotropin (Novarel®/Pregnyl®)
PDF iconClonidine extended-release (Kapvay)/Guanfacine (Intuniv)
PDF iconCompounded Products
PDF iconControlled Substance Prior Authorization
PDF iconControlled Substance Quantity Limits
PDF iconCosmetic Policy
PDF iconCrofelemer (Fulyzaq®)
PDF iconCysteamine-Containing Products
PDF iconDabigatran (Pradaxa®)
PDF iconDeferasirox (Exjade®)
PDF iconDeferiprone (Ferriprox)
PDF iconDextromethorphan hydrobromide and Quinidine sulfate (Nuedexta)
PDF iconDiclofenac epolamine 1.3% (Flector® Patch)
PDF iconDiclofenac potassium (Zipsor™)
PDF iconDiclofenac sodium 1% (Voltaren®) Gel
PDF iconEpinephrine Pen
PDF iconErectile Dysfunction Agents
PDF iconEtanercept (Enbrel®)
PDF iconEverolimus (Zortress®)
PDF iconExperimental/Investigational/Off-label Drug Use
PDF iconFesoterodine fumarate extended-release (Toviaz™)
PDF iconGabapentin (Gralise)
PDF iconGabapentin Enacarbil (Horizant)
PDF iconGender Edits
PDF iconGlycerol Phenylbutyrate (Ravicti®)
PDF iconGolibumab (Simponi™)
PDF iconGrowth Hormones
PDF iconHemophilia Agents
PDF iconHepatitis C
PDF iconHomozygous Familial Hypercholesterolemia Agents
PDF iconIcatibant (Firazyr™)
PDF iconIloperidone (Fanapt™)
PDF iconIngenol mebutate (Picato)
PDF iconInhaled Beta Agonists
PDF iconInsulin Glargine (Lantus®)
PDF iconIntranasal Steroids
PDF iconIvacaftor (Kalydeco)
PDF iconLacosamide (Vimpat) (Oral)
PDF iconLinagliptin (Tradjenta) and Linagliptin/metformin (Jentadueto)
PDF iconLiraglutide (Victoza®)
PDF iconLong Acting Beta Agonist (LABA) combination policy
PDF iconLurasidone (Latuda)
PDF iconMecamylamine (Vecamyl)
PDF iconMecasermin (Increlex™)
PDF iconMechlorethamine (Valchlor)
PDF iconMethadone
PDF iconMethylphenidate Transdermal System (Daytrana®)
PDF iconMifepristone (Korlym)
PDF iconMigraine Agents
PDF iconMinocycline hydrochloride extended release (Solodyn)
PDF iconModafinil (Provigil®)
PDF iconMultiple Sclerosis Agents
PDF iconNonformulary Medication Requests
PDF iconNon-Preferred Diabetic Test Strips
PDF iconNon-Preferred Insulins
PDF iconOpthalmic Prostaglandins
PDF iconOral Anti-infective Agents
PDF iconOral Antihypertensive Agents
PDF iconOral Chemotherapy Agents
PDF iconOral Antidiabetic Agents
PDF iconPaliperidone (Invega®)
PDF iconPasireotide (Signifor®)
PDF iconPeginterferon alfa-2b (Sylatron)
PDF iconPitavastatin calcium (Livalo™)
PDF iconPramlintide (Symlin®/SymlinPen®)
PDF iconPregabalin (Lyrica®)
PDF iconProton Pump Inhibitors
PDF iconPulmonary Arterial Hypertensive (PAH) agents
PDF iconQuantity Level Limits for Pharmaceuticals Covered Under the Pharmacy Benefit
PDF iconQuinine Sulfate (Qualaquin™)
PDF iconRetapamulin (Altabax®)
PDF iconRivaroxaban (Xarelto)
PDF iconSleep Agents
PDF iconSmoking Cessation Agents
PDF iconSodium Oxybate (Xyrem)
PDF iconTapentadol (Nucynta™)/Tapentadol extended-release (Nucynta™ ER)
PDF iconTeduglutide (Gattex)
PDF iconTeriparatide (Forteo™) (rDNA origin) Injection
PDF iconTetrabenazine (Xenazine)
PDF iconTetracycline policy
PDF iconTocilizumab (Actemra SQ)
PDF iconTofacitinib citrate (Xeljanz)
PDF iconTolvaptan (Samsca™)
PDF iconTopical Retinoid Products
PDF iconTramadol Extended Release (Conzip)
PDF iconWeight Loss Agents