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:

Policy Name
PDF iconAge Edits
PDF iconAndrogens
PDF iconAntidepressant policy
PDF iconAntipsychotic Agents
PDF iconArmodafinil (Nuvigil)/Modafinil (Provigil)
PDF iconAttention Deficit Hyperactivity Disorder Agents
PDF iconAztreonam (Cayston®)
PDF iconBrand drugs with generic equivalents
PDF iconBuprenorphine and Naloxone (Bunavail Suboxone® Zubsolv®) and Buprenorphine (Subutex®)
PDF iconCalcipotriene and betamethasone dipropionate (Taclonex®/Taclonex Scalp®)
PDF iconCarglumic Acid (Carbaglu)
PDF iconCelecoxib (Celebrex)
PDF iconChelation Agents
PDF iconChorionic gonadotropin (Novarel®/Pregnyl®)
PDF iconCompounded Products
PDF iconControlled Substance Prior Authorization
PDF iconControlled Substance Quantity Limits
PDF iconCosmetic Policy
PDF iconCrofelemer (Fulyzaq®)
PDF iconCysteamine-Containing Products
PDF iconDextromethorphan hydrobromide and Quinidine sulfate (Nuedexta)
PDF iconDiclofenac Products
PDF iconDroxidopa (Northera)
PDF iconEpinephrine Pen
PDF iconErectile Dysfunction Agents
PDF iconExperimental/Investigational Use
PDF iconFesoterodine fumarate extended-release (Toviaz™)
PDF iconGaucher Disease agents
PDF iconGabapentin (Gralise/Horizant)/Pregabalin (Lyrica)
PDF iconGender Edits
PDF iconGlycerol Phenylbutyrate (Ravicti®)
PDF iconGrowth Hormones
PDF iconHemophilia Agents
PDF iconHepatitis C
PDF iconHomozygous Familial Hypercholesterolemia Agents
PDF iconIcatibant (Firazyr™)
PDF iconImmune Modulating Therapies for Rheumatologic, Dermatologic and Gastrointestinal Diseases
PDF iconIngenol mebutate (Picato)
PDF iconInhaled Beta Agonists
PDF iconInhaled Corticosteroid (ICS)
PDF iconInjectable antidiabetic agents
PDF iconIntranasal Corticosteroids
PDF iconIsotretinoin (Absorica®)
PDF iconIvacaftor (Kalydeco)
PDF iconLacosamide (Vimpat) (Oral)
PDF iconLong Acting Beta Agonist (LABA) combination policy
PDF iconLoxapine inhalation (Adasuve®)
PDF iconMecamylamine (Vecamyl)
PDF iconMecasermin (Increlex™)
PDF iconMetreleptin (Myalept®)
PDF iconMifepristone (Korlym)
PDF iconMiglustat (Zavesca®)
PDF iconMigraine Agents
PDF iconMultiple Sclerosis Agents
PDF iconNaloxone auto injector (Evzio)
PDF iconNonformulary Medication Requests
PDF iconNon-Preferred Diabetic Test Strips
PDF iconNon-Preferred Insulins
PDF iconOnychomycosis agents
PDF iconOphthalmic Prostaglandins
PDF iconOral Anti-infective Agents
PDF iconOral Antihypertensive Agents
PDF iconOral Chemotherapy Agents
PDF iconOral Antidiabetic Agents
PDF iconPasireotide (Signifor®)
PDF iconPeginterferon alfa-2b (Sylatron)
PDF iconPitavastatin calcium (Livalo™)
PDF iconProton Pump Inhibitors
PDF iconPulmonary Arterial Hypertensive (PAH) agents
PDF iconPulmonary fibrosis agents
PDF iconQuantity Level Limits for Pharmaceuticals Covered Under the Pharmacy Benefit
PDF iconQuinine Sulfate (Qualaquin™)
PDF iconRetapamulin (Altabax®)
PDF iconSleep Agents
PDF iconSmoking Cessation Agents
PDF iconSodium Oxybate (Xyrem)
PDF iconSublingual Immunotherapy
PDF iconTeduglutide (Gattex)
PDF iconTeriparatide (Forteo™)
PDF iconTetrabenazine (Xenazine)
PDF iconTetracycline policy
PDF iconTolvaptan (Samsca™)
PDF iconTopical Antineoplastic Agents
PDF iconTopical Retinoid Products
PDF iconTramadol Extended Release (Conzip)
PDF iconWeight Loss Agents