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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 icon Adalimumab (Humira®)
PDF icon Age Edits for Pharmaceuticals Covered Under the Pharmacy Benefit
PDF icon Anakinra (Kineret®)
PDF icon Atorvastatin (Lipitor®) / Amlodipine/atorvastatin (Caduet®)
PDF icon Budesonide/Formoterol Fumarate Dihydrate (Symbicort®)
PDF icon Calcipotriene and betamethasone dipropionate (Taclonex®/Taclonex Scalp®)
PDF icon Ciclesonide (Alvesco™)
PDF icon Contraceptive Agents
PDF icon Controlled Substance Prior Authorization
PDF icon Controlled Substance Quantity Limits
PDF icon Cyclobenzaprine hydrochloride extended-release (Amrix®)
PDF icon Cyclooxygenase-2 (COX-2) Inhibitors and Meloxicam (Mobic®)
PDF icon Deferasirox (Exjade®)
PDF icon Desvenlafaxine (Pristiq™)
PDF icon Diclofenac epolamine 1.3% (Flector® Patch)
PDF icon Doxycycline hyclate (Alodox™)
PDF icon Duloxetine (Cymbalta®)
PDF icon Efalizumab (Raptiva®)
PDF icon Erectile Dysfunction Agents
PDF icon Etanercept (Enbrel®)
PDF icon Exenatide (Byetta®)
PDF icon Experimental/Investigational/Off-label Drug Use
PDF icon Ezetimibe/simvastatin (Vytorin®)
PDF icon Fluticasone Furoate (Veramyst®) Nasal Spray
PDF icon Gender Edits
PDF icon Injectable Fertility Medications
PDF icon Isosorbide Dinitrate and Hydralazine Hydrochloride (BiDil®)
PDF icon Levocetirizine (Xyzal®)
PDF icon Lisdexamfetamine Dimesylate (Vyvanse®)
PDF icon Methylphenidate Transdermal System (Daytrana®)
PDF icon Migraine Agents
PDF icon Modafinil (Provigil®)
PDF icon Montelukast (Singulair®)
PDF icon Nabilone (Cesamet®)
PDF icon Nonformulary Medication Requests
PDF icon Olopatadine Hydrochloride (Pataday™) 0.2 Percent
PDF icon Omalizumab (Xolair®)
PDF icon Oral Antihypertensive Agents
PDF icon Oral Anti-infective Agents
PDF icon Oral Chemotherapy Agents
PDF icon Oral Diabetic Agents
PDF icon Paliperidone (Invega®)/Quetiapine fumarate (Seroquel XR®)
PDF icon Pramlintide (Symlin®/SymlinPen®)
PDF icon Pregabalin (Lyrica®)
PDF icon Proton Pump Inhibitors
PDF icon Quantity Level Limits for Pharmaceuticals Covered Under the Pharmacy Benefit
PDF icon Quinine Sulfate (Qualaquin™)
PDF icon Ranolazine (Ranexa®)
PDF icon Repaglinide and Metformin hydrochloride (PrandiMet™)
PDF icon Retapamulin (Altabax®)
PDF icon Rosuvastatin calcium (Crestor®)
PDF icon Schedule II Prior Authorization
PDF icon Schedule II Quantity Level Limits
PDF icon Selegiline HCl (Zelapar®)
PDF icon Sildenafil (Revatio®)
PDF icon Sleep Agents
PDF icon Sumatriptan and naproxen sodium (Treximet™)
PDF icon Teriparatide (Forteo™) (rDNA origin) Injection
PDF icon Topical Retinoid Products
PDF icon Tramadol Extended-Release (ER) (Ultram ER®)
PDF icon Weight Loss Agents