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 iconAmphetamine Sulfate (EvekeoTM)
PDF iconAndrogens
PDF iconAntidepressant policy
PDF iconAntiepileptic Agents
PDF iconAntipsychotic Agents
PDF iconAllergen Specific Immunotherapy (SL)
PDF iconArmodafinil (Nuvigil)/Modafinil (Provigil)
PDF iconAttention Deficit Hyperactivity Disorder Agents
PDF iconAztreonam (Cayston®)
PDF iconBrand drugs with generic alternatives
PDF iconBuprenorphine and Naloxone (Zubsolv® Bunavail) and Buprenorphine (Subutex®)
PDF iconCalcipotriene and betamethasone (Enstilar®/Taclonex®/Taclonex Scalp®)
PDF iconCarglumic Acid (Carbaglu)
PDF iconChelation Agents
PDF iconCholic acid (Cholbam)
PDF iconChorionic gonadotropin (Novarel®/Pregnyl®)
PDF iconCompounded Products
PDF iconControlled Substance Prior Authorization
PDF iconControlled Substance Quantity Limits
PDF iconCost Share Exception Policy
PDF iconCrofelemer (Fulyzaq®)
PDF iconCyanocobalamin Inhalation (Nascobal®)
PDF iconCysteamine-Containing Products
PDF iconCystic Fibrosis Agents (Kalydeco, Orkambi)
PDF iconDextromethorphan hydrobromide and Quinidine sulfate (Nuedexta)
PDF iconDichlorphenamide (Keveyis)
PDF iconDiclofenac Products
PDF iconDroxidopa (Northera)
PDF iconEpinephrine Pen
PDF iconErectile Dysfunction Agents
PDF iconExperimental/Investigational Use
PDF iconFixed Dose Combination Products
PDF iconFlibanserin (Addyi)
PDF iconFormulary Exception Policy
PDF iconGabapentin (Gralise/Horizant)/Pregabalin (Lyrica)
PDF iconGaucher Disease agents
PDF iconGlycerol Phenylbutyrate (Ravicti®)
PDF iconGrowth Hormones
PDF iconHeart Failure Agents
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 iconInhaled Beta Agonists
PDF iconInhaled Corticosteroid (ICS)
PDF iconInjectable antidiabetic agents
PDF iconInsulin Human, Inhalation (Afrezza)
PDF iconInterim Clinical Policy
PDF iconIntranasal Corticosteroids
PDF iconIrritable Bowel Syndrome Agents
PDF iconIsotretinoin (Absorica®)
PDF iconLifitegrast (Xiidra)
PDF iconLong Acting Beta Agonist (LABA) combination policy
PDF iconLoxapine inhalation (Adasuve®)
PDF iconMecamylamine (Vecamyl)
PDF iconMecasermin (Increlex™)
PDF iconMetabolic Disorder Agents
PDF iconMetreleptin (Myalept®)
PDF iconMifepristone (Korlym)
PDF iconMigraine Agents
PDF iconMultiple Sclerosis Agents
PDF iconNaloxone auto injector (Evzio)
PDF iconNon-Preferred Diabetic Test Strips
PDF iconNon-Preferred Insulins
PDF iconObeticholic acid (Ocaliva)
PDF iconOnychomycosis agents
PDF iconOral Antidiabetic
PDF iconOral Anti-infective
PDF iconOral Chemotherapy
PDF iconParathyroid Hormone (Natpara)
PDF iconPasireotide (Signifor®)
PDF iconPCSK9 Inhibitors
PDF iconPeginterferon alfa-2b (Sylatron)
PDF iconPentosan Polysulfate (Elmiron®)
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 iconSodium Oxybate (Xyrem)
PDF iconTeduglutide (Gattex)
PDF iconTeriparatide (Forteo™)
PDF iconTetrabenazine (Xenazine)
PDF iconTolvaptan (Samsca™)
PDF iconTopical Antineoplastic Agents
PDF iconWeight Loss Agents

 

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PDF iconClaim Payment Policy: Non FDA Approved Medication Policy
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