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 iconAllergen Specific Immunotherapy (SL)
PDF iconAmphetamine Sulfate (EvekeoTM)
PDF iconAndrogens
PDF iconAntipsychotic Agents
PDF iconArmodafinil (Nuvigil)/Modafinil (Provigil)
PDF iconAtopic Dermatitis Agents
PDF iconAztreonam (Cayston®)
PDF iconCarglumic Acid (Carbaglu)
PDF iconChelation Agents
PDF iconCholic acid (Cholbam)
PDF iconCompounded Products
PDF iconCost Share Exception Policy
PDF iconCyanocobalamin Inhalation (Nascobal®)
PDF iconCysteamine-Containing Products
PDF iconCystic Fibrosis Agents (Kalydeco, Orkambi)
PDF iconDalfampridine (Ampyra)
PDF iconDeflazacort (Emflaza®)
PDF iconDextromethorphan hydrobromide and Quinidine sulfate (Nuedexta)
PDF iconDichlorphenamide (Keveyis)
PDF iconDiclofenac Products
PDF iconDoxylamine/pyridoxine (Diclegis)
PDF iconDroxidopa (Northera)
PDF iconEpinephrine Pen
PDF iconErectile Dysfunction Agents
PDF iconExperimental/Investigational Use
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 iconInsulin Human, Inhalation (Afrezza)
PDF iconInsulin, Human U-500 (Humulin R U-500)
PDF iconInterim Clinical Policy
PDF iconIntranasal Corticosteroids
PDF iconIrritable Bowel Syndrome Agents
PDF iconIsotretinoin (Absorica®)
PDF iconLesinurad (Zurampic)
PDF iconLifitegrast (Xiidra)
PDF iconLoxapine inhalation (Adasuve®)
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 Insulins
PDF iconObeticholic acid (Ocaliva)
PDF iconOnychomycosis agents
PDF iconOpioid Management Policy
PDF iconOral Anti-infective
PDF iconOral Chemotherapy Agents
PDF iconParathyroid Hormone (Natpara)
PDF iconPasireotide (Signifor®)
PDF iconPCSK9 Inhibitors
PDF iconPeginterferon alfa-2b (Sylatron)
PDF iconPentosan Polysulfate (Elmiron®)
PDF iconPhenoxybenzamine (Dibenzyline)
PDF iconPimavanserin (Nuplazid)
PDF iconPrednisone delayed release (Rayos)
PDF iconProton Pump Inhibitors
PDF iconPrior Authorization Requirements for Selected Non-Preferred Drugs
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 iconRifaximin (Xifaxan®)
PDF iconSleep Agents
PDF iconSodium Oxybate (Xyrem)
PDF iconTeduglutide (Gattex)
PDF iconTelotristat ethyl (Xermelo™)
PDF iconTeriparatide (Forteo™)
PDF iconTetrabenazine (Xenazine)/deutetrabenazine (Austedo)
PDF iconTiopronin (Thiola)
PDF iconTolvaptan (Samsca™)
PDF iconTopical Antineoplastic Agents
PDF iconWeight Loss Agents

 

Claim Payments

PDF iconClaim Payment Policy: Non FDA Approved Medication Policy
PDF iconExcluded Medications with No Significant Advantage Over Covered Alternatives
PDF iconPrescription Vitamins, Dietary Supplements, and Medical Foods
PDF iconMedical injectable medications covered under the pharmacy benefit