Pharmacy policy

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

• Abaloparatide/Teriparatide
• Actinic Keratosis agents and Zyclara^®
• Acute seizure activity agents
• Adjunctive treatment for Parkinson’s Disease
• Applicable age edits
• Allergen specific immunotherapy (SL)
• Amifampridine (Firdapse^®)
• Amikacin liposome inhalation suspension (Arikayce^®)
• Androgens
• Antigout agents
• Authorized generic drugs
• Avacopan (Tavneos™)
• Aztreonam (Cayston^®)
• Becaplermin gel (Regranex^®)
• Belimumab (Benlysta^®)/Voclosporin (Lupkynis™)
• Belumosudil (Rezurock™)
• Blood modifier agents
• Carglumic acid (Carbaglu)
• Cenegermin-bkbj (Oxervate™)
• Chelation agents
• Cholesterol lowering agents
• Cholic acid (Cholbam)
• Compounded products
• Continuous glucose monitor
• Cushing’s Disease Agents
• Cyanocobalamin inhalation (Nascobal^®)
• Cysteamine-containing products
• Cystic fibrosis agents (Kalydeco^®, Orkambi^®, Trikafta™, Symdeko^®)
• Dalfampridine (Ampyra)
• Deflazacort (Emflaza^®)
• Dextromethorphan hydrobromide and quinidine sulfate (Nuedexta)
• Dichlorphenamide (Keveyis)
• Diclofenac products
• Doxycycline ER/IR (Oracea)
• Doxylamine/pyridoxine (Diclegis, Bonjesta)
• Droxidopa (Northera)
• Drugs exceeding claim dollar limit threshold
• Dupilumab (Dupixent^®)
• Elagolix, estradiol, and norethindrone acetate (Oriahnn^®)/Relugolix, estradiol and norethindrone acetate (Myfembree^®)
• Elagolix sodium (Orilissa™)
• Epinephrine pen
• Fabry disease agents
• Finerenone (Kerendia^®)
• Formulary exception policy
• Fosdenopterin (Nulibry™)
• Fostemsavir (Rukobia), Enfuvirtide (Fuzeon^®)
• Gabapentin (Gralise/Horizant)/Pregabalin (Lyrica CR)
• Gaucher disease agents
• Glycerol Phenylbutyrate (Ravicti^®)
• Glycopyrronium topical (Qbrexza™)
• Growth hormones
• Heart failure agents
• Hemophilia agents
• Hepatitis C
• Hereditary angioedema agents
• Hereditary tyrosinemia Agents
• Hypoactive Sexual Desire Disorder (HSDD) agents
• Icosapent ethyl (Vascepa^®)
• Immune modulating therapies
• Insulin human, inhalation (Afrezza)
• Insulin, human U-500 (Humulin R U-500)
• Interferon gamma-1b (Actimmune^®)
• Interim clinical policy
• Interleukin-5 (IL-5) antibody agents
• Interstitial lung disease agents
• Intranasal corticosteroids
• Lonafarnib (Zokinvy™)
• Mannitol (Bronchitol^®)
• Maralixibat (Livmarli™)
• Mecasermin (Increlex™)
• Metabolic disorder agents (Strensiq^®, Xuriden^®)
• Metreleptin (Myalept^®)
• Migraine and Headache Agents
• Naloxone
• Obeticholic acid (Ocaliva^®)
• Octreotide products
• Odevixibat (Bylvay™)
• Off-label use
• Omalizumab (Xolair^®)
• Oncology agents
• Onychomycosis agents
• Opioid policy
• Oral anti-infective
• Oxymetazoline (Upneeq™)
• Peanut immunotherapy (Palforzia^®)
• Parathyroid hormone (Natpara)
• Pegcetacoplan (Empaveli™)
• Pegvaliase-pqpz (Palynziq™)
• Pegvisomant (Somavert^®)
• Pentosan polysulfate (Elmiron^®)
• Phenoxybenzamine (Dibenzyline)
• Pilocarpine (Vuity™)
• Pimavanserin (Nuplazid)
• Prednisone delayed release (Rayos)
• Proton pump inhibitors
• Prior authorization requirements for select drugs
• Pulmonary hypertension agents
• Quantity level limits for pharmaceuticals covered under the pharmacy benefit
• Quinine sulfate (Qualaquin™)
• Rifaximin (Xifaxan^®)
• Risiplam (Evrysdi™)
• Ruxolitinib (Opzelura™)
• Sacrosidase (Sucraid^®)
• Sapropterin dihydrochloride (Kuvan^®)
• Satralizumab (Enspryng^®)
• Seizure Disorder Agents
• Setmelanotide (Imcivree™)
• Sleep agents
• Sickle cell agents
• Sodium oxybate (Xyrem^®), Calcium, Magnesium, Potassium and Sodium Oxybate (Xywav™)
• Stimulants
• Teduglutide (Gattex)
• Telotristat ethyl (Xermelo™)
• Tolvaptan (Samsca^®, Jynarque^®)
• Transthyretin Amyloidosis Agents
• Triheptanoin (Dojolvi^®)
• VMAT2 inhibitors
• Vosoritide (Voxzogo™)
• Wakefulness promoting agents
• Weight loss agents

Claim payments

• Non-FDA approved medication policy
• FDA Approved Medications Deemed Experimental/Investigational
• Excluded medications with no significant advantage over covered alternatives
• Prescription vitamins, dietary supplements, and medical foods
• Medical injectable medications covered under the pharmacy benefit
• Convenience packs
• Cosmetic policy