Pharmacy policy
The policy bulletins on this website were developed to assist participating providers in administering and understanding the provisions of benefits.
- Abaloparatide/Teriparatide
- Acute migraine agents
- Acute seizure activity agents
- Adjunctive treatment for Parkinson’s Disease
- Applicable age edits
- Allergen specific immunotherapy (SL)
- Amifampridine (Firdapse®, Ruzurgi)
- Amikacin liposome inhalation suspension (Arikayce®)
- Androgens
- Antigout agents
- Authorized generic drugs
- Aztreonam (Cayston®)
- Becaplermin gel (Regranex®)
- Belimumab (Benlysta)
- Blood modifier agents
- Carglumic acid (Carbaglu)
- Cenegermin-bkbj (Oxervate™)
- CGRP antagonists
- 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/norethindrone acetate (Oriahnn®)
- Elagolix sodium (Orilissa™)
- Epinephrine pen
- Fabry disease agents
- Formulary exception policy
- Fosdenopterin (Nulibry™)
- Fostemsavir (Rukobia)
- 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
- Hypoactive Sexual Desire Disorder (HSDD) agents
- Icosapent ethyl (Vascepa®)
- Immune modulating therapies for rheumatologic, dermatologic and gastrointestinal diseases
- 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™)
- Loteprednol (Eysuvis)
- Mannitol (Bronchitol®)
- Mecasermin (Increlex™)
- Metabolic disorder agents
- Metreleptin (Myalept®)
- Naloxone auto injector (Evzio)
- Obeticholic acid (Ocaliva®)
- Octreotide products
- Off-label use
- Omalizumab (Xolair®)
- Oncology agents
- Onychomycosis agents
- Opioid policy
- Oral anti-infective
- Oxymetazoline (Upneeq™)
- Peanut immunotherapy (Palforzia®)
- Parathyroid hormone (Natpara)
- Pegvaliase-pqpz (Palynziq™)
- Pegvisomant (Somavert®)
- Pentosan polysulfate (Elmiron®)
- Phenoxybenzamine (Dibenzyline)
- Pimavanserin (Nuplazid)
- Prednisone delayed release (Rayos)
- Proton pump inhibitors
- Prior authorization requirements for select drugs
- Pulmonary arterial hypertensive (PAH) Agents
- Quantity level limits for pharmaceuticals covered under the pharmacy benefit
- Quinine sulfate (Qualaquin™)
- Rifaximin (Xifaxan®)
- Risiplam (Evrysdi™)
- 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®)
- Topical antineoplastic agents
- Transthyretin Amyloidosis Agents
- Triheptanoin (Dojolvi®)
- VMAT2 inhibitors
- Wakefulness promoting agents
- Weight loss agents