Pharmacy Policies
Navigate directly to a letter:
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A
- ANIFRO~2.PDF
- Abatacept (Orencia®) for Injection for Intravenous Use
- Agalsidase beta (Fabrazyme®)
- Alemtuzumab (Lemtrada®)
- Alglucosidase alfa (e.g., Lumizyme®)
- Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)
- Anifrolumab-fnia (Saphnelo™)
- Anifrolumab-fnia_(Saphnelo)_2.pdf
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B
- Belimumab (Benlysta®) for Intravenous Use
- Botulinum Toxin Agents
- Botulinum_Toxin_Agents_2.pdf
- Burosumab-twza (Crysvita®)
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C
- Canakinumab (Ilaris®)
- Cerliponase alfa (Brineura®)
- Coagulation Factors
- Collagenase clostridium histolyticum (Xiaflex®), collagenase clostridium histolyticum-aaes (Qwo™)
- Crizanlizumab-tmca (Adakveo®)
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D
- Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)
- Dofetilide (Tikosyn®) Use in the Inpatient Setting
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E
- Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
- Eculizumab_(Soliris)_and_Related_Biosimilars,_Ravulizumab-cwvz_(Ultomiris)_2.pdf
- Efgartigimod-alfa (VyvgartTM) and efgartgimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
- Emapalumab-lzsg (Gamifant®)
- Enteral Nutritional Therapy
- Enteral_Nutritional_Therapy_2.pdf
- Enzyme Replacement Therapy for Mucopolysaccharidosis
- Enzyme Replacement for the Treatment of Gaucher's Disease
- Eptinezumab-jjmr (VYEPTI™)
- Erythropoiesis Stimulating Agents (ESAs)
- Evinacumab-dgnb (Evkeeza)
- Evinacumab-dgnb_(Evkeeza)_2.pdf
- Exon Skipping Drugs for Duchenne Muscular Dystrophy (DMD)
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F
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G
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I
- Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
- Immune_Globulin_Intravenous_(IVIG),_Subcutaneous_(SCIG)_2.pdf
- Inclisiran (Leqvio®)
- Inebilizumab-cdon (Uplizna)
- Infliximab and Related Biosimilars
- Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
- Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)
- Intravenous_Ketamine_(Ketalar)_and_Intranasal_Esketamine_(Spravato)_2.pdf
- Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
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L
- Lanreotide (Somatuline® Depot)
- Local Coverage Determination for Glucose Monitors
- Lumasiran (Oxlumo™)
- Luspatercept–aamt (Reblozyl®)
-
M
- Medicare_Part_B_vs_Part_D_Crossover_Drugs_2.pdf
- Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer Disease
- Monoclonal_Antibodies_Directed_Against_Amyloid_For_The_Treatment_of_Alzheimer_Disease_2.pdf
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N
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O
- Ocrelizumab (Ocrevus®)
- Octreotide Acetate (Sandostatin® LAR Depot)
- Octreotide_Acetate_(Sandostatin_LAR_Depot)_2.pdf
- Off-label Coverage for Prescription Drugs and/or Biologics
- Olipudase alfa-rpcp (Xenpozyme™)
- Omalizumab (Xolair®)
-
P
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R
- Risankizumab-rzaa (Skyrizi®) for Intravenous Use
- Risankizumab-rzaa_(Skyrizi)_for_Intravenous_Use_2.pdf
- Rozanolixizumab-noli (Rystiggo)
-
S
- Sebelipase alfa (Kanuma®)
- Spesolimab--sbzo (Spevigo®)
- Spesolimab-sbzo_(Spevigo)_2.pdf
- Sutimlimab-jome (Enjaymo)
-
T
- Teplizumab-mzwv (Tzield)
- Teprotumumab (Tepezza™)
- Tezepelumab-ekko (Tezspire™)
- Tildrakizumab-asmn (Ilumya)
- Tocilizumab (Actemra®) for Intravenous Infusion and Subcutaneous Injection
- Tofersen (Qalsody™)
- Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Nutrition (IPN)
- Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
- Treatments for Complex Regional Pain Syndrome (CRPS)
- Triamcinolone Acetonide Extended-Release Injectable (Zilretta®)
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U
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V
- Vedolizumab (Entyvio®) for intravenous use
- Velmanase alfa (Lamzede)
- Voretigene Neparvovec-rzyl (Luxturna™)