Pharmacy Policies

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5
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C
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5
- 5-Hydroxytryptamine-3 Serotonin Receptor Antagonists (5-HT3 RA), Substance P/Neurokinin 1 Receptor Antagonists (NK1 RA), and Combination Agents
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A
- Adakveo (crizanlizumab-tmca)
- Agents to Treat Gaucher’s Disease
- Alpha-1 Proteinase Inhibitors (Human)
- Anti-CD19 CAR-T Immunotherapies
- Anti-FGF23 Monoclonal Antibodies
- Anti-amyloid Monoclonal Antibodies (mAb)
- Antisense Oligonucleotides for Duchenne Muscular Dystrophy
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B
- B-Cell Maturation Antigen (BCMA) Directed Chimeric Antigen Receptor (CAR) T-Cell Therapy
- Benlysta (belimumab)
- Biologic Agents for Nasal Polyposis
- Blincyto
- Botulinum Toxins A&B
- Brineura (cerliponase alfa)
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C
- Calcitonin Gene-Related Peptide (CGRP) Antagonists for Headache Prevention
- Chelating Agents
- Complement Inhibitors
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D
- Dendritic Cell Tumor Peptide Immunotherapy
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E
- Emergency Use Authorization (EUA) Drugs/Products for COVID-19
- Enzyme Replacement Therapies for Fabry Disease
- Enzyme replacement therapy for acid sphingomyelinase deficiency (ASMD)
- Erythropoiesis-Stimulating Agents (ESAs)
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F
- Fecal Microbiota
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G
- Generalized Pustular Psoriasis (GPP) Agents
- Gonadotropin Releasing Hormone Agonists (GNRH) **IF DIAGNOSIS IS CANCER, USE ONCOLOGY CRITERIA**
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H
- Healthcare professional (HCP) administered Disease Modifying Therapies (DMTs) for Multiple Sclerosis (MS)
- Hyaluronic Acid Derivatives
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I
- Immune Globulins
- Injectable/Infusible Bone-Modifying Agents for Oncology Indications
- Injectable/Infusible Bone-Modifying Agents for Osteoporosis and Paget’s Disease
- Insulin-Like Growth Factor-1 Receptor (Igf-1r) Antagonists For Thyroid Eye Disease
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J
- Jesduvroq
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K
- Ketamine
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L
- Leqvio
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M
- Medications without specific criteria
- Mucopolysaccharidosis II (Hunter Syndrome) Agents
- Mucopolysaccharidosis VI (Maroteaux-Lamy Syndrome) Agents
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N
- Natriuretic Peptides for Achondroplasia
- Neuromyelitis Optica Spectrum Disorder (NMOSD) Agents
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O
- Off-Label Uses Criteria
- Omisirge
- Oncology Drugs
- Oxlumo (lumasiran)
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P
- Palynziq
- Peanut Allergy Immunotherapy Agents (FDA Approved)
- Primary Hemophagocytic Lymphohistiocytosis (HLH) Agents
- Propel (drug eluting devices after sinus surgery)
- Pulmonary Biologics for Asthma and Eosinophilic Conditions
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Q
- Qalsody (tofersen)
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R
- Radicava
- Reblozyl (luspatercept-aamt)
- Rituximab
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S
- SMN2 Splicing Modifiers for the Treatment of Spinal Muscular Atrophy (SMA)
- Somatostatin Analogs and Growth Hormone Receptor Antagonists
- Specialty Biological Agents for Ankylosing Spondylitis and Non-Radiographic Axial Spondyloarthritis
- Specialty Biological Agents for Crohn’s Disease
- Specialty Biological Agents for Polyarticular Juvenile Idiopathic Arthritis
- Specialty Biological Agents for Psoriasis
- Specialty Biological Agents for Psoriatic Arthritis (PsA)
- Specialty Biological Agents for Rheumatoid Arthritis
- Specialty Biological Agents for Systemic Juvenile Idiopathic Arthritis
- Specialty Drugs for Ulcerative Colitis
- Spravato
- Synagis (palivizumab)
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T
- Transthyretin-mediated Amyloidosis Agents
- Treatment of Hereditary Angioedema (HAE)
- Treatments for Plasminogen Deficiency Type 1 (PLD1)
- Type I Interferon (IFN) Receptor Antagonist
- Tzield (teplizumab-mzwv)
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V
- Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Conditions
- Vasodilators for Pulmonary Hypertension
- Vimizim (elosulfase alfa)
- Vyvgart
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W
- White Blood Cell Stimulators
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X
- Xolair for Asthma and Urticaria
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Z
- Zulresso (brexanolone)
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