Archived Pharmacy Policies
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.
- Amvuttra (vutrisiran) – Archived on 03/31/2026
- Benlysta (belimumab) – Archived on 03/31/2026
- Encelto (revakinagene taroretcel-lwey) – Archived on 03/31/2026
- Enzyme Replacement Therapy (ERT) for Fabry Disease: Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa-iwxj) – Archived on 03/31/2026
- Gamifant (emapalumab-lzsg) – Archived on 03/31/2026
- Hemophilia and Other Clotting Disorders – Archived on 03/31/2026
- Iluvien (fluocinolone acetonide) – Archived on 03/31/2026
- Izervay (avacincaptad pegol) – Archived on 03/31/2026
- Lemtrada (alemtuzumab) – Archived on 03/31/2026
- Leqembi (lecanemab) – Archived on 03/31/2026
- Multi-ingredient Compound Policy – Archived on 03/31/2026
- Novantrone (mitoxantrone) – Archived on 03/31/2026
- Onpattro (patisiran) – Archived on 03/31/2026
- Oxlumo (lumasiran) – Archived on 03/31/2026
- Ozurdex (dexamethasone) – Archived on 03/31/2026
- Qalsody (tofersen) – Archived on 03/31/2026
- Radicava (edaravone injection); Radicava ORS (edaravone oral suspension) – Archived on 03/31/2026
- Retisert (fluocinolone acetonide) – Archived on 03/31/2026
- Rivfloza (nedosiran) – Archived on 03/31/2026
- Rystiggo (rozanolixizumab-noli) – Archived on 03/31/2026
- Saphnelo (anifrolumab-fnia) – Archived on 03/31/2026
- Skysona (elivaldogene autotemcel) – Archived on 03/31/2026
- Soliris (eculizumab) – Archived on 03/31/2026
- Susvimo (ranibizumab) – Archived on 03/31/2026
- Syfovre (pegcetacoplan) – Archived on 03/31/2026
- Ultomiris (ravulizumab-cwvz) – Archived on 03/31/2026
- Uplizna (inebilizumab-cdon) – Archived on 03/31/2026
- Vyjuvek (beremagene geperpavec-svdt) – Archived on 03/31/2026
- Xipere (triamcinolone) – Archived on 03/31/2026