Pharmacy Policies Available Online

The following medical drug policies are new and require precertification:

  • Chimeric Antigen Receptor Therapy for Hematologic Malignancies
  • Eptinezumab-jjmr (Vyepti)
  • Isatuximab-irfc (Sarclisa)
  • Ixabepilone (Ixempra)

The following medical drug policies were revised and require precertification:

  • Daratumumab (Darzalex™)
  • Idursulfase (Elaprase)

The following medical drug policies were revised:

  • Abatacept (Orencia)
  • Autologous Cellular Immunotherapy for Prostate Cancer
  • Chemodenervation with Botulinum Toxin
  • Diabetic Services and Supplies
  • Eculizumab (Soliris) and Ravulizumab (Ultomiris)
  • Edaravone (Radicava)
  • Emapalumab-lzsg (Gamifant)
  • Golimumab (Simponi Aria)
  • Granulocyte Colony-Stimulating Factors
  • Immune Globulin Therapy
  • Infliximab
  • Pertuzumab (Perjeta)
  • Portable External Infusion Pump
  • Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)
  • Sebelipase alfa (Kanuma)
  • Tagraxofusp-erzs (Elzonris)
  • Treatment of Gaucher Disease
  • Treatment of Hereditary Amyloidosis
  • Ustekinumab (Stelara®) IV
  • Vedolizumab (Entyvio®)
  • Voretigene Neparvovec-rzyl (Luxturna)

The following medical drug policy was retired:

  • Adoptive Immunotherapy

The following new Utilization Management program is effective on the pharmacy benefit as of 5/1/20:

  • Oxbryta PAQL