Enterprise Pharmacy Medical Policies

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Enterprise Pharmacy Medical Policies

 

Welcome to the Enterprise Pharmacy Medical Policies page. Members follow the Medical Policies for the company underwriting or administering their benefit plan. The Enterprise Pharmacy Policies shown on this page have been adopted for both EmblemHealth and ConnectiCare members. For other Medical Policies, see:

 

Title Download (PDF)
ABECMA® (idecabtagene vicleucel) Download PDF
Abecma - Medicare Only Download PDF
Abraxane® (paclitaxel protein-bound particles) Download PDF
Actemra (tocilizumab) Download PDF
Adakveo (crizanlizumab injection) Download PDF
Adasuve® (loxapine) Download PDF
Adcetris (brentuximab vedotin) Download PDF
Adstiladrin® (nadofaragene firadenovec-vncg) intravesical suspension Download PDF
Aduhelm™ (aducanumab-avwa) Download PDF
Aduhelm™ (aducanumab-avwa) —Medicaid Only Download PDF
Aduhelm - Medicare Only Download PDF
Akynzeo (fosnetupitant and palonosetron) Injection Download PDF
Aldurazyme (laronidase) Download PDF
Alferon-N (interferon alfa-n3) Download PDF
Alimta® (pemetrexed) Download PDF
Aliqopa™ (copanlisib) Download PDF
Aloxi® (palonosetron) Download PDF
Alpha-1-Proteinase Inhibitors Infusion Therapy Download PDF
Alprostadil —Medicaid Only Download PDF
Amondys 45™ (casimersen intravenous infusion) Download PDF
Amvuttra (vutrisiran) Download PDF
Aphexda Download PDF
Apokyn (apomorphine) Download PDF
Aranesp - Medicare Only Download PDF
Arcalyst (rilonacept) Download PDF
Arzerra (ofatumumab) Download PDF
Asparlas (calaspargase pegol-mknl) Download PDF
Avastin (bevacizumab) for oncology diagnosis Download PDF
Aveed (testosterone undecanoate) Download PDF
Azacitidine (Vidaza®) Download PDF
Azedra® (Iobenguane I-131) Download PDF
Barhemsys (amisulpride) Download PDF
Bavencio® (avelumab) Download PDF
Baxdela (delafloxacin) Download PDF
Bendamustine (Bendeka, Treanda, Belrapzo) Download PDF
Benlysta (belimumab) Download PDF
Beovu - Medicare Only Download PDF
Berinert (C1 Esterase Inhibitor Human) Download PDF
Besponsa® (inotuzumab ozogamicin) Download PDF
Bevacizumab-Products - Medicare Only Download PDF
Blenrep (belantamab mafodotin-blmf) Download PDF
Blincyto™ (blinatumomab) Download PDF
Boniva (ibandronate) Download PDF
Bortezomib - Medicare Only Download PDF
Botox - Medicare Only Download PDF
Breyanzi (lisocabtagene maraleucel) Download PDF
Breyanzi - Medicare Only Download PDF
Brineura (cerliponase alfa) Download PDF
Briumvi (ublituximab-xiii) Download PDF
Cabenuva (cabotegravir rilpivirine) Download PDF
Cablivi (caplacizumab-yhdp) Download PDF
CARVYKTI (ciltacabtagene autoleucel) intravenous infusion Download PDF
Carvykti - Medicare Only Download PDF
Cerezyme (imiglucerase) Download PDF
Cimzia® (certolizumab pegol) Download PDF
Cinqair (reslizumab) Download PDF
Cinryze (C1 Esterase Inhibitor Human) Download PDF
Cinvanti (aprepitant) Injectable Emulsion Download PDF
Clolar (clofarabine) Download PDF
Clotting Disorder Therapy Download PDF
Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb) Download PDF
Colony Stimulating Factors: Leukine® (sargramostim) Download PDF
Colony Stimulating Factors: Neulasta® (pegfilgrastim) Download PDF
Colony Stimulating Factors: Neupogen®, Granix® and Zarxio® (filgrastim) Download PDF
Colony Stimulating Factors: Nivestym™ (filgrastim-aafi) Download PDF
Colony Stimulating Factors: Rolvedon™ (eflapegrastim-xnst)
Download PDF
Colony Stimulating Factors: Stimufend (pegfilgrastim-fpgk) subcutaneous injection
Download PDF
Colony Stimulating Factors: Udenyca (pegfilgrastim-cbqv) Download PDF
Colony Stimulating Factors: Ziextenzo (pegfilgrastim-bmez) Download PDF
Cosela™ (trilaciclib injection) powder for injection Download PDF
Cresemba® (isavuconazonium sulfate) Download PDF
Crysvita (burosumab-twza) Download PDF
Cyramza® (ramucirumab) Download PDF
Cytogam (cytomegalovirus immune globulin, human) Download PDF
Dacogen (decitabine) Download PDF
DANYELZA® (naxitamab-gqgk) injection Download PDF
Darzalex (daratumumab) Download PDF
Dysport - Medicare Only Download PDF
Duchenne Muscular Dystrophy (DMD) Drugs (Amondys 45, Exondys 51, Vyondys 53 and Viltepso)—Medicaid Only Download PDF
Elahere (mirvetuximab soravtansine-gynx) Download PDF
Elaprase® (idursulfase) Download PDF
Elevidys (delandistrogene moxeparvovec-rokl) Download PDF
Elelyso (taliglucerase alfa) Download PDF
Eloxatin (oxaliplatin) Download PDF
Elrexfio (elranatamab-bcmm) injection solution Download PDF
Elzonris (Tagraxofusp-erzs) Download PDF
Empaveli™ (pegcetacoplan) Download PDF
Empliciti (elotuzumab) Download PDF
Enhertu (fam-trastuzumab deruxtecan-nxki) Download PDF
ENJAYMO™ (sutimlimab-jome) Intravenous Infusion Download PDF
Entyvio (vedolizumab) Download PDF
Epoetin Alfa Products - Medicare Only Download PDF
Epkinly (epcoritamab-bysp) subcutaneous injection Download PDF
Erbitux® (cetuximab) Download PDF
Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) Download PDF
Erythropoiesis Stimulating Agents (ESAs): Epogen, Procrit, Retacrit (epoetin alfa) Download PDF
Eteplirsen (Exondys 51™) Download PDF
Evenity (romosozumab-aqqg) Download PDF
EVKEEZA (evinacumab-dgnb) Download PDF
Eylea and Eylea HD - Medicare Only Download PDF
Fabrazyme (agalsidase beta) Download PDF
Fasenra™ (benralizumab) Download PDF
Feiba - Medicare Only Download PDF
Fensolvi (leuprolide_acetate) Download PDF
Fensolvi, Lupron Depot-Ped - Medicare Only Download PDF
Fetroja® (cefiderocol) Download PDF
Firazyr (icatibant) Download PDF
Folotyn (pralatrexate) Download PDF
Fusilev (levoleucovorin) Download PDF
Fyarro™ (sirolimus protein-bound particles intravenous infusion) Download PDF
Fylnetra (pegfilgrastim-pbbk) Download PDF
Gamifant (Emapalumab-lzsg) Download PDF
Gastric Eletric Stimulation Download PDF
Gazyva (obinutuzumab) Download PDF
Givlaari (givosiran) Download PDF
H.P. Acthar® Gel (repository corticotropin injection) Download PDF
Haegarda® (C1 esterase inhibitor human) and Takhzyro® (lanadelumab-flyo) Download PDF
Halaven™ (eribulin) Download PDF
Hemgenix (etranacogene dezaparvovec-drlb) Download PDF
Hepagam B (hepatitis B immune globulin) Download PDF
Hyaluronic Acid Derivatives - Medicare Only Download PDF
Hyaluronate Injections for Osteoarthritis of the Knee — COMMERICAL and MEDICARE Download PDF
Hydroxyprogesterone Caproate (Makena®) for the Prevention of Preterm Labor Download PDF
Ibandronate IV - Medicare Only Download PDF
Ilaris (canakinumab) Download PDF
Ilumya (tildrakizumab-asmn) Download PDF
Imfinzi™ (durvalumab) Download PDF
Imjudo (tremelimumab-actl) Download PDF
Imlygic (Talimogene laherparepvec) Download PDF
Infliximab Injectable (Avsola, Inflectra®, Remicade®, Renflexis™) Download PDF
Infliximab Products - Medicare Only Download PDF
Infugem (gemcitabine) Download PDF
Intravenous Immune Globulins (immune globulin) Download PDF
Intravenous Immune Globulin - Medicare Only Download PDF
Intravitreal Injections/Implants Download PDF
Istodax (romidepsin) Download PDF
Ixempra (ixabepilone) Download PDF
Izervay Download PDF
Jelmyto (mitomycin solution for pyelocalyceal administration) Download PDF
Jemperli (dostarlimab-gxly) Download PDF
Jesduvroq Download PDF
Jevtana (cabazitaxel) Download PDF
Kadcyla® (ado-trastuzumab emtansine) Download PDF
Kalbitor (ecallantide) Download PDF
Kanuma (sebelipase alfa) Download PDF
Keytruda® (pembrolizumab) Download PDF
KIMMTRAK (tebentafusp-tebn) intravenous infusion Download PDF
Khapzory (levoleucovorin) Download PDF
KORSUVA (difelikefalin) intravenous injection Download PDF
Krystexxa (pegloticase) Download PDF
Kymriah™ (tisagenlecleucel) Download PDF
Kymriah - Medicare Only Download PDF
Kyprolis (carfilzomib) Download PDF
Lamzede (velmanase alfa-tycv), injection powder for solution Download PDF
Lantidra Download PDF
Lartruvo (olaratumab) Download PDF
Lemtrada® (alemtuzumab) Download PDF
Leqembi (lecanemab-irmb) Download PDF
Leqembi - Medicare Only Download PDF
Leqvio® (inclisiran), subcutaneous injection Download PDF
LHRH Agonists/Antagonists (Camcevi, Firmagon, Lupron Depot, Lupron Depot-Ped, Trelstar, Zoladex) Download PDF
Libtayo (cemiplimab-rwlc) Download PDF
Liposomal Doxorubicin (Doxil & Lipodox) Download PDF
Lumizyme (alglucosidase alfa) Download PDF
Lumoxiti (moxetumomab pasudotox-tdfk) Download PDF
Lunsumio (mosunetuzumab-axgb) Download PDF
Lupron Depot and Lupaneta - Medicare Only Download PDF
Lutathera® (lutetium Lu 177 dotatate) Download PDF
Luxturna™ (Voretigene neparvovec) Download PDF
Marqibo® (vincristine sulfate liposomal) Download PDF
Margenza (margetuimab) Download PDF
Mepsevii (vestronidase alfa-vjbk) Download PDF
Monjuvi (tafasitamab-cxix) Download PDF
Mozobil (plerixafor) Download PDF
Mvasi (bevacizumab-awwb), Zirabev® (bevacizumab-bvcr) Download PDF
Mylotarg (gemtuzumab ozogamicin) Download PDF
Myobloc - Medicare Only Download PDF
Naglazyme (galsulfase) Download PDF
Nexviazyme® (avalglucosidase alfa-ngpt) intravenous infusion Download PDF
Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®) Download PDF
Nplate (romiplostim) Download PDF
Nulibry™ (fosdenopterin) Download PDF
Nucala® (mepolizumab) Download PDF
Nulojix (belatacept) Download PDF
NYVEPRIA™ (pegfilgrastim-apgf) Download PDF
Ocrevus™ (ocrelizumab) Download PDF
Omisirge (omidubicel-onlv) intravenous suspension Download PDF
Oncology GnRH Analogs - Medicare Only Download PDF
Onivyde (irinotecan liposome) Download PDF
Onpattro (patisiran) Download PDF
Opdivo® (nivolumab) Download PDF
OPDUALAG (nivolumab and relatlimab-rmbw) intravenous infusion Download PDF
Opfolda Download PDF
Orencia (abatacept) Download PDF
Oxlumo™ (lumasiran) Download PDF
Paclitaxel-Albumin-Bound - Medicare Only Download PDF
Padcev (enfortumab vedotin-ejfv) Download PDF
Parsabiv (Etelcalcetide) Download PDF
Signifor® LAR Download PDF
Pedmark (sodium thiosulfate) Download PDF
Pemfexy (pemetrexed injection), for intravenous use Download PDF
Perjeta (pertuzumab) Download PDF
Phentolamine and Papaverine—Medicaid Only Download PDF
Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf) Download PDF
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) Download PDF
Polivy (polatuzumab vedotin) Download PDF
Pombiliti Download PDF
Portrazza (necitumumab) Download PDF
Poteligeo (mogamulizumab-kpkc) Download PDF
Proleukin (aldesleukin) Download PDF
Prolia®/Xgeva® (denosumab) Download PDF
Prolia - Medicare Only Download PDF
PROVENGE® (sipuleucel-T) Download PDF
Provenge - Medicare Only Download PDF
Pulmonary Arterial Hypertension (Remodulin, Tyvaso, Veletri, Ventavis) Download PDF
Qalsody (tofersen) intrathecal injection Download PDF
Qutenza (capsaicin) Download PDF
Radicava (Edaravone) Download PDF
Ranibizumab Products - Medicare Only Download PDF
Reblozyl (luspatercept-aamt) Download PDF
Rebyota (fecal microbiota, live-jslm) Download PDF
Relistor (methylnatrexone) Download PDF
Relizorb (immobilized lipase) Cartridge Download PDF
Revcovi (Elapegademase-lvlr) Download PDF
RiaSTAP (fibrinogen) Download PDF
Rituxan Hycela (rituximab and hyaluronidase Human) Download PDF
Rituximab Injectable (Rituxan®, Ruxience®, Truxima®) Download PDF
Rituximab Intravenous Products - Medicare Only Download PDF
Roctavian Download PDF
Ruconest (C1 esterase inhibitor [recombinant]) Download PDF
RYBREVANT  (amivantamab-vmjw) Download PDF
Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Download PDF
Ryplazim™ (human plasminogen), injection Download PDF
Rystiggo Download PDF
Sandostatin LAR (octreotide suspension) Download PDF
Saphnelo™ (anifrolumab-fnia) intravenous infusion Download PDF
Sarclisa® (isatuximab) Download PDF
Simponi ARIA (golimumab) Download PDF
SITE OF SERVICE MEDICAL POLICY – Infusions and Injectables Download PDF
Skysona (elivaldogene autotemcel) Download PDF
Skyrizi (risankizumab-rzaa) Download PDF
Soliris® (eculizumab) Download PDF
Soliris - Medicare Only Download PDF
Somatuline Depot (lanreotide) Download PDF
Spinraza™ (Nusinersen) Download PDF
Spevigo (spesolimab-sbzo) Download PDF
Spravato (esketamine hydrochloride) Download PDF
Stelara® (ustekinumab) Download PDF
Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru Download PDF
Sunlenca (lenacapavir) Download PDF
Supprelin LA (histrelin acetate) Download PDF
Supprelin LA, Vantas, Zoladex Implants - Medicare Only Download PDF
Syfovre  Download PDF
Sylvant (siltuximab) Download PDF
Synagis Download PDF
Synribo (omacetaxine) Download PDF
Talvey (talquetamab-tgvs) subcutaneous injection Download PDF
Tecartus (brexucabtagene autoleucel) Download PDF
Tecartus - Medicare Only Download PDF
Tecentriq (atezolizumab) Download PDF
Tecvayli (teclistamab-cqyv) subcutaneous injection Download PDF
Tegsedi  Download PDF
Temodar (temozolomide) Download PDF
Tepadina (thiotepa) Download PDF
Tepezza® (teprotumumab-trbw) Download PDF
Tezspire (tezepelumab-ekko) subcutaneous injection Download PDF
Thyrogen (thyrotropine alfa) Download PDF
TIVDAK™ (tisotumab vedotin) injection, powder, for solution Download PDF
Torisel (temsirolimus) Download PDF
Trastuzumab Injection (Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) Download PDF
Tremfya (guselkumab) Download PDF
Trodelvy™ (sacituzumab govitecan-hziy) Download PDF
Trogarzo (Ibalizumab-uiyk) Download PDF
Tysabri (natalizumab) Download PDF
Tzield (teplizumab-mzwv) Download PDF
Ultomiris (Ravulizumab-cwvz) Download PDF
Unituxin™ (dinutuximab) Download PDF
Uplizna (inebilizumab-cdon) Download PDF
Vabysmo - Medicare Only Download PDF
Vectibix® (panitumumab) Download PDF
Velcade (bortezomib) Download PDF
Veopoz Download PDF
Viltepso (viltolarsen) Download PDF
Vimizim (elosulfase) Download PDF
Vpriv (velaglucerase alfa) Download PDF
Vyepti™ (eptinezumab-jjmr) Download PDF
VYONDYS 53® (golodirsen) Download PDF
Vyvgart (efgartigimod alfa-fcab intravenous infusion) Download PDF
Vyxeos™ (daunorubicin and cytarabine) Download PDF
Xaracoll (bupivacaine hydrochloride) Implant Download PDF
Xenpozyme (olipudase alfa-rpcp) Download PDF
Xeomin - Medicare Only Download PDF
Xgeva - Medicare Only Download PDF
Xiaflex (collagenase clostridium histolyticum) Download PDF
Xofigo for Castration-Resistant Prostate Cancer Download PDF
Xolair® (omalizumab) Download PDF
Xolair - Medicare Only Download PDF
Yervoy™ (ipilimumab) Download PDF
Yescarta (axicabtagene ciloleucel) Download PDF
Yescarta - Medicare Only Download PDF
Yondelis (trabectedin) Download PDF
Zaltrap (ziv-aflibercept) Download PDF
Zepzelca (lurbinectedin) Download PDF
Zevalin (ibritumomab tiuxetan) Download PDF
Zilretta (triamcinolone acetonide extended release injection) Download PDF
Zinplava (bezlotoxumab) Download PDF
Zoledronic acid (Zometa®, Reclast®) Download PDF
Zolgensma (onasemnogene abeparvovec-xioi) Download PDF
Zulresso (brexanolone) Download PDF
Zynlonta (loncastuximab-tesirine) Download PDF
Zynteglo Download PDF
Zynyz  Download PDF

JP59401:08/22