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:

Date (YYYY/MM/DD) Title Download (PDF)
2022/02/02 ABECMA® (idecabtagene vicleucel) Download PDF
2021/09/16 Abraxane® (paclitaxel protein-bound particles) Download PDF
2021/09/15 Actemra (tocilizumab) Download PDF
2021/04/13 Adakveo (crizanlizumab injection) Download PDF
2021/01/01 Adasuve® (loxapine) Download PDF
2021/02/12 Adcetris (brentuximab vedotin) Download PDF
2021/03/12 Aduhelm™ (aducanumab-avwa) Download PDF
2021/02/10 Ajovy (fremanezumab-vfrm) Download PDF
2021/03/28 Akynzeo (fosnetupitant and palonosetron) Injection Download PDF
2020/01/22 Aldurazyme (laronidase) Download PDF
2021/03/28 Alimta® (pemetrexed) Download PDF
2021/02/09 Aliqopa™ (copanlisib) Download PDF
2020/12/02 Aloxi® (palonosetron) Download PDF
2021/06/10 Alpha-1-Proteinase Inhibitors Infusion Therapy Download PDF
2021/09/02 Amondys 45™ (casimersen intravenous infusion) Download PDF
2020/01/22 Apokyn (apomorphine) Download PDF
2021/01/20 Arcalyst (rilonacept) Download PDF
2021/02/09 Arzerra (ofatumumab) Download PDF
2020/12/02 Asparlas (calaspargase pegol-mknl) Download PDF
2020/12/02 Avastin (bevacizumab) for oncology diagnosis Download PDF
2021/06/10 Aveed (testosterone undecanoate) Download PDF
2021/09/02 Azacitidine (Vidaza®) Download PDF
2021/09/02 Azedra® (Iobenguane I-131) Download PDF
2021/10/22 Barhemsys (amisulpride) Download PDF
2021/01/20 Bavencio® (avelumab) Download PDF
2021/10/09 Baxdela (delafloxacin) Download PDF
2021/10/02 Bendamustine (Bendeka, Treanda, Belrapzo) Download PDF
2021/10/02 Benlysta (belimumab) Download PDF
2021/10/10 Berinert (C1 Esterase Inhibitor Human) Download PDF
2021/09/02 Besponsa® (inotuzumab ozogamicin) Download PDF
2021/09/02 Blenrep (belantamab mafodotin-blmf) Download PDF
2021/09/02 Blincyto™ (blinatumomab) Download PDF
2021/09/02 Boniva (ibandronate) Download PDF
2021/09/02 Breyanzi (lisocabtagene maraleucel) Download PDF
2021/09/02 Brineura (cerliponase alfa) Download PDF
2021/09/02 Cabenuva (cabotegravir rilpivirine) Download PDF
2021/09/02 Cablivi (caplacizumab-yhdp) Download PDF
2021/09/02 Campath® (Alemtuzumab) Download PDF
2022/05/19 CARVYKTI (ciltacabtagene autoleucel) intravenous infusion Download PDF
2021/09/02 Cerezyme (imiglucerase) Download PDF
2021/09/02 Cimzia® (certolizumab pegol) Download PDF
2021/09/02 Cinqair (reslizumab) Download PDF
2021/09/02 Cinryze (C1 Esterase Inhibitor Human) Download PDF
2021/09/02 Cinvanti (aprepitant) Injectable Emulsion Download PDF
2021/09/02 Clolar (clofarabine) Download PDF
2022/03/08 Clotting Disorder Therapy Download PDF
2021/09/02 Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb) Download PDF
2021/09/02 Colony Stimulating Factors: Leukine® (sargramostim) Download PDF
2021/09/02 Colony Stimulating Factors: Neulasta® (pegfilgrastim) Download PDF
2022/05/19 Colony Stimulating Factors: Neupogen®, Granix® and Zarxio® (filgrastim) Download PDF
2021/09/02 Colony Stimulating Factors: Nivestym™ (filgrastim-aafi) Download PDF
2021/09/02 Colony Stimulating Factors: Udenyca (pegfilgrastim-cbqv) Download PDF
2021/09/02 Colony Stimulating Factors: Ziextenzo (pegfilgrastim-bmez) Download PDF
2021/09/02 Cosela™ (trilaciclib injection) powder for injection Download PDF
2021/09/02 Cresemba® (isavuconazonium sulfate) Download PDF
2021/09/02 Crysvita (burosumab-twza) Download PDF
2021/09/02 Cyramza® (ramucirumab) Download PDF
2021/09/02 Cytogam (cytomegalovirus immune globulin, human) Download PDF
2021/09/02 Dacogen (decitabine) Download PDF
2021/09/02 DANYELZA® (naxitamab-gqgk) injection Download PDF
2021/09/02 Darzalex (daratumumab) Download PDF
2022/03/31 Duchenne Muscular Dystrophy (DMD) Drugs (Amondys 45, Exondys 51, Vyondys 53 and Viltepso)—MEDICAID ONLY Download PDF
2021/09/02 Elaprase® (idursulfase) Download PDF
2021/09/02 Elelyso (taliglucerase alfa Download PDF
2021/09/02 Eloxatin (oxaliplatin) Download PDF
2021/09/02 Elzonris (Tagraxofusp-erzs) Download PDF
2022/02/02 Empaveli™ (pegcetacoplan) Download PDF
2021/09/02 Empliciti (elotuzumab) Download PDF
2021/09/02 Enhertu (fam-trastuzumab deruxtecan-nxki) Download PDF
2022/05/19 ENJAYMO™ (sutimlimab-jome) Intravenous Infusion Download PDF
2021/09/02 Entyvio (vedolizumab) Download PDF
2021/09/02 Erbitux® (cetuximab) Download PDF
2021/09/02 Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) Download PDF
2021/09/02 Erythropoiesis Stimulating Agents (ESAs): Epogen, Procrit, Retacrit (epoetin alfa) Download PDF
2021/09/02 Eteplirsen (Exondys 51™) Download PDF
2021/09/02 Evenity (romosozumab-aqqg) Download PDF
2022/05/19 EVKEEZA (evinacumab-dgnb) Download PDF
2021/09/02 Fabrazyme (agalsidase beta) Download PDF
2021/09/02 Fasenra™ (benralizumab) Download PDF
2021/09/02 Fensolvi (leuprolide_acetate) Download PDF
2021/09/02 Fetroja® (cefiderocol) Download PDF
2021/09/02 Firazyr (icatibant) Download PDF
2021/09/02 Folotyn (pralatrexate) Download PDF
2021/09/02 Fusilev (levoleucovorin) Download PDF
2022/03/09 Fyarro™ (sirolimus protein-bound particles intravenous infusion) Download PDF
2021/09/02 Gamifant (Emapalumab-lzsg) Download PDF
2021/09/02 Gazyva (obinutuzumab) Download PDF
2021/09/02 Givlaari (givosiran) Download PDF
2021/09/02 H.P. Acthar® Gel (repository corticotropin injection) Download PDF
2021/09/02 Haegarda® (C1 esterase inhibitor human) and Takhzyro® (lanadelumab-flyo) Download PDF
2021/09/02 Halaven™ (eribulin) Download PDF
2021/09/02 Hepagam B (hepatitis B immune globulin) Download PDF
2021/09/02 Hyaluronate Injections for Osteoarthritis of the Knee — COMMERICAL and MEDICARE Download PDF
2021/09/03 Hydroxyprogesterone Caproate (Makena®) for the Prevention of Preterm Labor Download PDF
2021/09/02 Ilaris (canakinumab) Download PDF
2021/09/02 Ilumya (tildrakizumab-asmn) Download PDF
2021/09/02 Imfinzi™ (durvalumab) Download PDF
2021/09/02 Imlygic (Talimogene laherparepvec) Download PDF
2021/09/02 Infliximab Injectable (Avsola, Inflectra®, Remicade®, Renflexis™) Download PDF
2021/09/02 Infugem (gemcitabine) Download PDF
2021/09/02 Intravenous Immune Globulins (immune globulin) Download PDF
2022/05/19 Intravitreal Injections/Implants Download PDF
2021/09/02 Istodax (romidepsin) Download PDF
2021/09/02 Ixempra (ixabepilone) Download PDF
2021/09/02 Jelmyto (mitomycin solution for pyelocalyceal administration) Download PDF
2021/09/02 Jemperli (dostarlimab-gxly) Download PDF
2021/09/02 Jevtana (cabazitaxel) Download PDF
2021/09/02 Kadcyla® (ado-trastuzumab emtansine) Download PDF
2021/09/02 Kalbitor (ecallantide) Download PDF
2021/09/02 Kanuma (sebelipase alfa) Download PDF
2021/09/02 Keytruda® (pembrolizumab) Download PDF
2022/05/19 KIMMTRAK (tebentafusp-tebn) intravenous infusion Download PDF
2021/09/02 Khapzory (levoleucovorin) Download PDF
2022/05/19 KORSUVA (difelikefalin) intravenous injection Download PDF
2021/09/02 Krystexxa (pegloticase) Download PDF
2021/09/02 Kymriah™ (tisagenlecleucel) Download PDF
2021/09/02 Kyprolis (carfilzomib) Download PDF
2021/09/02 Lartruvo (olaratumab) Download PDF
2021/09/02 Lemtrada® (alemtuzumab) Download PDF
2022/03/09 Leqvio® (inclisiran), subcutaneous injection Download PDF
2021/09/02 Libtayo (cemiplimab-rwlc) Download PDF
2021/09/02 Liposomal Doxorubicin (Doxil & Lipodox) Download PDF
2021/09/02 Lumizyme (alglucosidase alfa) Download PDF
2021/09/02 Lumoxiti (moxetumomab pasudotox-tdfk) Download PDF
2021/09/02 Lutathera® (lutetium Lu 177 dotatate) Download PDF
2021/09/02 Luxturna™ (Voretigene neparvovec) Download PDF
2021/09/02 Marqibo® (vincristine sulfate liposomal) Download PDF
2021/09/02 Margenza (margetuimab) Download PDF
2021/09/02 Mepsevii (vestronidase alfa-vjbk) Download PDF
2021/09/02 Monjuvi (tafasitamab-cxix) Download PDF
2021/09/02 Mozobil (plerixafor) Download PDF
2021/09/02 Mvasi (bevacizumab-awwb), Zirabev® (bevacizumab-bvcr) Download PDF
2021/09/02 Mylotarg (gemtuzumab ozogamicin) Download PDF
2021/09/02 Naglazyme (galsulfase) Download PDF
2022/01/07 Nexviazyme® (avalglucosidase alfa-ngpt) intravenous infusion Download PDF
2021/09/02 Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®) Download PDF
2021/09/02 Nplate (romiplostim) Download PDF
2022/02/02 Nulibry™ (fosdenopterin) Download PDF
2021/09/02 Nucala® (mepolizumab) Download PDF
2021/09/02 Nulojix (belatacept) Download PDF
2021/09/02 NYVEPRIA™ (pegfilgrastim-apgf) Download PDF
2021/09/02 Ocrevus™ (ocrelizumab) Download PDF
2021/09/02 Onivyde (irinotecan liposome) Download PDF
2021/09/02 Onpattro (patisiran) Download PDF
2021/09/02 Opdivo® (nivolumab) Download PDF
2022/05/19 OPDUALAG (nivolumab and relatlimab-rmbw) intravenous infusion Download PDF
2021/09/02 Orencia (abatacept) Download PDF
2021/09/02 Oxlumo™ (lumasiran) Download PDF
2021/09/02 Padcev (enfortumab vedotin-ejfv) Download PDF
2021/09/02 Parsabiv (Etelcalcetide) Download PDF
2021/09/02 Pasireotide (Signifor® LAR) Download PDF
2021/09/02 Pemfexy (pemetrexed injection), for intravenous use Download PDF
2021/09/02 Perjeta (pertuzumab)  
2021/09/02 Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf Download PDF
2021/09/02 Polivy (polatuzumab vedotin) Download PDF
2021/09/02 Portrazza (necitumumab)  
2021/09/02 Poteligeo (mogamulizumab-kpkc) Download PDF
2021/09/02 Probuphine (buprenorphine) Download PDF
2021/09/02 Proleukin (aldesleukin) Download PDF
2021/09/02 Prolia®/Xgeva® (denosumab) Download PDF
2021/09/02 PROVENGE® (sipuleucel-T) Download PDF
2021/09/02 Pulmonary Arterial Hypertension (Remodulin, Tyvaso, Veletri, Ventavis) Download PDF
2021/09/02 Qutenza (capsaicin) Download PDF
2021/09/02 Radicava (Edaravone) Download PDF
2021/09/02 Reblozyl (luspatercept-aamt) Download PDF
2021/09/02 Relistor (methylnatrexone) Download PDF
2021/09/02 Relizorb (immobilized lipase) Cartridge Download PDF
2021/09/02 Revcovi (Elapegademase-lvlr) Download PDF
2021/09/02 RiaSTAP (fibrinogen) Download PDF
2021/09/02 Rituxan Hycela (rituximab and hyaluronidase Human) Download PDF
2021/09/02 Rituximab Injectable (Rituxan®, Ruxience®, Truxima®) Download PDF
2021/09/02 Ruconest (C1 esterase inhibitor [recombinant]) Download PDF
2022/02/02 RYBREVANT  (amivantamab-vmjw) Download PDF
2022/02/02 Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Download PDF
2022/03/09 Ryplazim™ (human plasminogen), injection Download PDF
2022/01/07 Saphnelo™ (anifrolumab-fnia) intravenous infusion Download PDF
2021/09/02 Sarclisa® (isatuximab) Download PDF
2021/09/02 Simponi Aria (golimumab) Download PDF
2021/09/02 Soliris® (eculizumab) Download PDF
2021/09/02 Somatuline Depot (lanreotide) Download PDF
2021/09/02 Spinraza™ (Nusinersen) Download PDF
2021/09/02 Spravato (esketamine hydrochloride) Download PDF
2022/05/10 SITE OF SERVICE MEDICAL POLICY – Infusions and Injectables Download PDF
2021/09/02 Stelara® (ustekinumab) Download PDF
2021/09/02 Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru Download PDF
2021/09/02 Supprelin LA (histrelin acetate) Download PDF
2021/09/02 Sylvant (siltuximab) Download PDF
2021/09/02 Synagis Download PDF
2021/09/02 Synribo (omacetaxine) Download PDF
2021/09/02 Tecartus (brexucabtagene autoleucel) Download PDF
2021/09/02 Tecentriq (atezolizumab) Download PDF
2021/09/02 Temodar (temozolomide) Download PDF
2021/09/02 Tepadina (thiotepa) Download PDF
2021/09/02 Tepezza® (teprotumumab-trbw) Download PDF
2022/05/25 Tezspire (tezepelumab-ekko) subcutaneous injection Download PDF
2021/09/02 Thyrogen (thyrotropine alfa) Download PDF
2022/01/07 TIVDAK™ (tisotumab vedotin) injection, powder, for solution Download PDF
2021/09/02 Torisel (temsirolimus) Download PDF
2021/09/02 Trastuzumab Injection (Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) Download PDF
2021/09/02 Tremfya (guselkumab) Download PDF
2021/09/02 Trodelvy™ (sacituzumab govitecan-hziy) Download PDF
2021/09/02 Trogarzo (Ibalizumab-uiyk) Download PDF
2021/09/02 Tysabri (natalizumab) Download PDF
2021/09/02 Ultomiris (Ravulizumab-cwvz) Download PDF
2021/09/02 Unituxin™ (dinutuximab) Download PDF
2021/09/02 Uplizna (inebilizumab-cdon) Download PDF
2021/09/02 Vantas® (histrelin acetate) Download PDF
2021/09/02 Vectibix® (panitumumab) Download PDF
2021/09/02 Velcade (bortezomib) Download PDF
2021/09/02 Viltepso (viltolarsen) Download PDF
2021/09/02 Vimizim (elosulfase) Download PDF
2021/09/02 Vpriv (velaglucerase alfa) Download PDF
2021/09/02 Vyepti™ (eptinezumab-jjmr) Download PDF
2021/09/02 VYONDYS 53® (golodirsen) Download PDF
2022/03/09 Vyvgart (efgartigimod alfa-fcab intravenous infusion) Download PDF
2021/09/02 Vyxeos™ (daunorubicin and cytarabine) Download PDF
2022/02/03 Xaracoll (bupivacaine hydrochloride) Implant Download PDF
2021/09/03 Xiaflex (collagenase clostridium histolyticum) Download PDF
2021/09/02 Xofigo for Castration-Resistant Prostate Cancer Download PDF
2021/09/02 Xolair® (omalizumab) Download PDF
2021/09/02 Yervoy™ (ipilimumab) Download PDF
2021/09/02 Yescarta (axicabtagene ciloleucel) Download PDF
2021/09/02 Yondelis (trabectedin) Download PDF
2021/09/02 Zaltrap (ziv-aflibercept) Download PDF
2021/09/02 Zepzelca (lurbinectedin) Download PDF
2021/09/02 Zevalin (ibritumomab tiuxetan) Download PDF
2021/09/02 Zilretta (triamcinolone acetonide extended release injection) Download PDF
2021/09/02 Zinplava (bezlotoxumab) Download PDF
2021/09/02 Zoledronic acid (Zometa®, Reclast®) Download PDF
2021/09/02 Zolgensma (onasemnogene abeparvovec-xioi) Download PDF
2021/09/02 Zulresso (brexanolone) Download PDF
2021/09/02 Zynlonta (loncastuximab-tesirine) Download PDF

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