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:
Enterprise Pharmacy Medical Policies
| Title | Download (PDF) |
|---|---|
| Abecma® (idecabtagene vicleucel) | Download PDF |
| Abecma - Medicare Only | Download PDF |
| Abraxane® (paclitaxel protein-bound particles) | 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 |
| Adzynma (ADAMTS13, recombinant-krhn) | 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 |
| Amtagvi | Download PDF |
| Amvuttra (vutrisiran) | Download PDF |
| Anktiva (nogapendekin alfa inbakicept-pmln) intravesical solution | 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 |
| Bevacizumab (Avastin, Alymsys, Mvasi, Vegzelma, Zirabev) for oncology diagnosis | Download PDF |
| Aucatzyl (obecabtagene autoleucel) | Download PDF |
| Aveed (testosterone undecanoate) | Download PDF |
| Axtle (pemetrexed dipotassium) | 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 |
| Beqvez (fidanacogene elaparvovec-dzkt kit) Intravenous Infusion | Download PDF |
| Berinert (C1 Esterase Inhibitor Human) | Download PDF |
| Besponsa® (inotuzumab ozogamicin) | Download PDF |
| Bevacizumab Products for oncology diagnosis – Medicare Only | Download PDF |
| Bizengri (zenocutuzumab-zbco) | 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 |
| Casgevy | 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- Fylnetra | 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 |
| Columvi (glofitamab-gxbm) intravenous solution | Download PDF |
| Cosela™ (trilaciclib injection) powder for injection | Download PDF |
| Cosentyx IV | 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 |
| Datroway (datopotamab deruxtecan) | Download PDF |
| Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj) | Download PDF |
| Daxxify - Medicare Only | Download PDF |
| Dysport - Medicare Only | Download PDF |
| Duchenne Muscular Dystrophy (DMD) Drugs (Amondys 45, Exondys 51, Vyondys 53 and Viltepso)—Medicaid Only | Download PDF |
| Eculizumab: Soliris, Bkemv, Epsyqli | DownloadPDF |
| Eculizumab – Bkemv, Epysqli, Soliris Medicare Only | Download PDF |
| Elahere (mirvetuximab soravtansine-gynx) | Download PDF |
| Elaprase® (idursulfase) | Download PDF |
| Elevidys (delandistrogene moxeparvovec-rokl) | Download PDF |
| Elevidys® (delandistrogene moxeparvovec-rokl) Intravenous –Medicaid Only | Download PDF |
| Elelyso (taliglucerase alfa) | Download PDF |
| Elfabrio (pegunigalsidase alfa-iwxj) intravenous injection | 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, Eylea HD, and Pavblu - Medicare Only | Download PDF |
| Evomela® (melphalan) | 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 |
| Gamifant (Emapalumab-lzsg) | Download PDF |
| Gazyva (obinutuzumab) | Download PDF |
| Givlaari (givosiran) | Download PDF |
| Grafapex (treosulfan) | 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 |
| Hepzato (melphalan hydrochloride) | Download PDF |
| Hyaluronic Acid Derivatives - Medicare Only | Download PDF |
| Hyaluronate Injections for Osteoarthritis of the Knee | Download PDF |
| Ibandronate IV - Medicare Only | Download PDF |
| Ilaris (canakinumab) | Download PDF |
| Ilumya (tildrakizumab-asmn) | Download PDF |
| Imdelltra (Tarlatamab-dlle), intravenous infusion | 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 |
| 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 |
| Kebilidi (eladocagene exuparvovec-tneq) | Download PDF |
| Keytruda® (pembrolizumab) | Download PDF |
| Kimmtrak (tebentafusp-tebn) intravenous infusion | Download PDF |
| Kisunla (Donanemab) 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 |
| Lenmeldy | Download PDF |
| Leqembi (lecanemab-irmb) | Download PDF |
| Leqembi - Medicare Only | Download PDF |
| Leqembi™ (lecanemab-irmb) Intravenous - Medicaid 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 |
| Loqtorzi (toripalimab) | Download PDF |
| Lumizyme (alglucosidase alfa) | 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 |
| Lyfgenia | Download PDF |
| Marqibo® (vincristine sulfate liposomal) | Download PDF |
| Margenza (margetuimab) | Download PDF |
| Mepsevii (vestronidase alfa-vjbk) | Download PDF |
| Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum | Download (PDF) |
| Monjuvi (tafasitamab-cxix) | Download PDF |
| Mozobil (plerixafor) | 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 |
| Niktimvo (axatilimab-csfr) | 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 |
| Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) | Download PDF |
| Omisirge (omidubicel-onlv) intravenous suspension | Download PDF |
| Omvoh | Download PDF |
| Onapgo (apomorphine) | Download PDF |
| Oncology GnRH Analogs - Medicare Only | Download PDF |
| Onivyde (irinotecan liposome) | Download PDF |
| Onpattro (patisiran) | Download PDF |
| Opdivo® (nivolumab) | Download PDF |
| Opdivo Qvantig (nivolumab and hyaluronidase-nvhy) | 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 |
| 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 |
| PiaSky (crovalimab-akkz) intravenous infusion or subcutaneous injection | 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 |
| Qalsody (tofersen) - Medicare Only | Download PDF |
| Qutenza (capsaicin) | Download PDF |
| Radicava (Edaravone) | Download PDF |
| Ranibizumab Products (Byooviz, Cimerli, Lucentis) – 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 |
| Rivfloza | 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 |
| Ryoncil (remestemcel-L-rknd) | Download PDF |
| Ryplazim™ (human plasminogen), injection | Download PDF |
| Rystiggo | Download PDF |
| Rytelo (imetelstat) Intravenous Infusion | 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 - Medicare Only | Download PDF |
| Somatuline Depot (lanreotide) | Download PDF |
| Spinraza™ (Nusinersen) | Download PDF |
| Spevigo (spesolimab-sbzo) | Download PDF |
| Spravato (esketamine hydrochloride) | 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 |
| Tevimbra (tislelizumab) | Download PDF |
| Tezspire (tezepelumab-ekko) subcutaneous injection | Download PDF |
| Thyrogen (thyrotropine alfa) | Download PDF |
| Tivdak™ (tisotumab vedotin) injection, powder, for solution | Download PDF |
| Tocilizumab – Actemra, Tyenne, Tofidence | 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 |
| Ustekinumab IV/SQ: Stelara, Pyzchiva, Selarsdi, Otulfi | 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 |
| Vyalev (foscarbidopa and foslevodopa) | Download PDF |
| Vyepti™ (eptinezumab-jjmr) | Download PDF |
| Vyjuvek (beremagene geperpavec-svdt) topical suspension | Download PDF |
| Vyloy (zolbetuximab-clzb) | 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 |
| Ziihera (zanidatamab-hrii) | 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 |
JP 46167 1/25