Welcome to the Pharmacy Policies page. We are in the process of moving pharmacy policies to the following table.

If you do not see an expected policy below, please also check the Medical Policies page where it may be housed.

For ConnectiCare members, please follow ConnectiCare’s Pharmacy Policies.

You may sort by Date Issued or Title. You may also enter a keyword to search for a policy.

Date (YYYY/MM/DD) Title Download (PDF)
2021/07/30 Avastin (bevacizumab) and Biosimilars Download (PDF)
2021/07/30 5HT3 Receptor Antagonists Download (PDF)
2021/02/26 Emend Cinvanti and Varubi Download (PDF)
2021/02/26 Faslodex (fulvestrant) Download (PDF)
2021/05/28 LHRH (Agonists and antagonist) Download (PDF)
2021/02/26 Somatostatin Analog Download (PDF)
2021/08/27 Oncospar (pegaspargase) Download (PDF)
2021/07/30 Trisenox (arsenic trioxide) Download (PDF)
2021/07/30 Valstar (valrubicin) Download (PDF)
2021/05/28 Myeloid Growth Factors Download (PDF)
2021/04/30 Libtayo (cemiplimab-rwlc) Download (PDF)
2021/03/26 Alimta (pemetrexed) Download (PDF)
2021/02/26 Rituximab Products Download (PDF)
2021/04/30 Erbitux (cetuximab) Download (PDF)
2021/04/30 Trastuzumab Products and Phesgo (pertuzumab trastuzumab and hyaluronidase-zzxf) Download (PDF)
2021/02/26 Vectibix (panitumumab) Download (PDF)
2020/09/25 Velcade (bortezomib) Download (PDF)
2021/07/30 Erythropoiesis Stimulating Agents Download (PDF)
2021/05/28 Abraxane (nab paclitaxel) Download (PDF)
2021/08/27 Intravenous Immune Globulin (IG) Download (PDF)
2021/01/29 Bone Modifying Agents (Aredia Zometa Xgeva Prolia) Download (PDF)
2021/05/28 Torisel (temsirolimus) Download (PDF)
2021/04/30 Yervoy (ipilimumab) Download (PDF)
2021/02/26 Adcetris (brentuximab vedotin) Download (PDF)
2020/11/30 Halaven (eribulin) Download (PDF)
2021/01/29 Treanda_Bendeka_Belrapz (bendamustine) Download (PDF)
2021/04/30 Perjeta (pertuzumab) and Phesgo (pertuzumab trastuzumab and hyaluronidase-zzxf) Download (PDF)
2021/02/26 Provenge (sipuleucel-T) Download (PDF)
2021/01/29 Jevtana (cabazitaxel) Download (PDF)
2020/11/30 Arzerra (ofatumumab) Download (PDF)
2021/04/30 Kyprolis (carfilzomib) Download (PDF)
2021/05/28 Zaltrap (ziv-aflibercept) Download (PDF)
2021/08/27 Istodax (romidepsin) Download (PDF)
2021/01/29 Marqibo (vincristine liposome) Download (PDF)
2021/02/26 Doxil or Lipodox (liposomal doxorubicin) Download (PDF)
2021/04/30 Kadcyla (ado-trastuzumab emtansine) Download (PDF)
2021/05/28 Synribo (omacetaxine) Download (PDF)
2021/08/27 Nplate (romiplostim) Download (PDF)
2020/11/30 Ixempra (ixabepilone) Download (PDF)
2021/02/26 Gazyva (obinutuzumab) Download (PDF)
2021/02/26 Beleodaq (belinosat) Download (PDF)
2021/07/30 Cyramza (ramucirumab) Download (PDF)
2021/08/27 Keytruda (pembrolizumab) Download (PDF)
2020/10/30 Blincyto (blinatumomab) Download (PDF)
2021/06/25 Opdivo (nivolumab) Download (PDF)
2020/11/30 Onivyde (irinotecan liposome) Download (PDF)
2021/04/30 Darzalex and Darzalex Faspro Download (PDF)
2021/04/30 Empliciti (elotuzumab) Download (PDF)
2020/11/30 Imlygic (Talimogene Laherparepvec) Download (PDF)
2020/11/30 Fusilev (levoleucovorin) Download (PDF)
2020/11/30 Yondelis (trabectedin) Download (PDF)
2021/04/30 Tecentriq (atezolizumab) Download (PDF)
2021/06/25 Generic Drugs Download (PDF)
2021/08/27 Bavencio (avelumab) Download (PDF)
3021/04/30 Folotyn (pralatrexate) Download (PDF)
2021/04/30 Iressa (gefitinib) Download (PDF)
2021/04/30 Imfinzi (durvalumab) Download (PDF)
2021/08/27 Mylotarg (gemtuzumab ozogamicin) Download (PDF)
2021/04/30 Vyxeos (daunorubicin and cytarabine liposomal) Download (PDF)
2021/05/28 Aliqopa (copanlisib) Download (PDF)
2021/06/25 Besponsa (inotuzumab ozogamicin) Download (PDF)
2021/01/29 Poteligeo (mogamulizumab-kpkc) Download (PDF)
2020/10/30 Lumoxiti (moxetumomab pasudotox) Download (PDF)
2020/12/28 Asparlas (calaspargase pegol-mknl) Download (PDF)
2020/12/28 Cablivi (caplacizumab-yhdp) Download (PDF)
2021/06/25 Elzonris (tagraxofusp) Download (PDF)
2021/06/25 Arranon (nelarabine) Download (PDF)
2021/08/27 Erwinaze_and_Rylaze_(asparaginase_Erwinia_chrysanthemi_and_recombinant-rywn) Download (PDF)
2021/03/26 Polivy (polatuzumab vedotin) Download (PDF)
2021/03/26 Adakveo (crizanlizumab) Download (PDF)
2020/12/28 Enhertu (fam-trastuzumab deruxtecan-nxki) Download (PDF)
2020/12/28 Gamifant (emapalumab-lzsg) Download (PDF)
2021/09/27 Padcev (enfortumab vedotin-ejfv) Download (PDF)
2021/07/30 Soliris (eculizumab) Download (PDF)
2020/12/28 Sylvant (siltuximab) Download (PDF)
2021/07/30 Ultomiris (ravulizumab) Download (PDF)
2020/12/28 Unituxin (dinutuximab) Download (PDF)
2020/11/30 Reblozyl (luspatercept-aamt) Download (PDF)
2021/06/25 Sarclisa (isatuximab-irfc) Download (PDF)
2021/04/30 Clolar (clofarabine) Download (PDF)
2021/04/30 Photofrin (porfimer) Download (PDF)
2020/05/29 Tepadina (thiotepa) Download (PDF)
2021/07/30 Trodelvy (sacituzumab govitecan-hziy) Download (PDF)
2021/07/30 Zepzelca (lurbinectedin) Download (PDF)
2020/09/25 Blenrep (belantamab mafodotin-blmf) Download (PDF)
2020/09/25 Monjuvi (tafasitamab-cxix) Download (PDF)
2020/10/30 Jelmyto (mitomycin for pyelocalyceal instillation) Download (PDF)
2021/01/29 Danyelza (naxitamab-gqgk) Download (PDF)
2021/05/28 Margenza (margetuximab-cmkb) Download (PDF)
2021/04/30 Cosela (trilaciclib) Download (PDF)
2021/08/27 Pepaxto (melphalan flufenamide) Download (PDF)
2021/06/25 Jemperli (dostarlimab-gxly) Download (PDF)
2021/06/25 Zynlonta (loncastuzimab tesirine-lpyl) Download (PDF)