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) |
