Medication Policy Index

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Introduction | Browse policies by brand name | Browse policies by generic name | View recent medication policy updates (PDF) | View past medication policy updates

	Policy Name	Revised
A
	Accretropin®, somatropin	07/18/2008
	Aciphex®, rabeprazole	09/11/2009
	Actiq®, fentanyl citrate oral transmucosal lozenges	09/11/2009
	Actonel®, risedronate-Containing Medications (Actonel®, Actonel® with Calcium)	07/17/2009
	Actos®, pioglitazone	05/08/2009
	Actos®, pioglitazone-Containing Medications (Actos®, ACTOplus met®, Duetact™)	05/09/2008
	ACTOplus met®, pioglitazone/metformin	05/09/2008
	Adcirca ™, tadalafil	07/17/2009
	Afinitor®, everolimus	05/09/2009
	AllerNaze ™, triamcinolone nasal	04/07/2009
	Aloxi®, palonosetron	11/14/2008
	Altinac®, tretinoin topical	07/18/2008
	Ambien®, zolpidem	05/08/2009
	Ambien CR ® , zolpidem MR	05/08/2009
	Amerge®, naratriptan	11/14/2008
	Amerge®, naratriptan, effective December 1, 2009	10/28/2009
	Amevive®, alefacept	11/14/2008
	Amphetamine-dextroamphetamine ER capsules	05/08/2009
	Antineoplaston Cancer Therapy	03/18/2008
	Anzemet®, dolasetron	11/14/2008
	Aranesp®, darbepoetin	05/09/2008
	Arcalyst®, rilonacept	07/17/2009
	Atralin®, tretinoin topical	07/18/2008
	Avandamet®, rosiglitizone/metformin	05/09/2008
	Avandaryl®, rosiglitazone/glimepiride	05/09/2008
	Avandia®, rosiglitazone	05/09/2008
	Avandia®, rosiglitazone-Containing Medications (Avandia®, Avandamet®, Avandaryl®)	05/08/2009
	Avita®, tretinoin topical	07/18/2008
	Axert®, almotriptan	11/14/2008
	Axert®, almotriptan, effective December 1, 2009	10/28/2009
B
	Baygam® (Immune Globulin Replacement Therapy)	05/09/2008
	Beconase AQ®, beclomethasone nasal	04/07/2009
	Betaseron®, interferon beta-1b	09/11/2009
	Boniva®, ibandronate injection	07/17/2009
	Boniva®, ibandronate oral	07/17/2009
	Botox®, botulinum toxin Type A Injection	04/04/2009
	Byetta®, exenatide	05/08/2009
C
	Carimune NF (Immune Globulin Replacement Therapy)	05/09/2008
	Celebrex®, celecoxib	11/14/2008
	Cerezyme®, imiglucerase	01/09/2009
	Cialis®, tadalafil	07/17/2009
	Cimzia®, certolizumab pegol	07/17/2009
	Cinryze ™, C1 inhibitor (human)	03/13/2009
	Compounded Medications	07/18/2008
	Contraceptives for Medical Conditions, Self-administered	03/18/2008
	Crestor®, rosuvastatin	04/07/2009
	Cymbalta®, duloxetine	05/08/2009
E
	Edluar®, zolpidem sublingual tablets	05/08/2009
	Effexor XR®, venlafaxine extended-release capsules	09/11/2009
	Emend®, aprepitant	01/09/2009
	Enbrel®, etanercept	11/14/2008
	Epogen®, epoetin alfa	05/09/2008
	Erbitux®, cetuximab, effective date February 1, 2010	09/11/2009
F
	Fentora®, fentanyl citrate buccal tablet	11/14/2008
	Flebogamma ® (Immune Globulin Replacement Therapy)	05/09/2008
	Forteo®, teriparatide	07/17/2009
	Frova®, frovatriptan	11/14/2008
	Frova®, frovatriptan, effective December 1, 2009	10/28/2009
G
	Gamastan® (Immune Globulin Replacement Therapy)	05/09/2008
	Gammagard S/D®, (Immune Globulin Replacement Therapy)	05/09/2008
	Gamunex® (Immune Globulin Replacement Therapy)	05/09/2008
	Genotropin®, somatropin	07/18/2008
	Gleevec®, imatinib mesylate	11/14/2008
	Growth Hormone	07/17/2009
H
	Humatrope®, somatropin	07/18/2008
	Humira®, adalimumab	11/14/2008
I
	Illaris®, canakinumab	07/17/2009
	Imitrex®, sumatriptan	11/14/2008
	Imitrex®, sumatriptan, effective December 1, 2009	10/28/2009
	Immune Globulin Replacement Therapy (IVIG, SQ)	05/08/2009
	Increlex®, mecasermin	01/09/2009
	Infergen®, interferon alfacon-1	05/08/2009
	Iveegam® (Immune Globulin Replacement Therapy)	05/09/2008
J
	Januvia®, sitagliptin-Containing Medications (Januvia, Janumet®)	05/08/2009
K
	Kapidex ™, dexlansoprazole	09/11/2009
	Kineret®, anakinra	11/14/2008
	Kuvan ™, sapropterin dihydrochloride	04/07/2009
	Kytril®, granisetron	11/14/2008
L
	Lamisil®, terbinafine oral	07/17/2009
	Levitra®, vardenafil	07/17/2009
	Lexapro®, escitalopram	05/08/2009
	Livalo®, pitacastatin	09/11/2009
	Lipitor®, atorvastatin	04/07/2009
	Lunesta ®, eszopiclone	05/08/2009
	Luvox ® CR , fluvoxamine extended-release capsules	05/08/2009
	Lyrica®, pregabalin	01/09/2009
M
	Maxalt®, Maxalt MLT®, rizatriptan	11/14/2008
	Maxalt®, Maxalt MLT®, rizatriptan, effective December 1, 2009	10/28/2009
	Medication Policy Manual Introduction	9/11/2009
	Mirena®, levonorgestrel-containing Intrauterine System (LNG-IUS) for Medical Conditions	04/07/2009
	Myobloc®, botulinum toxin Type B	04/07/2009
N
	Nasacort AQ®, triamcinolone nasal	04/07/2009
	Nasonex®, mometasone nasal	04/07/2009
	Nexavar®, sorafenib	04/07/2009
	Nexium®, esomeprazole	09/11/2009
	Non-Formulary Medications, Medical Exception Criteria for Closed Pharmacy Benefit Designs	01/09/2009
	Non-Preferred Medications, Medical Exception Criteria for Tiered Benefit Designs with Tier Copay Exceptions	01/09/2009
	Norditropin®, somatropin	07/18/2008
	Nplate®, romiplostim	11/14/2008
	Nutropin®, somatropin	07/18/2008
	Nutropin AQ®, somatropin	07/18/2008
	Nuvigil®, armodafinil	07/17/2009
O
	Octagam® (Immune Globulin Replacement Therapy)	05/09/2008
	Off-Label Use of FDA Approved Drugs	09/11/2009
	Omnaris ™, ciclesonide nasal	04/07/2009
	Omnitrope®, somatropin	07/18/2008
	Onglyza®, saxagliptin	09/11/2009
	Onsolis ™, fentanyl buccal soluble film	09/11/2009
	Opana® ER, oxymorphone, Extended-Release	11/14/2008
	Opioids for Chronic Non-Cancer Pain	11/14/2008
	Orencia®, abatacept	11/14/2008
	OxyContin®, oxycodone CR	11/14/2008
P
	Pegasys®, peginterferon alfa-2a	05/08/2009
	PEG-Intron®, peginterferon alfa-2b	05/08/2009
	Penlac®, ciclopirox	07/17/2009
	Polygam S/D® (Immune Globulin Replacement Therapy)	05/09/2008
	Prevacid ®, lansoprazole	09/11/2009
	Pristiq ™, desvenlafaxine	05/08/2009
	Privigen® (Immune Globulin Replacement Therapy)	05/09/2008
	Procrit®, epoetin alfa	05/09/2008
	Promacta®, eltrombopag	05/08/2009
	Protonix®, pantoprazole	09/11/2009
	Provigil®, modafinil	07/17/2009
R
	Raptiva®, efalizumab	11/14/2008
	Reclast®, zoledronic acid	07/17/2009
	Relenza®, zanamivir	05/08/2009
	Relpax®, eletriptan	11/14/2008
	Relpax®, eletriptan, effective December 1, 2009	10/28/2009
	Relistor®, methylnaltrexone	09/11/2009
	Remicade®, infliximab	05/08/2009
	Renova®, tretinoin topical	07/18/2008
	Retin A®, tretinoin topical	07/17/2009
	Retin A Micro®, tretinoin topical	07/17/2009
	Revatio ®, sildenafil 20mg	07/17/2009
	Revlimid®, lenalidomide	07/17/2009
	Rhinocort Aqua®, budesonide nasal	04/07/2009
	Rozerem ™, ramelteon	05/08/2009
S
	Saizen®, somatropin	07/18/2008
	Sancuso®, granisetron topical patches	11/14/2008
	Savella ™, milnacipran	05/08/2009
	Self-administered Contraceptives for Medical Conditions	04/07/2009
	Self-Administered Injectables	09/11/2009
	Serostim®, somatropin	07/18/2008
	Serostim LQ®, somatropin	07/18/2008
	Simponi®, golimumab	08/12/2009
	Solage®, tretinoin topical	07/18/2008
	Sonata®, zaleplon	05/08/2009
	Sporanox®, itraconazole oral	07/17/2009
	Sprycel®, dasatinib	11/14/2008
	Sumavel ™, DosePro™, sumatriptan, effective December 1, 2009	10/28/2009
	Sutent®, sunitinib	04/07/2009
	Symlin®, pramlintide	05/08/2009
	Synagis®, palivizumab, respiratory syncytial virus immune prophylaxis	09/11/2009
	Synagis®, palivizumab, respiratory syncytial virus immune prophylaxis, effective Jan. 15, 2010	11/09/2009
T
	Tarceva ®, erlotinib	07/17/2009
	Tasigna®, nilotinib	11/14/2008
	Tamiflu®, oseltamivir	05/08/2009
	Tev-Tropin®, somatropin	07/18/2008
	Treximet ™, sumatriptan/naproxen	11/14/2008
	Treximet ™, sumatriptan/naproxen, effective December 1, 2009	10/28/2009
	Tykerb®, lapatinib	09/11/2009
	Tysabri®, natalizumab	09/11/2009
V
	Velcade®, bortezomib, effective date February 1, 2010	09/11/2009
	Veramyst®, fluticasone furoate nasal	04/07/2009
	Viagra®, sildenafil	07/17/2009
	Vivaglobin®, subcutaneous immunoglobulin (Immune Globulin Replacement Therapy)	05/09/2008
	Vytorin®, simvastatin/ezetimibe	08/12/2009
X
	Xenazine®, tetrabenazine	04/07/2009
	Xolair®, omalizumab	07/17/2009
	Xyrem®, sodium oxybate	09/11/2009
Z
	Zavesca®, miglustat	01/09/2009
	Zofran®, ondansetron	11/14/2008
	Zolinza ™, vorinostat	04/07/2009
	Zomig®, Zomig ZMT®, zolmitriptan	11/14/2008
	Zomig®, Zomig ZMT®, zolmitriptan, effective December 1, 2009	10/28/2009
	ZolpiMist®, zolpidem	05/08/2009
	Zorbtive®, somatropin	07/18/2008


	The Blue Cross and/or Blue Shield Plans comprising The Regence Group serve Idaho, Oregon, Utah and much of Washington state. The Regence Group and each of its affiliate Plans are independent licensees of the Blue Cross and Blue Shield Association.