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Browse policies by brand name
| Browse policies by generic name | View recent medication policy
updates (PDF) | View past medication policy
updates
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Policy
Name
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Revised
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A
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abatacept, Orencia®
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11/18/2011
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abiraterone, Zytiga™
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02/01/2012
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abobotulinumtoxinA, Dysport®
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03/06/2012
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adalimumab, Humira®
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11/18/2011
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aflibercept,
Eylea™
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02/01/2012
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alefacept, Amevive®
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11/18/2011
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aliskiren-containing medications
(Tekturna, Tekturna HCT®, Valturna®, Amturnide™, Tekamlo™)
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03/16/2012
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almotriptan, Axert®
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02/01/2012
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ambrisentan, Letairis®
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07/08/2011
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amphetamine-dextroamphetamine ER
capsules
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05/13/2011
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anakinra, Kineret®
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11/18/2011
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Antineoplaston Cancer Therapy
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03/18/2008
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aripiprazole,
Abilify®
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11/18/2011
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armodafinil, Nuvigil®
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09/16/2011
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asenapine,
Saphris®
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11/18/2011
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atorvastatin
(generic)
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03/02/2012
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atorvastatin, Lipitor®
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03/02/2012
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axitinib,
Inlyta®
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03/16/2012
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azilsartan, Edarbi™
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03/16/2012
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B
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beclomethasone nasal, Beconase AQ®
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03/02/2011
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belimumab, Benlysta®
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09/16/2011
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bevacizumab, Avastin®
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07/08/2011
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boceprevir, Victrelis™
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09/28/2011
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bortezomib, Velcade®
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09/16/2011
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bosentan, Tracleer®
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07/08/2011
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botulinum
toxic Type B, MyoBloc®
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03/16/2012
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brentuximab,
Adcetris™
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11/18/2011
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budesonide nasal, Rhinocort Aqua®
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03/02/2012
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C
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C1 inhibitor (human), Cinryze™
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11/18/2011
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cabazitaxel, Jevtana®
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02/01/2012
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canakinumab, Illaris®
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07/08/2011
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candesartan-containing medications
(Atacand, Atacand®
HCT), Atacand®
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03/16/2012
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capsaicin 8% patch, Qutenza®
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07/08/2011
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celecoxib, Celebrex®
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11/18/2011
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certolizumab pegol, Cimzia®
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11/18/2011
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cetuximab, Erbitux®
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09/16/2011
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ciclesonide nasal, Omnaris®
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03/02/2012
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ciclopirox, Penlac®
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07/08/2011
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Compounded Medications
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02/01/2012
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crizotinib,
Xalkori®
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11/18/2011
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D
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dalampridine,
Ampyra™
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09/16/2011
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dasatinib, Sprycel®
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01/13/2012
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denosumab, Prolia™, Xgeva™
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11/18/2011
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desvenlafaxine, Pristiq™
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05/13/2011
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dexlansoprazole, Dexilant®
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02/01/2012
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Diabetic Test Supply: Abbott Blood
Glucose Meters and Testing Strips; (Including, but not limited to
FreeStyle Lite, FreeStyle Freedom Lite, and Precision Xtra)
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11/18/2011
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Diabetic Test Supply: LifeScan
(OneTouch) Blood Glucose Meters and Testing Strips (including, but not
limited to OneTouch Ultra, OneTouch Select, OneTouch SureStep, and
OneTouch FastTake)
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11/18/2011
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Diabetic Test Supply: Roche Blood
Glucose Meters and Testing Strips (including, but not limited to
Accu-Chek)
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11/18/2011
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doxorubicin liposomal injection,
Doxil®,
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02/01/2012
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doxycycline
hyclate, Doryx®
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04/01/2012
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duloxetine, Cymbalta®
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05/13/2011
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E
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eletriptan, Relpax®
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02/01/2012
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eltrombopag, Promacta®
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05/13/2011
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eprosartan-containing medications
(Teveten, Teveten HCT®), Teveten®
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03/16/2012
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eribulin, Halaven™
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02/01/2012
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erlotinib, Tarceva®
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03/16/2012
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erwina
chrysanthemi, Erwinaze®
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02/01/2012
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esomeprazole, Nexium®, Vimovo™)
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02/01/2012
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eszopiclone, Lunesta®
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05/13/2011
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etanercept, Enbrel®
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11/18/2011
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everolimus, Afinitor®
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03/16/2012
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exenatide, Byetta®
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05/13/2011
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F
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fentanyl buccal tablet, Fentora®
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03/16/2012
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fentanyl buccal soluble film,
Onsolis™
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03/16/2012
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fentanyl citrate oral transmucosal
lozenges, Actiq®
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03/16/2012
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fentanyl nasal spray, Lazanda™
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03/16/2012
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fentanyl sublingual tablets, Abstral®
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03/16/2012
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fentanyl
sublingual spray, Subsys®
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03/16/2012
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fingolimod, Gilenya™
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09/16/2011
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fluticasone furoate nasal, Veramyst®
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03/02/2012
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frovatriptan, Frova®
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02/01/2012
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G
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golimumab, Simponil®
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09/16/2011
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Growth Hormone
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11/18/2011
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H
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hydromorphone, Extended-Release,
Exalgo™
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11/18/2011
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hydroxyprogesterone caproate,
Makena™
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09/16/2011
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I
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ibandronate injection, Boniva®
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11/18/2011
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icatibant,
Firazyr®
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11/18/2011
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iloperidone,
Fanapt®
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11/18/2011
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iloprost inhalation, Ventavis®
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07/08/2011
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imatinib mesylate, Gleevec®
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01/13/2012
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imiglucerase, Cerezyme®
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03/02/2012
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incobotulinumtoxinA, Xeomin®
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03/16/2012
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infliximab, Remicade®
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11/18/2011
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interferon alfacon-1, Infergen®
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05/13/2011
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interferon beta-1b, Betaseron®
Extavia®
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11/18/2011
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ipilimumab, Yervoy™, effective July 1, 2011
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05/13/2011
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irbesartan-containing medications
(Avapro, Acalide®), Avapro®
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03/16/2012
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itraconazole oral, Sporanox®
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07/08/2011
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Immune Globulin Replacement
Therapy (IVIG, SQ), (Carimune NF®, Flebogamma® DIF, Gammagard®,
Gammagard S/D®, Gammaplex®, Gamunex®, Hizentra™(SQ preparation),
Octagam®, Privigen®, Vivaglobin®(SQ preparation)
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05/13/2011
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ivacaftor, Kalydeco™
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03/16/2012
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L
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lansoprazole, Prevacid®
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02/01/2012
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lapatinib, Tykerb®
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09/16/2011
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lenalidomide, Revlimid®
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09/16/2011
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linagliptin,Tradjenta®
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05/13/2011
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liraglutide, Victoza®
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05/13/2011
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Levonorgestrel-containing
Intrauterine System (LNG-IUS) for Medical Conditions, Mirena®
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03/18/2011
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lurasidone,
Latuda®
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11/18/2011
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M
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Maximum Drug Dosage
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03/02/2012
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mecasermin, Increlex®
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01/13/2012
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Medication Policy Manual
Introduction
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03/16/2012
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methylnaltrexone, Relistor®
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09/16/2011
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miglustat, Zavesca®
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03/02/2012
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milnacipran, Savella™
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05/13/2011
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minocycline
HCI, Solodyn®
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04/01/2012
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modafinil, Provigil®
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09/16/2011
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mometasone nasal, Nasonex®
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03/02/2012
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morphine/naltrexone, Embeda™
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09/16/2011
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N
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naratriptan, Amerge®
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01/13/2012
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natalizumab, Tysabri®
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09/16/2011
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nilotinib, Tasigna®
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02/01/2012
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Non-Formulary Medications, Medical
Exception Criteria for Closed Pharmacy Benefit Designs
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02/01/2012
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O
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ofatumumab, Arzerra™
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01/13/2012
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Off-Label Use of FDA Approved
Medications
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02/01/2012
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olmesartan-containing medicaitons (Benicar, Benicar HTC®, AZOR®, Tribenzor™)
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03/16/2012
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omalizumab, Xolair®
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07/08/2011
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onabotulinumtoxinA, Botox®
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03/16/2012
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Opioids for Chronic Non-Cancer
Pain
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09/16/2011
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oseltamivir, Tamiflu®
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07/08/2011
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oxaliplatin, Eloxatin®
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03/16/2012
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oxycodone, Controlled Release,
OxyContin®
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02/01/2012
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oxymorphone, Extended-Release, Opana® ER
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09/16/2011
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P
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paliperidone,
Invega®
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11/18/2011
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palivizumab, Synagis® respiratory syncytial virus
prophylaxis)
|
02/01/2012
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pazopanib, Votrient™
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02/01/2012
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pegaptanib, Macugen®
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05/13/2011
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peginterferon alfa-2a, Pegasys®
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08/30/2011
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peginterferon alfa-2b, PEG-Intron®
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08/30/2011
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peginterferon alfa-2b, Sylatron™
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07/08/2011
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pegloticase, Krystexxa™
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03/02/2012
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pemetrexed, Alimta®
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03/16/2012
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pioglitazone, Actos®
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05/13/2011
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pioglitazone/glimepiride, Duetact™
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05/13/2011
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pioglitazone/metformin, ACTOplus met®
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05/13/2011
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pitavastatin, Livalo®
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03/02/2012
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pralatrexate, Folotyn™
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02/01/2012
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pregabalin, Lyrica®
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01/13/2012
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Q
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quinine, Qualaquin®
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11/18/2011
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R
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rabeprazole, Aciphex®
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02/01/2012
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ramelteon, Rozerem™
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05/13/2011
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ranibizumab, Lucentis®
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05/13/2011
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respiratory syncytial virus
prophylaxis, Synagis®
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03/15/2007
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rilonacept, Arcalyst®
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07/08/2011
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rimabotulinumtoxin
B, MyoBloc®
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03/18/2011
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risedronate & Actonel with
Calcium risedronate with calcium), Actonel®
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07/08/2011
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rituximab, Rituxan®
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02/01/2012
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rizatriptan, Maxalt®,
Maxalt MLT®
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02/01/2012
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romidepsin, Istodax®
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02/01/2012
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romiplostim, Nplate®
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05/13/2011
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rosiglitazone, Avandia®
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05/13/2011
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rosiglitizone/glimepiride,
Avandaryl®
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05/13/2011
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rosiglitizone/metformin,
Avandamet®
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05/13/2011
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rosuvastatin, Crestor®
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03/02/2012
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ruxolitinib,
Jakafi™
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02/01/2012
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S
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saxagliptin, containing medications
(Onglyza, Kombiglyze XR®)
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05/13/2011
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Self-Administered Contraceptives for
Medical Conditions
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03/18/2011
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Self-Adminsitered
Injectables
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02/01/2012
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sildenafil 20 mg, Revatio®
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07/08/2011
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sildenafil, Viagra®
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07/08/2011
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simvastatin/ezetimibe, Vytorin®
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03/02/2012
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sipuleucel-T, Provenge®
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07/08/2011
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sitagliptin-Containing Medications
(Januvia®, Janumet®)
|
11/18/2011
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sodium oxybate, Xyrem®
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09/16/2011
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somatropin, Genotropin®, Humatrope®,
Norditropin®, Nutropin®, Nutropin AQ®, Omnitrope®, Saizen®, Serostim®, Serostim
LQ®, Tev-Tropin®, Zorbtive®
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11/18/2011
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sorafenib, Nexavar®
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01/13/2012
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sumatriptan, Alsuma®
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01/13/2012
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sumatriptan, Imitrex®
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01/13/2012
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sumatriptan, Imitrex® Injectable
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01/13/2012
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sumatriptan, Sumavel™ DosePro™
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01/13/2012
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sumatriptan/naproxen, Treximet™
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02/01/2012
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sunitinib, Sutent®
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01/13/2012
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T
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tadalafil, Adcirca®
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11/18/2011
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tadalafil, Cialis®
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11/18/2011
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telaprevir, Incivek™
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09/30/2011
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telmisartan-containing medications
(Micardis, Micardis HCT®), Micardis®
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03/16/2012
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terbinafine oral, Lamisil®
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07/08/2011
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teriparatide, Forteo®
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07/08/2011
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tesamorelin, Egrifta™
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01/13/2012
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tetrabenazine, Xenazine®
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03/02/2012
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tocilizumab, Actemra®
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11/18/2012
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topical tretinoin (Altinac®,
Atralin®, Avita®, Refissa™, Renova®, Retin
A®, Retin A Micro®, Solage®)
|
07/08/2011
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treprostinil inhalation, Tyvaso®
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07/08/2011
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treprostinil subcutaneous, Remodulin®
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07/08/2011
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U
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ustekinumab, Stelara™
|
11/18/2011
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V
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valsartan-containing medications
(Diovan, Diovan HCT®, Exforge®, Exforge HCT®, Valturna), Diovan®
|
03/16/2012
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vandetanib, Caprelsa®
|
07/08/2011
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vardenafil, Levitra®, Staxyn®
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01/13/2012
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velaglucerase, VPRIV™
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05/12/2010
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vemurafenib, Zelboraf™
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11/18/2011
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vilazodone, Viibryd™
|
05/13/2011
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vismodegib,
Erivedge™
|
03/16/2012
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vorinostat, Zolinza®
|
02/01/2012
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Z
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zanamivir, Relenza®
|
07/08/2011
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ziprasidone,
Geodon®
|
11/18/2011
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zoledronic acid, Reclast®
|
11/18/2011
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zoledronic acid, Zometa®
|
11/18/2011
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zolmitriptan,
Zomig®/Zomig-ZMT®
|
02/01/2012
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zolpidem MR, Ambien CR®
|
05/13/2011
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zolpidem, Edluar®
|
05/13/2011
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zolpidem, ZolpiMist®
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05/13/2011
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