View Drug Policies

Showing 1– 25 of 79 Results
Title Last Updated
Adalimumab (Humira® [adalimumab], Abrilada™[adalimumab-afzb], Amjevita™ [adalimumab-atto], Cyltezo®/ adalimumab-adbm [adalimumab-adbm], Hadlima™ [adalimumab-bwwd], [adalimumab-fkjp], Hyrimoz®/adalimumab-adaz [adalimumab-adaz], adalimumab-aacf [adalimumab-aacf], Simlandi®/ adalimumab-ryvk (adalimumab-ryvk), Yuflyma®/adalimumab-aaty [adalimumab-aaty], Yusimry™ [adalimumab-aqvh] Open a PDF 01/01/2026
Alpha-1 Antitrypsin Therapy (AAT) - Medical Benefit Open a PDF 11/19/2025
Amyotrophic Lateral Sclerosis (ALS) Policy - (Qalsody, Radicava and Radicava ORS, Relyvrio, Teglutik & Tiglutik) - Medical & Rx Benefit Open a PDF 11/19/2025
Anti-Amyloid Directed Therapies Policy - (Aduhelm, Kisunla, and Leqembi) (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Antihemophilic Agents for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), and Dual Eligible Special Needs Plan (D-SNP) Open a PDF 11/19/2025
Attention Deficit Hyperactivity Disorder (ADHD) Policy - Adzenys ER, Adzenys XR ODT, Azstarys, Cotempla XR ODT, Desoxyn, Dyanavel XR, Jornay PM, Mydayis, Onyda XR, Qelbree, Quillichew ER, Quillivant, Xelstrym Open a PDF 01/01/2026
Blood Modifiers - (Cosela, Fulphila, Fylnetra, Granix, Neupogen, Nivestym, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Ziextenzo) - Rx (Self Administration) & Medical Benefits (Health Professional Administered) Open a PDF 11/19/2025
Botulinum Toxin (Botox, Daxxify, Dysport, Myobloc, Xeomin) – for Medicaid Managed Care (MMC), Health and Recovery Program (HARP), Child Health Plus (CHP), Essential Plan (EP), Exchange Plans, Commercial, and Dual Eligible Special Needs Plan (D-SNP) - Medical Benefit Open a PDF 11/19/2025
Casgevy (exagamglogene autotemcel) Drug Policy (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Chimeric Antigen Receptor T Cell (CAR-T) Therapy – (Health Professional Administered) (Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, & Yescarta) - Medical Benefit Open a PDF 12/05/2025
Cimzia(certolizumab pegol) - for Ankylosing Spondylitis, Crohn’s Disease, Psoriatic Arthritis and Rheumatoid Arthritis (Self-Administered or Healthcare Professional Administered) - Rx Benefit or Medical Benefit Open a PDF 12/15/2025
Clinical Review Prior Authorization (CRPA) Medical Drug Policy for Medicaid Managed Care, HARP, Essential Plan & Dual Special Needs Plan (Benlysta IV, Briumvi, Cablivi (Rx & Medical), Ceprotin, Eylea, Eylea HD, Fensolvi, Gazyva, Gonadotropin-releasing hormone (GnRH) Analogs, Hydroxyprogesterone Caproate Injection, Krystexxa, Lemtrada, Leqvio, Ocrevus, Ocrevus Zunovo , Pavblo, Pemgarda, Ranibizumab, Rebyota, Saphnelo, Spravato, Supprelin LA, Triptodur, Tyruko, Tysabri, Vabysmo, Zilretta, & Zoladex) (Health Professional Administered) – Medical Benefit Open a PDF 01/01/2026
Clinical Review Prior Authorization (CRPA) Rx Drug Policy Open a PDF 01/01/2026
Compounded Drug Products Policy Open a PDF 02/06/2025
Cytomegalovirus (CMV) Policy (Livtencity (Rx) & Prevymis (Rx & Medical) (Self-Administered) & (Health Professional Administered) – Rx & Medical Benefit Open a PDF 01/01/2026
Diabetic Incretin Mimetic Agents Policy Open a PDF 01/01/2026
Dual Special Needs Plan (D-SNP) 2026 Prior Authorization Policy Open a PDF 01/02/2026
Dual Special Needs Plan (D-SNP) 2026 Step Therapy Policy Open a PDF 01/02/2026
Duchenne Muscular Dystrophy (DMD) - (Agamree, Amondys 45, Duvyzat, Emflaza, Exondys 51, Viltepso and Vyondys 53) (Self-Administered) - Rx Benefit & (Health Professional Administered) - Medical Benefit Open a PDF 11/20/2025
Elevidys (delandistrogene moxeparvovec-rokl) (Medicaid Managed Care, Essential Plan, Commercial, & Medicare) - Medical Benefit Open a PDF 11/19/2025
Enbrel (etanercept) – for Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, Plaque Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Open a PDF 11/13/2025
Encelto (revakinagene taroretcel-lwey) Implant (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Gamma-Aminobutyric Acid (GABA) A Receptor Positive Modulators for Postpartum Depression (Self-Administered) - Rx Benefit Open a PDF 11/20/2025
Generic Advantage Program / MAC Penalty Open a PDF 02/20/2025
Geographic Atrophy Drug Policy (Izervay, Syfovre) (Health Professional Administered) - Medical Benefit Open a PDF 01/01/2026
Showing 1– 25 of 79 Results

 

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