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Pharmacy Policy

The policy bulletins on this website were developed to assist participating providers in administering and understanding the provisions of benefits.

To access a policy, select the corresponding link below:

Policy Name
PDF icon Abaloparatide/Teriparatide
PDF icon Abaloparatide/Teriparatide (New Jersey)
PDF icon Acute Migraine Agents
PDF icon Acute Seizure Activity Agents
PDF icon Adjunctive Treatment for Parkinson’s Disease
PDF icon Applicable Age Edits
PDF icon Allergen Specific Immunotherapy (SL)
PDF icon Amikacin Liposome Inhalation Suspension (Arikayce®)
PDF icon Amifampridine (Firdapse®, Ruzurgi)
PDF icon Androgens
PDF icon Antigout Agents
PDF icon Authorized Generic Drugs
PDF icon Aztreonam (Cayston®)
PDF icon Becaplermin (Regranex®) Gel
PDF icon Belimumab (Benlysta)
PDF icon Blood Modifier Agents
PDF icon Carglumic Acid (Carbaglu)
PDF icon Cenegermin-bkbj (Oxervate™)
PDF icon CGRP Antagonists
PDF icon Chelation Agents
PDF icon Cholesterol Lowering Agents
PDF icon Cholic Acid (Cholbam)
PDF icon Compounded Products
PDF icon Continuous Glucose Monitor
PDF icon Cushing’s Disease Agents
PDF icon Cyanocobalamin Inhalation (Nascobal®)
PDF icon Cysteamine-containing Products
PDF icon Cystic Fibrosis Agents (Kalydeco, Orkambi, Symdeko)
PDF icon Dalfampridine (Ampyra)
PDF icon Deflazacort (Emflaza®)
PDF icon Dextromethorphan Hydrobromide and Quinidine Sulfate (Nuedexta)
PDF icon Dichlorphenamide (Keveyis)
PDF icon Diclofenac Products
PDF icon Doxycycline ER/IR (Oracea)
PDF icon Doxylamine/pyridoxine (Diclegis, Bonjesta)
PDF icon Droxidopa (Northera)
PDF icon Drugs Exceeding Claim Dollar Limit Threshold
PDF icon Dupilumab (Dupixent®)
PDF icon Elagolix/estradiol/norethindrone acetate (Oriahnn®)
PDF icon Elagolix sodium (Orilissa)
PDF icon Epinephrine Pen
PDF icon Excluded medications with no significant advantage over covered alternatives
PDF icon Fabry Disease Agents
PDF icon Formulary Exception
PDF icon Formulary Exception (New Jersey)
PDF icon Fostemsavir (Rukobia)
PDF icon Gabapentin (Gralise/Horizant)/Pregabalin (Lyrica CR)
PDF icon Gaucher Disease Agents
PDF icon Glycerol Phenylbutyrate (Ravicti)
PDF icon Glycopyrronium Topical (Qbrexza™)
PDF icon Growth Hormones
PDF icon Heart Failure Agents
PDF icon Hemophilia Agents
PDF icon Hepatitis C
PDF icon Hereditary Angioedema Agents
PDF icon Hypoactive Sexual Desire Disorder (HSDD) Agents
PDF icon Icosapent ethyl (Vascepa®)
PDF icon Immune Modulating Therapies for Rheumatologic, Dermatologic and Gastrointestinal Diseases
PDF icon Insulin Human, Inhalation (Afrezza)
PDF icon Insulin, Human U-500 (Humulin R U-500)
PDF icon Interferon gamma-1b (Actimmune®)
PDF icon Interim Clinical Policy
PDF icon Interleukin-5 (IL-5) Antibody Agents
PDF icon Interstitial Lung Disease Agents
PDF icon Intranasal Corticosteroids
PDF icon Loteprednol (Eysuvis)
PDF icon Mecasermin (Increlex™)
PDF icon Metabolic Disorder Agents
PDF icon Metreleptin (Myalept®)
PDF icon Naloxone Auto Injector (Evzio®)
PDF icon New Jersey Formulary Exception
PDF icon New Jersey Infant Formula Mandate
PDF icon New Jersey Medications with Therapeutic Alternatives
PDF icon Octreotide products
PDF icon Obeticholic Acid (Ocaliva)
PDF icon Off-Label Use
PDF icon Oncology Agents
PDF icon Oncology Agents (New Jersey)
PDF icon Onychomycosis Agents
PDF icon Opioid Policy
PDF icon Oral Anti–infective
PDF icon Oxymetazoline (Upneeq™)
PDF icon Parathyroid Hormone (Natpara)
PDF icon Peanut Immunotherapy (Palforzia®)
PDF icon Pegvaliase-pqpz (Palynziq)
PDF icon Pegvisomant (Somavert®)
PDF icon Pentosan Polysulfate (Elmiron®)
PDF icon Phenoxybenzamine (Dibenzyline)
PDF icon Pimavanserin (Nuplazid)
PDF icon Prednisone Delayed Release (Rayos)
PDF icon Prior Authorization Requirements for Select Drugs
PDF icon Prior Authorization Requirements for Select Drugs (New Jersey)
PDF icon Proton Pump Inhibitors
PDF icon Proton Pump Inhibitors (New Jersey)
PDF icon Pulmonary Arterial Hypertensive (PAH) agents
PDF icon Quantity Level Limits for Pharmaceuticals Covered Under the Pharmacy Benefit
PDF icon Quinine Sulfate (Qualaquin™)
PDF icon Rifaximin (Xifaxan)
PDF icon Risiplam (Evrysdi™)
PDF icon Sacrosidase (Sucraid®)
PDF icon Sapropterin dihydrochloride (Kuvan®)
PDF icon Satralizumab (Enspryng®)
PDF icon Seizure Disorder Agents
PDF icon Setmelanotide (Imcivree)
PDF icon Sickle Cell Agents
PDF icon Sleep Agents
PDF icon Smoking Cessation Agents
PDF icon Sodium Oxybate (Xyrem®), Calcium, Magnesium, Potassium and Sodium Oxybate (Xywav™)
PDF icon Stimulants
PDF icon Teduglutide (Gattex)
PDF icon Telotristat Ethyl (Xermelo™)
PDF icon Tolvaptan (Samsca®, Jynarque®)
PDF icon Topical Antineoplastic Agents
PDF icon Transthyretin Amyloidosis Agents
PDF icon Triheptanoin (Dojolvi®)
PDF icon VMAT2 Inhibitors
PDF icon Wakefulness Promoting Agents
PDF icon Weight Loss Agents

 

Claim Payments

PDF icon Convenience Pack
PDF icon Non-FDA Approved Medication
PDF icon Medical Injectable Medications Covered Under the Pharmacy Benefit
PDF icon Prescription Vitamins, Dietary Supplements, and Medical Foods