Pharmacy Policies

Pharmacy Clinical Policies

Crizanlizumab-tmca (Adakveo) CP-449

Crizanlizumab-tmca (Adakveo®) is a selectin blocker.

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Ceriponase alfa (Brineura) CP-338

Cerliponase alfa (Brineura®) is a hydrolytic lysosomal N-terminal tripeptidyl peptidase.

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Factor VIII (Human, Recombinant) CP-215

The following are factor VIII products requiring prior authorization: human – Hemofil M®, Koate-DVI®; recombinant – Advate®, Adynovate®, Afstyla®, Eloctate®, Esperoct®, Helixate FS®, Jivi®, Kogenate FS®, Kogenate FS with Vial Adapter®, Kogenate FS with Bio-Set®, Kovaltry®, NovoEight®, Nuwiq®, Obizur®, Recombinate®, ReFacto®, Xyntha®, and Xyntha® Solofuse™.

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Factor VIIa Recombinant (NovoSeven RT, SevenFact) CP-220

Factor VIIa, recombinant (NovoSeven® RT) and coagulation factor VIIa (recombinant)-jncw (SevenFact®) are coagulation factors.

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Patisiran (Onpattro) CP-395

Patisiran (Onpattro™) is a double-stranded small interfering ribonucleic acid, formulated as a lipid complex for delivery to hepatocytes.

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Mogamulizumab (Poteligeo) CP-139

Mogamulizumab-kpkc (Poteligeo®) is a CC chemokine receptor type 4 (CCR4)-directed monoclonal antibody.

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Eculizumab (Soliris) CP-97

Eculizumab (Soliris®) is a complement inhibitor.

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Trientine (Syprine) CP-438

Trientine (Syprine®) is a chelating agent.

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Ravulizumab-cwvz (Ultomiris) CP-415

Ravulizuamb-cwvz (Ultomiris®) is a complement inhibitor.

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Golodirsen (Vyondys 53) CP-453

Golodirsen (Vyondys 53TM) is an antisense oligonucleotide.

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