Utilization Management

Prior Authorization, Step Therapy, and Quantity Limit Policies for CareSource Marketplace Business

Not all medications will be covered on the formulary. Non-formulary medications are subject to the Medical Necessity for Non-Formulary Medications policy. Please consult the formulary to verify coverage.

A
Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy De-IdentifiedPolicy
Allergen Immunotherapy - Odactra PA Policy De-IdentifiedPolicy
Allergen Immunotherapy - Palforzia DQM Policy - Per Rx De-IdentifiedPolicy
Allergen Immunotherapy - Palforzia PA Policy De-IdentifiedPolicy
Allergen Immunotherapy - Ragwitek PA Policy De-IdentifiedPolicy
Alpha-Adrenergic Blockers - Doxazosin DQM Policy - Per Rx De-IdentifiedPolicy
Alpha-Adrenergic Blockers - Terazosin DQM Policy - Per Rx De-IdentifiedPolicy
Alpha1-Proteinase Inhibitor Products PA Policy De-IdentifiedPolicy
Alzheimer's Disease Step Therapy Policy De-IdentifiedPolicy
Alzheimers - Namenda, Namenda XR Step Therapy Policy De-IdentifiedPolicy
Amifampridine Products PA Policy De-IdentifiedPolicy
Amyloidosis - Amvuttra PA Policy De-IdentifiedPolicy
Amyloidosis - Onpattro PA Policy De-IdentifiedPolicy
Amyloidosis - Tafamidis Products PA Policy De-IdentifiedPolicy
Amyloidosis - Tegsedi PA Policy De-IdentifiedPolicy
Angiotensin Receptor Blocker Preferred Step Therapy Policy De-IdentifiedPolicy
Angiotensin Receptor Blocker Step Therapy Policy De-IdentifiedPolicy
Anti-Influenza - Relenza DQM Policy - Per Rx De-IdentifiedPolicy
Anti-Influenza - Xofluza DQM Policy - Per Rx De-IdentifiedPolicy
Anti-Influenza DQM Policy - Per Days De-IdentifiedPolicy
Antibiotics (Inhaled) - Arikayce PA Policy De-IdentifiedPolicy
Antibiotics (Inhaled) - Cayston PA Policy De-IdentifiedPolicy
Antibiotics (Inhaled) - TOBI Podhaler PA Policy De-IdentifiedPolicy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA Policy De-IdentifiedPolicy
Antibiotics (Inhaled) - Tobramycin Products PSM Policy De-IdentifiedPolicy
Antibiotics (Injectable) PA Policy De-IdentifiedPolicy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy De-IdentifiedPolicy
Antibiotics - Synercid PA Policy De-IdentifiedPolicy
Antibiotics - Vancomycin Capsules PA Policy De-IdentifiedPolicy
Antibiotics - Xifaxan PA Policy De-IdentifiedPolicy
Anticoagulants - Dabigatran PA Policy De-IdentifiedPolicy
Anticoagulants - Eliquis PA Policy De-IdentifiedPolicy
Anticoagulants - Savaysa PA Policy De-IdentifiedPolicy
Anticoagulants - Xarelto PA Policy De-IdentifiedPolicy
Antidepressants - Bupropion DQM Policy - Per Rx De-IdentifiedPolicy
Antidepressants - Bupropion Long-Acting Step Therapy Policy De-IdentifiedPolicy
Antidepressants - Selective Serotonin Reuptake Inhibitors DQM Policy - Per Rx De-IdentifiedPolicy
Antidepressants - Selective Serotonin Reuptake Inhibitors Step Therapy Policy De-IdentifiedPolicy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors DQM Policy - Per Rx De-IdentifiedPolicy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors Step Therapy Policy De-IdentifiedPolicy
Antiemetics - Doxylamine and Pyridoxine Combination Products DQM Policy - Per Days De-IdentifiedPolicy
Antiemetics - Serotonin Receptor Antagonists (Oral and Transdermal) DQM Policy - Per Rx De-IdentifiedPolicy
Antiemetics - Substance P-Neurokinin-1 Receptor Antagonists (Oral) DQM Policy - Per Rx De-IdentifiedPolicy
Antiepileptics - Banzel PA Policy De-IdentifiedPolicy
Antiepileptics - Clobazam Products PA Policy De-IdentifiedPolicy
Antiepileptics - Depakote, Depakene Step Therapy Policy De-IdentifiedPolicy
Antiepileptics - Diacomit PA Policy De-IdentifiedPolicy
Antiepileptics - Epidiolex PA Policy De-IdentifiedPolicy
Antiepileptics - Fintepla PA Policy De-IdentifiedPolicy
Antiepileptics - Lacosamide Step Therapy Policy De-IdentifiedPolicy
Antiepileptics - Lamictal XR Step Therapy Policy De-IdentifiedPolicy
Antiepileptics - Levetiracetam, Brivaracetam Step Therapy Policy De-IdentifiedPolicy
Antiepileptics - Nayzilam PA Policy De-IdentifiedPolicy
Antiepileptics - Oxtellar XR, Trileptal Step Therapy Policy De-IdentifiedPolicy
Antiepileptics - Valtoco PA Policy De-IdentifiedPolicy
Antiepileptics - Vigabatrin PA Policy De-IdentifiedPolicy
Antiepileptics - Zonisamide Step Therapy Policy De-IdentifiedPolicy
Antiepileptics - Ztalmy PA Policy De-IdentifiedPolicy
Antifungals (Azoles) - Intravenous Products PA Policy De-IdentifiedPolicy
Antifungals - Cresemba (Oral) PA Policy De-IdentifiedPolicy
Antifungals - Fluconazole (Oral) DQM Policy - Per Rx De-IdentifiedPolicy
Antifungals - Itraconazole DQM Policy - Per Rx De-IdentifiedPolicy
Antifungals - Noxafil (Oral) PA Policy De-IdentifiedPolicy
Antifungals - Vivjoa PA Policy De-IdentifiedPolicy
Antifungals - Voriconazole (Oral) PA Policy De-IdentifiedPolicy
Antifungals for Vulvovaginal Candidiasis Step Therapy Policy De-IdentifiedPolicy
Antiseizure Medications - Topiramate Step Therapy Policy De-IdentifiedPolicy
Antiseizure Medications - Xcopri DQM Policy - Per Rx De-IdentifiedPolicy
Antivirals - Famciclovir DQM Policy - Per Rx De-IdentifiedPolicy
Antivirals - Ribavirin (Inhaled Products) PA Policy De-IdentifiedPolicy
Antivirals - Ribavirin (Oral Products) PA Policy De-IdentifiedPolicy
Antivirals - Valacyclovir DQM Policy - Per Rx De-IdentifiedPolicy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy De-IdentifiedPolicy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy De-IdentifiedPolicy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy De-IdentifiedPolicy
Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy De-IdentifiedPolicy
B
Benign Prostatic Hyperplasia - 5-Alpha-Reductase Inhibitors Step Therapy Policy De-IdentifiedPolicy
Benign Prostatic Hyperplasia - Alpha Blockers Step Therapy Policy De-IdentifiedPolicy
Benign Prostatic Hyperplasia – Entadfi PA Policy De-IdentifiedPolicy
Benzodiazepines - Diazepam (Oral) DQM Policy - Per Days De-IdentifiedPolicy
Benzodiazepines DQM Policy for InMynd - Per Rx De-IdentifiedPolicy
Beta Blocker Step Therapy Policy De-IdentifiedPolicy
Bile Acid Sequestrants Step Therapy Policy De-IdentifiedPolicy
Bisphosphonates (Oral) Enhanced Step Therapy Policy De-IdentifiedPolicy
Bisphosphonates (Oral) Step Therapy Policy De-IdentifiedPolicy
Bone Modifiers - Evenity PA Policy De-IdentifiedPolicy
Bone Modifiers - Ibandronate Intravenous (Boniva IV) PA Policy De-IdentifiedPolicy
Bone Modifiers - Prolia PA Policy De-IdentifiedPolicy
Bone Modifiers - Teriparatide DQM Policy - Per Days De-IdentifiedPolicy
Bone Modifiers - Teriparatide Products PA Policy De-IdentifiedPolicy
Bone Modifiers - Tymlos PA Policy De-IdentifiedPolicy
Bone Modifiers - Xgeva DQM Policy - Per Rx De-IdentifiedPolicy
Bone Modifiers - Xgeva PA Policy De-IdentifiedPolicy
Bone Modifiers - Zoledronic Acid (Reclast) PA Policy De-IdentifiedPolicy
Botulinum Toxins - Botox PA Policy De-IdentifiedPolicy
Botulinum Toxins - Dysport PA Policy De-IdentifiedPolicy
Botulinum Toxins - Myobloc PA Policy De-IdentifiedPolicy
Botulinum Toxins - Xeomin PA Policy De-IdentifiedPolicy
Bowel Disease - Lubiprostone DQM Policy - Per Rx De-IdentifiedPolicy
Bowel Disease – Opioid-Induced Constipation Products Preferred Step Therapy Policy De-IdentifiedPolicy
C
Cabergoline DQM Policy - Per Days De-IdentifiedPolicy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig DQM Policy - Per Days De-IdentifiedPolicy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy De-IdentifiedPolicy
Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy De-IdentifiedPolicy
Calcitonin Gene-Related Peptide Inhibitors - Emgality DQM Policy - Per Days De-IdentifiedPolicy
Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy De-IdentifiedPolicy
Calcitonin Gene-Related Peptide Inhibitors - Vyepti PA Policy De-IdentifiedPolicy
Calcium Channel Blockers-Dihydropyridine Products Step Therapy Policy De-IdentifiedPolicy
Calcium Channel Blockers-Verapamil Products Step Therapy Policy De-IdentifiedPolicy
Carbinoxamine Step Therapy Policy De-IdentifiedPolicy
Cardiology - Camzyos PA Policy De-IdentifiedPolicy
Cardiology - Corlanor PA Policy De-IdentifiedPolicy
Cardiology - Ranolazine Products Step Therapy Policy De-IdentifiedPolicy
Cardiology - Verquvo DQM Policy - Per Rx De-IdentifiedPolicy
Cardiology - Zontivity PA Policy De-IdentifiedPolicy
Chelating Agents - Chemet PA Policy De-IdentifiedPolicy
Chelating Agents - Iron Chelators (Oral) PA Policy De-IdentifiedPolicy
Chelating Agents - Trientine PA Policy De-IdentifiedPolicy
Chelating Agents – Iron Chelators (Oral) PSM Policy De-IdentifiedPolicy
Chenodal PA Policy De-IdentifiedPolicy
Cholbam PA Policy De-IdentifiedPolicy
Chorionic Gonadotropins DQM Policy - Per Rx De-IdentifiedPolicy
Chorionic Gonadotropins PSM Policy De-IdentifiedPolicy
Cinacalcet PA De-IdentifiedPolicy
Colchicine Products Preferred Step Therapy Policy De-IdentifiedPolicy
Colony Stimulating Factors - Filgrastim Products PA Policy De-IdentifiedPolicy
Colony Stimulating Factors - Filgrastim Products PSM Policy for High Performance Formulary, effective 01 De-IdentifiedPolicy
Colony Stimulating Factors - Filgrastim Products PSM Policy for National Preferred Formulary and Basic Formulary De-IdentifiedPolicy
Colony Stimulating Factors - Granix PA Policy De-IdentifiedPolicy
Colony Stimulating Factors - Leukine PA Policy De-IdentifiedPolicy
Colony Stimulating Factors - Pegfilgrastim Products and Rolvedon PSM Policy De-IdentifiedPolicy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy De-IdentifiedPolicy
Colony Stimulating Factors - Pegfilgrastim Products PSM Policy De-IdentifiedPolicy
Colony Stimulating Factors - Rolvedon PA Policy De-IdentifiedPolicy
Complement Inhibitors - Empaveli PA Policy De-IdentifiedPolicy
Complement Inhibitors – Soliris PA Policy De-IdentifiedPolicy
Complement Inhibitors – Ultomiris Intravenous PA Policy De-IdentifiedPolicy
Complement Inhibitors – Ultomiris Subcutaneous PA Policy De-IdentifiedPolicy
Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy De-IdentifiedPolicy
Contraceptives - Phexxi PA Policy De-IdentifiedPolicy
Coronavirus Disease - Evusheld PA Policy De-IdentifiedPolicy
Coronavirus Disease - Veklury PA Policy De-IdentifiedPolicy
Coronavirus – Oral Medications for Treatment of COVID-19 DQM Policy – Per Days De-IdentifiedPolicy
Corticosteroids (Intraarticular) - Zilretta PA Policy De-IdentifiedPolicy
Corticosteroids (Nasal) - Mometasone DQM Policy - Per Rx De-IdentifiedPolicy
Corticosteroids (Nebulized) - Budesonide DQM Policy - Per Rx De-IdentifiedPolicy
Crysvita PA Policy De-IdentifiedPolicy
Cushing's - Isturisa PA Policy De-IdentifiedPolicy
Cushing's - Korlym PA Policy De-IdentifiedPolicy
Cushing's - Recorlev PA Policy De-IdentifiedPolicy
Cushing's - Signifor PA Policy De-IdentifiedPolicy
Cushing's Disease - Isturisa DQM Policy - Per Rx De-IdentifiedPolicy
Cyclooxygenase-2 Inhibitor Step Therapy Policy De-IdentifiedPolicy
Cystic Fibrosis - Bronchitol PA Policy De-IdentifiedPolicy
Cystic Fibrosis - Kalydeco PA Policy De-IdentifiedPolicy
Cystic Fibrosis - Orkambi PA Policy De-IdentifiedPolicy
Cystic Fibrosis - Pulmozyme PA Policy De-IdentifiedPolicy
Cystic Fibrosis - Symdeko PA Policy De-IdentifiedPolicy
Cystic Fibrosis - Trikafta PA Policy De-IdentifiedPolicy
D
Dermatology - Hyftor PA De-IdentifiedPolicy
Dermatology - Opzelura PA Policy De-IdentifiedPolicy
Dermatology - Vtama DQM Policy - Per Days De-IdentifiedPolicy
Dermatology - Zoryve DQM Policy - Per Days De-IdentifiedPolicy
Desmopressin Products - Nocdurna PA Policy De-IdentifiedPolicy
Diabetes - Canagliflozin Products DQM Policy - Per Rx De-IdentifiedPolicy
Diabetes - Continuous Glucose Monitoring Systems PA Policy De-IdentifiedPolicy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy De-IdentifiedPolicy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy De-IdentifiedPolicy
Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy De-IdentifiedPolicy
Diabetes - Kerendia PA Policy De-IdentifiedPolicy
Diabetes - Metformin Extended-Release DQM Policy - Per Rx De-IdentifiedPolicy
Diabetes - Metformin Step Therapy Policy De-IdentifiedPolicy
Diabetes - Mounjaro PA Policy De-IdentifiedPolicy
Diabetes - Omnipods DQM Policy - Per Days De-IdentifiedPolicy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy De-IdentifiedPolicy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy De-IdentifiedPolicy
Diabetes - Symlin PA Policy De-IdentifiedPolicy
Diabetes - Thiazolidinedione Step Therapy Policy De-IdentifiedPolicy
Diabetes - Tzield PA Policy De-IdentifiedPolicy
Diuretics - Loop Products Step Therapy Policy De-IdentifiedPolicy
E
Enspryng PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Aldurazyme PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Elaprase PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Fabrazyme PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Kanuma PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Lumizyme PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Mepsevii PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Naglazyme PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Nexviazyme PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Revcovi PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Strensiq PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Sucraid PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Vimizim PA Policy De-IdentifiedPolicy
Enzyme Replacement Therapy - Xenpozyme PA Policy De-IdentifiedPolicy
Epinephrine Auto-Injectors Preferred Step Therapy Policy 2 De-IdentifiedPolicy
Epinephrine Auto-injectors Preferred Step Therapy Policy De-IdentifiedPolicy
Epinephrine Auto-Injectors Step Therapy Policy De-IdentifiedPolicy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy De-IdentifiedPolicy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy De-IdentifiedPolicy
Erythropoiesis-Stimulating Agents - Mircera PA Policy De-IdentifiedPolicy
Erythropoiesis-Stimulating Agents PSM Policy De-IdentifiedPolicy
Estrogens (Topical) - Estradiol Gel DQM Policy - Per Rx De-IdentifiedPolicy
Estrogens (Topical) - Patches DQM Policy - Per Days De-IdentifiedPolicy
Ezetimibe Step Therapy Policy De-IdentifiedPolicy
F
Fabry Disease - Galafold PA Policy De-IdentifiedPolicy
Fenofibrate Preferred Step Therapy Policy De-IdentifiedPolicy
Fenofibrate Step Therapy Policy De-IdentifiedPolicy
G
Gabapentin Step Therapy Policy De-IdentifiedPolicy
Gamifant PA Policy De-IdentifiedPolicy
Gastroenterology - Gattex PA Policy De-IdentifiedPolicy
Gaucher Disease - Enzyme Replacement Therapy - Cerezyme PA Policy De-IdentifiedPolicy
Gaucher Disease - Enzyme Replacement Therapy - Elelyso PA Policy De-IdentifiedPolicy
Gaucher Disease - Enzyme Replacement Therapy - Vpriv PA Policy De-IdentifiedPolicy
Gaucher Disease - Enzyme Replacement Therapy PSM Policy De-IdentifiedPolicy
Gaucher Disease - Substrate Reduction Therapy - Cerdelga PA Policy De-IdentifiedPolicy
Gaucher Disease - Substrate Reduction Therapy - Miglustat PA Policy De-IdentifiedPolicy
Gaucher Disease - Substrate Reduction Therapy PSM Policy De-IdentifiedPolicy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy De-IdentifiedPolicy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy De-IdentifiedPolicy
Gonadotropin-Releasing Hormone Agonists - Implants PA Policy De-IdentifiedPolicy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products PA Policy De-IdentifiedPolicy
Gonadotropin-Releasing Hormone Antagonists - Myfembree PA Policy De-IdentifiedPolicy
Gonadotropin-Releasing Hormone Antagonists - Orilissa DQM Policy - Per Days De-IdentifiedPolicy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy De-IdentifiedPolicy
Gout - Krystexxa PA Policy De-IdentifiedPolicy
Gout Medications Step Therapy Policy De-IdentifiedPolicy
Growth Disorders - Growth Hormone (Daily) PSM Policy De-IdentifiedPolicy
Growth Disorders - Growth Hormone PA Policy De-IdentifiedPolicy
Growth Disorders - Increlex PA Policy De-IdentifiedPolicy
Growth Disorders - Skytrofa PA Policy De-IdentifiedPolicy
Growth Disorders - Voxzogo PA Policy De-IdentifiedPolicy
H
Helicobacter Pylori Infection Combination Products Preferred Step Therapy Policy De-IdentifiedPolicy
Hematology - Cablivi PA Policy De-IdentifiedPolicy
Hematology - Ceprotin PA Policy De-IdentifiedPolicy
Hematology - Coagadex PA Policy De-IdentifiedPolicy
Hematology - Corifact PA Policy De-IdentifiedPolicy
Hematology - Enjaymo PA Policy De-IdentifiedPolicy
Hematology - Fibrinogen Products PA Policy De-IdentifiedPolicy
Hematology - Gene Therapy - Zynteglo PA Policy De-IdentifiedPolicy
Hematology - Pyrukynd DQM Policy - Per Days De-IdentifiedPolicy
Hematology - Pyrukynd PA Policy De-IdentifiedPolicy
Hematology - Reblozyl PA Policy De-IdentifiedPolicy
Hematology - Ryplazim PA Policy De-IdentifiedPolicy
Hematology - Tretten PA Policy De-IdentifiedPolicy
Hematology - Vonvendi PA Policy De-IdentifiedPolicy
Hemophilia - Eptacog Products - NovoSeven RT PA Policy De-IdentifiedPolicy
Hemophilia - Eptacog Products - Sevenfact PA Policy De-IdentifiedPolicy
Hemophilia - Factor IX Products PA Policy De-IdentifiedPolicy
Hemophilia - Factor VIII Products PA Policy De-IdentifiedPolicy
Hemophilia - FEIBA PA Policy De-IdentifiedPolicy
Hemophilia - Hemlibra PA Policy De-IdentifiedPolicy
Hemophilia - Recombinant Factor VIII Products PSM Policy De-IdentifiedPolicy
Hepatitis C - Epclusa DQM Policy - Per Days De-IdentifiedPolicy
Hepatitis C - Epclusa PA Policy De-IdentifiedPolicy
Hepatitis C - Harvoni DQM Policy - Per Days De-IdentifiedPolicy
Hepatitis C - Harvoni PA Policy De-IdentifiedPolicy
Hepatitis C - Mavyret DQM Policy - Per Days De-IdentifiedPolicy
Hepatitis C - Mavyret PA for PSM Policy De-IdentifiedPolicy
Hepatitis C - Mavyret PA Policy De-IdentifiedPolicy
Hepatitis C - Sovaldi DQM Policy - Per Days De-IdentifiedPolicy
Hepatitis C - Sovaldi PA Policy De-IdentifiedPolicy
Hepatitis C - Viekira Pak DQM Policy - Per Days De-IdentifiedPolicy
Hepatitis C - Viekira Pak PA Policy De-IdentifiedPolicy
Hepatitis C - Vosevi PA Policy De-IdentifiedPolicy
Hepatitis C - Zepatier PA Policy De-IdentifiedPolicy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for High Performance Formulary De-IdentifiedPolicy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred FLEX Formulary De-IdentifiedPolicy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary De-IdentifiedPolicy
Hepatology - Bylvay DQM Policy - Per Rx De-IdentifiedPolicy
Hepatology - Givlaari PA Policy De-IdentifiedPolicy
Hepatology - Livmarli PA Policy De-IdentifiedPolicy
Hepatology - Ocaliva PA Policy De-IdentifiedPolicy
Hepatology – Bylvay PA Policy De-IdentifiedPolicy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy De-IdentifiedPolicy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PSM Policy De-IdentifiedPolicy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy De-IdentifiedPolicy
Hereditary Angioedema - Icatibant PA Policy De-IdentifiedPolicy
Hereditary Angioedema - Icatibant PSM Policy De-IdentifiedPolicy
Hereditary Angioedema - Kalbitor PA Policy De-IdentifiedPolicy
Hereditary Angioedema - Orladeyo PA Policy De-IdentifiedPolicy
Hereditary Angioedema - Takhzyro PA Policy De-IdentifiedPolicy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy De-IdentifiedPolicy
Homozygous Familial Hypercholesterolemia - Juxtapid PA Policy De-IdentifiedPolicy
Human Immunodeficiency Virus - Apretude PA Policy De-IdentifiedPolicy
Human Immunodeficiency Virus - Cabenuva DQM Policy - Per Days De-IdentifiedPolicy
Human Immunodeficiency Virus - Cabenuva PA Policy De-IdentifiedPolicy
Human Immunodeficiency Virus - Complera PSM Policy (Basic Formulary) De-IdentifiedPolicy
Human Immunodeficiency Virus - Prezcobix PSM Policy (Basic Formulary) De-IdentifiedPolicy
Human Immunodeficiency Virus - Rukobia PA Policy De-IdentifiedPolicy
Human Immunodeficiency Virus - Stribild PSM Policy (Basic Formulary) De-IdentifiedPolicy
Human Immunodeficiency Virus - Sunlenca PA Policy De-IdentifiedPolicy
Human Immunodeficiency Virus - Trogarzo PA Policy De-IdentifiedPolicy
Human Immunodeficiency Virus - Truvada PSM Policy De-IdentifiedPolicy
Hyaluronic Acid Derivatives Intraarticular PA Policy De-IdentifiedPolicy
Hyaluronic Acid Derivatives Intraarticular PSM Policy De-IdentifiedPolicy
Hydrocortisone Acetate Suppository Step Therapy Policy De-IdentifiedPolicy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors DQM Policy - Per Rx De-IdentifiedPolicy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors Step Therapy Policy De-IdentifiedPolicy
Hyperlipidemia - Nexletol PA Policy De-IdentifiedPolicy
Hyperlipidemia - Nexlizet PA Policy De-IdentifiedPolicy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy De-IdentifiedPolicy
Hypertension - Clonidine Patches DQM Policy - Per Days De-IdentifiedPolicy
Hypoactive Sexual Desire Disorder - Addyi PA Policy De-IdentifiedPolicy
Hypoactive Sexual Desire Disorder - Vyleesi PA Policy De-IdentifiedPolicy
I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy De-IdentifiedPolicy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PA Policy De-IdentifiedPolicy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PSM Policy De-IdentifiedPolicy
Immune Globulin - Atgam PA Policy De-IdentifiedPolicy
Immune Globulin - Intravenous PA Policy De-IdentifiedPolicy
Immune Globulin - Subcutaneous PA Policy De-IdentifiedPolicy
Immune Globulin – Cytogam PA Policy De-IdentifiedPolicy
Immunologicals - Adbry DQM Policy - Per Days De-IdentifiedPolicy
Immunologicals - Adbry PA Policy De-IdentifiedPolicy
Immunologicals - Anti-Interleukin-5 Agents PSM Policy De-IdentifiedPolicy
Immunologicals - Dupixent DQM Policy - Per Days De-IdentifiedPolicy
Immunologicals - Dupixent PA Policy De-IdentifiedPolicy
Immunologicals - Fasenra DQM Policy - Per Days De-IdentifiedPolicy
Immunologicals - Nucala DQM Policy - Per Days De-IdentifiedPolicy
Immunologicals - Nucala PA Policy De-IdentifiedPolicy
Immunologicals - Tezspire PA Policy De-IdentifiedPolicy
Immunologicals - Xolair DQM Policy - Per Days De-IdentifiedPolicy
Immunologicals – Cinqair PA Policy De-IdentifiedPolicy
Immunologicals – Fasenra PA Policy De-IdentifiedPolicy
Immunologicals – Xolair PA Policy De-IdentifiedPolicy
Immunosuppressive Agents - Rezurock DQM Policy - Per Rx De-IdentifiedPolicy
Immunosuppressive Agents - Rezurock PA Policy De-IdentifiedPolicy
Infectious Disease - Antiparasitic Agents DQM Policy - Per Days De-IdentifiedPolicy
Infectious Disease - Antiparasitics DQM Policy - Per Days De-IdentifiedPolicy
Infectious Disease - Impavido PA Policy De-IdentifiedPolicy
Infectious Disease - Ivermectin Tablets PA Policy De-IdentifiedPolicy
Infectious Disease - Livtencity DQM Policy - Per Days De-IdentifiedPolicy
Infectious Disease - Livtencity PA Policy De-IdentifiedPolicy
Infectious Disease - Pretomanid PA Policy De-IdentifiedPolicy
Infectious Disease - Prevymis DQM Policy - Per Days De-IdentifiedPolicy
Infectious Disease - Pyrimethamine PA Policy De-IdentifiedPolicy
Infectious Disease - Sirturo PA Policy De-IdentifiedPolicy
Infectious Disease - Vancomycin (Oral) DQM Policy - Per Rx De-IdentifiedPolicy
Inflammatory Conditions - Actemra Intravenous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Actemra Subcutaneous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Adalimumab Products PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Arcalyst DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Arcalyst PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Cibinqo PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Cimzia DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Cimzia PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Cosentyx DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Cosentyx PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Entyvio Intravenous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Etanercept Products DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Etanercept Products PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Ilaris PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Ilumya DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Ilumya PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Infliximab Products PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Kevzara PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Kineret DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Kineret PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Olumiant DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Olumiant PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Orencia Intravenous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Orencia Subcutaneous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Otezla DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Otezla PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Rinvoq DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Rinvoq PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Siliq DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Siliq PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Simponi Aria PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Simponi Subcutaneous DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Simponi Subcutaneous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Skyrizi Subcutaneous DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Skyrizi Subcutaneous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Sotyktu PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Spevigo PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Stelara Intravenous PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Stelara Subcutaneous DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Stelara Subcutaneous PA Policy with Dosing De-IdentifiedPolicy
Inflammatory Conditions - Taltz DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Taltz PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Tremfya DQM Policy - Per Days De-IdentifiedPolicy
Inflammatory Conditions - Tremfya PA Policy De-IdentifiedPolicy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy De-IdentifiedPolicy
Inflammatory Conditions PSM Policy De-IdentifiedPolicy
Interferon - Actimmune PA Policy De-IdentifiedPolicy
Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy De-IdentifiedPolicy
Iron Replacement – Feraheme PA Policy De-IdentifiedPolicy
Iron Replacement – Ferrlecit PA Policy De-IdentifiedPolicy
Iron Replacement – INFeD PA Policy De-IdentifiedPolicy
Iron Replacement – Injectafer PA Policy De-IdentifiedPolicy
Iron Replacement – Monoferric PA Policy De-IdentifiedPolicy
Iron Replacement – Venofer PA Policy De-IdentifiedPolicy
Isotretinoin Step Therapy Policy De-IdentifiedPolicy
K
Keveyis PA Policy De-IdentifiedPolicy
L
Lipodystrophy - Egrifta PA Policy De-IdentifiedPolicy
Lipodystrophy - Myalept PA Policy De-IdentifiedPolicy
Lucemyra PA Policy De-IdentifiedPolicy
Lupus - Benlysta Intravenous PA Policy De-IdentifiedPolicy
Lupus - Benlysta Subcutaneous DQM Policy - Per Days De-IdentifiedPolicy
Lupus - Benlysta Subcutaneous PA Policy De-IdentifiedPolicy
Lupus - Lupkynis PA Policy De-IdentifiedPolicy
Lupus - Saphnelo PA Policy De-IdentifiedPolicy
M
Makena (Hydroxyprogesterone caproate) PA Policy De-IdentifiedPolicy
Metabolic Disorders - Betaine Anhydrous PA Policy De-IdentifiedPolicy
Metabolic Disorders - Carbaglu PA Policy De-IdentifiedPolicy
Metabolic Disorders - Dojolvi PA Policy De-IdentifiedPolicy
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Natpara PA Policy De-IdentifiedPolicy
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Oncology (Injectable - CAR-T) - Abecma PA Policy De-IdentifiedPolicy
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Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy De-IdentifiedPolicy
Oncology (Injectable - Programmed Death Receptor-1) - Opdualag PA Policy De-IdentifiedPolicy
Oncology (Injectable - Programmed Death-Ligand 1) - Bavencio PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Adcetris PA Policy De-IdentifiedPolicy
Oncology (Injectable) - Aliqopa PA Policy De-IdentifiedPolicy
Oncology (Injectable) - Arsenic Trioxide PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Asparlas PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Bevacizumab Products PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Cosela PA Policy De-IdentifiedPolicy
Oncology (Injectable) - Cyramza PA Policy De-IdentifiedPolicy
Oncology (Injectable) - Danyelza PA Policy De-IdentifiedPolicy
Oncology (Injectable) - Darzalex Faspro PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Gazyva PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Imjudo PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Pralatrexate Products PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Torisel PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Unituxin PA Policy De-IdentifiedPolicy
Oncology (Injectable) - Vectibix PA Policy De-IdentifiedPolicy
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Oncology (Injectable) - Zepzelca PA Policy De-IdentifiedPolicy
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Oncology (Other) - Jelmyto PA Policy De-IdentifiedPolicy
Oncology (Other) - Valrubicin Products PA Policy De-IdentifiedPolicy
Oncology - Abiraterone Acetate DQM Policy - Per Rx De-IdentifiedPolicy
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Oncology - Alecensa PA Policy De-IdentifiedPolicy
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Oncology - Braftovi PA Policy De-IdentifiedPolicy
Oncology - Brukinsa PA Policy De-IdentifiedPolicy
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Oncology - Capecitabine PA Policy De-IdentifiedPolicy
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Oncology - Erlotinib DQM Policy - Per Rx De-IdentifiedPolicy
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Oncology - Exkivity PA Policy De-IdentifiedPolicy
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Oncology - Ibrance PA Policy De-IdentifiedPolicy
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Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy De-IdentifiedPolicy
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Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists Step Therapy Policy De-IdentifiedPolicy
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Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy De-IdentifiedPolicy
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Ophthalmology - Dry Eye Disease - Cyclosporine Products PA Policy De-IdentifiedPolicy
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Opioids - Butorphanol DQM Policy - Per Days De-IdentifiedPolicy
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Opioids - Tramadol Extended-Release Products DQM Policy - Per Rx De-IdentifiedPolicy
Overactive Bladder Medications Preferred Step Therapy Policy De-IdentifiedPolicy
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Parkinson's Disease - Kynmobi PA Policy De-IdentifiedPolicy
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Phenylketonuria - Palynziq DQM Policy - Per Rx De-IdentifiedPolicy
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Phosphate Binders DQM Policy - Per Rx De-IdentifiedPolicy
Potassium Binders - Lokelma DQM Policy - Per Rx De-IdentifiedPolicy
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Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy De-IdentifiedPolicy
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Proton Pump Inhibitors DQM Policy - Per Rx De-IdentifiedPolicy
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Psychiatry - Novel Psychotropics DQM Policy - Per Rx De-IdentifiedPolicy
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Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy De-IdentifiedPolicy
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Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy De-IdentifiedPolicy
Pulmonary - Roflumilast PA with Step Therapy Policy De-IdentifiedPolicy
Pulmonary Arterial Hypertension - Adempas DQM Policy - Per Rx De-IdentifiedPolicy
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Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy De-IdentifiedPolicy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PSM Policy De-IdentifiedPolicy
Pulmonary Arterial Hypertension - Orenitram DQM Policy - Per Rx De-IdentifiedPolicy
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Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy De-IdentifiedPolicy
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Pulmonary Arterial Hypertension - Treprostinil Injection PA Policy De-IdentifiedPolicy
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Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy De-IdentifiedPolicy
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Qbrexza PA Policy De-IdentifiedPolicy
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Repository Corticotropin - Acthar Gel PA Policy De-IdentifiedPolicy
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Rituximab Intravenous Products PA Policy De-IdentifiedPolicy
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Scenesse PA Policy De-IdentifiedPolicy
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Somatostatin Analogs for Acromegaly PSM Policy De-IdentifiedPolicy
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Somavert PA Policy De-IdentifiedPolicy
Spinal Muscular Atrophy - Evrysdi PA Policy De-IdentifiedPolicy
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Synagis PA Policy De-IdentifiedPolicy
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Tasimelteon Products PA Policy De-IdentifiedPolicy
Testosterone (injectable) Products PA Policy De-IdentifiedPolicy
Testosterone (Oral, Topical, and Nasal) Products PA Policy De-IdentifiedPolicy
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Testosterone Undecanoate (Oral) DQM Policy - Per Rx De-IdentifiedPolicy
Tetracyclines (Oral) Step Therapy Policy De-IdentifiedPolicy
Thrombocytopenia - Doptelet DQM Policy - Per Rx De-IdentifiedPolicy
Thrombocytopenia - Doptelet PA Policy De-IdentifiedPolicy
Thrombocytopenia - Mulpleta PA Policy De-IdentifiedPolicy
Thrombocytopenia - Nplate PA Policy De-IdentifiedPolicy
Thrombocytopenia - Promacta PA Policy De-IdentifiedPolicy
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Tolvaptan Products - Jynarque PA Policy De-IdentifiedPolicy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy De-IdentifiedPolicy
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Topical Acne - Cleansers Step Therapy Policy De-IdentifiedPolicy
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Topical Acne - Winlevi PA Policy De-IdentifiedPolicy
Topical Acyclovir Products PA Policy De-IdentifiedPolicy
Topical Agents for Atopic Dermatitis DQM Policy - Per Days De-IdentifiedPolicy
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Topical Alpha-Adrenergic Agonists for Rosacea - Brimonidine PA with Step Therapy Policy De-IdentifiedPolicy
Topical Alpha-Adrenergic Agonists for Rosacea - Rhofade PA Policy De-IdentifiedPolicy
Topical Anesthetics DQM Policy - Per Days De-IdentifiedPolicy
Topical Antibacterials Step Therapy Policy De-IdentifiedPolicy
Topical Antibiotics for Acne - Clindamycin DQM Policy - Per Days De-IdentifiedPolicy
Topical Antifungals DQM Policy - Per Days De-IdentifiedPolicy
Topical Antifungals for Onychomycosis Step Therapy Policy De-IdentifiedPolicy
Topical Antipruritics - Doxepin Products DQM Policy - Per Days De-IdentifiedPolicy
Topical Calcipotriene Products DQM Policy - Per Days De-IdentifiedPolicy
Topical Collagenase - Santyl DQM Policy - Per Rx De-IdentifiedPolicy
Topical Corticosteroids - Clobetasol DQM Policy - Per Days De-IdentifiedPolicy
Topical Corticosteroids - Diflorasone DQM Policy - Per Days De-IdentifiedPolicy
Topical Corticosteroids - Fluocinonide DQM Policy - Per Days De-IdentifiedPolicy
Topical Corticosteroids - Flurandrenolide DQM Policy - Per Days De-IdentifiedPolicy
Topical Corticosteroids - Hydrocortisone Butyrate DQM Policy - Per Days De-IdentifiedPolicy
Topical Corticosteroids - Triamcinolone Spray DQM Policy - Per Days De-IdentifiedPolicy
Topical Corticosteroids Step Therapy Policy De-IdentifiedPolicy
Topical Diclofenac Sodium 3 percent Gel PA Policy De-IdentifiedPolicy
Topical Doxepin Step Therapy Policy De-IdentifiedPolicy
Topical Medications for Inflammatory Rosacea Step Therapy De-IdentifiedPolicy
Topical Podofilox Products Step Therapy Policy De-IdentifiedPolicy
Topical Products - Vtama and Zoryve Step Therapy Policy De-IdentifiedPolicy
Topical Retinoids - Aklief PA Policy De-IdentifiedPolicy
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Topical Retinoids - Tazarotene Products PA Policy De-IdentifiedPolicy
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Topical Vitamin D Analogs Step Therapy Policy De-IdentifiedPolicy
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Uplizna PA Policy De-IdentifiedPolicy
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Vasculitis - Tavneos PA Policy De-IdentifiedPolicy
Vecamyl PA Policy De-IdentifiedPolicy
Veregen PA Policy De-IdentifiedPolicy
Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy De-IdentifiedPolicy
Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy De-IdentifiedPolicy
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy De-IdentifiedPolicy
Vesicular Monoamine Transporter Type 2 Inhibitors DQM Policy - Per Rx De-IdentifiedPolicy
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Vijoice PA Policy De-IdentifiedPolicy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy De-IdentifiedPolicy
Vitamin D Analog (Oral) Step Therapy Policy De-IdentifiedPolicy
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Wakefulness-Promoting Agents - Sunosi DQM Policy - Per Rx De-IdentifiedPolicy
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Xiaflex PA Policy De-IdentifiedPolicy
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Zavesca Market Events Clinical Policy De-IdentifiedPolicy
Zokinvy PA Policy De-IdentifiedPolicy