Utilization Management

Prescription Drug Prior Authorization and Step Therapy Policies for Cascade Select 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-Identified	Policy
Allergen Immunotherapy - Odactra PA Policy De-Identified	Policy
Allergen Immunotherapy - Palforzia DQM Policy - Per Rx De-Identified	Policy
Allergen Immunotherapy - Palforzia PA Policy De-Identified	Policy
Allergen Immunotherapy - Ragwitek PA Policy De-Identified	Policy
Alpha-Adrenergic Blockers - Doxazosin DQM Policy - Per Rx De-Identified	Policy
Alpha-Adrenergic Blockers - Terazosin DQM Policy - Per Rx De-Identified	Policy
Alpha1-Proteinase Inhibitor Products PA Policy De-Identified	Policy
Alzheimer's Disease Step Therapy Policy De-Identified	Policy
Alzheimers - Namenda, Namenda XR Step Therapy Policy De-Identified	Policy
Amifampridine Products PA Policy De-Identified	Policy
Amyloidosis - Amvuttra PA Policy De-Identified	Policy
Amyloidosis - Onpattro PA Policy De-Identified	Policy
Amyloidosis - Tafamidis Products PA Policy De-Identified	Policy
Amyloidosis - Tegsedi PA Policy De-Identified	Policy
Angiotensin Receptor Blocker Preferred Step Therapy Policy De-Identified	Policy
Angiotensin Receptor Blocker Step Therapy Policy De-Identified	Policy
Anti-Influenza - Relenza DQM Policy - Per Rx De-Identified	Policy
Anti-Influenza - Xofluza DQM Policy - Per Rx De-Identified	Policy
Anti-Influenza DQM Policy - Per Days De-Identified	Policy
Antibiotics (Inhaled) - Arikayce PA Policy De-Identified	Policy
Antibiotics (Inhaled) - Cayston PA Policy De-Identified	Policy
Antibiotics (Inhaled) - TOBI Podhaler PA Policy De-Identified	Policy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA Policy De-Identified	Policy
Antibiotics (Inhaled) - Tobramycin Products PSM Policy De-Identified	Policy
Antibiotics (Injectable) PA Policy De-Identified	Policy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy De-Identified	Policy
Antibiotics - Synercid PA Policy De-Identified	Policy
Antibiotics - Vancomycin Capsules PA Policy De-Identified	Policy
Antibiotics - Xifaxan PA Policy De-Identified	Policy
Anticoagulants - Dabigatran PA Policy De-Identified	Policy
Anticoagulants - Eliquis PA Policy De-Identified	Policy
Anticoagulants - Savaysa PA Policy De-Identified	Policy
Anticoagulants - Xarelto PA Policy De-Identified	Policy
Antidepressants - Bupropion DQM Policy - Per Rx De-Identified	Policy
Antidepressants - Bupropion Long-Acting Step Therapy Policy De-Identified	Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors DQM Policy - Per Rx De-Identified	Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors Step Therapy Policy De-Identified	Policy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors DQM Policy - Per Rx De-Identified	Policy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors Step Therapy Policy De-Identified	Policy
Antiemetics - Doxylamine and Pyridoxine Combination Products DQM Policy - Per Days De-Identified	Policy
Antiemetics - Serotonin Receptor Antagonists (Oral and Transdermal) DQM Policy - Per Rx De-Identified	Policy
Antiemetics - Substance P-Neurokinin-1 Receptor Antagonists (Oral) DQM Policy - Per Rx De-Identified	Policy
Antiepileptics - Banzel PA Policy De-Identified	Policy
Antiepileptics - Clobazam Products PA Policy De-Identified	Policy
Antiepileptics - Depakote, Depakene Step Therapy Policy De-Identified	Policy
Antiepileptics - Diacomit PA Policy De-Identified	Policy
Antiepileptics - Epidiolex PA Policy De-Identified	Policy
Antiepileptics - Fintepla PA Policy De-Identified	Policy
Antiepileptics - Lacosamide Step Therapy Policy De-Identified	Policy
Antiepileptics - Lamictal XR Step Therapy Policy De-Identified	Policy
Antiepileptics - Levetiracetam, Brivaracetam Step Therapy Policy De-Identified	Policy
Antiepileptics - Nayzilam PA Policy De-Identified	Policy
Antiepileptics - Oxtellar XR, Trileptal Step Therapy Policy De-Identified	Policy
Antiepileptics - Valtoco PA Policy De-Identified	Policy
Antiepileptics - Vigabatrin PA Policy De-Identified	Policy
Antiepileptics - Zonisamide Step Therapy Policy De-Identified	Policy
Antiepileptics - Ztalmy PA Policy De-Identified	Policy
Antifungals (Azoles) - Intravenous Products PA Policy De-Identified	Policy
Antifungals - Cresemba (Oral) PA Policy De-Identified	Policy
Antifungals - Fluconazole (Oral) DQM Policy - Per Rx De-Identified	Policy
Antifungals - Itraconazole DQM Policy - Per Rx De-Identified	Policy
Antifungals - Noxafil (Oral) PA Policy De-Identified	Policy
Antifungals - Vivjoa PA Policy De-Identified	Policy
Antifungals - Voriconazole (Oral) PA Policy De-Identified	Policy
Antifungals for Vulvovaginal Candidiasis Step Therapy Policy De-Identified	Policy
Antiseizure Medications - Topiramate Step Therapy Policy De-Identified	Policy
Antiseizure Medications - Xcopri DQM Policy - Per Rx De-Identified	Policy
Antivirals - Famciclovir DQM Policy - Per Rx De-Identified	Policy
Antivirals - Ribavirin (Inhaled Products) PA Policy De-Identified	Policy
Antivirals - Ribavirin (Oral Products) PA Policy De-Identified	Policy
Antivirals - Valacyclovir DQM Policy - Per Rx De-Identified	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy De-Identified	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy De-Identified	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy De-Identified	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy De-Identified	Policy

B
Benign Prostatic Hyperplasia - 5-Alpha-Reductase Inhibitors Step Therapy Policy De-Identified	Policy
Benign Prostatic Hyperplasia - Alpha Blockers Step Therapy Policy De-Identified	Policy
Benign Prostatic Hyperplasia – Entadfi PA Policy De-Identified	Policy
Benzodiazepines - Diazepam (Oral) DQM Policy - Per Days De-Identified	Policy
Benzodiazepines DQM Policy for InMynd - Per Rx De-Identified	Policy
Beta Blocker Step Therapy Policy De-Identified	Policy
Bile Acid Sequestrants Step Therapy Policy De-Identified	Policy
Bisphosphonates (Oral) Enhanced Step Therapy Policy De-Identified	Policy
Bisphosphonates (Oral) Step Therapy Policy De-Identified	Policy
Bone Modifiers - Evenity PA Policy De-Identified	Policy
Bone Modifiers - Ibandronate Intravenous (Boniva IV) PA Policy De-Identified	Policy
Bone Modifiers - Prolia PA Policy De-Identified	Policy
Bone Modifiers - Teriparatide DQM Policy - Per Days De-Identified	Policy
Bone Modifiers - Teriparatide Products PA Policy De-Identified	Policy
Bone Modifiers - Tymlos PA Policy De-Identified	Policy
Bone Modifiers - Xgeva DQM Policy - Per Rx De-Identified	Policy
Bone Modifiers - Xgeva PA Policy De-Identified	Policy
Bone Modifiers - Zoledronic Acid (Reclast) PA Policy De-Identified	Policy
Botulinum Toxins - Botox PA Policy De-Identified	Policy
Botulinum Toxins - Dysport PA Policy De-Identified	Policy
Botulinum Toxins - Myobloc PA Policy De-Identified	Policy
Botulinum Toxins - Xeomin PA Policy De-Identified	Policy
Bowel Disease - Lubiprostone DQM Policy - Per Rx De-Identified	Policy
Bowel Disease – Opioid-Induced Constipation Products Preferred Step Therapy Policy De-Identified	Policy

C
Cabergoline DQM Policy - Per Days De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig DQM Policy - Per Days De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality DQM Policy - Per Days De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy De-Identified	Policy
Calcitonin Gene-Related Peptide Inhibitors - Vyepti PA Policy De-Identified	Policy
Calcium Channel Blockers-Dihydropyridine Products Step Therapy Policy De-Identified	Policy
Calcium Channel Blockers-Verapamil Products Step Therapy Policy De-Identified	Policy
Carbinoxamine Step Therapy Policy De-Identified	Policy
Cardiology - Camzyos PA Policy De-Identified	Policy
Cardiology - Corlanor PA Policy De-Identified	Policy
Cardiology - Ranolazine Products Step Therapy Policy De-Identified	Policy
Cardiology - Verquvo DQM Policy - Per Rx De-Identified	Policy
Cardiology - Zontivity PA Policy De-Identified	Policy
Chelating Agents - Chemet PA Policy De-Identified	Policy
Chelating Agents - Iron Chelators (Oral) PA Policy De-Identified	Policy
Chelating Agents - Trientine PA Policy De-Identified	Policy
Chelating Agents – Iron Chelators (Oral) PSM Policy De-Identified	Policy
Chenodal PA Policy De-Identified	Policy
Cholbam PA Policy De-Identified	Policy
Chorionic Gonadotropins DQM Policy - Per Rx De-Identified	Policy
Chorionic Gonadotropins PSM Policy De-Identified	Policy
Cinacalcet PA De-Identified	Policy
Colchicine Products Preferred Step Therapy Policy De-Identified	Policy
Colony Stimulating Factors - Filgrastim Products PA Policy De-Identified	Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for High Performance Formulary, effective 01 De-Identified	Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for National Preferred Formulary and Basic Formulary De-Identified	Policy
Colony Stimulating Factors - Granix PA Policy De-Identified	Policy
Colony Stimulating Factors - Leukine PA Policy De-Identified	Policy
Colony Stimulating Factors - Pegfilgrastim Products and Rolvedon PSM Policy De-Identified	Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy De-Identified	Policy
Colony Stimulating Factors - Pegfilgrastim Products PSM Policy De-Identified	Policy
Colony Stimulating Factors - Rolvedon PA Policy De-Identified	Policy
Complement Inhibitors - Empaveli PA Policy De-Identified	Policy
Complement Inhibitors – Soliris PA Policy De-Identified	Policy
Complement Inhibitors – Ultomiris Intravenous PA Policy De-Identified	Policy
Complement Inhibitors – Ultomiris Subcutaneous PA Policy De-Identified	Policy
Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy De-Identified	Policy
Contraceptives - Phexxi PA Policy De-Identified	Policy
Coronavirus Disease - Evusheld PA Policy De-Identified	Policy
Coronavirus Disease - Veklury PA Policy De-Identified	Policy
Coronavirus – Oral Medications for Treatment of COVID-19 DQM Policy – Per Days De-Identified	Policy
Corticosteroids (Intraarticular) - Zilretta PA Policy De-Identified	Policy
Corticosteroids (Nasal) - Mometasone DQM Policy - Per Rx De-Identified	Policy
Corticosteroids (Nebulized) - Budesonide DQM Policy - Per Rx De-Identified	Policy
Crysvita PA Policy De-Identified	Policy
Cushing's - Isturisa PA Policy De-Identified	Policy
Cushing's - Korlym PA Policy De-Identified	Policy
Cushing's - Recorlev PA Policy De-Identified	Policy
Cushing's - Signifor PA Policy De-Identified	Policy
Cushing's Disease - Isturisa DQM Policy - Per Rx De-Identified	Policy
Cyclooxygenase-2 Inhibitor Step Therapy Policy De-Identified	Policy
Cystic Fibrosis - Bronchitol PA Policy De-Identified	Policy
Cystic Fibrosis - Kalydeco PA Policy De-Identified	Policy
Cystic Fibrosis - Orkambi PA Policy De-Identified	Policy
Cystic Fibrosis - Pulmozyme PA Policy De-Identified	Policy
Cystic Fibrosis - Symdeko PA Policy De-Identified	Policy
Cystic Fibrosis - Trikafta PA Policy De-Identified	Policy

D
Dermatology - Hyftor PA De-Identified	Policy
Dermatology - Opzelura PA Policy De-Identified	Policy
Dermatology - Vtama DQM Policy - Per Days De-Identified	Policy
Dermatology - Zoryve DQM Policy - Per Days De-Identified	Policy
Desmopressin Products - Nocdurna PA Policy De-Identified	Policy
Diabetes - Canagliflozin Products DQM Policy - Per Rx De-Identified	Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy De-Identified	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy De-Identified	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy De-Identified	Policy
Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy De-Identified	Policy
Diabetes - Kerendia PA Policy De-Identified	Policy
Diabetes - Metformin Extended-Release DQM Policy - Per Rx De-Identified	Policy
Diabetes - Metformin Step Therapy Policy De-Identified	Policy
Diabetes - Mounjaro PA Policy De-Identified	Policy
Diabetes - Omnipods DQM Policy - Per Days De-Identified	Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy De-Identified	Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy De-Identified	Policy
Diabetes - Symlin PA Policy De-Identified	Policy
Diabetes - Thiazolidinedione Step Therapy Policy De-Identified	Policy
Diabetes - Tzield PA Policy De-Identified	Policy
Diuretics - Loop Products Step Therapy Policy De-Identified	Policy

E
Enspryng PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Aldurazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Elaprase PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Fabrazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Kanuma PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Lumizyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Mepsevii PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Naglazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Nexviazyme PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Revcovi PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Strensiq PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Sucraid PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Vimizim PA Policy De-Identified	Policy
Enzyme Replacement Therapy - Xenpozyme PA Policy De-Identified	Policy
Epinephrine Auto-Injectors Preferred Step Therapy Policy 2 De-Identified	Policy
Epinephrine Auto-injectors Preferred Step Therapy Policy De-Identified	Policy
Epinephrine Auto-Injectors Step Therapy Policy De-Identified	Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy De-Identified	Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy De-Identified	Policy
Erythropoiesis-Stimulating Agents - Mircera PA Policy De-Identified	Policy
Erythropoiesis-Stimulating Agents PSM Policy De-Identified	Policy
Estrogens (Topical) - Estradiol Gel DQM Policy - Per Rx De-Identified	Policy
Estrogens (Topical) - Patches DQM Policy - Per Days De-Identified	Policy
Ezetimibe Step Therapy Policy De-Identified	Policy

F
Fabry Disease - Galafold PA Policy De-Identified	Policy
Fenofibrate Preferred Step Therapy Policy De-Identified	Policy
Fenofibrate Step Therapy Policy De-Identified	Policy

G
Gabapentin Step Therapy Policy De-Identified	Policy
Gamifant PA Policy De-Identified	Policy
Gastroenterology - Gattex PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy - Cerezyme PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy - Elelyso PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy - Vpriv PA Policy De-Identified	Policy
Gaucher Disease - Enzyme Replacement Therapy PSM Policy De-Identified	Policy
Gaucher Disease - Substrate Reduction Therapy - Cerdelga PA Policy De-Identified	Policy
Gaucher Disease - Substrate Reduction Therapy - Miglustat PA Policy De-Identified	Policy
Gaucher Disease - Substrate Reduction Therapy PSM Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonists - Implants PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Antagonists - Myfembree PA Policy De-Identified	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa DQM Policy - Per Days De-Identified	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy De-Identified	Policy
Gout - Krystexxa PA Policy De-Identified	Policy
Gout Medications Step Therapy Policy De-Identified	Policy
Growth Disorders - Growth Hormone (Daily) PSM Policy De-Identified	Policy
Growth Disorders - Growth Hormone PA Policy De-Identified	Policy
Growth Disorders - Increlex PA Policy De-Identified	Policy
Growth Disorders - Skytrofa PA Policy De-Identified	Policy
Growth Disorders - Voxzogo PA Policy De-Identified	Policy

H
Helicobacter Pylori Infection Combination Products Preferred Step Therapy Policy De-Identified	Policy
Hematology - Cablivi PA Policy De-Identified	Policy
Hematology - Ceprotin PA Policy De-Identified	Policy
Hematology - Coagadex PA Policy De-Identified	Policy
Hematology - Corifact PA Policy De-Identified	Policy
Hematology - Enjaymo PA Policy De-Identified	Policy
Hematology - Fibrinogen Products PA Policy De-Identified	Policy
Hematology - Gene Therapy - Zynteglo PA Policy De-Identified	Policy
Hematology - Pyrukynd DQM Policy - Per Days De-Identified	Policy
Hematology - Pyrukynd PA Policy De-Identified	Policy
Hematology - Reblozyl PA Policy De-Identified	Policy
Hematology - Ryplazim PA Policy De-Identified	Policy
Hematology - Tretten PA Policy De-Identified	Policy
Hematology - Vonvendi PA Policy De-Identified	Policy
Hemophilia - Eptacog Products - NovoSeven RT PA Policy De-Identified	Policy
Hemophilia - Eptacog Products - Sevenfact PA Policy De-Identified	Policy
Hemophilia - Factor IX Products PA Policy De-Identified	Policy
Hemophilia - Factor VIII Products PA Policy De-Identified	Policy
Hemophilia - FEIBA PA Policy De-Identified	Policy
Hemophilia - Hemlibra PA Policy De-Identified	Policy
Hemophilia - Recombinant Factor VIII Products PSM Policy De-Identified	Policy
Hepatitis C - Epclusa DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Epclusa PA Policy De-Identified	Policy
Hepatitis C - Harvoni DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Harvoni PA Policy De-Identified	Policy
Hepatitis C - Mavyret DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Mavyret PA for PSM Policy De-Identified	Policy
Hepatitis C - Mavyret PA Policy De-Identified	Policy
Hepatitis C - Sovaldi DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Sovaldi PA Policy De-Identified	Policy
Hepatitis C - Viekira Pak DQM Policy - Per Days De-Identified	Policy
Hepatitis C - Viekira Pak PA Policy De-Identified	Policy
Hepatitis C - Vosevi PA Policy De-Identified	Policy
Hepatitis C - Zepatier PA Policy De-Identified	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for High Performance Formulary De-Identified	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred FLEX Formulary De-Identified	Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary De-Identified	Policy
Hepatology - Bylvay DQM Policy - Per Rx De-Identified	Policy
Hepatology - Givlaari PA Policy De-Identified	Policy
Hepatology - Livmarli PA Policy De-Identified	Policy
Hepatology - Ocaliva PA Policy De-Identified	Policy
Hepatology – Bylvay PA Policy De-Identified	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy De-Identified	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PSM Policy De-Identified	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy De-Identified	Policy
Hereditary Angioedema - Icatibant PA Policy De-Identified	Policy
Hereditary Angioedema - Icatibant PSM Policy De-Identified	Policy
Hereditary Angioedema - Kalbitor PA Policy De-Identified	Policy
Hereditary Angioedema - Orladeyo PA Policy De-Identified	Policy
Hereditary Angioedema - Takhzyro PA Policy De-Identified	Policy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy De-Identified	Policy
Homozygous Familial Hypercholesterolemia - Juxtapid PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Apretude PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Cabenuva DQM Policy - Per Days De-Identified	Policy
Human Immunodeficiency Virus - Cabenuva PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Complera PSM Policy (Basic Formulary) De-Identified	Policy
Human Immunodeficiency Virus - Prezcobix PSM Policy (Basic Formulary) De-Identified	Policy
Human Immunodeficiency Virus - Rukobia PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Stribild PSM Policy (Basic Formulary) De-Identified	Policy
Human Immunodeficiency Virus - Sunlenca PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Trogarzo PA Policy De-Identified	Policy
Human Immunodeficiency Virus - Truvada PSM Policy De-Identified	Policy
Hyaluronic Acid Derivatives Intraarticular PA Policy De-Identified	Policy
Hyaluronic Acid Derivatives Intraarticular PSM Policy De-Identified	Policy
Hydrocortisone Acetate Suppository Step Therapy Policy De-Identified	Policy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors DQM Policy - Per Rx De-Identified	Policy
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors Step Therapy Policy De-Identified	Policy
Hyperlipidemia - Nexletol PA Policy De-Identified	Policy
Hyperlipidemia - Nexlizet PA Policy De-Identified	Policy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy De-Identified	Policy
Hypertension - Clonidine Patches DQM Policy - Per Days De-Identified	Policy
Hypoactive Sexual Desire Disorder - Addyi PA Policy De-Identified	Policy
Hypoactive Sexual Desire Disorder - Vyleesi PA Policy De-Identified	Policy

I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy De-Identified	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PA Policy De-Identified	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PSM Policy De-Identified	Policy
Immune Globulin - Atgam PA Policy De-Identified	Policy
Immune Globulin - Intravenous PA Policy De-Identified	Policy
Immune Globulin - Subcutaneous PA Policy De-Identified	Policy
Immune Globulin – Cytogam PA Policy De-Identified	Policy
Immunologicals - Adbry DQM Policy - Per Days De-Identified	Policy
Immunologicals - Adbry PA Policy De-Identified	Policy
Immunologicals - Anti-Interleukin-5 Agents PSM Policy De-Identified	Policy
Immunologicals - Dupixent DQM Policy - Per Days De-Identified	Policy
Immunologicals - Dupixent PA Policy De-Identified	Policy
Immunologicals - Fasenra DQM Policy - Per Days De-Identified	Policy
Immunologicals - Nucala DQM Policy - Per Days De-Identified	Policy
Immunologicals - Nucala PA Policy De-Identified	Policy
Immunologicals - Tezspire PA Policy De-Identified	Policy
Immunologicals - Xolair DQM Policy - Per Days De-Identified	Policy
Immunologicals – Cinqair PA Policy De-Identified	Policy
Immunologicals – Fasenra PA Policy De-Identified	Policy
Immunologicals – Xolair PA Policy De-Identified	Policy
Immunosuppressive Agents - Rezurock DQM Policy - Per Rx De-Identified	Policy
Immunosuppressive Agents - Rezurock PA Policy De-Identified	Policy
Infectious Disease - Antiparasitic Agents DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Antiparasitics DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Impavido PA Policy De-Identified	Policy
Infectious Disease - Ivermectin Tablets PA Policy De-Identified	Policy
Infectious Disease - Livtencity DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Livtencity PA Policy De-Identified	Policy
Infectious Disease - Pretomanid PA Policy De-Identified	Policy
Infectious Disease - Prevymis DQM Policy - Per Days De-Identified	Policy
Infectious Disease - Pyrimethamine PA Policy De-Identified	Policy
Infectious Disease - Sirturo PA Policy De-Identified	Policy
Infectious Disease - Vancomycin (Oral) DQM Policy - Per Rx De-Identified	Policy
Inflammatory Conditions - Actemra Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Actemra Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Adalimumab Products DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Adalimumab Products PA Policy De-Identified	Policy
Inflammatory Conditions - Arcalyst DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Arcalyst PA Policy De-Identified	Policy
Inflammatory Conditions - Cibinqo PA Policy De-Identified	Policy
Inflammatory Conditions - Cimzia DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Cimzia PA Policy De-Identified	Policy
Inflammatory Conditions - Cosentyx DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Cosentyx PA Policy De-Identified	Policy
Inflammatory Conditions - Entyvio Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Etanercept Products DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Etanercept Products PA Policy De-Identified	Policy
Inflammatory Conditions - Ilaris PA Policy De-Identified	Policy
Inflammatory Conditions - Ilumya DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Ilumya PA Policy De-Identified	Policy
Inflammatory Conditions - Infliximab Products PA Policy De-Identified	Policy
Inflammatory Conditions - Kevzara PA Policy De-Identified	Policy
Inflammatory Conditions - Kineret DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Kineret PA Policy De-Identified	Policy
Inflammatory Conditions - Olumiant DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Olumiant PA Policy De-Identified	Policy
Inflammatory Conditions - Orencia Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Orencia Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Otezla DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Otezla PA Policy De-Identified	Policy
Inflammatory Conditions - Rinvoq DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Rinvoq PA Policy De-Identified	Policy
Inflammatory Conditions - Siliq DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Siliq PA Policy De-Identified	Policy
Inflammatory Conditions - Simponi Aria PA Policy De-Identified	Policy
Inflammatory Conditions - Simponi Subcutaneous DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Simponi Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Skyrizi Subcutaneous DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Skyrizi Subcutaneous PA Policy De-Identified	Policy
Inflammatory Conditions - Sotyktu PA Policy De-Identified	Policy
Inflammatory Conditions - Spevigo PA Policy De-Identified	Policy
Inflammatory Conditions - Stelara Intravenous PA Policy De-Identified	Policy
Inflammatory Conditions - Stelara Subcutaneous DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy with Dosing De-Identified	Policy
Inflammatory Conditions - Taltz DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Taltz PA Policy De-Identified	Policy
Inflammatory Conditions - Tremfya DQM Policy - Per Days De-Identified	Policy
Inflammatory Conditions - Tremfya PA Policy De-Identified	Policy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy De-Identified	Policy
Inflammatory Conditions PSM Policy De-Identified	Policy
Interferon - Actimmune PA Policy De-Identified	Policy
Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy De-Identified	Policy
Iron Replacement – Feraheme PA Policy De-Identified	Policy
Iron Replacement – Ferrlecit PA Policy De-Identified	Policy
Iron Replacement – INFeD PA Policy De-Identified	Policy
Iron Replacement – Injectafer PA Policy De-Identified	Policy
Iron Replacement – Monoferric PA Policy De-Identified	Policy
Iron Replacement – Venofer PA Policy De-Identified	Policy
Isotretinoin Step Therapy Policy De-Identified	Policy

K
Keveyis PA Policy De-Identified	Policy

L
Lipodystrophy - Egrifta PA Policy De-Identified	Policy
Lipodystrophy - Myalept PA Policy De-Identified	Policy
Lucemyra PA Policy De-Identified	Policy
Lupus - Benlysta Intravenous PA Policy De-Identified	Policy
Lupus - Benlysta Subcutaneous DQM Policy - Per Days De-Identified	Policy
Lupus - Benlysta Subcutaneous PA Policy De-Identified	Policy
Lupus - Lupkynis PA Policy De-Identified	Policy
Lupus - Saphnelo PA Policy De-Identified	Policy

M
Makena (Hydroxyprogesterone caproate) PA Policy De-Identified	Policy
Metabolic Disorders - Betaine Anhydrous PA Policy De-Identified	Policy
Metabolic Disorders - Carbaglu PA Policy De-Identified	Policy
Metabolic Disorders - Dojolvi PA Policy De-Identified	Policy
Metabolic Disorders - Imcivree DQM Policy - Per Days De-Identified	Policy
Metabolic Disorders - Imcivree PA Policy De-Identified	Policy
Metabolic Disorders - Nitisinone Products PA Policy De-Identified	Policy
Metabolic Disorders - Nulibry PA Policy De-Identified	Policy
Metabolic Disorders - Oxlumo PA Policy De-Identified	Policy
Metabolic Disorders - Tiopronin Products PA Policy De-Identified	Policy
Metabolic Disorders - Xuriden PA Policy De-Identified	Policy
Metabolic Disorders -Betaine Anhydrous PSM Policy De-Identified	Policy
Metabolic Disorders – Cysteamine Ophthalmic Solution PA Policy De-Identified	Policy
Metabolic Disorders – Phenylbutyrate Products PA Policy De-Identified	Policy
Methotrexate Injection Step Therapy Policy De-Identified	Policy
Migraine - Elyxyb PA Policy De-Identified	Policy
Migraine - Nurtec ODT PA Policy De-Identified	Policy
Migraine - Other Acute Medications DQM Policy - Per Rx De-Identified	Policy
Migraine - Qulipta PA Policy De-Identified	Policy
Migraine - Reyvow PA Policy De-Identified	Policy
Migraine - Ubrelvy PA Policy De-Identified	Policy
Migraine Medication Step Therapy Policy De-Identified	Policy
Migraine – Non-Steroidal Anti-Inflammatory Drugs DQM Policy – Per Days De-Identified	Policy
Migraine – Other Acute Medications DQM Policy – Per Days De-Identified	Policy
Migraine – Triptans DQM Policy – Per Days De-Identified	Policy
Migraine – Triptans DQM Policy – Per Rx De-Identified	Policy
Multiple Sclerosis - Aubagio PA Policy De-Identified	Policy
Multiple Sclerosis - Avonex PA Policy De-Identified	Policy
Multiple Sclerosis - Bafiertam PA Policy De-Identified	Policy
Multiple Sclerosis - Betaseron, Extavia PA Policy De-Identified	Policy
Multiple Sclerosis - Briumvi PA Policy De-Identified	Policy
Multiple Sclerosis - CD20-Directed Cytolytic Antibody Infused Products PSM Policy De-Identified	Policy
Multiple Sclerosis - Dalfampridine PA Policy De-Identified	Policy
Multiple Sclerosis - Dalfampridine PSM Policy De-Identified	Policy
Multiple Sclerosis - Dimethyl Fumarate PA Policy De-Identified	Policy
Multiple Sclerosis - Fingolimod PA Policy De-Identified	Policy
Multiple Sclerosis - Glatiramer Products PA Policy De-Identified	Policy
Multiple Sclerosis - Kesimpta DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Kesimpta PA Policy De-Identified	Policy
Multiple Sclerosis - Lemtrada DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Lemtrada PA Policy De-Identified	Policy
Multiple Sclerosis - Mavenclad PA Policy De-Identified	Policy
Multiple Sclerosis - Mayzent DQM Policy - Per Rx De-Identified	Policy
Multiple Sclerosis - Mayzent PA Policy De-Identified	Policy
Multiple Sclerosis - Ocrevus DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Ocrevus PA Policy De-Identified	Policy
Multiple Sclerosis - Plegridy PA Policy De-Identified	Policy
Multiple Sclerosis - Ponvory DQM Policy - Per Days De-Identified	Policy
Multiple Sclerosis - Ponvory PA Policy De-Identified	Policy
Multiple Sclerosis - Rebif PA Policy De-Identified	Policy
Multiple Sclerosis - Tascenso ODT PA Policy De-Identified	Policy
Multiple Sclerosis - Vumerity PA Policy De-Identified	Policy
Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy De-Identified	Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PA Policy De-Identified	Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM Policy De-Identified	Policy
Multiple Sclerosis PSM Policy De-Identified	Policy
Muscular Dystrophy - Amondys 45 PA Policy De-Identified	Policy
Muscular Dystrophy - Emflaza PA Policy 2 De-Identified	Policy
Muscular Dystrophy - Emflaza PA Policy De-Identified	Policy
Muscular Dystrophy - Exondys 51 PA Policy De-Identified	Policy
Muscular Dystrophy - Viltepso PA Policy De-Identified	Policy
Muscular Dystrophy - Vyondys 53 PA Policy De-Identified	Policy

N
Naloxone Injection Step Therapy Policy De-Identified	Policy
Nasal Steroids Step Therapy Policy De-Identified	Policy
Natpara PA Policy De-Identified	Policy
Nephrology - Tarpeyo PA Policy De-Identified	Policy
Neurology - Aduhelm PA Policy De-Identified	Policy
Neurology - Brineura PA Policy De-Identified	Policy
Neurology - Gene Therapy - Skysona PA Policy De-Identified	Policy
Neurology - Leqembi PA Policy De-Identified	Policy
Neurology - Oxybate Products PA Policy De-Identified	Policy
Neurology - Radicava Products PA Policy De-Identified	Policy
Neurology - Relyvrio PA Policy De-Identified	Policy
Neurology - Riluzole Products PA Policy De-Identified	Policy
Neurology - Vyvgart PA Policy De-Identified	Policy
Nonsteroidal Anti-Inflammatory Drug - Tivorbex DQM Policy - Per Rx De-Identified	Policy
Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy De-Identified	Policy
Northera PA Policy De-Identified	Policy
Nuedexta PA Policy De-Identified	Policy

O
Oncology (Injectable - CAR-T) - Abecma PA Policy De-Identified	Policy
Oncology (Injectable - CAR-T) - Breyanzi PA Policy De-Identified	Policy
Oncology (Injectable - CAR-T) - Carvykti PA Policy De-Identified	Policy
Oncology (Injectable - CAR-T) - Kymriah PA Policy De-Identified	Policy
Oncology (Injectable - CAR-T) - Tecartus PA Policy De-Identified	Policy
Oncology (Injectable - CAR-T) - Yescarta PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death Receptor-1) - Jemperli PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death Receptor-1) - Libtayo PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death Receptor-1) - Opdualag PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death-Ligand 1) - Bavencio PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death-Ligand 1) - Imfinzi PA Policy De-Identified	Policy
Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq PA Policy De-Identified	Policy
Oncology (Injectable) - Adcetris PA Policy De-Identified	Policy
Oncology (Injectable) - Aliqopa PA Policy De-Identified	Policy
Oncology (Injectable) - Arsenic Trioxide PA Policy De-Identified	Policy
Oncology (Injectable) - Arzerra PA Policy De-Identified	Policy
Oncology (Injectable) - Asparlas PA Policy De-Identified	Policy
Oncology (Injectable) - Azedra PA Policy De-Identified	Policy
Oncology (Injectable) - Beleodaq PA Policy De-Identified	Policy
Oncology (Injectable) - Bendamustine Products PA Policy De-Identified	Policy
Oncology (Injectable) - Besponsa PA Policy De-Identified	Policy
Oncology (Injectable) - Besremi PA Policy De-Identified	Policy
Oncology (Injectable) - Bevacizumab Products PA Policy De-Identified	Policy
Oncology (Injectable) - Bevacizumab Products PSM Policy De-Identified	Policy
Oncology (Injectable) - Blenrep PA Policy De-Identified	Policy
Oncology (Injectable) - Blincyto PA Policy De-Identified	Policy
Oncology (Injectable) - Bortezomib PA Policy De-Identified	Policy
Oncology (Injectable) - Carmustine Products PA Policy De-Identified	Policy
Oncology (Injectable) - Cosela PA Policy De-Identified	Policy
Oncology (Injectable) - Cyramza PA Policy De-Identified	Policy
Oncology (Injectable) - Danyelza PA Policy De-Identified	Policy
Oncology (Injectable) - Darzalex Faspro PA Policy De-Identified	Policy
Oncology (Injectable) - Darzalex Intravenous PA Policy De-Identified	Policy
Oncology (Injectable) - Decitabine Products PA Policy De-Identified	Policy
Oncology (Injectable) - Elahere PA Policy De-Identified	Policy
Oncology (Injectable) - Elzonris PA Policy De-Identified	Policy
Oncology (Injectable) - Empliciti PA Policy De-Identified	Policy
Oncology (Injectable) - Enhertu PA Policy De-Identified	Policy
Oncology (Injectable) - Erbitux PA Policy De-Identified	Policy
Oncology (Injectable) - Erwinaze PA Policy De-Identified	Policy
Oncology (Injectable) - Fyarro PA Policy De-Identified	Policy
Oncology (Injectable) - Gazyva PA Policy De-Identified	Policy
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy De-Identified	Policy
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy De-Identified	Policy
Oncology (Injectable) - Halaven PA Policy De-Identified	Policy
Oncology (Injectable) - Herceptin Hylecta PA Policy De-Identified	Policy
Oncology (Injectable) - Imjudo PA Policy De-Identified	Policy
Oncology (Injectable) - Imlygic PA Policy De-Identified	Policy
Oncology (Injectable) - Ixempra PA Policy De-Identified	Policy
Oncology (Injectable) - Jevtana PA Policy De-Identified	Policy
Oncology (Injectable) - Kadcyla PA Policy De-Identified	Policy
Oncology (Injectable) - Kimmtrak PA Policy De-Identified	Policy
Oncology (Injectable) - Kyprolis PA Policy De-Identified	Policy
Oncology (Injectable) - Levoleucovorin Products PA Policy De-Identified	Policy
Oncology (Injectable) - Lumoxiti PA Policy De-Identified	Policy
Oncology (Injectable) - Lunsumio PA Policy De-Identified	Policy
Oncology (Injectable) - Margenza PA Policy De-Identified	Policy
Oncology (Injectable) - Monjuvi PA Policy De-Identified	Policy
Oncology (Injectable) - Mylotarg PA Policy De-Identified	Policy
Oncology (Injectable) - Oncaspar PA Policy De-Identified	Policy
Oncology (Injectable) - Onivyde PA Policy De-Identified	Policy
Oncology (Injectable) - Padcev PA Policy De-Identified	Policy
Oncology (Injectable) - Perjeta PA Policy De-Identified	Policy
Oncology (Injectable) - Phesgo PA Policy De-Identified	Policy
Oncology (Injectable) - Polivy PA Policy De-Identified	Policy
Oncology (Injectable) - Portrazza PA Policy De-Identified	Policy
Oncology (Injectable) - Poteligeo PA Policy De-Identified	Policy
Oncology (Injectable) - Pralatrexate Products PA Policy De-Identified	Policy
Oncology (Injectable) - Proleukin PA Policy De-Identified	Policy
Oncology (Injectable) - Rituxan Hycela PA Policy De-Identified	Policy
Oncology (Injectable) - Romidepsin Products PA Policy De-Identified	Policy
Oncology (Injectable) - Rybrevant PA Policy De-Identified	Policy
Oncology (Injectable) - Rylaze PA Policy De-Identified	Policy
Oncology (Injectable) - Sarclisa PA Policy De-Identified	Policy
Oncology (Injectable) - Sylvant PA Policy De-Identified	Policy
Oncology (Injectable) - Synribo PA Policy De-Identified	Policy
Oncology (Injectable) - Tecvayli PA Policy De-Identified	Policy
Oncology (Injectable) - Thiotepa Products PA Policy De-Identified	Policy
Oncology (Injectable) - Tivdak PA Policy De-Identified	Policy
Oncology (Injectable) - Topotecan Products PA Policy De-Identified	Policy
Oncology (Injectable) - Torisel PA Policy De-Identified	Policy
Oncology (Injectable) - Trastuzumab Products PA Policy De-Identified	Policy
Oncology (Injectable) - Trastuzumab Products PSM Policy De-Identified	Policy
Oncology (Injectable) - Trodelvy PA Policy De-Identified	Policy
Oncology (Injectable) - Unituxin PA Policy De-Identified	Policy
Oncology (Injectable) - Vectibix PA Policy De-Identified	Policy
Oncology (Injectable) - Vyxeos PA Policy De-Identified	Policy
Oncology (Injectable) - Yervoy PA Policy De-Identified	Policy
Oncology (Injectable) - Zaltrap PA Policy De-Identified	Policy
Oncology (Injectable) - Zepzelca PA Policy De-Identified	Policy
Oncology (Injectable) - Zynlonta PA Policy De-Identified	Policy
Oncology (Other) - Jelmyto PA Policy De-Identified	Policy
Oncology (Other) - Valrubicin Products PA Policy De-Identified	Policy
Oncology - Abiraterone Acetate DQM Policy - Per Rx De-Identified	Policy
Oncology - Abiraterone Acetate PA Policy De-Identified	Policy
Oncology - Abiraterone Acetate PSM Policy De-Identified	Policy
Oncology - Alecensa PA Policy De-Identified	Policy
Oncology - Alunbrig DQM Policy - Per Rx De-Identified	Policy
Oncology - Alunbrig PA Policy De-Identified	Policy
Oncology - Ayvakit PA Policy De-Identified	Policy
Oncology - Balversa PA Policy De-Identified	Policy
Oncology - Bexarotene (Oral) PA Policy De-Identified	Policy
Oncology - Bexarotene (Oral) PSM Policy De-Identified	Policy
Oncology - Bexarotene (Topical) PA Policy De-Identified	Policy
Oncology - Bexarotene (Topical) PSM Policy De-Identified	Policy
Oncology - Bosulif DQM Policy - Per Rx De-Identified	Policy
Oncology - Bosulif PA Policy De-Identified	Policy
Oncology - Braftovi PA Policy De-Identified	Policy
Oncology - Brukinsa PA Policy De-Identified	Policy
Oncology - Cabometyx DQM Policy - Per Rx De-Identified	Policy
Oncology - Cabometyx PA Policy De-Identified	Policy
Oncology - Calquence DQM Policy - Per Rx De-Identified	Policy
Oncology - Calquence PA Policy De-Identified	Policy
Oncology - Capecitabine PA Policy De-Identified	Policy
Oncology - Capecitabine PSM Policy De-Identified	Policy
Oncology - Caprelsa PA Policy De-Identified	Policy
Oncology - Cometriq DQM Policy - Per Rx De-Identified	Policy
Oncology - Cometriq PA Policy De-Identified	Policy
Oncology - Copiktra PA Policy De-Identified	Policy
Oncology - Cotellic PA Policy De-Identified	Policy
Oncology - Cyclin Dependent Kinases 4,6 Inhibitors PSM Policy De-Identified	Policy
Oncology - Daurismo PA Policy De-Identified	Policy
Oncology - Erivedge PA Policy De-Identified	Policy
Oncology - Erleada PA Policy De-Identified	Policy
Oncology - Erlotinib DQM Policy - Per Rx De-Identified	Policy
Oncology - Erlotinib PA Policy De-Identified	Policy
Oncology - Everolimus DQM Policy - Per Rx De-Identified	Policy
Oncology - Everolimus Products PA Policy De-Identified	Policy
Oncology - Everolimus Products PSM Policy De-Identified	Policy
Oncology - Exkivity PA Policy De-Identified	Policy
Oncology - Farydak PA Policy De-Identified	Policy
Oncology - Fotivda PA Policy De-Identified	Policy
Oncology - Gavreto DQM Policy - Per Rx De-Identified	Policy
Oncology - Gavreto PA Policy De-Identified	Policy
Oncology - Gilotrif PA Policy De-Identified	Policy
Oncology - Ibrance PA Policy De-Identified	Policy
Oncology - Iclusig PA Policy De-Identified	Policy
Oncology - Idhifa PA Policy De-Identified	Policy
Oncology - Imatinib DQM Policy - Per Rx De-Identified	Policy
Oncology - Imatinib PA Policy De-Identified	Policy
Oncology - Imatinib PSM Policy De-Identified	Policy
Oncology - Imbruvica PA Policy De-Identified	Policy
Oncology - Imbruvica PSM Policy De-Identified	Policy
Oncology - Inlyta PA Policy De-Identified	Policy
Oncology - Inqovi PA Policy De-Identified	Policy
Oncology - Inrebic PA Policy De-Identified	Policy
Oncology - Iressa DQM Policy - Per Rx De-Identified	Policy
Oncology - Iressa PA Policy De-Identified	Policy
Oncology - Jakafi PA Policy De-Identified	Policy
Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy De-Identified	Policy
Oncology - Koselugo PA De-Identified	Policy
Oncology - Krazati PA Policy De-Identified	Policy
Oncology - Lapatinib DQM Policy - Per Rx De-Identified	Policy
Oncology - Lapatinib PA Policy De-Identified	Policy
Oncology - Lenalidomide PA Policy De-Identified	Policy
Oncology - Lenvima PA Policy De-Identified	Policy
Oncology - Lonsurf PA Policy De-Identified	Policy
Oncology - Lorbrena PA Policy De-Identified	Policy
Oncology - Lumakras PA Policy De-Identified	Policy
Oncology - Lynparza PA Policy De-Identified	Policy
Oncology - Lytgobi PA Policy De-Identified	Policy
Oncology - Mekinist PA Policy De-Identified	Policy
Oncology - Mektovi PA Policy De-Identified	Policy
Oncology - Nerlynx PA Policy De-Identified	Policy
Oncology - Nilutamide PA Policy De-Identified	Policy
Oncology - Ninlaro PA Policy De-Identified	Policy
Oncology - Nubeqa PA Policy De-Identified	Policy
Oncology - Odomzo PA Policy De-Identified	Policy
Oncology - Onureg PA Policy De-Identified	Policy
Oncology - Orgovyx DQM Policy - Per Rx De-Identified	Policy
Oncology - Orgovyx PA Policy De-Identified	Policy
Oncology - Pemazyre PA Policy De-Identified	Policy
Oncology - Piqray PA Policy De-Identified	Policy
Oncology - Pomalyst PA Policy De-Identified	Policy
Oncology - Qinlock DQM Policy - Per Rx De-Identified	Policy
Oncology - Qinlock PA Policy De-Identified	Policy
Oncology - Retevmo PA Policy De-Identified	Policy
Oncology - Rezlidhia PA Policy De-Identified	Policy
Oncology - Rozlytrek DQM Policy - Per Rx De-Identified	Policy
Oncology - Rozlytrek PA Policy De-Identified	Policy
Oncology - Rubraca PA Policy De-Identified	Policy
Oncology - Rydapt PA Policy De-Identified	Policy
Oncology - Scemblix PA Policy De-Identified	Policy
Oncology - Sorafenib PA Policy De-Identified	Policy
Oncology - Sorafenib PSM Policy De-Identified	Policy
Oncology - Sprycel DQM Policy - Per Rx De-Identified	Policy
Oncology - Sprycel PA Policy De-Identified	Policy
Oncology - Stivarga PA Policy De-Identified	Policy
Oncology - Sunitinib PA Policy De-Identified	Policy
Oncology - Sunitinib PSM Policy De-Identified	Policy
Oncology - Sutent DQM Policy - Per Rx De-Identified	Policy
Oncology - Tabrecta PA Policy De-Identified	Policy
Oncology - Tafinlar PA Policy De-Identified	Policy
Oncology - Tagrisso PA Policy De-Identified	Policy
Oncology - Talzenna PA Policy De-Identified	Policy
Oncology - Tasigna DQM Policy - Per Rx De-Identified	Policy
Oncology - Tasigna PA Policy De-Identified	Policy
Oncology - Tazverik PA Policy De-Identified	Policy
Oncology - Temozolomide Capsules PA Policy De-Identified	Policy
Oncology - Tepmetko PA Policy De-Identified	Policy
Oncology - Thalomid PA Policy De-Identified	Policy
Oncology - Tibsovo PA Policy De-Identified	Policy
Oncology - Truseltiq PA Policy De-Identified	Policy
Oncology - Tukysa PA Policy De-Identified	Policy
Oncology - Turalio PA Policy De-Identified	Policy
Oncology - Valchlor PA Policy De-Identified	Policy
Oncology - Venclexta DQM policy - Per Rx De-Identified	Policy
Oncology - Venclexta PA Policy De-Identified	Policy
Oncology - Verzenio PA Policy De-Identified	Policy
Oncology - Vistogard DQM Policy - Per Rx De-Identified	Policy
Oncology - Vistogard PA Policy De-Identified	Policy
Oncology - Vitrakvi DQM Policy - Per Rx De-Identified	Policy
Oncology - Vitrakvi PA Policy De-Identified	Policy
Oncology - Vizimpro PA Policy De-Identified	Policy
Oncology - Vonjo PA Policy De-Identified	Policy
Oncology - Votrient PA Policy De-Identified	Policy
Oncology - Welireg PA Policy De-Identified	Policy
Oncology - Xalkori DQM Policy - Per Rx De-Identified	Policy
Oncology - Xalkori PA Policy De-Identified	Policy
Oncology - Xermelo DQM Policy - Per Rx De-Identified	Policy
Oncology - Xermelo PA Policy De-Identified	Policy
Oncology - Xospata PA Policy De-Identified	Policy
Oncology - Xpovio PA Policy De-Identified	Policy
Oncology - Xtandi DQM Policy - Per Rx De-Identified	Policy
Oncology - Xtandi PA Policy De-Identified	Policy
Oncology - Yonsa PA Policy De-Identified	Policy
Oncology - Zejula PA Policy De-Identified	Policy
Oncology - Zelboraf PA Policy De-Identified	Policy
Oncology - Zolinza PA Policy De-Identified	Policy
Oncology - Zydelig PA Policy De-Identified	Policy
Oncology - Zykadia PA Policy De-Identified	Policy
Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Beta-adrenergic Blockers Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Combination Products Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy De-Identified	Policy
Ophthalmic - Glaucoma - Prostaglandins PA Policy De-Identified	Policy
Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy De-Identified	Policy
Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy De-Identified	Policy
Ophthalmic Corticosteroids Step Therapy Policy De-Identified	Policy
Ophthalmic Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Cyclosporine Products PA Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Eysuvis PA Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Lacrisert DQM Policy - Per Rx De-Identified	Policy
Ophthalmology - Dry Eye Disease - Lacrisert PA Policy De-Identified	Policy
Ophthalmology - Dry Eye Disease - Xiidra PA Policy De-Identified	Policy
Ophthalmology - Durysta PA Policy De-Identified	Policy
Ophthalmology - Luxturna PA Policy De-Identified	Policy
Ophthalmology - Tepezza PA Policy De-Identified	Policy
Ophthalmology - Upneeq PA Policy De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu PA De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Eylea PA De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PA De-Identified	Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA De-Identified	Policy
Ophthalmology - Verkazia PA Policy De-Identified	Policy
Ophthalmology – Oxervate PA Policy De-Identified	Policy
Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Vabysmo PA Policy De-Identified	Policy
Opioids - Butorphanol DQM Policy - Per Days De-Identified	Policy
Opioids - Fentanyl Transdermal Products DQM Policy - Per Days De-Identified	Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy De-Identified	Policy
Opioids - Fentanyl Transmucosal Products DQM Policy - Per Days De-Identified	Policy
Opioids - Long-Acting Products (Oral) DQM - Per Days De-Identified	Policy
Opioids - Long-Acting Products PA Policy De-Identified	Policy
Opioids - Morphine Milligram Equivalent (200) DQM Policy De-Identified	Policy
Opioids - Morphine Milligram Equivalent (90) DQM Policy De-Identified	Policy
Opioids - Nucynta DQM Policy - Per Rx De-Identified	Policy
Opioids - Short-Acting Products DQM Policy (Adults) - Per Rx De-Identified	Policy
Opioids - Short-Acting Products DQM Policy (All Ages) - Per Rx De-Identified	Policy
Opioids - Short-Acting Products DQM Policy (Pediatrics) - Per Rx De-Identified	Policy
Opioids - Tramadol Extended-Release Products DQM Policy - Per Rx De-Identified	Policy
Overactive Bladder Medications Preferred Step Therapy Policy De-Identified	Policy
Overactive Bladder Medications Step Therapy Policy De-Identified	Policy

P
Parkinson's Disease - Kynmobi PA Policy De-Identified	Policy
Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy Policy De-Identified	Policy
Parkinson's Disease - Ongentys PA Policy De-Identified	Policy
Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy Policy De-Identified	Policy
Parkinson’s Disease - Apokyn PA Policy De-Identified	Policy
Parkinson’s Disease - Carbidopa PA Policy De-Identified	Policy
Parkinson’s Disease - Duopa PA Policy De-Identified	Policy
Parkinson’s Disease - Inbrija PA Policy De-Identified	Policy
Parkinson’s Disease - Nourianz PA Policy De-Identified	Policy
Parkinson’s Disease - Nuplazid PA Policy De-Identified	Policy
Parkinson’s Disease - Tolcapone PA Policy De-Identified	Policy
Phenylketonuria - Palynziq DQM Policy - Per Rx De-Identified	Policy
Phenylketonuria - Palynziq PA Policy De-Identified	Policy
Phenylketonuria - Sapropterin PA Policy De-Identified	Policy
Phosphate Binders DQM Policy - Per Rx De-Identified	Policy
Potassium Binders - Lokelma DQM Policy - Per Rx De-Identified	Policy
Potassium Binders - Veltassa DQM Policy - Per Rx De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha DQM Policy - Per Days De-Identified	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Related Products - Leqvio PA Policy De-Identified	Policy
Proton Pump Inhibitors DQM Policy - Per Rx De-Identified	Policy
Proton Pump Inhibitors Step Therapy Policy De-Identified	Policy
Psychiatry - Novel Psychotropics DQM Policy - Per Rx De-Identified	Policy
Psychiatry - Spravato PA Policy De-Identified	Policy
Psychiatry - Zulresso PA Policy De-Identified	Policy
Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy De-Identified	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers DQM Policy - Per Rx De-Identified	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy De-Identified	Policy
Pulmonary - Roflumilast PA with Step Therapy Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Adempas DQM Policy - Per Rx De-Identified	Policy
Pulmonary Arterial Hypertension - Adempas PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PSM Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Orenitram DQM Policy - Per Rx De-Identified	Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Treprostinil Injection PSM Policy De-Identified	Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PA Policy De-Identified	Policy
Pulmonary Arterial Hypertension and Related Lung Disease - Inhaled Prostacyclin Products PSM Policy De-Identified	Policy

Q
Qbrexza PA Policy De-Identified	Policy

R
Repository Corticotropin - Acthar Gel PA Policy De-Identified	Policy
Repository Corticotropin - Cortrophin Gel PA Policy De-Identified	Policy
Rituximab Intravenous Products PA Policy De-Identified	Policy
Rituximab Intravenous Products PSM Policy De-Identified	Policy

S
Scenesse PA Policy De-Identified	Policy
Sedative Hypnotics DQM Policy - Per Days De-Identified	Policy
Sedative Hypnotics Step Therapy Policy De-Identified	Policy
Sickle Cell Disease - Adakveo PA Policy De-Identified	Policy
Sickle Cell Disease - Endari PA Policy De-Identified	Policy
Sickle Cell Disease - Hydroxyurea Products Preferred Step Therapy Policy De-Identified	Policy
Sickle Cell Disease - Oxbryta DQM Policy - Per Rx De-Identified	Policy
Sickle Cell Disease - Oxbryta PA Policy De-Identified	Policy
Somatostatin Analogs - Mycapssa PA Policy De-Identified	Policy
Somatostatin Analogs for Acromegaly PSM Policy De-Identified	Policy
Somatostatin Analogs – Octreotide Immediate-Release Products PA Policy De-Identified	Policy
Somatostatin Analogs – Octreotide Immediate-Release Products PSM Policy De-Identified	Policy
Somatostatin Analogs – Sandostatin LAR Depot PA Policy De-Identified	Policy
Somatostatin Analogs – Signifor LAR PA Policy De-Identified	Policy
Somavert PA Policy De-Identified	Policy
Spinal Muscular Atrophy - Evrysdi PA Policy De-Identified	Policy
Spinal Muscular Atrophy - Spinraza DQM Policy - Per Days De-Identified	Policy
Spinal Muscular Atrophy - Spinraza PA Policy De-Identified	Policy
Spinal Muscular Atrophy - Zolgensma PA Policy De-Identified	Policy
Synagis PA Policy De-Identified	Policy

T
Tasimelteon Products PA Policy De-Identified	Policy
Testosterone (injectable) Products PA Policy De-Identified	Policy
Testosterone (Oral, Topical, and Nasal) Products PA Policy De-Identified	Policy
Testosterone Products (Topical) DQM Policy - Per Rx De-Identified	Policy
Testosterone Undecanoate (Oral) DQM Policy - Per Rx De-Identified	Policy
Tetracyclines (Oral) Step Therapy Policy De-Identified	Policy
Thrombocytopenia - Doptelet DQM Policy - Per Rx De-Identified	Policy
Thrombocytopenia - Doptelet PA Policy De-Identified	Policy
Thrombocytopenia - Mulpleta PA Policy De-Identified	Policy
Thrombocytopenia - Nplate PA Policy De-Identified	Policy
Thrombocytopenia - Promacta PA Policy De-Identified	Policy
Thrombocytopenia - Tavalisse PA Policy De-Identified	Policy
Tolvaptan Products - Jynarque PA Policy De-Identified	Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy De-Identified	Policy
Tolvaptan Products DQM Policy - Per Rx De-Identified	Policy
Topical Acne - Cleansers Step Therapy Policy De-Identified	Policy
Topical Acne - Kits Step Therapy Policy De-Identified	Policy
Topical Acne - Topical Products Step Therapy Policy De-Identified	Policy
Topical Acne - Winlevi PA Policy De-Identified	Policy
Topical Acyclovir Products PA Policy De-Identified	Policy
Topical Agents for Atopic Dermatitis DQM Policy - Per Days De-Identified	Policy
Topical Agents for Atopic Dermatitis Step Therapy Policy De-Identified	Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Brimonidine PA with Step Therapy Policy De-Identified	Policy
Topical Alpha-Adrenergic Agonists for Rosacea - Rhofade PA Policy De-Identified	Policy
Topical Anesthetics DQM Policy - Per Days De-Identified	Policy
Topical Antibacterials Step Therapy Policy De-Identified	Policy
Topical Antibiotics for Acne - Clindamycin DQM Policy - Per Days De-Identified	Policy
Topical Antifungals DQM Policy - Per Days De-Identified	Policy
Topical Antifungals for Onychomycosis Step Therapy Policy De-Identified	Policy
Topical Antipruritics - Doxepin Products DQM Policy - Per Days De-Identified	Policy
Topical Calcipotriene Products DQM Policy - Per Days De-Identified	Policy
Topical Collagenase - Santyl DQM Policy - Per Rx De-Identified	Policy
Topical Corticosteroids - Clobetasol DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Diflorasone DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Fluocinonide DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Flurandrenolide DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Hydrocortisone Butyrate DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids - Triamcinolone Spray DQM Policy - Per Days De-Identified	Policy
Topical Corticosteroids Step Therapy Policy De-Identified	Policy
Topical Diclofenac Sodium 3 percent Gel PA Policy De-Identified	Policy
Topical Doxepin Step Therapy Policy De-Identified	Policy
Topical Medications for Inflammatory Rosacea Step Therapy De-Identified	Policy
Topical Podofilox Products Step Therapy Policy De-Identified	Policy
Topical Products - Vtama and Zoryve Step Therapy Policy De-Identified	Policy
Topical Retinoids - Aklief PA Policy De-Identified	Policy
Topical Retinoids - Panretin PA Policy De-Identified	Policy
Topical Retinoids - Tazarotene Products PA Policy De-Identified	Policy
Topical Retinoids - Tretinoin Products PA Policy De-Identified	Policy
Topical Vitamin D Analogs Step Therapy Policy De-Identified	Policy

U
Uplizna PA Policy De-Identified	Policy

V
Vasculitis - Tavneos PA Policy De-Identified	Policy
Vecamyl PA Policy De-Identified	Policy
Veregen PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors DQM Policy - Per Rx De-Identified	Policy
Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy De-Identified	Policy
Vijoice PA Policy De-Identified	Policy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy De-Identified	Policy
Vitamin D Analog (Oral) Step Therapy Policy De-Identified	Policy

W
Wakefulness-Promoting Agents - Sunosi DQM Policy - Per Rx De-Identified	Policy
Wakefulness-Promoting Agents – Wakix DQM Policy – Per Rx De-Identified	Policy

X
Xiaflex PA Policy De-Identified	Policy

Z
Zavesca Market Events Clinical Policy De-Identified	Policy
Zokinvy PA Policy De-Identified	Policy