Express Scripts
CHNW Cascade Select

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 B C D E F G H I J K L M N O P Q R S T U V W X Y Z
A
Acterma DQM - per Days
Acthar Gel PA Policy
Afinitor_DQM - Oncology per Rx
Aimovig_DQM - Per Days_30 days
Ajovy_DQM - Per Days_30 days
Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy
Allergen Immunotherapy - Grastek and Oralair PA Policy
Allergen Immunotherapy - Odactra PA Policy
Allergen Immunotherapy - Palforzia PA Policy
Allergen Immunotherapy - Ragwitek PA Policy
Alpha Blockers for BPH Step Therapy Policy
Alpha1-Proteinase Inhibitor Products PSM policy
Alunbrig_DQM - Oncology Per Rx
Alzheimer's Disease Step Therapy Policy
Alzheimers - Namenda, Namenda XR Step Therapy Policy
Amifampridine Products PA Policy
Amifampridine PSM Policy
Amitiza_DQM - Per Rx
Amyloidosis - Onpattro PA Policy
Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy
Amyloidosis - Tegsedi PA Policy
Angiotensin Receptor Blocker Preferred Step Therapy Policy
Angiotensin Receptor Blocker Step Therapy Policy
Antibiotics (Inhaled) - Arikayce PA Policy
Antibiotics (Inhaled) - Cayston PA Policy
Antibiotics (Inhaled) - TOBI Podhaler PA Policy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA Policy
Antibiotics (Inhaled) - Tobramycin Products PSM Policy
Antibiotics (Injectable) PA Policy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy
Antibiotics - Synercid PA Policy
Antibiotics - Vancomycin Capsules PA Policy
Antibiotics - Xifaxan PA Policy
Anticoagulants - Eliquis PA Policy
Anticoagulants - Pradaxa PA Policy with Preferred Step Therapy
Anticoagulants - Savaysa PA Policy with Preferred Step Therapy
Anticoagulants - Xarelto PA Policy
Antidepressants - Bupropion Long-Acting Step Therapy Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors Step Therapy Policy
Antidepressants - Serotonin Norepinephrine Reuptake Inhibitors Step Therapy Policy
Antiepileptics - Banzel PA Policy
Antiepileptics - Clobazam Products PA Policy
Antiepileptics - Depakote, Depakene Step Therapy Policy
Antiepileptics - Diacomit PA Policy
Antiepileptics - Epidiolex PA Policy
Antiepileptics - Fintepla PA Policy
Antiepileptics - Lamictal XR Step Therapy Policy
Antiepileptics - Levetiracetam, Brivaracetam Step Therapy Policy
Antiepileptics - Nayzilam PA Policy
Antiepileptics - Oxtellar XR, Trileptal Step Therapy Policy
Antiepileptics - Topiramate Step Therapy Policy
Antiepileptics - Valtoco PA Policy
Antiepileptics - Vigabatrin (Sabril) PA Policy
Antifungals (Azoles) - Intravenous PA Policy
Antifungals (Topical) for Onychomycosis Step Therapy Policy
Antifungals - Cresemba (Oral) PA Policy
Antifungals - Noxafil (Oral) PA Policy
Antifungals - Tolsura PA with Step Therapy Policy
Antifungals - Voriconazole (Oral) PA Policy
Antiparasitics - Impavido PA Policy
Apokyn, Kynmobi_DQM - Per Days
Ativan (lorazepam) DQM - Per Days
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy
Attention Deficit Hyperactivity Disorder Stimulant Step Therapy Policy
Attention Deficit Hyperactivity Disorder Stimulants PA Policy
Atypical Antipsychotics_DQM - Per Rx
Avodart Step Therapy Policy
B
Beta Blocker Step Therapy Policy
Bevyxxa_DQM - Per Days_30 days
Bile Acid Sequestrants Step Therapy Policy
Bisphosphonates (oral) Enhanced Step Therapy Policy
Bisphosphonates (Oral) Step Therapy Policy
Bone Modifiers - Evenity PA Policy
Bone Modifiers - Ibandronate Intravenous (Boniva IV) PA Policy
Bone Modifiers - Prolia PA Policy
Bone Modifiers - Teriparatide Products PA Policy
Bone Modifiers - Tymlos PA Policy
Bone Modifiers - Xgeva PA Policy
Bone Modifiers - Zoledronic Acid (Reclast) PA Policy
Bone Modifiers - Zoledronic Acid (Zometa) PA Policy
Bosulif_DQM - Oncology per Rx
Botulinum Toxins - Botox PA Policy
Botulinum Toxins - Dysport PA Policy
Botulinum Toxins - Myobloc PA Policy
Botulinum Toxins - Xeomin PA Policy
Bowel Disease - Opioid-Induced Constipation Preferred Step Therapy Policy
C
Cabenuva_DQM - per Days
Cabometyx_DQM - Oncology per Rx
Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy
Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy
Calcitonin Gene-Related Peptide Inhibitors - Vyepti PA Policy
Calcium Channel Blockers-Dihydropyridine Products Step Therapy Policy
Calcium Channel Blockers-Verapamil Products Step Therapy Policy
Calquence_DQM - Oncology per Rx
Cardiology - Corlanor PA Policy
Cardiology - Zontivity PA Policy
Cardura, XL (doxazosin)_DQM - Per Rx
Catapres (clonidine) Patches_DQM - Per Days
Catapres (clonidine) Patches_DQM - Per Days_28 days
Chelating Agents - Chemet PA Policy
Chelating Agents - Iron Chelators (Oral) PA Policy
Chelating Agents - Penicillamine Products PA Policy
Chelating Agents - Syprine PA Policy
Chenodal PA Policy
Cholbam PA Policy
Chorionic Gonadotropins PSM Policy
Cimzia_DQM - per Days
Cinacalcet (Sensipar) PA Policy
Clindamycin Topical Products_DQM - per Days_30 days
Clobetasol Topical Products_DQM - per Days_28 days
Colchicine Products Preferred Step Therapy Policy
Colchicine Products Preferred Step Therapy Policy
Colony Stimulating Factors - Filgrastim Products PA Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy
Colony Stimulating Factors - Granix PA Policy
Colony Stimulating Factors - Leukine PA Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy
Colony Stimulating Factors - Pegfilgrastim Products PSM Policy
Complement Inhibitors - Empaveli PA Policy
Complement Inhibitors - Soliris PA Policy
Complement Inhibitors - Ultomiris PA Policy
Compounded Select Topical Medications PA Policy
Contraceptives - Oral and Patch Products Step Therapy Policy
Contraceptives - Phexxi PA Policy
Coronavirus Disease - Veklury PA Policy
Coronavirus Infection Drugs - Azithromycin - Per Days
Coronavirus Infection Drugs - Kaletra, Plaquenil, Chloroquine - Per Days
Coronavirus Infection Drugs - Short Acting Beta-Agonists - Per Days
Coronavirus Tests (antibody) - Per Days
Coronavirus Tests (diagnostic) - Per Days
Cosentyx_DQM - per Days
Crysvita PA Policy
Cushing's - Isturisa PA Policy
Cushing's - Korlym PA Policy
Cushing's - Signifor PA Policy
Cyclooxygenase-2 Inhibitor Step Therapy Policy
Cystic Fibrosis - Bronchitol PA Policy
Cystic Fibrosis - Kalydeco PA Policy
Cystic Fibrosis - Orkambi PA Policy
Cystic Fibrosis - Pulmozyme PA Policy
Cystic Fibrosis - Symdeko PA Policy
Cystic Fibrosis - Trikafta PA Policy
D
Depression - bupropion (Wellbutrin-Forfivo-Aplenzin)_DQM - Per Rx
Depression - SNRI_DQM - Per Rx
Depression - SSRI_DQM - Per Rx
Desmopressin Products - Nocdurna PA Policy
Desmopressin Products - Noctiva PA Policy
Diabetes - Continuous Glucose Monitors PA Policy
Diabetes - Diabetic Test Strips Preferred Step Therapy Policy
Diabetes - Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Step Therapy Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy
Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy
Diabetes - Glucagon-Like Peptide-1 Agonists Preferred Step Therapy
Diabetes - Insulin (Other) Preferred Step Therapy Policy
Diabetes - Insulin (Rapid-Acting) Preferred Step Therapy Policy
Diabetes - Kerendia PA Policy
Diabetes - Metformin Step Therapy Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy
Diabetes - Symlin PA Policy
Diabetes - Thiazolidinedione Step Therapy Policy
Diclofenac sodium gel (Solaraze) PA Policy
Diclofenac Topical_DQM - per Days
Diflorasone Topical Products_DQM - per Days_30 days
Diflucan 150 mg (fluconazole)_DQM - Per Rx
Divigel_DQM - Per Rx
Doptelet_DQM - Per Rx
Dostinex (cabergoline)_DQM - Per Days_28 days
Dronabinol PA Policy
Dupixent_DQM - Per Days_28 days
E
Emgality_DQM - Per Days_30 days
Enbrel_DQM - per Days_28 days
Enspryng PA Policy
Enzyme Replacement Therapy - Adagen PA Policy
Enzyme Replacement Therapy - Aldurazyme PA Policy
Enzyme Replacement Therapy - Elaprase PA Policy
Enzyme Replacement Therapy - Elaprase PA Policy
Enzyme Replacement Therapy - Fabrazyme PA Policy
Enzyme Replacement Therapy - Kanuma PA Policy
Enzyme Replacement Therapy - Lumizyme PA Policy
Enzyme Replacement Therapy - Mepsevii PA Policy
Enzyme Replacement Therapy - Naglazyme PA Policy
Enzyme Replacement Therapy - Revcovi PA Policy
Enzyme Replacement Therapy - Strensiq PA Policy
Enzyme Replacement Therapy - Sucraid PA Policy
Enzyme Replacement Therapy - Vimizim PA Policy
Epclusa_DQM - Per Days_28 days
Epinephrine Auto-injectors Preferred Step Therapy Policy
Epinephrine Auto-Injectors Step Therapy Policy
Erythroid Stimulating Agents - Aranesp PA Policy
Erythroid Stimulating Agents - Epoetin Alfa Products PA Policy
Erythroid Stimulating Agents - Mircera PA Policy
Erythroid Stimulating Agents PSM Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy
Erythropoiesis-Stimulating Agents - Mircera PA Policy
Estrogen - Transdermal (Non-Patch) Preferred Step Therapy Policy
Estrogen - Transdermal Step Therapy Policy
Estrogen - Vaginal Products and Estrogen Modifiers Preferred Step Therapy Policy
Estrogen Patches_DQM - Per Days_28 days
Estrogen-Progestin Combinations (patches) Preferred Step Therapy
F
Fabry Disease - Galafold PA Policy
Famvir (famciclovir)_DQM - Per Rx
Fenofibrate Preferred Step Therapy Policy
Fenofibrate Step Therapy Policy
Fentanyl Transdermal Patch_DQM - Per Days_30 days
Fentanyl Transmucosal Drugs_DQM - Per Days
Fluocinonide Topical Products_DQM - per Days_30 days
Flurandrenolide Topical Products_DQM - per Days_30 days
G
Gabapentin Step Therapy Policy
Gamifant PA Policy
Gastroenterology - Gattex PA Policy
Gaucher Disease - Enzyme Replacement Therapy PSM Policy
Gaucher Disease - Substrate Reduction Therapy PSM Policy
Gaucher Disease Substrate Reduction Therapy - Cerdelga PA Policy
Gaucher Disease Substrate Reduction Therapy - Miglustat (Zavesca) PA Policy
Gleevec (imatinib)_DQM - Oncology per Rx
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty (Fensolvi, Lupron Depot-Ped, and Triptodur) PA Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty (Lupron Depot-Ped and Triptodur) PA Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy
Gonadotropin-Releasing Hormone Agonists - Implants PA Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products PA Policy
Gonadotropin-Releasing Hormone Antagonists - Myfembree PA Policy
Gonadotropin-Releasing Hormone Antagonists - Oriahnn PA Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy
Gout - Krystexxa PA Policy
Gout Medications Step Therapy Policy
Growth Disorders - Growth Hormone PA policy
Growth Disorders - Increlex PA Policy
Growth Hormone PSM Policy
H
HCG_DQM - Per Rx
Helicobacter Pylori Infection Combination Products Preferred Step Therapy Policy
Hematology - Cablivi PA Policy
Hematology - Ceprotin PA Policy
Hematology - Coagadex PA
Hematology - Corifact PA
Hematology - Fibrinogen Products PA Policy
Hematology - Reblozyl PA Policy
Hematology - Tretten PA
Hematology - Vonvendi PA
Hemophilia - Eptacog Products - NovoSeven RT PA Policy
Hemophilia - Eptacog Products - Sevenfact PA Policy
Hemophilia - Eptacog Products PA Policy
Hemophilia - FEIBA PA Policy
Hemophilia - Hemlibra PA Policy
Hemophilia - Recombinant Factor VIII Products PSM Policy
Hepatitis C - Epclusa PA Policy
Hepatitis C - Harvoni PA Policy
Hepatitis C - Mavyret PA for PSM
Hepatitis C - Ribavirin PA Policy
Hepatitis C - Sovaldi PA Policy
Hepatitis C - Viekira Pak PA Policy
Hepatitis C Virus Direct Acting Antivirals PSM Policy for National Preferred Formulary
Hepatology - Bylvay PA Policy
Hepatology - Givlaari PA
Hepatology - Ocaliva PA Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PSM Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy
Hereditary Angioedema - Icatibant (Firazyr) PA Policy
Hereditary Angioedema - Icatibant (Firazyr) PSM Policy
Hereditary Angioedema - Kalbitor PA Policy
Hereditary Angioedema - Orladeyo PA Policy
Hereditary Angioedema - Takhzyro PA Policy
Hetlioz PA Policy
HMGs_DQM - Per Rx
Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy
Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy
Human Immunodeficiency Virus - Atripla PSM Policy (Basic Formulary)
Human Immunodeficiency Virus - Cabenuva PA Policy
Human Immunodeficiency Virus - Complera PSM Policy (Basic Formulary)
Human Immunodeficiency Virus - Prezcobix PSM Policy (Basic Formulary)
Human Immunodeficiency Virus - Rukobia PA Policy
Human Immunodeficiency Virus - Stribild PSM Policy (Basic Formulary)
Human Immunodeficiency Virus - Trogarzo PA Policy
Human Immunodeficiency Virus - Truvada PSM Policy
Human Immunodeficiency Virus - Vocabria PA Policy
Humira_DQM - Per Days_28 days
Hyaluronic Acid Derivatives Intraarticular PA Policy
Hyaluronic Acid Derivatives Intraarticular PSM Policy
Hyaluronic Acid Derivatives PSM Policy
Hydrocortisone Acetate Suppository Step Therapy Policy
Hydroxy-methylglutaryl-coenzyme A Reductase Inhibitors (HMG) Step Therapy Policy
Hyperlipidemia - Nexletol PA Policy
Hyperlipidemia - Nexlizet PA Policy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy
Hypoactive Sexual Desire Disorder - Addyi PA Policy
Hypoactive Sexual Desire Disorder - Vyleesi PA Policy
Hytrin (terazosin)_DQM - Per Rx
I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy
Ilumya_DQM - Per Days
Imcivree_DQM - Per Days
Immune Globulin - Atgam PA Policy
Immune Globulin - Cytogam PA Policy
Immune Globulin - Intravenous PA Policy
Immune Globulin - Subcutaneous PA Policy
Immunologicals - Anti-Interleukin-5 Agents PSM Policy
Immunologicals - Dupixent PA Policy
Immunologicals - Nucala PA Policy
Immunologicals - Xolair PA Policy
Infectious Disease - Daraprim PA Policy
Infectious Disease - Pretomanid PA Policy
Infectious Disease - Pyrimethamine (Daraprim) PA Policy
Infectious Disease - Sirturo PA Policy
Infertility - Follitropins, Clomiphene PSM policy
Infertility - Gonadotropin Releasing Hormone Antagonists PSM Policy
Inflammatory Bowel Preferred Step Therapy
Inflammatory Conditions - Actemra IV PA Policy
Inflammatory Conditions - Actemra SC PA Policy
Inflammatory Conditions - Adalimumab Products PA Policy
Inflammatory Conditions - Arcalyst PA Policy
Inflammatory Conditions - Benlysta Intravenous PA Policy
Inflammatory Conditions - Benlysta Subcutaneous PA Policy
Inflammatory Conditions - Cosentyx PA Policy
Inflammatory Conditions - Entyvio Intravenous PA Policy
Inflammatory Conditions - Etanercept Products PA Policy
Inflammatory Conditions - Ilaris PA Policy
Inflammatory Conditions - Ilumya PA Policy
Inflammatory Conditions - Infliximab Products PA Policy
Inflammatory Conditions - Kevzara PA Policy
Inflammatory Conditions - Kineret PA Policy
Inflammatory Conditions - Olumiant PA Policy
Inflammatory Conditions - Orencia IV PA Policy
Inflammatory Conditions - Orencia SC PA Policy
Inflammatory Conditions - Otezla PA Policy
Inflammatory Conditions - Rinvoq PA Policy
Inflammatory Conditions - Siliq PA Policy
Inflammatory Conditions - Simponi Aria PA Policy
Inflammatory Conditions - Simponi SC PA Policy
Inflammatory Conditions - Skyrizi PA Policy
Inflammatory Conditions - Stelara IV PA Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy
Inflammatory Conditions - Taltz PA Policy
Inflammatory Conditions - Tremfya PA Policy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy
Inflammatory Conditions PSM Policy
Influenza Drugs_Select per Days_365 days
Interferon - Actimmune PA Policy
Interleukin-1 (IL-1) Blockers for Cryopyrin-Associated Periodic Syndromes (CAPS) PSM Policy
Iressa_DQM - Oncology per Rx
Iron Replacement - Feraheme PA Policy
Iron Replacement - Ferrlecit PA Policy
Iron Replacement - INFeD PA Policy
Iron Replacement - Injectafer PA Policy
Iron Replacement - Monoferric PA Policy
Iron Replacement - Venofer PA Policy
Isotretinoin Step Therapy Policy
Isturisa_DQM - Per Rx
Itraconazole _DQM - Per Rx
J
Jatenzo_DQM - Per Rx
K
Kesimpta_DQM - per Days
Keveyis PA Policy
Kineret_DQM - per Days
Klonopin (clonazepam) DQM - Per Days
L
Lacrisert_DQM - Per Rx
Lemtrada_DQM per Days
Lidocaine Patch PA Policy
Lipodystrophy - Egrifta PA Policy
Lipodystrophy - Myalept PA Policy
Locoid (hydrocortisone butyrate) Topical Products_DQM - per Days_30 days
Lokelma_DQM - Per Rx
Lucemyra PA Policy
Lupus - Lupkynis PA Policy
M
Makena (Hydroxyprogesterone caproate) PA Policy
Mavyret_DQM - Per Days_28 days
Mayzent_DQM per Rx
Metabolic Disorders - Carbaglu PA Policy
Metabolic Disorders - Cystaran PA Policy
Metabolic Disorders - Cysteamine (Oral) Products (Cystagon, Procysbi) PA Policy
Metabolic Disorders - Cysteamine Ophthalmic Solution PA Policy
Metabolic Disorders - Dojolvi PA Policy
Metabolic Disorders - Imcivree PA Policy
Metabolic Disorders - Nitisinone Products PA Policy
Metabolic Disorders - Nulibry PA Policy
Metabolic Disorders - Oxlumo PA Policy
Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy
Metabolic Disorders - Tiopronin Products PA Policy
Metabolic Disorders - Xuriden PA Policy
Metformin ER_DQM - Per Rx
Methotrexate Injection Step Therapy Policy
Methylergonovine (Methergine) PA Policy
Migraine - Nurtec ODT PA Policy
Migraine - Reyvow PA Policy
Migraine - Ubrelvy PA Policy
Migraine Drugs_DQM - Per Days
Migraine Drugs_DQM - Per Rx
Migraine Medication Step Therapy Policy
MME 90 DQM_30 days
MME greater than 200 Based QL_30 days
Multiple Sclerosis - Ampyra PSM Policy
Multiple Sclerosis - Aubagio PA Policy
Multiple Sclerosis - Avonex PA Policy
Multiple Sclerosis - Bafiertam PA Policy
Multiple Sclerosis - Betaseron, Extavia PA Policy
Multiple Sclerosis - Dimethyl Fumarate (Tecfidera) PA Policy
Multiple Sclerosis - Gilenya PA Policy
Multiple Sclerosis - Glatiramer Products PA Policy
Multiple Sclerosis - Kesimpta PA Policy
Multiple Sclerosis - Lemtrada PA Policy
Multiple Sclerosis - Mavenclad PA Policy
Multiple Sclerosis - Ocrevus PA Policy
Multiple Sclerosis - Plegridy PA Policy
Multiple Sclerosis - Ponvory PA Policy
Multiple Sclerosis - Rebif PA Policy
Multiple Sclerosis - Tecfidera PA Policy
Multiple Sclerosis - Vumerity PA Policy
Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PA Policy
Multiple Sclerosis PSM Policy
Muscular Dystrophy - Amondys 45 PA Policy
Muscular Dystrophy - Emflaza PA Policy
Muscular Dystrophy - Exondys 51 PA Policy
Muscular Dystrophy - Viltepso PA Policy
Muscular Dystrophy - Vyondys 53 PA Policy
N
Naloxone Injection Step Therapy Policy
Nasal Steroids Step Therapy Policy
Nasonex (mometasone furoate)_DQM - Per Rx
Natpara PA Policy
Nausea Vomiting Agents for Pregnancy_DQM - Per Days
Nausea-Vomiting - Cesamet _DQM - Per Rx
Nausea-Vomiting Agents - Serotonin Antagonists_DQM - Per Rx
Nausea-Vomiting Agents_Akynzeo, Emend, Varubi_DQM - Per Rx
Neurology - Aduhelm PA Policy
Neurology - Brineura PA Policy
Neurology - Lyrica CR PA Policy
Neurology - Radicava PA Policy
Neurology - Riluzole Products PA Policy
Neurontin (gabapentin), Gralise, Horizant DQM - Per Days
Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy
Northera PA Policy
Nucala_DQM - Per Days_28 days
Nucynta_DQM - Per Rx
Nuedexta PA Policy
O
Oncology (Injectable - CAR-T) - Abecma PA Policy
Oncology (Injectable - CAR-T) - Breyanzi PA Policy
Oncology (Injectable - CAR-T) - Kymriah PA Policy
Oncology (Injectable - CAR-T) - Tecartus PA Policy
Oncology (Injectable - CAR-T) - Yescarta PA Policy
Oncology (Injectable - Programmed Death Receptor-1) - Jemperli PA Policy
Oncology (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy
Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy
Oncology (Injectable) - Adcetris PA Policy
Oncology (Injectable) - Aliqopa PA Policy
Oncology (Injectable) - Arsenic Trioxide PA Policy
Oncology (Injectable) - Arzerra PA Policy
Oncology (Injectable) - Asparlas PA Policy
Oncology (Injectable) - Azedra PA Policy
Oncology (Injectable) - Bavencio PA Policy
Oncology (Injectable) - Beleodaq PA Policy
Oncology (Injectable) - Bendamustine Products PA Policy
Oncology (Injectable) - Besponsa PA Policy
Oncology (Injectable) - Bevacizumab Products PSM Policy
Oncology (Injectable) - Blenrep PA Policy
Oncology (Injectable) - Blincyto PA Policy
Oncology (Injectable) - Bortezomib (Velcade) PA Policy
Oncology (Injectable) - Carmustine PA Policy
Oncology (Injectable) - Cosela PA Policy
Oncology (Injectable) - Cyramza PA Policy
Oncology (Injectable) - Danyelza PA Policy
Oncology (Injectable) - Darzalex Faspro PA Policy
Oncology (Injectable) - Decitabine Products PA Policy
Oncology (Injectable) - Elzonris PA Policy
Oncology (Injectable) - Erbitux PA Policy
Oncology (Injectable) - Folotyn PA Policy
Oncology (Injectable) - Fulvestrant (Faslodex) PA Policy
Oncology (Injectable) - Gazyva PA Policy
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy
Oncology (Injectable) - Imfinzi PA Policy
Oncology (Injectable) - Imlygic PA Policy
Oncology (Injectable) - Ixempra PA Policy
Oncology (Injectable) - Jevtana PA Policy
Oncology (Injectable) - Kadcyla PA Policy
Oncology (Injectable) - Kyprolis PA Policy
Oncology (Injectable) - Levoleucovorin Products PA Policy
Oncology (Injectable) - Libtayo PA Policy
Oncology (Injectable) - Lumoxiti PA Policy
Oncology (Injectable) - Margenza PA Policy
Oncology (Injectable) - Monjuvi PA Policy
Oncology (Injectable) - Mylotarg PA Policy
Oncology (Injectable) - Oncaspar PA Policy
Oncology (Injectable) - Onivyde PA Policy
Oncology (Injectable) - Padcev PA Policy
Oncology (Injectable) - Pepaxto PA Policy
Oncology (Injectable) - Perjeta PA Policy
Oncology (Injectable) - Phesgo PA Policy
Oncology (Injectable) - Polivy PA Policy
Oncology (Injectable) - Portrazza PA Policy
Oncology (Injectable) - Poteligeo PA Policy
Oncology (Injectable) - Proleukin PA Policy
Oncology (Injectable) - Rituxan Hycela PA Policy
Oncology (Injectable) - Romidepsin Products (Istodax) PA Policy
Oncology (Injectable) - Rybrevant PA Policy
Oncology (Injectable) - Rylaze PA Policy
Oncology (Injectable) - Sarclisa PA Policy
Oncology (Injectable) - Sylatron PA Policy
Oncology (Injectable) - Sylvant PA Policy
Oncology (Injectable) - Synribo PA Policy
Oncology (Injectable) - Tecentriq PA Policy
Oncology (Injectable) - Thiotepa Products PA Policy
Oncology (Injectable) - Topotecan Products PA Policy
Oncology (Injectable) - Torisel PA Policy
Oncology (Injectable) - Trastuzumab Products PA Policy
Oncology (Injectable) - Trastuzumab Products PSM Policy
Oncology (Injectable) - Trastuzumab Products PSM Policy
Oncology (Injectable) - Trodelvy PA Policy
Oncology (Injectable) - Unituxin PA Policy
Oncology (Injectable) - Vectibix PA Policy
Oncology (Injectable) - Vyxeos PA Policy
Oncology (Injectable) - Yervoy PA Policy
Oncology (Injectable) - Zaltrap PA Policy
Oncology (Injectable) - Zepzelca PA Policy
Oncology (Injectable) - Zynlonta PA Policy
Oncology (Other) - Jelmyto PA Policy
Oncology - Abiraterone Acetate (Zytiga) PA Policy
Oncology - Abiraterone Acetate (Zytiga) PSM Policy
Oncology - Adcetris PA Policy
Oncology - Afinitor PA Policy
Oncology - Afinitor PSM Policy
Oncology - Alecensa PA Policy
Oncology - Aliqopa PA Policy
Oncology - Alunbrig PA Policy
Oncology - Arsenic Trioxide PA Policy
Oncology - Arzerra PA Policy
Oncology - Ayvakit PA Policy
Oncology - Azedra PA Policy
Oncology - Balversa PA Policy
Oncology - Bavencio PA Policy
Oncology - Beleodaq PA Policy
Oncology - Bendamustine Products PA Policy
Oncology - Besponsa PA Policy
Oncology - Bevacizumab Products PA Policy
Oncology - Blincyto PA Policy
Oncology - Bosulif PA Policy
Oncology - Braftovi PA Policy
Oncology - Brukinsa PA Policy
Oncology - Cabometyx PA Policy
Oncology - Calquence PA Policy
Oncology - Capecitabine (Xeloda) PA Policy
Oncology - Caprelsa PA Policy
Oncology - Cometriq PA Policy
Oncology - Copiktra PA Policy
Oncology - Cotellic PA Policy
Oncology - Cyclin Dependent Kinases 4,6 Inhibitors for Breast Cancer PSM Policy
Oncology - Cyramza PA Policy
Oncology - Darzalex PA Policy
Oncology - Daurismo PA Policy
Oncology - Decitabine Products PA Policy
Oncology - Empliciti PA Policy
Oncology - Enhertu PA Policy
Oncology - Erbitux PA Policy
Oncology - Erivedge PA Policy
Oncology - Erivedge PA Policy
Oncology - Erleada PA Policy
Oncology - Erlotinib (Tarceva) PA Policy
Oncology - Erwinaze PA Policy
Oncology - Farydak PA Policy
Oncology - Faslodex PA Policy
Oncology - Fotivda PA Policy
Oncology - Gavreto PA Policy
Oncology - Gazyva PA Policy
Oncology - Gilotrif PA Policy
Oncology - Gonadotropin-Releasing Hormone Analogs Injectable Products (Eligard, Firmagon, Trelstar) PA Policy
Oncology - Halaven PA Policy
Oncology - Herceptin Hylecta PA Policy
Oncology - Ibrance PA Policy
Oncology - Iclusig PA Policy
Oncology - Idhifa PA Policy
Oncology - Imatinib (Gleevec) PA Policy
Oncology - Imbruvica PA Policy
Oncology - Imbruvica PSM Policy
Oncology - Imfinzi PA Policy
Oncology - Inlyta PA Policy
Oncology - Inqovi PA Policy
Oncology - Inrebic PA Policy
Oncology - Iressa PA Policy
Oncology - Jakafi PA Policy
Oncology - Kadcyla PA Policy
Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy
Oncology - Koselugo PA
Oncology - Lapatinib (Tykerb) PA Policy
Oncology - Lartruvo PA Policy
Oncology - Lenvima PA Policy
Oncology - Libtayo PA Policy
Oncology - Lonsurf PA Policy
Oncology - Lumakras PA Policy
Oncology - Lumoxiti PA Policy
Oncology - Lynparza PA Policy
Oncology - Mekinist PA Policy
Oncology - Mektovi PA Policy
Oncology - Mylotarg PA Policy
Oncology - Nerlynx PA Policy
Oncology - Nexavar PA Policy
Oncology - Nilutamide PA Policy
Oncology - Ninlaro PA Policy
Oncology - Nubeqa PA Policy
Oncology - Odomzo PA Policy
Oncology - Onureg PA Policy
Oncology - Orgovyx PA Policy
Oncology - Pemazyre PA Policy
Oncology - Perjeta PA Policy
Oncology - Piqray PA Policy
Oncology - Pomalyst PA Policy
Oncology - Poteligeo PA Policy
Oncology - Prostate Cancer Injectable Gonadotropin-Releasing Hormone Analogs PSM policy
Oncology - Qinlock PA Policy
Oncology - Retevmo PA Policy
Oncology - Revlimid PA Policy
Oncology - Rituxan Hycela PA Policy
Oncology - Rozlytrek PA Policy
Oncology - Rubraca PA Policy
Oncology - Rydapt PA Policy
Oncology - Sprycel PA Policy
Oncology - Stivarga PA Policy
Oncology - Sutent PA Policy
Oncology - Synribo PA Policy
Oncology - Tabrecta PA Policy
Oncology - Tabrecta PA Policy
Oncology - Tafinlar PA Policy
Oncology - Tagrisso PA Policy
Oncology - Talzenna PA Policy
Oncology - Tarceva PA Policy
Oncology - Targretin (oral) PA Policy
Oncology - Targretin (topical) PA Policy
Oncology - Tasigna PA Policy
Oncology - Tazverik PA Policy
Oncology - Temozolomide Capsules PA Policy
Oncology - Tepmetko PA Policy
Oncology - Thalomid PA Policy
Oncology - Thiotepa Products PA Policy
Oncology - Tibsovo PA Policy
Oncology - Torisel PA Policy
Oncology - Trastuzumab Products PA Policy
Oncology - Trodelvy PA Policy
Oncology - Truseltiq PA Policy
Oncology - Tukysa PA Policy
Oncology - Turalio PA Policy
Oncology - Ukoniq PA Policy
Oncology - Valchlor PA Policy
Oncology - Valrubicin Products PA Policy
Oncology - Vectibix PA Policy
Oncology - Venclexta PA Policy
Oncology - Verzenio PA Policy
Oncology - Vistogard PA Policy
Oncology - Vitrakvi PA Policy
Oncology - Vizimpro PA Policy
Oncology - Votrient PA Policy
Oncology - Vyxeos PA Policy
Oncology - Xalkori PA Policy
Oncology - Xermelo PA Policy
Oncology - Xospata PA
Oncology - Xpovio PA Policy
Oncology - Xtandi PA Policy
Oncology - Yervoy PA Policy
Oncology - Yonsa PA Policy
Oncology - Zaltrap PA Policy
Oncology - Zejula PA Policy
Oncology - Zelboraf PA Policy
Oncology - Zolinza PA Policy
Oncology - Zydelig PA Policy
Oncology - Zykadia PA Policy
Ophthalmic - Glaucoma - Alpha-adrenergic Agonists Preferred Step Therapy Policy
Ophthalmic - Glaucoma - Beta-adrenergic Blockers Preferred Step Therapy Policy
Ophthalmic - Glaucoma - Beta-adrenergic Blockers Step Therapy Policy
Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Preferred Step Therapy Policy
Ophthalmic - Glaucoma - Combination Products Preferred Step Therapy Policy
Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy
Ophthalmic - Glaucoma - Prostaglandins PA Policy
Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy
Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy
Ophthalmic Corticosteroids Preferred Step Therapy Policy
Ophthalmic Corticosteroids Preferred Step Therapy Policy - Effective 7.1.2021
Ophthalmic for Dry Eye Disease - Cyclosporine Products PA Policy
Ophthalmic for Dry Eye Disease - Eysuvis PA Policy
Ophthalmic for Dry Eye Disease - Lacrisert PA Policy
Ophthalmic for Dry Eye Disease - Xiidra PA Policy
Ophthalmic NSAIDs Preferred Step Therapy Policy
Ophthalmic Prostaglandin Step Therapy Policy
Ophthalmic Prostaglandins PA Policy
Ophthalmic Quinolone Antibiotics Preferred Step Therapy Policy
Ophthalmology - Durysta PA Policy
Ophthalmology - Luxturna PA Policy
Ophthalmology - Oxervate PA Policy
Ophthalmology - Tepezza PA Policy
Ophthalmology - Upneeq PA Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu PA
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Eylea PA
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Lucentis PA
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Macugen PA
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors PSM Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy
Opioids - Long-Acting Products PA Policy
Opioids - Tramadol Extended-Release PA Policy
Opioids Short-Acting DQM per RX - Adult
Opioids Short-Acting DQM per RX - All ages
Opioids Short-Acting DQM per RX - Pediatric
Oral Long-Acting Opioids_DQM - Per Days_30 days
Orencia_DQM - per Days
Orgovyx_DQM - Oncology per Rx
Orilissa_DQM - Per Days
Otic Quinolone - Ciprofloxacin Preferred Step Therapy Policy
Overactive Bladder Agents Preferred Step Therapy Policy
Oxbryta_DQM - Per Rx
P
Palforzia_DQM - Per Rx
Palynziq_DQM - Per Rx
Pancreatic Enzymes (Enteric-Coated) Preferred Step Therapy Policy
Parasitic Infection Drugs - Per Days_30 days
Parkinson's Disease - Amantadine Extended-Release Drugs PA with Step Therapy Policy
Parkinson's Disease - Apokyn PA Policy
Parkinson's Disease - Duopa PA Policy
Parkinson's Disease - Inbrija PA Policy
Parkinson's Disease - Kynmobi PA Policy
Parkinson's Disease - Lodosyn PA Policy
Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy Policy
Parkinson's Disease - Nourianz PA Policy
Parkinson's Disease - Nuplazid PA Policy
Parkinson's Disease - Ongentys PA Policy
Parkinson's Disease - Tolcapone Products PA Policy
Parkinson's Disease - Zelapar PA Policy
Pegylated Interferons PA Policy
Phenylketonuria - Palynziq PA Policy
Phenylketonuria - Sapropterin (Kuvan) PA Policy
Pheochromocytoma - Demser and Phenoxybenzamine PA
Pheochromocytoma - Metyrosine Capsules and Phenoxybenzamine Capsules PA Policy
Phosphate Binders - Calcium acetate, Fosrenol, Renagel, Renvela_DQM - Per Days
Potassium Binders Preferred Step Therapy Policy
Prevymis_DQM - Per Days
Progesterone (Vaginal-Infertility) Preferred Step Therapy Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy
Proton Pump Inhibitors Step Therapy Policy
Psychiatry - Spravato PA Policy
Psychiatry - Zulresso PA Policy
Pulmicort (budesonide)_DQM - Per Rx
Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy
Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy - Effective 07.01.2021
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy
Pulmonary - Daliresp PA Policy
Pulmonary - Long-Acting Beta2-Agonist Inhalers Preferred Step Therapy Policy
Pulmonary - Long-Acting Muscarinic Antagonist Inhalers Preferred Step Therapy Policy
Pulmonary - Long-Acting Muscarinic Antagonist Long-Acting Beta2-Agonist Combination Inhalers Preferred Step Therapy Policy
Pulmonary - Short-Acing Beta2-Agonist Inhalers Preferred Step Therapy Policy
Pulmonary - Short-Acing Beta2-Agonist Inhalers Preferred Step Therapy Policy
Pulmonary Arterial Hypertension - Adempas PA Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist PSM Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy
Pulmonary Arterial Hypertension - Epoprostenol PA Policy
Pulmonary Arterial Hypertension - Epoprostenol Products PA Policy
Pulmonary Arterial Hypertension - Inhaled Prostacyclin Products PA Policy
Pulmonary Arterial Hypertension - Inhaled Prostacyclin Products PSM Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy
Pulmonary Arterial Hypertension - Treprostinil Injection (Remodulin) PSM Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy
Q
Qbrexza PA with Step Therapy Policy
Qsymia_DQM - Per Rx
R
Relenza_Standard per Rx
Repatha_DQM - Per Days_28 days
Revatio (sildenafil)_DQM - Per Rx
Rituximab Intravenous Products PSM Policy
Rozlytrek_DQM - Oncology per Rx
S
Samsca-Jynarque_DQM - Per Rx
Scenesse PA Policy
Sedative Hypnotics Step Therapy Policy
Sensipar PA Policy
Sickle Cell Disease - Adakveo PA Policy
Sickle Cell Disease - Endari PA Policy
Sickle Cell Disease - Hydroxyurea Products Preferred Step Therapy Policy
Sickle Cell Disease - Oxbryta PA Policy
Skyrizi_DQM - per Days
Solaraze PA Policy
Soliris PA Policy
Soma (carisoprodol), Soma Compound (carisoprodol-ASA) DQM - Per Days
Somatostatin Analogs - Mycapssa PA Policy
Somatostatin Analogs - Octreotide Immediate-Release Products Prior Authorization Policy
Somatostatin Analogs - Sandostatin LAR Depot PA Policy
Somatostatin Analogs - Sandostatin LAR Depot PA Policy
Somatostatin Analogs - Signifor LAR PA Policy
Somatostatin Analogs - Somatuline Depot PA Policy
Somatostatin Analogs for Acromegaly Utilization Management Policy
Somavert PA Policy
Spinal Muscular Atrophy - Evrysdi PA Policy
Spinal Muscular Atrophy - Spinraza PA Policy
Spinal Muscular Atrophy - Zolgensma PA Policy
Spinraza_DQM - per Days
Sprycel_DQM - Oncology Per Rx
Stadol (butorphanol)_Select per Days_28 days
Stelara_DQM - per Days
Suboxone Zubsolv Bunavail (buprenorphine-naloxone)_DQM - Per Rx
Sunosi_DQM - Per Rx
Sutent_DQM - Oncology Per Rx
Synagis PA Policy
T
Tamiflu_Standard per Rx
Tarceva (erlotinib)_DQM - Oncology per Rx
Tasigna_DQM - Oncology per Rx
Tasigna_DQM - Oncology per Rx
Tasigna_DQM - Oncology per Rx
Teripararide_DQM - per Days
Testosterone (injectable) Products PA Policy
Testosterone (Oral, Topical, and Nasal) Products PA Policy
Tetracyclines (oral) Step Therapy Policy
Thrombocytopenia - Doptelet PA Policy
Thrombocytopenia - Mulpleta PA Policy
Thrombocytopenia - Nplate PA Policy
Thrombocytopenia - Promacta PA Policy
Thrombocytopenia - Tavalisse PA Policy
Tolvaptan Products - Jynarque PA Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy
Topical Acne - Cleansers Step Therapy Policy
Topical Acne - Kits Step Therapy Policy
Topical Acne - Topical Products Step Therapy Policy
Topical Acne - Winlevi PA Policy
Topical Acyclovir Products PA Policy
Topical Agents for Atopic Dermatitis Step Therapy Policy
Topical Alpha-Adrenergic Agonists for Rosacea PA Policy
Topical Anesthetic - Lidocaine.Tetracaine Products PA with Step Therapy Policy
Topical Anesthetic - Pliaglis PA with Step Therapy Policy
Topical Anesthetics_DQM - per Days_30 days
Topical Antibacterials Step Therapy Policy
Topical Calcipotriene Products_DQM - per Days
Topical Collagenase Santyl Ointment_DQM - per Rx
Topical Corticosteroids Step Therapy Policy
Topical diclofenac sodium gel (Solaraze) PA Policy
Topical Doxepin Cream_DQM - per Days
Topical Doxepin Step Therapy Policy
Topical Medications for Actinic Keratosis Preferred Step Therapy
Topical Medications for Inflammatory Rosacea Step Therapy
Topical Podofilox Products Step Therapy Policy
Topical Products for Atopic Dermatitis_DQM - per Days
Topical Retinoids - Aklief PA Policy
Topical Retinoids - Panretin PA Policy
Topical Retinoids - Tazarotene Products PA Policy
Topical Retinoids - Tazarotene Products PA Policy
Topical Retinoids - Tretinoin Products PA Policy
Topical Testosterone Products DQM - Per Rx
Topical Vitamin D Analogs Step Therapy Policy
Topical_Antifungals_DQM - per Days_28 days
Tramadol extended-release_DQM - Per Rx
Triamcinolone Topical Spray_DQM - per Days
Tykerb_DQM - Oncology per Rx
U
Uplizna PA Policy
V
Valium (diazepam) DQM - Per Days
Valtrex (valacyclovir)_DQM - Per Rx
Vancomycin Oral_DQM - Per Rx
Vecamyl PA Policy
Velphoro_DQM - Per Rx
Veltassa_DQM - Per Rx
Veregen PA Policy
Verquvo_DQM - Per Rx
Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors DQM - Per Rx
Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy
Vitamin D Analog (Oral) Step Therapy Policy
Vocabria_DQM - per Days
W
Wakefulness-Promoting Agents - Armodafinil, Modafinil PA Policy
Wakefulness-Promoting Agents - Sunosi PA Policy with Step Therapy
Wakefulness-Promoting Agents - Wakix PA Policy with Step Therapy
Wakix_DQM - Per Rx
Wegovy_DQM - Per Days
Weight Loss - Glucagon-Like Peptide-1 Agonists PA Policy
X
Xanax (alprazolam) DQM - Per Days
Xcopri_DQM - Per Rx
Xcopri_DQM - Per Rx
Xermelo_DQM - Per Rx
Xiaflex PA Policy
Xofluza_DQM per Rx
Xolair_DQM - per Days
Xyrem-Xywav PA Policy with Step Therapy
Y
Yonsa_DQM - Oncology Per Rx
Z
Zavesca Market Events Clinical Policy
Zepatier_DQM - Per Days_28 days
Zetia Step Therapy Policy
Zokinvy PA Policy
Zontivity PA Policy
Zovirax (Topical) PA Policy
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