Cascade Select UM Policies | Express Scripts

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

Acterma DQM - per Days

Policy

Acthar Gel PA Policy

Policy

Afinitor_DQM - Oncology per Rx

Policy

Aimovig_DQM - Per Days_30 days

Policy

Ajovy_DQM - Per Days_30 days

Policy

Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy

Policy

Allergen Immunotherapy - Grastek and Oralair PA Policy

Policy

Allergen Immunotherapy - Odactra PA Policy

Policy

Allergen Immunotherapy - Palforzia PA Policy

Policy

Allergen Immunotherapy - Ragwitek PA Policy

Policy

Alpha Blockers for BPH Step Therapy Policy

Policy

Alpha1-Proteinase Inhibitor Products PSM policy

Policy

Alunbrig_DQM - Oncology Per Rx

Policy

Alzheimer's Disease Step Therapy Policy

Policy

Alzheimers - Namenda, Namenda XR Step Therapy Policy

Policy

Amifampridine Products PA Policy

Policy

Amifampridine PSM Policy

Policy

Amitiza_DQM - Per Rx

Policy

Amyloidosis - Onpattro PA Policy

Policy

Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy

Policy

Amyloidosis - Tegsedi PA Policy

Policy

Angiotensin Receptor Blocker Preferred Step Therapy Policy

Policy

Angiotensin Receptor Blocker Step Therapy Policy

Policy

Antibiotics (Inhaled) - Arikayce PA Policy

Policy

Antibiotics (Inhaled) - Cayston PA Policy

Policy

Antibiotics (Inhaled) - TOBI Podhaler PA Policy

Policy

Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA Policy

Policy

Antibiotics (Inhaled) - Tobramycin Products PSM Policy

Policy

Antibiotics (Injectable) PA Policy

Policy

Antibiotics - Linezolid (Zyvox), Sivextro PA Policy

Policy

Antibiotics - Synercid PA Policy

Policy

Antibiotics - Vancomycin Capsules PA Policy

Policy

Antibiotics - Xifaxan PA Policy

Policy

Anticoagulants - Eliquis PA Policy

Policy

Anticoagulants - Pradaxa PA Policy with Preferred Step Therapy

Policy

Anticoagulants - Savaysa PA Policy with Preferred Step Therapy

Policy

Anticoagulants - Xarelto PA Policy

Policy

Antidepressants - Bupropion Long-Acting Step Therapy Policy

Policy

Antidepressants - Selective Serotonin Reuptake Inhibitors Step Therapy Policy

Policy

Antidepressants - Serotonin Norepinephrine Reuptake Inhibitors Step Therapy Policy

Policy

Antiepileptics - Banzel PA Policy

Policy

Antiepileptics - Clobazam Products PA Policy

Policy

Antiepileptics - Depakote, Depakene Step Therapy Policy

Policy

Antiepileptics - Diacomit PA Policy

Policy

Antiepileptics - Epidiolex PA Policy

Policy

Antiepileptics - Fintepla PA Policy

Policy

Antiepileptics - Lamictal XR Step Therapy Policy

Policy

Antiepileptics - Levetiracetam, Brivaracetam Step Therapy Policy

Policy

Antiepileptics - Nayzilam PA Policy

Policy

Antiepileptics - Oxtellar XR, Trileptal Step Therapy Policy

Policy

Antiepileptics - Topiramate Step Therapy Policy

Policy

Antiepileptics - Valtoco PA Policy

Policy

Antiepileptics - Vigabatrin (Sabril) PA Policy

Policy

Antifungals (Azoles) - Intravenous PA Policy

Policy

Antifungals (Topical) for Onychomycosis Step Therapy Policy

Policy

Antifungals - Cresemba (Oral) PA Policy

Policy

Antifungals - Noxafil (Oral) PA Policy

Policy

Antifungals - Tolsura PA with Step Therapy Policy

Policy

Antifungals - Voriconazole (Oral) PA Policy

Policy

Antiparasitics - Impavido PA Policy

Policy

Apokyn, Kynmobi_DQM - Per Days

Policy

Ativan (lorazepam) DQM - Per Days

Policy

Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy

Policy

Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy

Policy

Attention Deficit Hyperactivity Disorder Stimulant Step Therapy Policy

Policy

Attention Deficit Hyperactivity Disorder Stimulants PA Policy

Policy

Atypical Antipsychotics_DQM - Per Rx

Policy

Avodart Step Therapy Policy

Policy

Beta Blocker Step Therapy Policy

Policy

Bevyxxa_DQM - Per Days_30 days

Policy

Bile Acid Sequestrants Step Therapy Policy

Policy

Bisphosphonates (oral) Enhanced Step Therapy Policy

Policy

Bisphosphonates (Oral) Step Therapy Policy

Policy

Bone Modifiers - Evenity PA Policy

Policy

Bone Modifiers - Ibandronate Intravenous (Boniva IV) PA Policy

Policy

Bone Modifiers - Prolia PA Policy

Policy

Bone Modifiers - Teriparatide Products PA Policy

Policy

Bone Modifiers - Tymlos PA Policy

Policy

Bone Modifiers - Xgeva PA Policy

Policy

Bone Modifiers - Zoledronic Acid (Reclast) PA Policy

Policy

Bone Modifiers - Zoledronic Acid (Zometa) PA Policy

Policy

Bosulif_DQM - Oncology per Rx

Policy

Botulinum Toxins - Botox PA Policy

Policy

Botulinum Toxins - Dysport PA Policy

Policy

Botulinum Toxins - Myobloc PA Policy

Policy

Botulinum Toxins - Xeomin PA Policy

Policy

Bowel Disease - Opioid-Induced Constipation Preferred Step Therapy Policy

Policy

Cabenuva_DQM - per Days

Policy

Cabometyx_DQM - Oncology per Rx

Policy

Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy

Policy

Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy

Policy

Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy

Policy

Calcitonin Gene-Related Peptide Inhibitors - Vyepti PA Policy

Policy

Calcium Channel Blockers-Dihydropyridine Products Step Therapy Policy

Policy

Calcium Channel Blockers-Verapamil Products Step Therapy Policy

Policy

Calquence_DQM - Oncology per Rx

Policy

Cardiology - Corlanor PA Policy

Policy

Cardiology - Zontivity PA Policy

Policy

Cardura, XL (doxazosin)_DQM - Per Rx

Policy

Catapres (clonidine) Patches_DQM - Per Days

Policy

Catapres (clonidine) Patches_DQM - Per Days_28 days

Policy

Chelating Agents - Chemet PA Policy

Policy

Chelating Agents - Iron Chelators (Oral) PA Policy

Policy

Chelating Agents - Penicillamine Products PA Policy

Policy

Chelating Agents - Syprine PA Policy

Policy

Chenodal PA Policy

Policy

Cholbam PA Policy

Policy

Chorionic Gonadotropins PSM Policy

Policy

Cimzia_DQM - per Days

Policy

Cinacalcet (Sensipar) PA Policy

Policy

Clindamycin Topical Products_DQM - per Days_30 days

Policy

Clobetasol Topical Products_DQM - per Days_28 days

Policy

Colchicine Products Preferred Step Therapy Policy

Policy

Colchicine Products Preferred Step Therapy Policy

Policy

Colony Stimulating Factors - Filgrastim Products PA Policy

Policy

Colony Stimulating Factors - Filgrastim Products PSM Policy

Policy

Colony Stimulating Factors - Granix PA Policy

Policy

Colony Stimulating Factors - Leukine PA Policy

Policy

Colony Stimulating Factors - Pegfilgrastim Products PA Policy

Policy

Colony Stimulating Factors - Pegfilgrastim Products PSM Policy

Policy

Complement Inhibitors - Empaveli PA Policy

Policy

Complement Inhibitors - Soliris PA Policy

Policy

Complement Inhibitors - Ultomiris PA Policy

Policy

Compounded Select Topical Medications PA Policy

Policy

Contraceptives - Oral and Patch Products Step Therapy Policy

Policy

Contraceptives - Phexxi PA Policy

Policy

Coronavirus Disease - Veklury PA Policy

Policy

Coronavirus Infection Drugs - Azithromycin - Per Days

Policy

Coronavirus Infection Drugs - Kaletra, Plaquenil, Chloroquine - Per Days

Policy

Coronavirus Infection Drugs - Short Acting Beta-Agonists - Per Days

Policy

Coronavirus Tests (antibody) - Per Days

Policy

Coronavirus Tests (diagnostic) - Per Days

Policy

Cosentyx_DQM - per Days

Policy

Crysvita PA Policy

Policy

Cushing's - Isturisa PA Policy

Policy

Cushing's - Korlym PA Policy

Policy

Cushing's - Signifor PA Policy

Policy

Cyclooxygenase-2 Inhibitor Step Therapy Policy

Policy

Cystic Fibrosis - Bronchitol PA Policy

Policy

Cystic Fibrosis - Kalydeco PA Policy

Policy

Cystic Fibrosis - Orkambi PA Policy

Policy

Cystic Fibrosis - Pulmozyme PA Policy

Policy

Cystic Fibrosis - Symdeko PA Policy

Policy

Cystic Fibrosis - Trikafta PA Policy

Policy

Depression - bupropion (Wellbutrin-Forfivo-Aplenzin)_DQM - Per Rx

Policy

Depression - SNRI_DQM - Per Rx

Policy

Depression - SSRI_DQM - Per Rx

Policy

Desmopressin Products - Nocdurna PA Policy

Policy

Desmopressin Products - Noctiva PA Policy

Policy

Diabetes - Continuous Glucose Monitors PA Policy

Policy

Diabetes - Diabetic Test Strips Preferred Step Therapy Policy

Policy

Diabetes - Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Step Therapy Policy

Policy

Diabetes - Dipeptidyl Peptidase-4 Inhibitors Preferred Step Therapy Policy

Policy

Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy

Policy

Diabetes - Glucagon-Like Peptide-1 Agonists Preferred Step Therapy

Policy

Diabetes - Insulin (Other) Preferred Step Therapy Policy

Policy

Diabetes - Insulin (Rapid-Acting) Preferred Step Therapy Policy

Policy

Diabetes - Kerendia PA Policy

Policy

Diabetes - Metformin Step Therapy Policy

Policy

Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy

Policy

Diabetes - Symlin PA Policy

Policy

Diabetes - Thiazolidinedione Step Therapy Policy

Policy

Diclofenac sodium gel (Solaraze) PA Policy

Policy

Diclofenac Topical_DQM - per Days

Policy

Diflorasone Topical Products_DQM - per Days_30 days

Policy

Diflucan 150 mg (fluconazole)_DQM - Per Rx

Policy

Divigel_DQM - Per Rx

Policy

Doptelet_DQM - Per Rx

Policy

Dostinex (cabergoline)_DQM - Per Days_28 days

Policy

Dronabinol PA Policy

Policy

Dupixent_DQM - Per Days_28 days

Policy

Emgality_DQM - Per Days_30 days

Policy

Enbrel_DQM - per Days_28 days

Policy

Enspryng PA Policy

Policy

Enzyme Replacement Therapy - Adagen PA Policy

Policy

Enzyme Replacement Therapy - Aldurazyme PA Policy

Policy

Enzyme Replacement Therapy - Elaprase PA Policy

Policy

Enzyme Replacement Therapy - Elaprase PA Policy

Policy

Enzyme Replacement Therapy - Fabrazyme PA Policy

Policy

Enzyme Replacement Therapy - Kanuma PA Policy

Policy

Enzyme Replacement Therapy - Lumizyme PA Policy

Policy

Enzyme Replacement Therapy - Mepsevii PA Policy

Policy

Enzyme Replacement Therapy - Naglazyme PA Policy

Policy

Enzyme Replacement Therapy - Revcovi PA Policy

Policy

Enzyme Replacement Therapy - Strensiq PA Policy

Policy

Enzyme Replacement Therapy - Sucraid PA Policy

Policy

Enzyme Replacement Therapy - Vimizim PA Policy

Policy

Epclusa_DQM - Per Days_28 days

Policy

Epinephrine Auto-injectors Preferred Step Therapy Policy

Policy

Epinephrine Auto-Injectors Step Therapy Policy

Policy

Erythroid Stimulating Agents - Aranesp PA Policy

Policy

Erythroid Stimulating Agents - Epoetin Alfa Products PA Policy

Policy

Erythroid Stimulating Agents - Mircera PA Policy

Policy

Erythroid Stimulating Agents PSM Policy

Policy

Erythropoiesis-Stimulating Agents - Aranesp PA Policy

Policy

Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy

Policy

Erythropoiesis-Stimulating Agents - Mircera PA Policy

Policy

Estrogen - Transdermal (Non-Patch) Preferred Step Therapy Policy

Policy

Estrogen - Transdermal Step Therapy Policy

Policy

Estrogen - Vaginal Products and Estrogen Modifiers Preferred Step Therapy Policy

Policy

Estrogen Patches_DQM - Per Days_28 days

Policy

Estrogen-Progestin Combinations (patches) Preferred Step Therapy

Policy

Fabry Disease - Galafold PA Policy

Policy

Famvir (famciclovir)_DQM - Per Rx

Policy

Fenofibrate Preferred Step Therapy Policy

Policy

Fenofibrate Step Therapy Policy

Policy

Fentanyl Transdermal Patch_DQM - Per Days_30 days

Policy

Fentanyl Transmucosal Drugs_DQM - Per Days

Policy

Fluocinonide Topical Products_DQM - per Days_30 days

Policy

Flurandrenolide Topical Products_DQM - per Days_30 days

Policy

Gabapentin Step Therapy Policy

Policy

Gamifant PA Policy

Policy

Gastroenterology - Gattex PA Policy

Policy

Gaucher Disease - Enzyme Replacement Therapy PSM Policy

Policy

Gaucher Disease - Substrate Reduction Therapy PSM Policy

Policy

Gaucher Disease Substrate Reduction Therapy - Cerdelga PA Policy

Policy

Gaucher Disease Substrate Reduction Therapy - Miglustat (Zavesca) PA Policy

Policy

Gleevec (imatinib)_DQM - Oncology per Rx

Policy

Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy

Policy

Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty (Fensolvi, Lupron Depot-Ped, and Triptodur) PA Policy

Policy

Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty (Lupron Depot-Ped and Triptodur) PA Policy

Policy

Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy

Policy

Gonadotropin-Releasing Hormone Agonists - Implants PA Policy

Policy

Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products PA Policy

Policy

Gonadotropin-Releasing Hormone Antagonists - Myfembree PA Policy

Policy

Gonadotropin-Releasing Hormone Antagonists - Oriahnn PA Policy

Policy

Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy

Policy

Gout - Krystexxa PA Policy

Policy

Gout Medications Step Therapy Policy

Policy

Growth Disorders - Growth Hormone PA policy

Policy

Growth Disorders - Increlex PA Policy

Policy

Growth Hormone PSM Policy

Policy

HCG_DQM - Per Rx

Policy

Helicobacter Pylori Infection Combination Products Preferred Step Therapy Policy

Policy

Hematology - Cablivi PA Policy

Policy

Hematology - Ceprotin PA Policy

Policy

Hematology - Coagadex PA

Policy

Hematology - Corifact PA

Policy

Hematology - Fibrinogen Products PA Policy

Policy

Hematology - Reblozyl PA Policy

Policy

Hematology - Tretten PA

Policy

Hematology - Vonvendi PA

Policy

Hemophilia - Eptacog Products - NovoSeven RT PA Policy

Policy

Hemophilia - Eptacog Products - Sevenfact PA Policy

Policy

Hemophilia - Eptacog Products PA Policy

Policy

Hemophilia - FEIBA PA Policy

Policy

Hemophilia - Hemlibra PA Policy

Policy

Hemophilia - Recombinant Factor VIII Products PSM Policy

Policy

Hepatitis C - Epclusa PA Policy

Policy

Hepatitis C - Harvoni PA Policy

Policy

Hepatitis C - Mavyret PA for PSM

Policy

Hepatitis C - Ribavirin PA Policy

Policy

Hepatitis C - Sovaldi PA Policy

Policy

Hepatitis C - Viekira Pak PA Policy

Policy

Hepatitis C Virus Direct Acting Antivirals PSM Policy for National Preferred Formulary

Policy

Hepatology - Bylvay PA Policy

Policy

Hepatology - Givlaari PA

Policy

Hepatology - Ocaliva PA Policy

Policy

Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy

Policy

Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PSM Policy

Policy

Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy

Policy

Hereditary Angioedema - Icatibant (Firazyr) PA Policy

Policy

Hereditary Angioedema - Icatibant (Firazyr) PSM Policy

Policy

Hereditary Angioedema - Kalbitor PA Policy

Policy

Hereditary Angioedema - Orladeyo PA Policy

Policy

Hereditary Angioedema - Takhzyro PA Policy

Policy

Hetlioz PA Policy

Policy

HMGs_DQM - Per Rx

Policy

Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy

Policy

Homozygous Familial Hypercholesterolemia - Evkeeza PA Policy

Policy

Human Immunodeficiency Virus - Atripla PSM Policy (Basic Formulary)

Policy

Human Immunodeficiency Virus - Cabenuva PA Policy

Policy

Human Immunodeficiency Virus - Complera PSM Policy (Basic Formulary)

Policy

Human Immunodeficiency Virus - Prezcobix PSM Policy (Basic Formulary)

Policy

Human Immunodeficiency Virus - Rukobia PA Policy

Policy

Human Immunodeficiency Virus - Stribild PSM Policy (Basic Formulary)

Policy

Human Immunodeficiency Virus - Trogarzo PA Policy

Policy

Human Immunodeficiency Virus - Truvada PSM Policy

Policy

Human Immunodeficiency Virus - Vocabria PA Policy

Policy

Humira_DQM - Per Days_28 days

Policy

Hyaluronic Acid Derivatives Intraarticular PA Policy

Policy

Hyaluronic Acid Derivatives Intraarticular PSM Policy

Policy

Hyaluronic Acid Derivatives PSM Policy

Policy

Hydrocortisone Acetate Suppository Step Therapy Policy

Policy

Hydroxy-methylglutaryl-coenzyme A Reductase Inhibitors (HMG) Step Therapy Policy

Policy

Hyperlipidemia - Nexletol PA Policy

Policy

Hyperlipidemia - Nexlizet PA Policy

Policy

Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy

Policy

Hypoactive Sexual Desire Disorder - Addyi PA Policy

Policy

Hypoactive Sexual Desire Disorder - Vyleesi PA Policy

Policy

Hytrin (terazosin)_DQM - Per Rx

Policy

Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy

Policy

Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy

Policy

Ilumya_DQM - Per Days

Policy

Imcivree_DQM - Per Days

Policy

Immune Globulin - Atgam PA Policy

Policy

Immune Globulin - Cytogam PA Policy

Policy

Immune Globulin - Intravenous PA Policy

Policy

Immune Globulin - Subcutaneous PA Policy

Policy

Immunologicals - Anti-Interleukin-5 Agents PSM Policy

Policy

Immunologicals - Dupixent PA Policy

Policy

Immunologicals - Nucala PA Policy

Policy

Immunologicals - Xolair PA Policy

Policy

Infectious Disease - Daraprim PA Policy

Policy

Infectious Disease - Pretomanid PA Policy

Policy

Infectious Disease - Pyrimethamine (Daraprim) PA Policy

Policy

Infectious Disease - Sirturo PA Policy

Policy

Infertility - Follitropins, Clomiphene PSM policy

Policy

Infertility - Gonadotropin Releasing Hormone Antagonists PSM Policy

Policy

Inflammatory Bowel Preferred Step Therapy

Policy

Inflammatory Conditions - Actemra IV PA Policy

Policy

Inflammatory Conditions - Actemra SC PA Policy

Policy

Inflammatory Conditions - Adalimumab Products PA Policy

Policy

Inflammatory Conditions - Arcalyst PA Policy

Policy

Inflammatory Conditions - Benlysta Intravenous PA Policy

Policy

Inflammatory Conditions - Benlysta Subcutaneous PA Policy

Policy

Inflammatory Conditions - Cosentyx PA Policy

Policy

Inflammatory Conditions - Entyvio Intravenous PA Policy

Policy

Inflammatory Conditions - Etanercept Products PA Policy

Policy

Inflammatory Conditions - Ilaris PA Policy

Policy

Inflammatory Conditions - Ilumya PA Policy

Policy

Inflammatory Conditions - Infliximab Products PA Policy

Policy

Inflammatory Conditions - Kevzara PA Policy

Policy

Inflammatory Conditions - Kineret PA Policy

Policy

Inflammatory Conditions - Olumiant PA Policy

Policy

Inflammatory Conditions - Orencia IV PA Policy

Policy

Inflammatory Conditions - Orencia SC PA Policy

Policy

Inflammatory Conditions - Otezla PA Policy

Policy

Inflammatory Conditions - Rinvoq PA Policy

Policy

Inflammatory Conditions - Siliq PA Policy

Policy

Inflammatory Conditions - Simponi Aria PA Policy

Policy

Inflammatory Conditions - Simponi SC PA Policy

Policy

Inflammatory Conditions - Skyrizi PA Policy

Policy

Inflammatory Conditions - Stelara IV PA Policy

Policy

Inflammatory Conditions - Stelara Subcutaneous PA Policy

Policy

Inflammatory Conditions - Taltz PA Policy

Policy

Inflammatory Conditions - Tremfya PA Policy

Policy

Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy

Policy

Inflammatory Conditions PSM Policy

Policy

Influenza Drugs_Select per Days_365 days

Policy

Interferon - Actimmune PA Policy

Policy

Interleukin-1 (IL-1) Blockers for Cryopyrin-Associated Periodic Syndromes (CAPS) PSM Policy

Policy

Iressa_DQM - Oncology per Rx

Policy

Iron Replacement - Feraheme PA Policy

Policy

Iron Replacement - Ferrlecit PA Policy

Policy

Iron Replacement - INFeD PA Policy

Policy

Iron Replacement - Injectafer PA Policy

Policy

Iron Replacement - Monoferric PA Policy

Policy

Iron Replacement - Venofer PA Policy

Policy

Isotretinoin Step Therapy Policy

Policy

Isturisa_DQM - Per Rx

Policy

Itraconazole _DQM - Per Rx

Policy

Jatenzo_DQM - Per Rx

Policy

Kesimpta_DQM - per Days

Policy

Keveyis PA Policy

Policy

Kineret_DQM - per Days

Policy

Klonopin (clonazepam) DQM - Per Days

Policy

Lacrisert_DQM - Per Rx

Policy

Lemtrada_DQM per Days

Policy

Lidocaine Patch PA Policy

Policy

Lipodystrophy - Egrifta PA Policy

Policy

Lipodystrophy - Myalept PA Policy

Policy

Locoid (hydrocortisone butyrate) Topical Products_DQM - per Days_30 days

Policy

Lokelma_DQM - Per Rx

Policy

Lucemyra PA Policy

Policy

Lupus - Lupkynis PA Policy

Policy

Makena (Hydroxyprogesterone caproate) PA Policy

Policy

Mavyret_DQM - Per Days_28 days

Policy

Mayzent_DQM per Rx

Policy

Metabolic Disorders - Carbaglu PA Policy

Policy

Metabolic Disorders - Cystaran PA Policy

Policy

Metabolic Disorders - Cysteamine (Oral) Products (Cystagon, Procysbi) PA Policy

Policy

Metabolic Disorders - Cysteamine Ophthalmic Solution PA Policy

Policy

Metabolic Disorders - Dojolvi PA Policy

Policy

Metabolic Disorders - Imcivree PA Policy

Policy

Metabolic Disorders - Nitisinone Products PA Policy

Policy

Metabolic Disorders - Nulibry PA Policy

Policy

Metabolic Disorders - Oxlumo PA Policy

Policy

Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy

Policy

Metabolic Disorders - Tiopronin Products PA Policy

Policy

Metabolic Disorders - Xuriden PA Policy

Policy

Metformin ER_DQM - Per Rx

Policy

Methotrexate Injection Step Therapy Policy

Policy

Methylergonovine (Methergine) PA Policy

Policy

Migraine - Nurtec ODT PA Policy

Policy

Migraine - Reyvow PA Policy

Policy

Migraine - Ubrelvy PA Policy

Policy

Migraine Drugs_DQM - Per Days

Policy

Migraine Drugs_DQM - Per Rx

Policy

Migraine Medication Step Therapy Policy

Policy

MME 90 DQM_30 days

Policy

MME greater than 200 Based QL_30 days

Policy

Multiple Sclerosis - Ampyra PSM Policy

Policy

Multiple Sclerosis - Aubagio PA Policy

Policy

Multiple Sclerosis - Avonex PA Policy

Policy

Multiple Sclerosis - Bafiertam PA Policy

Policy

Multiple Sclerosis - Betaseron, Extavia PA Policy

Policy

Multiple Sclerosis - Dimethyl Fumarate (Tecfidera) PA Policy

Policy

Multiple Sclerosis - Gilenya PA Policy

Policy

Multiple Sclerosis - Glatiramer Products PA Policy

Policy

Multiple Sclerosis - Kesimpta PA Policy

Policy

Multiple Sclerosis - Lemtrada PA Policy

Policy

Multiple Sclerosis - Mavenclad PA Policy

Policy

Multiple Sclerosis - Ocrevus PA Policy

Policy

Multiple Sclerosis - Plegridy PA Policy

Policy

Multiple Sclerosis - Ponvory PA Policy

Policy

Multiple Sclerosis - Rebif PA Policy

Policy

Multiple Sclerosis - Tecfidera PA Policy

Policy

Multiple Sclerosis - Vumerity PA Policy

Policy

Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy

Policy

Multiple Sclerosis and Ulcerative Colitis - Zeposia PA Policy

Policy

Multiple Sclerosis PSM Policy

Policy

Muscular Dystrophy - Amondys 45 PA Policy

Policy

Muscular Dystrophy - Emflaza PA Policy

Policy

Muscular Dystrophy - Exondys 51 PA Policy

Policy

Muscular Dystrophy - Viltepso PA Policy

Policy

Muscular Dystrophy - Vyondys 53 PA Policy

Policy

Naloxone Injection Step Therapy Policy

Policy

Nasal Steroids Step Therapy Policy

Policy

Nasonex (mometasone furoate)_DQM - Per Rx

Policy

Natpara PA Policy

Policy

Nausea Vomiting Agents for Pregnancy_DQM - Per Days

Policy

Nausea-Vomiting - Cesamet _DQM - Per Rx

Policy

Nausea-Vomiting Agents - Serotonin Antagonists_DQM - Per Rx

Policy

Nausea-Vomiting Agents_Akynzeo, Emend, Varubi_DQM - Per Rx

Policy

Neurology - Aduhelm PA Policy

Policy

Neurology - Brineura PA Policy

Policy

Neurology - Lyrica CR PA Policy

Policy

Neurology - Radicava PA Policy

Policy

Neurology - Riluzole Products PA Policy

Policy

Neurontin (gabapentin), Gralise, Horizant DQM - Per Days

Policy

Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy

Policy

Northera PA Policy

Policy

Nucala_DQM - Per Days_28 days

Policy

Nucynta_DQM - Per Rx

Policy

Nuedexta PA Policy

Policy

Oncology (Injectable - CAR-T) - Abecma PA Policy

Policy

Oncology (Injectable - CAR-T) - Breyanzi PA Policy

Policy

Oncology (Injectable - CAR-T) - Kymriah PA Policy

Policy

Oncology (Injectable - CAR-T) - Tecartus PA Policy

Policy

Oncology (Injectable - CAR-T) - Yescarta PA Policy

Policy

Oncology (Injectable - Programmed Death Receptor-1) - Jemperli PA Policy

Policy

Oncology (Injectable - Programmed Death Receptor-1) - Keytruda PA Policy

Policy

Oncology (Injectable - Programmed Death Receptor-1) - Opdivo PA Policy

Policy

Oncology (Injectable) - Adcetris PA Policy

Policy

Oncology (Injectable) - Aliqopa PA Policy

Policy

Oncology (Injectable) - Arsenic Trioxide PA Policy

Policy

Oncology (Injectable) - Arzerra PA Policy

Policy

Oncology (Injectable) - Asparlas PA Policy

Policy

Oncology (Injectable) - Azedra PA Policy

Policy

Oncology (Injectable) - Bavencio PA Policy

Policy

Oncology (Injectable) - Beleodaq PA Policy

Policy

Oncology (Injectable) - Bendamustine Products PA Policy

Policy

Oncology (Injectable) - Besponsa PA Policy

Policy

Oncology (Injectable) - Bevacizumab Products PSM Policy

Policy

Oncology (Injectable) - Blenrep PA Policy

Policy

Oncology (Injectable) - Blincyto PA Policy

Policy

Oncology (Injectable) - Bortezomib (Velcade) PA Policy

Policy

Oncology (Injectable) - Carmustine PA Policy

Policy

Oncology (Injectable) - Cosela PA Policy

Policy

Oncology (Injectable) - Cyramza PA Policy

Policy

Oncology (Injectable) - Danyelza PA Policy

Policy

Oncology (Injectable) - Darzalex Faspro PA Policy

Policy

Oncology (Injectable) - Decitabine Products PA Policy

Policy

Oncology (Injectable) - Elzonris PA Policy

Policy

Oncology (Injectable) - Erbitux PA Policy

Policy

Oncology (Injectable) - Folotyn PA Policy

Policy

Oncology (Injectable) - Fulvestrant (Faslodex) PA Policy

Policy

Oncology (Injectable) - Gazyva PA Policy

Policy

Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy

Policy

Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy

Policy

Oncology (Injectable) - Imfinzi PA Policy

Policy

Oncology (Injectable) - Imlygic PA Policy

Policy

Oncology (Injectable) - Ixempra PA Policy

Policy

Oncology (Injectable) - Jevtana PA Policy

Policy

Oncology (Injectable) - Kadcyla PA Policy

Policy

Oncology (Injectable) - Kyprolis PA Policy

Policy

Oncology (Injectable) - Levoleucovorin Products PA Policy

Policy

Oncology (Injectable) - Libtayo PA Policy

Policy

Oncology (Injectable) - Lumoxiti PA Policy

Policy

Oncology (Injectable) - Margenza PA Policy

Policy

Oncology (Injectable) - Monjuvi PA Policy

Policy

Oncology (Injectable) - Mylotarg PA Policy

Policy

Oncology (Injectable) - Oncaspar PA Policy

Policy

Oncology (Injectable) - Onivyde PA Policy

Policy

Oncology (Injectable) - Padcev PA Policy

Policy

Oncology (Injectable) - Pepaxto PA Policy

Policy

Oncology (Injectable) - Perjeta PA Policy

Policy

Oncology (Injectable) - Phesgo PA Policy

Policy

Oncology (Injectable) - Polivy PA Policy

Policy

Oncology (Injectable) - Portrazza PA Policy

Policy

Oncology (Injectable) - Poteligeo PA Policy

Policy

Oncology (Injectable) - Proleukin PA Policy

Policy

Oncology (Injectable) - Rituxan Hycela PA Policy

Policy

Oncology (Injectable) - Romidepsin Products (Istodax) PA Policy

Policy

Oncology (Injectable) - Rybrevant PA Policy

Policy

Oncology (Injectable) - Rylaze PA Policy

Policy

Oncology (Injectable) - Sarclisa PA Policy

Policy

Oncology (Injectable) - Sylatron PA Policy

Policy

Oncology (Injectable) - Sylvant PA Policy

Policy

Oncology (Injectable) - Synribo PA Policy

Policy

Oncology (Injectable) - Tecentriq PA Policy

Policy

Oncology (Injectable) - Thiotepa Products PA Policy

Policy

Oncology (Injectable) - Topotecan Products PA Policy

Policy

Oncology (Injectable) - Torisel PA Policy

Policy

Oncology (Injectable) - Trastuzumab Products PA Policy

Policy

Oncology (Injectable) - Trastuzumab Products PSM Policy

Policy

Oncology (Injectable) - Trastuzumab Products PSM Policy

Policy

Oncology (Injectable) - Trodelvy PA Policy

Policy

Oncology (Injectable) - Unituxin PA Policy

Policy

Oncology (Injectable) - Vectibix PA Policy

Policy

Oncology (Injectable) - Vyxeos PA Policy

Policy

Oncology (Injectable) - Yervoy PA Policy

Policy

Oncology (Injectable) - Zaltrap PA Policy

Policy

Oncology (Injectable) - Zepzelca PA Policy

Policy

Oncology (Injectable) - Zynlonta PA Policy

Policy

Oncology (Other) - Jelmyto PA Policy

Policy

Oncology - Abiraterone Acetate (Zytiga) PA Policy

Policy

Oncology - Abiraterone Acetate (Zytiga) PSM Policy

Policy

Oncology - Adcetris PA Policy

Policy

Oncology - Afinitor PA Policy

Policy

Oncology - Afinitor PSM Policy

Policy

Oncology - Alecensa PA Policy

Policy

Oncology - Aliqopa PA Policy

Policy

Oncology - Alunbrig PA Policy

Policy

Oncology - Arsenic Trioxide PA Policy

Policy

Oncology - Arzerra PA Policy

Policy

Oncology - Ayvakit PA Policy

Policy

Oncology - Azedra PA Policy

Policy

Oncology - Balversa PA Policy

Policy

Oncology - Bavencio PA Policy

Policy

Oncology - Beleodaq PA Policy

Policy

Oncology - Bendamustine Products PA Policy

Policy

Oncology - Besponsa PA Policy

Policy

Oncology - Bevacizumab Products PA Policy

Policy

Oncology - Blincyto PA Policy

Policy

Oncology - Bosulif PA Policy

Policy

Oncology - Braftovi PA Policy

Policy

Oncology - Brukinsa PA Policy

Policy

Oncology - Cabometyx PA Policy

Policy

Oncology - Calquence PA Policy

Policy

Oncology - Capecitabine (Xeloda) PA Policy

Policy

Oncology - Caprelsa PA Policy

Policy

Oncology - Cometriq PA Policy

Policy

Oncology - Copiktra PA Policy

Policy

Oncology - Cotellic PA Policy

Policy

Oncology - Cyclin Dependent Kinases 4,6 Inhibitors for Breast Cancer PSM Policy

Policy

Oncology - Cyramza PA Policy

Policy

Oncology - Darzalex PA Policy

Policy

Oncology - Daurismo PA Policy

Policy

Oncology - Decitabine Products PA Policy

Policy

Oncology - Empliciti PA Policy

Policy

Oncology - Enhertu PA Policy

Policy

Oncology - Erbitux PA Policy

Policy

Oncology - Erivedge PA Policy

Policy

Oncology - Erivedge PA Policy

Policy

Oncology - Erleada PA Policy

Policy

Oncology - Erlotinib (Tarceva) PA Policy

Policy

Oncology - Erwinaze PA Policy

Policy

Oncology - Farydak PA Policy

Policy

Oncology - Faslodex PA Policy

Policy

Oncology - Fotivda PA Policy

Policy

Oncology - Gavreto PA Policy

Policy

Oncology - Gazyva PA Policy

Policy

Oncology - Gilotrif PA Policy

Policy

Oncology - Gonadotropin-Releasing Hormone Analogs Injectable Products (Eligard, Firmagon, Trelstar) PA Policy

Policy

Oncology - Halaven PA Policy

Policy

Oncology - Herceptin Hylecta PA Policy

Policy

Oncology - Ibrance PA Policy

Policy

Oncology - Iclusig PA Policy

Policy

Oncology - Idhifa PA Policy

Policy

Oncology - Imatinib (Gleevec) PA Policy

Policy

Oncology - Imbruvica PA Policy

Policy

Oncology - Imbruvica PSM Policy

Policy

Oncology - Imfinzi PA Policy

Policy

Oncology - Inlyta PA Policy

Policy

Oncology - Inqovi PA Policy

Policy

Oncology - Inrebic PA Policy

Policy

Oncology - Iressa PA Policy

Policy

Oncology - Jakafi PA Policy

Policy

Oncology - Kadcyla PA Policy

Policy

Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy

Policy

Oncology - Koselugo PA

Policy

Oncology - Lapatinib (Tykerb) PA Policy

Policy

Oncology - Lartruvo PA Policy

Policy

Oncology - Lenvima PA Policy

Policy

Oncology - Libtayo PA Policy

Policy

Oncology - Lonsurf PA Policy

Policy

Oncology - Lumakras PA Policy

Policy

Oncology - Lumoxiti PA Policy

Policy

Oncology - Lynparza PA Policy

Policy

Oncology - Mekinist PA Policy

Policy

Oncology - Mektovi PA Policy

Policy

Oncology - Mylotarg PA Policy

Policy

Oncology - Nerlynx PA Policy

Policy

Oncology - Nexavar PA Policy

Policy

Oncology - Nilutamide PA Policy

Policy

Oncology - Ninlaro PA Policy

Policy

Oncology - Nubeqa PA Policy

Policy

Oncology - Odomzo PA Policy

Policy

Oncology - Onureg PA Policy

Policy

Oncology - Orgovyx PA Policy

Policy

Oncology - Pemazyre PA Policy

Policy

Oncology - Perjeta PA Policy

Policy

Oncology - Piqray PA Policy

Policy

Oncology - Pomalyst PA Policy

Policy

Oncology - Poteligeo PA Policy

Policy

Oncology - Prostate Cancer Injectable Gonadotropin-Releasing Hormone Analogs PSM policy

Policy

Oncology - Qinlock PA Policy

Policy

Oncology - Retevmo PA Policy

Policy

Oncology - Revlimid PA Policy

Policy

Oncology - Rituxan Hycela PA Policy

Policy

Oncology - Rozlytrek PA Policy

Policy

Oncology - Rubraca PA Policy

Policy

Oncology - Rydapt PA Policy

Policy

Oncology - Sprycel PA Policy

Policy

Oncology - Stivarga PA Policy

Policy

Oncology - Sutent PA Policy

Policy

Oncology - Synribo PA Policy

Policy

Oncology - Tabrecta PA Policy

Policy

Oncology - Tabrecta PA Policy

Policy

Oncology - Tafinlar PA Policy

Policy

Oncology - Tagrisso PA Policy

Policy

Oncology - Talzenna PA Policy

Policy

Oncology - Tarceva PA Policy

Policy

Oncology - Targretin (oral) PA Policy

Policy

Oncology - Targretin (topical) PA Policy

Policy

Oncology - Tasigna PA Policy

Policy

Oncology - Tazverik PA Policy

Policy

Oncology - Temozolomide Capsules PA Policy

Policy

Oncology - Tepmetko PA Policy

Policy

Oncology - Thalomid PA Policy

Policy

Oncology - Thiotepa Products PA Policy

Policy

Oncology - Tibsovo PA Policy

Policy

Oncology - Torisel PA Policy

Policy

Oncology - Trastuzumab Products PA Policy

Policy

Oncology - Trodelvy PA Policy

Policy

Oncology - Truseltiq PA Policy

Policy

Oncology - Tukysa PA Policy

Policy

Oncology - Turalio PA Policy

Policy

Oncology - Ukoniq PA Policy

Policy

Oncology - Valchlor PA Policy

Policy

Oncology - Valrubicin Products PA Policy

Policy

Oncology - Vectibix PA Policy

Policy

Oncology - Venclexta PA Policy

Policy

Oncology - Verzenio PA Policy

Policy

Oncology - Vistogard PA Policy

Policy

Oncology - Vitrakvi PA Policy

Policy

Oncology - Vizimpro PA Policy

Policy

Oncology - Votrient PA Policy

Policy

Oncology - Vyxeos PA Policy

Policy

Oncology - Xalkori PA Policy

Policy

Oncology - Xermelo PA Policy

Policy

Oncology - Xospata PA

Policy

Oncology - Xpovio PA Policy

Policy

Oncology - Xtandi PA Policy

Policy

Oncology - Yervoy PA Policy

Policy

Oncology - Yonsa PA Policy

Policy

Oncology - Zaltrap PA Policy

Policy

Oncology - Zejula PA Policy

Policy

Oncology - Zelboraf PA Policy

Policy

Oncology - Zolinza PA Policy

Policy

Oncology - Zydelig PA Policy

Policy

Oncology - Zykadia PA Policy

Policy

Ophthalmic - Glaucoma - Alpha-adrenergic Agonists Preferred Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Beta-adrenergic Blockers Preferred Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Beta-adrenergic Blockers Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Preferred Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Combination Products Preferred Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Prostaglandins PA Policy

Policy

Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy

Policy

Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy

Policy

Ophthalmic Corticosteroids Preferred Step Therapy Policy

Policy

Ophthalmic Corticosteroids Preferred Step Therapy Policy - Effective 7.1.2021

Policy

Ophthalmic for Dry Eye Disease - Cyclosporine Products PA Policy

Policy

Ophthalmic for Dry Eye Disease - Eysuvis PA Policy

Policy

Ophthalmic for Dry Eye Disease - Lacrisert PA Policy

Policy

Ophthalmic for Dry Eye Disease - Xiidra PA Policy

Policy

Ophthalmic NSAIDs Preferred Step Therapy Policy

Policy

Ophthalmic Prostaglandin Step Therapy Policy

Policy

Ophthalmic Prostaglandins PA Policy

Policy

Ophthalmic Quinolone Antibiotics Preferred Step Therapy Policy

Policy

Ophthalmology - Durysta PA Policy

Policy

Ophthalmology - Luxturna PA Policy

Policy

Ophthalmology - Oxervate PA Policy

Policy

Ophthalmology - Tepezza PA Policy

Policy

Ophthalmology - Upneeq PA Policy

Policy

Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu PA

Policy

Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Eylea PA

Policy

Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Lucentis PA

Policy

Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Macugen PA

Policy

Ophthalmology - Vascular Endothelial Growth Factor Inhibitors PSM Policy

Policy

Opioids - Fentanyl Transmucosal Drugs PA Policy

Policy

Opioids - Long-Acting Products PA Policy

Policy

Opioids - Tramadol Extended-Release PA Policy

Policy

Opioids Short-Acting DQM per RX - Adult

Policy

Opioids Short-Acting DQM per RX - All ages

Policy

Opioids Short-Acting DQM per RX - Pediatric

Policy

Oral Long-Acting Opioids_DQM - Per Days_30 days

Policy

Orencia_DQM - per Days

Policy

Orgovyx_DQM - Oncology per Rx

Policy

Orilissa_DQM - Per Days

Policy

Otic Quinolone - Ciprofloxacin Preferred Step Therapy Policy

Policy

Overactive Bladder Agents Preferred Step Therapy Policy

Policy

Oxbryta_DQM - Per Rx

Policy

Palforzia_DQM - Per Rx

Policy

Palynziq_DQM - Per Rx

Policy

Pancreatic Enzymes (Enteric-Coated) Preferred Step Therapy Policy

Policy

Parasitic Infection Drugs - Per Days_30 days

Policy

Parkinson's Disease - Amantadine Extended-Release Drugs PA with Step Therapy Policy

Policy

Parkinson's Disease - Apokyn PA Policy

Policy

Parkinson's Disease - Duopa PA Policy

Policy

Parkinson's Disease - Inbrija PA Policy

Policy

Parkinson's Disease - Kynmobi PA Policy

Policy

Parkinson's Disease - Lodosyn PA Policy

Policy

Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy Policy

Policy

Parkinson's Disease - Nourianz PA Policy

Policy

Parkinson's Disease - Nuplazid PA Policy

Policy

Parkinson's Disease - Ongentys PA Policy

Policy

Parkinson's Disease - Tolcapone Products PA Policy

Policy

Parkinson's Disease - Zelapar PA Policy

Policy

Pegylated Interferons PA Policy

Policy

Phenylketonuria - Palynziq PA Policy

Policy

Phenylketonuria - Sapropterin (Kuvan) PA Policy

Policy

Pheochromocytoma - Demser and Phenoxybenzamine PA

Policy

Pheochromocytoma - Metyrosine Capsules and Phenoxybenzamine Capsules PA Policy

Policy

Phosphate Binders - Calcium acetate, Fosrenol, Renagel, Renvela_DQM - Per Days

Policy

Potassium Binders Preferred Step Therapy Policy

Policy

Prevymis_DQM - Per Days

Policy

Progesterone (Vaginal-Infertility) Preferred Step Therapy Policy

Policy

Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy

Policy

Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy

Policy

Proton Pump Inhibitors Step Therapy Policy

Policy

Psychiatry - Spravato PA Policy

Policy

Psychiatry - Zulresso PA Policy

Policy

Pulmicort (budesonide)_DQM - Per Rx

Policy

Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy

Policy

Pulmonary - Corticosteroid Inhalers Preferred Step Therapy Policy - Effective 07.01.2021

Policy

Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy

Policy

Pulmonary - Daliresp PA Policy

Policy

Pulmonary - Long-Acting Beta2-Agonist Inhalers Preferred Step Therapy Policy

Policy

Pulmonary - Long-Acting Muscarinic Antagonist Inhalers Preferred Step Therapy Policy

Policy

Pulmonary - Long-Acting Muscarinic Antagonist Long-Acting Beta2-Agonist Combination Inhalers Preferred Step Therapy Policy

Policy

Pulmonary - Short-Acing Beta2-Agonist Inhalers Preferred Step Therapy Policy

Policy

Pulmonary - Short-Acing Beta2-Agonist Inhalers Preferred Step Therapy Policy

Policy

Pulmonary Arterial Hypertension - Adempas PA Policy

Policy

Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist PSM Policy

Policy

Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy

Policy

Pulmonary Arterial Hypertension - Epoprostenol PA Policy

Policy

Pulmonary Arterial Hypertension - Epoprostenol Products PA Policy

Policy

Pulmonary Arterial Hypertension - Inhaled Prostacyclin Products PA Policy

Policy

Pulmonary Arterial Hypertension - Inhaled Prostacyclin Products PSM Policy

Policy

Pulmonary Arterial Hypertension - Orenitram PA Policy

Policy

Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy

Policy

Pulmonary Arterial Hypertension - Treprostinil Injection (Remodulin) PSM Policy

Policy

Pulmonary Arterial Hypertension - Uptravi PA Policy

Policy

Qbrexza PA with Step Therapy Policy

Policy

Qsymia_DQM - Per Rx

Policy

Relenza_Standard per Rx

Policy

Repatha_DQM - Per Days_28 days

Policy

Revatio (sildenafil)_DQM - Per Rx

Policy

Rituximab Intravenous Products PSM Policy

Policy

Rozlytrek_DQM - Oncology per Rx

Policy

Samsca-Jynarque_DQM - Per Rx

Policy

Scenesse PA Policy

Policy

Sedative Hypnotics Step Therapy Policy

Policy

Sensipar PA Policy

Policy

Sickle Cell Disease - Adakveo PA Policy

Policy

Sickle Cell Disease - Endari PA Policy

Policy

Sickle Cell Disease - Hydroxyurea Products Preferred Step Therapy Policy

Policy

Sickle Cell Disease - Oxbryta PA Policy

Policy

Skyrizi_DQM - per Days

Policy

Solaraze PA Policy

Policy

Soliris PA Policy

Policy

Soma (carisoprodol), Soma Compound (carisoprodol-ASA) DQM - Per Days

Policy

Somatostatin Analogs - Mycapssa PA Policy

Policy

Somatostatin Analogs - Octreotide Immediate-Release Products Prior Authorization Policy

Policy

Somatostatin Analogs - Sandostatin LAR Depot PA Policy

Policy

Somatostatin Analogs - Sandostatin LAR Depot PA Policy

Policy

Somatostatin Analogs - Signifor LAR PA Policy

Policy

Somatostatin Analogs - Somatuline Depot PA Policy

Policy

Somatostatin Analogs for Acromegaly Utilization Management Policy

Policy

Somavert PA Policy

Policy

Spinal Muscular Atrophy - Evrysdi PA Policy

Policy

Spinal Muscular Atrophy - Spinraza PA Policy

Policy

Spinal Muscular Atrophy - Zolgensma PA Policy

Policy

Spinraza_DQM - per Days

Policy

Sprycel_DQM - Oncology Per Rx

Policy

Stadol (butorphanol)_Select per Days_28 days

Policy

Stelara_DQM - per Days

Policy

Suboxone Zubsolv Bunavail (buprenorphine-naloxone)_DQM - Per Rx

Policy

Sunosi_DQM - Per Rx

Policy

Sutent_DQM - Oncology Per Rx

Policy

Synagis PA Policy

Policy

Tamiflu_Standard per Rx

Policy

Tarceva (erlotinib)_DQM - Oncology per Rx

Policy

Tasigna_DQM - Oncology per Rx

Policy

Tasigna_DQM - Oncology per Rx

Policy

Tasigna_DQM - Oncology per Rx

Policy

Teripararide_DQM - per Days

Policy

Testosterone (injectable) Products PA Policy

Policy

Testosterone (Oral, Topical, and Nasal) Products PA Policy

Policy

Tetracyclines (oral) Step Therapy Policy

Policy

Thrombocytopenia - Doptelet PA Policy

Policy

Thrombocytopenia - Mulpleta PA Policy

Policy

Thrombocytopenia - Nplate PA Policy

Policy

Thrombocytopenia - Promacta PA Policy

Policy

Thrombocytopenia - Tavalisse PA Policy

Policy

Tolvaptan Products - Jynarque PA Policy

Policy

Tolvaptan Products - Tolvaptan (Samsca) PA Policy

Policy

Topical Acne - Cleansers Step Therapy Policy

Policy

Topical Acne - Kits Step Therapy Policy

Policy

Topical Acne - Topical Products Step Therapy Policy

Policy

Topical Acne - Winlevi PA Policy

Policy

Topical Acyclovir Products PA Policy

Policy

Topical Agents for Atopic Dermatitis Step Therapy Policy

Policy

Topical Alpha-Adrenergic Agonists for Rosacea PA Policy

Policy

Topical Anesthetic - Lidocaine.Tetracaine Products PA with Step Therapy Policy

Policy

Topical Anesthetic - Pliaglis PA with Step Therapy Policy

Policy

Topical Anesthetics_DQM - per Days_30 days

Policy

Topical Antibacterials Step Therapy Policy

Policy

Topical Calcipotriene Products_DQM - per Days

Policy

Topical Collagenase Santyl Ointment_DQM - per Rx

Policy

Topical Corticosteroids Step Therapy Policy

Policy

Topical diclofenac sodium gel (Solaraze) PA Policy

Policy

Topical Doxepin Cream_DQM - per Days

Policy

Topical Doxepin Step Therapy Policy

Policy

Topical Medications for Actinic Keratosis Preferred Step Therapy

Policy

Topical Medications for Inflammatory Rosacea Step Therapy

Policy

Topical Podofilox Products Step Therapy Policy

Policy

Topical Products for Atopic Dermatitis_DQM - per Days

Policy

Topical Retinoids - Aklief PA Policy

Policy

Topical Retinoids - Panretin PA Policy

Policy

Topical Retinoids - Tazarotene Products PA Policy

Policy

Topical Retinoids - Tazarotene Products PA Policy

Policy

Topical Retinoids - Tretinoin Products PA Policy

Policy

Topical Testosterone Products DQM - Per Rx

Policy

Topical Vitamin D Analogs Step Therapy Policy

Policy

Topical_Antifungals_DQM - per Days_28 days

Policy

Tramadol extended-release_DQM - Per Rx

Policy

Triamcinolone Topical Spray_DQM - per Days

Policy

Tykerb_DQM - Oncology per Rx

Policy

Uplizna PA Policy

Policy

Valium (diazepam) DQM - Per Days

Policy

Valtrex (valacyclovir)_DQM - Per Rx

Policy

Vancomycin Oral_DQM - Per Rx

Policy

Vecamyl PA Policy

Policy

Velphoro_DQM - Per Rx

Policy

Veltassa_DQM - Per Rx

Policy

Veregen PA Policy

Policy

Verquvo_DQM - Per Rx

Policy

Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy

Policy

Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy

Policy

Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy

Policy

Vesicular Monoamine Transporter Type 2 Inhibitors DQM - Per Rx

Policy

Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy

Policy

Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy

Policy

Vitamin D Analog (Oral) Step Therapy Policy

Policy

Vocabria_DQM - per Days

Policy

Wakefulness-Promoting Agents - Armodafinil, Modafinil PA Policy

Policy

Wakefulness-Promoting Agents - Sunosi PA Policy with Step Therapy

Policy

Wakefulness-Promoting Agents - Wakix PA Policy with Step Therapy

Policy

Wakix_DQM - Per Rx

Policy

Wegovy_DQM - Per Days

Policy

Weight Loss - Glucagon-Like Peptide-1 Agonists PA Policy

Policy

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

Policy

Xyrem-Xywav PA Policy with Step Therapy

Policy

Yonsa_DQM - Oncology Per Rx

Policy

Zavesca Market Events Clinical Policy

Policy

Zepatier_DQM - Per Days_28 days

Policy

Zetia Step Therapy Policy

Policy

Zokinvy PA Policy

Policy

Zontivity PA Policy

Policy

Zovirax (Topical) PA Policy

Policy