Utilization Management

Prior Authorization and Step Therapy Policies for Commercial and Individual Family Business

A B C D E F G H I K L M N O P Q S T V W Z

Acthar Gel PA Policy

Policy

Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy

Policy

Allergen Immunotherapy - Odactra PA Policy

Policy

Allergen Immunotherapy - Ragwitek PA Policy

Policy

Alzheimer's Disease Step Therapy Policy

Policy

Alzheimers - Namenda, Namenda XR Step Therapy Policy

Policy

Amifampridine Products PA Policy

Policy

Amifampridine Products PSM Policy

Policy

Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy

Policy

Amyloidosis - Tegsedi PA Policy

Policy

Angiotensin Receptor Blocker Step Therapy Policy

Policy

Antibiotics (Inhaled) - Arikayce PA Policy

Policy

Antibiotics (Inhaled) - Cayston PA

Policy

Antibiotics (Inhaled) - TOBI Podhaler PA Policy

Policy

Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA

Policy

Antibiotics (Inhaled) - Tobramycin Products Care Value Policy

Policy

Antibiotics (Inhaled) - Tobramycin Products PSM Policy

Policy

Antibiotics - Linezolid (Zyvox), Sivextro PA Policy

Policy

Antibiotics - Vancomycin Capsules PA Policy

Policy

Antibiotics - Xifaxan PA Policy

Policy

Anticoagulants - Eliquis PA Policy

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 and 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 - 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 - Vigabatrin (Sabril) PA Policy

Policy

Antifungals - Cresemba (Oral) PA Policy

Policy

Antifungals - Noxafil (Oral) PA Policy

Policy

Antifungals - Voriconazole (Oral) PA Policy

Policy

Antifungals for Vulvovaginal Candidiasis Step Therapy Policy

Policy

Antiparasitics - Impavido PA Policy

Policy

Antiseizure Medications - Diacomit PA Policy

Policy

Antiseizure Medications - Epidiolex PA Policy

Policy

Antiseizure Medications - Valtoco PA Policy

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 Medications PA Policy

Policy

Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy

Policy

Benign Prostatic Hyperplasia - 5-Alpha-Reductase Inhibitors Step Therapy Policy

Policy

Benign Prostatic Hyperplasia – Alpha Blockers Step Therapy

Policy

Beta Blocker Step Therapy Policy

Policy

Bile Acid Sequestrants Step Therapy Policy

Policy

Bisphosphonates (Oral) Enhanced Step Therapy Policy

Policy

Bone Modifiers - Teriparatide Products PA Policy

Policy

Bone Modifiers - Tymlos PA Policy

Policy

Bone Modifiers - Xgeva PA Policy

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

Calcium Channel Blockers - Dihydropyridine Products Step Therapy Policy

Policy

Calcium Channel Blockers - Verapamil Products Step Therapy Policy

Policy

Carbinoxamine Step Therapy Policy

Policy

Cardiology - Zontivity PA Policy

Policy

Chelating Agents - Chemet PA Policy

Policy

Chelating Agents - Iron Chelators (Oral) Care Value Policy

Policy

Chelating Agents - Iron Chelators (Oral) PA Policy

Policy

Chelating Agents - Iron Chelators (Oral) PSM Policy

Policy

Chelating Agents - Penicillamine Products PA Policy

Policy

Chelating Agents - Trientine PA

Policy

Chenodal PA Policy

Policy

Cholbam PA Policy

Policy

Chorionic Gonadotropins PSM Policy

Policy

Cinacalcet (Sensipar) PA Policy

Policy

Colony Stimulating Factors - Filgrastim Products PA Policy

Policy

Colony Stimulating Factors - Filgrastim Products PSM Policy

Policy

Colony Stimulating Factors - Leukine PA Policy

Policy

Colony Stimulating Factors - Pegfilgrastim Products and Rolvedon PSM Policy

Policy

Colony Stimulating Factors - Pegfilgrastim Products PA Policy

Policy

Complement Inhibitors - Empaveli PA Policy

Policy

Complement Inhibitors – Ultomiris Intravenous PA Policy

Policy

Complement Inhibitors – Ultomiris Subcutaneous PA Policy

Policy

Compounded Select Topical Medications PA Policy

Policy

Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy

Policy

Corticosteroids (Intraarticular) - Zilretta PA Policy

Policy

Cushing's - Recorlev 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

Desmopressin Products - Nocdurna PA Policy

Policy

Diabetes - Continuous Glucose Monitoring Systems PA Policy

Policy

Diabetes - Dipeptidyl Peptidase-4 Inhibitors Care Value Policy

Policy

Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy

Policy

Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy

Policy

Diabetes - Metformin Care Value Policy

Policy

Diabetes - Metformin Step Therapy Policy

Policy

Diabetes - Mounjaro PA

Policy

Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy

Policy

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

Policy

Diabetes - Symlin PA Policy

Policy

Diabetes - Thiazolidinedione Step Therapy Policy

Policy

Dronabinol PA Policy

Policy

Enspryng PA Policy

Policy

Enzyme Replacement Therapy - Strensiq PA Policy

Policy

Enzyme Replacement Therapy - Sucraid PA Policy

Policy

Epinephrine Auto-Injectors Step Therapy Policy

Policy

Erectile Dysfunction - Tadalafil (Cialis) PA Policy

Policy

Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy

Policy

Erythropoiesis-Stimulating Agents PSM Policy

Policy

Estrogen - Transdermal Step Therapy Policy

Policy

Ezetimibe (Zetia) Step Therapy Policy

Policy

Fabry Disease - Galafold PA Policy

Policy

Fenofibrate Step Therapy Policy

Policy

Gabapentin Step Therapy Policy

Policy

Gaucher Disease - Substrate Reduction Therapy Care Value 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

Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy

Policy

Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy

Policy

Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products (Lupron Depot-Ped and Triptodur) PA

Policy

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

Policy

Gonadotropin-Releasing Hormone Antagonists - Oriahnn PA Policy

Policy

Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy

Policy

Gout Medications Step Therapy Policy

Policy

Growth Disorders - Daily Growth Hormone PSM Policy

Policy

Growth Disorders - Growth Hormone PA

Policy

Growth Disorders - Increlex PA Policy

Policy

Hematology - Cablivi PA Policy

Policy

Hematology - Enjaymo PA Policy

Policy

Hepatitis C - Epclusa PA Policy

Policy

Hepatitis C - Harvoni PA Policy

Policy

Hepatitis C - Ribavirin PA Policy

Policy

Hepatitis C - Viekira Pak PA Policy

Policy

Hepatitis C - Vosevi PA Policy

Policy

Hepatitis C - Zepatier PA Policy

Policy

Hepatitis C Virus Direct - Acting Antivirals PSM Policy

Policy

Hepatology - Ocaliva PA Policy

Policy

Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy

Policy

Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy

Policy

Hereditary Angioedema - Icatibant (Firazyr) Care Value 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 – Hetlioz LQ (tasimelteon oral suspension)

Policy

Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy

Policy

Human Immunodeficiency Virus - Truvada PSM Policy

Policy

Hydrocortisone Acetate Suppository Step Therapy Policy

Policy

Hydroxy-methylglutaryl-coenzyme A Reductase Inhibitors Step Therapy Policy

Policy

Hyperlipidemia - Nexletol PA Policy

Policy

Hyperlipidemia - Nexlizet PA Policy

Policy

Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy

Policy

Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy

Policy

Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy

Policy

Immunologicals - Anti-Interleukin-5 Agents PSM Policy

Policy

Immunologicals - Dupixent PA Policy

Policy

Immunologicals - Fasenra PA Policy

Policy

Immunologicals - Nucala PA

Policy

Immunologicals - Tezspire PA Policy

Policy

Immunologicals - Xolair PA Policy

Policy

Infectious Disease - Ivermectin Tablets PA Policy

Policy

Infectious Disease - Pretomanid PA Policy

Policy

Infectious Disease - Pyrimethamine PA Policy

Policy

Infectious Disease - Sirturo PA Policy

Policy

Infertility - Gonadotropin-Releasing Hormone Antagonists PSM Policy

Policy

Infertility – Follitropins, Clomiphene Preferred Specialty Management

Policy

Inflammatory Conditions - Actemra Subcutaneous PA Policy

Policy

Inflammatory Conditions - Adalimumab Products PA Policy

Policy

Inflammatory Conditions - Arcalyst PA Policy

Policy

Inflammatory Conditions - Care Value Policy

Policy

Inflammatory Conditions - Etanercept Products PA Policy

Policy

Inflammatory Conditions - Otezla PA Policy

Policy

Inflammatory Conditions - Rinvoq PA Policy

Policy

Inflammatory Conditions - Skyrizi Subcutaneous 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

Interferon - Actimmune PA Policy

Policy

Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy

Policy

Isotretinoin Step Therapy Policy

Policy

Keveyis PA Policy

Policy

Lidocaine Patch PA Policy

Policy

Lipodystrophy - Egrifta PA Policy

Policy

Lipodystrophy - Myalept PA Policy

Policy

Lupus – Benlysta Subcutaneous PA Policy

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 - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy

Policy

Metabolic Disorders - Tiopronin Products PA Policy

Policy

Metabolic Disorders - Xuriden PA Policy

Policy

Methotrexate Injection Step Therapy

Policy

Methylergonovine (Methergine) PA Policy

Policy

Migraine - Nurtec ODT PA Policy

Policy

Migraine - Qulipta PA Policy

Policy

Migraine - Reyvow PA Policy

Policy

Migraine - Ubrelvy PA Policy

Policy

Migraine Medication Step Therapy 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 - Dalfampridine PSM Policy

Policy

Multiple Sclerosis - Dimethyl Fumarate PA Policy

Policy

Multiple Sclerosis - Fingolimod 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 - Mayzent PA Policy

Policy

Multiple Sclerosis - Plegridy PA

Policy

Multiple Sclerosis - Ponvory PA Policy

Policy

Multiple Sclerosis - Rebif 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 and Ulcerative Colitis - Zeposia PSM Policy

Policy

Multiple Sclerosis Care Value Policy

Policy

Multiple Sclerosis PSM Policy

Policy

Naloxone Injection Step Therapy Policy

Policy

Nasal Steroids Step Therapy Policy

Policy

Natpara PA Policy

Policy

Neurology - Oxybate Products PA Policy

Policy

Neurology - Riluzole Products PA Policy

Policy

Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy

Policy

Northera PA Policy

Policy

Nuedexta PA Policy

Policy

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

Policy

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

Policy

Oncology (Injectable) - Synribo PA Policy

Policy

Oncology - Abiraterone Acetate (Zytiga) Care Value Policy

Policy

Oncology - Abiraterone Acetate (Zytiga) PA Policy

Policy

Oncology - Abiraterone Acetate (Zytiga) PSM Policy

Policy

Oncology - Afinitor PSM Policy

Policy

Oncology - Alecensa PA Policy

Policy

Oncology - Alunbrig PA Policy

Policy

Oncology - Ayvakit PA Policy

Policy

Oncology - Balversa PA Policy

Policy

Oncology - Bexarotene (Oral) PA

Policy

Oncology - Bexarotene (Topical) PA

Policy

Oncology - Bosulif PA Policy

Policy

Oncology - Braftovi PA Policy

Policy

Oncology - Brukinsa PA Policy

Policy

Oncology - Cabometyx PA

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 PSM Policy

Policy

Oncology - Daurismo PA Policy

Policy

Oncology - Erivedge PA Policy

Policy

Oncology - Erleada PA Policy

Policy

Oncology - Erlotinib (Tarceva) PA Policy

Policy

Oncology - Everolimus Products PA Policy

Policy

Oncology - Farydak PA Policy

Policy

Oncology - Gavreto PA Policy

Policy

Oncology - Gilotrif 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 - Inlyta PA Policy

Policy

Oncology - Iressa PA Policy

Policy

Oncology - Jakafi PA Policy

Policy

Oncology - Koselugo PA

Policy

Oncology - Lapatinib (Tykerb) PA Policy

Policy

Oncology - Lenvima PA Policy

Policy

Oncology - Lonsurf PA Policy

Policy

Oncology - Lorbrena PA Policy

Policy

Oncology - Lynparza PA

Policy

Oncology - Mekinist PA Policy

Policy

Oncology - Mektovi 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 - Pemazyre PA Policy

Policy

Oncology - Pomalyst PA Policy

Policy

Oncology - Retevmo PA Policy

Policy

Oncology - Revlimid 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 - Sunitinib Prior Authorization Policy

Policy

Oncology - Tabrecta PA Policy

Policy

Oncology - Tafinlar PA Policy

Policy

Oncology - Tagrisso PA Policy

Policy

Oncology - Talzenna PA Policy

Policy

Oncology - Tasigna PA Policy

Policy

Oncology - Tazverik PA Policy

Policy

Oncology - Temozolomide Capsules PA Policy

Policy

Oncology - Thalomid PA Policy

Policy

Oncology - Tibsovo PA

Policy

Oncology - Tukysa PA Policy

Policy

Oncology - Turalio PA Policy

Policy

Oncology - Ukoniq PA Policy

Policy

Oncology - Valchlor 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 - Xalkori PA

Policy

Oncology - Xermelo PA Policy

Policy

Oncology - Xospata PA Policy

Policy

Oncology - Xtandi PA Policy

Policy

Oncology - Yonsa 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 Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Beta-adrenergic Blockers Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Step Therapy Policy

Policy

Ophthalmic - Glaucoma - Combination Products 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 Step Therapy Policy

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 Nonsteroidal Antiinflammatory Drugs Step Therapy Policy

Policy

Ophthalmic Prostaglandin Step Therapy Policy

Policy

Ophthalmic Quinolone Antibiotics Step Therapy Policy

Policy

Ophthalmology - Oxervate PA Policy

Policy

Opioids - Fentanyl Transmucosal Drugs PA Policy

Policy

Opioids - Long-Acting Products PA Policy

Policy

Opioids - Tramadol Extended-Release PA Policy

Policy

Otic Quinolone - Ciprofloxacin Step Therapy Policy

Policy

Overactive Bladder Medications Step Therapy Policy

Policy

Parkinson's Disease - Carbidopa PA

Policy

Parkinson's Disease - Kynmobi PA Policy

Policy

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

Policy

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

Policy

Parkinson’s Disease - Inbrija PA Policy

Policy

Parkinson’s Disease - Nourianz PA Policy

Policy

Parkinson’s Disease - Nuplazid PA Policy

Policy

Parkinson’s Disease - Tolcapone Products PA Policy

Policy

Pegylated Interferons PA Policy

Policy

Phenylketonuria - Palynziq PA Policy

Policy

Phenylketonuria - Sapropterin (Kuvan) PA Policy

Policy

Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy

Policy

Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy

Policy

Proton Pump Inhibitors

Policy

Pulmonary - Corticosteroid Inhalers Care Value

Policy

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

Policy

Pulmonary - Short-Acing Beta2-Agonist Inhalers 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 - Orenitram PA Policy

Policy

Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy

Policy

Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy

Policy

Pulmonary Arterial Hypertension - Uptravi PA Policy

Policy

Qbrexza PA Policy

Policy

Sedative Hypnotics Step Therapy Policy

Policy

Sickle Cell Disease - Endari PA Policy

Policy

Somatostatin Analogs - Octreotide Immediate-Release Products Prior Authorization Policy

Policy

Somatostatin Analogs - Octreotide Immediate-Release Products PSM Policy

Policy

Somatostatin Analogs - Somatuline Depot PA Policy

Policy

Somatostatin Analogs for Acromegaly PSM Policy

Policy

Somavert PA Policy

Policy

Spinal Muscular Atrophy - Evrysdi PA Policy

Policy

ST: Antidepressants Bupropion to Antidepressants Bupropion Long Acting

Policy

Testosterone (injectable) Products PA Policy

Policy

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

Policy

Tetracyclines (Oral) Step Therapy

Policy

Thrombocytopenia - Doptelet PA Policy

Policy

Thrombocytopenia - Promacta 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 Acyclovir Products PA Policy

Policy

Topical Agents for Atopic Dermatitis Step Therapy Policy

Policy

Topical Alpha - Adrenergic Agonists for Rosacea PA Policy

Policy

Topical Antibacterials Step Therapy

Policy

Topical Antifungals for Onychomycosis Step Therapy Policy

Policy

Topical Corticosteroids Step Therapy Policy

Policy

Topical Diclofenac Sodium 3% Gel

Policy

Topical Doxepin Step Therapy Policy

Policy

Topical Medications for Inflammatory Rosacea Step Therapy

Policy

Topical Podofilox Products Step Therapy Policy

Policy

Topical Retinoids - Aklief PA Policy

Policy

Topical Retinoids - Panretin PA Policy

Policy

Topical Retinoids - Tazarotene Products PA Policy

Policy

Topical Retinoids - Tretinoin Products PA Policy

Policy

Topical Vitamin D Analogs Step Therapy Policy

Policy

Vecamyl PA Policy

Policy

Veregen PA Policy

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 PSM Policy

Policy

Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy

Policy

Vitamin D Analog (Oral) Step Therapy Policy

Policy

Wakefulness-Promoting Agents - Armodafinil, Modafinil PA with Step Therapy Policy

Policy

Wakefulness-Promoting Agents - Sunosi PA Policy with Step Therapy

Policy

Wakefulness-Promoting Agents - Wakix PA Policy with Step Therapy

Policy

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

Policy

Weight Loss - Other Appetite Suppressants and Orlistat

Policy

Zokinvy PA Policy

Policy