Utilization Management

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

A
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 - Amvuttra PA Policy
Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy Policy
Amyloidosis - Tegsedi PA Policy Policy
Amyloidosis - Wainua PA 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
Antidepressants ST Policy
Antiepileptics - Topiramate Step Therapy Policy Policy
Antifungals - Cresemba (Oral) PA Policy Policy
Antifungals - Posaconazole (Oral) PA Policy
Antifungals - Voriconazole (Oral) PA Policy Policy
Antifungals for Vulvovaginal Candidiasis Step Therapy Policy Policy
Antiseizure Medications - Clobazam Products PA Policy
Antiseizure Medications - Depakote, Depakene Step Therapy Policy
Antiseizure Medications - Diacomit PA Policy Policy
Antiseizure Medications - Epidiolex PA Policy Policy
Antiseizure Medications - Lacosamide ST Policy
Antiseizure Medications - Lamotrigine Step Therapy Policy Policy
Antiseizure Medications - Levetiracetam, Brivaracetam Step Therapy Policy
Antiseizure Medications - Nayzilam PA Policy
Antiseizure Medications - Oxtellar XR, Trileptal ST Policy
Antiseizure Medications - Rufinamide PA Policy
Antiseizure Medications - Topiramate Step Therapy Policy Policy
Antiseizure Medications - Valtoco PA Policy Policy
Antiseizure Medications - Vigabatrin PA Policy
Antiseizure Medications - Zonisamide ST Policy
Antiseizure Medications - Ztalmy PA Policy
Antivirals - Ribavirin (Inhaled Products) PA Policy Policy
Antivirals - Ribavirin (Oral Products) 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
B
Benign Prostatic Hyperplasia - 5-Alpha-Reductase Inhibitors Step Therapy Policy Policy
Benign Prostatic Hyperplasia - Entadfi PA 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
Botulinum Toxin - Daxxify PA Policy
Botulinum Toxin Products PSM Policy
C
Calcium Channel Blockers - Dihydropyridine Products Step Therapy Policy Policy
Calcium Channel Blockers - Verapamil Products Step Therapy Policy Policy
Carbinoxamine Step Therapy Policy Policy
Cardiology - Camzyos PA Policy
Cardiology - Lodoco PA Policy
Cardiology - Ranolazine Products ST 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 Products 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 Preferred Specialty Management Policy for Basic Formulary Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for High Performance and National Preferred Formularies Policy
Colony Stimulating Factors - Leukine PA Policy Policy
Colony Stimulating Factors - Pegfilgrastim Products and Rolvedon Preferred Specialty Management Policy for High Performance and National Preferred Formularies Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy Policy
Colony Stimulating Factors - Rolvedon PA Policy
Complement Inhibitors - Empaveli PA Policy Policy
Complement Inhibitors - Fabhalta PA Policy
Complement Inhibitors - PiaSky PA Policy
Complement Inhibitors - Veopoz PA Policy
Complement Inhibitors - Voydeya PA Policy
Complement Inhibitors - Zilbrysq PA Policy
Complement Inhibitors – Ultomiris Intravenous PA Policy Policy
Complement Inhibitors – Ultomiris Subcutaneous PA Policy Policy
Complement System Disorders - WHIM Syndrome - Xolremdi PA Policy
Compounded Select Topical Medications PA Policy Policy
Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy Policy
Coronavirus Disease - Evusheld PA Policy
Corticosteroids (Intraarticular) - Zilretta PA Policy Policy
Cushing's - Recorlev PA Policy Policy
Cushing's - Signifor PA Policy Policy
Cushings - Mifepristone PSM 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
D
Dermatology - Filsuvez PA Policy
Dermatology - Gene Therapy - Vyjuvek PA Policy
Dermatology - Hyftor PA 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 - Optional 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
Diabetes - Tzield PA Policy
Dichlorphenamide PA Policy Policy
Dichlorphenamide PSM Policy
Diuretics - Loop Products Step Therapy Policy Policy
Dronabinol Products PA Policy
E
Enspryng PA Policy Policy
Enzyme Replacement Therapy - Elfabrio Policy
Enzyme Replacement Therapy - Lamzede PA Policy
Enzyme Replacement Therapy - Strensiq PA Policy Policy
Enzyme Replacement Therapy - Sucraid PA Policy Policy
Enzyme Replacement Therapy - Xenpozyme PA Policy
Epinephrine Auto-Injectors Step Therapy Policy Policy
Erectile Dysfunction - Tadalafil (Cialis) PA Policy Policy
Erythropoiesis - Stimulating Agents Preferred Specialty Management Policy for High Performance and National Preferred Formularies Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy Policy
Estrogen - Transdermal Step Therapy Policy Policy
Ezetimibe (Zetia) Step Therapy Policy Policy
F
Fabry Disease - Galafold PA Policy Policy
Fenofibrate Step Therapy Policy Policy
G
Gabapentin Step Therapy Policy Policy
Gastroenterology - Eohilia PA 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 - Growth Hormone Long-Acting Products PSM Policy
Growth Disorders - Growth Hormone PA Policy
Growth Disorders - Growth Hormone Short-Acting Products PSM Policy Policy
Growth Disorders - Increlex PA Policy Policy
Growth Disorders - Ngenla PA Policy
Growth Disorders - Sogroya PA Policy
Growth Disorders - Voxzogo PA Policy
H
Hematology - Adzynma PA Policy
Hematology - Aphexda PA Policy
Hematology - Cablivi PA Policy Policy
Hematology - Enjaymo PA Policy Policy
Hematology - Gene Therapy - Casgevy PA Policy
Hematology - Gene Therapy - Lyfgenia PA Policy
Hematology - Gene Therapy - Zynteglo PA Policy
Hematology - Pyrukynd PA Policy
Hematology - Ryplazim PA Policy
Hematology - Rytelo PA Policy
Hematology - Rytelo PA Policy
Hemophilia - Altuviiio PA Policy
Hemophilia - Gene Therapy - Beqvez PA Policy
Hemophilia - Gene Therapy - Hemgenix PA Policy
Hemophilia - Gene Therapy - Roctavian PA Policy
Hemophilia - Recombinant Factor IX Products 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 for National Preferred Formulary and Basic Formulary Policy
Hepatology - Iqirvo PA Policy
Hepatology - Livdelzi PA Policy
Hepatology - Ocaliva PA Policy Policy
Hepatology - Rezdiffra PA 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 - Apretude PA Policy
Human Immunodeficiency Virus - Sunlenca PA 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
Hyperhidrosis - Qbrexza PA Policy
Hyperlipidemia - Nexletol PA Policy Policy
Hyperlipidemia - Nexlizet PA Policy Policy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy Policy
I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PSM Policy
Immune Disorder - Joenja PA Policy
Immunologicals - Anti-Interleukin-5 Agents PSM Policy Policy
Immunologicals - Dupixent PA Policy Policy
Immunologicals - Fasenra PA Policy Policy
Immunologicals - Nemluvio PA Policy
Immunologicals - Nucala PA Policy
Immunologicals - Tezspire PA Policy Policy
Immunologicals - Xolair PA Policy Policy
Immunologicals – Adbry PA Policy
Infectious Disease - Impavido PA Policy Policy
Infectious Disease - Ivermectin Tablets PA Policy Policy
Infectious Disease - Livtencity PA 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 - Vaginal Progesterone PSM Policy
Infertility – Follitropins, Clomiphene Preferred Specialty Management Policy
Inflammatory Conditions - Adalimumab Products PA Policy Policy
Inflammatory Conditions - Adalimumab Products PSM Policy
Inflammatory Conditions - Adalimumab Products PSM for National Preferred, High Performance, and Basic Formularies - Choice Policy
Inflammatory Conditions - Arcalyst PA Policy Policy
Inflammatory Conditions - Bimzelx PA Policy
Inflammatory Conditions - Care Value Policy Policy
Inflammatory Conditions - Cibinqo PA Policy
Inflammatory Conditions - Cosentyx Intravenous PA Policy
Inflammatory Conditions - Entyvio Subcutaneous PA Policy
Inflammatory Conditions - Etanercept Products PA Policy Policy
Inflammatory Conditions - Litfulo PA Policy
Inflammatory Conditions - Omvoh Intravenous PA Policy
Inflammatory Conditions - Omvoh Subcutaneous PA Policy
Inflammatory Conditions - Otezla PA Policy Policy
Inflammatory Conditions - Rinvoq PA Policy Policy
Inflammatory Conditions - Skyrizi Intravenous PA Policy
Inflammatory Conditions - Skyrizi Subcutaneous PA Policy Policy
Inflammatory Conditions - Sotyktu PA Policy
Inflammatory Conditions - Spevigo Subcutaneous PA Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy with Dosing Policy
Inflammatory Conditions - Taltz PA Policy Policy
Inflammatory Conditions - Tocilizumab Subcutaneous Products PA Policy
Inflammatory Conditions - Tremfya PA Policy Policy
Inflammatory Conditions - Velsipity PA Policy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy Policy
Inflammatory Conditions - Zymfentra PA Policy
Inflammatory Conditions - Zymfentra PA Policy
Inflammatory Conditions PSM for FLEX Formulary Policy
Inflammatory Conditions PSM for FLEX Formulary Policy
Inpefa PA Policy
Interferon - Actimmune PA Policy Policy
Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy Policy
Isotretinoin Step Therapy Policy Policy
L
Levothyroxine Products ST Policy
Lidocaine Patch Products PA Policy
Lipodystrophy - Egrifta PA Policy Policy
Lipodystrophy - Myalept PA Policy Policy
Lupus – Benlysta Subcutaneous PA Policy Policy
M
Metabolic Disorders - Betaine Anhydrous PSM 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 - Phenylbutyrate Products PSM Policy
Metabolic Disorders - Primary Hyperoxaluria - Rivfloza PA Policy
Metabolic Disorders - Tiopronin Products PA Policy Policy
Metabolic Disorders - Tiopronin Products PSM Policy
Metabolic Disorders - Xuriden PA Policy Policy
Methotrexate Injection Step Therapy Policy
Methylergonovine (Methergine) PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality 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 - Zavzpret PA Policy
Migraine Medication Step Therapy Policy Policy
Multiple Sclerosis - Avonex PA Policy Policy
Multiple Sclerosis - Bafiertam PA Policy Policy
Multiple Sclerosis - Betaseron, Extavia PA Policy Policy
Multiple Sclerosis - Briumvi PA Policy
Multiple Sclerosis - CD20-Directed Cytolytic Antibody Infused Products 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 - Tascenso ODT PA Policy
Multiple Sclerosis - Teriflunomide PA 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 for National Preferred, High Performance, and Basic Formularies Policy
Multiple Sclerosis Care Value Policy Policy
Multiple Sclerosis PSM Policy Policy
Muscular Dystrophy - Agamree PA Policy
Muscular Dystrophy - Deflazacort PSM Policy
Muscular Dystrophy - Duvyzat PA Policy
Muscular Dystrophy - Gene Therapy - Elevidys PA Policy
N
Naloxone Injection Step Therapy Policy Policy
Nasal Steroids Step Therapy Policy Policy
Natpara PA Policy Policy
Nephrology - Filspari PA Policy
Nephrology - Jesduvroq PA Policy
Nephrology - Tarpeyo PA Policy
Nephrology - Vafseo PA Policy
Nephrology - Xphozah PA Policy
Neurology - Daybue PA Policy
Neurology - Kisunla PA Policy Policy
Neurology - Leqembi PA Policy
Neurology - Oxybate Products PA Policy Policy
Neurology - Qalsody PA Policy
Neurology - Relyvrio PA Policy
Neurology - Riluzole Products PA Policy Policy
Neurology - Rystiggo PA Policy
Neurology - Skyclarys PA Policy
Neurology - Vyvgart Hytrulo PA Policy
Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy Policy
Northera PA Policy Policy
Nuedexta PA Policy Policy
O
Oncology (Injectable - Programmed Death Receptor-1) - Opdualag PA Policy
Oncology (Injectable - Programmed Death Receptor-1) - Tevimbra PA Policy
Oncology (Injectable - Programmed Death Receptor-1) - Zynyz PA Policy
Oncology (Injectable) - Amtagvi PA Policy
Oncology (Injectable) - Besremi PA Policy
Oncology (Injectable) - Columvi PA Policy
Oncology (Injectable) - Elahere PA Policy
Oncology (Injectable) - Elrexfio PA Policy
Oncology (Injectable) - Epkinly PA Policy
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy Policy
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy Policy
Oncology (Injectable) - Imdelltra PA Policy
Oncology (Injectable) - Imjudo PA Policy
Oncology (Injectable) - Lunsumio Policy
Oncology (Injectable) - Synribo PA Policy Policy
Oncology (Injectable) - Talvey PA Policy
Oncology (Injectable) - Tecelra PA Policy
Oncology (Injectable) - Tecvayli PA Policy
Oncology (Other) - Adstiladrin PA Policy
Oncology (Other) - Anktiva PA Policy
Oncology - Abiraterone Acetate (Zytiga) Care Value Policy Policy
Oncology - Abiraterone Acetate (Zytiga) PA Policy Policy
Oncology - Abiraterone Acetate (Zytiga) PSM Policy Policy
Oncology - Akeega PA Policy
Oncology - Alecensa PA Policy Policy
Oncology - Alunbrig PA Policy Policy
Oncology - Augtyro PA 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 PA Policy Policy
Oncology - Everolimus Products PA Policy Policy
Oncology - Everolimus Products PSM Policy Policy
Oncology - Farydak PA Policy Policy
Oncology - Fruzaqla PA Policy
Oncology - Gavreto PA Policy Policy
Oncology - Gefitinib PA 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 - Imatinib PSM Policy Policy
Oncology - Imbruvica PA Policy Policy
Oncology - Imbruvica PSM Policy Policy
Oncology - Inlyta PA Policy Policy
Oncology - Iwilfin PA Policy
Oncology - Jakafi PA Policy Policy
Oncology - Jaypirca PA Policy
Oncology - Koselugo PA Policy
Oncology - Krazati Policy
Oncology - Lapatinib (Tykerb) PA Policy Policy
Oncology - Lenalidomide PA Policy
Oncology - Lenvima PA Policy Policy
Oncology - Lonsurf PA Policy Policy
Oncology - Lorbrena PA Policy Policy
Oncology - Lynparza PA Policy
Oncology - Lytgobi 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 - Ogsiveo PA Policy
Oncology - Ojemda PA Policy
Oncology - Ojjaara PA Policy
Oncology - Orserdu PA Policy
Oncology - Pazopanib PA Policy
Oncology - Pemazyre PA Policy Policy
Oncology - Pomalyst PA Policy Policy
Oncology - Retevmo PA Policy Policy
Oncology - Revlimid PA Policy Policy
Oncology - Rezlidhia PA Policy
Oncology - Rozlytrek PA Policy Policy
Oncology - Rubraca PA Policy Policy
Oncology - Rydapt PA Policy Policy
Oncology - Sorafenib PA Policy
Oncology - Sprycel PA Policy Policy
Oncology - Stivarga PA Policy Policy
Oncology - Sunitinib PA 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 - Truqap PA Policy
Oncology - Tukysa PA Policy Policy
Oncology - Turalio PA Policy Policy
Oncology - Ukoniq PA Policy Policy
Oncology - Valchlor PA Policy Policy
Oncology - Vanflyta PA 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 - Vonjo PA Policy
Oncology - Voranigo PA 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 - Dry Eye Disease - Cyclosporine Products PA Policy
Ophthalmology - Dry Eye Disease – Miebo PA Policy
Ophthalmology - iDose TR PA Policy
Ophthalmology - Izervay PA Policy
Ophthalmology - Oxervate PA Policy Policy
Ophthalmology - Syfovre PA Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PSM Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA Policy
Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA Policy
Ophthalmology - Verkazia PA Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy Policy
Opioids - Long-Acting Products PA Policy Policy
Opioids - Methadone Prior Authorization Policy Policy
Opioids - Tramadol Extended-Release Products PA Policy
Otic Quinolone - Ciprofloxacin Step Therapy Policy Policy
Overactive Bladder Medications Step Therapy Policy Policy
P
Parkinson's Disease - Carbidopa PA Policy
Parkinson's Disease - Inbrija PA Policy Policy
Parkinson's Disease - Kynmobi 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 - Tolcapone PA Policy
Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy Policy
Parkinson’s Disease - Nuplazid 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
Pompe Disease - Enzyme Replacement Therapy - Pombiliti Prior Policy
Pompe Disease - Enzyme Stabilization Therapy - Opfolda Prior Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy Policy
Proton Pump Inhibitors Step Therapy Policy Policy
Pulmonary - Airsupra ST 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 - 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
Pulmonary Arterial Hypertension - Winrevair PA Policy
R
Repository Corticotropin - Acthar Gel PA Policy Policy
Repository Corticotropin - Cortrophin Gel PA Policy
S
Sedative Hypnotics Step Therapy Policy Policy
Sickle Cell Disease - Endari PA Policy Policy
Sohonos PA Policy
Somatostatin Analogs - Lanreotide Products PA Policy
Somatostatin Analogs - Octreotide Immediate-Release Products PA 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
T
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 - Eltrombopag Products PA Policy
Thrombocytopenia - Eltrombopag Products PSM 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 - Rhofade PA Policy
Topical Antibacterials Step Therapy Policy
Topical Antifungals for Onychomycosis Step Therapy Policy Policy
Topical Antifungals for Seborrheic Dermatitis Step Therapy Policy
Topical Corticosteroids Step Therapy Policy Policy
Topical Diclofenac Sodium 3% Gel PA Policy
Topical Doxepin Step Therapy Policy Policy
Topical Medications for Inflammatory Rosacea Step Therapy Policy
Topical Podofilox Products Step Therapy Policy Policy
Topical Products - Vtama and Zoryve Cream ST Policy
Topical Products - Zoryve Foam ST 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
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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
Vijoice PA Policy
Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy Policy
Vitamin D Analog (Oral) Step Therapy Policy Policy
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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 PA Policy
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Zokinvy PA Policy Policy