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 X Z
A
Acthar Gel PA Policy
Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy
Allergen Immunotherapy - Odactra PA Policy
Allergen Immunotherapy - Ragwitek PA Policy
Alpha Blockers for BPH Step Therapy Policy
Alzheimer's Disease Step Therapy Policy
Alzheimers - Namenda, Namenda XR Step Therapy Policy
Amifampridine Products PA Policy
Amifampridine Products PSM Policy
Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy
Amyloidosis - Tegsedi PA Policy
Angiotensin Receptor Blocker Step Therapy Policy
Antibiotics (Inhaled) - Arikayce PA Policy
Antibiotics (Inhaled) - Cayston PA
Antibiotics (Inhaled) - TOBI Podhaler PA Policy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA
Antibiotics (Inhaled) - Tobramycin Products PSM Policy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy
Antibiotics - Xifaxan PA Policy
Antidepressants - Bupropion Long-Acting Step Therapy Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors Step Therapy Policy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors Step Therapy Policy
Antiepileptics - Clobazam Products PA Policy
Antiepileptics - Depakote, Depakene Step Therapy Policy
Antiepileptics - Diacomit PA Policy
Antiepileptics - Epidiolex PA Policy
Antiepileptics - Lamictal XR Step Therapy Policy
Antiepileptics - Levetiracetam, Brivaracetam Step Therapy Policy
Antiepileptics - Oxtellar XR, Trileptal Step Therapy Policy
Antiepileptics - Topiramate Step Therapy Policy
Antiepileptics - Valtoco PA Policy
Antifungals - Cresemba (Oral) PA Policy
Antifungals - Noxafil (Oral) PA Policy
Antifungals - Tolsura PA with Step Therapy Policy
Antifungals - Voriconazole Tablets and Oral Suspension PA Policy
Antiparasitics - Impavido PA Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy
Attention Deficit Hyperactivity Disorder Stimulant Step Therapy Policy
Avodart Step Therapy Policy
B
Beta Blocker Step Therapy Policy
Bile Acid Sequestrants Step Therapy Policy
Bisphosphonates (Oral) Enhanced Step Therapy Policy
Bone Modifiers - Prolia PA Policy
Bone Modifiers - Teriparatide Products PA Policy
Bone Modifiers - Tymlos PA Policy
C
Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy
Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy
Calcium Channel Blockers - Dihydropyridine Products Step Therapy Policy
Calcium Channel Blockers - Verapamil Products Step Therapy Policy
Carbinoxamine Step Therapy Policy
Chelating Agents - Penicillamine Products PA Policy
Chelating Agents - Syprine PA Policy
Chenodal PA Policy
Cholbam PA Policy
Chorionic Gonadotropins PSM Policy
Cinacalcet (Sensipar) PA Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy
Colony Stimulating Factors - Granix PA Policy
Colony Stimulating Factors - Leukine PA Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy
Colony Stimulating Factors - Pegfilgrastim Products PSM Policy
Contraceptives - Oral and Patch Products Step Therapy Policy
Cushing's - Isturisa PA Policy
Cushing's - Korlym PA Policy
Cushing's - Signifor PA Policy
Cyclooxygenase - 2 Inhibitor Step Therapy Policy
Cystic Fibrosis - Kalydeco PA Policy
Cystic Fibrosis - Orkambi PA Policy
Cystic Fibrosis - Pulmozyme PA Policy
Cystic Fibrosis - Symdeko PA Policy
Cystic Fibrosis - Trikafta PA Policy
D
Desmopressin Products - Nocdurna PA Policy
Desmopressin Products - Noctiva PA with Step Therapy Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy
Diabetes - Metformin Step Therapy Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy
Diabetes - Thiazolidinedione Step Therapy Policy
Dronabinol PA Policy
E
Enzyme Replacement Therapy - Strensiq PA Policy
Enzyme Replacement Therapy - Sucraid PA Policy
Epinephrine Auto-Injectors Step Therapy Policy
Erythroid Stimulating Agents - Mircera PA Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy
Erythropoiesis-Stimulating Agents PSM Policy
F
Fabry Disease - Galafold PA Policy
Fenofibrate Step Therapy Policy
G
Gabapentin Step Therapy Policy
Gaucher Disease - Substrate Reduction Therapy PSM Policy
Gaucher Disease Substrate Reduction Therapy - Cerdelga PA Policy
Gaucher Disease Substrate Reduction Therapy - Miglustat (Zavesca) PA Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products (Lupaneta Pack and Lupron Depot) PA Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products (Lupron Depot-Ped and Triptodur) PA
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy
Gout Medications Step Therapy Policy
Growth Disorders - Growth Hormone PA
Growth Disorders - Increlex PA Policy
Growth Hormone PSM Policy
H
Helicobacter Pylori Infection Combination Products Preferred Step Therapy Policy
Hepatitis C - Epclusa PA Policy
Hepatitis C - Harvoni PA Policy
Hepatitis C - Mavyret PA Policy
Hepatitis C - Ribavirin PA Policy
Hepatitis C - Viekira Pak PA Policy
Hepatitis C - Vosevi PA Policy
Hepatitis C - Zepatier PA Policy
Hepatitis C Virus Direct-Acting Antivirals PSM Policy for National Preferred Formulary
Hepatology - Ocaliva PA Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy
Hereditary Angioedema - Icatibant (Firazyr) PA Policy
Hereditary Angioedema - Kalbitor PA Policy
Hereditary Angioedema - Takhzyro PA Policy
Hetlioz PA – Hetlioz LQ (tasimelteon oral suspension)
Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy
Hydrocortisone Acetate Suppository Step Therapy Policy
Hydroxy-methylglutaryl-coenzyme A Reductase Inhibitors (HMG) Step Therapy Policy
Hyperlipidemia - Nexletol PA Policy
Hyperlipidemia - Nexlizet PA Policy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy
I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy
Immunologicals - Anti-Interleukin-5 Agents PSM Policy
Immunologicals - Cinqair PA Policy
Immunologicals - Dupixent PA Policy
Immunologicals - Fasenra PA Policy
Immunologicals - Nucala PA
Immunologicals - Xolair PA Policy
Increlex PA Policy
Infectious Disease - Daraprim PA Policy
Infertility - Gonadotropin-Releasing Hormone Antagonists PSM Policy
Infertility – Follitropins, Clomiphene Preferred Specialty Management
Inflammatory Bowel Preferred Step Therapy
Inflammatory Conditions - Actemra Subcutaneous PA Policy
Inflammatory Conditions - Adalimumab Products PA Policy
Inflammatory Conditions - Arcalyst PA Policy
Inflammatory Conditions - Benlysta Subcutaneous PA Policy
Inflammatory Conditions - Care Value Policy
Inflammatory Conditions - Cimzia PA Policy
Inflammatory Conditions - Etanercept Products PA Policy
Inflammatory Conditions - Ilumya PA Policy
Inflammatory Conditions - Kevzara PA Policy
Inflammatory Conditions - Kineret PA Policy
Inflammatory Conditions - Olumiant PA Policy
Inflammatory Conditions - Orencia Subcutaneous PA Policy
Inflammatory Conditions - Otezla PA Policy
Inflammatory Conditions - PSM Policy
Inflammatory Conditions - Rinvoq PA Policy
Inflammatory Conditions - Siliq PA Policy
Inflammatory Conditions - Simponi Subcutaneous PA Policy
Inflammatory Conditions - Skyrizi PA Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy
Inflammatory Conditions - Taltz PA Policy
Inflammatory Conditions - Tremfya PA Policy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy
Interferon - Actimmune PA Policy
Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy
Isotretinoin Step Therapy Policy
K
Keveyis PA Policy
L
Lidocaine Patch PA Policy
Lipodystrophy - Egrifta PA Policy
Lipodystrophy - Myalept PA Policy
Lupus – Benlysta Subcutaneous PA Policy
Lyrica CR PA Policy
M
Metabolic Disorders - Carbaglu PA Policy
Metabolic Disorders - Cystaran PA Policy
Metabolic Disorders - Cysteamine (Oral) Products (Cystagon, Procysbi) PA Policy
Metabolic Disorders - Nitisinone Products PA Policy
Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy
Metabolic Disorders - Tiopronin Products PA Policy
Metabolic Disorders - Xuriden PA Policy
Methergine PA Policy
Methotrexate Injection Step Therapy
Migraine - Nurtec ODT PA Policy
Migraine - Reyvow PA Policy
Migraine - Ubrelvy PA Policy
Migraine Medication Step Therapy Policy
Multiple Sclerosis - Ampyra PA Policy
Multiple Sclerosis - Ampyra PSM Policy
Multiple Sclerosis - Aubagio PA Policy
Multiple Sclerosis - Avonex PA Policy
Multiple Sclerosis - Betaseron, Extavia PA Policy
Multiple Sclerosis - Dimethyl Fumarate (Tecfidera) PA Policy
Multiple Sclerosis - Gilenya PA Policy
Multiple Sclerosis - Glatiramer Products PA Policy
Multiple Sclerosis - Lemtrada PA Policy
Multiple Sclerosis - Mavenclad PA Policy
Multiple Sclerosis - Mayzent PA Policy
Multiple Sclerosis - Plegridy PA
Multiple Sclerosis - Rebif PA Policy
Multiple Sclerosis - Vumerity PA Policy
Multiple Sclerosis - Zeposia PA Policy
Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy
Multiple Sclerosis PSM Policy
Muscular Dystrophy - Emflaza PA Policy
N
Naloxone Injection Step Therapy Policy
Nasal Steroids Step Therapy Policy
Natpara PA Policy
Neurology - Riluzole Products PA Policy
Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy
Northera PA Policy
Nuedexta PA Policy
O
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy
Oncology (Injectable) - Synribo PA Policy
Oncology (Injectable) - Topotecan Products PA Policy
Oncology - Abiraterone Acetate (Zytiga) Care Value Policy
Oncology - Abiraterone Acetate (Zytiga) PA Policy
Oncology - Abiraterone Acetate (Zytiga) PSM Policy
Oncology - Afinitor PA
Oncology - Afinitor PSM Policy
Oncology - Alecensa PA Policy
Oncology - Alunbrig PA Policy
Oncology - Ayvakit PA
Oncology - Balversa PA Policy
Oncology - Bosulif PA Policy
Oncology - Braftovi PA Policy
Oncology - Brukinsa PA Policy
Oncology - Cabometyx PA
Oncology - Calquence PA Policy
Oncology - Caprelsa PA Policy
Oncology - Cometriq PA Policy
Oncology - Copiktra PA Policy
Oncology - Cotellic PA Policy
Oncology - Daurismo PA Policy
Oncology - Erivedge PA Policy
Oncology - Erleada PA Policy
Oncology - Erlotinib (Tarceva) PA Policy
Oncology - Farydak PA Policy
Oncology - Gavreto PA Policy
Oncology - Gilotrif PA Policy
Oncology - Ibrance PA Policy
Oncology - Iclusig PA Policy
Oncology - Idhifa PA Policy
Oncology - Imatinib (Gleevec) PA Policy
Oncology - Imbruvica PA Policy
Oncology - Imbruvica PSM Policy
Oncology - Inlyta PA Policy
Oncology - Inrebic PA Policy
Oncology - Iressa PA Policy
Oncology - Jakafi PA Policy
Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy
Oncology - Koselugo PA
Oncology - Lapatinib (Tykerb) PA Policy
Oncology - Lenvima PA Policy
Oncology - Lonsurf PA Policy
Oncology - Lorbrena PA Policy
Oncology - Lynparza PA
Oncology - Mekinist PA Policy
Oncology - Mektovi PA Policy
Oncology - Nerlynx PA Policy
Oncology - Nexavar PA Policy
Oncology - Nilutamide PA Policy
Oncology - Ninlaro PA Policy
Oncology - Nubeqa PA Policy
Oncology - Odomzo PA Policy
Oncology - Pemazyre PA Policy
Oncology - Piqray PA Policy
Oncology - Pomalyst PA Policy
Oncology - Revlimid PA Policy
Oncology - Rozlytrek PA Policy
Oncology - Rubraca PA Policy
Oncology - Rydapt PA
Oncology - Sprycel PA Policy
Oncology - Stivarga PA Policy
Oncology - Sutent PA Policy
Oncology - Tafinlar PA Policy
Oncology - Tagrisso PA Policy
Oncology - Talzenna PA Policy
Oncology - Targretin (topical) PA Policy
Oncology - Tazverik PA Policy
Oncology - Temozolomide Capsules PA Policy
Oncology - Thalomid PA Policy
Oncology - Tibsovo PA
Oncology - Tukysa PA Policy
Oncology - Turalio PA Policy
Oncology - Valchlor PA Policy
Oncology - Venclexta PA Policy
Oncology - Verzenio PA Policy
Oncology - Vistogard PA Policy
Oncology - Vitrakvi PA Policy
Oncology - Vizimpro PA Policy
Oncology - Votrient PA Policy
Oncology - Xalkori PA
Oncology - Xermelo PA Policy
Oncology - Xospata PA Policy
Oncology - Xpovio PA Policy
Oncology - Xtandi PA Policy
Oncology - Yonsa PA Policy
Oncology - Zejula PA Policy
Oncology - Zelboraf PA Policy
Oncology - Zolinza PA Policy
Oncology - Zydelig PA Policy
Oncology - Zykadia PA Policy
Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy
Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy
Ophthalmic for Dry Eye Disease - Eysuvis PA Policy
Ophthalmic for Dry Eye Disease - Lacrisert PA Policy
Ophthalmic Nonsteroidal Antiinflammatory Drugs Step Therapy Policy
Ophthalmic Prostaglandin Step Therapy Policy
Ophthalmology – Oxervate PA Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy
Opioids - Long-Acting Products PA Policy
Opioids - Tramadol Extended-Release PA Policy
Overactive Bladder Medications Step Therapy
P
Pancreatic Enzymes (Enteric-Coated) Preferred Step Therapy Policy
Parkinson's Disease - Kynmobi PA Policy
Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy Policy
Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy
Parkinson’s Disease - Apokyn PA Policy
Parkinson’s Disease - Inbrija PA Policy
Parkinson’s Disease - Lodosyn PA Policy
Parkinson’s Disease - Nourianz PA Policy
Parkinson’s Disease - Nuplazid PA Policy
Parkinson’s Disease - Tolcapone Products PA Policy
Pegylated Interferons PA Policy
Phenylketonuria - Kuvan PA Policy
Phenylketonuria - Palynziq PA Policy
Pheochromocytoma – Metyrosine Capsules and Phenoxybenzamine Capsules PA Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy
Proton Pump Inhibitors Step Therapy Policy
Psychiatry - Spravato PA Policy
Pulmonary - Corticosteroid Inhalers Care Value
Pulmonary - Daliresp PA Policy
Pulmonary Arterial Hypertension - Adempas PA Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist PSM Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy
Pulmonary Arterial Hypertension - Inhaled Prostacyclin Products PA Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy
Q
Qbrexza PA with Step Therapy Policy
S
Sedative Hypnotics Step Therapy Policy
Sickle Cell Disease - Endari PA Policy
Somatostatin Analogs - Octreotide Immediate-Release Products PSM Policy
Somatostatin Analogs - Sandostatin LAR Depot PA Policy
Somatostatin Analogs - Signifor LAR PA Policy
Somatostatin Analogs - Somatuline Depot PA Policy
Somavert PA Policy
T
Testosterone (injectable) Products PA Policy
Testosterone (Oral, Topical, and Nasal) Products PA Policy
Tetracyclines (Oral) Step Therapy
Thrombocytopenia - Doptelet PA Policy
Thrombocytopenia - Promacta PA Policy
Tolvaptan Products - Jynarque PA Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy
Topical Acne - Cleansers Step Therapy Policy
Topical Acne - Kits Step Therapy Policy
Topical Acne - Topical Products Step Therapy Policy
Topical Acyclovir Cream and Ointment PA Policy
Topical Agents for Atopic Dermatitis Step Therapy Policy
Topical Antibacterials Step Therapy
Topical Antifungals for Onychomycosis Step Therapy Policy
Topical Corticosteroids Step Therapy Policy
Topical Diclofenac Sodium Gel (Solaraze) PA Policy
Topical Doxepin Step Therapy Policy
Topical Medications for Inflammatory Rosacea Step Therapy
Topical Podofilox Products Step Therapy Policy
Topical Retinoids - Aklief PA Policy
Topical Retinoids - Tazarotene Products PA Policy
Topical Retinoids - Tretinoin Products PA Policy
V
Vecamyl PA Policy
Veregen PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy
Vitamin D Analog (Oral) Step Therapy Policy
W
Wakefulness-Promoting Agents - Armodafinil, Modafinil PA Policy
Wakefulness-Promoting Agents - Sunosi PA Policy with Step Therapy
Wakefulness-Promoting Agents - Wakix PA Policy with Step Therapy
Weight Loss Drugs PA
X
Xyrem PA Policy
Z
Zetia Step Therapy Policy
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