Utilization Management
Prior Authorization and Step Therapy Policies for Commercial and Individual Family Business
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Fabry Disease - Galafold PA Policy | Policy |
| Fenofibrate Step Therapy Policy | Policy |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Repository Corticotropin - Acthar Gel PA Policy | Policy |
| Repository Corticotropin - Cortrophin Gel PA | Policy |
| 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 |
| 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 |
| 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 |
| 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 |
| Zokinvy PA Policy | Policy |