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 |