Utilization Management
Prior Authorization and Step Therapy Policies for Commercial and Individual Family Business (IFB)
Certain drugs within policies may not be applicable to the specific formulary and plan design. Please refer to the formulary drug list and/or member plan documents to determine coverage status.
| (Droxidopa) Northera PA | Policy |
| Adrenal Hyperplasia - Crenessity PA | Policy |
| Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy | Policy |
| Allergen Immunotherapy - Odactra PA Policy | Policy |
| Allergen Immunotherapy - Ragwitek PA Policy | Policy |
| Alzheimer's - Namenda/Namenda XR ST | 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 - Attruby 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 |
| Angiotensin Receptor Blockers ST | Policy |
| Antibiotics - Linezolid (Zyvox), Sivextro PA Policy | Policy |
| Antibiotics - Vancomycin Capsules PA Policy | Policy |
| Antibiotics - Xifaxan PA Policy | Policy |
| Antibiotics (Inhaled) - Arikayce PA Policy | Policy |
| Antibiotics (Inhaled) - Cayston PA | Policy |
| Antibiotics (Inhaled) - TOBI Podhaler PA Policy | Policy |
| Antibiotics (Inhaled) - Tobramcyin Products | Policy |
| Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA | Policy |
| Antibiotics (Inhaled) - Tobramycin Products Care Value Policy | Policy |
| Antibiotics (Inhaled) - Tobramycin Products PSM Policy | Policy |
| Anticoagulants - Eliquis PA Policy | Policy |
| Anticoagulants - Xarelto PA Policy | Policy |
| Antidepressants - Bupropion Long-Acting Step Therapy Policy | Policy |
| Antidepressants - Raldesy ST | 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 |
| Antiepileptics - Zonisamide ST | Policy |
| Antifungals - Cresemba (Oral) PA Policy | Policy |
| Antifungals - Posaconazole (Oral) PA | Policy |
| Antifungals - Voriconazole (Oral) PA | Policy |
| Antifungals - Voriconazole (Oral) PA Policy | Policy |
| Antifungals for Vulvovaginal Candidiasis Step Therapy Policy | Policy |
| Antiplatelets - Ticagrelor ST | Policy |
| Antiseizure Medications - (Oxcarbazepine) Oxtellar XR, Trileptal ST | 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 Step Therapy Policy | 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 |
| Antiseizure Medications - Ztalmy PA | Policy |
| Antivirals - Ribavirin (Inhaled Products) 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 - Denosumab Products (Xgeva) PA | Policy |
| Bone Modifiers - Teriparatide Products PA Policy | Policy |
| Bone Modifiers - Tymlos PA Policy | 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 - Penicillamine Products PA with Step Therapy | 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 PSM 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 |