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.

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 for Flex, High Performance, and National Preferred Formularies 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 PSM for High Performance and National Preferred Formularies Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy_Commercial Policy
Colony Stimulating Factors - Pegfilgrastim Products, Rolvedon and Ryzneuta PSM for Flex, High Performance, and National Preferred Formularies Policy
Colony Stimulating Factors - Rolvedon PA Policy
Complement Inhibitors - Empaveli PA Policy_Commercial Policy
Complement Inhibitors - Fabhalta PA_Commercial Policy
Complement Inhibitors - PiaSky PA Policy
Complement Inhibitors - Ultomiris PA Policy
Complement Inhibitors - Veopoz PA Policy
Complement Inhibitors - Voydeya PA_Commercial Policy
Complement Inhibitors - Zilbrysq PA Policy
Complement Inhibitors – Ultomiris Subcutaneous PA Policy Policy
Complement System Disorders – WHIM Syndrome – Xolremdi PA Policy_Commercial 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
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_Commercial Policy
Cystic Fibrosis - Pulmozyme PA Policy Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Kalydeco PA_Commercial Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Orkambi PA_Commercial Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Symdeko PA_Commercial Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Trikafta PA Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Alyftrek PA_Commercial Policy
Dermatology - Anzupgo PA Policy
Dermatology - Filsuvez PA Policy
Dermatology - Gene Therapy - Vyjuvek PA_Commercial Policy
Dermatology - Hyftor PA_Commercial Policy
Desmopressin Products - Nocdurna PA Policy Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy
Diabetes - Glucagon-Like Peptide-1 Agonists (Optional) PA Policy
Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy Policy
Diabetes - Metformin Care Value Policy Policy
Diabetes - Metformin Step Therapy Policy 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 - Tzield PA Policy
Dichlorphenamide PA Policy_Commercial Policy
Dichlorphenamide PSM Policy
Diuretics - Loop Products Step Therapy Policy Policy
Dronabinol PA with Step Therapy Policy_Commercial Policy
Dronabinol Products PA Policy
Enspryng PA Policy_Commercial 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_Commercial 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
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy Policy
Erythropoiesis-Stimulating Agents PSM for High Performance and National Preferred Formularies Policy
Estrogen - Transdermal Step Therapy Policy Policy
Ezetimibe (Zetia) Step Therapy Policy Policy
Fabry Disease - Galafold PA Policy_Commercial Policy
Familial Chylomicronemia Syndrome - Redemplo PA Policy
Familial Chylomicronemia Syndrome - Tryngolza PA_Commercial Policy
Fenofibrate Step Therapy Policy Policy
Gabapentin Step Therapy Policy Policy
Gastroenterology - Eohilia PA Policy
Gastroenterology - Gimoti PA Policy
Gaucher Disease - Substrate Reduction Therapy Agents 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_Commercial Policy
Gaucher Disease Substrate Reduction Therapy - Miglustat PA Policy
Gonadotropin-Releasing Hormone Agonist - Lupron Depot PA Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy_Commercial 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 Antagonists - Oriahnn PA Policy_Commercial Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy Policy
Gout Medications Step Therapy Policy_Commercial Policy
Growth Disorders - Growth Hormone Long-Acting Products PSM Policy
Growth Disorders - Growth Hormone PA_Commercial Policy
Growth Disorders - Growth Hormone Short-Acting Products PSM Policy Policy
Growth Disorders - Increlex PA Policy_Commercial Policy
Growth Disorders - Ngenla PA_Commercial Policy
Growth Disorders - Sogroya PA Policy
Growth Disorders - Voxzogo PA_Commercial Policy
Hemangeol PA with Step Therapy Policy_Commercial Policy
Hematology - Adzynma PA Policy
Hematology - Aphexda PA Policy
Hematology - Cablivi PA Policy_Commercial Policy
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