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.

Colony Stimulating Factors - Rolvedon PA	Policy
Complement Inhibitors - Empaveli PA Policy	Policy
Complement Inhibitors - Fabhalta PA	Policy
Complement Inhibitors - PiaSky PA	Policy
Complement Inhibitors - Ultomiris PA	Policy
Complement Inhibitors - Voydeya PA	Policy
Complement Inhibitors - Zilbrysq PA	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
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 - Pulmozyme PA Policy	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Kalydeco PA	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Orkambi PA	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Symdeko PA	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Trikafta PA	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Alyftrek PA	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 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 - 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	Policy
Dichlorphenamide PSM	Policy
Diuretics - Loop Products Step Therapy Policy	Policy
Dronabinol Products PA	Policy
Dronabinol Products PA with Step Therapy	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
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	Policy
Familial Chylomicronemia Syndrome - Tryngolza PA	Policy
Fenofibrate Step Therapy Policy	Policy
Gabapentin Step Therapy Policy	Policy
Gastroenterology - Eohilia PA	Policy
Gastroenterology - Gimoti 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 PA	Policy
Gonadotropin-Releasing Hormone Agonist - Lupron Depot PA	Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty 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 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
Hemangeol PA with Step Therapy Policy	Policy
Hematology - Adzynma PA	Policy
Hematology - Cablivi 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 - Rytelo PA	Policy
Hemophilia - Altuviiio PA	Policy
Hemophilia - Gene Therapy - Beqvez PA	Policy
Hemophilia - Gene Therapy - Hemgenix PA	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Alhemo PA Policy	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Hympavzi PA Policy	Policy
Hemophilia - Non-Factor Routine Prophylaxis Products - Qfitlia PA Policy	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

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