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.
| Hepatitis C - Vosevi PA Policy | Policy |
| Hepatitis C - Zepatier PA Policy | Policy |
| Hepatitis C Virus (HCV) Direct Acting Antivirals (DAAs) PSM for National Preferred Formulary and Basic Formulary | 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 - Andembry PA | Policy |
| Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy | Policy |
| Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy | Policy |
| Hereditary Angioedema - Ekterly PA | 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 |
| 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 |
| Homozygous Familial Hypercholesterolemia - Juxtapid PA | 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 ST | 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 |
| Hypoparathyroidism - Natpara PA | Policy |
| Hypoparathyroidism - Yorvipath PA | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA | 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 - Ebglyss PA | Policy |
| Immunologicals - Nemluvio PA | Policy |
| Immunologicals - Tezspire PA | 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 | Policy |
| Inflammatory Conditions - Cosentyx Intravenous PA | Policy |
| Inflammatory Conditions - Entyvio Subcutaneous PA | Policy |
| Inflammatory Conditions - Etanercept Products PA Policy | Policy |
| Inflammatory Conditions - Leqselvi PA | 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 - Rinvoq, Rinvoq LQ PA | 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 (Ustekinumab Subcutaneous Products) 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 - Tremfya Subcutaneous PA | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous Products PSM Policy for National Preferred and Basic Formularies - Choice | Policy |
| Inflammatory Conditions - Velsipity PA | Policy |
| Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy | Policy |
| Inflammatory Conditions - Zymfentra PA | Policy |
| Inflammatory Conditions Preferred Specialty Management Policy for National Preferred, High Performance, and Basic Formularies – Choice/Alternate | 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 |
| 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 |