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.
| 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 Medications - 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 - Elyxyb PA | 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 - CD20-Directed Cytolytic Antibody Infused Products | Policy |
| Multiple Sclerosis - Dalfampridine PSM Policy | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Avonex PA | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Betaseron PA | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Plegridy PA | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Rebif PA | Policy |
| Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Briumvi PA | Policy |
| Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Kesimpta PA | Policy |
| Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Ocrevus Zunovo PA | Policy |
| Multiple Sclerosis (Injectable) - Glatiramer Products PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Bafiertam PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Dimethyl Fumarate PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Vumerity PA | Policy |
| Multiple Sclerosis (Oral - Other) - Mavenclad PA | Policy |
| Multiple Sclerosis (Oral - Other) - Teriflunomide PA | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Fingolimod PA | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Mayzent PA | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Ponvory PA | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Tascenso ODT PA | Policy |
| Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM for National Preferred, High Performance, and Basic Formularies - Choice, Alternate | Policy |
| Multiple Sclerosis and Ulcerative Colitis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Zeposia PA | 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 | Policy |
| Nephrology - Jesduvroq PA | Policy |
| Nephrology - Tarpeyo PA | Policy |
| Nephrology - Vafseo PA | Policy |
| Nephrology - Vanrafia PA | Policy |
| Nephrology - Xphozah PA | Policy |
| Neurology - Daybue PA | Policy |
| Neurology - Kisunla PA | 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 |
| Niemann-Pick disease type C - Aqneursa PA | Policy |
| Niemann-Pick disease type C - Aqneursa PA | Policy |
| Niemann-Pick disease type C - Miplyffa PA | Policy |
| Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy | Policy |
| Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy | Policy |
| Nuedexta PA Policy | Policy |
| Oncology - Abiraterone Acetate (Zytiga) Care Value Policy | Policy |
| Oncology - Abiraterone Acetate (Zytiga) PSM Policy | Policy |
| Oncology - Avmapki Fakzynja 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 - Cabometyx PA | Policy |
| Oncology - Caprelsa PA Policy | Policy |
| Oncology - Cometriq PA Policy | Policy |
| Oncology - Copiktra PA Policy | Policy |
| Oncology - Cyclin Dependent Kinases 4,6 Inhibitors for Breast Cancer | Policy |
| Oncology - Cyclin Dependent Kinases 4,6 Inhibitors PSM Policy | Policy |
| Oncology - Dasatinib PSM | Policy |
| Oncology - Daurismo 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 - Gomekli PA | Policy |
| Oncology - Iclusig PA Policy | Policy |
| Oncology - Idhifa PA Policy | Policy |
| Oncology - Imatinib Products PA | Policy |
| Oncology - Imatinib PSM Policy | Policy |
| Oncology - Imbruvica PSM Policy | Policy |
| Oncology - Inlyta PA Policy | Policy |