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.
| Oncology - Cyclin Dependent Kinases 4,6 Inhibitors for Breast Cancer | Policy |
| Oncology - Cyclin Dependent Kinases 4,6 Inhibitors PSM Policy | Policy |
| Oncology - Dasatinib Products PA | Policy |
| Oncology - Dasatinib PSM | Policy |
| Oncology - Daurismo PA Policy_Commercial | Policy |
| Oncology - Everolimus Products PA Policy | Policy |
| Oncology - Everolimus Products PSM Policy | Policy |
| Oncology - Farydak PA Policy | Policy |
| Oncology - Fruzaqla PA_Commercial | Policy |
| Oncology - Gomekli PA | Policy |
| Oncology - Iclusig PA Policy_Commercial | Policy |
| Oncology - Idhifa PA Policy | Policy |
| Oncology - Imatinib Products PA | Policy |
| Oncology - Imatinib PSM Policy | Policy |
| Oncology - Imbruvica PSM Policy | Policy |
| Oncology - Inluriyo PA | Policy |
| Oncology - Inlyta PA Policy | Policy |
| Oncology - Itovebi PA | Policy |
| Oncology - Iwilfin PA_Commercial_Commercial | Policy |
| Oncology - Jakafi PA Policy | Policy |
| Oncology - Koselugo PA | Policy |
| Oncology - Lapatinib (Tykerb) PA Policy | Policy |
| Oncology - Lenvima PA Policy | Policy |
| Oncology - Lonsurf PA Policy | Policy |
| Oncology - Mercaptopurine Products ST | Policy |
| Oncology - Modeyso PA | Policy |
| Oncology - Nerlynx PA Policy_Commercial | Policy |
| Oncology - Nexavar PA Policy | Policy |
| Oncology - Nilotinib Products PA_Commercial | Policy |
| Oncology - Nilotinib PSM | Policy |
| Oncology - Nilutamide PA Policy_Commercial | Policy |
| Oncology - Ogsiveo PA_Commercial | Policy |
| Oncology - Ojemda PA_Commercial | Policy |
| Oncology - Ojjaara PA | Policy |
| Oncology - Orserdu PA | Policy |
| Oncology - Pazopanib PA_Commercial | Policy |
| Oncology - Revlimid PA Policy | Policy |
| Oncology - Romvimza PA_Commercial | Policy |
| Oncology - Sorafenib PA_Commercial | Policy |
| Oncology - Sprycel PA Policy | Policy |
| Oncology - Stivarga PA Policy | Policy |
| Oncology - Sunitinib PA Policy_Commercial | Policy |
| Oncology - Tazverik PA Policy_Commercial | Policy |
| Oncology - Temozolomide Capsules PA Policy | Policy |
| Oncology - Truqap PA_Commercial | Policy |
| Oncology - Tukysa PA Policy_Commercial | Policy |
| Oncology - Turalio PA Policy | Policy |
| Oncology - Ukoniq PA Policy | Policy |
| Oncology - Valchlor PA Policy_Commercial | Policy |
| Oncology - Venclexta PA Policy_Commercial | Policy |
| Oncology - Vistogard PA Policy_Commercial | Policy |
| Oncology - Vonjo PA_Commercial | Policy |
| Oncology - Voranigo PA_Commercial | Policy |
| Oncology - Xermelo PA Policy_Commercial | Policy |
| Oncology - Zolinza PA Policy | Policy |
| Oncology - Zydelig PA Policy | Policy |
| Oncology – Avmapki Fakzynja Co-Pack PA Policy_Commercial | Policy |
| Oncology (Injectable - Bispecific - BCMA-Directed) - Elrexfio PA | Policy |
| Oncology (Injectable - Bispecific - BCMA-Directed) - Tecvayli PA | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Columvi PA | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Epkinly PA | Policy |
| Oncology (Injectable - Bispecific - CD20-Directed) - Lunsumio Intravenous PA_Commercial | Policy |
| Oncology (Injectable - Bispecific - GPRC5D-Directed) - Talvey PA | Policy |
| Oncology (Injectable - CTLA-4 Antibody) - Imjudo PA | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Keytruda Qlex PA | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Opdualag PA | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Tevimbra PA_IFB | Policy |
| Oncology (Injectable - Programmed Death Receptor-1) - Zynyz PA | Policy |
| Oncology (Injectable - Programmed Death-Ligand 1) - Tecentriq Hybreza PA_Commercial | Policy |
| Oncology (Injectable - T-Cell Immunotherapy - MAGE-A4) - Tecelra PA | Policy |
| Oncology (Injectable) - Amtagvi PA | Policy |
| Oncology (Injectable) - Besremi PA | Policy |
| Oncology (Injectable) - Columvi PA | Policy |
| Oncology (Injectable) - Elahere PA | Policy |
| Oncology (Injectable) - Epkinly PA | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy | Policy |
| Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PSM policy | Policy |
| Oncology (Injectable) - Imdelltra PA | Policy |
| Oncology (Injectable) - Synribo PA Policy | Policy |
| Oncology (Intravesical) - Adstiladrin PA | Policy |
| Oncology (Intravesical) - Anktiva PA | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alecensa PA | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Alunbrig PA_Commercial | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Ensacove PA_Commercial | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Lorbrena PA | Policy |
| Oncology (Oral - Anaplastic Lymphoma Kinase [ALK]-Positive Agent) - Xalkori PA | Policy |
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Abiraterone Acetate PA | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Nubeqa PA | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Xtandi PA | Policy |
| Oncology (Oral - BRAF Inhibitor) - Braftovi PA_Commercial | Policy |
| Oncology (Oral - BRAF Inhibitor) - Tafinlar PA | Policy |
| Oncology (Oral - BRAF Inhibitor) - Zelboraf PA | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Brukinsa PA | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Imbruvica PA _Commercial | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Jaypirca PA | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Verzenio PA | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Erlotinib PA | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gefitinib PA_Commercial | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gilotrif PA | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Lazcluze PA_Commercial | Policy |