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 (Oral - MEK Inhibitor) - Cotellic PA | Policy |
| Oncology (Oral - MEK Inhibitor) - Mekinist PA | Policy |
| Oncology (Oral - MEK Inhibitor) - Mektovi PA | Policy |
| Oncology (Oral - Mesenchymal-Epithelial Transition Skipping Agent) - Tabrecta PA | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Augtyro PA | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek PA | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Vitrakvi PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Akeega PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Lynparza PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Rubraca PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Talzenna PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Zejula PA | Policy |
| Oncology (Oral - Proteasome Inhibitor) - Ninlaro PA | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto PA | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Retevmo PA | Policy |
| Oncology (Oral - ROS1 Inhibitor) - Ibtrozi PA | Policy |
| Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Beta-adrenergic Blockers Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Combination Products Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors | Policy |
| Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Prostaglandins PA Policy | Policy |
| Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy | Policy |
| Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy | Policy |
| Ophthalmic Corticosteroids Step Therapy Policy | Policy |
| Ophthalmic for Dry Eye Disease - Cyclosporine Products PA Policy | Policy |
| Ophthalmic for Dry Eye Disease - Eysuvis PA Policy | Policy |
| Ophthalmic for Dry Eye Disease - Lacrisert PA Policy | Policy |
| Ophthalmic for Dry Eye Disease - Xiidra PA Policy | Policy |
| Ophthalmic Nonsteroidal Antiinflammatory Drugs Step Therapy Policy | Policy |
| Ophthalmic Prostaglandin Step Therapy Policy | Policy |
| Ophthalmic Quinolone Antibiotics Step Therapy Policy | Policy |
| Ophthalmology - Dry Eye Disease - Cyclosporine Products PA | Policy |
| Ophthalmology - Dry Eye Disease - Eysuvis PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Lacrisert PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Xiidra PA | Policy |
| Ophthalmology - Dry Eye Disease – Miebo PA | Policy |
| Ophthalmology - iDose TR PA | Policy |
| Ophthalmology - Izervay PA | Policy |
| Ophthalmology - Oxervate PA Policy | Policy |
| Ophthalmology - Syfovre PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PSM | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA | Policy |
| Ophthalmology - Verkazia PA | Policy |
| Opioids - Fentanyl Transmucosal Drugs PA Policy | Policy |
| Opioids - Long-Acting Products PA Policy | Policy |
| Opioids - Methadone PA | Policy |
| Opioids - Methadone Prior Authorization Policy | Policy |
| Opioids - Tramadol Extended-Release Products PA | Policy |
| Otic Quinolone - Ciprofloxacin Step Therapy Policy | Policy |
| Overactive Bladder Medications Step Therapy Policy | Policy |
| Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy | Policy |
| Parkinson's Disease - Carbidopa PA | Policy |
| Parkinson’s Disease - Carbidopa-Levodopa (Oral) ST | Policy |
| Parkinson's Disease - Inbrija PA Policy | Policy |
| Parkinson's Disease - Kynmobi PA Policy | Policy |
| Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy Policy | Policy |
| Parkinson's Disease - Nourianz PA Policy | Policy |
| Parkinson’s Disease - Nuplazid PA Policy | Policy |
| Parkinson's Disease - Ongentys PA | Policy |
| Parkinson's Disease - Tolcapone PA | Policy |
| Parkinson’s Disease - Vyalev PA | Policy |
| Pegylated Interferons PA Policy | Policy |
| Phenylketonuria - Palynziq PA Policy | Policy |
| Phenylketonuria - Sapropterin (Kuvan) PA Policy | Policy |
| Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy | Policy |
| Pompe Disease - Enzyme Replacement Therapy - Pombiliti Prior | Policy |
| Pompe Disease - Enzyme Stabilization Therapy - Opfolda Prior | Policy |
| Prader-Willi Syndrome - Vykat XR PA | Policy |
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy | Policy |
| Proton Pump Inhibitors Step Therapy Policy | Policy |
| Pulmonary - Airsupra ST | Policy |
| Pulmonary - Corticosteroid Inhalers Care Value | Policy |
| Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy | Policy |
| Pulmonary - Short-Acing Beta2-Agonist Inhalers Step Therapy Policy | Policy |
| Pulmonary – Short-Acting Beta2-Agonist Inhalers | Policy |
| Pulmonary Arterial Hypertension - Adempas PA Policy | Policy |
| Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist PSM Policy | Policy |
| Pulmonary Arterial Hypertension - Orenitram PA Policy | Policy |
| Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy | Policy |
| Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy | Policy |
| Pulmonary Arterial Hypertension - Winrevair PA | Policy |
| Repository Corticotropin - Acthar Gel PA Policy | Policy |
| Repository Corticotropin - Cortrophin Gel PA | Policy |
| Sedative Hypnotics Step Therapy Policy | Policy |
| Sickle Cell Disease - Endari PA Policy | Policy |
| Sohonos PA | Policy |
| Somatostatin Analogs - Lanreotide Products PA | Policy |
| Somatostatin Analogs - Octreotide Immediate-Release Products PA Policy | Policy |
| Somatostatin Analogs - Octreotide Immediate-Release Products PSM Policy | Policy |
| Somatostatin Analogs - Somatuline Depot PA Policy | Policy |
| Somatostatin Analogs for Acromegaly PSM Policy | Policy |
| Somavert PA Policy | Policy |
| Spinal Muscular Atrophy - Evrysdi PA Policy | Policy |
| ST: Antidepressants Bupropion to Antidepressants Bupropion Long Acting | Policy |
| Tasimelteon Capsules PSM Policy | Policy |
| Tasimelteon Products PA | Policy |
| Testosterone (injectable) Products PA Policy | Policy |