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 - FMS-Like Tyrosine Kinase 3 Inhibitor) - Rydapt PA _Commercial | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Vanflyta PA | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Xospata PA_Commercial | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Erivedge PA _Commercial | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Odomzo PA_Commercial | Policy |
| Oncology (Oral - HER2 Inhibitor) - Hernexeos PA | Policy |
| Oncology (Oral - HER2 Inhibitor) - Hyrnuo PA | Policy |
| Oncology (Oral - Immunomodulator) - Lenalidomide PA | Policy |
| Oncology (Oral - Immunomodulator) - Lenalidomide PSM | Policy |
| Oncology (Oral - Immunomodulator) - Pomalyst PA | Policy |
| Oncology (Oral - Immunomodulator) - Thalomid PA | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Rezlidhia PA_Commercial | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Tibsovo PA _Commercial | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Krazati PA_Commercial | Policy |
| Oncology (Oral - MEK Inhibitor) - Cotellic PA | Policy |
| Oncology (Oral - MEK Inhibitor) - Mekinist PA | Policy |
| Oncology (Oral - MEK Inhibitor) - Mektovi PA_Commercial | Policy |
| Oncology (Oral - Menin Inhibitor) - Komzifti PA | Policy |
| Oncology (Oral - Menin Inhibitor) - Revuforj PA_Commercial | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Augtyro PA_Commerical | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek 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 _Commercial | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Talzenna PA | Policy |
| Oncology (Oral - Proteasome Inhibitor) - Ninlaro PA_Commercial | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto PA | Policy |
| Oncology (Oral - ROS1 Inhibitor) - Ibtrozi PA | Policy |
| Oncology (Oral – Anaplastic Lymphoma Kinase-Positive Agent) – Zykadia PA Policy_Commercial | Policy |
| Oncology (Oral – Androgen Biosynthesis Inhibitor) – Yonsa PA Policy_Commercial | Policy |
| Oncology (Oral – Androgen Receptor Inhibitor) – Erleada PA Policy_Commercial | Policy |
| Oncology (Oral – Cyclin-Dependent Kinase 4 and 6 Inhibitor) – Kisqali and Kisqali Femara Co-Pack Prior Authorization Policy | Policy |
| Oncology (Oral – Cyclin-Dependent Kinase 4/6 Inhibitor) – Ibrance PA Policy_Commercial | Policy |
| Oncology (Oral – Epidermal Growth Factor Receptor Inhibitor) – Tagrisso PA Policy_Commercial | Policy |
| Oncology (Oral – Epidermal Growth Factor Receptor Inhibitor) – Vizimpro PA Policy_Commercial | Policy |
| Oncology (Oral – Fibroblast Growth Factor Receptor Agent) – Lytgobi PA Policy_Commercial | Policy |
| Oncology (Oral – Fibroblast Growth Factor Receptor Agent) – Pemazyre PA Policy_Commercial | Policy |
| Oncology (Oral – Mesenchymal-Epithelial Transition Skipping Agent) – Tabrecta PA Policy_Commercial | Policy |
| Oncology (Oral – Neurotrophic Tyrosine Receptor Kinase Gene Fusion) – Vitrakvi PA Policy_Commercial | Policy |
| Oncology (Oral – Poly [ADP-Ribose] Polymerase Inhibitor) – Zejula PA _IFB | Policy |
| Oncology (Oral – Rearranged During Transfection-Targeting Agent) – Retevmo PA Policy_Commercial | 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 - Lacrisert PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Tryptyr PA | Policy |
| Ophthalmology - Dry Eye Disease - Xiidra PA_Commercial | Policy |
| Ophthalmology - iDose TR PA | Policy |
| Ophthalmology - Izervay PA | Policy |
| Ophthalmology - Oxervate PA Policy_Commercial | 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 |
| Ophthalmology – Dry Eye Disease – Eysuvis PA Policy_Commercial | Policy |
| Ophthalmology – Dry Eye Disease – Miebo PA Policy_Commercial | Policy |
| Ophthlamic Nonsteroidal Antiinflammatory Drugs | 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_Commercial | Policy |
| Otic Quinolone - Ciprofloxacin Step Therapy Policy | Policy |
| Overactive Bladder Medications Step Therapy Policy | Policy |
| Papillomatosis - Gene Therapy - Papzimeos PA | Policy |
| Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy | Policy |
| Parkinson's Disease - Carbidopa PA_Commercial | Policy |
| Parkinson’s Disease - Carbidopa-Levodopa (Oral) ST | Policy |
| Parkinson's Disease - Inbrija PA Policy_Commercial | 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 - Onapgo PA | Policy |
| Parkinson's Disease - Ongentys PA_Commercial | Policy |
| Parkinson's Disease - Tolcapone PA_Commercial | Policy |
| Parkinson’s Disease - Vyalev PA | Policy |
| Pegylated Interferons PA Policy | Policy |
| Phenylketonuria - Palynziq PA Policy_Commercial | Policy |
| Phenylketonuria - Sapropterin (Kuvan) PA Policy | Policy |
| Phenylketonuria - Sephience PA | Policy |
| Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy_Commercial | Policy |
| Pompe Disease - Enzyme Replacement Therapy - Pombiliti Prior | Policy |
| Pompe Disease - Enzyme Stabilization Therapy - Opfolda PA_Commercial | Policy |