Utilization Management
Prior Authorization and Step Therapy Policies for Commercial and Individual Family Business
| 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 – 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 - Carbidopa PA | 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 - Tolcapone PA | Policy |
| Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy | Policy |
| Parkinson’s Disease - Carbidopa-Levodopa (Oral) ST | Policy |
| Parkinson’s Disease - Nuplazid PA Policy | 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 Stabilization Therapy - Opfolda Prior | 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 Products PA | Policy |
| Testosterone (injectable) Products PA Policy | Policy |
| Testosterone (Oral, Topical, and Nasal) Products PA Policy | Policy |
| Tetracyclines (Oral) Step Therapy | Policy |
| Thrombocytopenia - Doptelet PA Policy | Policy |
| Thrombocytopenia - Eltrombopag Products PA | Policy |
| Thrombocytopenia - Eltrombopag Products PSM | Policy |
| Tolvaptan Products - Jynarque PA Policy | Policy |
| Tolvaptan Products - Tolvaptan (Samsca) PA Policy | Policy |
| Topical Acne - Cleansers Step Therapy Policy | Policy |
| Topical Acne - Kits Step Therapy Policy | Policy |
| Topical Acne - Topical Products Step Therapy Policy | Policy |
| Topical Acyclovir Products PA Policy | Policy |
| Topical Agents for Atopic Dermatitis Step Therapy Policy | Policy |
| Topical Alpha-Adrenergic Agonists for Rosacea - Rhofade PA | Policy |
| Topical Antibacterials Step Therapy | Policy |
| Topical Antifungals for Onychomycosis Step Therapy Policy | Policy |
| Topical Antifungals for Seborrheic Dermatitis Step Therapy | Policy |
| Topical Corticosteroids Step Therapy Policy | Policy |
| Topical Diclofenac Sodium 3% Gel PA | Policy |
| Topical Doxepin Step Therapy Policy | Policy |
| Topical Medications for Inflammatory Rosacea Step Therapy | Policy |
| Topical Podofilox Products Step Therapy Policy | Policy |
| Topical Products - Vtama and Zoryve 0.3% Cream ST | Policy |
| Topical Products - Zoryve Foam ST | Policy |
| Topical Retinoids - Aklief PA Policy | Policy |
| Topical Retinoids - Panretin PA Policy | Policy |
| Topical Retinoids - Tazarotene Products PA Policy | Policy |
| Topical Retinoids - Tretinoin Products PA Policy | Policy |
| Topical Vitamin D Analogs Step Therapy Policy | Policy |
| Vecamyl PA Policy | Policy |
| Veregen PA Policy | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy | Policy |
| Vijoice PA | Policy |
| Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy | Policy |
| Vitamin D Analog (Oral) Step Therapy Policy | Policy |