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.
| Prader-Willi Syndrome - Vykat XR PA_Commercial | Policy |
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy | Policy |
| Proton Pump Inhibitors Step Therapy Policy | Policy |
| Pulmonary - Airsupra ST | Policy |
| Pulmonary - Brinsupri PA | Policy |
| Pulmonary - Corticosteroid Inhalers Care Value | Policy |
| Pulmonary - Short-Acing Beta2-Agonist Inhalers Step Therapy Policy | Policy |
| Pulmonary - Short-Acting Beta2-Agonist Inhalers ST | Policy |
| Pulmonary – Short-Acting Beta2-Agonist Inhalers | Policy |
| Pulmonary Arterial Hypertension - Adempas PA Policy_Commercial | Policy |
| Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist PSM Policy | Policy |
| Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA | Policy |
| Pulmonary Arterial Hypertension - Orenitram PA Policy_Commercial | Policy |
| Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy | Policy |
| Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PSM Policy | Policy |
| Pulmonary Arterial Hypertension - Uptravi PA | Policy |
| Pulmonary Arterial Hypertension - Winrevair PA_Commercial | Policy |
| Repository Corticotropin - Acthar Gel PA Policy_Commercial | Policy |
| Repository Corticotropin - Cortrophin Gel PA | Policy |
| Sedative Hypnotics Step Therapy Policy | Policy |
| Sickle Cell Disease - Endari PA Policy | Policy |
| Sickle Cell Disease - L-glutamine PSM | Policy |
| Sohonos PA_Commercial | Policy |
| Somatostatin Analogs - Lanreotide Products PA_Commercial | Policy |
| Somatostatin Analogs - Octreotide Immediate-Release Products PA Policy_Commercial | Policy |
| Somatostatin Analogs - Octreotide Immediate-Release Products PSM Policy | Policy |
| Somatostatin Analogs - Somatuline Depot PA Policy | Policy |
| Somatostatin Analogs for Acromegaly PSM Policy | Policy |
| Somatostatin Receptor Agonist - Palsonify PA Policy | Policy |
| Somavert PA Policy | Policy |
| Spinal Muscular Atrophy - Evrysdi PA Policy_Commercial | Policy |
| ST: Antidepressants Bupropion to Antidepressants Bupropion Long Acting | Policy |
| Tasimelteon Capsules PSM Policy | Policy |
| Tasimelteon Products PA_Commercial | Policy |
| Testosterone (injectable) Products PA Policy_Commercial | Policy |
| Testosterone (Oral, Topical, and Nasal) Products PA Policy | Policy |
| Tetracyclines (Oral) Step Therapy | Policy |
| Thrombocytopenia - Doptelet PA Policy_Commercial | Policy |
| Thrombocytopenia - Eltrombopag Products PA | Policy |
| Thrombocytopenia - Eltrombopag Products PSM | Policy |
| Thrombocytopenia - Eltromboppag Products PA | Policy |
| Thrombocytopenia - Wayrilz PA | Policy |
| Tolvaptan Products - Jynarque PA Policy | Policy |
| Tolvaptan Products - Tolvaptan (Jynarque) PA Policy | Policy |
| Tolvaptan Products - Tolvaptan (Jynarque) PSM | 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_Commercial | 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_Commercial | 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 Vitamin D Analogs Step Therapy Policy | Policy |
| Vecamyl PA Policy_Commercial | Policy |
| Veregen PA Policy | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza Products PA_Commercial | Policy |
| Vesicular Monoamine Transporter Type 2 Inhibitors PSM Policy | Policy |
| Vijoice PA | Policy |
| Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy_Commercial | Policy |
| Vitamin D Analog (Oral) Step Therapy Policy | Policy |
| Wakefulness-Promoting Agents - Armodafinil, Modafinil PA with Step Therapy Policy | Policy |
| Wakefulness-Promoting Agents - Sunosi PA Policy with Step Therapy_Commercial | Policy |
| Wakefulness-Promoting Agents - Wakix PA Policy with Step Therapy_Commercial | Policy |
| Weight Loss - Glucagon-Like Peptide-1 Agonists PA Policy_Commercial | Policy |
| Weight Loss - Other Appetite Suppressants and Orlistat PA Policy_Commercial | Policy |
| Zokinvy PA Policy_Commercial | Policy |