Utilization Management

Prior Authorization and Step Therapy Policies for Medicaid

A
Amifampridine Products PA Policy	Policy
Amyloidosis - Amvuttra PA	Policy
Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy	Policy
Amyloidosis - Tegsedi PA Policy	Policy
Antibiotics (Inhaled) - Arikayce PA Policy	Policy
Antibiotics (Inhaled) - Cayston PA	Policy
Antibiotics (Inhaled) - TOBI Podhaler PA Policy	Policy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA	Policy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy	Policy
Antibiotics - Vancomycin Capsules PA Policy	Policy
Antibiotics - Xifaxan PA Policy	Policy
Anticoagulants - Dabigatran PA Policy	Policy
Anticoagulants - Eliquis PA Policy	Policy
Anticoagulants - Savaysa PA	Policy
Anticoagulants - Xarelto PA Policy	Policy
Antiepileptics - Fintepla PA Policy	Policy
Antifungals - Cresemba (Oral) PA Policy	Policy
Antifungals - Posaconazole (Oral) PA	Policy
Antifungals - Tolsura PA with Step Therapy Policy	Policy
Antifungals - Voriconazole (Oral) PA Policy	Policy
Antiseisure Medications - Fintepla PA	Policy
Antiseizure Medications - Clobazam Products PA	Policy
Antiseizure Medications - Diacomit PA Policy	Policy
Antiseizure Medications - Epidiolex PA Policy	Policy
Antiseizure Medications - Nayzilam PA	Policy
Antiseizure Medications - Rufinamide PA	Policy
Antiseizure Medications - Valtoco PA Policy	Policy
Antiseizure Medications - Vigabatrin PA	Policy
Antivirals - Ribavirin (Oral Products) PA Policy	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy	Policy

B
Bone Modifiers - Prolia PA Policy	Policy
Bone Modifiers - Tymlos PA Policy	Policy
Bone Modifiers - Xgeva PA Policy	Policy

C
Cardiology - Camzyos PA	Policy
Cardiology - Corlanor PA Policy	Policy
Cardiology - Zontivity PA Policy	Policy
Chelating Agents - Iron Chelators (Oral) PA Policy	Policy
Chelating Agents - Penicillamine Products PA Policy	Policy
Chenodal PA Policy	Policy
Cholbam PA Policy	Policy
Cialis PA Policy	Policy
Cinacalcet (Sensipar) PA Policy	Policy
Colony Stimulating Factors - Filgrastim Products PA Policy	Policy
Colony Stimulating Factors - Leukine PA Policy	Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy	Policy
Compounded Select Topical Medications PA Policy	Policy
Coronavirus Disease - Evusheld PA	Policy
Corticosteroids (Intraarticular) - Zilretta PA Policy	Policy
Cushing's - Recorlev PA Policy	Policy
Cushing's - Signifor PA Policy	Policy
Cystic Fibrosis - Kalydeco PA Policy	Policy
Cystic Fibrosis - Orkambi PA Policy	Policy
Cystic Fibrosis - Pulmozyme PA Policy	Policy
Cystic Fibrosis - Symdeko PA Policy	Policy
Cystic Fibrosis - Trikafta PA Policy	Policy

D
Diabetes - Continuous Glucose Monitoring Systems PA Policy	Policy
Diabetes - Symlin PA Policy	Policy
Dronabinol Products PA	Policy

E
Enspryng PA Policy	Policy
Enzyme Replacement Therapy - Strensiq PA Policy	Policy
Enzyme Replacement Therapy - Sucraid PA Policy	Policy
Erectile Dysfunction - Tadalafil (Cialis) PA Policy	Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy	Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy	Policy

G
Gaucher Disease Substrate Reduction Therapy - Cerdelga PA Policy	Policy
Gaucher Disease Substrate Reduction Therapy - Miglustat (Zavesca) PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products (Lupron Depot-Ped and Triptodur) PA	Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products PA Policy	Policy
Gonadotropin-Releasing Hormone Antagonists - Oriahnn PA Policy	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy	Policy
Growth Disorders - Growth Hormone PA	Policy
Growth Disorders - Increlex PA Policy	Policy

H
Hematology - Cablivi PA Policy	Policy
Hematology - Enjaymo PA Policy	Policy
Hepatitis C - Epclusa PA Policy	Policy
Hepatitis C - Harvoni PA Policy	Policy
Hepatitis C - Mavyret PA Policy	Policy
Hepatitis C - PDL Drug Policy	Policy
Hepatitis C - Ribavirin PA Policy	Policy
Hepatitis C - Sovaldi PA Policy	Policy
Hepatitis C - Viekira Pak PA Policy	Policy
Hepatitis C - Vosevi PA Policy	Policy
Hepatitis C - Zepatier PA Policy	Policy
Hepatology - Ocaliva PA Policy	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy	Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy	Policy
Hereditary Angioedema - Icatibant (Firazyr) PA Policy	Policy
Hereditary Angioedema - Kalbitor PA Policy	Policy
Hereditary Angioedema - Takhzyro PA Policy	Policy
Hetlioz PA – Hetlioz LQ (tasimelteon oral suspension)	Policy
Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy	Policy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy	Policy

I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy	Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy	Policy
Immunologicals - Dupixent PA Policy	Policy
Immunologicals - Fasenra PA Policy	Policy
Immunologicals - Nucala PA	Policy
Immunologicals - Tezspire PA Policy	Policy
Immunologicals - Xolair PA Policy	Policy
Infectious Disease - Impavido PA Policy	Policy
Infectious Disease - Ivermectin Tablets PA Policy	Policy
Infectious Disease - Pyrimethamine PA Policy	Policy
Infectious Disease - Sirturo PA Policy	Policy
Inflammatory Conditions - Actemra Subcutaneous PA Policy	Policy
Inflammatory Conditions - Adalimumab Products PA Policy	Policy
Inflammatory Conditions - Cimzia PA Policy	Policy
Inflammatory Conditions - Etanercept Products PA Policy	Policy
Inflammatory Conditions - Ilumya PA Policy	Policy
Inflammatory Conditions - Kevzara PA Policy	Policy
Inflammatory Conditions - Kineret PA Policy	Policy
Inflammatory Conditions - Orencia Subcutaneous PA Policy	Policy
Inflammatory Conditions - Otezla PA Policy	Policy
Inflammatory Conditions - Rinvoq PA Policy	Policy
Inflammatory Conditions - Siliq PA Policy	Policy
Inflammatory Conditions - Simponi Subcutaneous PA Policy	Policy
Inflammatory Conditions - Skyrizi Subcutaneous PA Policy	Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy	Policy
Inflammatory Conditions - Taltz PA Policy	Policy
Inflammatory Conditions - Tremfya PA Policy	Policy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy	Policy
Interferon - Actimmune PA Policy	Policy

L
Lidocaine Patch Products PA	Policy
Lipodystrophy - Egrifta PA Policy	Policy
Lipodystrophy - Myalept PA Policy	Policy
Lupus – Benlysta Subcutaneous PA Policy	Policy
Lyrica CR PA Policy	Policy

M
Metabolic Disorders - Carbaglu PA Policy	Policy
Metabolic Disorders - Cystaran PA Policy	Policy
Metabolic Disorders - Cysteamine (Oral) Products (Cystagon, Procysbi) PA Policy	Policy
Metabolic Disorders - Cysteamine Ophthalmic Solution PA Policy	Policy
Metabolic Disorders - Nitisinone Products PA Policy	Policy
Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy	Policy
Metabolic Disorders - Xuriden PA Policy	Policy
Methylergonovine (Methergine) PA Policy	Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy	Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy	Policy
Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy	Policy
Migraine - Nurtec ODT PA Policy	Policy
Migraine - Reyvow PA Policy	Policy
Multiple Sclerosis - Avonex PA Policy	Policy
Multiple Sclerosis - Bafiertam PA Policy	Policy
Multiple Sclerosis - Betaseron, Extavia PA Policy	Policy
Multiple Sclerosis - Dalfampridine PA	Policy
Multiple Sclerosis - Dimethyl Fumarate PA Policy	Policy
Multiple Sclerosis - Fingolimod PA Policy	Policy
Multiple Sclerosis - Glatiramer Products PA Policy	Policy
Multiple Sclerosis - Kesimpta PA Policy	Policy
Multiple Sclerosis - Lemtrada PA Policy	Policy
Multiple Sclerosis - Mavenclad PA Policy	Policy
Multiple Sclerosis - Mayzent PA Policy	Policy
Multiple Sclerosis - Plegridy PA	Policy
Multiple Sclerosis - Ponvory PA Policy	Policy
Multiple Sclerosis - Rebif PA Policy	Policy
Multiple Sclerosis - Teriflunomide PA	Policy
Multiple Sclerosis - Vumerity PA Policy	Policy
Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy	Policy
Multiple Sclerosis and Ulcerative Colitis - Zeposia PA Policy	Policy

N
Natpara PA Policy	Policy
Neurology - Lyrica CR Prior Authorization with Step Therapy Policy	Policy
Neurology - Oxybate Products PA Policy	Policy
Neurology - Riluzole Products PA Policy	Policy
Non-Preferred PDL Drug Policy	Policy
Nuedexta PA Policy	Policy

O
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy	Policy
Oncology - Abiraterone Acetate (Zytiga) PA Policy	Policy
Oncology - Alecensa PA Policy	Policy
Oncology - Alunbrig PA Policy	Policy
Oncology - Balversa PA Policy	Policy
Oncology - Bexarotene (Oral) PA	Policy
Oncology - Bexarotene (Topical) PA	Policy
Oncology - Bosulif PA Policy	Policy
Oncology - Braftovi PA Policy	Policy
Oncology - Cabometyx PA	Policy
Oncology - Caprelsa PA Policy	Policy
Oncology - Cometriq PA Policy	Policy
Oncology - Cotellic PA Policy	Policy
Oncology - Erivedge PA Policy	Policy
Oncology - Erleada PA Policy	Policy
Oncology - Erlotinib PA Policy	Policy
Oncology - Everolimus Products PA Policy	Policy
Oncology - Gavreto PA Policy	Policy
Oncology - Gefitinib PA	Policy
Oncology - Gilotrif PA Policy	Policy
Oncology - Ibrance PA Policy	Policy
Oncology - Iclusig PA Policy	Policy
Oncology - Idhifa PA Policy	Policy
Oncology - Imatinib (Gleevec) PA Policy	Policy
Oncology - Imbruvica PA Policy	Policy
Oncology - Inlyta PA Policy	Policy
Oncology - Jakafi PA Policy	Policy
Oncology - Koselugo PA	Policy
Oncology - Lenvima PA Policy	Policy
Oncology - Lonsurf PA Policy	Policy
Oncology - Lorbrena PA Policy	Policy
Oncology - Lynparza PA	Policy
Oncology - Mekinist PA Policy	Policy
Oncology - Nerlynx PA Policy	Policy
Oncology - Nexavar PA Policy	Policy
Oncology - Nilutamide PA Policy	Policy
Oncology - Ninlaro PA Policy	Policy
Oncology - Nubeqa PA Policy	Policy
Oncology - Odomzo PA Policy	Policy
Oncology - Pomalyst PA Policy	Policy
Oncology - Revlimid PA Policy	Policy
Oncology - Rozlytrek PA Policy	Policy
Oncology - Rubraca PA Policy	Policy
Oncology - Rydapt PA Policy	Policy
Oncology - Sprycel PA Policy	Policy
Oncology - Stivarga PA Policy	Policy
Oncology - Sunitinib PA Policy	Policy
Oncology - Tafinlar PA Policy	Policy
Oncology - Tagrisso PA Policy	Policy
Oncology - Talzenna PA Policy	Policy
Oncology - Tasigna PA Policy	Policy
Oncology - Temozolomide Capsules PA Policy	Policy
Oncology - Thalomid PA Policy	Policy
Oncology - Tibsovo PA	Policy
Oncology - Valchlor PA Policy	Policy
Oncology - Venclexta PA Policy	Policy
Oncology - Verzenio PA Policy	Policy
Oncology - Vistogard PA Policy	Policy
Oncology - Vitrakvi PA Policy	Policy
Oncology - Vizimpro PA Policy	Policy
Oncology - Votrient PA Policy	Policy
Oncology - Xalkori PA	Policy
Oncology - Xermelo PA Policy	Policy
Oncology - Xospata PA Policy	Policy
Oncology - Yonsa PA Policy	Policy
Oncology - Zejula PA Policy	Policy
Oncology - Zelboraf PA Policy	Policy
Oncology - Zolinza PA Policy	Policy
Oncology - Zydelig PA Policy	Policy
Oncology - Zykadia PA Policy	Policy
Ophthalmic - Glaucoma - Prostaglandins PA 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 - Xiidra PA Policy	Policy
Ophthalmology - Oxervate PA Policy	Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy	Policy
Opioids - Long-Acting Products PA Policy	Policy
Opioids - Tramadol Extended-Release Products PA	Policy

P
Parkinson's Disease - Inbrija PA Policy	Policy
Parkinson's Disease - Kynmobi PA 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 - Apomorphine Subcutaneous PA	Policy
Parkinson’s Disease - Nuplazid PA Policy	Policy
Phenylketonuria - Palynziq PA Policy	Policy
Phenylketonuria - Sapropterin (Kuvan) PA Policy	Policy
Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy	Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy	Policy
Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy	Policy
Pulmonary - Roflumilast Prior Authorization with Step Therapy Policy	Policy
Pulmonary Arterial Hypertension - Adempas PA Policy	Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy	Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy	Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy	Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy	Policy

Q
Qbrexza PA Policy	Policy

R
Repository Corticotropin - Acthar Gel PA Policy	Policy

S
Sickle Cell Disease - Endari PA Policy	Policy
Sickle Cell Disease - Oxbryta PA Policy	Policy
Somatostatin Analogs - Octreotide Immediate-Release Products PA Policy	Policy
Somatostatin Analogs - Somatuline Depot PA Policy	Policy
Somavert PA Policy	Policy

T
Testosterone (Oral, Topical, and Nasal) Products PA Policy	Policy
Thrombocytopenia - Doptelet PA Policy	Policy
Thrombocytopenia - Eltromboppag Products PA	Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy	Policy
Topical Acyclovir Products PA Policy	Policy
Topical Diclofenac Sodium 3% Gel	Policy
Topical Retinoids - Aklief PA Policy	Policy
Topical Retinoids - Tazarotene Products PA Policy	Policy
Topical Retinoids - Tretinoin Products PA Policy	Policy

V
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy	Policy

W
Wakefulness-Promoting Agents - Armodafinil, Modafinil PA with Step Therapy Policy	Policy
Wakefulness-Promoting Agents - Sunosi PA Policy with Step Therapy	Policy
Weight Loss - Glucagon-Like Peptide - 1 Agonists PA Policy	Policy