Utilization Management
Prior Authorization and Step Therapy Policies for Medicaid
| Adrenal Hyperplasia - Crenessity PA | Policy |
| Alzheimer's - Namenda/Namenda XR ST | Policy |
| Amifampridine Products PA Policy | Policy |
| Amyloidosis - Amvuttra PA | Policy |
| Amyloidosis - Amvuttra PA | Policy |
| Amyloidosis - Attruby PA | Policy |
| Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy | Policy |
| Amyloidosis - Tegsedi PA Policy | Policy |
| Amyloidosis - Wainua PA | Policy |
| Antibiotics - Linezolid (Zyvox), Sivextro PA Policy | Policy |
| Antibiotics - Vancomycin Capsules PA Policy | Policy |
| Antibiotics - Xifaxan 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 |
| 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 |
| Antifungals - Voriconazole (Oral) PA with Step Therapy | 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 |
| Benign Prostatic Hyperplasia - Entadfi PA | Policy |
| Bone Modifiers - Denosumab Products (Prolia) PA | Policy |
| Bone Modifiers - Denosumab Products (Xgeva) PA | Policy |
| Bone Modifiers - Tymlos PA Policy | Policy |
| Botulinum Toxin - Daxxify PA | Policy |
| Cardiology - Camzyos PA | Policy |
| Cardiology - Corlanor (Ivabradine) PA | Policy |
| Cardiology - Corlanor PA Policy | Policy |
| Cardiology - Ivabradine PA | Policy |
| Cardiology - Lodoco PA | Policy |
| Cardiology - Zontivity PA Policy | Policy |
| Chelating Agents - Chemet PA Policy | Policy |
| Chelating Agents - Iron Chelators (Oral) PA Policy | Policy |
| Chelating Agents - Penicillamine Products PA Policy | Policy |
| Chelating Agents - Penicillamine Products PA with Step Therapy | 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 |
| Colony Stimulating Factors - Rolvedon PA | Policy |
| Complement Inhibitors - Fabhalta PA | Policy |
| Complement Inhibitors - PiaSky PA | Policy |
| Complement Inhibitors - PiaSky PA | Policy |
| Complement Inhibitors - Ultomiris PA | Policy |
| Complement Inhibitors - Veopoz PA | Policy |
| Complement Inhibitors - Voydeya PA | Policy |
| Complement Inhibitors - Zilbrysq PA | Policy |
| Complement System Disorders - WHIM Syndrome - Xolremdi PA | Policy |
| Compounded Select Topical Medications PA Policy | Policy |
| Coronavirus Disease - Evusheld PA | Policy |
| Corticosteroids (Intraarticular) - Zilretta PA | Policy |
| Corticosteroids (Intraarticular) - Zilretta PA Policy | Policy |
| Cushing's - Recorlev PA Policy | Policy |
| Cushing's - Signifor PA Policy | Policy |
| Cystic Fibrosis - Pulmozyme PA Policy | Policy |
| Cystic Fibrosis (Transmembrane Conductance Regulator) - Kalydeco PA | Policy |
| Cystic Fibrosis (Transmembrane Conductance Regulator) - Orkambi PA | Policy |
| Cystic Fibrosis (Transmembrane Conductance Regulator) - Symdeko PA | Policy |
| Cystic Fibrosis (Transmembrane Conductance Regulator) - Trikafta PA | Policy |
| Cystic Fibrosis Transmembrane Conductance Regulator - Alyftrek PA | Policy |
| Dermatology - Filsuvez PA | Policy |
| Dermatology - Gene Therapy - Vyjuvek PA | Policy |
| Diabetes - Continuous Glucose Monitoring Systems PA Policy | Policy |
| Diabetes - Glucagon-Like Peptide-1 Agonists PA - Optional | Policy |
| Diabetes - Symlin PA Policy | Policy |
| Diabetes - Tzield PA | Policy |
| Diabetes - Tzield PA | Policy |
| Dronabinol Products PA | Policy |
| Dronabinol Products PA with Step Therapy | Policy |
| Enspryng PA Policy | Policy |
| Enzyme Replacement Therapy - Elfabrio | Policy |
| Enzyme Replacement Therapy - Lamzede PA | Policy |
| Enzyme Replacement Therapy - Lamzede PA | Policy |
| Enzyme Replacement Therapy - Strensiq PA Policy | Policy |
| Enzyme Replacement Therapy - Sucraid PA Policy | Policy |
| Enzyme Replacement Therapy - Xenpozyme PA | Policy |
| Erectile Dysfunction - Tadalafil (Cialis) PA Policy | Policy |
| Erythropoiesis-Stimulating Agents - Aranesp PA Policy | Policy |
| Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy | Policy |
| Familial Chylomicronemia Syndrome - Tryngolza PA | Policy |