Utilization Management

Prior Authorization and Step Therapy Policies for Medicaid

A B C D E G H I L M N O P Q S T V W

Acthar Gel PA Policy

Policy

Amifampridine Products PA Policy

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 - Banzel PA Policy

Policy

Antiepileptics - Clobazam Products PA Policy

Policy

Antiepileptics - Fintepla PA Policy

Policy

Antiepileptics - Nayzilam PA Policy

Policy

Antiepileptics - Vigabatrin (Sabril) PA Policy

Policy

Antifungals - Cresemba (Oral) PA Policy

Policy

Antifungals - Noxafil (Oral) PA Policy

Policy

Antifungals - Tolsura PA with Step Therapy Policy

Policy

Antifungals - Voriconazole (Oral) PA Policy

Policy

Antiparasitics - Impavido PA Policy

Policy

Antiseizure Medications - Diacomit PA Policy

Policy

Antiseizure Medications - Epidiolex PA Policy

Policy

Antiseizure Medications - Valtoco PA Policy

Policy

Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy

Policy

Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy

Policy

Bone Modifiers - Prolia PA Policy

Policy

Bone Modifiers - Tymlos PA Policy

Policy

Bone Modifiers - Xgeva PA Policy

Policy

Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy

Policy

Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy

Policy

Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy

Policy

Cardiology - Corlanor PA Policy

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

Chenodal PA Policy

Cholbam PA Policy

Cialis PA 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

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

Diabetes - Continuous Glucose Monitoring Systems PA Policy

Policy

Diabetes - Symlin PA Policy

Policy

Dronabinol PA Policy

Policy

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

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

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

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 - 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

Lidocaine Patch PA Policy

Policy

Lipodystrophy - Egrifta PA Policy

Policy

Lipodystrophy - Myalept PA Policy

Policy

Lupus – Benlysta Subcutaneous PA Policy

Policy

Lyrica CR PA Policy

Policy

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 - Nurtec ODT PA Policy

Policy

Migraine - Reyvow PA Policy

Policy

Multiple Sclerosis - Aubagio 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 - Vumerity PA Policy

Policy

Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy

Policy

Multiple Sclerosis and Ulcerative Colitis - Zeposia PA Policy

Policy

Natpara PA Policy

Policy

Neurology - Lyrica CR PA Policy

Policy

Neurology - Oxybate Products PA Policy

Policy

Neurology - Riluzole Products PA Policy

Policy

Non-Preferred PDL Drug Policy

Policy

Nuedexta PA Policy

Policy

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 (Tarceva) PA Policy

Policy

Oncology - Everolimus Products PA Policy

Policy

Oncology - Gavreto PA Policy

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 - Iressa 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 Prior Authorization 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 - Lacrisert 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 PA Policy

Policy

Parkinson's Disease - Kynmobi PA Policy

Policy

Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy

Policy

Parkinson’s Disease - Apokyn PA Policy

Policy

Parkinson’s Disease - Inbrija PA Policy

Policy

Parkinson’s Disease - Nourianz PA Policy

Policy

Parkinson’s Disease - Nuplazid PA Policy

Policy

Parkinson’s Disease - Tolcapone Products 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

Qbrexza PA Policy

Policy

Sickle Cell Disease - Endari PA Policy

Policy

Sickle Cell Disease - Oxbryta PA Policy

Policy

Somatostatin Analogs - Octreotide Immediate-Release Products Prior Authorization Policy

Policy

Somatostatin Analogs - Somatuline Depot PA Policy

Policy

Somavert PA Policy

Policy

Testosterone (Oral, Topical, and Nasal) Products PA Policy

Policy

Thrombocytopenia - Doptelet PA Policy

Policy

Thrombocytopenia - Promacta PA Policy

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

Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy

Policy

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