Utilization Management

Prior Authorization and Step Therapy Policies for Medicaid

A B C D E F G H I K L M N O P Q S T V W X
A
Acthar Gel PA Policy
Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy
Allergen Immunotherapy - Odactra PA Policy
Allergen Immunotherapy - Ragwitek PA Policy
Amifampridine Products PA Policy
Amyloidosis - Tegsedi PA Policy
Antibiotics (Inhaled) - Arikayce PA Policy
Antibiotics (Inhaled) - Cayston PA
Antibiotics (Inhaled) - TOBI Podhaler PA Policy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy
Antibiotics - Xifaxan PA Policy
Antiepileptics - Clobazam Products PA Policy
Antiepileptics - Diacomit PA Policy
Antiepileptics - Epidiolex PA Policy
Antiepileptics - Valtoco PA Policy
Antifungals - Cresemba (Oral) PA Policy
Antifungals - Noxafil (Oral) PA Policy
Antifungals - Voriconazole Tablets and Oral Suspension PA Policy
Antiparasitics - Impavido PA Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy
B
Bone Modifiers - Prolia PA Policy
Bone Modifiers - Teriparatide Products PA Policy
Bone Modifiers - Tymlos PA Policy
C
Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy
Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy
Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy
Chelating Agents - Penicillamine Products PA Policy
Chelating Agents - Syprine PA Policy
Chenodal PA Policy
Cholbam PA Policy
Cialis PA Policy
Cinacalcet (Sensipar) PA Policy
Colony Stimulating Factors - Granix PA Policy
Colony Stimulating Factors - Leukine PA Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy
Cushing's - Isturisa PA Policy
Cushing's - Korlym PA Policy
Cushing's - Signifor PA Policy
Cystic Fibrosis - Kalydeco PA Policy
Cystic Fibrosis - Orkambi PA Policy
Cystic Fibrosis - Pulmozyme PA Policy
Cystic Fibrosis - Symdeko PA Policy
Cystic Fibrosis - Trikafta PA Policy
D
Desmopressin Products - Nocdurna PA Policy
Desmopressin Products - Noctiva PA with Step Therapy Policy
Dronabinol PA Policy
E
Enzyme Replacement Therapy - Strensiq PA Policy
Enzyme Replacement Therapy - Sucraid PA Policy
Erythroid Stimulating Agents - Mircera PA Policy
Erythropoiesis-Stimulating Agents - Aranesp PA Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy
F
Fabry Disease - Galafold PA Policy
G
Gaucher Disease Substrate Reduction Therapy - Cerdelga PA Policy
Gaucher Disease Substrate Reduction Therapy - Miglustat (Zavesca) PA Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products (Lupaneta Pack and Lupron Depot) PA Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products (Lupron Depot-Ped and Triptodur) PA
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy
Growth Disorders - Growth Hormone PA
Growth Disorders - Increlex PA Policy
H
Helicobacter Pylori Infection Combination Products Preferred Step Therapy Policy
Hepatitis C - Epclusa PA Policy
Hepatitis C - Harvoni PA Policy
Hepatitis C - Mavyret PA Policy
Hepatitis C - PDL Drug Policy
Hepatitis C - Ribavirin PA Policy
Hepatitis C - Viekira Pak PA Policy
Hepatitis C - Vosevi PA Policy
Hepatology - Ocaliva PA Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy
Hereditary Angioedema - Icatibant (Firazyr) PA Policy
Hereditary Angioedema - Kalbitor PA Policy
Hereditary Angioedema - Takhzyro PA Policy
Hetlioz PA – Hetlioz LQ (tasimelteon oral suspension)
Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy
Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy
I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy
Immunologicals - Cinqair PA Policy
Immunologicals - Dupixent PA Policy
Immunologicals - Fasenra PA Policy
Immunologicals - Nucala PA
Immunologicals - Xolair PA Policy
Increlex PA Policy
Infectious Disease - Daraprim PA Policy
Inflammatory Conditions - Actemra Subcutaneous PA Policy
Inflammatory Conditions - Adalimumab Products PA Policy
Inflammatory Conditions - Arcalyst PA Policy
Inflammatory Conditions - Benlysta Subcutaneous PA Policy
Inflammatory Conditions - Cimzia PA Policy
Inflammatory Conditions - Etanercept Products PA Policy
Inflammatory Conditions - Ilumya PA Policy
Inflammatory Conditions - Kevzara PA Policy
Inflammatory Conditions - Kineret PA Policy
Inflammatory Conditions - Olumiant PA Policy
Inflammatory Conditions - Otezla PA Policy
Inflammatory Conditions - Rinvoq PA Policy
Inflammatory Conditions - Siliq PA Policy
Inflammatory Conditions - Simponi Subcutaneous PA Policy
Inflammatory Conditions - Skyrizi PA Policy
Inflammatory Conditions - Stelara Subcutaneous PA Policy
Inflammatory Conditions - Taltz PA Policy
Inflammatory Conditions - Tremfya PA Policy
Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy
Interferon - Actimmune PA Policy
K
Keveyis PA Policy
L
Lidocaine Patch PA Policy
Lipodystrophy - Egrifta PA Policy
Lipodystrophy - Myalept PA Policy
Lupus – Benlysta Subcutaneous PA Policy
Lyrica CR PA Policy
M
Metabolic Disorders - Carbaglu PA Policy
Metabolic Disorders - Cystaran PA Policy
Metabolic Disorders - Cysteamine (Oral) Products (Cystagon, Procysbi) PA Policy
Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy
Metabolic Disorders - Tiopronin Products PA Policy
Metabolic Disorders - Xuriden PA Policy
Methergine PA Policy
Migraine - Nurtec ODT PA Policy
Migraine - Reyvow PA Policy
Migraine - Ubrelvy PA Policy
Multiple Sclerosis - Ampyra PA Policy
Multiple Sclerosis - Aubagio PA Policy
Multiple Sclerosis - Avonex PA Policy
Multiple Sclerosis - Betaseron, Extavia PA Policy
Multiple Sclerosis - Dimethyl Fumarate (Tecfidera) PA Policy
Multiple Sclerosis - Gilenya PA Policy
Multiple Sclerosis - Glatiramer Products PA Policy
Multiple Sclerosis - Lemtrada PA Policy
Multiple Sclerosis - Mavenclad PA Policy
Multiple Sclerosis - Mayzent PA Policy
Multiple Sclerosis - Plegridy PA
Multiple Sclerosis - Rebif PA Policy
Multiple Sclerosis - Vumerity PA Policy
Multiple Sclerosis - Zeposia PA Policy
Multiple Sclerosis and Crohn's Disease - Tysabri PA Policy
Muscular Dystrophy - Emflaza PA Policy
N
Natpara PA Policy
Neurology - Riluzole Products PA Policy
Non-Preferred PDL Drug Policy
Northera PA Policy
Nuedexta PA Policy
O
Oncology (Injectable) - Gonadotropin-Releasing Hormone Analogs PA Policy
Oncology (Injectable) - Synribo PA Policy
Oncology (Injectable) - Topotecan Products PA Policy
Oncology - Abiraterone Acetate (Zytiga) PA Policy
Oncology - Afinitor PA
Oncology - Alecensa PA Policy
Oncology - Alunbrig PA Policy
Oncology - Balversa PA Policy
Oncology - Bosulif PA Policy
Oncology - Braftovi PA Policy
Oncology - Brukinsa PA Policy
Oncology - Cabometyx PA
Oncology - Calquence PA Policy
Oncology - Caprelsa PA Policy
Oncology - Cometriq PA Policy
Oncology - Copiktra PA Policy
Oncology - Cotellic PA Policy
Oncology - Daurismo PA Policy
Oncology - Erivedge PA Policy
Oncology - Erleada PA Policy
Oncology - Erlotinib (Tarceva) PA Policy
Oncology - Farydak PA Policy
Oncology - Gavreto PA Policy
Oncology - Gilotrif PA Policy
Oncology - Ibrance PA Policy
Oncology - Iclusig PA Policy
Oncology - Idhifa PA Policy
Oncology - Imatinib (Gleevec) PA Policy
Oncology - Imbruvica PA Policy
Oncology - Inlyta PA Policy
Oncology - Inrebic PA Policy
Oncology - Iressa PA Policy
Oncology - Jakafi PA Policy
Oncology - Kisqali and Kisqali Femara Co-Pack PA Policy
Oncology - Koselugo PA
Oncology - Lapatinib (Tykerb) PA Policy
Oncology - Lenvima PA Policy
Oncology - Lonsurf PA Policy
Oncology - Lorbrena PA Policy
Oncology - Lynparza PA
Oncology - Mekinist PA Policy
Oncology - Mektovi PA Policy
Oncology - Nerlynx PA Policy
Oncology - Nexavar PA Policy
Oncology - Nilutamide PA Policy
Oncology - Ninlaro PA Policy
Oncology - Nubeqa PA Policy
Oncology - Odomzo PA Policy
Oncology - Pemazyre PA Policy
Oncology - Piqray PA Policy
Oncology - Pomalyst PA Policy
Oncology - Revlimid PA Policy
Oncology - Rozlytrek PA Policy
Oncology - Rubraca PA Policy
Oncology - Rydapt PA
Oncology - Sprycel PA Policy
Oncology - Stivarga PA Policy
Oncology - Sutent PA Policy
Oncology - Tafinlar PA Policy
Oncology - Tagrisso PA Policy
Oncology - Talzenna PA Policy
Oncology - Targretin (topical) PA Policy
Oncology - Tazverik PA Policy
Oncology - Temozolomide Capsules PA Policy
Oncology - Thalomid PA Policy
Oncology - Tibsovo PA
Oncology - Tukysa PA Policy
Oncology - Turalio PA Policy
Oncology - Valchlor PA Policy
Oncology - Venclexta PA Policy
Oncology - Verzenio PA Policy
Oncology - Vistogard PA Policy
Oncology - Vitrakvi PA Policy
Oncology - Vizimpro PA Policy
Oncology - Votrient PA Policy
Oncology - Xalkori PA
Oncology - Xermelo PA Policy
Oncology - Xospata PA Policy
Oncology - Xpovio PA Policy
Oncology - Yonsa PA Policy
Oncology - Zejula PA Policy
Oncology - Zelboraf PA Policy
Oncology - Zolinza PA Policy
Oncology - Zydelig PA Policy
Oncology - Zykadia PA Policy
Ophthalmic for Dry Eye Disease - Eysuvis PA Policy
Ophthalmic for Dry Eye Disease - Lacrisert PA Policy
Ophthalmology – Oxervate PA Policy
Opioids - Fentanyl Transmucosal Drugs PA Policy
Opioids - Long-Acting Products PA Policy
Opioids - Tramadol Extended-Release PA Policy
P
Parkinson's Disease - Kynmobi PA Policy
Parkinson’s Disease - Apokyn PA Policy
Parkinson’s Disease - Inbrija PA Policy
Parkinson’s Disease - Lodosyn PA Policy
Parkinson’s Disease - Nourianz PA Policy
Parkinson’s Disease - Nuplazid PA Policy
Parkinson’s Disease - Tolcapone Products PA Policy
Phenylketonuria - Kuvan PA Policy
Phenylketonuria - Palynziq PA Policy
Pheochromocytoma – Metyrosine Capsules and Phenoxybenzamine Capsules PA Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy
Pulmonary - Daliresp PA Policy
Pulmonary Arterial Hypertension - Adempas PA Policy
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA Policy
Pulmonary Arterial Hypertension - Inhaled Prostacyclin Products PA Policy
Pulmonary Arterial Hypertension - Orenitram PA Policy
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy
Pulmonary Arterial Hypertension - Uptravi PA Policy
Q
Qbrexza PA with Step Therapy Policy
S
Sickle Cell Disease - Endari PA Policy
Somatostatin Analogs - Sandostatin LAR Depot PA Policy
Somatostatin Analogs - Signifor LAR PA Policy
Somatostatin Analogs - Somatuline Depot PA Policy
Somavert PA Policy
T
Testosterone (injectable) Products PA Policy
Testosterone (Oral, Topical, and Nasal) Products PA Policy
Thrombocytopenia - Doptelet PA Policy
Thrombocytopenia - Promacta PA Policy
Tolvaptan Products - Jynarque PA Policy
Tolvaptan Products - Tolvaptan (Samsca) PA Policy
Topical Acyclovir Cream and Ointment PA Policy
Topical Diclofenac Sodium Gel (Solaraze) PA Policy
Topical Retinoids - Aklief PA Policy
Topical Retinoids - Tazarotene Products PA Policy
V
Vecamyl PA Policy
Veregen PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Ingrezza PA Policy
Vesicular Monoamine Transporter Type 2 Inhibitors - Tetrabenazine PA Policy
W
Wakefulness-Promoting Agents - Armodafinil, Modafinil PA Policy
X
Xyrem PA Policy
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