Utilization Management
Prior Authorization and Step Therapy Policies for Medicaid
| Oncology (Oral - Androgen Biosynthesis Inhibitor) - Abiraterone Acetate PA | Policy |
| Oncology (Oral - Androgen Receptor Inhibitor) - Nubeqa PA | Policy |
| Oncology (Oral - BRAF Inhibitor) - Tafinlar PA | Policy |
| Oncology (Oral - BRAF Inhibitor) - Zelboraf PA | Policy |
| Oncology (Oral - Bruton's Tyrosine Kinase Inhibitor) - Jaypirca PA | Policy |
| Oncology (Oral - Cyclin-Dependent Kinase 4 and 6 Inhibitor) - Verzenio PA | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Erlotinib PA | Policy |
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gilotrif PA | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Vanflyta PA | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Odomzo PA | Policy |
| Oncology (Oral - HER2 Inhibitor) - Hernexeos PA | Policy |
| Oncology (Oral - HER2 Inhibitor) - Hyrnuo PA | Policy |
| Oncology (Oral - Immunomodulator) - Lenalidomide PA | Policy |
| Oncology (Oral - Immunomodulator) - Pomalyst PA | Policy |
| Oncology (Oral - Immunomodulator) - Thalomid PA | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Rezlidhia PA | Policy |
| Oncology (Oral - Kirsten RAt Sarcoma Virus Inhibitor) - Krazati PA | Policy |
| Oncology (Oral - MEK Inhibitor) - Cotellic PA | Policy |
| Oncology (Oral - MEK Inhibitor) - Mekinist PA | Policy |
| Oncology (Oral - Menin Inhibitor) - Komzifti PA | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Akeega PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Lynparza PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Rubraca PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Talzenna PA | Policy |
| Oncology (Oral - Poly [ADP-Ribose] Polymerase Inhibitor) - Zejula PA | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto PA | Policy |
| Oncology (Oral - ROS1 Inhibitor) - Ibtrozi PA | Policy |
| Oncology (Oral – Anaplastic Lymphoma Kinase-Positive Agent) – Alunbrig PA Policy | Policy |
| Oncology (Oral – Anaplastic Lymphoma Kinase-Positive Agent) – Zykadia PA Policy | Policy |
| Oncology (Oral – Androgen Biosynthesis Inhibitor) – Yonsa PA Policy | Policy |
| Oncology (Oral – Androgen Receptor Inhibitor) – Erleada PA Policy | Policy |
| Oncology (Oral – BRAF Inhibitor) – Braftovi PA Policy | Policy |
| Oncology (Oral – Bruton's Tyrosine Kinase Inhibitor) – Imbruvica PA | Policy |
| Oncology (Oral – Cyclin-Dependent Kinase 4/6 Inhibitor) – Ibrance PA Policy | Policy |
| Oncology (Oral – Epidermal Growth Factor Receptor Inhibitor) – Lazcluze PA Policy | Policy |
| Oncology (Oral – Epidermal Growth Factor Receptor Inhibitor) – Gefitinib PA Policy | Policy |
| Oncology (Oral – Epidermal Growth Factor Receptor Inhibitor) – Tagrisso PA Policy | Policy |
| Oncology (Oral – Epidermal Growth Factor Receptor Inhibitor) – Vizimpro PA Policy | Policy |
| Oncology (Oral – FMS-Like Tyrosine Kinase 3 Inhibitor) – Rydapt PA | Policy |
| Oncology (Oral – FMS-Like Tyrosine Kinase 3 Inhibitor) – Xospata PA | Policy |
| Oncology (Oral – Hedgehog Pathway Inhibitor) – Erivedge PA | Policy |
| Oncology (Oral – Isocitrate Dehydrogenase 1 Inhibitor) – Tibsovo PA | Policy |
| Oncology (Oral – Neurotrophic Tyrosine Receptor Kinase Gene Fusion) – Vitrakvi PA Policy | Policy |
| Oncology (Oral – Neurotrophic Tyrosine Receptor Kinase Gene Fusion) – Augtyro PA Policy | Policy |
| Oncology (Oral – Proteasome Inhibitor) – Ninlaro PA | Policy |
| Oncology (Other) - Anktiva PA | Policy |
| Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors | 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 - Dry Eye Disease - Cyclosporine Products PA | Policy |
| Ophthalmology - Dry Eye Disease - Eysuvis PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Lacrisert PA Policy | Policy |
| Ophthalmology - Dry Eye Disease - Tryptyr PA | Policy |
| Ophthalmology - Dry Eye Disease - Xiidra PA | Policy |
| Ophthalmology - iDose TR PA | Policy |
| Ophthalmology - iDose TR PA | Policy |
| Ophthalmology - Izervay PA | Policy |
| Ophthalmology - Izervay PA | Policy |
| Ophthalmology - Oxervate PA | Policy |
| Ophthalmology - Syfovre PA | Policy |
| Ophthalmology - Syfovre PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA | Policy |
| Ophthalmology - Verkazia PA | Policy |
| Ophthalmology – Dry Eye Disease – Miebo PA Policy | Policy |
| Opioids - Fentanyl Transmucosal Drugs PA Policy | Policy |
| Opioids - Long-Acting Products PA Policy | Policy |
| Opioids - Methadone PA | Policy |
| Opioids - Methadone Prior Authorization Policy | Policy |
| Opioids - Tramadol extended-release PA | Policy |
| Papillomatosis - Gene Therapy - Papzimeos PA | Policy |
| Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy | Policy |
| Parkinson’s Disease - Apomorphine Subcutaneous PA | Policy |
| Parkinson's Disease - Apomorphine Subcutaneous PA | Policy |
| Parkinson's Disease - Inbrija PA | Policy |
| Parkinson's Disease - Kynmobi PA Policy | Policy |
| Parkinson's Disease - Nourianz PA Policy | Policy |
| Parkinson’s Disease - Nuplazid PA Policy | Policy |
| Parkinson’s Disease - Onapgo PA | Policy |
| Parkinson's Disease - Ongentys PA | Policy |
| Parkinson's Disease - Tolcapone PA | Policy |
| Parkinson’s Disease - Vyalev PA | Policy |
| Phenylketonuria - Palynziq PA | Policy |
| Phenylketonuria - Sapropterin (Kuvan) PA Policy | Policy |
| Phenylketonuria - Sephience PA | Policy |
| Pheochromocytoma - Metyrosine and Phenoxybenzamine PA | Policy |
| Pompe Disease - Enzyme Replacement Therapy - Pombiliti Prior | Policy |
| Pompe Disease - Enzyme Replacement Therapy - Pombiliti Prior | Policy |
| Pompe Disease - Enzyme Stabilization Therapy - Opfolda PA | Policy |
| Prader-Willi Syndrome - Vykat XR PA | Policy |
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Praluent PA Policy | Policy |
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy | Policy |
| Psychiatry - Zurzuvae PA | Policy |
| Pulmonary - Brinsupri PA | Policy |
| Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA | Policy |