Utilization Management
Prior Authorization and Step Therapy Policies for Commercial and Individual Family Business
| Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy | Policy |
| Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy | Policy |
| Hereditary Angioedema - Icatibant (Firazyr) Care Value Policy | Policy |
| Hereditary Angioedema - Icatibant (Firazyr) PA Policy | Policy |
| Hereditary Angioedema - Icatibant (Firazyr) PSM Policy | Policy |
| Hereditary Angioedema - Kalbitor PA | Policy |
| Hereditary Angioedema - Orladeyo PA Policy | Policy |
| Hereditary Angioedema - Takhzyro PA Policy | Policy |
| Hetlioz PA – Hetlioz LQ (tasimelteon oral suspension) | Policy |
| Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy | Policy |
| Human Immunodeficiency Virus - Apretude PA | Policy |
| Human Immunodeficiency Virus - Sunlenca PA | Policy |
| Human Immunodeficiency Virus - Truvada PSM Policy | Policy |
| Hydrocortisone Acetate Suppository Step Therapy Policy | Policy |
| Hydroxy-methylglutaryl-coenzyme A Reductase Inhibitors Step Therapy Policy | Policy |
| Hyperhidrosis - Qbrexza PA | Policy |
| Hyperlipidemia - Nexletol PA Policy | Policy |
| Hyperlipidemia - Nexlizet PA Policy | Policy |
| Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy | Policy |
| Hypoparathyroidism - Natpara PA | Policy |
| Hypoparathyroidism - Yorvipath PA | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA Policy | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PSM | Policy |
| Immune Disorder - Joenja PA | Policy |
| Immunologicals - Anti-Interleukin-5 Agents PSM Policy | Policy |
| Immunologicals - Dupixent PA Policy | Policy |
| Immunologicals - Ebglyss PA | Policy |
| Immunologicals - Nemluvio PA | Policy |
| Immunologicals - Tezspire PA | Policy |
| Immunologicals - Xolair PA Policy | Policy |
| Immunologicals – Adbry PA | Policy |
| Infectious Disease - Impavido PA Policy | Policy |
| Infectious Disease - Ivermectin Tablets PA Policy | Policy |
| Infectious Disease - Livtencity PA | Policy |
| Infectious Disease - Pretomanid PA Policy | Policy |
| Infectious Disease - Pyrimethamine PA Policy | Policy |
| Infectious Disease - Sirturo PA Policy | Policy |
| Infertility - Gonadotropin-Releasing Hormone Antagonists PSM Policy | Policy |
| Infertility - Vaginal Progesterone PSM | Policy |
| Infertility – Follitropins, Clomiphene Preferred Specialty Management | Policy |
| Inflammatory Conditions - Adalimumab Products PA Policy | Policy |
| Inflammatory Conditions - Adalimumab Products PSM | Policy |
| Inflammatory Conditions - Adalimumab Products PSM for National Preferred, High Performance, and Basic Formularies - Choice | Policy |
| Inflammatory Conditions - Arcalyst PA Policy | Policy |
| Inflammatory Conditions - Bimzelx PA | Policy |
| Inflammatory Conditions - Care Value Policy | Policy |
| Inflammatory Conditions - Cibinqo PA Policy | Policy |
| Inflammatory Conditions - Cosentyx Intravenous PA | Policy |
| Inflammatory Conditions - Entyvio Subcutaneous PA | Policy |
| Inflammatory Conditions - Etanercept Products PA Policy | Policy |
| Inflammatory Conditions - Litfulo PA | Policy |
| Inflammatory Conditions - Omvoh Intravenous PA | Policy |
| Inflammatory Conditions - Omvoh Subcutaneous PA | Policy |
| Inflammatory Conditions - Otezla PA Policy | Policy |
| Inflammatory Conditions - Rinvoq PA Policy | Policy |
| Inflammatory Conditions - Skyrizi Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Sotyktu PA | Policy |
| Inflammatory Conditions - Spevigo Subcutaneous PA | Policy |
| Inflammatory Conditions - Stelara (Ustekinumab Subcutaneous Products) PA Policy with Dosing | Policy |
| Inflammatory Conditions - Taltz PA Policy | Policy |
| Inflammatory Conditions - Tocilizumab Subcutaneous Products PA | Policy |
| Inflammatory Conditions - Tremfya PA Policy | Policy |
| Inflammatory Conditions - Tremfya Subcutaneous PA | Policy |
| Inflammatory Conditions - Ustekinumab Subcutaneous Products PSM Policy for National Preferred and Basic Formularies - Choice | Policy |
| Inflammatory Conditions - Velsipity PA | Policy |
| Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy | Policy |
| Inflammatory Conditions - Zymfentra PA | Policy |
| Inflammatory Conditions - Zymfentra PA | Policy |
| Inflammatory Conditions Preferred Specialty Management Policy for National Preferred, High Performance, and Basic Formularies – Choice/Alternate | Policy |
| Inflammatory Conditions PSM for FLEX Formulary | Policy |
| Inpefa PA | Policy |
| Interferon - Actimmune PA Policy | Policy |
| Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy | Policy |
| Isotretinoin Step Therapy Policy | Policy |
| Levothyroxine Products ST | Policy |
| Lidocaine Patch Products PA | Policy |
| Lipodystrophy - Egrifta PA Policy | Policy |
| Lipodystrophy - Myalept PA Policy | Policy |
| Lupus - Benlysta Subcutaneous PA | Policy |
| Metabolic Disorders - Betaine Anhydrous PSM | 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 - Dojolvi PA Policy | Policy |
| Metabolic Disorders - Imcivree PA Policy | Policy |
| Metabolic Disorders - Nitisinone Products PA Policy | Policy |
| Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy | Policy |
| Metabolic Disorders - Phenylbutyrate Products PSM | Policy |
| Metabolic Disorders - Primary Hyperoxaluria Medications - Rivfloza PA | Policy |
| Metabolic Disorders - Tiopronin Products PA Policy | Policy |
| Metabolic Disorders - Tiopronin Products PSM | Policy |
| Metabolic Disorders - Xuriden PA Policy | Policy |
| Methotrexate Injection Step Therapy | 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 - Elyxyb PA | Policy |