Utilization Management
Prior Authorization and Step Therapy Policies for Commercial and Individual Family Business (IFB)
Certain drugs within policies may not be applicable to the specific formulary and plan design. Please refer to the formulary drug list and/or member plan documents to determine coverage status.
| Hematology - Gene Therapy - Casgevy PA | Policy |
| Hematology - Gene Therapy - Lyfgenia PA | Policy |
| Hematology - Gene Therapy - Zynteglo PA | Policy |
| Hematology - Pyrukynd PA_Commercial | Policy |
| Hematology - Rytelo PA | Policy |
| Hemophilia - Altuviiio PA | Policy |
| Hemophilia - Gene Therapy - Beqvez PA | Policy |
| Hemophilia - Gene Therapy - Hemgenix PA_Commercial | Policy |
| Hemophilia - Gene Therapy - Roctavian PA | Policy |
| Hemophilia - Non-Factor Routine Prophylaxis Products - Alhemo PA Policy | Policy |
| Hemophilia - Non-Factor Routine Prophylaxis Products - Hympavzi PA Policy | Policy |
| Hemophilia - Non-Factor Routine Prophylaxis Products - Qfitlia PA Policy | Policy |
| Hemophilia - Recombinant Factor IX Products | Policy |
| Hepatitis C - Epclusa PA Policy_Commercial | Policy |
| Hepatitis C - Harvoni PA Policy_Commercial | Policy |
| Hepatitis C - Ribavirin PA Policy | Policy |
| Hepatitis C - Viekira Pak PA Policy | Policy |
| Hepatitis C - Vosevi PA Policy | Policy |
| Hepatitis C - Zepatier PA Policy_Commercial | Policy |
| Hepatitis C Virus (HCV) Direct Acting Antivirals (DAAs) PSM for National Preferred Formulary and Basic Formulary | Policy |
| Hepatitis C Virus Direct - Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary | Policy |
| Hepatology - Iqirvo PA_Commercial | Policy |
| Hepatology - Livdelzi PA_Commercial | Policy |
| Hepatology - Ocaliva PA Policy | Policy |
| Hepatology - Rezdiffra PA | Policy |
| Hereditary Angioedema - Andembry PA | Policy |
| Hereditary Angioedema - C1 Esterase Inhibitors (Intravenous) PA Policy | Policy |
| Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) PA Policy_Commercial | Policy |
| Hereditary Angioedema - Dawnzera PA | Policy |
| Hereditary Angioedema - Ekterly PA | 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_Commercial | Policy |
| Hereditary Angioedema - Takhzyro PA Policy_Commercial | Policy |
| Hetlioz PA – Hetlioz LQ (tasimelteon oral suspension) | Policy |
| Homozgous Familial Hypercholesterolemia - Juxtapid PA Policy | Policy |
| Homozygous Familial Hypercholesterolemia - Juxtapid PA_Commercial | Policy |
| Human Immunodeficiency Virus - Apretude PA | Policy |
| Human Immunodeficiency Virus - Sunlenca PA_Commercial | Policy |
| Human Immunodeficiency Virus - Truvada PSM Policy | Policy |
| Hydrocortisone Acetate Suppository Step Therapy Policy_Commercial | Policy |
| Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors ST | Policy |
| Hydroxy-methylglutaryl-coenzyme A Reductase Inhibitors Step Therapy Policy | Policy |
| Hyperhidrosis - Qbrexza PA | Policy |
| Hyperlipidemia - Nexletol PA Policy_Commercial | Policy |
| Hyperlipidemia - Nexlizet PA Policy_Commercial | Policy |
| Hyperlipidemia - Omega-3 Fatty Acid Products PA Policy | Policy |
| Hypoparathyroidism - Natpara PA | Policy |
| Hypoparathyroidism - Yorvipath PA_Commercial | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Esbriet PA Policy | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Jascayd PA_Commercial | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev PA_Commercial | Policy |
| Idiopathic Pulmonary Fibrosis and Related Lung Disease - Pirfenidone PSM | Policy |
| Immune Disorder - Joenja PA_Commerical | Policy |
| Immunologicals - Anti-Interleukin-5 Agents PSM Policy | Policy |
| Immunologicals - Dupixent PA Policy | Policy |
| Immunologicals - Ebglyss PA_Commercial | Policy |
| Immunologicals - Nemluvio PA_Commercial | Policy |
| Immunologicals - Tezspire PA_Commercial | Policy |
| Immunologicals - Xolair PA Policy | Policy |
| Immunologicals – Adbry PA | Policy |
| Infectious Disease - Impavido PA Policy_Commercial | Policy |
| Infectious Disease - Ivermectin Tablets PA Policy_Commercial | Policy |
| Infectious Disease - Livtencity PA_Commercial | Policy |
| Infectious Disease - Pretomanid PA Policy | Policy |
| Infectious Disease - Pyrimethamine PA Policy_Commercial | Policy |
| Infectious Disease - Sirturo PA Policy_Commercial | Policy |
| Infectious Disease - Sirturo PA Policy_IFB | Policy |
| Infertility - Follitropins, Clomiphene PSM | 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_Commercial | 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 - Leqselvi PA_Commercial | Policy |
| Inflammatory Conditions - Litfulo PA_Commercial | Policy |
| Inflammatory Conditions - Omvoh Intravenous PA | Policy |
| Inflammatory Conditions - Omvoh Subcutaneous PA | Policy |
| Inflammatory Conditions - Otezla Otezla XR PA | Policy |
| Inflammatory Conditions - Rinvoq PA Policy | Policy |
| Inflammatory Conditions - Rinvoq, Rinvoq LQ PA | Policy |
| Inflammatory Conditions - Skyrizi Intravenous PA | Policy |
| Inflammatory Conditions - Skyrizi Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Sotyktu PA | Policy |
| Inflammatory Conditions - Spevigo Subcutaneous PA_Commercial | 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 |