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.
| 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 |
| Inpefa PA | Policy |
| Interferon - Actimmune PA Policy | Policy |
| Interleukin-1 Blockers for Cryopyrin-Associated Periodic Syndromes PSM Policy | Policy |
| Isotretinoin Step Therapy Policy_Commercial | Policy |
| Levothyroxine Products ST | Policy |
| Lidocaine Patch Products PA Policy_Commercial | Policy |
| Lipodystrophy - Egrifta PA Policy_Commercial | Policy |
| Lipodystrophy - Myalept PA Policy_Commercial | Policy |
| Lupus - Benlysta Subcutaneous PA_Commercial | Policy |
| Metabolic Disorders - Betaine Anhydrous PSM | Policy |
| Metabolic Disorders - Carbaglu PA Policy | Policy |
| Metabolic Disorders - Cystaran PA Policy | Policy |
| Metabolic Disorders - Cysteamine Ophthalmic Solution PA Policy_Commercial | Policy |
| Metabolic Disorders - Dojolvi PA Policy_Commercial | Policy |
| Metabolic Disorders - Imcivree PA Policy_Commercial | Policy |
| Metabolic Disorders - Nitisinone Products PA Policy_Commercial | Policy |
| Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy_Commercial | Policy |
| Metabolic Disorders - Phenylbutyrate Products PSM | Policy |
| Metabolic Disorders - Primary Hyperoxaluria Medications - Rivfloza PA | Policy |
| Metabolic Disorders - Tiopronin Products PA Policy_Commercial | Policy |
| Metabolic Disorders - Tiopronin Products PSM | Policy |
| Metabolic Disorders - Xuriden PA Policy_Commercial | Policy |
| Methotrexate Injection Step Therapy | Policy |
| Methylergonovine (Methergine) PA Policy | Policy |
| Migraine - Calcitonin Gene-Related Peptide Inhibitors - Aimovig PA Policy_Commercial | Policy |
| Migraine - Calcitonin Gene-Related Peptide Inhibitors - Ajovy PA Policy_Commercial | Policy |
| Migraine - Calcitonin Gene-Related Peptide Inhibitors - Emgality PA Policy | Policy |
| Migraine - Elyxyb PA | Policy |
| Migraine - Nurtec ODT PA Policy_Commercial | Policy |
| Migraine - Qulipta PA Policy_Commercial | Policy |
| Migraine - Reyvow PA Policy_Commercial | Policy |
| Migraine - Ubrelvy PA Policy_Commercial | Policy |
| Migraine - Zavzpret PA | Policy |
| Migraine Medication Step Therapy Policy | Policy |
| Multiple Sclerosis - CD20-Directed Cytolytic Antibody Infused Products | Policy |
| Multiple Sclerosis - Dalfampridine PSM Policy | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Avonex PA_Commercial | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Betaseron PA_Commercial | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Plegridy PA_Commercial | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Rebif PA | Policy |
| Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Briumvi PA | Policy |
| Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Kesimpta PA | Policy |
| Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Ocrevus Zunovo PA_Commercial | Policy |
| Multiple Sclerosis (Injectable) - Glatiramer Products PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Bafiertam PA_Commercial | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Dimethyl Fumarate PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Vumerity PA | Policy |
| Multiple Sclerosis (Oral - Other) - Cladribine PA | Policy |
| Multiple Sclerosis (Oral - Other) - Teriflunomide PA | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Fingolimod PA | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Mayzent PA_Commercial | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Ponvory PA | Policy |
| Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Tascenso ODT PA | Policy |
| Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM for High Performance Formulary | Policy |
| Multiple Sclerosis and Ulcerative Colitis - Zeposia PSM for National Preferred, High Performance, and Basic Formularies - Choice, Alternate | Policy |
| Multiple Sclerosis and Ulcerative Colitis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Zeposia PA_Commercial | Policy |
| Multiple Sclerosis Care Value Policy | Policy |
| Multiple Sclerosis PSM Policy | Policy |
| Muscular Dystrophy - Agamree PA | Policy |
| Muscular Dystrophy - Deflazacort PSM | Policy |
| Muscular Dystrophy - Duvyzat PA | Policy |
| Muscular Dystrophy - Gene Therapy - Elevidys PA | Policy |
| Naloxone Injection Step Therapy Policy | Policy |
| Nasal Steroids Step Therapy Policy | Policy |
| Natpara PA Policy | Policy |
| Nephrology - Filspari PA Policy_Commercial | Policy |
| Nephrology - Jesduvroq PA | Policy |
| Nephrology - Tarpeyo PA_Commercial | Policy |
| Nephrology - Vafseo PA | Policy |
| Nephrology - Vanrafia PA_Commercial | Policy |
| Nephrology - Voyxact PA | Policy |
| Nephrology - Xphozah PA | Policy |
| Neurology - Daybue PA | Policy |
| Neurology - Oxybate Products PA Policy_Commercial | Policy |
| Neurology - Qalsody PA | Policy |
| Neurology - Relyvrio PA | Policy |
| Neurology - Riluzole Products PA Policy | Policy |
| Neurology - Rystiggo PA | Policy |
| Neurology - Skyclarys PA_Commercial | Policy |
| Neurology - Vyvgart Hytrulo PA_Commercial | Policy |
| Niemann-Pick disease type C - Aqneursa PA | Policy |
| Niemann-Pick disease type C - Miplyffa PA | Policy |
| Nonsteroidal Anti-Inflammatory Drug Step Therapy Policy | Policy |
| Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy_Commercial | Policy |
| Nuedexta PA Policy | Policy |
| Oncology - Abiraterone Acetate (Zytiga) Care Value Policy | Policy |
| Oncology - Abiraterone Acetate (Zytiga) PSM Policy_Commercial | Policy |
| Oncology - Ayvakit PA Policy_Commercial | Policy |
| Oncology - Balversa PA Policy_Commercial | Policy |
| Oncology - Bexarotene (Oral) PA_Commercial | Policy |
| Oncology - Bexarotene (Topical) PA_Commercial | Policy |
| Oncology - Bosulif PA Policy | Policy |
| Oncology - Cabometyx PA | Policy |
| Oncology - Caprelsa PA Policy | Policy |
| Oncology - Cometriq PA Policy | Policy |
| Oncology - Copiktra PA Policy_Commercial | Policy |