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.
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Vizimpro PA | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Lytgobi PA | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Pemazyre PA | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Rydapt PA | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Vanflyta PA | Policy |
| Oncology (Oral - FMS-Like Tyrosine Kinase 3 Inhibitor) - Xospata PA | Policy |
| Oncology (Oral - Hedgehog Pathway Inhibitor) - Erivedge 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) - Lenalidomide PSM | Policy |
| Oncology (Oral - Immunomodulator) - Pomalyst PA | Policy |
| Oncology (Oral - Immunomodulator) - Thalomid PA | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Rezlidhia PA | Policy |
| Oncology (Oral - Isocitrate Dehydrogenase 1 Inhibitor) - Tibsovo 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 - MEK Inhibitor) - Mektovi PA | Policy |
| Oncology (Oral - Menin Inhibitor) - Komzifti PA | Policy |
| Oncology (Oral - Menin Inhibitor) - Revuforj PA | Policy |
| Oncology (Oral - Mesenchymal-Epithelial Transition Skipping Agent) - Tabrecta PA | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Augtyro PA | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Rozlytrek PA | Policy |
| Oncology (Oral - Neurotrophic Tyrosine Receptor Kinase Gene Fusion) - Vitrakvi 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 - Proteasome Inhibitor) - Ninlaro PA | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Gavreto PA | Policy |
| Oncology (Oral - Rearranged During Transfection-Targeting Agent) - Retevmo PA | Policy |
| Oncology (Oral - ROS1 Inhibitor) - Ibtrozi PA | Policy |
| Oncology (Oral – Cyclin-Dependent Kinase 4 and 6 Inhibitor) – Kisqali and Kisqali Femara Co-Pack Prior Authorization Policy | Policy |
| Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Beta-adrenergic Blockers Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Combination Products Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors | Policy |
| Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors Step Therapy Policy | Policy |
| Ophthalmic - Glaucoma - Prostaglandins PA Policy | Policy |
| Ophthalmic Anti-Allergics - Mast Cell Stabilizers Step Therapy Policy | Policy |
| Ophthalmic Anti-Allergics - Miscellaneous Step Therapy Policy | Policy |
| Ophthalmic Corticosteroids Step Therapy 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 - Lacrisert PA Policy | Policy |
| Ophthalmic for Dry Eye Disease - Xiidra PA Policy | Policy |
| Ophthalmic Nonsteroidal Antiinflammatory Drugs Step Therapy Policy | Policy |
| Ophthalmic Prostaglandin Step Therapy Policy | Policy |
| Ophthalmic Quinolone Antibiotics Step Therapy 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 - Dry Eye Disease – Miebo PA | Policy |
| Ophthalmology - iDose TR PA | Policy |
| Ophthalmology - Izervay PA | Policy |
| Ophthalmology - Oxervate PA Policy | Policy |
| Ophthalmology - Syfovre PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Ranibizumab Products PSM | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA | Policy |
| Ophthalmology - Verkazia PA | Policy |
| Ophthlamic Nonsteroidal Antiinflammatory Drugs | 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 Products PA | Policy |
| Otic Quinolone - Ciprofloxacin Step Therapy Policy | Policy |
| Overactive Bladder Medications Step Therapy Policy | Policy |
| Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy | Policy |
| Parkinson's Disease - Carbidopa PA | Policy |
| Parkinson’s Disease - Carbidopa-Levodopa (Oral) ST | Policy |
| Parkinson's Disease - Inbrija PA Policy | Policy |
| Parkinson's Disease - Kynmobi PA Policy | Policy |
| Parkinson's Disease - Monoamine Oxidase Type B Inhibitors Step Therapy 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 |
| Pegylated Interferons PA Policy | Policy |
| Phenylketonuria - Palynziq PA Policy | Policy |
| Phenylketonuria - Sapropterin (Kuvan) PA Policy | Policy |
| Phenylketonuria - Sephience PA | Policy |
| Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy | Policy |
| Pompe Disease - Enzyme Replacement Therapy - Pombiliti Prior | Policy |
| Pompe Disease - Enzyme Stabilization Therapy - Opfolda Prior | Policy |
| Prader-Willi Syndrome - Vykat XR PA | Policy |
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy | Policy |
| Proton Pump Inhibitors Step Therapy Policy | Policy |
| Pulmonary - Airsupra ST | Policy |
| Pulmonary - Brinsupri PA | Policy |
| Pulmonary - Corticosteroid Inhalers Care Value | Policy |