Utilization Management
Prior Authorization and Step Therapy Policies for Medicaid
| Inflammatory Conditions - Etanercept Products PA Policy | Policy |
| Inflammatory Conditions - Ilumya PA Policy | Policy |
| Inflammatory Conditions - Kevzara PA Policy | Policy |
| Inflammatory Conditions - Kineret PA Policy | Policy |
| Inflammatory Conditions - Leqselvi PA | Policy |
| Inflammatory Conditions - Litfulo PA | Policy |
| Inflammatory Conditions - Omvoh Intravenous PA | Policy |
| Inflammatory Conditions - Omvoh Subcutaneous PA | Policy |
| Inflammatory Conditions - Omvoh Subcutaneous PA | Policy |
| Inflammatory Conditions - Orencia Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Otezla PA Policy | Policy |
| Inflammatory Conditions - Rinvoq PA Policy | Policy |
| Inflammatory Conditions - Rinvoq, Rinvoq LQ PA | Policy |
| Inflammatory Conditions - Siliq PA Policy | Policy |
| Inflammatory Conditions - Simponi Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Skyrizi Intravenous 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 | Policy |
| Inflammatory Conditions - Spevigo Subcutaneous PA | Policy |
| Inflammatory Conditions - Stelara (Ustekinumab Subcutaneous Products) PA Policy with Dosing | Policy |
| Inflammatory Conditions - Stelara Subcutaneous PA Policy | Policy |
| Inflammatory Conditions - Stelara Subcutaneous 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 - Velsipity PA | Policy |
| Inflammatory Conditions - Xeljanz Xeljanz XR PA Policy | Policy |
| Inflammatory Conditions - Zymfentra PA | Policy |
| Inpefa PA | Policy |
| Interferon - Actimmune PA Policy | Policy |
| Lidocaine Patch Products PA | Policy |
| Lipodystrophy - Egrifta PA Policy | Policy |
| Lipodystrophy - Myalept PA Policy | Policy |
| Lupus - Benlysta Subcutaneous PA | Policy |
| Lupus – Benlysta Subcutaneous PA Policy | Policy |
| Lyrica CR PA Policy | 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 - Nitisinone Products PA Policy | Policy |
| Metabolic Disorders - Phenylbutyrate Products (Buphenyl, Ravicti) PA Policy | Policy |
| Metabolic Disorders - Primary Hyperoxaluria Medications - Rivfloza PA | Policy |
| Metabolic Disorders - Xuriden PA Policy | 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 |
| Migraine - Nurtec ODT PA Policy | Policy |
| Migraine - Reyvow PA Policy | Policy |
| Migraine - Zavzpret PA | Policy |
| Multiple Sclerosis - Briumvi PA | Policy |
| Multiple Sclerosis - Dalfampridine PA | Policy |
| Multiple Sclerosis - Lemtrada PA Policy | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Avonex PA | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Betaseron PA | Policy |
| Multiple Sclerosis (Injectable - Beta Interferon) - Plegridy PA | 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 | Policy |
| Multiple Sclerosis (Injectable) - Glatiramer Products PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Bafiertam PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Dimethyl Fumarate PA | Policy |
| Multiple Sclerosis (Oral - Fumarate) - Vumerity PA | Policy |
| Multiple Sclerosis (Oral - Other) - Mavenclad 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 | 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 Crohn's Disease - Tysabri PA Policy | Policy |
| Multiple Sclerosis and Ulcerative Colitis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Zeposia PA | Policy |
| Muscular Dystrophy - Agamree PA | Policy |
| Muscular Dystrophy - Duvyzat PA | Policy |
| Muscular Dystrophy - Gene Therapy - Elevidys PA | Policy |
| Natpara PA Policy | Policy |
| Nephrology - Filspari PA Policy | Policy |
| Nephrology - Jesduvroq PA | Policy |
| Nephrology - Tarpeyo PA | Policy |
| Nephrology - Vafseo PA | Policy |
| Nephrology - Vanrafia PA | Policy |
| Nephrology - Xphozah PA | Policy |
| Neurology - Daybue PA | Policy |
| Neurology - Kisunla PA | Policy |
| Neurology - Kisunla PA Policy | Policy |
| Neurology - Leqembi PA | Policy |
| Neurology - Leqembi PA | Policy |
| Neurology - Lyrica CR PA with Step Therapy | Policy |
| Neurology - Lyrica CR Prior Authorization with Step Therapy Policy | Policy |
| Neurology - Oxybate Products PA Policy | Policy |
| Neurology - Qalsody PA | Policy |
| Neurology - Qalsody PA | Policy |
| Neurology - Relyvrio PA | Policy |
| Neurology - Riluzole Products PA Policy | Policy |
| Neurology - Rystiggo PA | Policy |