Utilization Management
Prior Authorization and Step Therapy Policies for Medicaid
| Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Vizimpro PA | Policy |
| Oncology (Oral - Fibroblast Growth Factor Receptor Agent) - Lytgobi 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 - Immunomodulator) - Lenalidomide PA | 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 - 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 (Other) - Anktiva PA | Policy |
| Ophthalmic - Glaucoma - Prostaglandins and Rho Kinase Inhibitors | Policy |
| Ophthalmic - Glaucoma - Prostaglandins PA 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 - Xiidra PA 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 - Xiidra PA | Policy |
| Ophthalmology - Dry Eye Disease – Miebo PA | Policy |
| Ophthalmology - iDose TR PA | Policy |
| Ophthalmology - iDose TR PA | Policy |
| Ophthalmology - Izervay PA | Policy |
| Ophthalmology - Izervay PA | Policy |
| Ophthalmology - Oxervate PA Policy | Policy |
| Ophthalmology - Syfovre PA | Policy |
| Ophthalmology - Syfovre PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Susvimo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA | Policy |
| Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Vabysmo PA | Policy |
| Ophthalmology - Verkazia PA | 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 |
| Parkinson's Disease - Inbrija PA Policy | Policy |
| Parkinson's Disease - Kynmobi PA Policy | Policy |
| Parkinson's Disease - Nourianz PA Policy | Policy |
| Parkinson's Disease - Tolcapone PA | Policy |
| Parkinson’s Disease - Amantadine Extended-Release Drugs PA with Step Therapy | Policy |
| Parkinson’s Disease - Apomorphine Subcutaneous PA | Policy |
| Parkinson’s Disease - Nuplazid PA Policy | Policy |
| Parkinson’s Disease - Vyalev PA | Policy |
| Phenylketonuria - Palynziq PA Policy | Policy |
| Phenylketonuria - Sapropterin (Kuvan) PA Policy | Policy |
| Pheochromocytoma - Metyrosine and Phenoxybenzamine (Oral) PA Policy | Policy |
| Pompe Disease - Enzyme Replacement Therapy - Pombiliti Prior | 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 - Praluent PA Policy | Policy |
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors - Repatha PA Policy | Policy |
| Psychiatry - Zurzuvae PA | Policy |
| Pulmonary - Corticosteroid Long-Acting Beta2-Agonist Combination Inhalers PA Policy | Policy |
| Pulmonary - Roflumilast PA with Step Therapy Policy | Policy |
| Pulmonary - Roflumilast Prior Authorization with Step Therapy Policy | Policy |
| Pulmonary – Short-Acting Beta2-Agonist Inhalers | Policy |
| Pulmonary Arterial Hypertension - Adempas PA Policy | Policy |
| Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist PSM Policy | Policy |
| Pulmonary Arterial Hypertension - Orenitram PA Policy | Policy |
| Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors PA Policy | Policy |
| Pulmonary Arterial Hypertension - Uptravi PA Policy | Policy |
| Pulmonary Arterial Hypertension - Winrevair PA | Policy |
| Repository Corticotropin - Acthar Gel PA Policy | Policy |
| Repository Corticotropin - Cortrophin Gel PA | Policy |
| Sickle Cell Disease - Endari PA Policy | Policy |
| Sickle Cell Disease - Oxbryta PA Policy | Policy |
| Sohonos PA | Policy |
| Somatostatin Analogs - Lanreotide Products PA | Policy |
| Somatostatin Analogs - Octreotide Immediate-Release Products PA Policy | Policy |
| Somatostatin Analogs - Octreotide Long-Acting Products PA | Policy |
| Somatostatin Analogs - Somatuline Depot PA Policy | Policy |
| Somavert PA Policy | Policy |
| Tasimelteon Products PA | Policy |
| Testosterone (Oral, Topical, and Nasal) Products PA Policy | Policy |
| Thrombocytopenia - Doptelet PA Policy | Policy |
| Thrombocytopenia - Eltrombopag Products PA | Policy |
| Thrombocytopenia - Eltromboppag Products PA | Policy |
| Tolvaptan Products - Tolvaptan (Samsca) PA Policy | Policy |
| Topical Acyclovir Products PA Policy | Policy |
| Topical Diclofenac Sodium 3% Gel PA | Policy |
| Topical Retinoids - Aklief PA Policy | Policy |