Utilization Management

Prior Authorization and Step Therapy Policies for Commercial and Individual Family Business

Allergen Immunotherapy - Grass Pollen Sublingual Products PA Policy	Policy
Allergen Immunotherapy - Odactra PA Policy	Policy
Allergen Immunotherapy - Ragwitek PA Policy	Policy
Alzheimer's Disease Step Therapy Policy	Policy
Alzheimers - Namenda, Namenda XR Step Therapy Policy	Policy
Amifampridine Products PA Policy	Policy
Amifampridine Products PSM Policy	Policy
Amyloidosis - Tafamidis Products (Vyndaqel and Vyndamax) PA Policy	Policy
Amyloidosis - Tegsedi PA Policy	Policy
Amyloidosis - Wainua PA	Policy
Angiotensin Receptor Blocker Step Therapy Policy	Policy
Antibiotics - Linezolid (Zyvox), Sivextro PA Policy	Policy
Antibiotics - Vancomycin Capsules PA Policy	Policy
Antibiotics - Xifaxan PA Policy	Policy
Antibiotics (Inhaled) - Arikayce PA Policy	Policy
Antibiotics (Inhaled) - Cayston PA	Policy
Antibiotics (Inhaled) - TOBI Podhaler PA Policy	Policy
Antibiotics (Inhaled) - Tobramycin Inhalation Solution PA	Policy
Antibiotics (Inhaled) - Tobramycin Products Care Value Policy	Policy
Antibiotics (Inhaled) - Tobramycin Products PSM Policy	Policy
Anticoagulants - Eliquis PA Policy	Policy
Anticoagulants - Xarelto PA Policy	Policy
Antidepressants - Bupropion Long-Acting Step Therapy Policy	Policy
Antidepressants - Selective Serotonin Reuptake Inhibitors Step Therapy Policy	Policy
Antidepressants - Serotonin and Norepinephrine Reuptake Inhibitors Step Therapy Policy	Policy
Antidepressants ST	Policy
Antiepileptics - Topiramate Step Therapy Policy	Policy
Antifungals - Cresemba (Oral) PA Policy	Policy
Antifungals - Posaconazole (Oral) PA	Policy
Antifungals - Voriconazole (Oral) PA Policy	Policy
Antifungals for Vulvovaginal Candidiasis Step Therapy Policy	Policy
Antiseizure Medications - (Oxcarbazepine) Oxtellar XR, Trileptal ST	Policy
Antiseizure Medications - Clobazam Products PA	Policy
Antiseizure Medications - Depakote, Depakene Step Therapy	Policy
Antiseizure Medications - Diacomit PA Policy	Policy
Antiseizure Medications - Epidiolex PA Policy	Policy
Antiseizure Medications - Lacosamide ST	Policy
Antiseizure Medications - Lamotrigine Step Therapy Policy	Policy
Antiseizure Medications - Levetiracetam, Brivaracetam Step Therapy	Policy
Antiseizure Medications - Nayzilam PA	Policy
Antiseizure Medications - Oxtellar XR, Trileptal ST	Policy
Antiseizure Medications - Rufinamide PA	Policy
Antiseizure Medications - Topiramate Step Therapy Policy	Policy
Antiseizure Medications - Valtoco PA Policy	Policy
Antiseizure Medications - Vigabatrin PA	Policy
Antiseizure Medications - Zonisamide ST	Policy
Antiseizure Medications - Ztalmy PA	Policy
Antivirals - Ribavirin (Inhaled Products) PA Policy	Policy
Antivirals - Ribavirin (Oral Products) PA Policy	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications PA Policy	Policy
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications Step Therapy Policy	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications PA Policy	Policy
Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy	Policy
Benign Prostatic Hyperplasia - 5-Alpha-Reductase Inhibitors Step Therapy Policy	Policy
Benign Prostatic Hyperplasia - Entadfi PA	Policy
Benign Prostatic Hyperplasia – Alpha Blockers Step Therapy	Policy
Beta Blocker Step Therapy Policy	Policy
Bile Acid Sequestrants Step Therapy Policy	Policy
Bisphosphonates (Oral) Enhanced Step Therapy Policy	Policy
Bone Modifiers - Teriparatide Products PA Policy	Policy
Bone Modifiers - Tymlos PA Policy	Policy
Bone Modifiers - Xgeva PA Policy	Policy
Botulinum Toxin Products PSM	Policy
Calcium Channel Blockers - Dihydropyridine Products Step Therapy Policy	Policy
Calcium Channel Blockers - Verapamil Products Step Therapy Policy	Policy
Carbinoxamine Step Therapy Policy	Policy
Cardiology - Camzyos PA	Policy
Cardiology - Lodoco PA	Policy
Cardiology - Ranolazine Products ST	Policy
Cardiology - Zontivity PA Policy	Policy
Chelating Agents - Chemet PA Policy	Policy
Chelating Agents - Iron Chelators (Oral) Care Value Policy	Policy
Chelating Agents - Iron Chelators (Oral) PA Policy	Policy
Chelating Agents - Iron Chelators (Oral) PSM Policy	Policy
Chelating Agents - Penicillamine Products PA Policy	Policy
Chelating Agents - Trientine Products PA	Policy
Chenodal PA Policy	Policy
Cholbam PA Policy	Policy
Chorionic Gonadotropins PSM Policy	Policy
Cinacalcet (Sensipar) PA Policy	Policy
Colony Stimulating Factors - Filgrastim Products PA Policy	Policy
Colony Stimulating Factors - Filgrastim Products Preferred Specialty Management Policy for Basic Formulary	Policy
Colony Stimulating Factors - Filgrastim Products PSM Policy for High Performance and National Preferred Formularies	Policy
Colony Stimulating Factors - Leukine PA Policy	Policy
Colony Stimulating Factors - Pegfilgrastim Products and Rolvedon Preferred Specialty Management Policy for High Performance and National Preferred Formularies	Policy
Colony Stimulating Factors - Pegfilgrastim Products PA Policy	Policy
Colony Stimulating Factors - Rolvedon PA	Policy
Complement Inhibitors - Empaveli PA Policy	Policy
Complement Inhibitors - Fabhalta PA	Policy
Complement Inhibitors - Voydeya PA	Policy
Complement Inhibitors - Zilbrysq PA	Policy
Complement Inhibitors – Ultomiris Subcutaneous PA Policy	Policy
Complement System Disorders - WHIM Syndrome - Xolremdi PA	Policy
Compounded Select Topical Medications PA Policy	Policy
Contraceptives - Oral, Patch, and Vaginal Ring Products Step Therapy Policy	Policy
Coronavirus Disease - Evusheld PA	Policy
Cushing's - Recorlev PA Policy	Policy
Cushing's - Signifor PA Policy	Policy
Cushings - Mifepristone PSM	Policy
Cyclooxygenase - 2 Inhibitor Step Therapy Policy	Policy

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