Utilization Management

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

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
Cystic Fibrosis - Bronchitol PA Policy	Policy
Cystic Fibrosis - Pulmozyme PA Policy	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Kalydeco PA	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Orkambi PA	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Symdeko PA	Policy
Cystic Fibrosis (Transmembrane Conductance Regulator) - Trikafta PA	Policy
Cystic Fibrosis Transmembrane Conductance Regulator - Alyftrek PA	Policy
Dermatology - Filsuvez PA	Policy
Dermatology - Gene Therapy - Vyjuvek PA	Policy
Dermatology - Hyftor PA	Policy
Desmopressin Products - Nocdurna PA Policy	Policy
Diabetes - Continuous Glucose Monitoring Systems PA Policy	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Care Value Policy	Policy
Diabetes - Dipeptidyl Peptidase-4 Inhibitors Step Therapy	Policy
Diabetes - Glucagon-Like Peptide-1 Agonists PA - Optional	Policy
Diabetes - Glucagon-Like Peptide-1 Agonists PA Policy	Policy
Diabetes - Metformin Care Value Policy	Policy
Diabetes - Metformin Step Therapy Policy	Policy
Diabetes - Mounjaro PA	Policy
Diabetes - Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy	Policy
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy	Policy
Diabetes - Symlin PA Policy	Policy
Diabetes - Thiazolidinedione Step Therapy Policy	Policy
Diabetes - Tzield PA	Policy
Dichlorphenamide PA Policy	Policy
Dichlorphenamide PSM	Policy
Diuretics - Loop Products Step Therapy Policy	Policy
Dronabinol Products PA	Policy
Dronabinol Products PA with Step Therapy	Policy
Enspryng PA Policy	Policy
Enzyme Replacement Therapy - Lamzede PA	Policy
Enzyme Replacement Therapy - Strensiq PA Policy	Policy
Enzyme Replacement Therapy - Sucraid PA Policy	Policy
Epinephrine Auto-Injectors Step Therapy Policy	Policy
Erectile Dysfunction - Tadalafil (Cialis) PA Policy	Policy
Erythropoiesis - Stimulating Agents Preferred Specialty Management Policy for High Performance and National Preferred Formularies	Policy
Erythropoiesis-Stimulating Agents - Epoetin Alfa Products PA Policy	Policy
Erythropoiesis-Stimulating Agents PSM for High Performance and National Preferred Formularies	Policy
Estrogen - Transdermal Step Therapy Policy	Policy
Ezetimibe (Zetia) Step Therapy Policy	Policy
Fabry Disease - Galafold PA Policy	Policy
Familial Chylomicronemia Syndrome - Tryngolza PA	Policy
Fenofibrate Step Therapy Policy	Policy
Gabapentin Step Therapy Policy	Policy
Gastroenterology - Eohilia PA	Policy
Gaucher Disease - Substrate Reduction Therapy Care Value Policy	Policy
Gaucher Disease - Substrate Reduction Therapy PSM Policy	Policy
Gaucher Disease Substrate Reduction Therapy - Cerdelga PA Policy	Policy
Gaucher Disease Substrate Reduction Therapy - Miglustat PA	Policy
Gonadotropin-Releasing Hormone Agonist - Lupron Depot PA	Policy
Gonadotropin-Releasing Hormone Agonist - Synarel PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Central Precocious Puberty PA Policy	Policy
Gonadotropin-Releasing Hormone Agonists - Injectable Long-Acting Products (Lupron Depot-Ped and Triptodur) PA	Policy
Gonadotropin-Releasing Hormone Antagonists - Oriahnn PA Policy	Policy
Gonadotropin-Releasing Hormone Antagonists - Orilissa PA Policy	Policy
Gout Medications Step Therapy Policy	Policy
Growth Disorders - Growth Hormone Long-Acting Products PSM	Policy
Growth Disorders - Growth Hormone PA	Policy
Growth Disorders - Growth Hormone Short-Acting Products PSM Policy	Policy
Growth Disorders - Increlex PA Policy	Policy
Growth Disorders - Ngenla PA	Policy
Growth Disorders - Sogroya PA	Policy
Growth Disorders - Voxzogo PA	Policy
Hemangeol PA with Step Therapy Policy	Policy
Hematology - Adzynma PA	Policy
Hematology - Cablivi PA Policy	Policy
Hematology - Gene Therapy - Casgevy PA	Policy
Hematology - Gene Therapy - Lyfgenia PA	Policy
Hematology - Gene Therapy - Zynteglo PA	Policy
Hematology - Pyrukynd PA	Policy
Hemophilia - Alhemo PA	Policy
Hemophilia - Altuviiio PA	Policy
Hemophilia - Gene Therapy - Beqvez PA	Policy
Hemophilia - Gene Therapy - Hemgenix PA	Policy
Hemophilia - Hympavzi PA	Policy
Hemophilia - Recombinant Factor IX Products	Policy
Hepatitis C - Epclusa PA Policy	Policy
Hepatitis C - Harvoni PA Policy	Policy
Hepatitis C - Ribavirin PA Policy	Policy
Hepatitis C - Viekira Pak PA Policy	Policy
Hepatitis C - Vosevi PA Policy	Policy
Hepatitis C - Zepatier PA Policy	Policy
Hepatitis C Virus (HCV) Direct Acting Antivirals (DAAs) PSM for National Preferred Formulary and Basic Formulary	Policy
Hepatitis C Virus Direct - Acting Antivirals PSM Policy for National Preferred Formulary and Basic Formulary	Policy
Hepatology - Iqirvo PA	Policy
Hepatology - Livdelzi PA	Policy
Hepatology - Ocaliva PA Policy	Policy
Hepatology - Rezdiffra PA	Policy

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