Pharmacy Criteria
- Accrufer
- Acitretin Non-Oncology
- Adbry
- Adempas
- Advair HFA/Breo/Dulera
- Age Restriction
- Ajovy/Emgality
- Apretude
- Aranesp Non-Oncology
- Arikayce
- Aripiprazole Injection: Abilify Maintena, Aristada, Aristada Initio
- Austedo
- Benlysta
- Benefit Exclusion
- Botox
- Brexafemme
- Bronchitol
- Budesonide Rectal Foam
- Bylvay
- Camzyos
- Carglumic Acid
- Cerdelga
- Chemet
- Chenodal
- Cholbam
- Cibinqo
- Cinacalcet
- Cholbam
- Constipation Drugs: lubiprostone, Linzess, Motegrity, Movantik, Relistor, Symproic, Trulance, Ibsrela
- Cosentyx
- Cresemba
- Crysvita
- Cyclosporine opthalmic emulsion
- Cystadrops
- Cystagon
- Dalfampridine
- Dayvigo/Belsomra/Quviviq
- Descovy
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Diacomit
- Diclofenac Gel Prescription
- Dojolvi
- Doxylamine succinate- Pyridoxine
- DPP-4 Inhibitors (Gliptins): Alogliptin, Alogliptin-metformin, Alogliptin-pioglitazone
- Dupixent
- Dysport
- Emend Non-Oncology
- Emflaza
- Enbrel
- Enspryng
- Entresto
- Epidiolex
- Entyvio
- Epogen-Procrit-Retacrit Non-Oncology
- Esbriet
- Eucrisa
- Evrysdi
- Fasenra
- Fensolvi
- Fintepla
- Firdapse
- Freestyle Libre/Dexcom
- Fycompa
- Galafold
- Gattex
- GLP-1 Agonist and GIP/GLP-1 Agonists Step Therapy: Ozempic, Rybelsus, Trulicity, Mounjaro
- Haegarda
- Hemlibra
- Hemophilia Products – Factor IX: AlphaNine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
- Hemophilia Products – Factor VIII: Advate, Adynovate, Afstyla, Eloctate, Hemofil M, Koate DVI, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha/Xyntha Solofuse, Jivi, Esperoct
- Hemophilia Products – von Willebrand Factor: Vonvendi
- Hepatitis C: Mavyret
- Hetlioz
- HP Acthar Gel
- Humate-P
- Humira
- Humulin R
- Hypodermic Needles & Syringes
- lanreotide Depot Non-Oncology
- Icatibant
- Ilumya
- Imcivree
- Impavido
- Isotretinoins Non-Oncology
- Isturisa
- Ivermectin
- Juxtapid
- Jynarque
- Kalydeco
- Kanuma
- Kerendia
- Kesimpta
- Keveyis
- Kevzara
- Latuda
- Leuprolide Non Oncology
- Livmarli
- Livtencity
- Lokelma
- Long Acting Opioid
- Long Acting Stimulant: Vyvanse, Methylphenidate ER
- Lumizyme
- Lupkynis
- Lybalvi
- Mavenclad
- Medicaid Medical Benefit Only Policy
- Medicaid Pharmacy Benefit Only Policy
- Miglustat
- Mircera
- Myalept
- Myobloc
- Myrbetriq Step Therapy
- Nexviazyme
- Nicotrol
- Non-Formulary Exception
- Norditropin
- Northera
- Nourianz
- Nucala
- Nuedexta
- Nuplazid
- Nurtec/Ubrelvy/Qulipta
- Octreotide Non-Oncology
- Ofev
- Olopatadine Ophthalmic
- Omnipod
- Opzelura
- Orfadin_Nitry_Nitisinone
- Oriahnn Myfembree
- Orilissa
- Orkambi
- Orladeyo
- Osphena Step Therapy
- Otezla
- Oxervate
- Palforzia
- Paliperidone palmitate extended-release injectable: Invega Hafyera, Invega Sustenna and Invega Trinza
- Palynziq
- Pharmacy Benefit Only
- Phosphate Binders Step Therapy (Lanthanum, Sevelamer)
- Prevymis
- Prior Authorization Global Criteria
- Prolia Non-Oncology
- Pulmonary Arterial Hypertension Global: Sildenafil, Tadalafil, Ambrisentan, Opsumit, Bosentan, Epoprostenol, Veletri, Treprostinil, Remodulin, Ventavis, Orenitram, Uptravi
- Pyrimethamine
- Quantity Limit Exception
- Radicava ORS
- Ravicti
- Recorlev
- Relyvrio
- Repatha
- Rezlidhia
- Rinvoq
- Risperdal Consta
- Sapropterin
- Serostim
- Sodium-Glucose Cotransporter-2 (SGLT2): Farxiga, Invokana, Invokamet, Invokamet XR, Jardiance, Steglatro
- Short-Acting Opioid Naïve
- Short-Acting Opioid Post Limit
- Simponi
- Skyrizi
- Skytrofa
- Sodium Phenylbutyrate
- Solosec
- Somatuline Depot
- Spiriva Handihaler Step Therapy
- Stelara
- Step Therapy Exception
- Strensiq
- Sublocade
- Sucraid
- Sunosi
- Symdeko
- Synagis
- Takhzyro
- Tarpeyo
- Tavneos
- Tazarotene
- Tegsedi
- Terconazole
- Teriparatide
- Testosterone (topical – generic): Testosterone Transdermal Gel 1%
- Tetrabenazine
- Thalomid
- Thiola EC
- Tobramycin Inhalation Solution
- Travoprost Step Therapy
- Tremfya
- Tretinoin Topical Products
- Trijardy XR
- Trikafta
- Tyvaso
- Varenicline
- Veltassa
- Verquvo
- Vijoice
- Vivjoa
- Voriconazole
- Voxzogo
- Vraylar
- Vtama
- Vyndamax-Vyndaqel
- Wakix
- Weight Loss-Contrave-Qsymia-Saxenda-Wegovy
- Xcopri
- Xeljanz
- Xenleta
- Xeomin
- Xifaxan
- Xolair
- Xyrem
- Xywav
- Zeposia
- Zokinvy
- Zoryve
- Ztalmy
- Zyprexa
- Antiemetics: Zofran, Kytril, Anzemet, Aloxi, Sancuso, Susto, Akynzeo, Emend, Cinvanti, Varubi
- Abiraterone
- Alecensa
- Alunbrig
- Ayvakit
- Balversa
- Bone Modifying Agents: Aredia, Zometa, Xgeva/Prolia
- Bosulif
- Braftovi
- Brukinsa
- Cablivi
- Calquence
- Caprelsa
- Cometriq or Cabometyx
- Copiktra
- Cotellic
- Daurismo
- Doptelet
- Endari
- Erythropoiesis Stimulating Agents: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Erivedge
- Erleada
- Erlotinib
- Exkivity
- Ferriprox
- Fotivda
- Gavreto
- Generic Drug Policy
- Gilotrif
- Ibrance
- Iclusig
- Idhifa
- Imbruvica
- Inlyta
- Inqovi
- Inrebic
- Iressa
- Iron Products: Infed, Venofer, Ferrlecit, Feraheme, Monferric, Injectafer
- Jakafi
- Jaypirca
- Jemperli
- Kisqali
- Koselugo
- Krazati
- Lenvima
- LHRH agonists and antagonists: Lupron, Trelstar, Zoladex, Irmagon, Orgovyx
- Lonsurf
- Lorbrena
- Lumakras
- Lynparza
- Lytgobi
- Medicaid Oncology/Hematology Preferred Drug Policy
- Mekinist
- Mektovi
- Monjuvi
- Mozobil
- Mulpleta
- Myeloid Growth Factors: Neupogen, Granix, Sargramostim, Zarxio, Nivestym, Releuko, Neulasta/Neulasta Onpro, Fulphila, Udenyca, Ziextenzo, Fylnetra, Stimufend, Rolvedon
- Nerlynx
- Nexavar
- Ninlaro
- Nubeqa
- Odomzo
- Onureg
- Orserdu
- Oxbryta
- Pemazyre
- Piqray
- Pomalyst
- Promacta
- Qinlock
- Retevmo
- Revlimid
- Rezlidhia (olutasidenib)
- Rozlytrek
- Rubraca
- Rydapt
- Scemblix
- Somatostatin Analog: Sandostatin SQ, LAR depot (Octreotide), and Somatuline (lanreotide)
- Sprycel
- Stivarga
- Tabrecta
- Tafinlar
- Tagrisso
- Talzenna
- Tarceva
- Targretin
- Tasigna
- Tavalisse
- Tazverik
- Tepmetko
- Thalomid
- Tibsovo
- Topical and Intralesional Therapies use in Non-Melanoma Skin Cancers and Primary Cutaneous Lymphomas
- Truseltiq
- Tukysa
- Turalio
- Venclexta
- Verzenio
- Vitrakvi
- Vizimpro
- Vonjo
- Votrient
- Welireg
- Xalkori
- Xermelo
- Xospata
- Xpovio
- Xtandi
- Zejula
- Zelboraf
- Zolinza
- Zydelig
- Zykadia
- Zytiga
- 5-HT1 Agonist: sumatriptan-naproxen
- Acamprosate calcium tab
- Actemra
- Actimmune
- Alecensa
- Alosetron
- Alpha1-Proteinase Inhibitors (Prolastin-C)
- Ambrisentan
- Antidiabetic Agents: Glyxambi, Jardiance, Ozempic, Trulicity, Victoza, Soliqua, Synjardy/Synjardy XR, Xultophy
- Apokyn Inj
- Aranesp
- Arcalyst
- Armodafinil_Nuvigil
- Atypical Antipsychotics ST: Latuda, Vraylar
- Aubagio
- Azacitidine
- Benefit Exclusion
- Betaseron
- Bexarotene-Targretin
- Bosentan
- BPH Cialis
- Cabometyx
- Calquence
- Caprelsa
- Carbaglu
- Cayston
- Cetrotide-Fyremadel-Ganirelix
- Cinacalcet-Sensipar
- Cometriq
- Cosentyx
- Cystadane
- Cystagon
- Cystaran Sol 0.44%
- Dalfampridine ER
- Daliresp
- Daraprim
- Decitabine-Dacogen
- Deferiprone_Ferriprox
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Dificid
- Dimethyl fumarate delayed release
- Dipentum
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Alogliptin Alogliptin/metformin, Januvia, Janumet, Jentadueto XR
- Dofetilide-Tikosyn
- Doptelet
- Eligard
- Emflaza
- Emsam
- Enbrel
- Entecavir-Baraclude
- Epclusa
- Erbitux
- Erivedge
- Erleada
- Erlotinib-Tarceva
- Eucrisa
- Everolimus-Afinitor Products
- Evrysdi Sol
- Fasenra
- Fingolimod-Gilenya
- Follitropins (Gonal-F)
- Febuxostat_Uloric
- Fentanyl citrate lozenge
- Fulvestrant-Faslodex
- Fuzeon
- Gazyva
- Glatiramer acetate_Copaxone_Glatopa
- Growth Hormone Without ISS (Norditropin)
- GSTP Bisphosphonates: Fosamax + D
- GSTP Prostaglandin Analogues & Combos: Lumigan, Zioptan
- Haegarda
- Harvoni
- HCG (chorionic gonadotropin, Ovidrel)
- Hemlibra
- Hetlioz
- High Risk Medications
- Humira and Biosimilars
- Ibrance
- Icatibant acetate
- Iclusig
- Idhifa
- Imatinib-Gleevec
- Imbruvica
- Inbrija
- Increlex
- Inlyta
- Insomnia Products: Belsomra, Dayvigo
- Intron A
- Isotretinoin
- Itraconazole (Capsules)
- Itraconazole (Oral Solution)
- Ivermectin lotion 0.5%
- Jakafi
- Kadcyla
- Kalydeco
- Kerendia
- Kevzara
- Keytruda
- Kisqali
- Lanreotide Injection-Somatuline Depot
- Lapatinib-Tykerb
- Lenalidomide-Revlimid
- Lenvima
- Leuprolide
- Lidoderm, ZTLido: lidocaine patch 5%
- Lorbrena
- Lotronex
- Lynparza
- Lyrica, Lyrica CR, Gralise, Horizant ST: Pregabalin
- Malathion_Ovide
- Medical Benefit Only
- Mekinist
- Mircera
- Modafinil_Provigil
- Multaq
- Myalept
- Nexavar (sorafenib)
- Nitisinone-Orfadin
- Nivestym
- Non-Formulary Exception
- Noxafil
- Nubeqa
- Nuedexta
- Octreotide
- Odomzo
- Ofev
- Omnaris
- Oncaspar
- Ongentys
- Opioids ER: Belbuca, buprenorphine patch
- Opsumit
- Orenitram
- Orkambi
- Osphena
- Otezla
- Oxandrolone
- Pancrelipase (Creon, Viokace, Zenpep)
- PCSK9i (Praluent)
- Pegasys
- Penicillamine tab 250 mg
- Pharmacy Benefit Only
- Phenoxybenzamine_Dibenzyline
- Sodium phenylbutyrate products: sodium phenylbutyrate, Buphenyl, Pheburane
- Pimecrolimus cream_Elidel
- Pirfenidone-Esbriet
- Pomalyst
- Prolia
- Quantity Limit Exception
- Ranolazine ER_Ranexa
- Regranex Gel 0.01%
- Infliximab and Biosimilars: Remicade Avsola Inflectra Renflexis
- Retacrit
- Ribavirin
- Rinvoq
- Riociguat-Adempas
- Rivastigmine tartrate capsules and patches
- Rosacea Products: ivermectin cream, Mirvaso gel
- Rydapt
- Sapropterin-Kuvan
- Savella
- SCIG (HyQvia)
- Signifor
- Sildenafil_Revatio
- Simponi
- Simvastatin tab 80 mg
- Sirturo
- Skyrizi
- Somavert
- Sovaldi
- Spinosad_Natroba
- Sprycel
- Stelara
- Stivarga
- Sucraid
- Sunitinib-Sutent
- Sunosi
- Supprelin LA
- Symdeko
- SymlinPen
- Synarel
- Tacrolimus_Protopic
- Tadalafil
- Tafinlar
- Taltz
- Tazarotene_Tazorac cream
- Temozolomide-Temodar
- Testosterone
- Tetrabenazine
- Thalomid
- Tobramycin Inhalation
- Tolvaptan-Samsca
- Tremfya
- Treprostinil-Remodulin
- Trikafta
- Trintellix tab 5 mg
- Triptodur
- Tukysa
- Tymlos
- Tysabri
- Tyvaso
- Ubrevly
- Uptravi
- Valcyte
- Vemlidy
- Venclexta
- Ventavis
- Vfend
- Vigabatrin
- Vitrakvi
- Vosevi
- Votrient
- Xalkori
- Xeljanz-Xeljanz XR
- Xeloda
- Xepi
- Xifaxan
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Ziextenzo
- Zileuton
- Zoledronic Acid-Reclast
- Zoledronic Acid-Zometa
- Zolinza
- Zydelig
- Zykadia
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.
- Acamprosate
- Actemra
- Actimmune
- Adapalene
- Adempas
- Alecensa
- Alpha1-Proteinase Inhibitors
- Ambrisentan-Letairis
- Anabolic Steroids
- Anadrol
- Antidiabetic Agents Step Therapy Policy
- Apokyn-Kynmobi
- Aranesp
- Arcalyst
- Aubagio
- Avonex
- Azacitidine-Vidaza
- Banzel
- Benefit Exclusion
- Betaseron-Extavia
- Bexarotene-Targretin
- Bosentan-Tracleer
- Bosulif
- BPH Cialis
- Cabometyx
- Calquence
- Caprelsa
- Carbaglu
- Cayston
- Cetrotide-Ganirelix
- Cinacalcet-Sensipar
- Cometriq
- Copaxone-Glatopa
- Cosentyx
- Cuprimine, Depen, Syprine
- Cystadane
- Cystagon
- Cystaran-Cystadrops
- Dalfampridine-Ampyra
- Daliresp
- Daraprim
- Decitabine-Dacogen
- Dibenzyline
- Dificid
- Dimethyl fumarate
- Dipentum
- Dofetilide-Tikosyn
- Eligard
- Emflaza
- Emsam
- Enbrel
- Epclusa
- Epidiolex
- Epogen-Procrit-Retacrit
- Erbitux
- Erivedge
- Erleada
- Erlotinib-Tarceva
- Esbriet
- Everolimus-Afinitor Products
- Evrysdi
- Exchange Medical Benefit Only
- Exchange Pharmacy Benefit Only
- Exelon
- Farydak
- Ferriprox
- Follitropins
- Fulvestrant-Faslodex
- Fuzeon
- Gazyva
- Gilenya
- Growth Hormone Without ISS
- Haegarda
- Harvoni
- HCG
- Hemlibra
- Hetlioz
- High Risk Medications (HRM Long List)
- Humira
- Ibrance
- Icatibant-Sajazir-Firazyr
- Iclusig
- Idhifa
- Imatinib-Gleevec
- Imbruvica
- Inbrija
- Increlex
- Inlyta
- Insomnia (Belsomra, Dayvigo)
- Intron A
- Isotretinoins
- Itraconazole (Sporanox Capsules)
- Itraconazole (Sporanox Oral Solution)
- Jakafi
- Jublia
- Kadcyla
- Kalydeco
- Kevzara
- Keytruda
- Kisqali
- Kuvan
- Lenvima
- Leuprolide
- Lidoderm
- Lorbrena
- Lotronex
- Lupaneta Pack
- Lynparza
- Mekinist
- Mircera
- Mitoxantrone
- Multaq
- Myalept
- Namenda
- Neulasta and pegfilgrastim biosimilars
- Neupogen and filgrastim biosimilars
- Nexavar
- Noxafil
- Nubeqa
- Nucala
- Nuedexta
- Nuvigil
- Octreotide products
- Odomzo
- Ofev
- Oncaspar
- Onfi Sympazan
- Opsumit
- Oral-Intranasal Fentanyl Products
- Orenitram
- Orfadin-Nityr
- Orkambi
- Osphena
- Otezla
- Oxandrolone
- Pancrelipase
- PCSK9i
- Pegasys
- Peg-Intron
- Phenylbutyrate-Buphenyl
- Plegridy
- Pomalyst
- Praluent
- Prolia
- Promacta
- Provigil
- Rebif
- Regranex
- Revlimid
- Ribavirin
- Rinvoq
- Rosacea Products
- Rydapt
- Samsca
- Signifor
- Signifor LAR
- Sildenafil-Revatio
- Simponi
- Simponi Aria
- Sirturo
- Skyrizi
- Somatuline Depot
- Somavert
- Sovaldi
- Sprycel
- Stelara
- Stivarga
- Subcutaneous Immune Globulin
- Sucraid
- Sunosi
- Supprelin LA
- Sutent
- Symdeko
- Synarel
- Tadalafil Products
- Tafinlar
- Taltz
- Tazorac
- Temozolomide-Temodar
- Testosterone – Oral Methyltestosterone Non-TGC
- Testosterone Products TGC
- Tetrabenazine-Xenazine
- Thalomid
- Tobramycin Inhalation
- Tremfya
- Treprostinil-Remodulin
- Tretinoins (Topical)
- Trikafta
- Triptodur
- Tukysa
- Tykerb
- Tymlos
- Tysabri
- Tyvaso
- Uptravi
- Valcyte
- Varenicline Step Therapy
- Vemlidy
- Venclexta
- Ventavis
- Vfend
- Vigabatrin-Sabril-Vigadrone
- Vitrakvi
- Vivitrol
- Vosevi
- Votrient
- Welireg
- Xalkori
- Xeloda
- Xeljanz-Xeljanz XR
- Xeloda
- Xifaxan
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Zileuton
- Zoledronic acid-Reclast
- Zoledronic acid-Zometa
- Zolinza
- Zydelig
- Zykadia
- Zytiga
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.
- 5-Alpha Reductase Inhibitors
- 5-HT1 Agonist Limit
- 5-HT1 Agonist Post Limit
- Acamprosate Calcium
- Actemra
- Actimmune
- Adapalene
- Adempas
- Afinitor Disperz
- Alecensa
- Alpha-1 Proteinase Inhibitors: Aralast Np, Glassia, Prolastin-C, Zemaira
- Ambrisentan
- Anadrol-50
- Antidiabetic Agents Step Therapy
- Antifungal Topical Step Therapy
- Apokyn & Kynmobi
- Aptiom
- Aranesp
- Arcalyst
- Atypical Antipsychotics Step Therapy
- Aubagio
- Avonex
- Azacitidine
- Benefit Exclusion
- Betaseron/Extavia
- Bexarotene
- Bosentan
- Bosulif
- Briviact
- Calquence
- Caprelsa
- Carbaglu
- Cayston
- Cerdelga
- Cetrotide/Ganirelix
- CGRP Receptor Antagonists Step Therapy
- Cialis
- Cinacalcet
- Cometriq
- Copaxone/Glatopa
- Cosentyx
- Cystadane
- Cystagon
- Cystaran/Cystadrops
- Dalfampridine
- Daliresp
- Daraprim
- Desvenlafaxine & Fetzima Step Therapy
- Dificid
- Dipentum
- Dofetilide
- DPP-4 Inhibitors Step Therapy
- Eligard
- Emsam
- Enbrel
- Epclusa
- Epidiolex
- Epogen Procrit Retacrit
- Erbitux
- Erivedge
- Erleada
- Esbriet
- Eucrisa Step Therapy
- Evrysdi
- Exchange Medical Benefit Only
- Exchange Pharmacy Benefit Only
- Farydak
- Ferriprox
- Fulvestrant
- Fuzeon
- Gazyva
- Gilenya
- Harvoni
- Hemlibra
- Hetlioz
- Human Chorionic Gonadotropin (hCG): Novarel, Pregnyl, & Ovidrel
- Humira
- Ibrance
- Icatibant
- Iclusig
- Idhifa
- Imatinib
- Imbruvica
- Increlex
- Inlyta
- Intron
- Isotretinoins
- Itraconazole (Sporanox Capsules)
- Itraconazole (Sporanox Oral Solution)
- Ivermectin
- Jakafi
- Jublia
- Jublia Limit-Post Limit
- Kadcyla
- Kalydeco
- Kevzara
- Keytruda
- Kisqali
- Kuvan
- Lenvima
- Leuprolide
- Lidoderm ZTLido
- Lorbrena
- Lupaneta Pack
- Lupron Depot-PED
- Lynparza
- Lyrica, Gralise, & Horizant Step Therapy
- Marketplace Sklice Step Therapy
- Mekinist
- Mircera
- Mitoxantrone
- Modafinil
- Multaq
- Myalept
- Namenda
- Neulasta and Pegfilgrastim Biosimilars
- Neupogen and Filgrastim Biosimilars
- Nexavar
- Non-Formulary
- Noxafil
- Nubeqa
- Nucala
- Nuedexta
- Octreotide Products: Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot
- Odomzo
- Omega-3 Fatty Acids: Epanova, Lovaza, Vascepa
- Oncaspar
- Opioids ER – Step Therapy with MME Limit and Post Limit
- Opioids IR – 7-Day Acute Pain Duration Limit with MME Limit and Post Limit
- Opioids IR – 7-Day APAP-ASA-IBU Combo Products – Acute Pain Duration Limit
- Opsumit
- Orenitram
- Orfadin & Nityr
- Orkambi
- Otezla
- Oxandrin
- Pegasys
- Phenylbutyrate-Buphenyl
- Plegridy
- Pomalyst
- Praluent
- Prolia
- Promacta
- Prudoxin & Zonalon Step Therapy
- Quantity Limit Exception
- Ranexa Step Therapy
- Rebif
- Reclast
- Regranex
- Revlimid
- Ribavirin
- Rinvoq
- Rosuvastatin Step Therapy
- Rydapt
- Samsca
- Savella Step Therapy
- Subcutaneous Immune Globulin (SCIG): Hizentra, HyQvia, Cutaquig, Cuvitru, and Xembify
- Signifor
- Sildenafil
- Simponi
- Simponi Aria
- Simvastatin 80mg, Simvastatin/Ezetimibe 10/80mg Step Therapy
- Sirturo
- Skyrizi
- Somatuline Depot
- Somavert
- Sovaldi
- Sprycel
- Stelara
- Stivarga
- Sucraid
- Sutent
- Symdeko
- Tadalafil Products
- Tafinlar
- Taltz
- Tarceva
- Tazorac
- Tecfidera
- Temozolomide
- Testosterone Products
- Tetrabenazine
- Thalomid
- Tobramycin (Inhalation)
- Tremfya
- Treprostinil
- Tretinoins (Topical)
- Treximet Step Therapy
- Trikafta
- Tukysa
- Tykerb
- Tymlos
- Tysabri
- Tyvaso
- Uloric Step Therapy
- Uptravi
- Valcyte
- Vemlidy
- Venclexta
- Ventavis
- Vigabatrin (Sabril, Vigadrone)
- Vitrakvi
- Vivitrol
- Vosevi
- Votrient
- Xalkori
- Xeljanz & Xeljanz XR
- Xeloda
- Xifaxan
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Zolinza
- Zometa
- Zydelig
- Zykadia
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.
Clinical Medical Policies
The Medical Review staff of the Medical Management Department utilize clinical medical policies (CMPs) to guide decisions regarding Neighborhood’s Conditional Benefits.
Through collaboration with Neighborhood’s Associate Medical Director, and our specialty consultants, the policies are developed and/or revised following thorough review of current medical literature and standards of practice. To the extent possible, Neighborhood’s CMPs are developed according to evidence-based outcomes.
To view one of Neighborhood’s approved CMPs, please click the link below:
- Acupuncture
- Adult Day Health
- Ambulance Transportation
- Assisted Living
- Chiropractic Care
- Circulating Cell-free (ccfDNA)
- Cognitive Rehabilitation
- Continuous Glucose Monitoring
- Experimental Investigational
- External Beam/Teletherapy, Brachytherapy, IMRT, SBRT/SRS, IORT, and IGRT
- Gender Affirmation
- Genetic Testing
- Genomic/Genetic/Biomarker/Tumor Marker Tests
- Hasbro Partial Program
- Home Care Services
- Infertility Services
- In Lieu of Services
- Levels of Care
- Neutron Beam and Proton Beam Radiation Therapy
- No Criteria – Use of Evidence Based Medicine
- Non Standard Requests
- Obstetrical Ultrasound
- Out-of-Network & Out-of-Area
- Outpatient PT-OT Special Needs
- Outpatient Speech Special Needs
- Outpatient Rehab Therapies-Adult
- Phototherapy and Photochemotherapy for Dermatologic Conditions
- Plastic Surgery
- Private Duty-Extended Home Care-Skilled Hours
- Relizorb Enzyme Cartridge
- Termination of Pregnancy
- Actemra
- Aldurazyme
- Alpha-1-Proteinase Inhibitors: Aralast, Glassia, prolastin, Zemaira
- Amondys45
- Amvuttra
- Apretude
- Bal in Oil and Calcium EDTA
- Benefit Exclusion
- Benlysta
- Beovu
- Berinert
- Botox
- Brineura
- Cerezyme Elelyso VPRIV
- Cimzia
- Cinacalcet
- Cinqair
- Cinryze
- Crysvita
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Duopa
- Durysta
- Dysport
- Elaprase
- Entyvio
- Erythropoiesis stimulating agents Non-Oncology: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Evenity
- Evkeeza
- Exondys51
- Eylea
- Fabrazyme
- Fasenra
- General PA Policy
- Givlaari
- Haegarda
- Hemgenix
- Hemophilia Products – Anti-inhibitor Antibody: Hemlibra
- Hemophilia Products-Anti-inhibitor Coagulant Complex: Feiba NF/Feiba VF
- Hemophilia Products – Factor IX: AlphaNine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
- Hemophilia Products- Factor VIIa: NovoSeven RT, Sevenfact
- Hemophilia Products- Factor VIII: Advate, Adynovate, Afstyla, Eloctate, Hemofil M, Koate DVI,
Kogenate FS, Kovaltry, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha/Xyntha Solofuse, Jivi, Esperoct - Hemophilia Products – Factor X: Coagadex
- Hemophilia Products – Factor XIII: Corifact
- Hemophilia Products – Coagulation Factor XIII A-subunit: Tretten
- Hemophilia Products – Factor VIII/VWF Complex: Alphanate, Humate-P, Wilate
- Hemophilia Products – von Willebrand Factor (Vonvendi)
- H. P. Acthar
- Hyaluronic Acid Intraarticular Injections: Durolane, Euflexxa, Gel-One , Gelsyn, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synojoynt, Synvisc, Synvisc-One, Triluron, Trivisc, , Visco-3, & sodium hyaluronate 1%
- Ilaris
- Ilumya
- Immune Globulin – Intravenous Non-oncology: Asceniv, Flebogamma 10% DIF, Flebogamma 5% DIF, Gamunex-C , Gammagard Liquid, Gammaked, Gammaplex, Octagam 10%, Octagam 5%, Privigen, Panzyga
- Immune Globulin – Subcutaneous: Hizentra, Gammagard Liquid, Gamunex-C, Gammaked, Hyqvia, Cuvitru, Cutaquig, Xembify
- Infliximab/Remicade/Renflexis/Inflectra/Avsola
- Kalbitor
- Kanuma
- Krystexxa
- Lemtrada
- Leqvio
- Long acting granulocyte colony stimulating factors non-oncology: Fulphila, Neulasta, Nyvepria, Udencya, and Zietenzo
- Lucentis/Byooviz
- Lumizyme
- Luxturna
- Medical Benefit Only Policy
- Mepsevii
- Miacalcin
- Monoferric
- Myobloc
- Naglazyme
- Nexviazyme
- Nipent
- Nucala
- Nulibry
- Ocrevus
- Oncology Hematology Policy
- Onpattro
- Orencia
- Oxlumo
- Parsabiv
- Prevymis
- Probuphine
- Radicava
- Revcovi
- Rituxan Non-Oncology
- Ruconest
- Ryplazim
- Saphnelo
- Scenesse
- Serostim
- Short-Acting Granulocyte Colony Stimulating Factors: Nivestym, Neupogen, Granix, Zarxio
- Signifor LAR
- Simponi Aria
- Skyrizi
- Skysona
- Soliris Ultomiris
- Somatuline Depot
- Spevigo
- Spinraza
- Stelara
- Step Therapy Part B
- Step Therapy Medicaid and Commercial
- Strensiq
- Sublocade
- Susvimo
- Synagis
- Tepezza
- Testopel
- Tezspire
- Triptodur
- Trogarzo
- Tysabri
- Uplizna
- Vabysmo
- Viltepso
- Vimizim
- Vonvendi
- Vyepti
- Vyondys53
- Vyvgart
- Xenleta
- Xeomin
- Xiaflex
- Xolair
- Zolgensma
- Zulresso
- Zynteglo
- Abecma
- Abraxane
- Adakveo
- Adcetris
- Adstiladrin
- Aliqopa
- Antiemetics: Zofran, Kytril, Anzemet, Aloxi, Sancuso, Susto, Akynzeo, Emend, Cinvanti, Varubi
- Arzerra
- Asparlas
- Azedra
- Bavencio
- Beleodaq
- Besponsa
- Besremi
- Bevacizumab Products
- Blenrep
- Blincyto
- Bone Modifying Agents: Aredia, Zometa, Xgeva/Prolia
- Breyanzi
- Cablivi
- Carvykti
- Clolar
- Cosela
- Cyramza
- Danyelza
- Darzalex and Darzalex Faspro
- Doxil
- Elahere
- Elitek
- Elzonris
- Empaveli
- Empliciti
- Enhertu
- Enjaymo
- Erbitux
- Erwinaze and Rylaze
- Erythropoiesis Stimulating Agents: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Folotyn
- Fusilev/Khapzory
- Fyarro
- Gamifant
- Gazyva
- Generic Drugs
- Halaven
- Imfinzi
- Imjudo
- Imlygic
- Immune Globulin (IG) (IVIG, SCIG, IMIG)
- Iron Products: Infed, Venofer, Ferrlecit, Feraheme, Monferric, Injectafer
- Istodax
- Ixempra
- Jelmyto
- Jemperli
- Jevtana
- Kadcyla
- Keytruda
- Kimmtrak
- Kymriah
- Kyprolis
- LHRH agonists and antagonists: Lupron, Trelstar, Zoladex, Irmagon, Orgovyx
- Libtayo
- Lumoxiti
- Lunsumio
- Lutathera
- Margenza
- Monjuvi
- Myeloid Growth Factors: Neupogen, Granix, Sargramostim, Zarxio, Nivestym, Releuko, Neulasta/Neulasta Onpro, Fulphila, Udenyca, Ziextenzo, Fylnetra, Stimufend, Rolvedon
- Mylotarg
- Nplate
- Oncaspar
- Onivyde
- Opdivo
- Opdualag
- Padcev
- Pedmark
- Photofrin
- Pluvicto
- Polivy
- Poteligeo
- Provenge
- Reblozyl
- Rituxan Products: Rituxan, Rituxan Hycela, Truxima, Ruxience
- Rybrevant
- Sarclisa
- Soliris
- Somatostatin Analog: Sandostatin SQ, LAR depot (Octreotide), and Somatuline (lanreotide)
- Step Therapy Medicare Part B Medications
- Step Therapy Medicaid and Commercial
- Sylvant
- Synribo
- Tecartus
- Tecentriq
- Tecvayli
- Tivdak
- Torisel
- Trastuzumab Products and Phesgo
- Treanda/Bendeka/Belrapzo
- Trodelvy
- Ultomiris
- Unituxin
- Valstar
- Vectibix
- Voraxaze
- Vyxeos
- Xofigo
- Yervoy
- Yescarta
- Yondelis
- Zaltrap
- Zepzelca
- Zevalin
- Zynlonta