DRAFT Self-Administered Drug Policies

Drug policies are based on:

  • information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
  • research of current medical and pharmacy literature; and/or,
  • review of common medical practices in the treatment and diagnosis of disease.

Final and draft policies are published on this site. Draft policies are available for provider comment for 45 days from the posting date on the document. We encourage practicing physicians to provide input.

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies, when applicable. Always verify member eligibilty and benefits.

Please use the Search function above to locate specific drug policy information.

Pharmacy Policies Disclaimer

Pharmacy drug policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

 

Policy # Policy Title Print View
MP-1114 Sunosi Prior Authorization with Quantity Limit Program Summary
PH-1114 Cablivi Quantity Limit Program Summary
PH-1116 Acute Migraine 5HT Step Therapy and Quantity Limit Program Summary
PH-1118 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-1119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91005
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-91013 Mandatory Generic/Member Pays the Difference Exception Prior Authorization Program Summary
PH-91015 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91018 Opioid Immediate Release Duration Limit and Quantity Limit Program Summary
PH-91020 Topical Doxepin Prior Authorization with Quantity Limit Program Summary
PH-91024 Oral Anticoagulant - Bevyxxa, (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-91025 Antiemetic Agents Quantity Limit Program Summary
PH-91026 Anti-Influenza Agents Quantity Limit Program Summary
PH-91031 Carbaglu (carglumic acid) Prior Authorization Program Summary
PH-91034 Antifungal Agents - ciclopirox, efinaconazole, tavaborole Prior Authorization with Quantity Limit Program Summary
PH-91037 Topical Diclofenac Gel, Fluorouracil Cream, Imiquimod Cream, and Ingenol Gel Prior Authorization with Quantity Limit and Quantity Limit Program Summary
PH-91046 H.P. Acthar Gel (repository corticotropin) Prior Authorization Program Summary
PH-91054 Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary
PH-91058 Myalept (metreleptin) Prior Authorization Program Summary
PH-91059 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-91065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-91067 Phenylketonuria Prior Authorization Program Summary
PH-91070
PH-91073 Strensiq (asfotase alfa) Prior Authorization Program Summary
PH-91087 Coverage Exception Program Summary
PH-91093 Orilissa Prior Authorization with Quantity Limit Program Summary
PH-91100 Cannabidiol Prior Authorization Program Summary
PH-91101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-91110 Alinia Quantity Limit Program Summary
PH-91111 Tafamidis Prior Authorization with Quantity Limit Program Summary
PH-91112 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-991000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Topical Androgen Program Summary
PH-991009 PePeg-interferon Prior Authorization Program Summary
PH-991012 Immune Globulins Prior Authorization Program Summary
PH-991017 Opioids IR Quantity Limit Program Summary
PH-991038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-991043 Growth Hormone Prior authoriztion
PH-991059 Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary
PH-991063 Oral Pulmonary Hupertension Agents Prior Authorization wiht Quantity Limit Program Summary
PH-991080 Urea Cycle Disorders Prior Authorization Program Summary
PH-991107 hATTR Amyloidosis Neuropathy Prior Authorization with Quantity Limit Program Summary
PH-9991002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-9991009 Hepatitis C Direct Acting Antivirals Prior Authorization - Through Preferred Agent(s) Program Summary
PH-9991075 Thrombopoietin receptor agonists Prior Authorization with Quantity Limit Program Summary