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Content with Policies & Guidelines Final Self-Administered Drug Policies .
Androderm, AndroGel, Fortesta, Natesto, Striant, Testim, testosterone solution, Vogelxo, Jatenzo, Methitest, methyltestosterone capsule, Tlando, Anadrol-50, danazol, Oxandrin, Kyzatrex
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Benlysta (belimumab) Prior Authorization Program Summary
Policy Number: PH-1001
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Abrilada, Actemra, Amjevita, Bimzelx, Cimzia, Cosentyx, Cyltezo, Enbrel, Entyvio, Hadlima, Hulio, Humira, Hyrimoz/Adalimumab-adaz, Idacio, Kevzara, Kineret, Litfulo, Olumiant, Omvoh, Orencia,...
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Compounded Medications Prior Authorization Program Summary
Policy Number: PH-1004
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Adlyxin, Byetta, Bydureon, Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza
Belbuca, Butrans, Conzip, Duragesic, fentanyl transdermal patch, Hydrocodone ER, hydromorphone ER, Hysingla ER, Kadian, Morphabond ER, Morphine Sulfate ER, MS Contin, Nucynta ER, Oxycodone ER,...
butorphanol, Codeine, Dilaudid, Levorphanol, Meperidine, Methadose, Methadone, Morphine sulfate, Oxaydo, Roxybond, Roxicodone, Opana, Nucynta, Qdolo, Ultram, Tramadol, Apadaz,...