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.

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-00340 Esperoct
PH-1000 Androgens/Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Topical Androgen Agent
PH-1001 Benlysta (belimumab) Prior Authorization with Quantity Limit Program Summary
PH-1002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-1003 Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary
PH-1004 Compounded Medications Prior Authorization Program Summary
PH-1005 Contraceptive Prior Authorization Program Summary
PH-1006 Flector® Prior Authorization with Quantity Limit Program Summary
PH-1007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-1008 Hereditary Angioedema Prior Authorization with Quantity Limit Program Summary
PH-1009 PePeg-interferon Prior Authorization Program Summary
PH-1010 Hepatitis C First Generation Prior Authorization – Through Preferred Agent(s) Program Summary
PH-1011 Hepatitis C Second Generation Antivirals Prior Authorization - Through Preferred Agent(s) Program Summary
PH-1012 Immune Globulins Prior Authorization Program Summary
PH-1013 Mandatory Generic - Member Pays the Difference Exception Summary
PH-1014 Methotrexate Injectable Summary
PH-1015 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-1016 Opioid Antidote - Evzio (Naloxone Hydrochloride Auto-injection) and Narcan (Naloxone Hydrochloride Nasal Spray) Summary
PH-1017 Opioid ER Prior Authorization and Quantity Limit Criteria
PH-1018 Opioid Immediate Release Duration Limit and Quantity Limit Program Summary
PH-1019 Otezla (Apremilast) Prior Authorization with Quantity Limit Program Summary
PH-1020 Topical Doxepin Summary
PH-1022 Afrezza Summary
PH-1023 Ampyra (dalfampridine) Prior Authorization with Quantity Limit Program Summary
PH-1024 Oral Anticoagulant - Bevyxxa (Betrixaban), Eliquis (Apixaban), Pradaxa (Dabigatran), Savaysa (Edoxaban), Xarelto (Rivaroxaban) Summary
PH-1025 Antiemetic Agents Quantity Limit
PH-1026 Anti-Influenza Agents Quantity Limit Program Summary
PH-1027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary
PH-1028 Atopic Dermatitis Step Therapy Program Summary
PH-1029 Atypical Antipsychotics Step Therapy and Quantity Limit
PH-1030 Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary
PH-1031 Carbaglu (carglumic acid) Prior Authorization Program Summary
PH-1032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary
PH-1033 CGRP Prior Authorization with Quantity Limit Criteria Program Summary
PH-1034 Antifungal Agents - ciclopirox, efinaconazole, tavaborole Prior Authorization with Quantity Limit Program Summary
PH-1035 Circadian Rhythm Disorder Prior Authorization with Quantity Limit Program Summary
PH-1036 Constipation Agents Prior Authorization Program Summary
PH-1037 Topical Diclofenac Gel, Fluorouracil Cream, Imiquimod Cream, and Ingenol Gel Prior Authorization with Quantity Limit and Quantity Limit Program Summary
PH-1038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-1039 Endari Prior Authorization Program Summary
PH-1040 Gabapentin ER (extended-release) [Horizant®, Gralise®] Step Therapy and Quantity Limit Program Summary
PH-1041 Gattex (teduglutide) Prior Authorization Program Summary
PH-1042 Glucose Test Strips/Disks/ Meters Step Therapy Program Summary
PH-1043 Growth Hormone Prior Authorization Program Summary
PH-1044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-1045 Homozygous Familial Hypercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary
PH-1046 H.P. Acthar Gel (repository corticotropin) Prior Authorization Program Summary
PH-1047 Inhaled Antibiotics Duplicate Therapy Prior Authorization Program Summary
PH-1048 Injectable Atopic Dermatitis Agent(s) Prior Authorization with Quantity Limit Program Summary
PH-1049 Insomnia Agents Step Therapy and Quantity Limit Program Summary
PH-1050 Insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary
PH-1052 Idiopathic Pulmonary Fibrosis Summary
PH-1053 Keveyis Summary
PH-1054 Korlym (Mifepristone) Summary
PH-1055 Lyrica (Pregabalin CR) Summary
PH-1056 Metformin ER Summary
PH-1057 Multiple Sclerosis Agents Summary
PH-1058 Myalept (Metreleptin) Summary
PH-1059 Natpara (Parathyroid Hormone) Summary
PH-1060 Northera® (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-1061 Nuvigil (Armodafinil), Provigil (Modafinil) Summary
PH-1062 Ocaliva (Obeticholic Acid) Summary
PH-1063 Oral Pulmonary Arterial Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-1064 Oral Tetracycline Derivatives (Doxycycline-Minocycline) Summary
PH-1065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-1066 Proprotein Convertase Subtilisin/Kexin type 9(PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary- Through Preferred Agent(s)
PH-1067 Phenylketonuria Prior Authorization Program Summary
PH-1068 Proton Pump Inhibitors (PPIs) Step Therapy and Quantity Limit Program Summary
PH-1069 Self Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-1070 Signifor (pasireotide) Prior Authorization with Quantity Limit Program Summary
PH-1071 Selective Serotonin Inverse Agonist (SSIA) Prior Authorization with Quantity Limit Program Summary
PH-1072 Statin Step Therapy Program Summary
PH-1073 Strensiq (asfotase alfa) Prior Authorization Program Summary
PH-1074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-1075 Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary
PH-1076 Transmucosal Immediate Release Fentanyl Prior Authorization (Through Generic) and Quantity Limit Program Summary
PH-1077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-1078 Triptans Step Therapy and Quantity Limit Program Summary
PH-1079 URAT1 Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-1080 Urea Cycle Disorders Prior Authorization Program Summary
PH-1081 Xanthine Oxidase Inhibitor Step Therapy with Quantity Limit Program Summary
PH-1082 XermeloTM (telotristat) Prior Authorization with Quantity Limit Program Summary
PH-1083 Xyrem® (sodium oxybate) Prior Authorization with Quantity Limit Program Summary
PH-1084 Zetia® (ezetimibe) Step Therapy Program Summary
PH-1085 Insulin Prior Authorization Program Summary
PH-1087 Coverage Exception Program Summary
PH-1088 Copay Waiver for Breast Cancer Prevention Therapy ACA Copay Waiver Program Summary - Individual Marketplace, Commercial Program Summary
PH-1089 Erectile Dysfunction -Phosphodiesterase Type 5 Inhibitors, Topical Prostaglandin Quantity Limit Program Summary
PH-1090 Amantadine Extended Release Prior Authorization with Quantity Limit Program Summary
PH-1091 Lucemyra Prior Authorization with Quantity Limit Program Summary
PH-1092 Jynarque Prior Authorization with Quantity Limit Program Summary
PH-1094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Criteria
PH-1095 Galafold (migalastat) Prior Authorization with Quantity Limit
PH-1097 Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limits Criteria
PH-1098 Samsca® (tolvaptan) Prior Authorization And Quantity Limit Criteria
PH-1099 Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
PH-1100 Cannabidiol Prior Authorization Criteria
PH-1101 Antidepressant Agents Step Therapy and Quantity Limit Criteria
PH-1102 Nocturia Prior Authorization with Quantity Limit Criteria
PH-1103 Firdapse (amifampridine)Prior Authorization with Quantity Limit Program Summary
PH-1104 Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary
PH-1105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-1106 Arikayce Prior Authorization with Quantity Limit Program Summary
PH-1107 ATTR Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-1108 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-1109 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-1110 Alinia Quantity Limit Program Summary
PH-1111 Tafamidis Prior Authorization with Quantity Limit Program Summary
PH-1112 Ocaliva (obeticholic acid) Prior Authorization with Quantity Limit Program Summary
PH-1113 Procysbi (cysteamine bitartrate) Prior Authorization Program Summary
PH-1114 Cablivi Quantity Limit Program Summary
PH-1115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with 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-1120 Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit- Through Preferred Agent(s)
PH-1121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-1122 Wakix Prior Authorization with Quantity Limit Program Summary
PH-1123 5HT-1F Prior Authorization with Quantity Limit Program Summary
PH-1124 Interstitial Lung Disease Prior Authorization with Quantity Limit Program Summary
PH-1125 Chloroquine, Hydroxychloroquine Quantity Limit Criteria
PH-1126 Azithromycin Quantity Limit Criteria
PH-1127 Oxbryta Prior Authorization with Quantity Limit Program Summary
PH-1128 Peanut Allergy Prior Authorization with Quantity Limit Program Summary
PH-1129 ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-1130 Risdiplam Prior Authorization with Quantity Limit Program Summary
PH-1131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-1132 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-1133 Isturisa Prior Authorization with Quantity Limit Program Summary
PH-1134 Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-1200 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-1201 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-99991000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit through Generic Topical Androgen Program Summary