PH1000 
Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Program Summary 

PH1001 
Benlysta (belimumab) Prior Authorization Program Summary 

PH1002 
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary 

PH10022 
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary 

PH1004 
Compounded Medications Prior Authorization Program Summary 

PH1005 
Contraceptive Prior Authorization Program Summary 

PH1007 
GLP1 (glucagonlike peptide1) Agonists Prior Authorization with Quantity Limit Program Summary 

PH1008 
Hereditary Angioedema Prior Authorization with Quantity Limit Program Summary 

PH1009 
Peginterferon Prior Authorization Program Summary 

PH1012 
Subcutaneous Immune Globulins Prior Authorization Program Summary 

PH1013 
Mandatory Generic/Member Pays the Difference (MPTD) Exception Prior Authorization Program Summary 

PH1014 
Methotrexate Injectable Step Therapy Program Summary 

PH1015 
Constipation Agents Prior Authorization with Quantity Limit Program Summary 

PH1017 
Opioids ER Prior Authorization and Quantity Limit Program Summary 

PH1018 
Opioids Immediate Release (IR) Duration Limit and Quantity Limit Program Summary 

PH1019 
Otezla (Apremilast) Prior Authorization with Quantity Limit Program Summary 

PH1020 
Topical Doxepin Prior Authorization with Quantity Limit Program Summary 

PH1022 
Afrezza (regular human insulin, inhaled) Prior Authorization with Quantity Limit Program Summary 

PH1023 
Ampyra (dalfampridine) Prior Authorization with Quantity Limit Program Summary 

PH1024 
Oral Anticoagulant  Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary 

PH1025 
Antiemetic Step Therapy with Quantity Limit Program Summary 

PH1026 
AntiInfluenza Agents Quantity Limit Program Summary 

PH1027 
Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary 

PH1028 
Atopic Dermatitis (Elidel [pimecrolimus], Eucrisa, Protopic [tacrolimus]) Step Therapy Program Summary 

PH1029 
Atypical Antipsychotics Step Therapy with Quantity Program Limit Summary 

PH1030 
Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary 

PH1031 
Carbaglu (carglumic acid) Prior Authorization Program Summary 

PH1032 
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary 

PH1033 
Calcitonin GeneRelated Peptide (CGRP) Prior Authorization with Quantity Limit Program Summary 

PH1034 
Antifungal Agents  ciclopirox, efinaconazole, tavaborole Prior Authorization with Quantity Limit Program Summary 

PH1035 
Circadian Rhythm Disorder Prior Authorization with Quantity Limit Program Summary 

PH1036 
Constipation Agents Prior Authorization with Quantity Limit Program Summary 

PH1037 
Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit and Quantity Limit Program Summary 

PH1038 
Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary 

PH1039 
Endari (Lglutamine) Prior Authorization Program Summary 

PH1040 
Gabapentin ER (extendedrelease) [Horizant, Gralise] Quantity Limit Program Summary 

PH1041 
Gattex (teduglutide) Prior Authorization Program Summary 

PH1042 
Glucose Test Strips and Meters Step Therapy Program Summary 

PH1043 
Growth Hormone Prior Authorization Program Summary 

PH1044 
HyperpolarizationActivated Cyclic NucleotideGated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary 

PH1045 
Homozygous Familial Hypercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary 

PH1046 
Corticotropin Prior Authorization Program Summary 

PH1047 
Inhaled Antibiotics Duplicate Therapy Prior Authorization with Quantity Limit Program Summary 

PH1048 
Injectable Atopic Dermatitis Agent(s) Prior Authorization with Quantity Limit Program Summary 

PH1049 
Insomnia Agents Quantity Limit Program Summary 

PH1050 
Insulin Combination Agents (Soliqua, Xultophy) Step Therapy with Quantity Limit Program Summary 

PH1051 
Interleukin (IL)1 Inhibitors Prior Authorization with Quantity Limit Program Summary 

PH1052 
Idiopathic Pulmonary Fibrosis Summary 

PH1053 
Keveyis Prior Authorization with Quantity Limit Program Summary 

PH1054 
Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary 

PH1055 
Lyrica and Savella Step Therapy with Quantity Limit Program Summary 

PH1056 
Metformin ER Step Therapy with Program Summary 

PH1057 
Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary 

PH1058 
Myalept (Metreleptin) Prior Authorization Program Summary 

PH1059 
Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary 

PH1060 
Northera (droxidopa) Prior Authorization with Quantity Limit Program Summary 

PH1062 
Riluzole Prior Authorization with Quantity Limit Porgram Summary 

PH1063 
Oral Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary 

PH1064 
Oral Tetracycline Derivatives Step Therapy Program Summary 

PH1065 
Parathyroid Hormone Analog for Osteoporosis Prior Authorization with Quantity Limit Program Summary 

PH1066 
Proprotein Convertase Subtilisin/Kexin type 9(PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary Through Preferred Agent(s) 

PH1067 
Phenylketonuria Prior Authorization Program Summary 

PH1068 
Proton Pump Inhibitors (PPIs) Step Therapy with Quantity Limit Program Summary 

PH1069 
SelfAdministered Oncology Agents Prior Authorization with Quantity Limit Program Summary Pt. 1 

PH10691 
SelfAdministered Oncology Agents Prior Authorization with Quantity Limit Program Summary Pt. 2 

PH1070 
Signifor Prior Authorization with Quantity Limit Program Summary 

PH1071 
Selective Serotonin Inverse Agonist (SSIA) Prior Authorization with Quantity Limit Program Summary 

PH1072 
Statin Step Therapy Program Summary 

PH1073 
Strensiq Prior Authorization Program Summary 

PH1074 
Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary 

PH1075 
Thrombopoietin Receptor Agonists and Tavalisse Prior Authorization with Quantity Limit Program Summary 

PH1076 
Transmucosal Immediate Release Fentanyl (TIRF) Prior Authorization (Through Generic) and Quantity Limit Program Summary 

PH1077 
Topiramate ER Prior Authorization with Quantity Limit Program Summary 

PH1078 
Triptans Step Therapy and Quantity Limit Program Summary 

PH1079 
URAT1 Inhibitor Prior Authorization with Quantity Limit Program Summary 

PH1080 
Urea Cycle Disorders Prior Authorization Program Summary 

PH1081 
Xanthine Oxidase Inhibitor Quantity Limit Program Summary 

PH1082 
Xermelo (telotristat) Prior Authorization with Quantity Limit Program Summary 

PH1083 
Oxybate Prior Authorization with Quantity Limit Program Summary 

PH1084 
Zetia® (ezetimibe) Step Therapy Program Summary 

PH1085 
Insulin Prior Authorization Program Summary 

PH1086 
Quantity Limit Summary 

PH1087 
Coverage Exception Program Summary 

PH1088 
Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary – Individual Marketplace, Commercial 

PH1089 
Erectile Dysfunction Phosphodiesterase Type 5 Inhibitors, Topical Prostaglandin Quantity Limit Program Summary 

PH1090 
Amantadine Extended Release Prior Authorization with Quantity Limit Program Summary 

PH1091 
Lucemyra (lofexidine) Prior Authorization with Quantity Limit Program Summary 

PH1092 
Jynarque Prior Authorization with Quantity Limit Program Summary 

PH1093 
Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary 

PH1094 
Elmiron (pentosan polysulfate sodium) Prior Authorization Program Summary 

PH1095 
Galafold (migalastat) Prior Authorization with Quantity Limit Program Summary 

PH1096 
Hyperhidrosis Prior Authorization with Quantity Limit Program Summary 

PH1097 
Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limit Program Summary 

PH1098 
Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary 

PH1099 
Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary 

PH1100 
Cannabidiol Prior Authorization Program Summary 

PH1101 
Antidepressant Agents Step Therapy and Quantity Limit Program Summary 

PH1102 
Nocturia Prior Authorization with Quantity Limit Program Summary 

PH1103 
Amifampridine Prior Authorization with Quantity Limit Program Summary 

PH1104 
Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary 

PH1105 
Weight Loss Agents Prior Authorization with Quantity Limit Program Summary 

PH1106 
Arikayce Prior Authorization with Quantity Limit Program Summary 

PH1107 
ATTR (transthyretin amyloid) Amyloidosis Prior Authorization with Quantity Limit Program Summary 

PH1108 
Eysuvis (loteprednol etabonate) Prior Authorization with Quantity Limit Program Summary 

PH1110 
Alinia Quantity Limit Program Summary 

PH1111 
Tafamidis Prior Authorization with Quantity Limit Program Summary 

PH1112 
Ocaliva (obeticholic acid) Prior Authorization with Quantity Limit Program Summary 

PH1113 
Procysbi (cysteamine bitartrate) Prior Authorization Program Summary 

PH1114 
Cablivi (caplacizumabyhdp) Quantity Limit Program Summary 

PH1115 
Interleukin5 (IL5) Inhibitors Prior Authorization with Quantity Limit Program Summary 

PH1117 
Opioids Immediate Release (IR) Quantity Limit Program Summary 

PH1118 
Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary 

PH1119 
Interleukin4 (IL4) Inhibitor Prior Authorization with Quantity Limit Program Summary 

PH1120 
Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit Program Summary 

PH1121 
Baclofen Prior Authorization with Quantity Limit Program Summary 

PH1122 
Wakix (pitolisant) Prior Authorization with Quantity Limit Program Summary 

PH1123 
5HT1F Prior Authorization with Quantity Limit Program Summary 

PH1124 
Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary 

PH1125 
Chloroquine, Hydroxychloroquine Quantity Limit Criteria 

PH1126 
Azithromycin Quantity Limit Criteria 

PH1127 
Oxbryta (voxelotor) Prior Authorization with Quantity Limit Program Summary 

PH1128 
Peanut Allergy Prior Authorization with Quantity Limit Program Summary 

PH1129 
Copay Waiver for Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis (PrEP) ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial 

PH1130 
Risdiplam Prior Authorization with Quantity Limit Program Summary 

PH1131 
Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary 

PH1132 
Bempedoic Acid Prior Authorization with Quantity Limit Program Summary 

PH1133 
Isturisa (osilodrostat) Prior Authorization with Quantity Limit Program Summary 

PH1134 
Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary 

PH1135 
Sodiumglucose Cotransporter 2 (SGLT2) Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary 

PH1138 
Dojolvi Prior Authorization Program Summary 

PH1139 
Dipeptidyl Peptidase4 (DPP4) Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary 

PH1140 
Fintepla (fenfluramine) Prior Authorization with Quantiy Limit Program Summary 

PH1141 
Rho Kinase Inhibitor Step Therapy with Quantity Limit program Summary 

PH1142 
Enspryng (satralizumabmwge) Prior Authorization with Quantity Limit Program Summary 

PH1143 
Sunosi (solriamfetol) Prior Authorization with Quantity Limit Program Summary 

PH1144 
Sucraid (sacrosidase) Prior Authorization with Quantity Limit Program Summary 

PH1145 
Xhance Prior Authorization with Quantity Limit Program Summary 

PH1146 
Zokinvy Prior Authorization with Quantity Limit Program Summary 

PH1147 
Zeposia (ozanimod) Prior Authorization with Quantity Limit Program Summary 

PH1148 
Verquvo Prior Authorization with Quantity Limit Program Summary 

PH1149 
Topical NSAID (NonSteroidal AntiInflammatory Drug) Prior Authorization with Quantity Limit Program Summary 

PH1150 
Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary 

PH1151 
Iron Chelation Prior Authorization with Quantity Limit Program Summary 

PH1152 
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors Prior Authorization with Quantity Limit Program Summary 

PH1153 
Ivermectin Prior Authorization Program Summary 

PH1154 
Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary 

PH1155 
Insulin Pumps Quantity Limit Program Summary 

PH1156 
Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary 

PH1157 
Cholestasis Pruritus Prior Authorization Program Summary 

PH1158 
Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary 

PH1159 
Long Acting Insulin Prior Authorization Program Summary 

PH1160 
Rapid to Intermediate Acting Insulin Prior Authorization Program Summary 

PH1161 
Winlevi (clascoterone) Step Therapy Program Summary 

PH1162 
Opzelura (ruxolitinib) Prior Authorization with Quantity Limit Program Summary 

PH1163 
Tavneos (avacopan) Prior Authorization with Quantity Limit Program Summary 

PH1164 
Tyrvaya (varenicline) Prior Authorization with Quantity Limit Program Summary 

PH1165 
Imcivree Prior Authorization with Quantity Limit Program Summary 

PH1166 
Lupus Prior Authorization with Quantity Limit Program Summary 

PH1168 
Hetlioz (tasimelteon) Prior Authorization with Quantity Limit Program Summary 

PH1169 
Voxzogo (vosoritide) Prior Authorization with Quantity Limit Program Summary 

PH1170 
Interleukin13 (IL13) Antagonist Prior Authorization with Quantity Limit Program Summary 

PH1171 
Xolair (omalizumab) Prior Authorization Program Summary 

PH1173 
Bempedoic Acid Prior Authorization with Quantity Limit Program Summary 

PH1174 
Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary 

PH1175 
Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary 

PH1176 
Recorlev (levoketoconazole) Prior Authorization with Quantity Limit Program Summary 

PH1178 
Topical Psoriasis Quantity Limit 

PH1179 
Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary 

PH1180 
Camzyos (mavacamten) Prior Authorization with Quantity Limit Program Summary 

PH1181 
Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary 

PH1182 
Penicillamine Step Therapy Program Summary 

PH1183 
Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary 

PH1184 
Topical Estrogen Quantity Limit Program Summary 

PH1185 
Vtama (tapinarof) Prior Authorization Program Summary 

PH1186 
Copay Waiver for Statin ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial 

PH1187 
ACA Prevention Copay Waiver Contraceptives Program Summary – Individual Marketplace, Commercial 

PH1188 
Hyftor (sirolimus) Prior Authorization with Quantity Limit Program Summary 

PH1189 
Nasal Antiepileptics Quantity Limit Program Summary 

PH1190 
Nasal Inhalers Quantity Limit Program Summary 

PH1191 
Oral Inhalers Quantity Limit Program Summary 

PH1192 
Pain Medications (Combination Products) Quantity Limit Program Summary 

PH1193 
Relyvrio (sodium phenylbutyrate/taurursodiol) Prior Authorization with Quantity Limit Program Summary 

PH1194 
Zoryve (roflumilast) Prior Authorization Program Summary 

PH1195 
Antitussive Combination Products Quantity Limit Program Summary 

PH1196 
Furoscix (furosemide) Prior Authorization with Quantity Limit Program Summary 

PH1197 
Tezspire (tezepelumabekko) Prior Authorization with Quantity Limit Program Summary 

PH1198 
Vijoice (alpelisib) Prior Authorization with Quantity Limit Program Summary 

PH1200 
Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary 

PH1201 
Winlevi (clascoterone) Step Therapy Program Summary 
