Final 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 review for 45 days from the posting date on the policy. 

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

 

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

 

Policy # Policy Title Print View
PH-1000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Program Summary
PH-1001 Benlysta (belimumab) Prior Authorization Program Summary
PH-1002 Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-1004 Compounded Medications Prior Authorization Program Summary
PH-1005 Contraceptive Prior Authorization Program Summary
PH-1007 GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit Program Summary
PH-1008 Hereditary Angioedema Prior Authorization with Quantity Limit Program Summary
PH-1009 Peginterferon Prior Authorization Program Summary
PH-1012 Subcutaneous Immune Globulins Prior Authorization Program Summary
PH-1013 Mandatory Generic/Member Pays the Difference (MPTD) Exception Prior Authorization Program Summary
PH-1014 Methotrexate Injectable Step Therapy Program Summary
PH-1015 Constipation Agents Prior Authorization with Quantity Limit Program Summary
PH-1017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-1018 Opioids Immediate Release (IR) Duration Limit and Quantity Limit Program Summary
PH-1019 Otezla (Apremilast) Prior Authorization with Quantity Limit Program Summary
PH-1020 Topical Doxepin Prior Authorization with Quantity Limit Program Summary
PH-1022 Afrezza (regular human insulin, inhaled) Prior Authorization with Quantity Limit Program Summary
PH-1023 Ampyra (dalfampridine) Prior Authorization with Quantity Limit Program Summary
PH-1024 Oral Anticoagulant - Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-1025 Antiemetic Step Therapy with Quantity Limit Program Summary
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 (Elidel [pimecrolimus], Eucrisa, Protopic [tacrolimus]) Step Therapy Program Summary
PH-1029 Atypical Antipsychotics Step Therapy with Quantity Program Limit Summary
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 Calcitonin Gene-Related Peptide (CGRP) Prior Authorization with Quantity Limit 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 with Quantity Limit Program Summary
PH-1037 Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit and Quantity Limit Program Summary
PH-1038 Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary
PH-1039 Endari (L-glutamine) 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 and 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 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 with Quantity Limit Program Summary
PH-1051 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-1052 Idiopathic Pulmonary Fibrosis Summary
PH-1053 Keveyis Prior Authorization with Quantity Limit Program Summary
PH-1054 Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary
PH-1055 Lyrica CR (pregabalin ER) Prior Authorization with Quantity Limit Program Summary
PH-1056 Metformin ER Step Therapy with Program Summary
PH-1057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-1058 Myalept (Metreleptin) Prior Authorization Program Summary
PH-1059 Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary
PH-1060 Northera (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-1062 Riluzole Prior Authorization with Quantity Limit Porgram Summary
PH-1063 Oral Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-1064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-1065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization 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 with Quantity Limit Program Summary
PH-1069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-10691 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-1070 Signifor 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 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 (TIRF) 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 Quantity Limit Program Summary
PH-1082 Xermelo (telotristat) Prior Authorization with Quantity Limit Program Summary
PH-1083 Oxybate Prior Authorization with Quantity Limit Program Summary
PH-1084 Zetia® (ezetimibe) Step Therapy Program Summary
PH-1085 Insulin Prior Authorization Program Summary
PH-1086 Quantity Limit Summary
PH-1087 Coverage Exception Program Summary
PH-1088 Copay Waiver for Breast Cancer Primary Prevention Agent ACA Copay Waiver Program Summary – Individual Marketplace, Commercial
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 (lofexidine) Prior Authorization with Quantity Limit Program Summary
PH-1092 Jynarque (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-1093 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-1094 Elmiron (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-1095 Galafold (migalastat) Prior Authorization with Quantity Limit Program Summary
PH-1096 Hyperhidrosis Prior Authorization with Quantity Limit Program Summary
PH-1097 Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limit Program Summary
PH-1098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-1099 Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
PH-1100 Cannabidiol Prior Authorization Program Summary
PH-1101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-1102 Nocturia Prior Authorization with Quantity Limit Program Summary
PH-1103 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 (transthyretin amyloid) Amyloidosis Prior Authorization with Quantity Limit Program Summary
PH-1108 Eysuvis (loteprednol etabonate) 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 (caplacizumab-yhdp) Quantity Limit Program Summary
PH-1115 Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-1117 Opioids Immediate Release (IR) 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 Program Summary
PH-1121 Baclofen Prior Authorization with Quantity Limit Program Summary
PH-1122 Wakix (pitolisant) Prior Authorization with Quantity Limit Program Summary
PH-1123 5HT-1F Prior Authorization with Quantity Limit Program Summary
PH-1124 Interstitial Lung Disease (ILD) Prior Authorization with Quantity Limit Program Summary
PH-1125 Chloroquine, Hydroxychloroquine Quantity Limit Criteria
PH-1126 Azithromycin Quantity Limit Criteria
PH-1127 Oxbryta (voxelotor) Prior Authorization with Quantity Limit Program Summary
PH-1128 Peanut Allergy Prior Authorization with Quantity Limit Program Summary
PH-1129 Copay Waiver for Human Immunodeficiency Virus (HIV) Infection: Pre-exposure Prophylaxis (PrEP) 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 (osilodrostat) Prior Authorization with Quantity Limit Program Summary
PH-1134 Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-1135 Sodium-glucose Co-transporter 2 (SGLT-2) Inhibitors and Combinations Step Therapy with Quantity Limit Program Summary
PH-1138 Dojolvi Prior Authorization Program Summary
PH-1139 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
PH-1140 Fintepla (fenfluramine) Prior Authorization with Quantiy Limit Program Summary
PH-1141 Rho Kinase Inhibitor Step Therapy with Quantity Limit program Summary
PH-1142 Enspryng (satralizumab-mwge) Prior Authorization with Quantity Limit Program Summary
PH-1143 Sunosi (solriamfetol) Prior Authorization with Quantity Limit Program Summary
PH-1144 Sucraid (sacrosidase) Prior Authorization with Quantity Limit Program Summary
PH-1145 Xhance Prior Authorization with Quantity Limit Program Summary
PH-1146 Zokinvy Prior Authorization with Quantity Limit Program Summary
PH-1147 Zeposia (ozanimod) Prior Authorization with Quantity Limit Program Summary
PH-1148 Verquvo Prior Authorization with Quantity Limit Program Summary
PH-1149 Topical NSAID (Non-Steroidal Anti-Inflammatory Drug) Prior Authorization with Quantity Limit Program Summary
PH-1150 Continuous Glucose Monitor (CGM) Step Therapy with Quantity Limit Program Summary
PH-1151 Iron Chelation Prior Authorization with Quantity Limit Program Summary
PH-1152 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-1153 Ivermectin Prior Authorization Program Summary
PH-1154 Empaveli (pegcetacoplan) Prior Authorization with Quantity Limit Program Summary
PH-1155 Insulin Pumps Quantity Limit Program Summary
PH-1156 Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-1157 Cholestasis Pruritus Prior Authorization Program Summary
PH-1158 Kerendia (finerenone) Prior Authorization with Quantity Limit Program Summary
PH-1159 Long Acting Insulin Prior Authorization Program Summary
PH-1160 Rapid to Intermediate Acting Insulin Prior Authorization Program Summary
PH-1161 Winlevi (clascoterone) Step Therapy Program Summary
PH-1162 Opzelura (ruxolitinib) Prior Authorization with Quantity Limit Program Summary
PH-1163 Tavneos (avacopan) Prior Authorization with Quantity Limit Program Summary
PH-1164 Tyrvaya (varenicline) Prior Authorization with Quantity Limit Program Summary
PH-1165 Imcivree Prior Authorization with Quantity Limit Program Summary
PH-1166 Lupus Prior Authorization with Quantity Limit Program Summary
PH-1168 Hetlioz (tasimelteon) Prior Authorization with Quantity Limit Program Summary
PH-1169 Voxzogo (vosoritide) Prior Authorization with Quantity Limit Program Summary
PH-1170 Interleukin-13 (IL-13) Antagonist Prior Authorization with Quantity Limit Program Summary
PH-1171 Xolair (omalizumab) Prior Authorization Program Summary
PH-1173 Bempedoic Acid Prior Authorization with Quantity Limit Program Summary
PH-1174 Cibinqo (abrocitinib) Prior Authorization with Quantity Limit Program Summary
PH-1175 Pyrukynd (mitapivat) Prior Authorization with Quantity Limit Program Summary
PH-1176 Recorlev (levoketoconazole) Prior Authorization with Quantity Limit Program Summary
PH-1178 Topical Psoriasis Quantity Limit
PH-1179 Attention Deficit [Hyperactivity] Disorder (ADHD/ADD) Agents Quantity Limit Program Summary
PH-1180 Camzyos (mavacamten) Prior Authorization with Quantity Limit Program Summary
PH-1181 Elagolix/Relugolix Prior Authorization with Quantity Limit Program Summary
PH-1182 Penicillamine Step Therapy Program Summary
PH-1183 Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary
PH-1184 Topical Estrogen Quantity Limit Program Summary
PH-1185 Vtama (tapinarof) Prior Authorization Program Summary
PH-1186 Copay Waiver for Statin ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial
PH-1187 ACA Prevention Copay Waiver Contraceptives Program Summary – Individual Marketplace, Commercial
PH-1188 Hyftor (sirolimus) Prior Authorization with Quantity Limit Program Summary
PH-1189 Nasal Antiepileptics Quantity Limit Program Summary
PH-1190 Nasal Inhalers Quantity Limit Program Summary
PH-1191 Oral Inhalers Quantity Limit Program Summary
PH-1192 Pain Medications (Combination Products) Quantity Limit Program Summary
PH-1193 Relyvrio (sodium phenylbutyrate/taurursodiol) Prior Authorization with Quantity Limit Program Summary
PH-1194 Zoryve (roflumilast) Prior Authorization Program Summary
PH-1195 Antitussive Combination Products Quantity Limit Program Summary
PH-1200 Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary
PH-1201 Winlevi (clascoterone) Step Therapy Program Summary