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 |
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PH-00340 |
Esperoct |
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PH-1000 |
Androgens and /Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Topical Androgen Program Summary |
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PH-1001 |
Benlysta (belimumab) Prior Authorization with Quantity Limit Program Summary |
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PH-1002 |
Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary |
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PH-1003 |
Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary |
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PH-1004 |
Compounded Medications Prior Authorization Program Summary |
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PH-1005 |
Contraceptive Prior Authorization Program Summary |
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PH-1006 |
Flector® Prior Authorization with Quantity Limit Program Summary |
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PH-1007 |
GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary |
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PH-1008 |
Hereditary Angioedema Prior Authorization with Quantity Limit Program Summary |
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PH-1009 |
PePeg-interferon Prior Authorization Program Summary |
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PH-1010 |
Hepatitis C First Generation Prior Authorization – Through Preferred Agent(s) Program Summary |
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PH-1011 |
Hepatitis C Second Generation Antivirals Prior Authorization - Through Preferred Agent(s) Program Summary |
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PH-1012 |
Immune Globulins Prior Authorization Program Summary |
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PH-1013 |
Mandatory Generic - Member Pays the Difference Exception Summary |
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PH-1014 |
Methotrexate Injectable Step Therapy Program Summary |
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PH-1015 |
Constipation Agents Prior Authorization with Quantity Limit Program Summary |
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PH-1017 |
Opioid ER Prior Authorization and Quantity Limit Criteria |
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PH-1018 |
Opioid Immediate Release Duration Limit and Quantity Limit Program Summary |
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PH-1019 |
Otezla (Apremilast) Prior Authorization with Quantity Limit Program Summary |
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PH-1020 |
Topical Doxepin Summary |
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PH-1022 |
Afrezza Summary |
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PH-1023 |
Ampyra (dalfampridine) Prior Authorization with Quantity Limit Program Summary |
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PH-1024 |
Oral Anticoagulant - Bevyxxa (Betrixaban), Eliquis (Apixaban), Pradaxa (Dabigatran), Savaysa (Edoxaban), Xarelto (Rivaroxaban) Wuantity Limit Program Summary |
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PH-1025 |
Antiemetic Step Therapy with Quantity Limit and Quantity Limit Program Summary |
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PH-1026 |
Anti-Influenza Agents Quantity Limit Program Summary |
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PH-1027 |
Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary |
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PH-1028 |
Atopic Dermatitis Step Therapy Program Summary |
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PH-1029 |
Atypical Antipsychotics Step Therapy and Quantity Limit |
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PH-1030 |
Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary |
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PH-1031 |
Carbaglu (carglumic acid) Prior Authorization Program Summary |
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PH-1032 |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary |
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PH-1033 |
CGRP Prior Authorization with Quantity Limit Criteria Program Summary |
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PH-1034 |
Antifungal Agents - ciclopirox, efinaconazole, tavaborole Prior Authorization with Quantity Limit Program Summary |
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PH-1035 |
Circadian Rhythm Disorder Prior Authorization with Quantity Limit Program Summary |
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PH-1036 |
Constipation Agents Prior Authorization Program Summary |
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PH-1037 |
Topical Diclofenac Gel, Fluorouracil Cream, Imiquimod Cream, and Ingenol Gel Prior Authorization with Quantity Limit and Quantity Limit Program Summary |
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PH-1038 |
Emflaza (deflazacort) Prior Authorization with Quantity Limit Program Summary |
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PH-1039 |
Endari Prior Authorization Program Summary |
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PH-1040 |
Gabapentin ER (extended-release) [Horizant®, Gralise®] Step Therapy and Quantity Limit Program Summary |
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PH-1041 |
Gattex (teduglutide) Prior Authorization Program Summary |
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PH-1042 |
Glucose Test Strips/Disks/ Meters Step Therapy Program Summary |
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PH-1043 |
Growth Hormone Prior Authorization Program Summary |
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PH-1044 |
Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary |
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PH-1045 |
Homozygous Familial Hypercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary |
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PH-1046 |
Corticotropin (repository corticotropin) Prior Authorization Program Summary |
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PH-1047 |
Inhaled Antibiotics Duplicate Therapy Prior Authorization Program Summary |
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PH-1048 |
Injectable Atopic Dermatitis Agent(s) Prior Authorization with Quantity Limit Program Summary |
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PH-1049 |
Insomnia Agents Step Therapy and Quantity Limit Program Summary |
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PH-1050 |
Insulin Combination Agents (Soliqua, Xultophy) Step Therapy and Quantity Limit Program Summary |
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PH-1051 |
Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary |
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PH-1052 |
Idiopathic Pulmonary Fibrosis Summary |
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PH-1053 |
Keveyis Summary |
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PH-1054 |
Korlym (Mifepristone) Prior Authorization with Quantity Limit Program Summary |
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PH-1055 |
Lyrica (Pregabalin CR) Summary |
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PH-1056 |
Metformin ER Summary |
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PH-1057 |
Multiple Sclerosis Agents Summary |
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PH-1058 |
Myalept (Metreleptin) Prior Authorization Program Summary |
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PH-1059 |
Natpara (parathyroid hormone) Prior Authorization with Quantity Limit Program Summary |
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PH-1060 |
Northera® (droxidopa) Prior Authorization with Quantity Limit Program Summary |
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PH-1061 |
Nuvigil (Armodafinil), Provigil (Modafinil) Summary |
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PH-1062 |
Riluzol Prior Authorization with Quantity Limit Porgram Summary |
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PH-1063 |
Oral Pulmonary Arterial Hypertension Agents Prior Authorization with Quantity Limit Program Summary |
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PH-1064 |
Oral Tetracycline Derivatives (Doxycycline-Minocycline) Summary |
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PH-1065 |
Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary |
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PH-1066 |
Proprotein Convertase Subtilisin/Kexin type 9(PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary- Through Preferred Agent(s) |
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PH-1067 |
Phenylketonuria Prior Authorization Program Summary |
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PH-1068 |
Proton Pump Inhibitors (PPIs) Step Therapy and Quantity Limit Program Summary |
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PH-1069 |
Self Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary |
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PH-1070 |
Signifor Prior Authorization with Quantity Limit Program Summary |
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PH-1071 |
Selective Serotonin Inverse Agonist (SSIA) Prior Authorization with Quantity Limit Program Summary |
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PH-1072 |
Statin Step Therapy Program Summary |
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PH-1073 |
Strensiq (asfotase alfa) Prior Authorization Program Summary |
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PH-1074 |
Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary |
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PH-1075 |
Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary |
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PH-1076 |
Transmucosal Immediate Release Fentanyl Prior Authorization (Through Generic) and Quantity Limit Program Summary |
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PH-1077 |
Topiramate ER Prior Authorization with Quantity Limit Program Summary |
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PH-1078 |
Triptans Step Therapy and Quantity Limit Program Summary |
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PH-1079 |
URAT1 Inhibitor Prior Authorization with Quantity Limit Program Summary |
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PH-1080 |
Urea Cycle Disorders Prior Authorization Program Summary |
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PH-1081 |
Xanthine Oxidase Inhibitor Step Therapy with Quantity Limit Program Summary |
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PH-1082 |
XermeloTM (telotristat) Prior Authorization with Quantity Limit Program Summary |
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PH-1083 |
Sodium Oxybate Prior Authorization with Quantity Limit Program Summary |
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PH-1084 |
Zetia® (ezetimibe) Step Therapy Program Summary |
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PH-1085 |
Insulin Prior Authorization Program Summary |
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PH-1087 |
Coverage Exception Program Summary |
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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 |
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PH-1090 |
Amantadine Extended Release Prior Authorization with Quantity Limit Program Summary |
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PH-1091 |
Lucemyra Prior Authorization with Quantity Limit Program Summary |
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PH-1092 |
Jynarque Prior Authorization with Quantity Limit Program Summary |
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PH-1093 |
Elagolix Prior Authorization with Quantity Limit Program Summary |
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PH-1094 |
Elmiron® (pentosan polysulfate sodium) Prior Authorization Criteria |
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PH-1096 |
Hyperhidrosis Prior Authorization with Quantity Limit Program Summary |
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PH-1097 |
Pseudobulbar Affect (PBA) Prior Authorization with Quantity Limits Criteria |
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PH-1098 |
Samsca® (tolvaptan) Prior Authorization And Quantity Limit Criteria |
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PH-1099 |
Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary |
|
PH-1100 |
Cannabidiol Prior Authorization Program Summary |
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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 |
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PH-1104 |
Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary |
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PH-1105 |
Weight Loss Agents Prior Authorization with Quantity Limit Program Summary |
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PH-1106 |
Arikayce Prior Authorization with Quantity Limit Program Summary |
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PH-1107 |
ATTR Amyloidosis Prior Authorization with Quantity Limit Program Summary |
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PH-1108 |
Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary |
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PH-1109 |
Interleukin-5 (IL-5) Inhibitors Prior Authorization with Quantity Limit Program Summary |
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PH-1110 |
Alinia Quantity Limit Program Summary |
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PH-1111 |
Tafamidis Prior Authorization with Quantity Limit Program Summary |
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PH-1112 |
Ocaliva (obeticholic acid) Prior Authorization with Quantity Limit Program Summary |
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PH-1113 |
Procysbi (cysteamine bitartrate) Prior Authorization Program Summary |
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PH-1114 |
Cablivi Quantity Limit Program Summary |
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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 |
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PH-1117 |
Opioids IR Quantity Limit Program Summary |
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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) Program Summary |
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PH-1121 |
Baclofen Prior Authorization with Quantity Limit Program Summary |
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PH-1122 |
Wakix Prior Authorization with Quantity Limit Program Summary |
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PH-1123 |
5HT-1F Prior Authorization with Quantity Limit Program Summary |
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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 |
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PH-1128 |
Peanut Allergy Prior Authorization with Quantity Limit Program Summary |
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PH-1129 |
ACA Prevention Copay Waiver Program Summary – Individual Marketplace, Commercial |
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PH-1130 |
Risdiplam Prior Authorization with Quantity Limit Program Summary |
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PH-1131 |
Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary |
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PH-1132 |
Bempedoic Acid Prior Authorization with Quantity Limit Program Summary |
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PH-1133 |
Isturisa Prior Authorization with Quantity Limit Program Summary |
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PH-1134 |
Immunomodulators Prior Authorization with Quantity Limit Program Summary |
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PH-1135 |
SGLT-2 Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary |
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PH-1136 |
Atypical Antipsychotics, Long Acting Step Therapy and Quantity Limit Program Summary |
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PH-1137 |
Atypical Antipsychotics, Short Acting Step Therapy and Quantity Limit Program Summary |
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PH-1138 |
Dojolvi Prior Authorization Program Summary |
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PH-1139 |
DPP-4 Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary |
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PH-1140 |
Fintepla (fenfluramine) Prior Authorization with Quantiy Limit Program Summary |
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PH-1141 |
Rho Kinase Inhibitor Step Therapy and Quantity Limit program Summary |
|
PH-1200 |
Hypoactive Sexual Desire Disorder (HSDD) Prior Authorization with Quantity Limit Program Summary |
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PH-1201 |
Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary |
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