PH-1000 |
Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Program Summary |
|
PH-1001 |
Benlysta (belimumab) Prior Authorization Program Summary |
|
PH-1002 |
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary |
|
PH-10022 |
Biologic Immunomodulators Prior Authorization with Quantity Limit 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-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 |
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-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 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 |
Topical Antifungals, itraconazole, terbinafine Prior Authorization with Quantity Limit Program Summary |
|
PH-1035 |
Hetlioz (tasimelteon) 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] 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 with Quantity Limit Program Summary |
|
PH-1048 |
Injectable Atopic Dermatitis Agent(s) Prior Authorization with Quantity Limit Program Summary |
|
PH-1049 |
Insomnia Agents 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 and Savella Step Therapy 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 |
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 |
|
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-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 Prior Authorization Program Summary |
|
PH-1074 |
Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary |
|
PH-1075 |
Thrombopoietin Receptor Agonists and Tavalisse Prior Authorization with Quantity Limit Program Summary |
|
PH-1076 |
Transmucosal Immediate Release Fentanyl (TIRF) Prior Authorization with 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, 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 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 |
DPP-4 Inhibitors and Combinations Step Therapy with 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-1177 |
Tarpeyo 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 Step Therapy with 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-1196 |
Furoscix (furosemide) Prior Authorization with Quantity Limit Program Summary |
|
PH-1197 |
Tezspire (tezepelumab-ekko) Prior Authorization with Quantity Limit Program Summary |
|
PH-1198 |
Vijoice (alpelisib) Prior Authorization with Quantity Limit Program Summary |
|
PH-1199 |
Antiretroviral Quantity Limit Program Summary |
|
PH-1200 |
CMV (cytomegalovirus) Quantity Limit Program Summary |
|
PH-1201 |
Winlevi (clascoterone) Prior Authorization Program Summary |
|
PH-1202 |
Filspari (sparsentan) Prior Authorization with Quantity Limit Program Summary |
|
PH-1203 |
Jesduvroq (daprodustat) Prior Authorization with Quantity Limit Program Summary |
|
PH-1204 |
Joenja (leniolisib) Prior Authorization with Quantity Limit Program Summary |
|
PH-1205 |
Ophthalmic Prostaglandins Quantity Limit Program Summary |
|
PH-1206 |
Rezurock (belumosudil) Prior Authorization with Quantity Limit Program Summary |
|
PH-1207 |
Skyclarys (omaveloxolone) Prior Authorization with Quantity Limit Program Summary |
|
PH-1208 |
Daybue (trofinetide) Prior Authorization with Quantity Limit Program Summary |
|
PH-1209 |
Qualaquin Quantity Limit Program Summary |
|
PH-1210 |
Miebo (perfluorohexyloctane) Prior Authorization with Quantity Limit Program Summary |
|