Draft 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.

 

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-1144 Sucraid 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 Prior Authorization with Quantity Limit Program Summary
PH-1149 Topical NSAID (Non-Steroidal Anti-Inflammatory Drug) Prior Authorization with Quantity Limit Program Summary
PH-91002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products
PH-91004 Compounded Medications Prior Authorization Program Summary
PH-91006 Flector® Prior Authorization with Quantity Limit Program Summary
PH-91007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-91009 Peg-interferon Prior Authorization Program Summary
PH-91017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-91024 Oral Anticoagulant - Bevyxxa, (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), Xarelto (rivaroxaban) Quantity Limit Program Summary
PH-91025 Antiemetic Agents Quantity Limit Program Summary
PH-91026 Anti-Influenza Agents Quantity Limit Program Summary
PH-91027 Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors, and Combinations Step Therapy Program Summary
PH-91030 Bonjesta, Diclegis Prior Authorization with Quantity Limit Program Summary
PH-91032 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prior Authorization with Quantity Limit Program Summary
PH-91036 Constipation Agents Prior Authorization Program Summary
PH-91039 Endari (L-glutamine) Prior Authorization Program Summary
PH-91040 Gabapentin ER (extended-release) [Horizant, Gralise] Step Therapy and Quantity Limit Program Summary
PH-91041 Gattex (teduglutide) Prior Authorization Program Summary
PH-91042 Glucose Test Strips and Meters Step Therapy
PH-91044 Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor) Prior Authorization with Quantity Limit Program Summary
PH-91051 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-91062 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-91063 Oral Pulmonary Hypertension Agents Prior Authorization with Quantity Limit Program Summary
PH-91064 Oral Tetracycline Derivatives Step Therapy Program Summary
PH-91065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-91066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary-Through Preferred agent(s)
PH-91068 Proton Pump Inhibitors (PPIs) Step Therapy and Quantity Limit Program Summary
PH-91069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Summary
PH-91072 Statin Step Therapy Program Summary
PH-91080 Urea Cycle Disorders Prior Authorization Program Summary
PH-91094 Elmiron® (pentosan polysulfate sodium) Prior Authorization Program Summary
PH-91095 Galafold (migalastat) Prior Authorization with Quantity Limit Program Summary
PH-91099 Sucralfate Suspension Prior Authorization with Quantity Limit Program Summary
PH-91102 Nocturia Prior Authorization with Quantity Limit Program Summary
PH-91104 Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary
PH-91105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-91108 Eysuvis (loteprednol etabonate) Prior Authorization with Quantity Limit Program Summary
PH-91109 Imcivree Prior Authorization with Quantity Limit
PH-91110 Alinia Quantity Limit Program Summary
PH-91112 Ocaliva (obeticholic acid) Prior Authorization with Quantity Limit Program Summary
PH-91114 Cablivi Quantity Limit Program Summary
PH-91119 Interleukin-4 (IL-4) Inhibitor Prior Authorization with Quantity Limit Program Summary
PH-91120 Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit- Through Preferred Agent(s)
PH-91127 Oxbryta Prior Authorization with Quantity Limit Program Summary
PH-91128 Peanut allergy Prior Authorization with Quantity Limit
PH-91134 Ophthalmic Immunomodulators Prior Authorization with Quantity Limit Program Summary
PH-91136 Atypical Antipsychotics - Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary
PH-91140 Fintepla (fenfluramine) Prior Authorization with Quantity Limit Program Summary
PH-91141 Rho Kinase Inhibitor Step Therapy and Quantity Limit Program Summary
PH-91150 Continuous Glucose Monitor Step Therapy Program Summary with Quantity Limit
PH-91151 Deferasirox Prior Authorization with Quantity Limit Program Summary
PH-91152 VMAT2 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-91201 Winlevi (clascoterone) Step Therapy Program Summary
PH-991001 Lupus Prior Authorization with Quantity Limit Program Summary
PH-991035 Hetlioz (tasimelteon) Prior Authoriztaion with Quantity Limit Program Summary
PH-991045 Homozygous Familial Hpercholesterolemia Agents (HoFH) Prior Authorization with Quantity Limit Program Summary
PH-991053 Keveyis Prior Authorization with Quantity Limit Program Summary
PH-991055 Lyrica CR® (pregabalin CR) Prior Authorization with Quantity Limit Program Summary
PH-991057 Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
PH-991060 Northera® (droxidopa) Prior Authorization with Quantity Limit Program Summary
PH-991062 Riluzole Prior Authorization with Quantity Limit Program Summary
PH-991071 Selective Serotonin Inverse Agonist (SSIA) Prior Authorization with Quantity Limit Program Summary
PH-991074 Substrate Reduction Therapy Prior Authorization with Quantity Limit Program Summary
PH-991089 Erectile Dysfunction - Phosphodiesterase Type 5 Inhibitors, Topical Prostaglandin Quantity Limit
PH-991090 Amantadine Extended Release Prior Authorization with Wuantity Limit Program Summary
PH-991092 Jynarque Prior Authorization with Quantity Limit
PH-991101 Antidepressant Agents Step Therapy and Quantity Limit Program Summary
PH-991117 Opioids IR Quantity Limit
PH-991131 Acute Migraine Agents Prior Authorization with Quantity Limit Program Summary
PH-991137 Atypical Antipsychotics Step Therapy and Quantity Limit Program Summary
PH-9991031 Carbaglu (carglumic acid) Prior Authorization Criteria
PH-9991033 CGRP Prior Authorization with Quantity Limit Program Summary
PH-9991037 Topical Actinic Keratosis, Basal Cell Carcinoma, Genital Warts Agents Prior Authorization with Quantity Limit and Quantity Limit Program Summary
PH-9991051 Interleukin (IL)-1 Inhibitors Prior Authorization with Quantity Limit Program Summary
PH-9991063 Oral Pulmonary Arterial Hypertension Agents Prior Authorization with Quantity Limit
PH-9991065 Parathyroid Hormone Analog for Osteoporosis Prior Authorization through Preferred with Quantity Limit Program Summary
PH-9991066 Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Inhibitors Prior Authorization with Quantity Limit-Through Preferred Agent(s)
PH-9991072 Statin Step Therapy Program Summary
PH-9991077 Topiramate ER Prior Authorization with Quantity Limit Program Summary
PH-9991078 Triptan Step Therapy and Quantity Limit Program Summary
PH-9991098 Samsca (tolvaptan) Prior Authorization with Quantity Limit Program Summary
PH-9991100 Cannabidiol Prior Authorization Prgram Summary
PH-9991105 Weight Loss Agents Prior Authorization with Quantity Limit Program Summary
PH-99991007 GLP-1 (glucagon-like peptide-1) Agonists Step Therapy and Quantity Limit Program Summary
PH-99991018 Opioids Immediate Release Duration Limit and Quantity Limit Program Summary
PH-99991019 Otezla (apremilast) Prior Authorization with Quantity Limit Program Summary
PH-99991075 Thrombopoietin Receptor Agonists Prior Authorization with Quantity Limit Program Summary
PH-999991000 Androgens and Anabolic Steroids Prior Authorization with Quantity Limit Through Generic Program Summary
PH-999991017 Opioids ER Prior Authorization and Quantity Limit Program Summary
PH-9999991069 Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
PH-99999991002 Biologic Immunomodulators Prior Authorization with Quantity Limit with Preferred Products Program Summary
PH-99999991003 Buprenorphine and Buprenorphine/Naloxone for Opioid Dependence Prior Authorization, Quantity Limit and Concomitant Use of Opioid Products Program Summary