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Content with Policies & Guidelines Final Self-Administered Drug Policies .

Androderm, AndroGel, Fortesta, Natesto, Striant, Testim, testosterone solution, Vogelxo, Jatenzo, Methitest, methyltestosterone capsule, Tlando, Anadrol-50, danazol, Oxandrin, Kyzatrex

print Print Back Back Benlysta (belimumab) Prior Authorization Program Summary Policy Number: PH-1001 This...

Actemra®, Amjevita®, Cimzia®, Cosentyx® , Enbrel®, Humira® , Kevzara® , Kineret® , Olumiant® , Orencia®, Rinvoq™, Siliq™, Simponi® , Skyrizi™ , Sotyktu, Stelara® , Taltz® , Tremfya® , Xeljanz® ,...

print Print Back Back Compounded Medications Prior Authorization Program Summary Policy Number: PH-1004 All...

All Self-Administered Contraceptives

Adlyxin, Byetta, Bydureon, Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza

Berinert, Cinryze, Firazyr, Haegarda, Orladeyo, Ruconest, Takhzyro

Pegasys, PegIntron

Cutaquiq, Cuvitru, Gammagard, Gammaked, Gamunex-C, Hizentra, Hyqvia, Xembify

See Policy for drugs

Otrexup® , RediTrex, Rasuvo®

Mopvantik, Symproic, Trulance, Amitiza, Ibsrela, Linzess, Lubiprostone, Motegrity, Relistor, Movantik, Zelnorm

Belbuca, Butrans, Conzip, Duragesic, fentanyl transdermal patch, Hydrocodone ER, hydromorphone ER, Hysingla ER, Kadian, Morphabond ER, Morphine Sulfate ER, MS Contin, Nucynta ER, Oxycodone ER,...

butorphanol, Codeine, Dilaudid, Levorphanol, Meperidine, Methadose, Methadone, Morphine sulfate, Oxaydo, Roxybond, Roxicodone, Opana, Nucynta, Qdolo, Ultram, Tramadol, Apadaz,...

Otezla

Prudoxin, Zonalon

Afrezza

Ampyra (dalfampridine)

Eliquis®, Pradaxa®, Savaysa®, Xarelto®

Akynzeo, Anzemet, Emend, granisetron, ondansetron ODT, Sancuso, Varubi, Zofran, Zofran ODT, Zuplenz