Cigna National Formulary Policies A-Z Index

Note - Multiple coverage policies may apply based on the customer's benefit plan (for example: prior authorization, step therapy, quantity limitations).

Document Title Product Identifier(s) Document Type Document Size Effective Date
A
Allergen Immunotherapy – Grass Pollen Sublingual Products - Prior Authorization - (CNF297) 109921 PDF 212kB
Allergen Immunotherapy – Odactra® (house dust mite [Dermatophagoides farina and Dermatophagoides pteronyssinus] allergen extract sublingual tablets) - Prior Authorization - (CNF298) 59464 PDF 210kB
Allergen Immunotherapy – Palforzia® (peanut [Arachis hypogaea] allergen powder-dnfp for oral administration) - Prior Authorization - (CNF299) 62115 PDF 214kB
Allergen Immunotherapy – Palforzia - Drug Quantity Management - (CNF202) 108038 PDF 224kB
Allergen Immunotherapy – Ragwitek® (short ragweed pollen allergen extract sublingual tablets) - Prior Authorization - (CNF300) 108943 PDF 224kB
Alpha-Adrenergic Blockers – Doxazosin - Drug Quantity Management - (CNF131) 34632 PDF 190kB
Alpha-Adrenergic Blockers – Terazosin - Drug Quantity Management - (CNF167) 32652 PDF 200kB
Alzheimer's Disease - Step Therapy - (CNF028) 12895 PDF 181kB
Alzheimer's - Namenda / Namenda XR - Step Therapy - (CNF027) 52867 PDF 160kB
Amifampridine Products - Firdapse® (amifampridine tablets), Ruzurgi® (amifampridine tablets) - Prior Authorization - (CNF301) 62867 PDF 221kB
Amyloidosis – Tafamidis Products - Prior Authorization - (CNF302) 109965 PDF 76kB
Amyloidosis – Tegsedi® (inotersen subcutaneous injection) - Prior Authorization - (CNF303) 110139 PDF 173kB
Amyloidosis – Wainua Prior Authorization Policy - (CNF842) PDF 172kB
Angiotensin Receptor Blockers - Step Therapy - (CNF029) 112141 PDF 208kB
Antibiotics (Inhaled) - Arikayce® (amikacin liposome inhalation suspension for oral inhalation) - Prior Authorization - (CNF118) 110270 PDF 190kB
Antibiotics (Inhaled) – Cayston Prior Authorization Policy - (CNF308) 108246 PDF 195kB
Antibiotics (Inhaled) – TOBI® Podhaler (tobramycin inhalation powder) - Prior Authorization - (CNF309) 107634 PDF 170kB
Antibiotics (Inhaled) – Tobramycin Inhalation Solution - Prior Authorization - (CNF310) 107672, 108308 PDF 225kB
Antibiotics (Inhaled) - Tobramycin Products - Preferred Specialty Management - (CNF258) 106938, 107386, 110573 PDF 179kB
Antibiotics – Linezolid (Zyvox), Sivextro - Prior Authorization - (CNF304) 109183 PDF 195kB
Antibiotics – Synercid® (quinupristin and dalfopristin powder for injection) - Prior Authorization - (CNF305) 112237 PDF 178kB
Antibiotics – Vancomycin Capsules (Vancocin®) - Prior Authorization - (CNF306) 108535 PDF 178kB
Anticoagulants - Eliquis® (apixaban tablets) - Prior Authorization - (CNF311) 21835 PDF 259kB
Anticoagulants - Pradaxa® (dabigatran capsule) - Prior Authorization - (CNF312) 12925 PDF 262kB
Anticoagulants - Savaysa® (edoxaban tablet) - Prior Authorization - (CNF313) 50347 PDF 260kB
Anticoagulants – Xarelto® (rivaroxaban tablets and oral suspension) - Prior Authorization - (CNF314) 12924 PDF 272kB
Antidepressants – Bupropion - Drug Quantity Management - (CNF140) 107640 PDF 203kB
Antidepressants - Bupropion Long-Acting - Step Therapy - (CNF030) 107659 PDF 187kB
Antidepressants – Selective Serotonin Reuptake Inhibitors - Drug Quantity Management - (CNF142) 110224, 108999, 109370, 109828, 109692, 109589, 112057, 110306, 110149 PDF 322kB
Antidepressants – Selective Serotonin Reuptake Inhibitors - Step Therapy - (CNF031) 107541 PDF 225kB
Antidepressants – Serotonin and Norepinephrine Reuptake Inhibitors - Drug Quantity Management - (CNF141) 107938, 108237, 111402, 107957, 108855 PDF 343kB
Antidepressants – Serotonin and Norepinephrine Reuptake Inhibitors - Step Therapy - (CNF032) 14753 PDF 265kB
Antiemetics – Doxylamine and Pyridoxine Combination Products - Drug Quantity Management - (CNF187) 108030 PDF 70kB
Antiemetics – Serotonin Receptor Antagonists (Oral and Transdermal) - Drug Quantity Management - (CNF189) 110575, 110183, 109869 PDF 251kB
Antiemetics – Substance P/Neurokinin-1 Receptor Antagonists (Oral) - Drug Quantity Management - (CNF190) 108301, 108623, 109118 PDF 235kB
Antiepileptics - Banzel® (rufinamide tablets and oral suspension) - Prior Authorization - (CNF316) 109530 PDF 216kB
Antiepileptics – Clobazam Products - Onfi® (clobazam tablets and oral suspension ), Sympazan™ (clobazam oral soluble film) - Prior Authorization - (CNF317) 110606 PDF 210kB
Antiepileptics – Depakote/Depakene - Step Therapy - (CNF033) 108565 PDF 161kB
Antiepileptics – Fintepla® (fenfluramine oral solution) - Prior Authorization - (CNF315) 108200 PDF 227kB
Antiepileptics – Lamictal XR - Step Therapy - (CNF034) 12908 PDF 158kB
Antiepileptics – Levetiracetam, Brivaracetam - Step Therapy - (CNF035) 12909 PDF 168kB
Antiepileptics -  Nayzilam® (midazolam nasal spray) - Prior Authorization - (CNF320) 108650 PDF 198kB
Antiepileptics – Oxtellar XR, Trileptal - Step Therapy - (CNF036) 107965 PDF 158kB
Antiepileptics - Sabril® (vigabatrin tablets and powder for solution) - Prior Authorization - (CNF321) 109163 PDF 218kB
Antiepileptics – Valtoco® (diazepam nasal spray) - Prior Authorization - (CNF706) 79950 PDF 197kB
Antiepileptics – Xcopri® (cenobamate tablets) - Drug Quantity Management - (CNF252) 109033 PDF 180kB
Antiepileptics – Zonisamide - Step Therapy - (CNF779) 113157 PDF 173kB
Antiepileptics – Ztalmy® (ganaxolone oral suspension) - Prior Authorization - (CNF761) 110203 PDF 87kB
Antifungals – Cresemba® Oral (isavuconazonium sulfate capsules) - Prior Authorization - (CNF323) 108088 PDF 188kB
Antifungals – Fluconazole (Oral) Drug Quantity Management Policy – Per Rx - (CNF145) 106902 PDF 187kB
Antifungals – Flucytosine Prior Authorization Policy - (CNF797) PDF 184KB
Antifungals for Vulvovaginal Candidiasis - Step Therapy - (CNF711) 97516 PDF 178kB
Antifungals – Itraconazole - Drug Quantity Management - (CNF173) 108311 PDF 226kB
Antifungals – Noxafil® Oral (posaconazole delayed-release tablets [generics], oral suspension, PowderMix for delayed-release oral suspension) - Prior Authorization - (CNF324) 109035 PDF 226kB
Antifungals - Tolsura™ (itraconazole capsules) - Prior Authorization - (CNF325) 108160 PDF 185kB
Antifungals – Vivjoa™ (oteseconazole capsules) - Prior Authorization - (CNF772) 111308 PDF 200kB
Antifungals – Voriconazole (Oral) - Prior Authorization - (CNF326) 108078 PDF 232kB
Anti-Influenza – Oseltamivir Drug Quantity Management Policy – Per Rx - (CNF227) 107952 PDF 192kB
Anti-Influenza – Relenza Drug Quantity Management Policy – Per Rx - (CNF207) 108434 PDF 165kB
Antiseizure Medications – Diacomit® (stiripentol capsules and powder for oral suspension) - Prior Authorization - (CNF318) 65463 PDF 254kB
Antiseizure Medications – Epidiolex® (cannabidiol oral solution) - Prior Authorization - (CNF319) 110619 PDF 272kB
Antiseizure Medications – Topiramate - Step Therapy - (CNF037) 52014 PDF 223kB
Antiseizure Medications – Vigabatrin - Drug Quantity Management - (CNF786) 131858 PDF 786kB
Antiseizure Medications – Vimpat® (lacosamide tablets and oral solution, generic) - Step Therapy - (CNF738) 103546 PDF 191kB
Antivirals – Famciclovir tablets (generic only) - Drug Quantity Management - (CNF157) 108851 PDF 222kB
Antivirals – Ribavirin (Inhaled Products) - Prior Authorization - (CNF760) 110217 PDF 188kB
Antivirals – Ribavirin (Oral Products) - Prior Authorization - (CNF396) 108928 PDF 233kB
Antivirals – Valacyclovir tablets (Valtrex®) - Drug Quantity Management - (CNF245) 107340 PDF 300kB
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications - Step Therapy - (CNF024) 109131 PDF 132kB
Attention Deficit Hyperactivity Disorder Stimulant Medications - Step Therapy - (CNF025)

110925 PDF 176kB
B
Benign Prostatic Hyperplasia – 5-Alpha-Reductase Inhibitors - Step Therapy - (CNF039) 109798 PDF 67kB
Benign Prostatic Hyperplasia – Alpha Blockers - Step Therapy - (CNF026) 109501 PDF 164kB
Benign Prostatic Hyperplasia – Entadfi™ (finasteride and tadalafil capsules) - Prior Authorization - (CNF750) 109762 PDF 62kB
Beta Blocker - Step Therapy - (CNF040) 109697 PDF 232kB
Bile Acid Sequestrants - Step Therapy - (CNF041) 109278 PDF 177kB
Bisphosphonates (Oral) Enhanced - Step Therapy - (CNF043) 109528, 111675 PDF 179kB
Bone Modifiers – Teriparatide Drug Quantity Management Policy – Per Days - (CNF231) 108045 PDF 173kB
Bone Modifiers – Teriparatide Products - Prior Authorization - (CNF328) 110530 PDF 239kB
Bone Modifiers – Tymlos® (abaloparatide subcutaneous injection) - Prior Authorization - (CNF329) 62840 PDF 217kB
Bone Modifiers – Xgeva® (denosumab subcutaneous injection) - Drug Quantity Management - (CNF736) 109126 PDF 159kB
Bowel Disease – Lubiprostone capsules (Amitiza®, generic) - Drug Quantity Management - (CNF121) 107982 PDF 203kB
Bowel Disease - Opioid-Induced Constipation - Preferred Step Therapy - (CNF086) 110045 PDF 198kB
Brand Name Products with Bioequivalent Generics - (CNF001)

various PDF 224kB
C
Cabergoline Drug Quantity Management Policy – Per Days - (CNF148) 108000 PDF 175kB
Calcitonin Gene-Related Peptide Inhibitors – Aimovig® (erenumab injection for subcutaneous use) - Prior Authorization - (CNF331) 110320 PDF 234kB
Calcitonin Gene-Related Peptide Inhibitors – Aimovig - Drug Quantity Management - (CNF122) 107362 PDF 176kB
Calcitonin Gene-Related Peptide Inhibitors – Ajovy® (Fremanezumab-vfrm injection for subcutaneous use) - Prior Authorization - (CNF332) 110315 PDF 253kB
Calcitonin Gene-Related Peptide Inhibitors – Emgality® (galcanezumab-gnlm injection for subcutaneous use) - Prior Authorization - (CNF333) 110355 PDF 235kB
Calcitonin Gene-Related Peptide Inhibitors – Emgality - Drug Quantity Management - (CNF150) 111398 PDF 213kB
Calcium Channel Blockers – Dihydropyridine Products - Step Therapy - (CNF044) 109009 PDF 238kB
Calcium Channel Blockers – Verapamil Products - Step Therapy - (CNF045) 108173 PDF 184kB
Carbinoxamine - Step Therapy - (CNF046) 107240 PDF 180kB
Cardiology – Camzyos™ (mavacamten capsules) - Prior Authorization - (CNF745) 110364 PDF 236kB
Cardiology – Corlanor® (ivabradine tablets and oral solution) - Prior Authorization - (CNF335) 108139 PDF 2513kB
Cardiology – Lodoco Prior Authorization Policy - (CNF798) PDF 163kB
Cardiology – Ranolazine Products Step Therapy Policy - (CNF785) 122797 PDF 153kB
Cardiology – Verquvo™ (vericiguat tablets) - Drug Quantity Management - (CNF660) 108050 PDF 173kB
Cardiology - Zontivity (vorapaxar tablets) - Prior Authorization - (CNF644) 110165 PDF 87kB
Chelating Agents – Chemet® (succimer capsules) - Prior Authorization - (CNF336) 107794 PDF 224kB
Chelating Agents – Iron Chelators (Oral) Preferred Specialty Management Policy - (CNF666) 111878, 107796 PDF 197kB
Chelating Agents - Iron Chelators (Oral) - Prior Authorization - (CNF337) 110201 PDF 225kB
Chelating Agents – Penicillamine Products - Prior Authorization - (CNF338) 110457 PDF 186kB
Chelating Agents – Syprine® (trientine hydrochloride capsules, generics) - Prior Authorization - (CNF339) 109684 PDF 179kB
Chenodal™ (chenodiol tablets) - Prior Authorization - (CNF340) 109190 PDF 179kB
Cholbam® (cholic acid capsules) - Prior Authorization - (CNF341) 108779 PDF 211kB
Chorionic Gonadotropins - Drug Quantity Management - (CNF164) 109214 PDF 213kB
Chorionic Gonadotropins - Preferred Specialty Management - (CNF259) 110941 PDF 206kB
Cinacalcet tablets (Sensipar®) - Prior Authorization - (CNF342) 02057 PDF 185kB
Colchicine Products Preferred Step Therapy - (CNF087) 108356 PDF 123kB
Colony Stimulating Factors - Pegfilgrastim Products - Preferred Specialty Management - (CNF266) 108763, 110130  PDF 183kB
Colony Stimulating Factors – Pegfilgrastim Products - Prior Authorization - (CNF346) 64509 PDF 217kB
Complement Inhibitors – Fabhalta Prior Authorization Policy - (CNF836) PDF 164kB
Complement Inhibitors – Zilbrysq Prior Authorization Policy - (CNF824) PDF 182kB
Contraceptives – Oral, Patch, and Vaginal Ring Products - Step Therapy - (CNF047) 111258 PDF 308kB
Coronavirus – Oral Medications for Treatment of Coronavirus Disease 2019 (COVID-19) - Drug Quality Management Policies - (CNF744) 110198, 109875 PDF 250kB
Corticosteroids (Nasal) – Mometasone Drug Quantity Management Policy – Per Rx - (CNF186) 110305 PDF 159kB
Corticosteroids (Nebulized) – Budesonide - Drug Quantity Management - (CNF206) 40472 PDF 206kB
Cushing’s Disease – Isturisa® (osilodrostat tablets) - Drug Quantity Management - (CNF172) 108074 PDF 174kB
Cushing’s - Isturisa® (osilodrostat tablets) - Prior Authorization - (CNF349) 109367 PDF 210kB
Cushing’s – Korlym® (mifepristone 300 mg tablets) - Prior Authorization - (CNF350) 109181 PDF 214kB
Cushing’s – Recorlev® (levoketoconazole tablets) - Prior Authorization - (CNF732) 109117 PDF 237kB
Cushing’s - Signifor™ (pasireotide injection) - Prior Authorization - (CNF351) 109698 PDF 207kB
Cycloxygenase-2 Inhibitor - Celebrex® (celecoxib capsules – generic) - Step Therapy - (CNF048) 109120 PDF 213kB
Cystic Fibrosis – Bronchitol® (mannitol inhalation powder, for oral inhalation - Prior Authorization - (CNF659) 64749 PDF 214kB
Cystic Fibrosis – Kalydeco® (ivacaftor tablets and oral granules) - Prior Authorization - (CNF352) 35724 PDF 252kB
Cystic Fibrosis – Orkambi™ (lumacaftor/ivacaftor tablets and oral granules) - Prior Authorization - (CNF353) 51674 PDF 225kB
Cystic Fibrosis – Pulmozyme® (dornase alfa inhalation solution) - Prior Authorization - (CNF354) 109513 PDF 67kB
Cystic Fibrosis – Symdeko® (tezacaftor/ivacaftor and ivacaftor tablets) - Prior Authorization - (CNF355) 60968 PDF 240kB
Cystic Fibrosis – Trikafta Drug Quantity Management Policy – Per Rx - (CNF837) 109603 PDF 179kB
Cystic Fibrosis – Trikafta™ (elexacaftor/tezacaftor/ivacaftor tablets; ivacaftor tablets, co-packaged) - Prior Authorization - (CNF356)

108868 PDF 256kB
D
Dermatology – Hyftor™ (sirolimus 0.2% topical gel) - Prior Authorization - (CNF751) 110247 PDF 91kB
Dermatology – Opzelura® (ruxolitinib 1.5% cream) - Prior Authorization - (CNF704) 110973 PDF 262kB
Dermatology – Vtama® (tapinarof 1% cream) - Drug Quantity Management - (CNF756) 109857 PDF 181kB
Dermatology – Zoryve Drug Quantity Management Policy – Per Days - (CNF765) 111265 PDF 194kB
Desmopressin Products - Nocdurna® (desmopressin acetate sublingual tablets [27.7 mcg and 55.3 mcg]) - Prior Authorization - (CNF358) 109153 PDF 216kB
Desmopressin Products – Noctiva™ (desmopressin acetate nasal spray [0.83 mcg/0.1 mL and 1.66 mcg/0.1 mL]) - Prior Authorization - (CNF359) 109797 PDF 179kB
Diabetes – Canagliflozin Products - Drug Quantity Management - (CNF758) 110245 PDF 210kB
Diabetes – Continuous Glucose Monitoring Systems - Prior Authorization - (CNF676) 106841 PDF 179kB
Diabetes – Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy - (CNF049) 110714 PDF 180kB
Diabetes – Glucagon-Like Peptide-1 Agonists - Prior Authorization - (CNF360) 109521 PDF 187kB
Diabetes – Kerendia™ (finerenone tablets) - Prior Authorization - (CNF691) 108296 PDF 247kB
Diabetes – Metformin Extended-Release - Drug Quantity Management - (CNF181) 111158 PDF 177kB
Diabetes - Metformin - Step Therapy - (CNF050) 111457 PDF 162kB
Diabetes – Mounjaro™ (tirzepatide subcutaneous injection) - Prior Authorization - (CNF749) 110248 PDF 191kB
Diabetes – Omnipod Pods Drug Quantity Management Policy – Per Days - (CNF776) 112397 PDF 174kB
Diabetes – Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy - (CNF051) 107317 PDF 206kB
Diabetes - Sodium Glucose Co-Transporter-2 Inhibitors - Step Therapy - (CNF072) 108628 PDF 191kB
Diabetes – Symlin® (pramlintide subcutaneous injection) - Prior Authorization - (CNF361) 109258 PDF 172kB
Diabetes - Thiazolidinedione - Step Therapy - (CNF052) 110164 PDF 182kB
Dichlorphenamide Preferred Specialty Management Policy - (CNF829) PDF 115kB
Dichlorphenamide Prior Authorization Policy - (CNF455) 53193, 65900 PDF 184kB
Diuretics – Loop Products - Step Therapy - (CNF753) 108041, 106772 PDF 172kB
Dronabinol - Marinol® (dronabinol capsules), Syndros® (dronabinol oral solution) - Prior Authorization - (CNF362)

109771 PDF 139kB
E
Enspryng™ (satralizumab-mwge for subcutaneous injection) - Prior Authorization - (CNF388) 108579 PDF 215kB
Enzyme Replacement Therapy - Strensiq® (asfotase alfa for subcutaneous use) - Prior Authorization - (CNF364) 110058 PDF 200kB
Enzyme Replacement Therapy – Sucraid® (sacrosidase oral solution) - Prior Authorization - (CNF365) 108433 PDF 199kB
Epinephrine Auto-Injectors - Step Therapy - (CNF053) 58110 PDF 177kB
Erectile Dysfunction Agents - Drug Quantity Management - (CNF155) 31072, 31112, 36934, 31093 PDF 250kB
Erectile Dysfunction – Alprostadil Products - Prior Authorization - (CNF366) 109027 PDF 169kB
Erectile Dysfunction – Stendra Prior Authorization Policy - (CNF369) 109506 PDF 148kB
Erectile Dysfunction – Tadalafil Prior Authorization - (CNF367) 110572 PDF 212kB
Erectile Dysfunction – Vardenafil (Levitra, Staxyn) - Prior Authorization - (CNF368) 109215 PDF 177kB
Erectile Dysfunction – Viagra® (sildenafil tablets) - Prior Authorization - (CNF370) 109355 PDF 186kB
Estrogen (Topical) Patches - Drug Quantity Management - (CNF156) 111784 PDF 200kB
Estrogens (Topical) – Divigel® (estradiol 0.1% topical gel, generic) - Drug Quantity Management - (CNF146) 108021 PDF 183kB
Estrogen – Transdermal - Step Therapy Policy - (CNF0094)

PDF 167kB
F
Fabry Disease - Galafold (migalastat capsules) - Prior Authorization - (CNF374) 109964 PDF 89kB
Fenofibrate - Step Therapy - (CNF054) 109096 PDF 199kB
Flurandrenolide Topical Products Duration Limit - Drug Quantity Management - (CNF161)

109031 PDF 185kB
G
Gabapentin - Step Therapy - (CNF055) 108945 PDF 115kB
Gastroenterology - Gattex (teduglutide injection for subcutaneous use) - Prior Authorization - (CNF375) 109080 PDF 211kB
Gaucher Disease Substrate Reduction Therapy – Cerdelga® (eliglustat capsules) - Prior Authorization - (CNF376) 108573 PDF 215kB
Gaucher Disease Substrate Reduction Therapy – Miglustat capsules (Zavesca®, generic) - Prior Authorization - (CNF377) 107843 PDF 196kB
Gaucher Disease - Substrate Reduction Therapy - Preferred Specialty Management - (CNF263) 108524, 109286 PDF 181kB
Gonadotropin-Releasing Hormone Agonist – Synarel® (nafarelin acetate nasal solution) - Prior Authorization - (CNF417) 90003 PDF 127kB
Gonadotropin-Releasing Hormone Antagonists – Myfembree® (relugolix, estradiol, and norethindrone acetate tablets) - Prior Authorization - (CNF679) 110458 PDF 209kB
Gonadotropin-Releasing Hormone Antagonists – Oriahnn™ (elagolix, estradiol, and norethindrone acetate capsules; elagolix capsules) - Prior Authorization - (CNF382) 108744 PDF 210kB
Gonadotropin-Releasing Hormone Antagonists – Orilissa™ (elagolix tablets) - Drug Quantity Management - (CNF199) 110154 PDF 60kB
Gonadotropin-Releasing Hormone Antagonists – Orilissa™ (elagolix tablets) - Prior Authorization - (CNF381) 107200 PDF 172kB
Gout Medications - Step Therapy - (CNF056) 107669 PDF 174kB
Growth Disorders – Growth hormone [somatropin] - Prior Authorization - (CNF384) 111268 PDF 356kB
Growth Disorders – Growth Hormone Long-Acting Products Preferred Specialty Management Policy - (CNF818_ PDF 170kB
Growth Disorders – Increlex® (mecasermin [rDNA origin] for subcutaneous injection) - Prior Authorization - (CNF383) 110212 PDF 194kB
Growth Disorders – Ngenla Prior Authorization Policy - (CNF800) PDF 193kB
Growth Disorders – Skytrofa Prior Authorization Policy - (CNF707) 110938 PDF 243kB
Growth Disorders – Sogroya Prior Authorization Policy - (CNF799) PDF 235kB
Growth Disorders – Voxzogo Prior Authorization Policy - (CNF714) 92202 PDF 220kB
Growth Hormone - Preferred Specialty Management - (CNF265)

111686, 108517, 15504, 79819 PDF 186kB
H
Hematology – Pyrukynd® (mitapivat tablets) - Drug Quantity Management - (CNF737) 110199 PDF 184kB
Hematology – Pyrukynd® (mitapivat tablets) - Prior Authorization - (CNF735) 110353 PDF 237kB
Hemophilia - Hemlibra® (emicizumab-kxwh injection for subcutaneous use) - Prior Authorization - (CNF391) 110647 PDF 239kB
Hepatitis C – Epclusa® (velpatasvir/sofosbuvir tablets) - Prior Authorization - (CNF392) 108874 PDF 266kB
Hepatitis C – Epclusa - Drug Quantity Management - (CNF152) 108361 PDF 241kB
Hepatitis C - Harvoni® (ledipasvir/sofosbuvir tablets and oral pellets) - Prior Authorization - (CNF393) 108804 PDF 301kB
Hepatitis C – Harvoni - Drug Quantity Management - (CNF163) 107992 PDF 290kB
Hepatitis C – Mavyret® (glecaprevir/pibrentasvir tablets and oral pellets) - Drug Quantity Management - (CNF179) 59875 PDF 264kB
Hepatitis C – Mavyret® (glecaprevir/pibrentasvir tablets and oral pellets) - Preferred Specialty Management - (CNF119) 112319 PDF 264kB
Hepatitis C - Mavyret™ (glecaprevir/pibrentasvir tablets and oral pellets) - Prior Authorization - (CNF394) 111064 PDF 242kB
Hepatitis C – Sovaldi® (sofosbuvir tablets and oral pellets) - Drug Quantity Management - (CNF218) 109892 PDF 260kB
Hepatitis C - Sovaldi® (sofosbuvir tablets and oral pellets) - Prior Authorization - (CNF397) 107697 PDF 242kB
Hepatitis C – Viekira Pak™ (ombitasvir/paritaprevir/ritonavir tablets; dasabuvir tablets [co-packaged]) - Prior Authorization - (CNF398) 110937 PDF 248kB
Hepatitis C – Viekira Pak™ (ombitasvir/paritaprevir/ritonavir tablets; dasabuvir tablets [co-packaged] - Drug Quantity Management - (CNF249) 108895 PDF 232kB
Hepatitis C Virus Direct-Acting Antivirals - Preferred Specialty Management - (CNF268) 65815, 65816, 65818, 65819, 65820, 65821, 65822, 65823 PDF 345kB
Hepatitis C – Vosevi® (sofosbuvir/velpatasvir/voxilaprevir tablets) - Prior Authorization - (CNF399) 108984 PDF 244kB
Hepatitis C – Zepatier® (grazoprevir/elbasvir tablets) - Drug Quantity Management - (CNF256) 110218 PDF 205kB
Hepatitis C – Zepatier® (grazoprevir/elbasvir tablets) - Prior Authorization - (CNF400) 65808 PDF 232kB
Hepatology – Bylvay Drug Quantity Management Policy – Per Rx - (CNF697) 109151 PDF 191kB
Hepatology – Bylvay™ (odevixibat capsules and oral pellets) - Prior Authorization - (CNF690) 110135 PDF 235kB
Hepatology – Livmarli Prior Authorization Policy - (CNF703) 9110354 PDF 461kB
Hepatology – Ocaliva® (obeticholic acid tablets) - Prior Authorization - (CNF401) 108092 PDF 223kB
Hereditary Angioedema – Berinert and Cinryze - Drug Quantity Management - (CNF787) 132017 PDF 243kB
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) - Haegarda® (C1 esterase inhibitor [human] subcutaneous injection) - Prior Authorization - (CNF403) 108981 PDF 221kB
Hereditary Angioedema – Haegarda - Drug Quantity Management - (CNF788) 132018 PDF 211kB
Hereditary Angioedema – Icatibant - Drug Quantity Management - (CNF789) 132019 PDF 205kB
Hereditary Angioedema - Icatibant - Preferred Specialty Management - (CNF270) 108299, 109193 PDF 200kB
Hereditary Angioedema – Icatibant - Prior Authorization - (CNF404) 108946 PDF 224kB
Hereditary Angioedema – Kalbitor - Drug Quantity Management - (CNF790) 132020 PDF 200kB
Hereditary Angioedema - Orladeyo™ (berotralstat capsules) - Prior Authorization - (CNF647) 79815, 79818 PDF 254kB
Hereditary Angioedema – Ruconest - Drug Quantity Management - (CNF791) 132021 PDF 181kB
Hereditary Angioedema - Takhzyro™ (lanadelumab-flyo for subcutaneous injection) - Prior Authorization - (CNF406) 110219 PDF 244kB
Homozygous Familial Hypercholesterolemia – Evkeeza™ (evinacumab-dgnb injection for intravenous use) - Prior Authorization - (CNF665) 107795 PDF 261kB
Homozygous Familial Hypercholesterolemia - Juxtapid® (lomitapide capsules) - Prior Authorization - (CNF408) 107740 PDF 252kB
Human Immunodeficiency Virus – Apretude® (cabotegravir intramuscular injection) - Prior Authorization - (CNF718) 109144 PDF 261kB
Human Immunodeficiency Virus – Rukobia™ (fostemsavir extended-release tablets) - Prior Authorization - (CNF409) 108321 PDF 213kB
Human Immunodeficiency Virus – Sunlenca® (lenacapavir tablets) - Prior Authorization - (CNF783) 92244 PDF 261kB
Hydrocortisone Acetate Suppository - Step Therapy - (CNF057) 58663 PDF 175kB
Hydroxy-methylglutaryl-coenzyme (HMG) A Reductase Inhibitors - Step Therapy - (CNF058) 14742 PDF 240kB
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors Drug Quantity Management Policy – Per Rx - (CNF165) 110497 PDF 241kB
Hyperlipidemia – Nexletol Prior Authorization Policy - (CNF410) 105652 PDF 257kB
Hyperlipidemia – Nexlizet™ (bempedoic acid and ezetimibe tablets) - Prior Authorization - (CNF411) 110280 PDF 277kB
Hyperlipidemia – Omega-3 Fatty Acid Products - Prior Authorization - (CNF412) 106919 PDF 254kB
Hypertension – Clonidine patch (Catapres TTS, generic) - Drug Quantity Management - (CNF132) 111513 PDF 172kB
Hypoactive Sexual Desire Disorder – Addyi™ (flibanserin tablets) - Prior Authorization - (CNF413) 52274 PDF 201kB
Hypoactive Sexual Desire Disorder – Vyleesi™ (bremelanotide subcutaneous injection) - Prior Authorization - (CNF414)

64750 PDF 199kB
I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev® (nintedanib capsules) - Prior Authorization - (CNF416) 108136 PDF 262kB
Idiopathic Pulmonary Fibrosis and Related Lung Disease – Pirfenidone - Preferred Specialty Management - (CNF754) 106916, 106917 PDF 182kB
Idiopathic Pulmonary Fibrosis and Related Lung Disease – Pirfenidone - Prior Authorization - (CNF415) 111388 PDF 106kB
Immune Disorder - Joenja Prior Authorization Policy - (CNF801) PDF 216kB
Immunologicals – Adbry® (tralokinumab-ldrm subcutaneous injection) - Prior Authorization - (CNF721) 79773 PDF 194kB
Immunologicals – Adbry™ (tralokinumab-ldrm subcutaneous injection) - Drug Quality Management Policies - (CNF717) 101657 PDF 174kB
Immunologicals - Anti-Interleukin-5 Agents - Preferred Specialty Management - (CNF276) 110559, 110221 PDF 201kB
Immunologicals – Dupixent® (dupilumab subcutaneous injection) - Drug Quantity Management - (CNF149) 109895 PDF 220kB
Immunologicals – Dupixent® (dupilumab subcutaneous injection) - Prior Authorization - (CNF420) 106939 PDF 264kB
Immunologicals – Fasenra® (benralizumab subcutaneous injection) - Drug Quantity Management - (CNF764) 111458 PDF 196kB
Immunologicals – Fasenra™ (benralizumab injection for subcutaneous use) - Prior Authorization - (CNF421) 110221 PDF 235kB
Immunologicals – Nucala® (mepolizumab subcutaneous injection) - Drug Quantity Management - (CNF192) 108853 PDF 212kB
Immunologicals – Nucala® (mepolizumab subcutaneous injection) - Prior Authorization - (CNF422) 107445 PDF 354kB
Immunologicals – Tezspire™ (tezepelumab-ekko subcutaneous injection) - Prior Authorization - (CNF720) 92236 PDF 230kB
Immunologicals – Xolair® (omalizumab subcutaneous injection) - Drug Quantity Management - (CNF651) 91127 PDF 316kB
Immunologicals – Xolair® (omalizumab subcutaneous injection) - Prior Authorization - (CNF423) 106799 PDF 303kB
Immunosuppressive Agents – Rezurock™ (belumosudil tablets) - Drug Quantity Management Policy - (CNF694) 109263 PDF 198kB
Immunosuppressive Agents – Rezurock™ (belumosudil tablets) - Prior Authorization - (CNF692) 108638 PDF 200kB
Infectious Disease – Antiparasitics Drug Quantity Management Policy – Per Days - (CNF204) 108457 PDF 306kB
Infectious Disease – Daraprim® (pyrimethamine tablets) - Prior Authorization - (CNF424) 109500 PDF 165kB
Infectious Disease – Impavido® (miltefosine capsules) - Prior Authorization -(CNF327) 107399 PDF 229kB
Infectious Disease – Livtencity™ (maribavir tablets) - Drug Quantity Management - (CNF734) 100751 PDF 220kB
Infectious Disease – Livtencity™ (maribavir tablets) - Prior Authorization - (CNF713) 110159 PDF 207kB
Infectious Disease – Pretomanid tablets - Prior Authorization - (CNF425) 110051 PDF 160kB
Infectious Disease – Prevymis Drug Quantity Management Policy – Per Days - (CNF205) 108631 PDF 174kB
Infectious Disease – Sirturo® (bedaquiline fumarate) - Prior Authorization - (CNF330) 110101 PDF 165kB
Infectious Disease – Stromectol® (ivermectin tablets, generic) - Prior Authorization - (CNF698) 109243 PDF 201kB
Infectious Disease – Vancomycin (Oral) - Drug Quantity Management - (CNF246) 79216 PDF 208kB
Infertility - Follitropins/Clomiphene - Preferred Specialty Management - (CNF277) 15005 PDF 213kB
Infertility - Gonadotropin-Releasing Hormone Antagonists - Preferred Specialty Management - (CNF264) 108654 PDF 174kB
Inflammatory Conditions – Actemra (tocilizumab for subcutaneous injection) - Prior Authorization - (CNF427) 36852 PDF 150kB
Inflammatory Conditions – Adalimumab Products Drug Quantity Management Policy – Per Days - (CNF166) PDF 292kB
Inflammatory Conditions – Adalimumab Products – Humira® (adalimumab for subcutaneous injection) - Prior Authorization - (CNF428 12957 PDF 333kB
Inflammatory Conditions – Adalimumab Products Preferred Specialty Management Policy for National Preferred Formularies – Choice - (CNF828) PDF 183kB
Inflammatory Conditions – Arcalyst® (rilonacept for subcutaneous injection) - Prior Authorization - (CNF429) 107678 PDF 250kB
Inflammatory Conditions – Arcalyst Drug Quantity Management Policy – Per Days - (CNF695) 96907 PDF 166kB
Inflammatory Conditions – Benlysta® (belimumab subcutaneous injection) - Prior Authorization - (CNF430) 108156 PDF 267kB
Inflammatory Conditions – Bimzelx Drug Quantity Management Policy – Per Days - (CNF839) PDF 163kB
Inflammatory Conditions – Bimzelx Prior Authorization Policy - (CNF823) PDF 194kB
Inflammatory Conditions – Cibinqo® (abrocitinib tablets) - Prior Authorization - (CNF733) 79774 PDF 244kB
Inflammatory Conditions – Cimzia® (certolizumab pegol for subcutaneous injection [lyophilized powder or solution]) - Prior Authorization - (CNF431) 107363 PDF 309kB
Inflammatory Conditions – Cimzia Drug Quantity Management Policy – Per Days - (CNF133) PDF 168kB
Inflammatory Conditions – Cosentyx® (secukinumab for subcutaneous injection) - Prior Authorization - (CNF432) 50207 PDF 252kB
Inflammatory Conditions – Cosentyx Subcutaneous Drug Quantity Management Policy – Per Days - (CNF139) 110197 PDF 211kB
Inflammatory Conditions – Entyvio Subcutaneous Prior Authorization Policy - (CNF817) PDF
Inflammatory Conditions – Etanercept Products Drug Quantity Management Policy – Per Days - (CNF151) PDF 193kB
Inflammatory Conditions – Etanercept Products Prior Authorization - (CNF434) 111175 PDF 337kB
Inflammatory Conditions – Ilumya Drug Quantity Management Policy – Per Days - (CNF168) PDF 155kB
Inflammatory Conditions – Ilumya™ (tildrakizumab-asmn for subcutaneous injection) - Prior Authorization - (CNF436) 107681 PDF 280kB
Inflammatory Conditions – Kevzara™ (sarilumab for subcutaneous injection) - Prior Authorization - (CNF438) 108749 PDF 205kB
Inflammatory Conditions – Kineret® (anakinra for subcutaneous injection) - Prior Authorization - (CNF439) 112318 PDF 117kB
Inflammatory Conditions – Kineret Drug Quantity Management Policy – Per Days - (CNF175) PDF 178kB
Inflammatory Conditions – Litfulo Prior Authorization Policy - (CNF802) PDF 168kB
Inflammatory Conditions – Olumiant® (baricitinib tablets) - Drug Quantity Management - (CNF763) 108208 PDF 214kB
Inflammatory Conditions – Olumiant® (baricitinib tablets) - Prior Authorization - (CNF440) 110727 PDF 242kB
Inflammatory Conditions – Omvoh Subcutaneous Prior Authorization Policy - (CNF821) PDF 229kB
Inflammatory Conditions – Orencia® Subcutaneous (abatacept subcutaneous injection) - Prior Authorization - (CNF442) 108787 PDF 268kB
Inflammatory Conditions – Otezla® (apremilast tablets) - Prior Authorization - (CNF443) 109527 PDF 293kB
Inflammatory Conditions – Otezla Drug Quantity Management Policy – Per Days - (CNF200) PDf 168kB
Inflammatory Conditions Preferred Specialty Management Policy for Cigna National Formulary - (CNF278) 03235, 13813, 36993, 03243, 20451, 03770, 47192, 55876, 57285, 59235, 62900, 64754, 58611, 56160, 13818, 57297, 59232, 59259, 60875, 94839, 92279 PDF 587kB
Inflammatory Conditions – Rinvoq® (upadacitinib extended-release tablets) - Prior Authorization - (CNF444) 65808 PDF 301kB
Inflammatory Conditions – Rinvoq Drug Quantity Management Policy – Per Days - (CNF727) 104122 PDF 185kB
Inflammatory Conditions – Siliq Drug Quantity Management Policy – Per Days - (CNF212) PDF 159kB
Inflammatory Conditions – Siliq™ (brodalumab for subcutaneous injection) - Prior Authorization - (CNF445) 108120 PDF 260kB
Inflammatory Conditions – Simponi® (golimumab for subcutaneous injection) - Prior Authorization - (CNF447) 107593 PDF 289kB
Inflammatory Conditions – Simponi Aria® (golimumab injection for intravenous use) - Prior Authorization - (CNF446) 13011, 15402 PDF 234kB
Inflammatory Conditions – Simponi Subcutaneous Drug Quantity Management Policy – Per Days - (CNF214) PDF 165kB
Inflammatory Conditions – Skyrizi Subcutaneous Drug Quantity Management Policy – Per Days - (CNF215) PDF 172kB
Inflammatory Conditions – Skyrizi™ (risankizumab-rzaa subcutaneous injection) - Prior Authorization - (CNF448) 108782 PDF 124kB
Inflammatory Conditions – Sotyktu™ (deucravacitinib tablets) - Prior Authorization - (CNF775) 112398 PDF 260kB
Inflammatory Conditions – Stelara® (ustekinumab intravenous infusion) - Prior Authorization - (CNF449) 109766, 109799 PDF 271kB
Inflammatory Conditions – Stelara® Subcutaneous (ustekinumab subcutaneous injection) with Dosing - Prior Authorization - (CNF450) 111399 PDF 328kB
Inflammatory Conditions – Stelara Drug Quantity Management Policy – Per Days - (CNF222) 62237 PDF 183kB
Inflammatory Conditions – Taltz® (ixekizumab for subcutaneous injection) - Prior Authorization - (CNF451) 110131 PDF 234kB
Inflammatory Conditions – Tremfya Drug Quantity Management Policy – Per Days - (CNF240) 79962 PDF 157kB
Inflammatory Conditions – Tremfya™ (guselkumab for subcutaneous injection) - Prior Authorization - (CNF452) 109186 PDF 243kB
Inflammatory Conditions – Velsipity Prior Authorization Policy - (CNF822) PDF 193kB
Inflammatory Conditions – Xeljanz®/Xeljanz XR (tofacitinib tablets, oral solution/extended-release tablets) - Prior Authorization - (CNF453) 110635 PDF 298kB
Inpefa Prior Authorization Policy - (CNF803) PDF 203kB
Interferon – Actimmune® (interferon gamma-1b subcutaneous injection) - Prior Authorization - (CNF454) 111767 PDF 190kB
Isotretinoin Capsules - Step Therapy - (CNF059) 107695 PDF 177kB
Ixekizumab injection (Taltz®) Duration Limit - Drug Quantity Management - (CNF226)

108059 PDF 211kB
L
Levothyroxine Products - Step Therapy Policy - (CNF834) PDF 131kB
Lidocaine Patch - Prior Authorization - (CNF456) 109280 PDF 249kB
Lipodystrophy – Egrifta SV® (tesamorelin subcutaneous injection) - Prior Authorization - (CNF457) 110521 PDF 244kB
Lipodystrophy – Myalept® (metreleptin subcutaneous injection) - Prior Authorization - (CNF487) 109090 PDF 78kB
Lucemyra™ (lofexidine tablets) - Prior Authorization - (CNF458) 108268 PDF 182kB
Lupkynis™ (voclosporin capsules) - Prior Authorization - (CNF656) 107941 PDF 111kB
Lupus – Benlysta® (belimumab subcutaneous injection) - Drug Quantity Management - (CNF766)

111201 PDF 203kB
M
Metabolic Disorders – Carbaglu (carglumic acid tablets for oral suspension) - Prior Authorization - (CNF460) 108697 PDF 241kB
Metabolic Disorders – Cystadane® (betaine anhydrous powder, generic) - Preferred Specialty Management - (CNF773) 111463, 111263 PDF 170kB
Metabolic Disorders – Cystadane® (betaine anhydrous powder, generic) - Prior Authorization - (CNF770) 111297 PDF 194kB
Metabolic Disorders – Cysteamine Ophthalmic Solution - Prior Authorization - (CNF461) 107716 PDF 197kB
Metabolic Disorders – Dojolvi™ (triheptanoin oral liquid) - Prior Authorization - (CNF463) 108340 PDF 68kB
Metabolic Disorders – Imcivree - Drug Quantity Management - (CNF664) 108633 PDF 664kB
Metabolic Disorders – Imcivree Prior Authorization Policy - (CNF654) 94306 PDF 237kB
Metabolic Disorders – Nitisinone Products - Prior Authorization - (CNF464) 110239 PDF 199kB
Metabolic Disorders – Phenylbutyrate Products Preferred Specialty Management Policy - (CNF820) PDF 185kB
Metabolic Disorders – Phenylbutyrate Products - Prior Authorization - (CNF465) 107839 PDF 204kB
Metabolic Disorders – Primary Hyperoxaluria Medications – Rivfloza Prior Authorization Policy - (CNF845) PDF 183kB
Metabolic Disorders – Tiopronin Products Prior Authorization Policy - (CNF466) 108920 PDF 206kB
Metabolic Disorders – Xuriden® (uridine triacetate oral granules) - Prior Authorization - (CNF467) 109145 PDF 175kB
Methergine® (methylergonovine maleate tablets) - Prior Authorization (CNF468) 108963 PDF 225kB
Methotrexate Injection - Step Therapy - (CNF060) 51597 PDf 180kB
Migraine – Elyxyb™ (celecoxib oral solution) - Prior Authorization - (CNF723) 109143 PDF 212kB
Migraine Medication - Step Therapy - (CNF061) 109960 PDF 210kB
Migraine – Nurtec™ ODT (rimegepant sulfate orally disintegrating tablet) - Prior Authorization - (CNF469) 62902 PDF 250kB
Migraine – Qulipta™ (atogepant tablets) - Prior Authorization - (CNF708) 92211 PDF 242kB
Migraine – Reyvow™ (lasmiditan tablet) - Prior Authorization - (CNF470) 64780 PDF 212kB
Migraine – Triptans Drug Quantity Management Policy – Per Rx - (CNF728) 111557 PDF 234kB
Migraine – Ubrelvy™ (ubrogepant tablet) - Prior Authorization - (CNF471) 64769 PDF 210kB
Migraine -  Zavzpret Prior Auhtorization - (CNF804) PDF 210kB
Multiple Sclerosis – Ampyra® (dalfampridine extended-release tablets, generic) - Preferred Specialty Management - (CNF281) 109900, 109549 PDF 170kB
Multiple Sclerosis – Ampyra® (dalfampridine extended-release tablets) - Prior Authorization - (CNF472) 109570 PDF 159kB
Multiple Sclerosis and Ulcerative Colitis – Zeposia® (ozanimod capsules) - Prior Authorization - (CNF485) 110469 PDF 270kB
Multiple Sclerosis and Ulcerative Colitis – Zeposia Preferred Specialty Management Policy for National Preferred Formularies - (CNF681) 62895 PDF 224kB
Multiple Sclerosis – Avonex® (interferon beta-1a injection for intramuscular use) - Prior Authorization - (CNF474) 111673 PDF 220kB
Multiple Sclerosis – Bafiertam™ (monomethyl fumarate delayed-release) - Prior Authorization - (CNF475) 109860 PDF 219kB
Multiple Sclerosis – Betaseron/Extavia - Prior Authorization - (CNF476) 111673 PDF 188kB
Multiple Sclerosis – Dimethyl Fumarate (Tecfidera® [dimethyl fumarate delayed-release capsules]) - Prior Authorization - (CNF483) 110048 PDF 255kB
Multiple Sclerosis – Gilenya® (fingolimod capsules, generic) - Prior Authorization - (CNF477) 70092 PDF 225kB
Multiple Sclerosis – Glatiramer Products - Prior Authorization - (CNF478) 111673 PDF 244kB
Multiple Sclerosis – Kesimpta® (ofatumumab injection for subcutaneous use) - Prior Authorization - (CNF389) 109942 PDF 83kB
Multiple Sclerosis – Kesimpta® (ofatumumab subcutaneous injection) - Drug Quality Management Policies - (CNF677) 110155 PDF 170kB
Multiple Sclerosis – Mavenclad Prior Authorization Policy - (CNF479) 109696 PDF 186kB
Multiple Sclerosis – Mayzent Prior Authorization Policy - (CNF480) 110161 PDF 185kB
Multiple Sclerosis – Plegridy® (peginterferon beta-1a injection for subcutaneous or intramuscular use) - Prior Authorization - (CNF481) 110519 PDF 219kB
Multiple Sclerosis – Ponvory™ (ponesimod tablets) - Drug Quantity Management - (CNF755) 110246 PDF 197kB
Multiple Sclerosis – Ponvory™ (ponesimod tablets) - Prior Authorization - (CNF673) 109870 PDF 218kB
Multiple Sclerosis - Preferred Specialty Management - (CNF280) 109360, 110118, 110500, 111007, 109048, 110357, 110405, 110356, 110188, 107198 PDF 170kB
Multiple Sclerosis – Rebif Prior Authorization Policy - (CNF482) 111673 PDF 183kB
Multiple Sclerosis – Tascenso ODT Prior Authorization Policy - (CNF771) 108914 PDF 191kB
Multiple Sclerosis – Teriflunomide Prior Authorization Policy - (CNF473) 110162 PDF 183kB
Multiple Sclerosis – Vumerity® (diroximel fumarate delayed-release) - Prior Authorization - (CNF484) 109583 PDF 218kB
Muscular Dystrophy – Agamree Prior Authorization Policy - (CNF846) PDF 173kB
Muscular Dystrophy - Emflaza™ (deflazacort tablets and oral suspension) - Prior Authorization - (CNF363)

58482 PDF 214kB
N
Natpara® (parathyroid hormone for subcutaneous injection) - Prior Authorization - (CNF488) 108060 PDF 226kB
Nephrology – Filspari Prior Authorization - (CNF805) PDF 210kB
Nephrology - Jesduvroq Prior Authorization Policy - (CNF812) PDF 205kB
Nephrology – Tarpeyo™ (budesonide delayed-release capsules) - Prior Authorization - (CNF715) 108893 PDF 241kB
Nephrology – Xphozah Prior Authorization Policy - (CNF826) PDF 168kB
Neurology – Daybue Prior Authorization Policy - (CNF806) PDF 805kB
Neurology – Lyrica® CR (pregabalin extended-release tablets) - Prior Authorization - (CNF459) 107692 PDF 215kB
Neurology – Oxybate Products - Prior Authorization - (CNF643) 110946 PDF 237kB
Neurology – Relyvrio Prior Authorization Policy - (CNF777) 92270 PDF 163kB
Neurology – Riluzole Products - Prior Authorization - (CNF489) 109240 PDF 198kB
Neurology – Skyclarys Prior Authorization Policy - (CNF807) PDF 214kB
Non-Preferred Drug Coverage Review - (Formulary Exception Criteria) - (CNF002) Various, included in policy PDF 1274kB
Nonsteroidal Anti-Inflammatory Drug - Step Therapy - (CNF065) 15406 PDF 252kB
Nonsteroidal Anti-Inflammatory Drug – Tivorbex® (indomethacin capsules, generic) - Drug Quantity Management - (CNF759) 110202 PDF 91kB
Northera® (droxidopa capsules) - Prior Authorization - (CNF490) 110044 PDF 182kB
Nuedexta® (dextromethorphan hydrobromide and quinidine sulfate capsules) - Prior Authorization - (CNF491)

109159 PDF 190kB
O
Oncology (Injectable) – Besremi® (ropeginterferon alfa-2b-njft subcutaneous injection) - Prior Authorization - (CNF719) 79770 PDF 86kB
Oncology - Abiraterone Acetate (Zytiga® tablets; generic) - Prior Authorization - (CNF492) 04263 PDF 227kB
Oncology – Abiraterone Acetate - Drug Quantity Management - (CNF255) 109607, 106368 PDF 198kB
Oncology – Abiraterone Acetate Preferred Specialty Management Policy - (CNF282) PDF 160kB
Oncology – Afinitor®/Afinitor® Disperz (everolimus tablets and tablets for oral suspension) Dispensing Limit - Drug Quantity Management - (CNF683) 110940 PDF 240kB
Oncology – Akeega Prior Authorization Policy - (CNF808) PDF 185kB
Oncology – Alecensa Prior Authorization Policy - (CNF494) 53272 PDF 213kB
Oncology – Alunbrig™ (brigatinib tablets) - Prior Authorization - (CNF495) 59341 PDF 235kB
Oncology - Alunbrig™ (brigatinib tablets for oral use) Dispensing Limit - Drug Quantity Management - (CNF124) 109578 PDF 61kB
Oncology – Augtyro Prior Authorization Policy - (CNF831) PDF 156kB
Oncology – Ayvakit® (avapritinib tablets) - Prior Authorization - (CNF496) 64777 PDF 221kB
Oncology – Balversa™ (erdafitinib tablets) - Prior Authorization - (CNF497) 62886 PDF 170kB
Oncology – Bexarotene (Oral) Preferred Specialty Management Policy - (CNF795) PDF 164kB
Oncology – Bexarotene (Oral) - Prior Authorization - (CNF552) 60287 PDF 171kB
Oncology – Bexarotene (Topical) Preferred Specialty Management Policy - (CNF796) PDF 165kB
Oncology – Bexarotene (Topical) - Prior Authorization - (CNF553) 60285 PDF 172kB
Oncology – Bosulif® (bosutinib tablets) - Prior Authorization - (CNF498) 18989 PDF 232kB
Oncology – Bosulif Drug Quantity Management Policy – Per Rx - (CNF128) 112137 PDF 178kB
Oncology – BRAF and MEK Inhibitors Preferred Specialty Management Policy - (CNF819) PDF 182kB
Oncology – Braftovi® (encorafenib capsules) - Prior Authorization - (CNF499) 61682 PDF 212kB
Oncology - Brukinsa™ (zanubrutinib capsules) - Prior Authorization - (CNF500) 64699 PDF 219kB
Oncology - Cabometyx (cabozantinib tablets) Dispensing Limit - Drug Quantity Management - (CNF129) 108740 PDF 209kB
Oncology - Cabometyx™ (cabozantinib tablets) - Prior Authorization - (CNF501) 54312 PDF 113kB
Oncology - Calquence® (acalabrutinib capsules) - Drug Quantity Management - (CNF130) 109078 PDF 179kB
Oncology - Calquence® (acalabrutinib capsules) - Prior Authorization - (CNF502) 60409 PDF 222kB
Oncology – Caprelsa® (vandetanib tablets) - Prior Authorization - (CNF503) 06516 PDF 88kB
Oncology – Cometriq® (cabozantinib capsules) - Drug Quantity Management - (CNF725) 109497 PDF 158kB
Oncology – Cometriq™ (cabozantinib capsules) - Prior Authorization - (CNF504) 21315 PDF 216kB
Oncology - Copiktra™ (duvelisib capsules) - Prior Authorization - (CNF505) 61689 PDF 100kB
Oncology – Cotellic® (cobimetinib tablets) - Prior Authorization - (CNF506) 52926 PDF 221kB
Oncology – Cyclin Dependent Kinases 4, 6 Inhibitors - Preferred Specialty Management - (CNF284) 67212, 67220, 67221 PDF 256kB
Oncology – Daurismo™ (glasdegib tablets) - Prior Authorization - (CNF507) 62117 PDF 227kB
Oncology – Doptelet® (avatrombopag tablets) - Drug Quantity Management - (CNF147) 109032 PDF 231kB
Oncology – Erivedge® (vismodegib capsules) - Prior Authorization - (CNF508) 08159 PDF 223kB
Oncology – Erleada™ (apalutamide tablets) - Prior Authorization - (CNF509) 61674 PDF 208kB
Oncology – Erlotinib (Tarceva® tablets, generics) - Prior Authorization - (CNF510) 02169 PDF 261kB
Oncology – Erlotinib Drug Quantity Management Policy – Per Rx - (CNF228) 109267 PDF 175kB
Oncology – Everolimus Products - Preferred Specialty Management - (CNF283) 79086, 78981 PDF 204kB
Oncology – Everolimus Products - Prior Authorization - (CNF493) 79085 PDF 234kB
Oncology – Exkivity™ (mobocertinib capsules) - Prior Authorization - (CNF702) 92219 PDF 198kB
Oncology – Farydak® (panobinostat capsules) - Prior Authorization - (CNF511) 50894 PDF 171kB
Oncology – Fotivda® (tivozanib tablets) - Prior Authorization - (CNF670) 79756 PDF 220kB
Oncology – Fruzaqla Prior Authorization Policy - (CNF825) PDF 163kB
Oncology – Gavreto (pralsetinib capsules) - Prior Authorization - (CNF441) 79813 PDF 221kB
Oncology – Gavreto® (pralsetinib capsules) - Drug Quality Management Policies - (CNF746) 105994 PDF 200kB
Oncology – Gilotrif™ (afatinib tablets) - Prior Authorization - (CNF512) 34052 PDF 221kB
Oncology – Gleevec® (imatinib tablets, generic) - Drug Quantity Management - (CNF162) 20951 PDF 206kB
Oncology – Gleevec® (imatinib tablets – generic) - Preferred Specialty Management - (CNF696) 96694, 97144 PDF 163kB
Oncology – Ibrance® (palbociclib capsules and tablets) - Prior Authorization - (CNF513) 50429 PDF 208kB
Oncology – Iclusig® (ponatinib tablets) - Prior Authorization - (CNF514) 21015 PDF 213kB
Oncology – Idhifa® (enasidenib tablets) - Prior Authorization - (CNF515) 59933 PDF 197kB
Oncology – Imatinib Prior Authorization Policy - (CNF516) 96696 PDF 206kB
Oncology – Imbruvica® (ibrutinib) - Preferred Specialty Management - (CNF285) 67671, 67672 PDF 67kB
Oncology - Imbruvica® (ibrutinib tablets and capsules) - Prior Authorization - (CNF517) 42933 PDF 228kB
Oncology – Imbruvica Drug Quantity Management Policy – Per Rx - (CNF838) PDF 176kB
Oncology – Inlyta® (axitinib tablets) - Prior Authorization - (CNF518) 08162 PDF 93kB
Oncology – Inqovi® (decitabine and cedazuridine tablets) - Prior Authorization - (CNF519) 64734 PDF 201kB
Oncology – Inrebic® (fedratinib capsules) - Prior Authorization - (CNF520) 64766 PDF 230kB
Oncology – Iressa® (gefitinib tablets) - Drug Quantity Management - (CNF171) 109690 PDF 197kB
Oncology – Iressa® (gefitinib tablets) - Prior Authorization - (CNF521) 51853 PDF 57kB
Oncology – Iwilfin Prior Authorization Policy - (CNF841) PDF 157kB
Oncology - Jakafi® (ruxolitinib tablets) - Prior Authorization - (CNF522) 07276 PDF 224kB
Oncology – Jaypirca Prior Authorization Policy - (CNF0813) PDF
Oncology – Jaypirca Prior Authorization Policy - (CNF813) PDF 201kB
Oncology – Jaypirca™ (pirtobrutinib tablets) - Drug Quantity Management - (CNF794) 135897 PDF 176kB
Oncology – Kisqali® (ribociclib tablets) and Kisqali® Femara® Co-Pack (ribociclib and letrozole tablets) - Prior Authorization - (CNF523) 62093 PDF 214kB
Oncology – Koselugo™ (selumetinib capsules) - Prior Authorization - (CNF418) 64713 PDF 212kB
Oncology – Krazati™ (adagrasib tablets) - Prior Authorization - (CNF782) 92297 PDF 204kB
Oncology – Lapatinib Drug Quantity Management Policy – Per Rx - (CNF242) 109725 PDF 172kB
Oncology – Lenvima™ (lenvatinib capsules) - Prior Authorization - (CNF524) 50549 PDF 100kB
Oncology – Lonsurf® (trifluridine and tipiracil tablets) - Prior Authorization - (CNF525) 52562 PDF 208kB
Oncology – Lorbrena® (lorlatinib tablets) - Prior Authorization - (CNF526) 61690 PDF 252kB
Oncology – Lumakras™ (sotorasib tablets) - Prior Authorization - (CNF678) 92201 PDF 91kB
Oncology – Lynparza™ (olaparib capsules and tablets) - Prior Authorization - (CNF527) 49972 PDF 260kB
Oncology – Lytgobi® (futibatinib tablets) - Prior Authorization - (CNF780) 92286 PDF 203kB
Oncology – Mekinist™ (trametinib tablets) - Prior Authorization - (CNF528) 31572 PDF 262kB
Oncology – Mektovi® (binimetinib tablets) - Prior Authorization - (CNF529) 61464 PDF 212kB
Oncology – Nerlynx Prior Authorization Policy - (CNF530) 59986 PDF 215kB
Oncology - Nexavar® (sorafenib tablets, generic) - Prior Authorization - (CNF531) 107858, 108046 PDF 114kB
Oncology - Nilandron® (nilutamide tablets) - Prior Authorization - (CNF532) 78664 PDF 171kB
Oncology - Ninlaro® (ixazomib capsules) - Prior Authorization - (CNF533) 53245 PDF 211kB
Oncology - Nubeqa® (darolutamide tablets) - Prior Authorization - (CNF534) 64767 PDF 232kB
Oncology – Odomzo Prior Authorization Policy - (CNF535) 52228 PDF 212kB
Oncology – Ogsiveo Prior Authorization Policy - (CNF832) PDF 164kB
Oncology – Ojjaara PA - (CNF814) PDF 203kB
Oncology – Onureg (azacitadine tablets) - Prior Authorization - (CNF486) 79803 PDF 223kB
Oncology – Orgovyx™ (relugolix tablets) - Drug Quantity Management - (CNF652) 108902 PDF 190kB
Oncology – Orgovyx™ (relugolix tablets) - Prior Authorization - (CNF653) 79829, 79830 PDF 168kB
Oncology – Orserdu Prior Authorization Policy - (CNF815) PDF 187kB
Oncology - Pemazyre™ (pemigatinib tablets) - Prior Authorization - (CNF536) 64715 PDF 209kB
Oncology - Piqray® (alpelisib tablets) - Prior Authorization - (CNF537) 64765 PDF 197kB
Oncology - Pomalyst® (pomalidomide capsules) - Prior Authorization - (CNF538) 60371 PDF 230kB
Oncology – Qinlock Drug Quantity Management Policy – Per Rx - (CNF747) 105995 PDF 168kB
Oncology - Qinlock - Prior Authorization (CNF539) 64735 PDF 168kB
Oncology - Retevmo™ (selpercatinib capsules) - Prior Authorization (CNF540) 64741 PDF 215kB
Oncology - Revlimid® (lenalidomide capsules) - Prior Authorization - (CNF541) 94302 PDF 265kB
Oncology – Rezlidhia™ (olutasidenib capsules) - Prior Authorization - (CNF781) 92308 PDF 196kB
Oncology – Rozlytrek Drug Quantity Management Policy – Per Rx - (CNF210) 109228 PDF 236kB
Oncology - Rozlytrek™ (entrectinib capsules) - Prior Authorization - (CNF542) 64762 PDF 227kB
Oncology - Rubraca™ (rucaparib tablets) - Prior Authorization - (CNF543) 58344 PDF 217kB
Oncology - Rydapt® (midostaurin capsules) - Prior Authorization - (CNF544) 59432 PDF 226kB
Oncology – Scemblix® (asciminib tablets) - Prior Authorization - (CNF712) 92249 PDF 224kB
Oncology – Sorafenib - Preferred Specialty Management - (CNF762) 107688, 107859 PDF 176kB
Oncology – Sprycel® (dasatinib tablets) - Drug Quantity Management - (CNF220) 21035 PDF 227kB
Oncology - Sprycel® (dasatinib tablets) - Prior Authorization - (CNF545) 02769 PDF 236kB
Oncology - Stivarga® (regorafenib tablets) - Prior Authorization - (CNF546) 18969 PDF 225kB
Oncology – Sutent® (sunitinib malate capsules, generic) - Drug Quantity Management - (CNF225) 110264 PDF 196kB
Oncology – Sutent® (sunitinib malate capsules, generic) - Preferred Specialty Management - (CNF793) 132277, 1323317 PDF 177kB
Oncology - Sutent® (sunitinib malate capsules) - Prior Authorization - (CNF547) 132297 PDF 255kB
Oncology - Tabrecta™ (capmatinib tablets) - Prior Authorization - (CNF548) 64733 PDF 199kB
Oncology - Tafinlar® (dabrafenib capsules) - Prior Authorization - (CNF549) 31592 PDF 256kB
Oncology - Tagrisso® (osimertinib tablets) - Prior Authorization - (CNF550) 53108 PDF 237kB
Oncology – Talzenna Prior Authorization Policy - (CNF551) 62114 PDF 168kB
Oncology - Tasigna (nilotinib capsules) - Drug Quantity Management - (CNF230) 110156 PDF 233kB
Oncology – Tasigna Prior Authorization Policy - (CNF554) 03053 PDF 182kB
Oncology - Tazverik™ (tazemetostat tablets) - Prior Authorization - (CNF555) 64781 PDF 242kB
Oncology – Temozolomide capsules (Temodar®, generic) - Prior Authorization - (CNF556) 01300 PDF 206kB
Oncology – Tepmetko® (tepotinib tablets) - Prior Authorization - (CNF667) 79840 PDF 222kB
Oncology – Thalomid Prior Authorization Policy - (CNF557) 94301 PDF 221kB
Oncology – Tibsovo Prior Authorization Policy - (CNF558) 61688 PDF 176kB
Oncology – Truqap Prior Authorization Policy - (CNF830) PDF 163kB
Oncology – Truseltiq™ (infigratinib capsules) - Prior Authorization - (CNF680) 79786 PDF 198kB
Oncology – Tukysa Prior Authorization Policy - (CNF559) 64724 PDF 167kB
Oncology – Turalio Prior Authorization Policy - (CNF560) 64759 PDF 158kB
Oncology - Tykerb® (lapatinib ditosylate tablets) - Prior Authorization - (CNF561) 02918 PDF 218kB
Oncology – Valchlor® (mechlorethamine topical gel) - Prior Authorization - (CNF562) 75740 PDF 203kB
Oncology – Vanflyta Prior Authorization - (CNF809) PDF 186kB
Oncology - Venclexta® (venetoclax tablets) - Prior Authorization - (CNF563) 54225 PDF 248kB
Oncology – Venclexta Drug Quantity Management Policy – Per Rx - (CNF726) 108903 PDF 183kB
Oncology - Verzenio™ (abemaciclib tablets) - Prior Authorization - (CNF564) 60377 PDF 262kB
Oncology – Vistogard Drug Quantity Management Policy – Per Rx - (CNF724) 109353 PDF 160kB
Oncology – Vistogard Prior Authorization Policy - (CNF565) 71114 PDF 178kB
Oncology – Vitrakvi® (larotrectinib capsules and oral solution) - Prior Authorization - (CNF566) 62092 PDF 174kB
Oncology – Vitrakvi Drug Quantity Management Policy – Per Rx - (CNF748) 105996 PDF 202kB
Oncology - Vizimpro® (dacomitinib tablets) - Prior Authorization - (CNF567) 62090 PDF 213kB
Oncology – Vonjo™ (pacritinib capsules) - Prior Authorization - (CNF730) 105929 PDF 189kB
Oncology - Votrient® (pazopanib tablets) - Prior Authorization - (CNF568) 03767 PDF 109kB
Oncology – Welireg Prior Authorization Policy - (CNF701) 92210 PDF 165kB
Oncology - Xalkori® (crizotinib capsules) - Prior Authorization - (CNF569) 05273 PDF 245kB
Oncology – Xalkori Drug Quantity Management Policy – Per Rx - (CNF757) 106301 PDF 175kB
Oncology – Xeloda® (capecitabine tablets, generic) - Preferred Specialty Management - (CNF774) 109616 PDF 181kB
Oncology – Xeloda® (capecitabine tablets, generic) - Prior Authorization - (CNF687) 96042 PDF 240kB
Oncology – Xermelo® (telotristat ethyl tablets) - Drug Quantity Management - (CNF253) 59069 PDF 202kB
Oncology - Xermelo™ (telotristat ethyl tablets) - Prior Authorization - (CNF570) 58982 PDF 192kB
Oncology - Xospata® (gilteritinib tablets) - Prior Authorization - (CNF571) 62113 PDF 208kB
Oncology - Xpovio™ (selinexor tablets) - Prior Authorization - (CNF572) 62885 PDF 246kB
Oncology - Xtandi® (enzalutamide capsules and tablets) - Prior Authorization - (CNF573) 20069 PDF 230kB
Oncology – Xtandi Drug Quantity Management Policy – Per Rx - (CNF669) 109083 PDF 164kB
Oncology – Yonsa Prior Authorization Policy - (CNF574) 60467 PDF 160kB
Oncology - Zejula™ (niraparib capsules) - Prior Authorization - (CNF575) 59129 PDF 236kB
Oncology - Zelboraf® (vemurafenib tablets) - Prior Authorization - (CNF576) 05274 PDF 228kB
Oncology – Zolinza Prior Authorization Policy - (CNF577) 70155 PDF 169kB
Oncology - Zydelig® (idelalisib tablets) - Prior Authorization - (CNF578) 46652 PDF 94kB
Oncology - Zykadia™ (ceritinib capsules and tablets) - Prior Authorization - (CNF579) 44412 PDF 231kB
Ophthalmic Anti-Allergics: Mast Cell Stabilizers - Step Therapy - (CNF066) 47153 PDF 257kB
Ophthalmic Anti-Allergics: Miscellaneous - Step Therapy - (CNF067) 47813 PDF 257kB
Ophthalmic Corticosteroids - Step Therapy - (CNF699) 109004 PDF 97kB
Ophthalmic for Dry Eye Disease - Cyclosporine Products - Prior Authorization - (CNF583) 108794 PDF 215kB
Ophthalmic for Dry Eye Disease – Eysuvis™ (loteprednol etabonate 0.25% ophthalmic suspension) - Prior Authorization - (CNF646) 90484 PDF 174kB
Ophthalmic for Dry Eye Disease - Lacrisert® (hydroxypropyl cellulose ophthalmic insert) - Prior Authorization - (CNF633) 90306 PDF 178kB
Ophthalmic for Dry Eye Disease – Xiidra™ (lifitegrast ophthalmic solution) - Prior Authorization - (CNF584) 109141 PDF 192kB
Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists - Step Therapy - (CNF739) 110490 PDF 176kB
Ophthalmic - Glaucoma - Beta-Adrenergic Blockers - Step Therapy - (CNF740) 110243 PDF 180kB
Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors - Step Therapy - (CNF741) 109861 PDF 64kB
Ophthalmic - Glaucoma - Combination Products - Step Therapy - (CNF742) 110200 PDF 174kB
Ophthalmic – Glaucoma – Prostaglandins - Prior Authorization - (CNF585) 106874 PDF 178kB
Ophthalmic Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) - Step Therapy - (CNF105) 109689 PDF 176kB
Ophthalmology – Dry Eye Disease – Lacrisert® (hydroxypropyl cellulose ophthalmic insert) - Drug Quantity Management - (CNF689) 109937 PDF 175kB
Ophthalmology – Dry Eye Disease – Miebo Prior Authorization Policy - (CNF810) PDF 183kB
Ophthalmology – Dry Eye Disease – Tyrvaya Prior Authorization Policy - (CNF710) 109837 PDF 164kB
Ophthalmology - Oxervate™ (cenegermin-bkbj ophthalmic solution) - Prior Authorization - (CNF586) 108964 PDF 201kB
Ophthalmology – Upneeq Prior Authorization Policy - (CNF387) 64745 PDF 171kB
Ophthalmology – Verkazia® (cyclosporine 0.1% ophthalmic emulsion) - Prior Authorization - (CNF722) 109082 PDF 207kB
Opioid – Morphine Milligram Equivalent (200) - Drug Quantity Management - (CNF185) 59582 PDF 230kB
Opioid – Morphine Milligram Equivalent (90) - Drug Quantity Management - (CNF184) 67864 PDF 203kB
Opioids - Fentanyl Transdermal Products - Drug Quantity Management - (CNF158) 61579 PDF 74kB
Opioids - Fentanyl Transmucosal Drugs - Prior Authorization - (CNF587) 02069 PDF 483kB
Opioids – Fentanyl Transmucosal Products - Drug Quantity Management - (CNF159) 111458 PDF 262kB
Opioids – Long-Acting Products (Oral) - Drug Quantity Management - (CNF197) 13924 PDF 288kB
Opioids – Long Acting Products - Prior Authorization - (CNF589) 86930, 59357 PDF 243kB
Opioids – Methadone Prior Authorization Policy - (CNF843) PDF 197kB
Opioids – Nucynta® (tapentadol immediate-release oral tablets) - Drug Quantity Management - (CNF193) 110350 PDF 176kB
Opioids – Short-Acting Products (Adults) - Drug Quantity Management - (CNF194) 74970, 67865 PDF 249kB
Opioids – Short-Acting Products (Pediatrics) - Drug Quantity Management - (CNF196) 74974, 67866 PDF 204kB
Opioids – Tramadol Extended Release - Prior Authorization - (CNF588) 14702 PDF 240kB
Opioids – Tramadol Extended-Release Products - Drug Quantity Management - (CNF239) 109804 PDF 184kB
Opioids Transmucosal – Fentora Formulary Exception Policy - (CNF017) 13691 PDF 57kB
Opioids Transmucosal - Lazanda® (fentanyl nasal spray) - Formulary Exception - (CNF018) 13692 PDF 57kB
Opioids Transmucosal – Subsys Formulary Exception Policy - (CNF019) 13693 PDF 156kB
Overactive Bladder Medications - Preferred Step Therapy - (CNF108) 111157 PDF 219kB
Oxbryta™ (voxelotor tablets) Dispensing Limit - Drug Quantity Management - (CNF201)

79252 PDF 252kB
P
Parkinson's Disease - Tolcapone Products - Prior Authorization - (CNF599) 110043 PDF 185kB
Parkinson’s Disease - Amantadine Extended-Release Drugs (Gocovri™ and Osmolex ER™) - Prior Authorization - (CNF590) 61501 PDF 242kB
Parkinson’s Disease - Apokyn® (apomorphine hydrochloride for subcutaneous injection) - Prior Authorization - (CNF591) 108310 PDF 223kB
Parkinson’s Disease - Duopa™ (carbidopa and levodopa enteral suspension) - Prior Authorization - (CNF592) 108634 PDF 203kB
Parkinson’s Disease – Inbrija Prior Authorization Policy - (CNF593) 108577 PDF 188kB
Parkinson’s Disease - Kynmobi™ (apomorphine sublingual film) - Prior Authorization - (CNF594) 109079 PDF 202kB
Parkinson’s Disease - Lodosyn® (carbidopa tablets) - Prior Authorization - (CNF595) 108939 PDF 195kB
Parkinson’s Disease – Monoamine Oxidase Type B Inhibitors - Step Therapy - (CNF062) 107822 PDF 227kB
Parkinson’s Disease - Nourianz™ (istradefylline tablets) - Prior Authorization - (CNF596) 109156 PDF 85kB
Parkinson’s Disease - Nuplazid® (pimavanserin capsules and tablets) - Prior Authorization - (CNF597) 108944 PDF 192kB
Parkinson’s Disease – Ongentys Prior Authorization Policy - (CNF598) 108264 PDF 183kB
Parkinson’s Disease - Zelapar® (selegiline hydrochloride tablets, orally disintegrating) - Prior Authorization - (CNF600) 109242 PDF 86kB
Phenylketonuria – Palynziq® (pegvaliase-pqpz injection for subcutaneous use) - Prior Authorization - (CNF602) 108753 PDF 223kB
Phenylketonuria – Palynziq Drug Quantity Management Policy – Per Rx - (CNF203) 109119 PDF 175kB
Phenylketonuria – Sapropterin Prior Authorization Policy - (CNF601) 109036 PDF 185kB
Pheochromocytoma – Metyrosine Capsules and Phenoxybenzamine Capsules - Prior Authorization - (CNF603) 108956, 109281 PDF 225kB
Phosphate Binders - Drug Quantity Management - (CNF671) 108044, 109034, 108080, 110304 PDF 234kB
Phosphate Binders - Preferred Step Therapy - (CNF110) 109179 PDF 179kB
Pompe Disease – Enzyme Stabilization Therapy – Opfolda Prior Authorization Policy - (CNF816) PDF 169kB
Potassium Binders – Lokelma® (sodium zirconium cyclosilicate for oral suspension) - Drug Quantity Management - (CNF178) 109265 PDF 192kB
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Praluent® (alirocumab subcutaneous injection) - Prior Authorization - (CNF604) 108391 PDF 306kB
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha Prior Authorization Policy - (CNF605) 106822 PDF 257kB
Proton Pump Inhibitors Drug Quantity Management Policy – Per Rx - (CNF243) 107674, 109576, 109508, 110153, 109887, 109276, 109178 PDF 334kB
Proton Pump Inhibitors Step Therapy Policy - (CNF070) 14530 PDF 141kB
Psychiatry – Novel Psychotropics - Drug Quantity Management - (CNF126) 108904, 110564, 109938, 109122, 110230, 110106, 109155, 110612, 110342, 109182, 110298, 110569, 110348, 99175 PDF 339kB
Psychiatry - Spravato™ (esketamine nasal spray) - Prior Authorization - (CNF606) 106948 PDF 232kB
Psychiatry – Zurzuvae Prior Authorization Policy - (CNF827) PDF 166kB
Pulmonary Arterial Hypertension – Adempas® (riociguat tablets) - Drug Quantity Management - (CNF767) 111217 PDF 198kB
Pulmonary Arterial Hypertension - Adempas® (riociguat tablets) - Prior Authorization - (CNF607) 109346 PDF 101kB
Pulmonary Arterial Hypertension and Related Lung Disease – Inhaled Prostacyclin Products Prior Authorization Policy - (CNF609) 109001, 109507, 109629 PDF 197kB
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist - Preferred Specialty Management - (CNF288) 109627 PDF 227kB
Pulmonary Arterial Hypertension – Endothelin Receptor Antagonists - Prior Authorization - (CNF608) 109524, 110157, 109628, 110137, 111728 PDF 117kB
Pulmonary Arterial Hypertension - Inhaled Prostacyclin - Preferred Specialty Management - (CNF289) 109381 PDF 198kB
Pulmonary Arterial Hypertension – Orenitram Drug Quantity Management Policy – Per Rx - (CNF768) 111317 PDF 177kB
Pulmonary Arterial Hypertension – Orenitram Prior Authorization Policy - (CNF610) 109094 PDF 192kB
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors - Preferred Specialty Management - (CNF290) 13802 PDF 205kB
Pulmonary Arterial Hypertension – Phosphodiesterase Type 5 Inhibitors - Prior Authorization - (CNF611) 109523, 109585 PDF 190kB
Pulmonary Arterial Hypertension – Sildenafil Drug Quantity Management Policy – Per Rx - (CNF209) 36934 PDF 186kB
Pulmonary Arterial Hypertension – Uptravi® (selexipag tablets) - Prior Authorization - (CNF612) 109526 PDF 98kB
Pulmonary – Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers Drug Quantity Management Policy – Per Rx - (CNF784) 129397 PDF 261kB
Pulmonary – Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers - Prior Authorization - (CNF348) 108800 PDF 261kB
Pulmonary – Daliresp® (roflumilast tablets) - Prior Authorization - (CNF357)

07296 PDF 206kB
Q
Qbrexza™ (glycopyrronium cloth 2.4% for topical use) - Prior Authorization - (CNF613)

63770 PDF 121kB
S
Sedative Hypnotics - Step Therapy - (CNF071) 14042 PDF 218kB
Sickle Cell Disease – Endari Prior Authorization Policy - (CNF615) 60446 PDF 202kB
Sickle Cell Disease - Hydroxyurea - Preferred Step Therapy - (CNF116) 109238 PDF 203kB
Sickle Cell Disease – Oxbryta™ (voxelotor tablets) - Prior Authorization - (CNF616) 64698 PDF 228kB
Sohonos Prior Authorization Policy - (CNF811) PDF 169kB
Somatostatin Analogs – Mycapssa - Drug Quantity Management - (CNF792) 131877 PDF 176kB
Somatostatin Analogs – Mycapssa - Prior Authorization - (CNF390) 109285 PDF 165kB
Somatostatin Analogs – Octreotide Immediate-Release Products Preferred Specialty Management Policy - (CNF693) 107953 PDF 175kB
Somatostatin Analogs – Octreotide Immediate-Release Products - Prior Authorization - (CNF685) 111669 PDF 121kB
Somavert® (pegvisomant for injection) - Prior Authorization - (CNF619) 108949 PDF 173kB
Spinal Muscle Atrophy – Spinraza Drug Quantity Management Policy – Per Days - (CNF219) 108791 PDF 166kB
Spinal Muscular Atrophy – Evrysdi® (risdiplam oral solution) - Prior Authorization - (CNF0386) 64714 PDF 270kB
Spinal Muscular Atrophy – Evrysdi Prior Authorization Policy - (CNF386)

PDF 220kB
T
Tasimelteon Products Prior Authorization Policy - (CNF407) 42473 PDF 277kB
Testosterone (Injectable) Products Prior Authorization Policy - (CNF620) PDF 184kB
Thrombocytopenia – Doptelet® (avatrombopag tablets for oral use) - Prior Authorization - (CNF622) 108124 PDF 215kB
Thrombocytopenia – Mulpleta® (lusutrombopag tablets for oral use) - Prior Authorization - (CNF623) 107826 PDF 212kB
Thrombocytopenia – Promacta Prior Authorization Policy - (CNF624) 107301 PDF 187kB
Thrombocytopenia - Tavalisse™ (fostamatinib disodium hexahydrate tablets) - Prior Authorization - (CNF625) 108122 PDF 215kB
Tolvaptan Products - Drug Quantity Management - (CNF211) 107718 PDF 209kB
Tolvaptan Products – Jynarque® (tolvaptan tablets) - Prior Authorization - (CNF626) 108072 PDF 215kB
Tolvaptan Products - Tolvaptan (Samsca) Prior Authorization Policy - (CNF627) 12884 PDF 134kB
Topical Acne – Cleansers Step Therapy Policy - (CNF074) 14524 PDF 167kB
Topical Acne – Kits Step Therapy Policy- (CNF075) 14526 PDF 171kB
Topical Acne – Topical Products Step Therapy Policy - (CNF076) 108519 PDF 186kB
Topical Acne – Winlevi® (clascoterone 1% cream) - Prior Authorization - (CNF705) 79804 PDF 202kB
Topical Acyclovir Products - Prior Authorization - (CNF628) 109098 PDF 210kB
Topical Agents for Atopic Dermatitis - Drug Quantity Management - (CNF236) 109142 PDF 248kB
Topical Agents for Atopic Dermatitis Step Therapy Policy - (CNF077) 15213 PDF 123B
Topical Alpha-Adrenergic Agonists for Rosacea – Rhofade Prior Authorization Policy - (CNF731) 108202 PDF 160kB
Topical Anesthetic – Lidocaine/Tetracaine Products - Prior Authorization - (CNF675) 109085 PDF 214kB
Topical Anesthetic Products Duration Limit - Drug Quantity Management - (CNF232) 54428 PDF 238kB
Topical Antibacterials - Step Therapy -(CNF078) 108907 PDF 227kB
Topical Antibiotics for Acne – Clindamycin - Drug Quantity Management - (CNF134) 65506 PDF 225kB
Topical Antifungal Products Duration Limit - Drug Quantity Management - (CNF238) 108864 PDF 350kB
Topical Antifungals for Onychomycosis - Step Therapy - (CNF038) 109525 PDF 118kB
Topical Antifungals for Seborrheic Dermatitis Step Therapy Policy - (CNF835) PDF 119kB
Topical Antipruritics – Doxepin Products - Drug Quantity Management - (CNF235) 111267 PDF 188kB
Topical Calcipotriene Products - Drug Quantity Management - (CNF233) 109332 PDF 247kB
Topical Collagenase – Santyl® (collagenase santyl ointment 250 units/gram) - Drug Quantity Management - (CNF234) 108966 PDF 176kB
Topical Corticosteroids – Clobetasol Drug Quantity Management Policy – Per Days - (CNF135) 108626 PDF 204kB
Topical Corticosteroids – Diflorasone - Drug Quantity Management - (CNF144) 65507 PDF 183kB
Topical Corticosteroids – Fluocinonide - Drug Quantity Management - (CNF160) 108788 PDF 231kB
Topical Corticosteroids – Hydrocortisone Butyrate - Drug Quantity Management - (CNF177) 109532 PDF 190kB
Topical Corticosteroids - Step Therapy - (CNF079) 108161 PDF 217kB
Topical Corticosteroids – Triamcinolone Spray - Drug Quantity Management - (CNF241) 65503 PDF 201kB
Topical Doxepin - Step Therapy - (CNF080) 109498 PDF 207kB
Topical Medications for Inflammatory Rosacea - Step Therapy - (CNF081) 50453 PDF 215kB
Topical Non-Steroidal Anti-Inflammatory Drugs – Diclofenac - Drug Quantity Management - (CNF143) 109016 PDF 191kB
Topical Podofilox Products - Step Therapy - (CNF674) 109158 PDF 171kB
Topical Products – Vtama and Zoryve - Step Therapy - (CNF778) 112580 PDF 186kB
Topical Retinoids – Aklief® - (trifarotene cream) - Prior Authorization - (CNF629) 78270 PDF 194kB
Topical Retinoids – Panretin Prior Authorization Policy - (CNF630) 111461 PDF 180kB
Topical Retinoids – Tazarotene Products - Prior Authorization - (CNF631) 108998 PDF 189kB
Topical Retinoid – Tretinoin Products - Prior Authorization - (CNF632) 108977 PDF 194kB
Topical Vitamin D Analogs - Step Therapy - (CNF645)

109477 PDF 196kB
V
Vasculitis – Tavneos™ (avacopan capsules) - Prior Authorization - (CNF709) 109691 PDF 214kB
Vecamyl™ (mecamylamine hydrochloride tablets) - Prior Authorization - (CNF634) 109699 PDF 229kB
Veltassa® (patiromer for oral suspension) Dispensing Limit - Drug Quantity Management - (CNF247) 108899 PDF 58kB
Veregen® (sinecatechins ointment) - Prior Authorization - CNF635) 107732 PDF 220kB
Vesicular Monoamine Transporter Type 2 Inhibitors – Austedo Prior Authorization Policy - (CNF636) 108659, 111159 PDF 178kB
Vesicular Monoamine Transporter Type 2 Inhibitors - Drug Quantity Management - (CNF248) 108856 PDF 261kB
Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza® (valbenazine capsules) - Prior Authorization - (CNF637) 108639, 108627 PDF 195kB
Vesicular Monoamine Transporter Type 2 Inhibitors - Preferred Specialty Management - (CNF293) 108095, 108298 PDF 179kB
Vesicular Monoamine Transporter Type 2 Inhibitors – Tetrabenazine tablets (Xenazine®, generics) - Prior Authorization - (CNF638) 108227 PDF 215kB
Vijoice Prior Authorization Policy - (CNF743) 109982 PDF 132kB
Vitamin B12 (Cyanocobalamin) Products - Step Therapy - (CNF682) 108617 PDF 184kB
Vitamin D Analog (oral) - Step Therapy - (CNF082)

108714 PDF 119kB
W
Wakefulness-Promoting Agents – Armodafinil, Modafinil - Prior Authorization - (CNF639) 109187 PDF 264kB
Wakefulness-Promoting Agents – Sunosi™ (solriamfetol tablets) - Drug Quantity Management - (CNF224) 109140 PDF 179kB
Wakefulness-Promoting Agents – Sunosi™ (solriamfetol tablets) - Prior Authorization - (CNF640) 110124 PDF 249kB
Wakefulness-Promoting Agents – Wakix® (pitolisant tablets) - Drug Quantity Management - (CNF250) 109209 PDF 176kB
Wakefulness-Promoting Agents – Wakix Prior Authorization with Step Therapy Policy - (CNF641) 110352 PDF 203kB
Weight Loss – Glucagon-Like Peptide-1 Agonists - Prior Authorization - (CNF684) 108924, 109202 PDF 284kB
Weight Loss – Other Appetite Suppressants and Orlistat - Prior Authorization - (CNF642) 12888, 51169, 51170, 51171 PDF 305kB
Weight Loss – Qsymia® (phentermine and topiramate extended-release capsules) - Drug Quantity Management - (CNF688) 111216 PDF 209kB
Weight Loss – Wegovy Drug Quantity Management Policy – Per Days - (CNF686) 108537 PDF 174kB
Weight Loss – Zepbound Drug Quantity Management Policy – Per Days - (CNF840)

PDF 164kB
Z
Zetia® (ezetimibe tablets) - Step Therapy - (CNF083) 108498 PDF 186kB
Zokinvy Prior Authorization Policy - (CNF655)

64721 PDF 267kB