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) PDF 212kB
Allergen Immunotherapy – Odactra® (house dust mite [Dermatophagoides farina and Dermatophagoides pteronyssinus] allergen extract sublingual tablets) - Prior Authorization - (CNF298) PDF 210kB
Allergen Immunotherapy – Palforzia - Drug Quantity Management - (CNF202) PDF 224kB
Allergen Immunotherapy – Palforzia Prior Authorization Policy - (CNF299) PDF 172kB
Allergen Immunotherapy – Ragwitek® (short ragweed pollen allergen extract sublingual tablets) - Prior Authorization - (CNF300) PDF 224kB
Alpha-Adrenergic Blockers – Doxazosin - Drug Quantity Management - (CNF131) PDF 190kB
Alpha-Adrenergic Blockers – Terazosin - Drug Quantity Management - (CNF167) PDF 200kB
Alzheimer's Disease - Step Therapy - (CNF028) PDF 181kB
Alzheimer's - Namenda / Namenda XR - Step Therapy - (CNF027) PDF 160kB
Amifampridine Products - Firdapse® (amifampridine tablets), Ruzurgi® (amifampridine tablets) - Prior Authorization - (CNF301) PDF 221kB
Amyloidosis – Tafamidis Products - Prior Authorization - (CNF302) PDF 76kB
Amyloidosis – Tegsedi® (inotersen subcutaneous injection) - Prior Authorization - (CNF303) PDF 173kB
Amyloidosis – Wainua Prior Authorization Policy - (CNF842) PDF 172kB
Angiotensin Receptor Blockers - Step Therapy - (CNF029) PDF 208kB
Antibiotics (Inhaled) - Arikayce® (amikacin liposome inhalation suspension for oral inhalation) - Prior Authorization - (CNF118) PDF 190kB
Antibiotics (Inhaled) – Cayston Prior Authorization Policy - (CNF308) PDF 170kB
Antibiotics (Inhaled) – TOBI Podhaler Prior Authorization Policy - (CNF309) PDF 170kB
Antibiotics (Inhaled) – Tobramycin Inhalation Solution - Prior Authorization - (CNF310) PDF 189kB
Antibiotics (Inhaled) - Tobramycin Products Preferred Specialty Management - (CNF258) PDF 183kB
Antibiotics – Linezolid (Zyvox), Sivextro - Prior Authorization - (CNF304) PDF 195kB
Antibiotics – Synercid® (quinupristin and dalfopristin powder for injection) - Prior Authorization - (CNF305) PDF 178kB
Antibiotics – Vancomycin Capsules (Vancocin®) - Prior Authorization - (CNF306) PDF 178kB
Anticoagulants - Eliquis® (apixaban tablets) - Prior Authorization - (CNF311) PDF 259kB
Anticoagulants - Pradaxa® (dabigatran capsule) - Prior Authorization - (CNF312) PDF 262kB
Anticoagulants - Savaysa® (edoxaban tablet) - Prior Authorization - (CNF313) PDF 260kB
Anticoagulants – Xarelto® (rivaroxaban tablets and oral suspension) - Prior Authorization - (CNF314) PDF 272kB
Antidepressants – Bupropion - Drug Quantity Management - (CNF140) PDF 203kB
Antidepressants - Bupropion Long-Acting - Step Therapy - (CNF030) PDF 187kB
Antidepressants – Selective Serotonin Reuptake Inhibitors - Drug Quantity Management - (CNF142) PDF 322kB
Antidepressants – Selective Serotonin Reuptake Inhibitors Step Therapy Policy - (CNF031) PDF 225kB
Antidepressants – Serotonin and Norepinephrine Reuptake Inhibitors - Drug Quantity Management - (CNF141) PDF 343kB
Antidepressants – Serotonin and Norepinephrine Reuptake Inhibitors Step Therapy Policy - (CNF032) PDF 265kB
Antiemetics – Doxylamine and Pyridoxine Combination Products - Drug Quantity Management - (CNF187) PDF 70kB
Antiemetics – Serotonin Receptor Antagonists (Oral and Transdermal) - Drug Quantity Management - (CNF189) PDF 251kB
Antiemetics – Substance P/Neurokinin-1 Receptor Antagonists (Oral) - Drug Quantity Management - (CNF190) PDF 235kB
Antiepileptics - Banzel® (rufinamide tablets and oral suspension) - Prior Authorization - (CNF316) PDF 216kB
Antiepileptics – Clobazam Products - Onfi® (clobazam tablets and oral suspension ), Sympazan™ (clobazam oral soluble film) - Prior Authorization - (CNF317) PDF 210kB
Antiepileptics – Depakote/Depakene - Step Therapy - (CNF033) PDF 161kB
Antiepileptics – Lamictal XR - Step Therapy - (CNF034) PDF 158kB
Antiepileptics – Levetiracetam, Brivaracetam - Step Therapy - (CNF035) PDF 168kB
Antiepileptics -  Nayzilam® (midazolam nasal spray) - Prior Authorization - (CNF320) PDF 198kB
Antiepileptics – Oxtellar XR, Trileptal - Step Therapy - (CNF036) PDF 158kB
Antiepileptics – Zonisamide - Step Therapy - (CNF779) PDF 173kB
Antiepileptics – Ztalmy® (ganaxolone oral suspension) - Prior Authorization - (CNF761) PDF 87kB
Antifungals – Cresemba® Oral (isavuconazonium sulfate capsules) - Prior Authorization - (CNF323) PDF 188kB
Antifungals – Fluconazole (Oral) Drug Quantity Management Policy – Per Rx - (CNF145) PDF 187kB
Antifungals – Flucytosine Prior Authorization Policy - (CNF797) PDF 184KB
Antifungals for Vulvovaginal Candidiasis - Step Therapy - (CNF711) PDF 178kB
Antifungals – Itraconazole Drug Quantity Management Policy – Per Rx - (CNF173) PDF 191kB
Antifungals – Noxafil® Oral (posaconazole delayed-release tablets [generics], oral suspension, PowderMix for delayed-release oral suspension) - Prior Authorization - (CNF324) PDF 226kB
Antifungals - Tolsura™ (itraconazole capsules) - Prior Authorization - (CNF325) PDF 185kB
Antifungals – Vivjoa™ (oteseconazole capsules) - Prior Authorization - (CNF772) PDF 200kB
Antifungals – Voriconazole (Oral) - Prior Authorization - (CNF326) PDF 232kB
Anti-Influenza – Oseltamivir Drug Quantity Management Policy – Per Rx - (CNF227) PDF 192kB
Anti-Influenza – Relenza Drug Quantity Management Policy – Per Rx - (CNF207) PDF 165kB
Antiseizure Medications – Diacomit® (stiripentol capsules and powder for oral suspension) - Prior Authorization - (CNF318) PDF 254kB
Antiseizure Medications – Epidiolex® (cannabidiol oral solution) - Prior Authorization - (CNF319) PDF 272kB
Antiseizure Medications – Fintepla Prior Authorization Policy - (CNF315) PDF 207kB
Antiseizure Medications – Lacosamide Step Therapy Policy - (CNF738) PDF 191kB
Antiseizure Medications – Topiramate - Step Therapy - (CNF037) PDF 223kB
Antiseizure Medications – Valtoco Prior Authorization Policy - (CNF706) PDF 159kB
Antiseizure Medications – Vigabatrin - Drug Quantity Management - (CNF786) PDF 786kB
Antiseizure Medications – Vigabatrin Prior Authorization Policy - (CNF321) PDF 196kB
Antiseizure Medications – Xcopri Drug Quantity Management Policy – Per Rx - (CNF252) PDF 181kB
Antivirals – Famciclovir Drug Quantity Management Policy – Per Rx - (CNF157) PDF 211kB
Antivirals – Ribavirin (Inhaled Products) - Prior Authorization - (CNF760) PDF 188kB
Antivirals – Ribavirin (Oral Products) - Prior Authorization - (CNF396) PDF 233kB
Antivirals – Valacyclovir Drug Quantity Management Policy – Per Rx - (CNF245) PDF 238kB
Attention Deficit Hyperactivity Disorder Non-Stimulant Medications - Step Therapy - (CNF024) PDF 132kB
Attention Deficit Hyperactivity Disorder Stimulant Medications Step Therapy Policy - (CNF025)

PDF 174kB
B
Benign Prostatic Hyperplasia – 5-Alpha-Reductase Inhibitors - Step Therapy - (CNF039) PDF 67kB
Benign Prostatic Hyperplasia – Alpha Blockers - Step Therapy - (CNF026) PDF 164kB
Benign Prostatic Hyperplasia – Entadfi™ (finasteride and tadalafil capsules) - Prior Authorization - (CNF750) PDF 62kB
Beta Blocker - Step Therapy - (CNF040) PDF 232kB
Bile Acid Sequestrants - Step Therapy - (CNF041) PDF 177kB
Bisphosphonates (Oral) Enhanced - Step Therapy - (CNF043) PDF 179kB
Bone Modifiers – Teriparatide Drug Quantity Management Policy – Per Days - (CNF231) PDF 173kB
Bone Modifiers – Teriparatide Products - Prior Authorization - (CNF328) PDF 239kB
Bone Modifiers – Tymlos® (abaloparatide subcutaneous injection) - Prior Authorization - (CNF329) PDF 217kB
Bone Modifiers – Xgeva® (denosumab subcutaneous injection) - Drug Quantity Management - (CNF736) PDF 159kB
Bowel Disease – Lubiprostone capsules (Amitiza®, generic) - Drug Quantity Management - (CNF121) PDF 203kB
Bowel Disease - Opioid-Induced Constipation - Preferred Step Therapy - (CNF086) PDF 198kB
Brand Name Products with Bioequivalent Generics - (CNF001)

PDF 225kB
C
Cabergoline Drug Quantity Management Policy – Per Days - (CNF148) PDF 175kB
Calcitonin Gene-Related Peptide Inhibitors – Aimovig - Drug Quantity Management - (CNF122) PDF 176kB
Calcitonin Gene-Related Peptide Inhibitors – Emgality - Drug Quantity Management - (CNF150) PDF 213kB
Calcium Channel Blockers – Dihydropyridine Products - Step Therapy - (CNF044) PDF 238kB
Calcium Channel Blockers – Verapamil Products - Step Therapy - (CNF045) PDF 184kB
Carbinoxamine Step Therapy Policy - (CNF046) PDF 124kB
Cardiology – Camzyos™ (mavacamten capsules) - Prior Authorization - (CNF745) PDF 236kB
Cardiology – Corlanor® (ivabradine tablets and oral solution) - Prior Authorization - (CNF335) PDF 2513kB
Cardiology – Lodoco Prior Authorization Policy - (CNF798) PDF 163kB
Cardiology – Ranolazine Products Step Therapy Policy - (CNF785) PDF 153kB
Cardiology – Verquvo™ (vericiguat tablets) - Drug Quantity Management - (CNF660) PDF 173kB
Cardiology - Zontivity (vorapaxar tablets) - Prior Authorization - (CNF644) PDF 87kB
Chelating Agents – Chemet Prior Authorization Policy - (CNF336) PDF 194kB
Chelating Agents – Iron Chelators (Oral) Preferred Specialty Management Policy - (CNF666) PDF 197kB
Chelating Agents - Iron Chelators (Oral) - Prior Authorization - (CNF337) PDF 225kB
Chelating Agents – Penicillamine Products - Prior Authorization - (CNF338) PDF 186kB
Chelating Agents – Syprine® (trientine hydrochloride capsules, generics) - Prior Authorization - (CNF339) PDF 179kB
Chenodal™ (chenodiol tablets) - Prior Authorization - (CNF340) PDF 179kB
Cholbam® (cholic acid capsules) - Prior Authorization - (CNF341) PDF 211kB
Chorionic Gonadotropins - Drug Quantity Management - (CNF164) PDF 213kB
Chorionic Gonadotropins - Preferred Specialty Management - (CNF259) PDF 206kB
Cinacalcet tablets (Sensipar®) - Prior Authorization - (CNF342) PDF 185kB
Colchicine Products Preferred Step Therapy - (CNF087) PDF 123kB
Colony Stimulating Factors – Pegfilgrastim Products Preferred Specialty Management Policy for National Preferred Formularies - (CNF266) PDF 167kB
Colony Stimulating Factors – Pegfilgrastim Products - Prior Authorization - (CNF346) PDF 217kB
Complement Inhibitors – Fabhalta Prior Authorization Policy - (CNF836) PDF 170kB
Complement Inhibitors – Voydeya Prior Authorization Policy - (CNF858) PDF 175kB
Complement Inhibitors – Zilbrysq Prior Authorization Policy - (CNF824) PDF 182kB
Contraceptives – Oral, Patch, and Vaginal Ring Products - Step Therapy - (CNF047) PDF 308kB
Contraceptives – Phexxi Prior Authorization Policy - (CNF334) PDF 166kB
Coronavirus – Oral Medications for Treatment of Coronavirus Disease 2019 (COVID-19) - Drug Quality Management Policies - (CNF744) PDF 250kB
Corticosteroids (Nasal) – Mometasone Drug Quantity Management Policy – Per Rx - (CNF186) PDF 159kB
Corticosteroids (Nebulized) – Budesonide - Drug Quantity Management - (CNF206) PDF 206kB
Cushing’s Disease – Isturisa® (osilodrostat tablets) - Drug Quantity Management - (CNF172) PDF 174kB
Cushing’s - Isturisa Prior Authorization Policy - (CNF349) PDF 173kB
Cushing’s – Mifepristone Prior Authorization Policy - (CNF350) PDF 178kB
Cushing’s – Recorlev Prior Authorization Policy - (CNF732) PDF 172kB
Cushing’s - Signifor Prior Authorization Policy - (CNF351) PDF 174kB
Cycloxygenase-2 Inhibitor - Celebrex® (celecoxib capsules – generic) - Step Therapy - (CNF048) PDF 213kB
Cystic Fibrosis – Bronchitol® (mannitol inhalation powder, for oral inhalation - Prior Authorization - (CNF659) PDF 214kB
Cystic Fibrosis – Kalydeco Prior Authorization Policy - (CNF352) PDF 194kB
Cystic Fibrosis – Orkambi Prior Authorization Policy - (CNF353) PDF 225kB
Cystic Fibrosis – Pulmozyme Prior Authorization Policy - (CNF354) PDF 173kB
Cystic Fibrosis – Symdeko Prior Authorization Policy - (CNF355) PDF 216kB
Cystic Fibrosis – Trikafta Drug Quantity Management Policy – Per Rx - (CNF837) PDF 179kB
Cystic Fibrosis – Trikafta Prior Authorization Policy - (CNF356)

PDF 256kB
D
Dermatology – Filsuvez Prior Authorization Policy - (CNF850) PDF 190kB
Dermatology – Hyftor™ (sirolimus 0.2% topical gel) - Prior Authorization - (CNF751) PDF 91kB
Dermatology – Opzelura® (ruxolitinib 1.5% cream) - Prior Authorization - (CNF704) PDF 262kB
Dermatology – Vtama® (tapinarof 1% cream) - Drug Quantity Management - (CNF756) PDF 181kB
Dermatology – Zoryve Drug Quantity Management Policy – Per Days - (CNF765) PDF 194kB
Desmopressin Products - Nocdurna® (desmopressin acetate sublingual tablets [27.7 mcg and 55.3 mcg]) - Prior Authorization - (CNF358) 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) PDF 179kB
Diabetes – Canagliflozin Products - Drug Quantity Management - (CNF758) PDF 210kB
Diabetes – Continuous Glucose Monitoring Systems Prior Authorization Policy - (CNF676) PDF 177kB
Diabetes – Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy - (CNF049) PDF 182kB
Diabetes – Glucagon-Like Peptide-1 Agonists - Prior Authorization - (CNF360) PDF 187kB
Diabetes – Kerendia™ (finerenone tablets) - Prior Authorization - (CNF691) PDF 247kB
Diabetes – Metformin Extended-Release - Drug Quantity Management - (CNF181) PDF 177kB
Diabetes - Metformin - Step Therapy - (CNF050) PDF 162kB
Diabetes – Mounjaro™ (tirzepatide subcutaneous injection) - Prior Authorization - (CNF749) PDF 191kB
Diabetes – Omnipod Pods Drug Quantity Management Policy – Per Days - (CNF776) PDF 185kB
Diabetes – Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy - (CNF051) PDF 200kB
Diabetes – Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy - (CNF072) PDF 215kB
Diabetes – Symlin® (pramlintide subcutaneous injection) - Prior Authorization - (CNF361) PDF 172kB
Diabetes – Thiazolidinedione Step Therapy Policy - (CNF052) PDF 175kB
Dichlorphenamide Preferred Specialty Management Policy - (CNF829) PDF 115kB
Dichlorphenamide Prior Authorization Policy - (CNF455) PDF 184kB
Diuretics – Loop Products - Step Therapy - (CNF753) PDF 172kB
Dronabinol - Marinol® (dronabinol capsules), Syndros® (dronabinol oral solution) - Prior Authorization - (CNF362)

PDF 139kB
E
Enspryng Prior Authorization Policy - (CNF388) PDF 168kB
Enzyme Replacement Therapy - Strensiq® (asfotase alfa for subcutaneous use) - Prior Authorization - (CNF364) PDF 200kB
Enzyme Replacement Therapy – Sucraid Prior Authorization Policy - (CNF365) PDF 169kB
Epinephrine Auto-Injectors - Step Therapy - (CNF053) PDF 177kB
Erectile Dysfunction Agents - Drug Quantity Management - (CNF155) PDF 250kB
Erectile Dysfunction – Alprostadil Products - Prior Authorization - (CNF366) PDF 169kB
Erectile Dysfunction – Stendra Prior Authorization Policy - (CNF369) PDF 148kB
Erectile Dysfunction – Tadalafil Prior Authorization - (CNF367) PDF 212kB
Erectile Dysfunction – Vardenafil (Levitra, Staxyn) - Prior Authorization - (CNF368) PDF 177kB
Erectile Dysfunction – Viagra® (sildenafil tablets) - Prior Authorization - (CNF370) PDF 186kB
Estrogen (Topical) Patches - Drug Quantity Management - (CNF156) PDF 200kB
Estrogens (Topical) – Divigel® (estradiol 0.1% topical gel, generic) - Drug Quantity Management - (CNF146) PDF 183kB
Estrogen – Transdermal - Step Therapy Policy - (CNF0094)

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

PDF 185kB
G
Gabapentin - Step Therapy - (CNF055) PDF 115kB
Gastroenterology – Eohilia Drug Quantity Management Policy – Per Days - (CNF849) PDF 162kB
Gastroenterology – Eohilia Prior Authorization Policy - (CNF848) PDF 172kB
Gastroenterology - Gattex (teduglutide injection for subcutaneous use) - Prior Authorization - (CNF375) PDF 211kB
Gaucher Disease Substrate Reduction Therapy – Cerdelga® (eliglustat capsules) - Prior Authorization - (CNF376) PDF 215kB
Gaucher Disease Substrate Reduction Therapy – Miglustat capsules (Zavesca®, generic) - Prior Authorization - (CNF377) PDF 196kB
Gaucher Disease - Substrate Reduction Therapy - Preferred Specialty Management - (CNF263) PDF 181kB
Gonadotropin-Releasing Hormone Agonist – Synarel® (nafarelin acetate nasal solution) - Prior Authorization - (CNF417) PDF 127kB
Gonadotropin-Releasing Hormone Antagonists – Myfembree Prior Authorization Policy - (CNF679) PDF 209kB
Gonadotropin-Releasing Hormone Antagonists – Oriahnn Prior Authorization Policy - (CNF382) PDF 173kB
Gonadotropin-Releasing Hormone Antagonists – Orilissa Prior Authorization Policy - (CNF381) PDF 168kB
Gonadotropin-Releasing Hormone Antagonists – Orilissa™ (elagolix tablets) - Drug Quantity Management - (CNF199) PDF 60kB
Gout Medications - Step Therapy - (CNF056) PDF 174kB
Growth Disorders – Growth Hormone Long-Acting Products Preferred Specialty Management Policy - (CNF818_ PDF 170kB
Growth Disorders – Growth Hormone Prior Authorization Policy - (CNF384) PDF 356kB
Growth Disorders – Increlex® (mecasermin [rDNA origin] for subcutaneous injection) - Prior Authorization - (CNF383) PDF 194kB
Growth Disorders – Ngenla Prior Authorization Policy - (CNF800) PDF 193kB
Growth Disorders – Skytrofa Prior Authorization Policy - (CNF707) PDF 243kB
Growth Disorders – Sogroya Prior Authorization Policy - (CNF799) PDF 235kB
Growth Disorders – Voxzogo Prior Authorization Policy - (CNF714) PDF 220kB
Growth Hormone - Preferred Specialty Management - (CNF265)

PDF 186kB
H
Hematology – Pyrukynd® (mitapivat tablets) - Drug Quantity Management - (CNF737) PDF 184kB
Hematology – Pyrukynd® (mitapivat tablets) - Prior Authorization - (CNF735) PDF 237kB
Hemophilia - Hemlibra® (emicizumab-kxwh injection for subcutaneous use) - Prior Authorization - (CNF391) PDF 239kB
Hepatitis C – Epclusa - Drug Quantity Management - (CNF152) PDF 241kB
Hepatitis C – Epclusa Prior Authorization Policy- (CNF392) PDF 192B
Hepatitis C – Harvoni - Drug Quantity Management - (CNF163) PDF 290kB
Hepatitis C – Harvoni Prior Authorization Policy - (CNF393) PDF 208kB
Hepatitis C – Mavyret® (glecaprevir/pibrentasvir tablets and oral pellets) - Drug Quantity Management - (CNF179) PDF 264kB
Hepatitis C – Mavyret Prior Authorization for Preferred Specialty Management Policy - (CNF119) PDF 212kB
Hepatitis C – Mavyret Prior Authorization Policy - (CNF394) PDF 211kB
Hepatitis C – Sovaldi® (sofosbuvir tablets and oral pellets) - Drug Quantity Management - (CNF218) PDF 260kB
Hepatitis C – Sovaldi Prior Authorization Policy - (CNF397) PDF 176kB
Hepatitis C – Viekira Pak™ (ombitasvir/paritaprevir/ritonavir tablets; dasabuvir tablets [co-packaged]) - Prior Authorization - (CNF398) PDF 248kB
Hepatitis C – Viekira Pak™ (ombitasvir/paritaprevir/ritonavir tablets; dasabuvir tablets [co-packaged] - Drug Quantity Management - (CNF249) PDF 232kB
Hepatitis C Virus Direct-Acting Antivirals Preferred Specialty Management Policy for National Preferred Formulary and Basic Formulary - (CNF268) PDF 205kB
Hepatitis C – Vosevi Prior Authorization Policy - (CNF399) PDF 202kB
Hepatitis C – Zepatier® (grazoprevir/elbasvir tablets) - Drug Quantity Management - (CNF256) PDF 205kB
Hepatitis C – Zepatier Prior Authorization Policy - (CNF400) PDF 194kB
Hepatology – Bylvay Drug Quantity Management Policy – Per Rx - (CNF697) PDF 191kB
Hepatology – Bylvay™ (odevixibat capsules and oral pellets) - Prior Authorization - (CNF690) PDF 235kB
Hepatology – Livmarli Prior Authorization Policy - (CNF703) PDF 461kB
Hepatology – Ocaliva® (obeticholic acid tablets) - Prior Authorization - (CNF401) PDF 223kB
Hepatology – Rezdiffra Prior Authorization Policy - (CNF852) PDF 220kB
Hereditary Angioedema – Berinert and Cinryze - Drug Quantity Management - (CNF787) PDF 243kB
Hereditary Angioedema - C1 Esterase Inhibitors (Subcutaneous) - Haegarda® (C1 esterase inhibitor [human] subcutaneous injection) - Prior Authorization - (CNF403) PDF 221kB
Hereditary Angioedema – Haegarda - Drug Quantity Management - (CNF788) PDF 211kB
Hereditary Angioedema – Icatibant - Drug Quantity Management - (CNF789) PDF 205kB
Hereditary Angioedema - Icatibant - Preferred Specialty Management - (CNF270) PDF 200kB
Hereditary Angioedema – Icatibant - Prior Authorization - (CNF404) PDF 224kB
Hereditary Angioedema – Kalbitor - Drug Quantity Management - (CNF790) PDF 200kB
Hereditary Angioedema - Orladeyo™ (berotralstat capsules) - Prior Authorization - (CNF647) PDF 254kB
Hereditary Angioedema – Ruconest - Drug Quantity Management - (CNF791) PDF 181kB
Hereditary Angioedema - Takhzyro™ (lanadelumab-flyo for subcutaneous injection) - Prior Authorization - (CNF406) PDF 244kB
Homozygous Familial Hypercholesterolemia – Evkeeza Prior Authorization Policy - (CNF665) PDF 201kB
Homozygous Familial Hypercholesterolemia - Juxtapid® (lomitapide capsules) - Prior Authorization - (CNF408) PDF 252kB
Human Immunodeficiency Virus – Apretude® (cabotegravir intramuscular injection) - Prior Authorization - (CNF718) PDF 261kB
Human Immunodeficiency Virus – Rukobia™ (fostemsavir extended-release tablets) - Prior Authorization - (CNF409) PDF 213kB
Human Immunodeficiency Virus – Sunlenca® (lenacapavir tablets) - Prior Authorization - (CNF783) PDF 261kB
Hydrocortisone Acetate Suppository - Step Therapy - (CNF057) PDF 175kB
Hydroxy-methylglutaryl-coenzyme (HMG) A Reductase Inhibitors - Step Therapy - (CNF058) PDF 240kB
Hydroxy-Methylglutaryl-Coenzyme A Reductase Inhibitors Drug Quantity Management Policy – Per Rx - (CNF165) PDF 241kB
Hyperlipidemia – Nexletol Prior Authorization Policy - (CNF410) PDF 241kB
Hyperlipidemia – Nexlizet Prior Authorization Policy - (CNF411) PDF 238kB
Hyperlipidemia – Omega-3 Fatty Acid Products - Prior Authorization - (CNF412) PDF 254kB
Hypertension – Clonidine patch (Catapres TTS, generic) - Drug Quantity Management - (CNF132) PDF 172kB
Hypoactive Sexual Desire Disorder – Addyi™ (flibanserin tablets) - Prior Authorization - (CNF413) PDF 201kB
Hypoactive Sexual Desire Disorder – Vyleesi™ (bremelanotide subcutaneous injection) - Prior Authorization - (CNF414)

PDF 199kB
I
Idiopathic Pulmonary Fibrosis and Related Lung Disease - Ofev® (nintedanib capsules) - Prior Authorization - (CNF416) PDF 262kB
Idiopathic Pulmonary Fibrosis and Related Lung Disease – Pirfenidone - Preferred Specialty Management - (CNF754) PDF 182kB
Idiopathic Pulmonary Fibrosis and Related Lung Disease – Pirfenidone - Prior Authorization - (CNF415) PDF 106kB
Immune Disorder - Joenja Prior Authorization Policy - (CNF801) PDF 175kB
Immunologicals – Adbry Prior Authorization Policy - (CNF721) PDF 194kB
Immunologicals – Adbry™ (tralokinumab-ldrm subcutaneous injection) - Drug Quality Management Policies - (CNF717) PDF 174kB
Immunologicals - Anti-Interleukin-5 Agents - Preferred Specialty Management - (CNF276) PDF 201kB
Immunologicals – Dupixent® (dupilumab subcutaneous injection) - Drug Quantity Management - (CNF149) PDF 220kB
Immunologicals – Dupixent Prior Authorization Policy - (CNF420) PDF 246kB
Immunologicals – Fasenra® (benralizumab subcutaneous injection) - Drug Quantity Management - (CNF764) PDF 196kB
Immunologicals – Fasenra Prior Authorization Policy - (CNF421) PDF 190kB
Immunologicals – Nucala® (mepolizumab subcutaneous injection) - Drug Quantity Management - (CNF192) PDF 212kB
Immunologicals – Nucala Prior Authorization Policy - (CNF422) PDF 233kB
Immunologicals – Tezspire Prior Authorization Policy - (CNF720) PDF 191kB
Immunologicals – Xolair Drug Quantity Management Policy – Per Days - (CNF651) PDF 275kB
Immunologicals - Xolair Prior Authorization Policy - (CNF423) PDF 232kB
Immunosuppressive Agents – Rezurock™ (belumosudil tablets) - Drug Quantity Management Policy - (CNF694) PDF 198kB
Immunosuppressive Agents – Rezurock™ (belumosudil tablets) - Prior Authorization - (CNF692) PDF 200kB
Infectious Disease – Antiparasitics Drug Quantity Management Policy – Per Days - (CNF204) PDF 306kB
Infectious Disease – Daraprim® (pyrimethamine tablets) - Prior Authorization - (CNF424) PDF 165kB
Infectious Disease – Impavido Prior Authorization Policy -(CNF327) PDF 161kB
Infectious Disease – Ivermectin Tablets Prior Authorization Policy - (CNF698) PDF 190kB
Infectious Disease – Livtencity™ (maribavir tablets) - Drug Quantity Management - (CNF734) PDF 220kB
Infectious Disease – Livtencity™ (maribavir tablets) - Prior Authorization - (CNF713) PDF 207kB
Infectious Disease – Pretomanid tablets - Prior Authorization - (CNF425) PDF 160kB
Infectious Disease – Prevymis Drug Quantity Management Policy – Per Days - (CNF205) PDF 174kB
Infectious Disease – Sirturo® (bedaquiline fumarate) - Prior Authorization - (CNF330) PDF 165kB
Infectious Disease – Vancomycin (Oral) - Drug Quantity Management - (CNF246) PDF 208kB
Infertility – Follitropins, Clomiphene Preferred Specialty Management Policy - (CNF277) PDF 175kB
Infertility - Gonadotropin-Releasing Hormone Antagonists - Preferred Specialty Management - (CNF264) PDF 174kB
Infertility – Vaginal Progesterone Preferred Specialty Management Policy - (CNF857) PDF 161kB
Inflammatory Conditions – Actemra Subcutaneous Products Prior Authorization Policy - (CNF427) PDF 246kB
Inflammatory Conditions – Adalimumab Products Drug Quantity Management Policy – Per Days - (CNF166) PDF 299kB
Inflammatory Conditions – Adalimumab Products Preferred Specialty Management Policy for National Preferred Formularies – Choice - (CNF828) PDF 187kB
Inflammatory Conditions – Adalimumab Products Prior Authorization - (CNF428) PDF 323kB
Inflammatory Conditions – Arcalyst Drug Quantity Management Policy – Per Days - (CNF695) PDF 166kB
Inflammatory Conditions – Arcalyst Prior Authorization Policy - (CNF429) PDF 209kB
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) PDF 244kB
Inflammatory Conditions – Cimzia Drug Quantity Management Policy – Per Days - (CNF133) PDF 168kB
Inflammatory Conditions – Cimzia Prior Authorization Policy - (CNF431) PDF 309kB
Inflammatory Conditions – Cosentyx Subcutaneous Drug Quantity Management Policy – Per Days - (CNF139) PDF 211kB
Inflammatory Conditions – Cosentyx Subcutaneous Prior Authorization Policy - (CNF432) PDF 252kB
Inflammatory Conditions – Entyvio Subcutaneous Prior Authorization Policy - (CNF817) PDF 207kB
Inflammatory Conditions – Etanercept Products Drug Quantity Management Policy – Per Days - (CNF151) PDF 193kB
Inflammatory Conditions – Etanercept Products Prior Authorization - (CNF434) PDF 308kB
Inflammatory Conditions – Ilumya Drug Quantity Management Policy – Per Days - (CNF168) PDF 155kB
Inflammatory Conditions – Ilumya Prior Authorization Policy - (CNF436) PDF 280kB
Inflammatory Conditions – Kevzara Prior Authorization Policy - (CNF438) PDF 209kB
Inflammatory Conditions – Kineret Drug Quantity Management Policy – Per Days - (CNF175) PDF 178kB
Inflammatory Conditions – Kineret Prior Authorization - (CNF439) PDF 261kB
Inflammatory Conditions – Litfulo Prior Authorization Policy - (CNF802) PDF 168kB
Inflammatory Conditions – Olumiant® (baricitinib tablets) - Drug Quantity Management - (CNF763) PDF 214kB
Inflammatory Conditions – Olumiant® (baricitinib tablets) - Prior Authorization - (CNF440) PDF 242kB
Inflammatory Conditions – Omvoh Subcutaneous Prior Authorization Policy - (CNF821) PDF 229kB
Inflammatory Conditions – Orencia® Subcutaneous (abatacept subcutaneous injection) - Prior Authorization - (CNF442) PDF 268kB
Inflammatory Conditions – Otezla Drug Quantity Management Policy – Per Days - (CNF200) PDf 168kB
Inflammatory Conditions – Otezla Prior Authorization Policy - (CNF443) PDF 214kB
Inflammatory Conditions Preferred Specialty Management Policy for National Preferred, High Performance, and Basic Formularies - (CNF278) PDF 665kB
Inflammatory Conditions – Rinvoq/Rinvoq LQ Prior Authorization Policy - (CNF444) PDF 298kB
Inflammatory Conditions – Rinvoq Drug Quantity Management Policy – Per Days - (CNF727) PDF 185kB
Inflammatory Conditions – Siliq Drug Quantity Management Policy – Per Days - (CNF212) PDF 159kB
Inflammatory Conditions – Siliq Prior Authorization Policy - (CNF445) PDF 202kB
Inflammatory Conditions – Simponi® (golimumab for subcutaneous injection) - Prior Authorization - (CNF447) PDF 289kB
Inflammatory Conditions – Simponi Aria® (golimumab injection for intravenous use) - Prior Authorization - (CNF446) 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 Subcutaneous Prior Authorization Policy- (CNF448) PDF 219kB
Inflammatory Conditions – Sotyktu Prior Authorization Policy - (CNF775) PDF 194kB
Inflammatory Conditions – Spevigo Subcutaneous Prior Authorization Policy - (CNF856) PDF 186kB
Inflammatory Conditions – Stelara® (ustekinumab intravenous infusion) - Prior Authorization - (CNF449) PDF 271kB
Inflammatory Conditions – Stelara Drug Quantity Management Policy – Per Days - (CNF222) PDF 202kB
Inflammatory Conditions – Stelara Subcutaneous Prior Authorization Policy with Dosing - (CNF450) PDF 257kB
Inflammatory Conditions – Taltz Prior Authorization Policy - (CNF451) PDF 215kB
Inflammatory Conditions – Tremfya Drug Quantity Management Policy – Per Days - (CNF240) PDF 157kB
Inflammatory Conditions – Tremfya Prior Authorization Policy - (CNF452) PDF 202kB
Inflammatory Conditions – Velsipity Prior Authorization Policy - (CNF822) PDF 193kB
Inflammatory Conditions – Xeljanz®/Xeljanz XR (tofacitinib tablets, oral solution/extended-release tablets) - Prior Authorization - (CNF453) PDF 298kB
Inflammatory Conditions – Zymfentra Prior Authorization Policy - (CNF833) PDF 206kB
Inpefa Prior Authorization Policy - (CNF803) PDF 203kB
Interferon – Actimmune® (interferon gamma-1b subcutaneous injection) - Prior Authorization - (CNF454) PDF 190kB
Isotretinoin Capsules - Step Therapy - (CNF059) PDF 177kB
Ixekizumab injection (Taltz®) Duration Limit - Drug Quantity Management - (CNF226)

PDF 211kB
L
Levothyroxine Products Step Therapy Policy- (CNF834) PDF 131kB
Lidocaine Patch - Prior Authorization - (CNF456) PDF 249kB
Lipodystrophy – Egrifta SV® (tesamorelin subcutaneous injection) - Prior Authorization - (CNF457) PDF 244kB
Lipodystrophy – Myalept® (metreleptin subcutaneous injection) - Prior Authorization - (CNF487) PDF 78kB
Lucemyra™ (lofexidine tablets) - Prior Authorization - (CNF458) PDF 182kB
Lupus – Benlysta® (belimumab subcutaneous injection) - Drug Quantity Management - (CNF766) PDF 203kB
Lupus – Benlysta Subcutaneous Prior Authorization Policy - (CNF430) PDF 204kB
Lupus – Lupkynis Prior Authorization Policy - (CNF656)

PDF 193kB
M
Metabolic Disorders – Carbaglu (carglumic acid tablets for oral suspension) - Prior Authorization - (CNF460) PDF 241kB
Metabolic Disorders – Cystadane® (betaine anhydrous powder, generic) - Preferred Specialty Management - (CNF773) PDF 170kB
Metabolic Disorders – Cystadane® (betaine anhydrous powder, generic) - Prior Authorization - (CNF770) PDF 194kB
Metabolic Disorders – Cysteamine Ophthalmic Solution Prior Authorization Policy - (CNF461) PDF 167kB
Metabolic Disorders – Dojolvi™ (triheptanoin oral liquid) - Prior Authorization - (CNF463) PDF 68kB
Metabolic Disorders – Imcivree - Drug Quantity Management - (CNF664) PDF 664kB
Metabolic Disorders – Imcivree Prior Authorization Policy - (CNF654) PDF 237kB
Metabolic Disorders – Nitisinone Products - Prior Authorization - (CNF464) PDF 199kB
Metabolic Disorders – Phenylbutyrate Products Preferred Specialty Management Policy - (CNF820) PDF 188kB
Metabolic Disorders – Phenylbutyrate Products Prior Authorization - (CNF465) PDF 204kB
Metabolic Disorders – Primary Hyperoxaluria Medications – Rivfloza Prior Authorization Policy - (CNF845) PDF 183kB
Metabolic Disorders – Tiopronin Products Prior Authorization Policy - (CNF466) PDF 206kB
Metabolic Disorders – Xuriden® (uridine triacetate oral granules) - Prior Authorization - (CNF467) PDF 175kB
Methergine® (methylergonovine maleate tablets) - Prior Authorization (CNF468) PDF 225kB
Methotrexate Injection - Step Therapy - (CNF060) PDf 180kB
Migraine – Calcitonin Gene-Related Peptide Inhibitors – Aimovig Prior Authorization Policy - (CNF331) PDF 187kB
Migraine – Calcitonin Gene-Related Peptide Inhibitors – Ajovy Prior Authorization Policy - (CNF332) PDF 216kB
Migraine – Calcitonin Gene-Related Peptide Inhibitors – Emgality Prior Authorization Policy - (CNF333) PDF 208kB
Migraine – Elyxyb Prior Authorization Policy - (CNF723) PDF 168kB
Migraine Medication - Step Therapy - (CNF061) PDF 210kB
Migraine – Nurtec ODT Prior Authorization Policy - (CNF469) PDF 182kB
Migraine – Qulipta Prior Authorization Policy - (CNF708) PDF 250kB
Migraine – Reyvow™ (lasmiditan tablet) - Prior Authorization - (CNF470) PDF 212kB
Migraine – Triptans Drug Quantity Management Policy – Per Rx - (CNF728) PDF 234kB
Migraine – Ubrelvy™ (ubrogepant tablet) - Prior Authorization - (CNF471) PDF 210kB
Migraine -  Zavzpret Prior Auhtorization - (CNF804) PDF 165kB
Multiple Sclerosis – Ampyra® (dalfampridine extended-release tablets, generic) - Preferred Specialty Management - (CNF281) PDF 170kB
Multiple Sclerosis – Ampyra® (dalfampridine extended-release tablets) - Prior Authorization - (CNF472) PDF 159kB
Multiple Sclerosis and Ulcerative Colitis – Zeposia® (ozanimod capsules) - Prior Authorization - (CNF485) PDF 270kB
Multiple Sclerosis and Ulcerative Colitis – Zeposia Preferred Specialty Management Policy for National Preferred Formularies - (CNF681) PDF 217kB
Multiple Sclerosis – Avonex® (interferon beta-1a injection for intramuscular use) - Prior Authorization - (CNF474) PDF 220kB
Multiple Sclerosis – Bafiertam™ (monomethyl fumarate delayed-release) - Prior Authorization - (CNF475) PDF 219kB
Multiple Sclerosis – Betaseron/Extavia - Prior Authorization - (CNF476) PDF 188kB
Multiple Sclerosis – Dimethyl Fumarate (Tecfidera® [dimethyl fumarate delayed-release capsules]) - Prior Authorization - (CNF483) PDF 255kB
Multiple Sclerosis – Gilenya® (fingolimod capsules, generic) - Prior Authorization - (CNF477) PDF 225kB
Multiple Sclerosis – Glatiramer Products - Prior Authorization - (CNF478) PDF 244kB
Multiple Sclerosis – Kesimpta® (ofatumumab injection for subcutaneous use) - Prior Authorization - (CNF389) PDF 83kB
Multiple Sclerosis – Kesimpta® (ofatumumab subcutaneous injection) - Drug Quality Management Policies - (CNF677) PDF 170kB
Multiple Sclerosis – Mavenclad Prior Authorization Policy - (CNF479) PDF 186kB
Multiple Sclerosis – Mayzent Prior Authorization Policy - (CNF480) PDF 185kB
Multiple Sclerosis – Plegridy® (peginterferon beta-1a injection for subcutaneous or intramuscular use) - Prior Authorization - (CNF481) PDF 219kB
Multiple Sclerosis – Ponvory™ (ponesimod tablets) - Drug Quantity Management - (CNF755) PDF 197kB
Multiple Sclerosis – Ponvory™ (ponesimod tablets) - Prior Authorization - (CNF673) PDF 218kB
Multiple Sclerosis - Preferred Specialty Management - (CNF280) PDF 170kB
Multiple Sclerosis – Rebif Prior Authorization Policy - (CNF482) PDF 183kB
Multiple Sclerosis – Tascenso ODT Prior Authorization Policy - (CNF771) PDF 191kB
Multiple Sclerosis – Teriflunomide Prior Authorization Policy - (CNF473) PDF 183kB
Multiple Sclerosis – Vumerity® (diroximel fumarate delayed-release) - Prior Authorization - (CNF484) PDF 218kB
Muscular Dystrophy – Agamree Prior Authorization Policy - (CNF846) PDF 173kB
Muscular Dystrophy – Deflazacort Preferred Specialty Management Policy - (CNF851) PDF 164kB
Muscular Dystrophy – Deflazacort Prior Authorization Policy - (CNF363)

PDF 182kB
N
Nasal Steroids Step Therapy Policy - (CNF064) PDF 152kB
Natpara Prior Authorization Policy - (CNF488) PDF 126kB
Nephrology – Filspari Prior Authorization Policy - (CNF805) PDF 181kB
Nephrology - Jesduvroq Prior Authorization Policy - (CNF812) PDF 205kB
Nephrology – Tarpeyo™ (budesonide delayed-release capsules) - Prior Authorization - (CNF715) PDF 241kB
Nephrology – Xphozah Prior Authorization Policy - (CNF826) PDF 168kB
Neurology – Daybue Prior Authorization Policy - (CNF806) PDF 176kB
Neurology – Lyrica® CR (pregabalin extended-release tablets) - Prior Authorization - (CNF459) PDF 215kB
Neurology – Oxybate Products - Prior Authorization - (CNF643) PDF 237kB
Neurology – Skyclarys Prior Authorization Policy - (CNF807) PDF 182kB
Non-Preferred Drug Coverage Review - (Formulary Exception Criteria) - (CNF002) PDF 154kB
Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy - (CNF065) PDF 180kB
Nonsteroidal Anti-Inflammatory Drug – Tivorbex® (indomethacin capsules, generic) - Drug Quantity Management - (CNF759) PDF 91kB
Northera® (droxidopa capsules) - Prior Authorization - (CNF490) PDF 182kB
Nuedexta® (dextromethorphan hydrobromide and quinidine sulfate capsules) - Prior Authorization - (CNF491)

PDF 190kB
O
Oncology (Injectable) – Besremi® (ropeginterferon alfa-2b-njft subcutaneous injection) - Prior Authorization - (CNF719) PDF 86kB
Oncology (Other) – Anktiva Prior Authorization Policy - (CNF861) PDF 164kB
Oncology - Abiraterone Acetate (Zytiga® tablets; generic) - Prior Authorization - (CNF492) PDF 227kB
Oncology – Abiraterone Acetate - Drug Quantity Management - (CNF255) 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) PDF 240kB
Oncology – Akeega Prior Authorization Policy - (CNF808) PDF 185kB
Oncology – Alecensa Prior Authorization Policy - (CNF494) PDF 173kB
Oncology – Alunbrig™ (brigatinib tablets) - Prior Authorization - (CNF495) PDF 235kB
Oncology - Alunbrig™ (brigatinib tablets for oral use) Dispensing Limit - Drug Quantity Management - (CNF124) PDF 61kB
Oncology – Augtyro Prior Authorization Policy - (CNF831) PDF 156kB
Oncology – Ayvakit Prior Authorization Policy - (CNF496) PDF 173kB
Oncology – Balversa Prior Authorization Policy - (CNF497) PDF 160kB
Oncology – Bexarotene (Oral) Preferred Specialty Management Policy - (CNF795) PDF 164kB
Oncology – Bexarotene (Oral) - Prior Authorization - (CNF552) PDF 171kB
Oncology – Bexarotene (Topical) Preferred Specialty Management Policy - (CNF796) PDF 165kB
Oncology – Bexarotene (Topical) - Prior Authorization - (CNF553) PDF 172kB
Oncology – Bosulif Drug Quantity Management Policy – Per Rx - (CNF128) PDF 178kB
Oncology – Bosulif Prior Authorization Policy - (CNF498) PDF 169kB
Oncology – BRAF and MEK Inhibitors Preferred Specialty Management Policy - (CNF819) PDF 182kB
Oncology – Braftovi Prior Authorization Policy - (CNF499) PDF 218kB
Oncology – Brukinsa Prior Authorization Policy - (CNF500) PDF 187kB
Oncology - Cabometyx (cabozantinib tablets) Dispensing Limit - Drug Quantity Management - (CNF129) PDF 209kB
Oncology – Cabometyx Prior Authorization Policy - (CNF501) PDF 192kB
Oncology - Calquence® (acalabrutinib capsules) - Drug Quantity Management - (CNF130) PDF 179kB
Oncology - Calquence® (acalabrutinib capsules) - Prior Authorization - (CNF502) PDF 222kB
Oncology – Caprelsa® (vandetanib tablets) - Prior Authorization - (CNF503) PDF 88kB
Oncology – Cometriq® (cabozantinib capsules) - Drug Quantity Management - (CNF725) PDF 158kB
Oncology – Cometriq™ (cabozantinib capsules) - Prior Authorization - (CNF504) PDF 216kB
Oncology - Copiktra™ (duvelisib capsules) - Prior Authorization - (CNF505) PDF 100kB
Oncology – Cotellic® (cobimetinib tablets) - Prior Authorization - (CNF506) PDF 221kB
Oncology – Cyclin Dependent Kinases 4, 6 Inhibitors Preferred Specialty Management Policy - (CNF284) PDF 209kB
Oncology – Daurismo™ (glasdegib tablets) - Prior Authorization - (CNF507) PDF 227kB
Oncology – Doptelet® (avatrombopag tablets) - Drug Quantity Management - (CNF147) PDF 231kB
Oncology – Erivedge® (vismodegib capsules) - Prior Authorization - (CNF508) PDF 223kB
Oncology – Erleada Prior Authorization Policy - (CNF509) PDF 208kB
Oncology – Erlotinib (Tarceva® tablets, generics) - Prior Authorization - (CNF510) PDF 261kB
Oncology – Erlotinib Drug Quantity Management Policy – Per Rx - (CNF228) PDF 175kB
Oncology – Everolimus Products - Preferred Specialty Management - (CNF283) PDF 204kB
Oncology – Everolimus Products - Prior Authorization - (CNF493) PDF 202kB
Oncology – Exkivity™ (mobocertinib capsules) - Prior Authorization - (CNF702) PDF 198kB
Oncology – Farydak® (panobinostat capsules) - Prior Authorization - (CNF511) PDF 171kB
Oncology – Fotivda Prior Authorization Policy - (CNF670) PDF 155kB
Oncology – Fruzaqla Prior Authorization Policy - (CNF825) PDF 163kB
Oncology – Gavreto (pralsetinib capsules) - Prior Authorization - (CNF441) PDF 221kB
Oncology – Gavreto Drug Quantity Management Policy – Per Rx - (CNF746) PDF 200kB
Oncology – Gilotrif™ (afatinib tablets) - Prior Authorization - (CNF512) PDF 221kB
Oncology – Gleevec® (imatinib tablets, generic) - Drug Quantity Management - (CNF162) PDF 206kB
Oncology – Ibrance Prior Authorization Policy - (CNF513) PDF 173kB
Oncology – Iclusig Prior Authorization Policy - (CNF514) PDF 213kB
Oncology – Idhifa Prior Authorization Policy - (CNF515) PDF 153kB
Oncology – Imatinib Preferred Specialty Management Policy - (CNF696) PDF 163kB
Oncology – Imatinib Prior Authorization Policy - (CNF516) PDF 208kB
Oncology – Imbruvica® (ibrutinib) - Preferred Specialty Management - (CNF285) PDF 67kB
Oncology - Imbruvica® (ibrutinib tablets and capsules) - Prior Authorization - (CNF517) PDF 228kB
Oncology – Imbruvica Drug Quantity Management Policy – Per Rx - (CNF838) PDF 176kB
Oncology – Inlyta® (axitinib tablets) - Prior Authorization - (CNF518) PDF 93kB
Oncology – Inqovi® (decitabine and cedazuridine tablets) - Prior Authorization - (CNF519) PDF 201kB
Oncology – Inrebic® (fedratinib capsules) - Prior Authorization - (CNF520) PDF 230kB
Oncology – Iressa® (gefitinib tablets) - Drug Quantity Management - (CNF171) PDF 197kB
Oncology – Iressa® (gefitinib tablets) - Prior Authorization - (CNF521) PDF 57kB
Oncology – Iwilfin Prior Authorization Policy - (CNF841) PDF 157kB
Oncology – Jakafi Prior Authorization Policy - (CNF522) PDF 190kB
Oncology – Jaypirca Prior Authorization Policy - (CNF813) PDF
Oncology – Jaypirca Prior Authorization Policy - (CNF813) PDF 201kB
Oncology – Jaypirca™ (pirtobrutinib tablets) - Drug Quantity Management - (CNF794) PDF 176kB
Oncology – Kisqali and Kisqali Femara Co-Pack Prior Authorization Policy - (CNF523) PDF 188kB
Oncology – Koselugo Prior Authorization Policy - (CNF418) PDF 212kB
Oncology – Krazati™ (adagrasib tablets) - Prior Authorization - (CNF782) PDF 204kB
Oncology – Lapatinib Drug Quantity Management Policy – Per Rx - (CNF242) PDF 172kB
Oncology – Lenvima™ (lenvatinib capsules) - Prior Authorization - (CNF524) PDF 100kB
Oncology – Lonsurf® (trifluridine and tipiracil tablets) - Prior Authorization - (CNF525) PDF 208kB
Oncology – Lorbrena® (lorlatinib tablets) - Prior Authorization - (CNF526) PDF 252kB
Oncology – Lumakras™ (sotorasib tablets) - Prior Authorization - (CNF678) PDF 91kB
Oncology – Lynparza Prior Authorization Policy - (CNF527) PDF 202kB
Oncology – Lytgobi® (futibatinib tablets) - Prior Authorization - (CNF780) PDF 203kB
Oncology – Mekinist Prior Authorization Policy - (CNF528) PDF 221kB
Oncology – Mektovi® (binimetinib tablets) - Prior Authorization - (CNF529) PDF 212kB
Oncology – Nerlynx Prior Authorization Policy - (CNF530) PDF 215kB
Oncology - Nexavar® (sorafenib tablets, generic) - Prior Authorization - (CNF531) PDF 114kB
Oncology - Nilandron® (nilutamide tablets) - Prior Authorization - (CNF532) PDF 171kB
Oncology – Ninlaro Prior Authorization Policy - (CNF533) PDF 167kB
Oncology - Nubeqa® (darolutamide tablets) - Prior Authorization - (CNF534) PDF 232kB
Oncology – Odomzo Prior Authorization Policy - (CNF535) PDF 212kB
Oncology – Ogsiveo Prior Authorization Policy - (CNF832) PDF 164kB
Oncology – Ojemda Prior Authorization Policy - (CNF860) PDF 159kB
Oncology – Ojjaara Prior Authorization Policy - (CNF814) PDF 164kB
Oncology – Onureg (azacitadine tablets) - Prior Authorization - (CNF486) PDF 223kB
Oncology – Orgovyx™ (relugolix tablets) - Drug Quantity Management - (CNF652) PDF 190kB
Oncology – Orgovyx™ (relugolix tablets) - Prior Authorization - (CNF653) PDF 168kB
Oncology – Orserdu Prior Authorization Policy - (CNF815) PDF 187kB
Oncology – Pemazyre Prior Authorization Policy - (CNF536) PDF 162kB
Oncology - Piqray® (alpelisib tablets) - Prior Authorization - (CNF537) PDF 197kB
Oncology - Pomalyst® (pomalidomide capsules) - Prior Authorization - (CNF538) PDF 230kB
Oncology – Qinlock Drug Quantity Management Policy – Per Rx - (CNF747) PDF 168kB
Oncology – Qinlock Prior Authorization Policy (CNF539) PDF 167kB
Oncology - Retevmo™ (selpercatinib capsules) - Prior Authorization (CNF540) PDF 215kB
Oncology - Revlimid® (lenalidomide capsules) - Prior Authorization - (CNF541) PDF 265kB
Oncology – Rezlidhia™ (olutasidenib capsules) - Prior Authorization - (CNF781) PDF 196kB
Oncology – Rozlytrek Drug Quantity Management Policy – Per Rx - (CNF210) PDF 236kB
Oncology - Rozlytrek™ (entrectinib capsules) - Prior Authorization - (CNF542) PDF 227kB
Oncology - Rubraca™ (rucaparib tablets) - Prior Authorization - (CNF543) PDF 217kB
Oncology – Rydapt Prior Authorization Policy - (CNF544) PDF 169kB
Oncology – Scemblix Prior Authorization Policy - (CNF712) PDF 167kB
Oncology – Sorafenib - Preferred Specialty Management - (CNF762) PDF 176kB
Oncology – Sprycel® (dasatinib tablets) - Drug Quantity Management - (CNF220) PDF 227kB
Oncology – Sprycel Prior Authorization Policy - (CNF545) PDF 204kB
Oncology – Stivarga Prior Authorization Policy - (CNF546) PDF 188kB
Oncology – Sutent® (sunitinib malate capsules, generic) - Drug Quantity Management - (CNF225) PDF 196kB
Oncology – Sutent® (sunitinib malate capsules, generic) - Preferred Specialty Management - (CNF793) PDF 177kB
Oncology - Sutent® (sunitinib malate capsules) - Prior Authorization - (CNF547) PDF 255kB
Oncology - Tabrecta™ (capmatinib tablets) - Prior Authorization - (CNF548) PDF 199kB
Oncology – Tafinlar Prior Authorization Policy - (CNF549) PDF 215kB
Oncology - Tagrisso® (osimertinib tablets) - Prior Authorization - (CNF550) PDF 237kB
Oncology – Talzenna Prior Authorization Policy - (CNF551) PDF 170kB
Oncology - Tasigna (nilotinib capsules) - Drug Quantity Management - (CNF230) PDF 233kB
Oncology – Tasigna Prior Authorization Policy - (CNF554) PDF 187kB
Oncology – Tazverik Prior Authorization Policy - (CNF555) PDF 185kB
Oncology – Temozolomide capsules (Temodar®, generic) - Prior Authorization - (CNF556) PDF 206kB
Oncology – Tepmetko® (tepotinib tablets) - Prior Authorization - (CNF667) PDF 222kB
Oncology – Thalomid Prior Authorization Policy - (CNF557) PDF 221kB
Oncology – Tibsovo Prior Authorization Policy - (CNF558) PDF 176kB
Oncology – Truqap Prior Authorization Policy - (CNF830) PDF 163kB
Oncology – Truseltiq™ (infigratinib capsules) - Prior Authorization - (CNF680) PDF 198kB
Oncology – Tukysa Prior Authorization Policy - (CNF559) PDF 172kB
Oncology – Turalio Prior Authorization Policy - (CNF560) PDF 158kB
Oncology - Tykerb® (lapatinib ditosylate tablets) - Prior Authorization - (CNF561) PDF 218kB
Oncology – Valchlor® (mechlorethamine topical gel) - Prior Authorization - (CNF562) PDF 203kB
Oncology – Vanflyta Prior Authorization Policy - (CNF809) PDF 159kB
Oncology - Venclexta® (venetoclax tablets) - Prior Authorization - (CNF563) PDF 248kB
Oncology – Venclexta Drug Quantity Management Policy – Per Rx - (CNF726) PDF 207kB
Oncology – Verzenio Prior Authorization Policy - (CNF564) PDF 262kB
Oncology – Vistogard Drug Quantity Management Policy – Per Rx - (CNF724) PDF 160kB
Oncology – Vistogard Prior Authorization Policy - (CNF565) PDF 178kB
Oncology – Vitrakvi Drug Quantity Management Policy – Per Rx - (CNF748) PDF 202kB
Oncology – Vitrakvi Prior Authorization Policy - (CNF566) PDF 156kB
Oncology - Vizimpro® (dacomitinib tablets) - Prior Authorization - (CNF567) PDF 213kB
Oncology – Vonjo™ (pacritinib capsules) - Prior Authorization - (CNF730) PDF 189kB
Oncology - Votrient® (pazopanib tablets) - Prior Authorization - (CNF568) PDF 109kB
Oncology – Welireg Prior Authorization Policy - (CNF701) PDF 165kB
Oncology - Xalkori® (crizotinib capsules) - Prior Authorization - (CNF569) PDF 245kB
Oncology – Xalkori Drug Quantity Management Policy – Per Rx - (CNF757) PDF 175kB
Oncology – Xeloda® (capecitabine tablets, generic) - Preferred Specialty Management - (CNF774) PDF 181kB
Oncology – Xeloda® (capecitabine tablets, generic) - Prior Authorization - (CNF687) PDF 240kB
Oncology – Xermelo® (telotristat ethyl tablets) - Drug Quantity Management - (CNF253) PDF 202kB
Oncology – Xermelo Prior Authorization Policy - (CNF570) PDF 157kB
Oncology - Xospata® (gilteritinib tablets) - Prior Authorization - (CNF571) PDF 208kB
Oncology – Xpovio Prior Authorization Policy - (CNF572) PDF 186kB
Oncology – Xtandi Drug Quantity Management Policy – Per Rx - (CNF669) PDF 164kB
Oncology – Xtandi Prior Authorization Policy - (CNF573) PDF 151kB
Oncology – Yonsa Prior Authorization Policy - (CNF574) PDF 160kB
Oncology – Zejula Prior Authorization Policy - (CNF575) PDF 175kB
Oncology - Zelboraf® (vemurafenib tablets) - Prior Authorization - (CNF576) PDF 228kB
Oncology – Zolinza Prior Authorization Policy - (CNF577) PDF 169kB
Oncology - Zydelig® (idelalisib tablets) - Prior Authorization - (CNF578) PDF 94kB
Oncology - Zykadia™ (ceritinib capsules and tablets) - Prior Authorization - (CNF579) PDF 231kB
Ophthalmic Anti-Allergics: Mast Cell Stabilizers - Step Therapy - (CNF066) PDF 257kB
Ophthalmic Anti-Allergics – Miscellaneous Step Therapy Policy - (CNF067) PDF 186kB
Ophthalmic Corticosteroids - Step Therapy - (CNF699) PDF 97kB
Ophthalmic for Dry Eye Disease – Eysuvis™ (loteprednol etabonate 0.25% ophthalmic suspension) - Prior Authorization - (CNF646) PDF 174kB
Ophthalmic for Dry Eye Disease - Lacrisert® (hydroxypropyl cellulose ophthalmic insert) - Prior Authorization - (CNF633) PDF 178kB
Ophthalmic - Glaucoma - Alpha-Adrenergic Agonists - Step Therapy - (CNF739) PDF 176kB
Ophthalmic - Glaucoma - Beta-Adrenergic Blockers - Step Therapy - (CNF740) PDF 180kB
Ophthalmic - Glaucoma - Carbonic Anhydrase Inhibitors - Step Therapy - (CNF741) PDF 64kB
Ophthalmic - Glaucoma - Combination Products - Step Therapy - (CNF742) PDF 174kB
Ophthalmic – Glaucoma – Prostaglandins Prior Authorization - (CNF585) PDF 180kB
Ophthalmic Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy - (CNF105) PDF 120kB
Ophthalmology – Dry Eye Disease – Cyclosporine Products Prior Authorization Policy - (CNF583) PDF 186kB
Ophthalmology – Dry Eye Disease – Lacrisert® (hydroxypropyl cellulose ophthalmic insert) - Drug Quantity Management - (CNF689) PDF 175kB
Ophthalmology – Dry Eye Disease – Miebo Prior Authorization Policy - (CNF810) PDF 162kB
Ophthalmology – Dry Eye Disease – Tyrvaya Prior Authorization Policy - (CNF710) PDF 164kB
Ophthalmology – Dry Eye Disease – Xiidra Prior Authorization Policy - (CNF584) PDF 163kB
Ophthalmology - Oxervate™ (cenegermin-bkbj ophthalmic solution) - Prior Authorization - (CNF586) PDF 201kB
Ophthalmology – Upneeq Prior Authorization Policy - (CNF387) PDF 171kB
Ophthalmology – Verkazia® (cyclosporine 0.1% ophthalmic emulsion) - Prior Authorization - (CNF722) PDF 207kB
Opioid – Morphine Milligram Equivalent (200) - Drug Quantity Management - (CNF185) PDF 230kB
Opioid – Morphine Milligram Equivalent (90) - Drug Quantity Management - (CNF184) PDF 203kB
Opioids - Fentanyl Transdermal Products - Drug Quantity Management - (CNF158) PDF 74kB
Opioids - Fentanyl Transmucosal Drugs - Prior Authorization - (CNF587) PDF 483kB
Opioids – Fentanyl Transmucosal Products - Drug Quantity Management - (CNF159) PDF 262kB
Opioids – Long-Acting Products (Oral) - Drug Quantity Management - (CNF197) PDF 288kB
Opioids – Long Acting Products - Prior Authorization - (CNF589) PDF 243kB
Opioids – Methadone Prior Authorization Policy - (CNF843) PDF 197kB
Opioids – Nucynta Drug Quantity Management Policy – Per Rx - (CNF193) PDF 176kB
Opioids – Short-Acting Products (Adults) - Drug Quantity Management - (CNF194) PDF 249kB
Opioids – Short-Acting Products (Pediatrics) - Drug Quantity Management - (CNF196) PDF 204kB
Opioids – Tramadol Extended Release - Prior Authorization - (CNF588) PDF 240kB
Opioids – Tramadol Extended-Release Products - Drug Quantity Management - (CNF239) PDF 184kB
Opioids Transmucosal – Fentora Formulary Exception Policy - (CNF017) PDF 57kB
Opioids Transmucosal - Lazanda® (fentanyl nasal spray) - Formulary Exception - (CNF018) PDF 57kB
Opioids Transmucosal – Subsys Formulary Exception Policy - (CNF019) PDF 156kB
Overactive Bladder Medications Preferred Step Therapy Policy - (CNF108) PDF 219kB
Oxbryta™ (voxelotor tablets) Dispensing Limit - Drug Quantity Management - (CNF201)

PDF 252kB
P
Parkinson's Disease - Tolcapone Products - Prior Authorization - (CNF599) PDF 189kB
Parkinson’s Disease – Amantadine Extended-Release Drugs Prior Authorization with Step Therapy Policy - (CNF590) PDF 211kB
Parkinson’s Disease –Apomorphine Subcutaneous Prior Authorization Policy - (CNF591) PDF 196kB
Parkinson’s Disease – Carbidopa Prior Authorization Policy- (CNF595) PDF 159kB
Parkinson’s Disease – Duopa Prior Authorization Policy - (CNF592) PDF 186kB
Parkinson’s Disease – Inbrija Prior Authorization Policy - (CNF593) PDF 187kB
Parkinson’s Disease – Kynmobi Prior Authorization Policy - (CNF594) PDF 190kB
Parkinson’s Disease – Monoamine Oxidase Type B Inhibitors - Step Therapy - (CNF062) PDF 227kB
Parkinson’s Disease – Nourianz Prior Authorization Policy - (CNF596) PDF 183kB
Parkinson’s Disease – Nuplazid Prior Authorization Policy - (CNF597) PDF 192kB
Parkinson’s Disease – Ongentys Prior Authorization Policy - (CNF598) PDF 183kB
Parkinson’s Disease – Zelapar Prior Authorization Policy - (CNF600) PDF 186kB
Phenylketonuria – Palynziq® (pegvaliase-pqpz injection for subcutaneous use) - Prior Authorization - (CNF602) PDF 223kB
Phenylketonuria – Palynziq Drug Quantity Management Policy – Per Rx - (CNF203) PDF 175kB
Phenylketonuria – Sapropterin Prior Authorization Policy - (CNF601) PDF 185kB
Pheochromocytoma – Metyrosine Capsules and Phenoxybenzamine Capsules - Prior Authorization - (CNF603) PDF 225kB
Phosphate Binders - Drug Quantity Management - (CNF671) PDF 234kB
Phosphate Binders - Preferred Step Therapy - (CNF110) PDF 179kB
Pompe Disease – Enzyme Stabilization Therapy – Opfolda Prior Authorization Policy - (CNF816) PDF 171kB
Potassium Binders – Lokelma® (sodium zirconium cyclosilicate for oral suspension) - Drug Quantity Management - (CNF178) PDF 192kB
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Praluent Prior Authorization Policy - (CNF604) PDF 266kB
Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha Prior Authorization Policy - (CNF605) PDF 267kB
Proton Pump Inhibitors Drug Quantity Management Policy – Per Rx - (CNF243) PDF 318kB
Proton Pump Inhibitors Step Therapy Policy - (CNF070) PDF 141kB
Psychiatry – Novel Psychotropics - Drug Quantity Management - (CNF126) PDF 339kB
Psychiatry – Spravato Prior Authorization Policy - (CNF606) PDF 191kB
Pulmonary Arterial Hypertension – Adempas® (riociguat tablets) - Drug Quantity Management - (CNF767) PDF 198kB
Pulmonary Arterial Hypertension - Adempas® (riociguat tablets) - Prior Authorization - (CNF607) PDF 101kB
Pulmonary Arterial Hypertension and Related Lung Disease – Inhaled Prostacyclin Products Prior Authorization Policy - (CNF609) PDF 197kB
Pulmonary Arterial Hypertension - Endothelin Receptor Antagonist - Preferred Specialty Management - (CNF288) PDF 227kB
Pulmonary Arterial Hypertension – Endothelin Receptor Antagonists - (CNF608) PDF 202kB
Pulmonary Arterial Hypertension - Inhaled Prostacyclin - Preferred Specialty Management - (CNF289) PDF 198kB
Pulmonary Arterial Hypertension – Orenitram Drug Quantity Management Policy – Per Rx - (CNF768) PDF 177kB
Pulmonary Arterial Hypertension – Orenitram Prior Authorization Policy - (CNF610) PDF 192kB
Pulmonary Arterial Hypertension - Phosphodiesterase Type 5 Inhibitors - Preferred Specialty Management - (CNF290) PDF 205kB
Pulmonary Arterial Hypertension – Phosphodiesterase Type 5 Inhibitors - Prior Authorization - (CNF611) PDF 190kB
Pulmonary Arterial Hypertension – Sildenafil Drug Quantity Management Policy – Per Rx - (CNF209) PDF 186kB
Pulmonary Arterial Hypertension – Uptravi® (selexipag tablets) - Prior Authorization - (CNF612) PDF 98kB
Pulmonary Arterial Hypertension – Uptravi Drug Quantity Management Policy – Per Days - (CNF854) PDF 163kB
Pulmonary Arterial Hypertension – Winrevair Prior Authorization Policy - (CNF855) PDF 177kB
Pulmonary – Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers Drug Quantity Management Policy – Per Rx - (CNF784) PDF 261kB
Pulmonary – Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers - Prior Authorization - (CNF348) PDF 261kB
Pulmonary – Daliresp® (roflumilast tablets) - Prior Authorization - (CNF357)

PDF 206kB
Q
Qbrexza Prior Authorization Policy - (CNF613)

PDF 113kB
S
Sedative Hypnotics - Step Therapy - (CNF071) PDF 218kB
Sickle Cell Disease – Endari Prior Authorization Policy - (CNF615) PDF 202kB
Sickle Cell Disease - Hydroxyurea - Preferred Step Therapy - (CNF116) PDF 203kB
Sickle Cell Disease – Oxbryta™ (voxelotor tablets) - Prior Authorization - (CNF616) PDF 228kB
Sohonos Prior Authorization Policy - (CNF811) PDF 169kB
Somatostatin Analogs – Mycapssa - Drug Quantity Management - (CNF792) PDF 176kB
Somatostatin Analogs – Mycapssa Prior Authorization - (CNF390) PDF 165kB
Somatostatin Analogs – Octreotide Immediate-Release Products Preferred Specialty Management Policy - (CNF693) PDF 175kB
Somatostatin Analogs – Octreotide Immediate-Release Products Prior Authorization Policy - (CNF685) PDF 173kB
Somavert® (pegvisomant for injection) - Prior Authorization - (CNF619) PDF 173kB
Spinal Muscle Atrophy – Spinraza Drug Quantity Management Policy – Per Days - (CNF219) PDF 166kB
Spinal Muscular Atrophy – Evrysdi® (risdiplam oral solution) - Prior Authorization - (CNF0386) PDF 270kB
Spinal Muscular Atrophy – Evrysdi Prior Authorization Policy - (CNF386)

PDF 220kB
T
Tasimelteon Products Prior Authorization Policy - (CNF407) PDF 277kB
Testosterone (Injectable) Products Prior Authorization Policy - (CNF620) PDF 184kB
Testosterone Undecanoate (Oral) Drug Quantity Management (DQM) – Per Rx - (CNF174) PDF 188kB
Tetracyclines (Oral) Step Therapy Policy - (CNF073) PDF 152kB
Thrombocytopenia – Doptelet Prior Authorization Policy - (CNF622) PDF 166kB
Thrombocytopenia – Eltrombopag Products Prior Authorization Policy - (CNF624) PDF 224kB
Thrombocytopenia – Mulpleta Prior Authorization Policy - (CNF623) PDF 157kB
Thrombocytopenia – Tavalisse Prior Authorization Policy - (CNF625) PDF 174kB
Tolvaptan Products - Drug Quantity Management - (CNF211) PDF 209kB
Tolvaptan Products – Jynarque® (tolvaptan tablets) - Prior Authorization - (CNF626) PDF 215kB
Tolvaptan Products - Tolvaptan (Samsca) Prior Authorization Policy - (CNF627) PDF 134kB
Topical Acne – Cleansers Step Therapy Policy - (CNF074) PDF 167kB
Topical Acne – Kits Step Therapy Policy- (CNF075) PDF 171kB
Topical Acne – Topical Products Step Therapy Policy - (CNF076) PDF 186kB
Topical Acne – Winlevi Prior Authorization Policy - (CNF705) PDF 164kB
Topical Acyclovir Products - Prior Authorization - (CNF628) PDF 210kB
Topical Agents for Atopic Dermatitis - Drug Quantity Management - (CNF236) PDF 248kB
Topical Agents for Atopic Dermatitis Step Therapy Policy - (CNF077) PDF 123B
Topical Alpha-Adrenergic Agonists for Rosacea – Rhofade Prior Authorization Policy - (CNF731) PDF 160kB
Topical Anesthetic – Lidocaine, Tetracaine Products Prior Authorization with Step Therapy Policy - (CNF675) PDF 168kB
Topical Anesthetic Products Duration Limit - Drug Quantity Management - (CNF232) PDF 238kB
Topical Antibacterials - Step Therapy -(CNF078) PDF 227kB
Topical Antibiotics for Acne – Clindamycin - Drug Quantity Management - (CNF134) PDF 225kB
Topical Antifungal Products Duration Limit - Drug Quantity Management - (CNF238) PDF 350kB
Topical Antifungals for Onychomycosis - Step Therapy - (CNF038) PDF 118kB
Topical Antifungals for Seborrheic Dermatitis Step Therapy Policy - (CNF835) PDF 119kB
Topical Antipruritics – Doxepin Products - Drug Quantity Management - (CNF235) PDF 188kB
Topical Calcipotriene Products - Drug Quantity Management - (CNF233) PDF 247kB
Topical Collagenase – Santyl® (collagenase santyl ointment 250 units/gram) - Drug Quantity Management - (CNF234) PDF 176kB
Topical Corticosteroids – Clobetasol Drug Quantity Management Policy – Per Days - (CNF135) PDF 204kB
Topical Corticosteroids – Diflorasone - Drug Quantity Management - (CNF144) PDF 183kB
Topical Corticosteroids – Fluocinonide - Drug Quantity Management - (CNF160) PDF 231kB
Topical Corticosteroids – Hydrocortisone Butyrate - Drug Quantity Management - (CNF177) PDF 190kB
Topical Corticosteroids - Step Therapy - (CNF079) PDF 217kB
Topical Corticosteroids – Triamcinolone Spray - Drug Quantity Management - (CNF241) PDF 201kB
Topical Doxepin Step Therapy Policy - (CNF080) PDF 132kB
Topical Medications for Inflammatory Rosacea Step Therapy Policy - (CNF081) PDF 130kB
Topical Non-Steroidal Anti-Inflammatory Drugs – Diclofenac - Drug Quantity Management - (CNF143) PDF 191kB
Topical Podofilox Products - Step Therapy - (CNF674) PDF 171kB
Topical Products – Vtama and Zoryve - Step Therapy - (CNF778) PDF 186kB
Topical Products – Zoryve Foam Step Therapy Policy - (CNF847) PDF 220kB
Topical Retinoids – Aklief® - (trifarotene cream) - Prior Authorization - (CNF629) PDF 194kB
Topical Retinoids – Panretin Prior Authorization Policy - (CNF630) PDF 180kB
Topical Retinoids – Tazarotene Products - Prior Authorization - (CNF631) PDF 189kB
Topical Retinoid – Tretinoin Products - Prior Authorization - (CNF632) PDF 194kB
Topical Vitamin D Analogs - Step Therapy - (CNF645)

PDF 196kB
V
Vasculitis – Tavneos™ (avacopan capsules) - Prior Authorization - (CNF709) PDF 214kB
Vecamyl™ (mecamylamine hydrochloride tablets) - Prior Authorization - (CNF634) PDF 229kB
Veltassa® (patiromer for oral suspension) Dispensing Limit - Drug Quantity Management - (CNF247) PDF 58kB
Veregen Prior Authorization Policy - CNF635) PDF 157kB
Vesicular Monoamine Transporter Type 2 Inhibitors – Austedo Prior Authorization Policy - (CNF636) PDF 181kB
Vesicular Monoamine Transporter Type 2 Inhibitors - Drug Quantity Management - (CNF248) PDF 261kB
Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza Prior Authorization Policy - (CNF637) PDF 163kB
Vesicular Monoamine Transporter Type 2 Inhibitors Preferred Specialty Management Policy - (CNF293) PDF 122kB
Vesicular Monoamine Transporter Type 2 Inhibitors – Tetrabenazine Prior Authorization Policy - (CNF638) PDF 196kB
Vijoice Prior Authorization Policy - (CNF743) PDF 133kB
Vitamin B12 (Cyanocobalamin) Products - Step Therapy - (CNF682) PDF 184kB
Vitamin D Analog (oral) - Step Therapy - (CNF082)

PDF 119kB
W
Wakefulness-Promoting Agents – Armodafinil, Modafinil - Prior Authorization - (CNF639) PDF 264kB
Wakefulness-Promoting Agents – Sunosi™ (solriamfetol tablets) - Drug Quantity Management - (CNF224) PDF 179kB
Wakefulness-Promoting Agents – Sunosi™ (solriamfetol tablets) - Prior Authorization - (CNF640) PDF 249kB
Wakefulness-Promoting Agents – Wakix® (pitolisant tablets) - Drug Quantity Management - (CNF250) PDF 176kB
Wakefulness-Promoting Agents – Wakix Prior Authorization with Step Therapy Policy - (CNF641) PDF 203kB
Weight Loss – Glucagon-Like Peptide-1 Agonists Prior Authorization Policy - (CNF684) PDF 339kB
Weight Loss – Other Appetite Suppressants and Orlistat - Prior Authorization - (CNF642) PDF 305kB
Weight Loss – Qsymia® (phentermine and topiramate extended-release capsules) - Drug Quantity Management - (CNF688) PDF 209kB
Weight Loss – Wegovy Drug Quantity Management Policy – Per Days - (CNF686) PDF 174kB
Weight Loss – Zepbound Drug Quantity Management Policy – Per Days - (CNF840)

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

PDF 267kB