| A |
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| 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 |
167kB |
|
| 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 |
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| Amyloidosis – Tafamidis Products - Prior Authorization - (CNF302) |
|
PDF |
76kB |
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| Amyloidosis – Tegsedi® (inotersen subcutaneous injection) - Prior Authorization - (CNF303) |
|
PDF |
173kB |
|
| Amyloidosis – Wainua Prior Authorization Policy - (CNF842) |
|
PDF |
172kB |
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| Angiotensin Receptor Blockers - Step Therapy - (CNF029) |
|
PDF |
208kB |
|
| Antibiotics (Inhaled) - Arikayce® (amikacin liposome inhalation suspension for oral inhalation) - Prior Authorization - (CNF118) |
|
PDF |
190kB |
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| Antibiotics (Inhaled) – Cayston Prior Authorization Policy - (CNF308) |
|
PDF |
195kB |
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| Antibiotics (Inhaled) – TOBI® Podhaler (tobramycin inhalation powder) - Prior Authorization - (CNF309) |
|
PDF |
170kB |
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| Antibiotics (Inhaled) – Tobramycin Inhalation Solution - Prior Authorization - (CNF310) |
|
PDF |
225kB |
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| 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 |
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| Anticoagulants - Eliquis® (apixaban tablets) - Prior Authorization - (CNF311) |
|
PDF |
259kB |
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| 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 |
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| Antidepressants - Bupropion Long-Acting - Step Therapy - (CNF030) |
|
PDF |
187kB |
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| Antidepressants – Selective Serotonin Reuptake Inhibitors - Drug Quantity Management - (CNF142) |
|
PDF |
322kB |
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| Antidepressants – Selective Serotonin Reuptake Inhibitors - Step Therapy - (CNF031) |
|
PDF |
225kB |
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| Antidepressants – Serotonin and Norepinephrine Reuptake Inhibitors - Drug Quantity Management - (CNF141) |
|
PDF |
343kB |
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| Antidepressants – Serotonin and Norepinephrine Reuptake Inhibitors - Step Therapy - (CNF032) |
|
PDF |
265kB |
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| 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 |
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| Antiepileptics - Banzel® (rufinamide tablets and oral suspension) - Prior Authorization - (CNF316) |
|
PDF |
216kB |
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| Antiepileptics – Clobazam Products - Onfi® (clobazam tablets and oral suspension ), Sympazan™ (clobazam oral soluble film) - Prior Authorization - (CNF317) |
|
PDF |
210kB |
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| Antiepileptics – Depakote/Depakene - Step Therapy - (CNF033) |
|
PDF |
161kB |
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| Antiepileptics – Fintepla® (fenfluramine oral solution) - Prior Authorization - (CNF315) |
|
PDF |
227kB |
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| 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 |
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| Antiepileptics - Sabril® (vigabatrin tablets and powder for solution) - Prior Authorization - (CNF321) |
|
PDF |
218kB |
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| Antiepileptics – Xcopri® (cenobamate tablets) - Drug Quantity Management - (CNF252) |
|
PDF |
180kB |
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| Antiepileptics – Zonisamide - Step Therapy - (CNF779) |
|
PDF |
173kB |
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| Antiepileptics – Ztalmy® (ganaxolone oral suspension) - Prior Authorization - (CNF761) |
|
PDF |
87kB |
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| 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 - (CNF173) |
|
PDF |
226kB |
|
| 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 |
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| Antifungals – Vivjoa™ (oteseconazole capsules) - Prior Authorization - (CNF772) |
|
PDF |
200kB |
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| Antifungals – Voriconazole (Oral) - Prior Authorization - (CNF326) |
|
PDF |
232kB |
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| Anti-Influenza – Oseltamivir Drug Quantity Management Policy – Per Rx - (CNF227) |
|
PDF |
192kB |
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| 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 |
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| Antiseizure Medications – Epidiolex® (cannabidiol oral solution) - Prior Authorization - (CNF319) |
|
PDF |
272kB |
|
| Antiseizure Medications – Topiramate - Step Therapy - (CNF037) |
|
PDF |
223kB |
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| Antiseizure Medications – Valtoco Prior Authorization Policy - (CNF706) |
|
PDF |
159kB |
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| Antiseizure Medications – Vigabatrin - Drug Quantity Management - (CNF786) |
|
PDF |
786kB |
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| Antiseizure Medications – Vimpat® (lacosamide tablets and oral solution, generic) - Step Therapy - (CNF738) |
|
PDF |
191kB |
|
| Antivirals – Famciclovir tablets (generic only) - Drug Quantity Management - (CNF157) |
|
PDF |
222kB |
|
| Antivirals – Ribavirin (Inhaled Products) - Prior Authorization - (CNF760) |
|
PDF |
188kB |
|
| Antivirals – Ribavirin (Oral Products) - Prior Authorization - (CNF396) |
|
PDF |
233kB |
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| Antivirals – Valacyclovir tablets (Valtrex®) - Drug Quantity Management - (CNF245) |
|
PDF |
300kB |
|
| Attention Deficit Hyperactivity Disorder Non-Stimulant Medications - Step Therapy - (CNF024) |
|
PDF |
132kB |
|
| Attention Deficit Hyperactivity Disorder Stimulant Medications - Step Therapy - (CNF025) |
|
PDF |
176kB |
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| B |
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| 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 |
224kB |
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| C |
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| Cabergoline Drug Quantity Management Policy – Per Days - (CNF148) |
|
PDF |
175kB |
|
| Calcitonin Gene-Related Peptide Inhibitors – Aimovig® (erenumab injection for subcutaneous use) - Prior Authorization - (CNF331) |
|
PDF |
234kB |
|
| Calcitonin Gene-Related Peptide Inhibitors – Aimovig - Drug Quantity Management - (CNF122) |
|
PDF |
176kB |
|
| Calcitonin Gene-Related Peptide Inhibitors – Ajovy® (Fremanezumab-vfrm injection for subcutaneous use) - Prior Authorization - (CNF332) |
|
PDF |
253kB |
|
| Calcitonin Gene-Related Peptide Inhibitors – Emgality® (galcanezumab-gnlm injection for subcutaneous use) - Prior Authorization - (CNF333) |
|
PDF |
235kB |
|
| 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 - (CNF046) |
|
PDF |
180kB |
|
| 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® (succimer capsules) - Prior Authorization - (CNF336) |
|
PDF |
224kB |
|
| 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 – Zilbrysq Prior Authorization Policy - (CNF824) |
|
PDF |
182kB |
|
| Contraceptives – Oral, Patch, and Vaginal Ring Products - Step Therapy - (CNF047) |
|
PDF |
308kB |
|
| 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® (osilodrostat tablets) - Prior Authorization - (CNF349) |
|
PDF |
210kB |
|
| Cushing’s – Korlym® (mifepristone 300 mg tablets) - Prior Authorization - (CNF350) |
|
PDF |
214kB |
|
| Cushing’s – Recorlev® (levoketoconazole tablets) - Prior Authorization - (CNF732) |
|
PDF |
237kB |
|
| Cushing’s - Signifor™ (pasireotide injection) - Prior Authorization - (CNF351) |
|
PDF |
207kB |
|
| 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™ (lumacaftor/ivacaftor tablets and oral granules) - Prior Authorization - (CNF353) |
|
PDF |
225kB |
|
| Cystic Fibrosis – Pulmozyme® (dornase alfa inhalation solution) - Prior Authorization - (CNF354) |
|
PDF |
67kB |
|
| Cystic Fibrosis – Symdeko Prior Authorization Policy - (CNF355) |
|
PDF |
203kB |
|
| Cystic Fibrosis – Trikafta Drug Quantity Management Policy – Per Rx - (CNF837) |
|
PDF |
179kB |
|
| Cystic Fibrosis – Trikafta™ (elexacaftor/tezacaftor/ivacaftor tablets; ivacaftor tablets, co-packaged) - Prior Authorization - (CNF356) |
|
PDF |
256kB |
|
| D |
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| 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 |
180kB |
|
| 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 |
206kB |
|
| Diabetes – Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy - (CNF072) |
|
PDF |
194kB |
|
| Diabetes – Symlin® (pramlintide subcutaneous injection) - Prior Authorization - (CNF361) |
|
PDF |
172kB |
|
| Diabetes - Thiazolidinedione - Step Therapy - (CNF052) |
|
PDF |
182kB |
|
| 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 |
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| Enspryng Prior Authorization Policy - (CNF388) |
|
PDF |
170kB |
|
| Enzyme Replacement Therapy - Strensiq® (asfotase alfa for subcutaneous use) - Prior Authorization - (CNF364) |
|
PDF |
200kB |
|
| Enzyme Replacement Therapy – Sucraid® (sacrosidase oral solution) - Prior Authorization - (CNF365) |
|
PDF |
199kB |
|
| 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 |
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|
| 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 |
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| 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® (relugolix, estradiol, and norethindrone acetate tablets) - Prior Authorization - (CNF679) |
|
PDF |
209kB |
|
| Gonadotropin-Releasing Hormone Antagonists – Oriahnn™ (elagolix, estradiol, and norethindrone acetate capsules; elagolix capsules) - Prior Authorization - (CNF382) |
|
PDF |
210kB |
|
| Gonadotropin-Releasing Hormone Antagonists – Orilissa™ (elagolix tablets) - Drug Quantity Management - (CNF199) |
|
PDF |
60kB |
|
| Gonadotropin-Releasing Hormone Antagonists – Orilissa™ (elagolix tablets) - Prior Authorization - (CNF381) |
|
PDF |
172kB |
|
| Gout Medications - Step Therapy - (CNF056) |
|
PDF |
174kB |
|
| Growth Disorders – Growth hormone [somatropin] - Prior Authorization - (CNF384) |
|
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) |
|
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 |
200kB |
|
| 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 - (CNF268) |
|
PDF |
345kB |
|
| 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 |
|
| 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™ (evinacumab-dgnb injection for intravenous use) - Prior Authorization - (CNF665) |
|
PDF |
261kB |
|
| 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 |
257kB |
|
| Hyperlipidemia – Nexlizet™ (bempedoic acid and ezetimibe tablets) - Prior Authorization - (CNF411) |
|
PDF |
277kB |
|
| 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 |
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|
|
| 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® (tralokinumab-ldrm subcutaneous injection) - Prior Authorization - (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 |
247kB |
|
| Immunologicals – Fasenra® (benralizumab subcutaneous injection) - Drug Quantity Management - (CNF764) |
|
PDF |
196kB |
|
| Immunologicals – Fasenra™ (benralizumab injection for subcutaneous use) - Prior Authorization - (CNF421) |
|
PDF |
235kB |
|
| Immunologicals – Nucala® (mepolizumab subcutaneous injection) - Drug Quantity Management - (CNF192) |
|
PDF |
212kB |
|
| Immunologicals – Nucala Prior Authorization Policy - (CNF422) |
|
PDF |
235kB |
|
| 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® (miltefosine capsules) - Prior Authorization -(CNF327) |
|
PDF |
229kB |
|
| 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 |
|
| Inflammatory Conditions – Actemra (tocilizumab for subcutaneous injection) - Prior Authorization - (CNF427) |
|
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 |
|
PDF |
333kB |
|
| Inflammatory Conditions – Adalimumab Products Preferred Specialty Management Policy for National Preferred Formularies – Choice - (CNF828) |
|
PDF |
183kB |
|
| 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® (certolizumab pegol for subcutaneous injection [lyophilized powder or solution]) - Prior Authorization - (CNF431) |
|
PDF |
309kB |
|
| Inflammatory Conditions – Cimzia Drug Quantity Management Policy – Per Days - (CNF133) |
|
PDF |
168kB |
|
| Inflammatory Conditions – Cosentyx® (secukinumab for subcutaneous injection) - Prior Authorization - (CNF432) |
|
PDF |
252kB |
|
| Inflammatory Conditions – Cosentyx Subcutaneous Drug Quantity Management Policy – Per Days - (CNF139) |
|
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) |
|
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) |
|
PDF |
280kB |
|
| Inflammatory Conditions – Kevzara™ (sarilumab for subcutaneous injection) - Prior Authorization - (CNF438) |
|
PDF |
205kB |
|
| Inflammatory Conditions – Kineret Drug Quantity Management Policy – Per Days - (CNF175) |
|
PDF |
178kB |
|
| Inflammatory Conditions – Kineret Prior Authorization - (CNF439) |
|
PDF |
263kB |
|
| 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® (apremilast tablets) - Prior Authorization - (CNF443) |
|
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) |
|
PDF |
587kB |
|
| Inflammatory Conditions – Rinvoq Drug Quantity Management Policy – Per Days - (CNF727) |
|
PDF |
185kB |
|
| Inflammatory Conditions – Rinvoq Prior Authorization Policy - (CNF444) |
|
PDF |
283kB |
|
| Inflammatory Conditions – Siliq Drug Quantity Management Policy – Per Days - (CNF212) |
|
PDF |
159kB |
|
| Inflammatory Conditions – Siliq™ (brodalumab for subcutaneous injection) - Prior Authorization - (CNF445) |
|
PDF |
260kB |
|
| 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™ (risankizumab-rzaa subcutaneous injection) - Prior Authorization - (CNF448) |
|
PDF |
124kB |
|
| Inflammatory Conditions – Sotyktu™ (deucravacitinib tablets) - Prior Authorization - (CNF775) |
|
PDF |
260kB |
|
| Inflammatory Conditions – Stelara® (ustekinumab intravenous infusion) - Prior Authorization - (CNF449) |
|
PDF |
271kB |
|
| Inflammatory Conditions – Stelara Drug Quantity Management Policy – Per Days - (CNF222) |
|
PDF |
201kB |
|
| Inflammatory Conditions – Stelara Subcutaneous Prior Authorization Policy with Dosing - (CNF450) |
|
PDF |
257kB |
|
| Inflammatory Conditions – Taltz® (ixekizumab for subcutaneous injection) - Prior Authorization - (CNF451) |
|
PDF |
234kB |
|
| Inflammatory Conditions – Tremfya Drug Quantity Management Policy – Per Days - (CNF240) |
|
PDF |
157kB |
|
| Inflammatory Conditions – Tremfya™ (guselkumab for subcutaneous injection) - Prior Authorization - (CNF452) |
|
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) |
|
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 |
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|
|
| 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 – Elyxyb™ (celecoxib oral solution) - Prior Authorization - (CNF723) |
|
PDF |
212kB |
|
| Migraine Medication - Step Therapy - (CNF061) |
|
PDF |
210kB |
|
| Migraine – Nurtec ODT Prior Authorization Policy - (CNF469) |
|
PDF |
182kB |
|
| Migraine – Qulipta Prior Authorization Policy - (CNF708) |
|
PDF |
175kB |
|
| 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 |
210kB |
|
| 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 |
224kB |
|
| 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 Prior Authorization Policy - (CNF363) |
|
PDF |
182kB |
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| N |
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| Natpara® (parathyroid hormone for subcutaneous injection) - Prior Authorization - (CNF488) |
|
PDF |
226kB |
|
| 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 |
805kB |
|
| Neurology – Lyrica® CR (pregabalin extended-release tablets) - Prior Authorization - (CNF459) |
|
PDF |
215kB |
|
| Neurology – Oxybate Products - Prior Authorization - (CNF643) |
|
PDF |
237kB |
|
| Neurology – Relyvrio Prior Authorization Policy - (CNF777) |
|
PDF |
163kB |
|
| Neurology – Riluzole Products - Prior Authorization - (CNF489) |
|
PDF |
198kB |
|
| Neurology – Skyclarys Prior Authorization Policy - (CNF807) |
|
PDF |
214kB |
|
| Non-Preferred Drug Coverage Review - (Formulary Exception Criteria) - (CNF002) |
|
PDF |
1251kB |
|
| 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 |
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| O |
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| Oncology (Injectable) – Besremi® (ropeginterferon alfa-2b-njft subcutaneous injection) - Prior Authorization - (CNF719) |
|
PDF |
86kB |
|
| 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 |
213kB |
|
| 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® (avapritinib tablets) - Prior Authorization - (CNF496) |
|
PDF |
221kB |
|
| Oncology – Balversa™ (erdafitinib tablets) - Prior Authorization - (CNF497) |
|
PDF |
170kB |
|
| 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® (bosutinib tablets) - Prior Authorization - (CNF498) |
|
PDF |
232kB |
|
| Oncology – Bosulif Drug Quantity Management Policy – Per Rx - (CNF128) |
|
PDF |
178kB |
|
| Oncology – BRAF and MEK Inhibitors Preferred Specialty Management Policy - (CNF819) |
|
PDF |
182kB |
|
| Oncology – Braftovi® (encorafenib capsules) - Prior Authorization - (CNF499) |
|
PDF |
212kB |
|
| 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™ (apalutamide tablets) - Prior Authorization - (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® (tivozanib tablets) - Prior Authorization - (CNF670) |
|
PDF |
220kB |
|
| Oncology – Fruzaqla Prior Authorization Policy - (CNF825) |
|
PDF |
163kB |
|
| Oncology – Gavreto (pralsetinib capsules) - Prior Authorization - (CNF441) |
|
PDF |
221kB |
|
| Oncology – Gavreto® (pralsetinib capsules) - Drug Quality Management Policies - (CNF746) |
|
PDF |
200kB |
|
| Oncology – Gilotrif™ (afatinib tablets) - Prior Authorization - (CNF512) |
|
PDF |
221kB |
|
| Oncology – Gleevec® (imatinib tablets, generic) - Drug Quantity Management - (CNF162) |
|
PDF |
206kB |
|
| Oncology – Gleevec® (imatinib tablets – generic) - Preferred Specialty Management - (CNF696) |
|
PDF |
163kB |
|
| Oncology – Ibrance Prior Authorization Policy - (CNF513) |
|
PDF |
173kB |
|
| Oncology – Iclusig® (ponatinib tablets) - Prior Authorization - (CNF514) |
|
PDF |
213kB |
|
| Oncology – Idhifa Prior Authorization Policy - (CNF515) |
|
PDF |
153kB |
|
| Oncology – Imatinib Prior Authorization Policy - (CNF516) |
|
PDF |
206kB |
|
| 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™ (selumetinib capsules) - Prior Authorization - (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™ (trametinib tablets) - Prior Authorization - (CNF528) |
|
PDF |
262kB |
|
| 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® (ixazomib capsules) - Prior Authorization - (CNF533) |
|
PDF |
211kB |
|
| 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 – 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™ (pemigatinib tablets) - Prior Authorization - (CNF536) |
|
PDF |
209kB |
|
| 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 (CNF539) |
|
PDF |
168kB |
|
| 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® (asciminib tablets) - Prior Authorization - (CNF712) |
|
PDF |
224kB |
|
| Oncology – Sorafenib - Preferred Specialty Management - (CNF762) |
|
PDF |
176kB |
|
| Oncology – Sprycel® (dasatinib tablets) - Drug Quantity Management - (CNF220) |
|
PDF |
227kB |
|
| Oncology - Sprycel® (dasatinib tablets) - Prior Authorization - (CNF545) |
|
PDF |
236kB |
|
| 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® (dabrafenib capsules) - Prior Authorization - (CNF549) |
|
PDF |
256kB |
|
| Oncology - Tagrisso® (osimertinib tablets) - Prior Authorization - (CNF550) |
|
PDF |
237kB |
|
| Oncology – Talzenna Prior Authorization Policy - (CNF551) |
|
PDF |
168kB |
|
| Oncology - Tasigna (nilotinib capsules) - Drug Quantity Management - (CNF230) |
|
PDF |
233kB |
|
| Oncology – Tasigna Prior Authorization Policy - (CNF554) |
|
PDF |
182kB |
|
| 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 |
167kB |
|
| 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 |
183kB |
|
| 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™ (telotristat ethyl tablets) - Prior Authorization - (CNF570) |
|
PDF |
192kB |
|
| Oncology - Xospata® (gilteritinib tablets) - Prior Authorization - (CNF571) |
|
PDF |
208kB |
|
| Oncology – Xpovio Prior Authorization Policy - (CNF572) |
|
PDF |
186kB |
|
| Oncology - Xtandi® (enzalutamide capsules and tablets) - Prior Authorization - (CNF573) |
|
PDF |
230kB |
|
| Oncology – Xtandi Drug Quantity Management Policy – Per Rx - (CNF669) |
|
PDF |
164kB |
|
| 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 - Cyclosporine Products - Prior Authorization - (CNF583) |
|
PDF |
215kB |
|
| 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 for Dry Eye Disease – Xiidra™ (lifitegrast ophthalmic solution) - Prior Authorization - (CNF584) |
|
PDF |
192kB |
|
| 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 |
178kB |
|
| Ophthalmic Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy - (CNF105) |
|
PDF |
120kB |
|
| 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 |
183kB |
|
| Ophthalmology – Dry Eye Disease – Tyrvaya Prior Authorization Policy - (CNF710) |
|
PDF |
164kB |
|
| 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) |
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PDF |
203kB |
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| Opioids - Fentanyl Transdermal Products - Drug Quantity Management - (CNF158) |
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PDF |
74kB |
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| Opioids - Fentanyl Transmucosal Drugs - Prior Authorization - (CNF587) |
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PDF |
483kB |
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| Opioids – Fentanyl Transmucosal Products - Drug Quantity Management - (CNF159) |
|
PDF |
262kB |
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| Opioids – Long-Acting Products (Oral) - Drug Quantity Management - (CNF197) |
|
PDF |
288kB |
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| Opioids – Long Acting Products - Prior Authorization - (CNF589) |
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PDF |
243kB |
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| Opioids – Methadone Prior Authorization Policy - (CNF843) |
|
PDF |
197kB |
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| Opioids – Nucynta® (tapentadol immediate-release oral tablets) - Drug Quantity Management - (CNF193) |
|
PDF |
176kB |
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| Opioids – Short-Acting Products (Adults) - Drug Quantity Management - (CNF194) |
|
PDF |
249kB |
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| Opioids – Short-Acting Products (Pediatrics) - Drug Quantity Management - (CNF196) |
|
PDF |
204kB |
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| Opioids – Tramadol Extended Release - Prior Authorization - (CNF588) |
|
PDF |
240kB |
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| Opioids – Tramadol Extended-Release Products - Drug Quantity Management - (CNF239) |
|
PDF |
184kB |
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| Opioids Transmucosal – Fentora Formulary Exception Policy - (CNF017) |
|
PDF |
57kB |
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| Opioids Transmucosal - Lazanda® (fentanyl nasal spray) - Formulary Exception - (CNF018) |
|
PDF |
57kB |
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| Opioids Transmucosal – Subsys Formulary Exception Policy - (CNF019) |
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PDF |
156kB |
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| Overactive Bladder Medications - Preferred Step Therapy - (CNF108) |
|
PDF |
219kB |
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| Oxbryta™ (voxelotor tablets) Dispensing Limit - Drug Quantity Management - (CNF201) |
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PDF |
252kB |
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| P |
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| Parkinson's Disease - Tolcapone Products - Prior Authorization - (CNF599) |
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PDF |
189kB |
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| Parkinson’s Disease – Amantadine Extended-Release Drugs Prior Authorization with Step Therapy Policy - (CNF590) |
|
PDF |
211kB |
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| Parkinson’s Disease –Apomorphine Subcutaneous Prior Authorization Policy - (CNF591) |
|
PDF |
196kB |
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| Parkinson’s Disease – Carbidopa Prior Authorization Policy- (CNF595) |
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PDF |
159kB |
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| Parkinson’s Disease – Duopa Prior Authorization Policy - (CNF592) |
|
PDF |
186kB |
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| Parkinson’s Disease – Inbrija Prior Authorization Policy - (CNF593) |
|
PDF |
187kB |
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| Parkinson’s Disease – Kynmobi Prior Authorization Policy - (CNF594) |
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PDF |
190kB |
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| Parkinson’s Disease – Monoamine Oxidase Type B Inhibitors - Step Therapy - (CNF062) |
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PDF |
227kB |
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| Parkinson’s Disease – Nourianz Prior Authorization Policy - (CNF596) |
|
PDF |
183kB |
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| Parkinson’s Disease – Nuplazid Prior Authorization Policy - (CNF597) |
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PDF |
192kB |
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| Parkinson’s Disease – Ongentys Prior Authorization Policy - (CNF598) |
|
PDF |
183kB |
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| Parkinson’s Disease – Zelapar Prior Authorization Policy - (CNF600) |
|
PDF |
186kB |
|
| Phenylketonuria – Palynziq® (pegvaliase-pqpz injection for subcutaneous use) - Prior Authorization - (CNF602) |
|
PDF |
223kB |
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| Phenylketonuria – Palynziq Drug Quantity Management Policy – Per Rx - (CNF203) |
|
PDF |
175kB |
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| Phenylketonuria – Sapropterin Prior Authorization Policy - (CNF601) |
|
PDF |
185kB |
|
| Pheochromocytoma – Metyrosine Capsules and Phenoxybenzamine Capsules - Prior Authorization - (CNF603) |
|
PDF |
225kB |
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| Phosphate Binders - Drug Quantity Management - (CNF671) |
|
PDF |
234kB |
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| Phosphate Binders - Preferred Step Therapy - (CNF110) |
|
PDF |
179kB |
|
| Pompe Disease – Enzyme Stabilization Therapy – Opfolda Prior Authorization Policy - (CNF816) |
|
PDF |
169kB |
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| Potassium Binders – Lokelma® (sodium zirconium cyclosilicate for oral suspension) - Drug Quantity Management - (CNF178) |
|
PDF |
192kB |
|
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Praluent® (alirocumab subcutaneous injection) - Prior Authorization - (CNF604) |
|
PDF |
306kB |
|
| Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors – Repatha Prior Authorization Policy - (CNF605) |
|
PDF |
257kB |
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| Proton Pump Inhibitors Drug Quantity Management Policy – Per Rx - (CNF243) |
|
PDF |
334kB |
|
| Proton Pump Inhibitors Step Therapy Policy - (CNF070) |
|
PDF |
141kB |
|
| Psychiatry – Novel Psychotropics - Drug Quantity Management - (CNF126) |
|
PDF |
339kB |
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| Psychiatry - Spravato™ (esketamine nasal spray) - Prior Authorization - (CNF606) |
|
PDF |
232kB |
|
| 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 |
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| Pulmonary Arterial Hypertension – Endothelin Receptor Antagonists - Prior Authorization - (CNF608) |
|
PDF |
117kB |
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| 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 |
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| 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 – 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 |
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| Pulmonary – Daliresp® (roflumilast tablets) - Prior Authorization - (CNF357) |
|
PDF |
206kB |
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| Q |
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| Qbrexza™ (glycopyrronium cloth 2.4% for topical use) - Prior Authorization - (CNF613) |
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PDF |
121kB |
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| Sedative Hypnotics - Step Therapy - (CNF071) |
|
PDF |
218kB |
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| 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 - (CNF685) |
|
PDF |
121kB |
|
| 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 |
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| 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 |
151kB |
|
| Thrombocytopenia – Doptelet® (avatrombopag tablets for oral use) - Prior Authorization - (CNF622) |
|
PDF |
215kB |
|
| Thrombocytopenia – Eltrombopag Products Prior Authorization Policy - (CNF624) |
|
PDF |
215kB |
|
| Thrombocytopenia – Mulpleta® (lusutrombopag tablets for oral use) - Prior Authorization - (CNF623) |
|
PDF |
212kB |
|
| Thrombocytopenia - Tavalisse™ (fostamatinib disodium hexahydrate tablets) - Prior Authorization - (CNF625) |
|
PDF |
215kB |
|
| 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 - (CNF675) |
|
PDF |
214kB |
|
| 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 - (CNF080) |
|
PDF |
207kB |
|
| 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 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 |
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| 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 |
178kB |
|
| Vesicular Monoamine Transporter Type 2 Inhibitors - Drug Quantity Management - (CNF248) |
|
PDF |
261kB |
|
| Vesicular Monoamine Transporter Type 2 Inhibitors – Ingrezza® (valbenazine capsules) - Prior Authorization - (CNF637) |
|
PDF |
195kB |
|
| Vesicular Monoamine Transporter Type 2 Inhibitors - Preferred Specialty Management - (CNF293) |
|
PDF |
179kB |
|
| Vesicular Monoamine Transporter Type 2 Inhibitors – Tetrabenazine tablets (Xenazine®, generics) - Prior Authorization - (CNF638) |
|
PDF |
215kB |
|
| Vijoice Prior Authorization Policy - (CNF743) |
|
PDF |
132kB |
|
| Vitamin B12 (Cyanocobalamin) Products - Step Therapy - (CNF682) |
|
PDF |
184kB |
|
| Vitamin D Analog (oral) - Step Therapy - (CNF082) |
|
PDF |
119kB |
|
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| 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 - (CNF684) |
|
PDF |
284kB |
|
| 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 |
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| Zetia® (ezetimibe tablets) - Step Therapy - (CNF083) |
|
PDF |
186kB |
|
| Zokinvy Prior Authorization Policy - (CNF655) |
|
PDF |
267kB |
|