Pharmacy Criteria
- Accrufer
- Acitretin Non-Oncology
- Adalimumab Products: Hadlima, adalimumab-adaz, & adalimumab-fkjp
- Adbry
- Adempas
- Advair HFA/Breo/Dulera
- Agamree
- Age Restriction
- Ajovy/Emgality
- Apretude
- Aranesp Non-Oncology
- Arikayce
- Aripiprazole Injection: Abilify Maintena, Aristada, Aristada Initio
- Austedo/Austedo XR
- Benlysta
- Benefit Exclusion
- Bimzelx
- Botox
- Brexafemme
- Bronchitol
- Budesonide Rectal Foam
- Bylvay
- Camzyos
- Carglumic Acid
- Cerdelga
- Chemet
- Chenodal
- Cholbam
- Cibinqo
- Cinacalcet
- Constipation Drugs: lubiprostone, Linzess, Motegrity, Movantik, Relistor, Symproic, Trulance, Ibsrela
- Corticotropin-ACTH: Acthar Gel (repository corticotropin injection), Cortrophin Gel
- Cosentyx
- Cresemba
- Crysvita
- Cyclosporine opthalmic emulsion
- Cystadrops
- Cystagon
- Daxxify
- Daybue
- Dayvigo/Belsomra/Quviviq
- Descovy
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Diacomit
- Diclofenac Gel Prescription
- Diclorphenamide
- Dificid
- Dojolvi
- Doxylamine succinate- Pyridoxine
- DPP-4 Inhibitors (Gliptins): Alogliptin, Alogliptin-metformin, Alogliptin-pioglitazone
- Drugs to Reduce Serum Phosphorus in Chronic Kidney Disease on Dialysis: Auryxia, Velphoro, Xphozah
- Dupixent
- Duvyzat
- Dysport
- Emend Non-Oncology
- Emflaza
- Enbrel
- Enspryng
- Entresto
- Eohilia
- Epidiolex
- Entyvio
- Epogen-Procrit-Retacrit Non-Oncology
- Eucrisa
- Evrysdi
- Fasenra
- Fensolvi
- Filspari
- Filsuvez
- Fintepla
- Firdapse
- Freestyle Libre/Dexcom
- Fycompa
- Galafold
- Gattex
- GLP-1 Agonist and GIP/GLP-1 Agonists Step Therapy: Ozempic, Rybelsus, Trulicity, Mounjaro
- Haegarda
- Hemlibra
- Hemophilia Products – Factor IX: AlphaNine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
- Hemophilia Products – Factor VIII: Advate, Adynovate, Afstyla, Altuviiio Eloctate, Hemofil M, Koate DVI, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha/Xyntha Solofuse, Jivi, Esperoct
- Hemophilia products- Factor_VIII VWF: Alphanate, Humate-P, Wilate
- Hemophilia Products – von Willebrand Factor: Vonvendi
- Hepatitis C: Mavyret
- Hetlioz: Hetlioz oral suspension & Tasimelteon capsules
- Humulin R
- Hypodermic Needles & Syringes
- Icatibant
- Ilumya
- Imcivree
- Impavido
- Isotretinoins Non-Oncology
- Isturisa
- Jardiance
- Joenja
- Juxtapid
- Jynarque
- Kalydeco
- Kanuma
- Kerendia
- Kesimpta
- Kevzara
- Livmarli
- Livtencity
- Lokelma
- Long Acting Opioid
- Long Acting Stimulant: Azstarys, Methylphenidate ER Patch and Chewables, Vyvanse Chewables
- Lumizyme
- Lupkynis
- Lybalvi
- Mavenclad
- Medicaid Medical Benefit Only Policy
- Medicaid Pharmacy Benefit Only Policy
- Miglustat
- Mircera
- Myalept
- Myobloc
- Myrbetriq Step Therapy
- Nexviazyme
- Nicotrol
- Non-Formulary Exception
- Norditropin _Nutropin
- Northera/Droxidopa
- Nourianz
- Nucala
- Nuedexta
- Nuplazid
- Octreotide Non-Oncology
- Ofev
- Omnipod
- Omvoh
- Opzelura
- Orfadin_Nitry_Nitisinone
- Oriahnn Myfembree
- Orilissa
- Orkambi
- Orladeyo
- Osphena
- Otezla
- Oxervate
- Palforzia
- Paliperidone palmitate extended-release injectable: Invega Hafyera, Invega Sustenna and Invega Trinza
- Palynziq
- Penicillamine
- Phosphate Binders Step Therapy (Lanthanum, Sevelamer)
- Pirfenidone
- Prevymis
- Prior Authorization Global Criteria
- Prolia Non-Oncology
- Pulmonary Arterial Hypertension Global: Sildenafil, Tadalafil, Ambrisentan, Opsumit, Bosentan, Epoprostenol, Veletri, Treprostinil, Remodulin, Ventavis, Orenitram, Uptravi, Winrevair
- Pyrimethamine
- Quantity Limit Exception
- Qulipta
- Radicava ORS
- Ravicti
- Recorlev
- Repatha
- Rexulti
- Rezdiffra
- Rezurock
- Rinvoq
- Risperidone Long Acting (Risperdal Consta)
- Rivfloza
- Sapropterin
- Serostim
- Short-Acting Opioid Naïve
- Short-Acting Opioid Post Limit
- Simponi
- Skyclarys
- Skyrizi IV and SC
- Skytrofa
- Sodium-Glucose Cotransporter-2 (SGLT2): Dapagliflozin, Invokamet, Invokamet XR, Steglatro
- Sodium Oxybate, Xyrem, Lumryz, Xywav
- Sodium Phenylbutyrate Products: generic Buphenyl, Pheburane, Olpruva
- Sogroya
- Sohonos
- Solosec
- Spevigo
- Stelara
- Step Therapy Exception
- Strensiq
- Sublocade/Brixadi
- Sucraid
- Sunlenca
- Sunosi
- Symdeko
- Synagis
- Takhzyro
- Tarpeyo
- Tavneos
- Tazarotene
- Tepezza
- Terconazole
- Teriparatide
- Testopel
- Testosterone (topical – generic): Testosterone Transdermal Gel 1%
- Tetrabenazine
- Thalomid
- Tiopronin
- Tobramycin Inhalation Solution
- Travoprost and Tafluprost
- Tremfya
- Tretinoin Topical Products
- Trijardy XR
- Trintellix
- Trikafta
- Tyvaso
- Ubrelvy
- Varenicline
- Velsipity
- Veltassa
- Verquvo
- Vijoice
- Vivjoa
- Voriconazole
- Vowst
- Voxzogo
- Vraylar
- Vtama
- Vyndamax-Vyndaqel
- Wainua
- Wakix
- Weight Loss-Contrave-Wegovy-Zepbound
- Xcopri
- Xdemvy
- Xeljanz
- Xenleta
- Xeomin
- Xifaxan
- Xolair
- Zilbrysq
- Zokinvy
- Zoryve
- Ztalmy
- Zurzuvae
- Antiemetics: Zofran, Kytril, Anzemet, Aloxi, Sancuso, Susto, Akynzeo, Emend, Cinvanti, Varubi
- Abiraterone
- Akeega
- Alecensa
- Alunbrig
- Augtyro
- Ayvakit
- Balversa
- Bone Modifying Agents: Aredia, Zometa, Xgeva/Prolia
- Bosulif
- Braftovi
- Brukinsa
- Cablivi
- Calquence
- Caprelsa
- Cometriq or Cabometyx
- Copiktra
- Cosela
- Cotellic
- Criteria for Evidence-Based Cancer Therapies
- Daurismo
- Doptelet
- Endari
- Erythropoiesis Stimulating Agents: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Erivedge
- Erleada
- Exkivity
- Fabhalta
- Ferriprox
- Fotivda
- Fruzaqla
- Gavreto
- Generic Drug Policy
- Genomic Genetic Biomarker Testing
- Gilotrif
- Ibrance
- Iclusig
- Idhifa
- Imbruvica
- Inlyta
- Inqovi
- Inrebic
- Iressa
- Iron Products: Infed, Venofer, Ferrlecit, Feraheme, Monferric, Injectafer
- Iwilfin
- Jakafi
- Jaypirca
- Jemperli
- Kisqali
- Koselugo
- Krazati
- Lenvima
- LHRH agonists and antagonists: Lupron, Trelstar, Zoladex, Irmagon, Orgovyx
- Lonsurf
- Lorbrena
- Lumakras
- Lynparza
- Lytgobi
- Mekinist
- Mektovi
- Monjuvi
- Mozobil
- Mulpleta
- Myeloid Growth Factors: Neupogen, Granix, Sargramostim, Zarxio, Nivestym, Releuko, Neulasta/Neulasta Onpro, Fulphila, Udenyca, Ziextenzo, Fylnetra, Stimufend, Rolvedon
- Nerlynx
- Nexavar
- Ninlaro
- Nubeqa
- Odomzo
- Ogsiveo
- Ojemda
- Ojjaara
- Onureg
- Orserdu
- Oxbryta
- Pegasys (peginterferon alfa-2a)
- Pemazyre
- Piqray
- Pomalyst
- Promacta
- Pyrukynd
- Qinlock
- Retevmo
- Revlimid
- Rezlidhia (olutasidenib)
- Rozlytrek
- Rubraca
- Rydapt
- Scemblix
- Somatostatin Analog: Sandostatin SQ, LAR depot (Octreotide), and Somatuline (lanreotide)
- Sprycel
- Stivarga
- Tabrecta
- Tafinlar
- Tagrisso
- Talzenna
- Tarceva
- Targretin
- Tasigna
- Tavalisse
- Tazverik
- Tepmetko
- Thalomid
- Tibsovo
- Topical and Intralesional Therapies use in Non-Melanoma Skin Cancers and Primary Cutaneous Lymphomas
- Truqap
- Truseltiq
- Tukysa
- Turalio
- Vanflyta
- Venclexta
- Verzenio
- Vitrakvi
- Vizimpro
- Vonjo
- Voranigo
- Votrient
- Voydeya
- Welireg
- Xalkori
- Xermelo
- Xospata
- Xpovio
- Xtandi
- Zejula
- Zelboraf
- Zolinza
- Zydelig
- Zykadia
- Abiraterone
- Acamprosate calcium tab
- Actemra
- Actimmune
- Adapalene
- Adempas
- Alecensa
- Alpha1-Proteinase Inhibitors (Prolastin-C)
- Ambrisentan
- Antidepressants Step: Desvenlafaxine, Fetzima
- Antidiabetic Agents ST: Glyxambi, Jardiance, Liraglutide, Mounjaro, Ozempic, Soliqua, Symlinpen, Synjardy/Synjardy XR, Trulicity, Victoza, Xultrophy Symlinpen
- Apokyn Inj
- Aranesp
- Arcalyst
- Armodafinil
- Atypical Antipsychotics ST: Vraylar
- Azacitidine
- Benefit Exclusion
- Betaseron
- Bexarotene-Targretin
- Bosentan
- BPH Cialis
- Cabenuva
- Cabometyx
- Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists Injection: Ajovy, Emgality
- Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists Oral: Ubrelvy, Qulipta
- Calquence
- Capecitabine
- Caprelsa
- Carglumic Acid
- Cayston
- Cerdelga
- Cinacalcet-Sensipar
- Cometriq
- Cosentyx
- Cystadane
- Cystagon
- Cystaran
- Dalfampridine
- Daliresp
- Daraprim
- Decitabine
- Deferiprone-Ferriprox solution
- Deflazacort-Emflaza
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Dibenzyline
- Dificid
- Dimethyl Fumarate
- Dipentum
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Alogliptin, Alogliptin/metformin, Januvia, Janumet, Janumet XR, Jentadueto XR
- Dofetilide
- Doptelet
- Dupixent
- ED-Alprostadils
- ED-BPH PDE-5 Inhibitors
- Elidel
- Eligard
- Emsam
- Enbrel
- Entecavir-Baraclude
- Epclusa
- Erbitux
- Erivedge
- Erleada
- Erlotinib-Tarceva
- Eucrisa
- Everolimus-Afinitor Products
- Evrysdi
- Fasenra
- Fingolimod
- Follitropins (Gonal-F)
- Fulvestrant
- Fuzeon
- Fyremadel-Ganirelix
- Gazyva
- Glatiramer products: Glatiramer, Copaxone, Glatopa
- Growth Hormone: Genotropin, Norditropin
- GSTP Bisphosphonates: Fosamax + D
- GSTP BPH-Alpha-1 Adrenergic Blockers: Cardura XL
- GSTP Insomnia Agents: Belsomra
- GSTP Nasal Steroids: Omnaris
- GSTP Prostaglandin Analogues & Combos: Lumigan
- GSTP SSRIs: Trintellix
- Haegarda
- Harvoni
- hCG (chorionic gonadotropin, Ovidrel)
- Hemlibra
- Hetlioz
- High Risk Medications
- Humira and Biosimilars: Humira, Hyrimoz, Adalimumab-adaz
- Icatibant Acetate
- Idhifa
- Imatinib
- Imbruvica
- Inbrija
- Increlex
- Infliximab (Remicade and Biosimilars)
- Inlyta
- Insomnia Products: Belsomra, Dayvigo
- Isotretinoin (capsules)
- Itraconazole Capsule 100mg
- Itraconazole (Sporanox oral solution) PA
- Ivermectin Tab 3mg
- Jakafi
- Jublia
- Kadcyla
- Kalydeco
- Kerendia
- Kevzara
- Keytruda
- Kisqali
- Lapatinib
- Lenvima
- Leuprolide
- Lidocaine patch 5%
- Lorbrena
- Lotronex
- Lupron Depot-Ped
- Lynparza
- Mekinist
- Metronidazole Topical
- Mircera
- Multaq
- Mupirocin
- Myalept
- Neulasta and Pegfilgrastim Biosimilars: Fylnetra, Nyvepria
- Neupogen and Filgrastim Biosimilars: Nivestym
- Nexletol
- Nitisinone-Orfadin capsules and solution
- Non-Formulary Exception
- Nubeqa
- Nucala
- Nuedexta
- Octreotide
- Odomzo
- Ofev
- Oncaspar
- Ongentys
- Opioid Containing Cough and Cold Products
- Opioids ER – Step Therapy with MME Limit: Hydromorphone ER, Xtampza ER, Belbuca, Buprenorphine patch
- Opioids IR – 7-Day Acute Pain Duration Limit with MME Limit: Codeine Sulfate, Hydromorphone HCL, Morphine Sulfate, Oxycodone Hydrochloride, Oxymorphone Hydrochloride, Nucynta, Tramadol Hydrochloride
- Opioids IR – 7-Day Combo Products: Endocet, Oxycodone/Acetaminophen, Acetaminophen/Codeine, Hydrocodone bitartrate/AC, Hydrocodone/Ibuprofen, Tramadol
- Opsumit
- Oral Fentanyl Products: Fentanyl Lozenges
- Orenitram
- Orkambi
- Osphena
- Otezla
- Ovide
- Padcev
- Pancrelipase (Creon, Viokace, Zenpep)
- Pazopanib
- Pegasys
- Pirfenidone
- Polivy
- Pomalyst
- Posaconazole Tab and Suspension
- Pregabalin
- Preventative Services Zero Copay Exception
- Prolia
- Protopic
- Provigil
- Prudoxin-Zonalon
- Quantity Limit Exception
- Ranolazine ER
- Regranex
- Remodulin
- Repatha
- Retacrit
- Revlimid
- Rinvoq
- Rosacea Topical Products: Brimonidine Gel, Ivermectin Cream
- Rydapt
- Sapropterin
- Savella
- SCIG: Cutaquig
- Signifor
- Sildenafil-Revatio
- Simponi
- Simponi Aria
- Skyrizi
- Sodium Oxybate
- Sodium Phenylbutyrate
- Somatuline Depot
- Somavert
- Sorafenib
- Sovaldi
- Sprycel
- Stelara
- Stivarga
- Sucraid
- Sunitinib Malate
- Sunosi
- Supprelin LA
- Symdeko
- Synarel
- Tacrolimus Ointment
- Tadalafil (Pulmonary Hypertension)
- Tafinlar
- Takhzyro
- Taltz
- Tazorac
- Temozolomide capsules-Temodar solution
- Teriflunomide
- Testosterone Products: Testosterone cypionate, Testosterone enanthate, Testosterone transdermal gel
- Tetrabenazine
- Tetracycline capsules
- Thalomid
- Tobramycin Inhalation
- Tolvaptan
- Tremfya
- Tretinoins Topicals: Tretinoin cream 0.1%, 0.05%, 0.025%; Tretinoin gel 0.01%, 0.05%, 0.025%; Tretinoin microsphere gel 0.1% and 0.04%
- Treximet
- Trikafta
- Triptodur
- Tukysa
- Tymlos
- Tysabri
- Tyvaso
- Uloric
- Uptravi
- Valcyte
- Vecamyl
- Velphoro
- Velsipity
- Vemlidy
- Venclexta
- Ventavis
- Verzenio
- Viberzi
- Vigabatrin
- Vitamin D Topical Analogs: Calcipotriene, Calcitriol, Calcipotriene-Bethamethasone
- Vitrakvi
- Voltaren Gel
- Voriconazole Tab and Suspension
- Vosevi
- Vowst
- Vytorin 10-80 Zocor 80: ezetimibe/simvastatin, simvastatin
- Weight Loss Drugs: Saxenda, Wegovy, and Zepbound
- Xalkori
- Xeljanz-Xeljanz XR
- Xepi
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Zileuton
- Zoledronic Acid-Reclast
- Zoledronic Acid-Zometa
- Zolinza
- Zydelig
- Zykadia
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.
- Abiraterone
- Acamprosate calcium tab
- Actemra
- Actimmune
- Adapalene
- Adempas
- Alecensa
- Alpha1-Proteinase Inhibitors (Prolastin-C)
- Ambrisentan
- Antidepressants Step: Desvenlafaxine, Fetzima
- Antidiabetic Agents ST: Symlipen, Alogliptin, Januvia, Janumet, Janumet XR, Alogliptan/metformin, Jentadueto XR, Mounjaro, Ozempic, Trulicity, Victoza, Soliqua, Xultophy, Synjardy, Synjardy XR, Glyxambi, Jardiance
- Apokyn Inj
- Aranesp
- Arcalyst
- Armodafinil
- Atypical Antipsychotics ST: Vraylar
- Azacitidine
- Benefit Exclusion
- Betaseron
- Bexarotene-Targretin
- Bosentan
- BPH Cialis
- Cabenuva
- Cabometyx
- Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists Injection: Ajovy, Emgality
- Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists Oral: Ubrelvy, Qulipta
- Calquence
- Capecitabine
- Caprelsa
- Carglumic Acid
- Cayston
- Cerdelga
- Cinacalcet-Sensipar
- Commercial Medical Benefit Only
- Commercial Pharmacy Benefit Only
- Cometriq
- Cosentyx
- Cystadane
- Cystagon
- Cystaran
- Dalfampridine
- Daliresp
- Daraprim
- Decitabine
- Deferiprone-Ferriprox solution
- Deflazacort-Emflaza
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Dibenzyline
- Dificid
- Dimethyl Fumarate
- Dipentum
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Alogliptin, Alogliptin/metformin, Januvia, Janumet, Janumet XR, Jentadueto XR
- Dofetilide
- Doptelet
- Dupixent
- Elidel
- Eligard
- Emsam
- Enbrel
- Entecavir-Baraclude
- Epclusa
- Erbitux
- Erivedge
- Erleada
- Erlotinib-Tarceva
- Eucrisa
- Everolimus-Afinitor Products
- Evrysdi
- Fasenra
- Fingolimod
- Follitropins (Gonal-F)
- Fulvestrant
- Fuzeon
- Fyremadel-Ganirelix
- Gazyva
- Glatiramer products: Glatiramer, Copaxone, Glatopa
- Growth Hormone: Genotropin, Norditropin
- GSTP Bisphosphonates: Fosamax + D
- GSTP Insomnia Agents: Belsomra
- GSTP Nasal Steroids: Omnaris
- Haegarda
- Harvoni
- hCG (chorionic gonadotropin, Ovidrel)
- Hemlibra
- Hetlioz
- High Risk Medications
- Humira and Biosimilars: Humira, Hyrimoz, Adalimumab-adaz
- Icatibant Acetate
- Idhifa
- Imatinib
- Imbruvica
- Inbrija
- Increlex
- Infliximab (Remicade and Biosimilars)
- Inlyta
- Insomnia Products: Belsomra, Dayvigo
- Isotretinoin (capsules)
- Itraconazole Capsule 100mg
- Itraconazole (Sporanox oral solution) PA
- Ivermectin Tab 3mg
- Jakafi
- Jublia
- Kadcyla
- Kalydeco
- Kerendia
- Kevzara
- Keytruda
- Kisqali
- Lapatinib
- Lenvima
- Leuprolide
- Lidocaine patch 5%
- Lorbrena
- Lotronex
- Lynparza
- Mekinist
- Metronidazole Topical
- Mircera
- Multaq
- Mupirocin
- Myalept
- Neulasta and Pegfilgrastim Biosimilars: Fylnetra, Nyvepria
- Neupogen and Filgrastim Biosimilars: Nivestym
- Nitisinone-Orfadin capsules and solution
- Non-Formulary Exception
- Nubeqa
- Nucala
- Nuedexta
- Octreotide
- Odomzo
- Ofev
- Oncaspar
- Ongentys
- Opioid Containing Cough and Cold Products
- Opioids ER – Step Therapy with MME Limit: Hydromorphone ER, Xtampza ER, Belbuca, Buprenorphine patch
- Opioids IR – 7-Day Acute Pain Duration Limit with MME Limit: Codeine Sulfate, Hydromorphone HCL, Morphine Sulfate, Oxycodone Hydrochloride, Oxymorphone Hydrochloride, Nucynta, Tramadol Hydrochloride
- Opioids IR – 7-Day Combo Products: Endocet, Oxycodone/Acetaminophen, Acetaminophen/Codeine, Hydrocodone bitartrate/AC, Hydrocodone/Ibuprofen, Tramadol
- Opsumit
- Oral Fentanyl Products: Fentanyl Lozenges
- Orenitram
- Orkambi
- Osphena
- Otezla
- Ovide
- Padcev
- Pancrelipase (Creon, Viokace, Zenpep)
- Pazopanib
- Pegasys
- Pirfenidone
- Polivy
- Pomalyst
- Posaconazole Tab and Suspension
- Pregabalin
- Preventative Services Zero Copay Exception
- Prolia
- Protopic
- Provigil
- Prudoxin-Zonalon
- Quantity Limit Exception
- Ranolazine ER
- Regranex
- Remodulin
- Repatha
- Retacrit
- Revlimid
- Rinvoq
- Rosacea Topical Products: Brimonidine Gel, Ivermectin Cream
- Rydapt
- Sapropterin
- SCIG: Cutaquig
- Signifor
- Sildenafil-Revatio
- Simponi
- Simponi Aria
- Skyrizi
- Sodium Oxybate
- Sodium Phenylbutyrate
- Somatuline Depot
- Somavert
- Sorafenib
- Sovaldi
- Sprycel
- Stelara
- Stivarga
- Sunitinib Malate
- Sunosi
- Supprelin LA
- Symdeko
- Synarel
- Tadalafil (Pulmonary Hypertension)
- Tafinlar
- Taltz
- Tazorac
- Temozolomide capsules-Temodar solution
- Teriflunomide
- Testosterone Products: Testosterone cypionate, Testosterone enanthate, Testosterone transdermal gel
- Tetrabenazine
- Tetracycline capsules
- Thalomid
- Tobramycin Inhalation
- Tolvaptan
- Tremfya
- Tretinoins Topicals: Tretinoin cream 0.1%, 0.05%, 0.025%; Tretinoin gel 0.01%, 0.05%, 0.025%; Tretinoin microsphere gel 0.1% and 0.04%
- Treximet
- Trikafta
- Triptodur
- Tukysa
- Tymlos
- Tysabri
- Tyvaso
- Uptravi
- Valcyte
- Vecamyl
- Vemlidy
- Venclexta
- Ventavis
- Verzenio
- Viberzi
- Vigabatrin
- Vitrakvi
- Voltaren Gel
- Voriconazole Tab and Suspension
- Vosevi
- Vytorin 10-80 Zocor 80: ezetimibe/simvastatin, simvastatin
- Weight Loss Drugs: Saxenda, Wegovy, and Zepbound
- Xalkori
- Xeljanz-Xeljanz XR
- Xeloda
- Xepi
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Zileuton
- Zoledronic Acid-Reclast
- Zoledronic Acid-Zometa
- Zolinza
- Zydelig
- Zykadia
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.
- 5-HT1 Agonist: sumatriptan-naproxen
- Acamprosate calcium tab
- Acne Products:Benzoyl Peroxide-Erythromycin, Clindamycin Phosphate-Benzoyl Peroxide
- Actemra
- Actimmune
- Adapalene
- Alecensa
- Alosetron
- Alpha1-Proteinase Inhibitors (Prolastin-C)
- Ambrisentan
- Antidiabetic Agents: Glyxambi, Jardiance, Ozempic, Trulicity, Victoza, Soliqua, Synjardy/Synjardy XR, Xultophy
- Apokyn Inj
- Aranesp
- Arcalyst
- Armodafinil_Nuvigil
- Atypical Antipsychotics ST: Vraylar
- Aubagio
- Azacitidine
- Benefit Exclusion
- Betaseron
- Bexarotene-Targretin
- Bosentan
- BPH Cialis
- Cabometyx
- Calcipotriene, Calcitriol (Topical), Calcipotriene-Betamethasone Dipropionate
- Calcitonin Gene-Related Peptide (CGRP): Ubrelvy, Qulipta
- Calquence
- Caprelsa
- Carbaglu
- Cayston
- Cetrotide-Fyremadel-Ganirelix
- Cinacalcet-Sensipar
- Clindamycin Phosphate (Topical), Erythromycin (Acne Aid)
- Cometriq
- Cosentyx
- Cystadane
- Cystagon
- Cystaran Sol 0.44%
- Dalfampridine ER
- Daliresp
- Daraprim
- Decitabine-Dacogen
- Deferiprone_Ferriprox
- Desvenlafaxine-Fetzima ST
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Diclofenac Sodium (Topical)
- Dificid
- Dimethyl fumarate delayed release
- Dipentum
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Alogliptin Alogliptin/metformin, Januvia, Janumet, Jentadueto XR
- Dofetilide-Tikosyn
- Doptelet
- Eligard
- Emflaza
- Emsam
- Enbrel
- Entecavir-Baraclude
- Epclusa
- Erbitux
- Erivedge
- Erleada
- Erlotinib-Tarceva
- Eucrisa
- Everolimus-Afinitor Products
- Evrysdi Sol
- Fasenra
- Fingolimod-Gilenya
- Follitropins (Gonal-F)
- Febuxostat_Uloric
- Fentanyl citrate lozenge
- Fulvestrant-Faslodex
- Fuzeon
- Gazyva
- Glatiramer acetate_Copaxone_Glatopa
- Growth Hormone Without ISS (Norditropin)
- GSTP Bisphosphonates: Fosamax + D
- GSTP Prostaglandin Analogues & Combos: Lumigan, Zioptan
- Haegarda
- Harvoni
- HCG (chorionic gonadotropin, Ovidrel)
- Hemlibra
- Hetlioz
- High Risk Medications
- Humira and Biosimilars: DALIMUMAB-ADAZ, HYRIMOZ, HYRIMOZ CROHN’S DISEASE A, HYRIMOZ PLAQUE PSORIASIS, HYRIMOZ PEDIATRIC CROHNS, HYRIMOZ PEDIATRIC CROHN’S, HUMIRA PEN, HUMIRA PEN-PS/UV STARTER, HUMIRA, HUMIRA. PEDIATRIC CROHNS D
- Ibrance
- Icatibant acetate
- Iclusig
- Idhifa
- Imatinib-Gleevec
- Imbruvica
- Inbrija
- Increlex
- Inlyta
- Insomnia Products: Belsomra, Dayvigo
- Intron A
- Isotretinoin
- Itraconazole (Capsules)
- Itraconazole (Oral Solution)
- Jakafi
- Jublia
- Kadcyla
- Kalydeco
- Kerendia
- Kevzara
- Keytruda
- Kisqali
- Lanreotide Injection-Somatuline Depot
- Lapatinib-Tykerb
- Lenalidomide-Revlimid
- Lenvima
- Leuprolide
- Lidoderm, ZTLido: lidocaine patch 5%
- Lorbrena
- Lotronex
- Lynparza
- Lyrica, Lyrica CR, Gralise, Horizant ST: Pregabalin
- Malathion_Ovide
- Medical Benefit Only
- Mekinist
- Milnacipran
- Mircera
- Modafinil_Provigil
- Multaq
- Myalept
- Nexavar (sorafenib)
- Nitisinone-Orfadin
- Nivestym
- Non-Formulary Exception
- Noxafil
- Nubeqa
- Nuedexta
- Octreotide
- Odomzo
- Ofev
- Omnaris
- Oncaspar
- Ongentys
- Opioids ER: Belbuca, buprenorphine patch
- Opsumit
- Orenitram
- Orkambi
- Osphena
- Otezla
- Oxandrolone
- Pancrelipase (Creon, Viokace, Zenpep)
- PCSK9i (Praluent)
- Pegasys
- Penicillamine tab 250 mg
- Pharmacy Benefit Only
- Phenoxybenzamine_Dibenzyline
- Sodium phenylbutyrate products: sodium phenylbutyrate, Buphenyl, Pheburane
- Pimecrolimus cream_Elidel
- Pirfenidone-Esbriet
- Polivy
- Pomalyst
- Preventative Services Zero Copay Exception
- Prolia
- Quantity Limit Exception
- Ranolazine ER_Ranexa
- Regranex Gel 0.01%
- Infliximab and Biosimilars: Remicade Avsola Inflectra Renflexis
- Retacrit
- Ribavirin
- Rinvoq
- Riociguat-Adempas
- Rivastigmine tartrate capsules and patches
- Rosacea Products: Brimonidine Tartrate (Topical), Ivermectin
- Rydapt
- Sapropterin-Kuvan
- SCIG (HyQvia)
- Signifor
- Sildenafil_Revatio
- Simponi
- Simponi Aria
- Simvastatin tab 80 mg
- Sirturo
- Skyrizi
- Sodium Oxybate-Xyrem
- Somavert
- Sovaldi
- Spinosad_Natroba
- Sprycel
- Stelara
- Stivarga
- Sucraid
- Sunitinib-Sutent
- Sunosi
- Supprelin LA
- Symdeko
- SymlinPen
- Synarel
- Tacrolimus_Protopic
- Tadalafil (Pulmonary Hypertension)
- Tafinlar
- Taltz
- Tazarotene
- Temozolomide-Temodar
- Testosterone Products
- Tetrabenazine
- Thalomid
- Tobramycin Inhalation
- Tolvaptan-Samsca
- Tremfya
- Treprostinil-Remodulin
- Tretinoins (Topical): Tretinoin, Tretinoin Microsphere
- Trikafta
- Trintellix tab 5 mg
- Triptodur
- Tukysa
- Tymlos
- Tysabri
- Tyvaso
- Uptravi
- Valcyte
- Vemlidy
- Venclexta
- Ventavis
- Vfend
- Vigabatrin
- Vitrakvi
- Vosevi
- Votrient
- Weight Loss Drugs: Saxenda, Wegovy
- Xalkori
- Xeljanz-Xeljanz XR
- Xeloda
- Xepi
- Xifaxan
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Ziextenzo
- Zileuton
- Zoledronic Acid-Reclast
- Zoledronic Acid-Zometa
- Zolinza
- Zydelig
- Zykadia
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.
Clinical Medical Policies
The Medical Review staff of the Medical Management Department utilize clinical medical policies (CMPs) to guide decisions regarding Neighborhood’s Conditional Benefits.
Click here to access the
Medical Pharmacy Benefit Searchable HCPCS Listing (Including J-Codes)
Through collaboration with Neighborhood’s Associate Medical Director, and our specialty consultants, the policies are developed and/or revised following thorough review of current medical literature and standards of practice. To the extent possible, Neighborhood’s CMPs are developed according to evidence-based outcomes.
To view one of Neighborhood’s approved CMPs, please click the link below:
Medicare Distinction
For INTEGRITY members: Neighborhood Health Plan of Rhode Island (Neighborhood) uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations, including medical necessity. Coverage determinations are based on applicable payment policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and other available CMS published guidance.
In the absence of an applicable or incomplete NCD, LCD, or other CMS published guidance OR if available Medicare coverage guidance is not met, then Neighborhood will apply coverage guidance from the Rhode Island Executive Office of Health & Human Services (EOHHS), or other peer-reviewed scientific evidence, such as InterQual® and/or internal Clinical Medical Policies as a means of secondary coverage through the members’ Medicaid benefit.
- Acupuncture
- Adult Day Health
- Assisted Living
- Biomarkers
- Chiropractic Care
- Circulating Cell-free (ccfDNA)
- Cognitive Rehabilitation
- Continuous Glucose Monitoring
- Experimental Investigational
- External Beam Teletherapy Brachytherapy IMRT SBRT SRS IORT and IGRT
- Gender Affirmation
- Genetic Testing
- Genomic/Genetic/Biomarker/Tumor Marker Tests
- Hasbro Partial Program
- Home Care Services
- Infertility Services
- In Lieu of Services
- Levels of Care
- Neutron and Proton Beam Policy
- No Criteria – Use of Evidence Based Medicine
- Non-Standard Requests
- Obstetrical Ultrasound
- Out-of-Network & Out-of-Area
- Outpatient Rehab PT-OT Special Needs
- Outpatient Rehab Speech Therapy Special Needs
- Outpatient Rehab Therapies-Adult
- Phototherapy and Photochemotherapy for Dermatologic Conditions
- Plastic Surgery
- Private Duty-Extended Home Care-Skilled Hours
- Relizorb Enzyme Cartridge
- Skilled Home Health Care
- Termination of Pregnancy
- Actemra
- Aflibercept: Eylea/Eylea HD
- Aldurazyme
- Alpha-1-Proteinase Inhibitors: Aralast, Glassia, prolastin, Zemaira
- Amondys45
- Amvuttra
- Apretude
- Bal in Oil and Calcium EDTA
- Benefit Exclusion
- Benlysta
- Beovu
- Beqvez
- Berinert
- Botox
- Brineura
- Briumvi
- Casgevy
- Cerezyme Elelyso VPRIV
- Cimzia
- Cinacalcet
- Cinqair
- Cinryze
- Corticotropin-ACTH: Acthar Gel (repository corticotropin injection), Cortrophin Gel
- Cosentyx
- Crysvita
- Daxxify
- Diabetic Test Strip/Supplies: Accu-Check, Dexcom, Omnipod, Freestyle
- Duopa
- Durysta
- Dysport
- Elaprase
- Elevidys
- Entyvio
- Erythropoiesis stimulating agents Non-Oncology: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Evenity
- Evkeeza
- Exondys51
- Fabrazyme and Elfabrio
- Fasenra
- General PA Policy
- Givlaari
- Haegarda
- Hemgenix
- Hemophilia Products – Anti-inhibitor Antibody: Hemlibra
- Hemophilia Products-Anti-inhibitor Coagulant Complex: Feiba NF/Feiba VF
- Hemophilia Products – Factor IX: AlphaNine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
- Hemophilia Products- Factor VIIa: NovoSeven RT, Sevenfact
- Hemophilia Products- Factor VIII: Advate, Adynovate, Afstyla, Altuviiio, Eloctate, Hemofil M, Koate DVI, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha/Xyntha Solofuse, Jivi, Esperoct
- Hemophilia Products – Factor X: Coagadex
- Hemophilia Products – Factor XIII: Corifact
- Hemophilia Products – Coagulation Factor XIII A-subunit: Tretten
- Hemophilia Products – Factor VIII/VWF Complex: Alphanate, Humate-P, Wilate
- Hemophilia Products – von Willebrand Factor (Vonvendi)
- Hyaluronic Acid Intraarticular Injections: Durolane, Euflexxa, Gel-One , Gelsyn, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synojoynt, Synvisc, Synvisc-One, Triluron, Trivisc, Visco-3,
- iDose TR
- Ilaris
- Ilumya
- Immune Globulin – Intravenous Non-oncology: Asceniv, Flebogamma 10% DIF, Flebogamma 5% DIF, Gamunex-C , Gammagard Liquid, Gammaked, Gammaplex, Octagam 10%, Octagam 5%, Privigen, Panzyga
- Immune Globulin – Subcutaneous: Hizentra, Gammagard Liquid, Gamunex-C, Gammaked, Hyqvia, Cuvitru, Cutaquig, Xembify
- Infliximab/Remicade/Renflexis/Avsola
- Izervay (avacincaptad pegol)
- Kalbitor
- Kanuma
- Krystexxa
- Lamzede
- Lantidra
- Lenmeldy
- Lemtrada
- Leqembi
- Leqvio
- Long Acting Granulocyte Colony Stimulating Factor (G-CSFs): Fulphila, Fylnetra, Neulasta, Neulasta Onpro, Nyvepria, Rolvedon, Stimufend, Udenyca, Ziextenzo
- Lucentis/Byooviz/Cimerli
- Lumizyme
- Luxturna
- Lyfgenia
- Medical Benefit Only Policy – Commercial
- Medical Benefit Only Policy – Medicaid
- Mepsevii
- Miacalcin
- Monoferric
- Myobloc
- Naglazyme
- Nexviazyme
- Nipent
- Nucala
- Nulibry
- Ocrevus
- Omisirge
- Omvoh
- Oncology Hematology Policy
- Onpattro
- Orencia
- Oxlumo
- Parsabiv
- Pombiliti Opfolda
- Prevymis
- Probuphine
- Qalsody
- Radicava
- Rebyota
- Revcovi
- Rituxan Non-Oncology
- Roctavian
- Ruconest
- Ryplazim
- Rystiggo
- Saphnelo
- Scenesse
- Serostim
- Short-Acting Granulocyte Colony Stimulating Factors: Nivestym, Neupogen, Granix, Zarxio, Releuko
- Signifor LAR
- Simponi Aria
- Skyrizi IV and SC
- Skysona
- Soliris Ultomiris
- Somatuline Depot
- Spevigo
- Spinraza
- Stelara
- Step Therapy Part B
- Step Therapy Medicaid and Commercial
- Strensiq
- Sublocade/Brixadi
- Sunlenca
- Susvimo
- Syfovre
- Synagis
- Tepezza
- Testopel
- Tezspire
- Triptodur
- Trogarzo
- Tysabri
- Tzield
- Uplizna
- Vabysmo
- Veopoz
- Viltepso
- Vimizim
- Vyepti
- Vyjuvek
- Vyondys53
- Vyvgart/Vyvgart Hytrulo
- Xenleta
- Xenpozyme
- Xeomin
- Xiaflex
- Xolair
- Zolgensma
- Zulresso
- Zynteglo
- Abecma
- Abraxane
- Adakveo
- Adcetris
- Adstiladrin
- Adzynma
- Alimta, Pemfexy (Pemetrexed)
- Aliqopa
- Amtagvi (lifileucel)
- Antiemetics: Zofran, Kytril, Anzemet, Aloxi, Sancuso, Susto, Akynzeo, Emend, Cinvanti, Varubi
- Anktiva
- Aphexda
- Arzerra
- Asparlas
- Azedra
- Bavencio
- Beleodaq
- Besponsa
- Besremi
- Bevacizumab Products: Avastin, Mvasi, Zirabev, Alymsys, Vegzelma
- Blenrep
- Blincyto
- Bone Modifying Agents: Aredia, Zometa, Xgeva/Prolia
- Breyanzi
- Cablivi
- Carvykti
- Clolar
- Columvi
- Cosela
- Criteria for Evidence-Based Cancer Therapies
- Cyramza
- Danyelza
- Darzalex and Darzalex Faspro
- Doxil
- Elahere
- Elitek
- Elrexfio
- Elzonris
- Empaveli
- Empliciti
- Enhertu
- Enjaymo
- Epkinly
- Erbitux
- Erwinaze
- Erythropoiesis Stimulating Agents: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Ferriprox
- Fusilev/Khapzory
- Fyarro
- Gamifant
- Gazyva
- Generic Drugs
- Genomic Genetic Biomarker Testing
- Halaven
- Hepzato
- Hicon
- Imdelltra
- Imfinzi
- Imjudo
- Imlygic
- Immune Globulin (IG) (IVIG, SCIG, IMIG)
- Iron Products: Infed, Venofer, Ferrlecit, Feraheme, Monferric, Injectafer
- Istodax
- Ixempra
- Jelmyto
- Jemperli
- Jevtana
- Kadcyla
- Keytruda
- Kimmtrak
- Kymriah
- Kyprolis
- LHRH agonists and antagonists: Lupron, Trelstar, Zoladex, Irmagon, Orgovyx
- Libtayo
- Loqtorzi
- Lumoxiti
- Lunsumio
- Lutathera
- Margenza
- Monjuvi
- Myeloid Growth Factors: Neupogen, Granix, Sargramostim, Zarxio, Nivestym, Releuko, Neulasta/Neulasta Onpro, Fulphila, Udenyca, Ziextenzo, Fylnetra, Stimufend, Rolvedon
- Mylotarg
- Nplate
- Oncaspar
- Onivyde
- Opdivo
- Opdualag
- Padcev
- Pedmark
- Photofrin
- Piasky
- Pluvicto
- Polivy
- Poteligeo
- Preferred Drug List
- Provenge
- Reblozyl
- Rituxan Products: Rituxan, Rituxan Hycela, Truxima, Ruxience
- Rybrevant
- Rytelo
- Sarclisa
- Soliris
- Somatostatin Analog: Sandostatin SQ, LAR depot (Octreotide), and Somatuline (lanreotide)
- Step Therapy Medicare Part B Medications
- Step Therapy Medicaid and Commercial
- Sylvant
- Synribo
- Talvey
- Tecartus
- Tecelra
- Tecentriq
- Tecvayli
- Tevimbra
- Tivdak
- Torisel
- Trastuzumab Products and Phesgo
- Treanda/Bendeka/Belrapzo
- Trodelvy
- Ultomiris
- Unituxin
- Valstar
- Vectibix
- Voraxaze
- Vyxeos
- Xofigo
- Yervoy
- Yescarta
- Yondelis
- Zaltrap
- Zepzelca
- Zevalin
- Zynlonta
- Zynyz
Medicare Distinction
For INTEGRITY members: Neighborhood Health Plan of Rhode Island (Neighborhood) uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations, including medical necessity. Coverage determinations are based on applicable payment policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and other available CMS published guidance.
In the absence of an applicable or incomplete NCD, LCD, or other CMS published guidance OR if available Medicare coverage guidance is not met, then Neighborhood will apply coverage guidance from the Rhode Island Executive Office of Health & Human Services (EOHHS), or other peer-reviewed scientific evidence, such as InterQual® and/or internal Clinical Medical Policies as a means of secondary coverage through the members’ Medicaid benefit.