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Behavioral Health
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Care Coordination
TBD
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Claims & CPT Codes
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Continuation of Care
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Contracting
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Member Related
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Pharmacy - Commercial
Drug Authorization
Actemra (Diagnosis of Giant Cell Arteritis)
Actemra (Diagnosis of Systemic Sclerosis-Associated Interstitial Lung Disease)
Actemra SQ (Pharmacy) (Non-Preferred)
Adalimumab (Preferred) Products (Cyltezo | Humira | Hyrimoz)
Adefovir Dipivoxil (ADV, Generic Hepsera)
Alosetron (Lotronex) | Viberzi
Anticonvulsants | Antiepileptic Drugs | Antiseizure Drugs
Antipsychotics-Children (0-17) - COMMERCIAL ONLY
Apokyn | Apomorphine Hydrochoride | Kynmobi
Arformoterol Nebulizer Solution (Generic Brovana & ABA)
Aspirin 81 mg (ACA Copay Waiver)
Auryxia | lanthanum chewable tablet (Fosrenol) | Velphoro
Benign Prostate Hyperplasia (BPH) (tadalafil 2.5 or 5 mg (BPH) ONLY)
Bevespi Aerosphere | Breztri | Duaklir Pressair
Breast Cancer Prevention Drugs (ACA Copay Waiver)
Butorphanol (Stadol) Nasal Spray
Cimzia SQ (Pharmacy Benefit Prefilled Syringe)
Contraceptive Medical Exception Request Form
Deferasirox (Exjade) | Deferasirox (Jadenu)
Deferiprone Tablets (Ferriprox) | Ferriprox Solution
Dihydroergotamine Mesylate (D.H.E. 45) | Dihydroergotamine Mesylate (Migranal)
Doxylamine-Pyridoxine (Diclegis)
Dry Eye Medications (Cequa | Lacrisert | Miebo | Restasis Multidose |Tyrvaya)
Erythropoiesis Stimulating Agents (ESAs) (Aranesp | Epogen | Mircera | Procrit | Retacrit)
Ezetimibe-Simvastatin (Vytorin)
Fetzima | Trintellix | Vilazodone (Viibryd)
Forteo | Tymlos | teriparatide
Gastrointestinal Motility Drugs (Amitiza | Ibsrela | Motegrity | Relistor | Trulance | Zelnorm)
Gaucher Disease Drugs (Substrate Reduction Therapy) (Cerdelga | Miglustat) (Pharmacy)
Glucagon Analogs (GlucaGen HypoKit | Zegalogue)
Gonadotropin-Releasing Hormone Agonists (GnRH) (Pharmacy)
Graft-Versus-Host Disease (GVHD) Drugs (Jakafi | Imbruvica)
Granulocyte Colony-Stimulating Factors (G-CSF)
(Granix, Neupogen, Nivestym, Releuko, Zarxio, Leukine, Fulphila, Fylnetra, Neulasta, Nyvepria, Rolvedon, Ryzneuta, Stimufend, Udenyca, Ziextenzo)High Dose Statins (ACA Copay Waiver)
Icatibant (Firazyr) | Sajazir (Firazyr) (Pharmacy)
Inbrija | Nourianz | Ongentys | Tolcapone (Tasmar)
Insomnia Drugs (Belsomra | Dayvigo |doxepin | quazepam (Doral) | Quviviq | ramelteon (Rozerem))
Ivermectin (Stromectol) Tablets
Javygtor | Sapropterin Dihydrochloride (Kuvan)
Lonhala Magnair | Tudorza Pressair | Yupelri
Mifepristone (Mifeprex) 200mg Tablet
Mifepristone (Mifeprex) 300mg Tablet
Migraine Treatment (Injectable) (Calcitonin Gene-Related Peptide (CGRP) Antagonists)
(Preferred: Aimovig, Emgality) (Non-preferred: Ajovy)Migraine Treatment (Oral)
(Preferred: Nurtec ODT, Qulipta) (Non-Preferred: Reyvow, Ubrelvy, Zavzpret)Nasal Corticosteroids
(azelastine HCL-fluticasone propionate (Dymista), Beconase AQ, flunisolide nasal spray, mometasone (Nasonex), Omnaris, Qnasl, Xhance, Zetonna)Novarel | Pregnyl | Ovidrel | chorionic gonadotropin
Nucala - CRSWNP (Chronic Rhinosinusitis with Nasal Polyps) (Pharmacy)
Nucala SQ - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Pharmacy)
Nucala SQ - Hypereosinophilic Syndome (HES) (Pharmacy)
Nucala SQ - Severe Eosinophilic Asthma (SEA) (Pharmacy)
Odactra House Dust Mite Allergen Extract
Oral Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Overactive Bladder Drugs (Gemtesa | Myrbetriq | fesoterodine (Toviaz))
Pancreatic Enzymes (Pancreaze | Pertzye | Viokace)
Parathyroid Hormone Analogs (teriparatide (Forteo) | Tymlos | teriparatide)
PCSK9 Inhibitors
(Preferred: Repatha) (Non-preferred: Praluent)Pharmacy Benefit Oncology Medications
Pitavastatin (Livalo) | Zypitamag
Posaconazole DR (Noxafil) tablets | Noxafil DR suspension
Potassium Binders (Lokelma | Veltassa)
Preferred Adalimumab Products (Cyltezo | Humira | Hyrimoz)
Prevymis (Tablets) (Pharmacy benefit)
Prophylaxis Hereditary Angiodema Drugs (Pharmacy) (Cinryze | Haegarda | Orladeyo | Takhzyro)
Purified Cortrophin Gel | HP Acthar Gel (Infantile Spasms)
Purified Cortrophin Gel | HP Acthar Gel (Myositis)
Purified Cortrophin Gel | HP Acthar Gel (Nephrotic Syndrome)
Purified Cortrophin Gel | HP Acthar Gel (Ocular Diseases)
Purified Cortrophin Gel | HP Acthar Gel (Other Indications)
Purified Cortrophin Gel | HP Acthar Gel (Sarcoidosis)
Purified Cortrophin Gel | HP Acthar Gel (Systemic Lupus Erythematosus)
Sabril | Vigadrone | vigabatrin| Vigpoder
Saliva Substitutes (Aquoral | Caphosol | NeutraSal | SalivaMax | Salivate Rx)
SGLT2 (Brenzavvy| Invokana | Invokamet/XR | Qtern | Segluromet | Steglatro | Steguljan|Segluromet)
Simponi SQ (Pharmacy Benefit Only)
Skyrizi - Crohn's Disease (CD) (Pharmacy)
Skyrizi - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)
Sodium Oxbate Products
(Lumryz, Sodium Oxbate oral solution, Xyrem, Xywav)Sodium Phenylbutyrate Products (sodium phenylbutyrate (Buphenyl) | Olpruva | Pheburane)
Stelara - Crohn's Disease & Ulcerative Colitis (CD & UC) (Pharmacy)
Stelara - Plaque Psoriasis & Psoriatic Arthritis (PsO & PsA) (Pharmacy)
Stendra | Vardenafil (Levitra)
Tiopronin (Thiola) | Tiopronin delayed-release tablets (Thiola EC)
Topical Antibiotics (Altabax | Xepi)
Topical Immunomodulators (Zyclara | imiquimod 3.75% packets/pump | Picato | Klisyri)
Topical Psoriasis Medications (Vtama | Zoryve)
Topical Rosacea Drugs (brimonidine (Mirvaso) | Rhofade | ivermectin (Soolantra) | Zilxi)
Vyvanse (Binge Eating Disorder)
Wegovy - Cardiovascular Event Risk Reduction
Zeposia - Diagnosis: Ulcerative Colitis (UC)
Zolmitriptan (Zomig) Nasal Spray
Zoryve Foam (Seborrheic Dermatitis)
Medication Exception
Maximum Daily Dosage Limit Exceptions Request Form
Pharmacy Medical Necessity Request Form
Prior Authorization
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Pharmacy - Medicare
2024 Part D Prior Authorization Criteria
2024 Part D Step Therapy Criteria
Medicare Coverage Determination Request (English)
Medicare Coverage Determination Request (Spanish)
Part B Authorization Criteria
Avastin and Bevacizumb Biosimilars (Ocular & Other)
Epoprostenol | Flolan | Veletri
Lupron Depot (Endometriosis, Fibroid)
Rituxan | Ruxience | Truxima | Riabni
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Prior Authorization and Hospital Admission Notification
Admission Notification
Hospital Admission Emergent Urgent Direct Admissions Form
Continuity of Care Authorization Form - Out of Network Providers
Medical Prior Authorization Request Form
Member Transition of Service Form – Medical and Pharmacy
Resources
Inpatient Discharge Planning Resources
No Authorization Required List Of Procedure Codes
Notice of Medicare Non-Coverage Form
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Provider Data & Demographics
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Quality Measures - HEDIS & Stars
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Specialty Providers
Behavioral Health
PCP-Behavioral Health Coordination Form
Cardiology
Oncology
Medical Oncology & Hematology Prior Authorization Matrix
Ophthalmology
EMI Ophthalmology CPT Code List
Radiology
TBD