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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
ACA Copay Waiver - Aspirin 81 mg
ACA Copay Waiver - Breast Cancer Prevention Drugs
ACA Copay Waiver - High Dose Statins
Actemra SQ - Giant Cell Arteritis
Actemra SQ - Other Indications
Actemra SQ - Systemic Sclerosis-Associated Interstitial Lung Disease
Adalimumab SQ
(Preferred: Cyltezo, Humira, Hyrimoz)Adefovir Dipivoxil
(ADV, Generic Hepsera)Albuterol Inhalers
(Generic ProAir HFA, Generic Proventil HFA, Generic Ventolin HFA, Generic Xopenex, ProAir, Proventil HFA)Anticonvulsants, Antiepileptic Drugs, Antiseizure Drugs
Antidepressant Drugs
(Fetzima, Trintellix, vilazodone, Viibryd)Antipsychotics (Children Ages 0 to 17)
Apokyn, Apomorphine Hydrochoride, Kynmobi
Arformoterol Nebulizer Solution
(Generic Brovana & ABA)Atypical Antipsychotics
(Asenapine, Saphris, Caplyta, Fanapt, Lurasidone, Latuda, Paliperidone, Invega, Rexulti, Vraylar)Auryxia, Lanthanum Chewable Tablet, Fosrenol Chewable Tablet, Velphoro
Benign Prostate Hyperplasia (BPH)
(Tadalafil 2.5 or 5 mg)Bevespi Aerosphere, Breztri, Duaklir Pressair
Butorphanol (Stadol) Nasal Spray
Central Nervous System (CNS) Stimulants - Age 19 and Above
Central Nervous System (CNS) Stimulants - Binge Eating Disorder
(Vyvanse)Central Nervous System (CNS) Stimulants - Non-Preferred Drugs for all Ages
Continuous Glucose Monitors (CGM)
Contraceptive Medical Exception Request Form
Deferiprone Tablets, Ferriprox, Ferriprox Solution
Dihydroergotamine Mesylate (D.H.E. 45), Dihydroergotamine Mesylate (Migranal)
Dipetidyl Peptidase 4 (DPP4) Inhibitors
Doxylamine-Pyridoxine (Diclegis)
Erythropoiesis Stimulating Agents (ESAs)
(Aranesp, Epogen, Mircera, Procrit, Retacrit)Ezetimibe-Simvastatin (Vytorin)
Gastrointestinal Motility Drugs
(Amitiza, Ibsrela, Motegrity, Relistor, Trulance, Zelnorm)Gaucher Disease Drugs
(Cerdelga, Miglustat)Glucagon Analogs
(GlucaGen HypoKit, Zegalogue)Glucagon-Like Peptide (GLP-1) Receptor Agonists
(Bydureon Bcise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)Gonadotropin-Releasing Hormone (GnRH) Agonists
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)Hepatitis-C Antiviral (HCV) Drugs
(Preferred: Sofosbuvir/Elpatasvir, Ledipasvir/Sofobuvir, Mavyret)
(Non-Preferred: Epclusa, Harvoni, Sovaldi, Viekira Pak, Vosevi, Zepatier)Hereditary Angioedema Drugs - Acute Treatment
(Icatibant, Firazyr, Sajazir)Hereditary Angioedema Drugs - Acute Treatment
(Ruconest)Hereditary Angioedema Drugs - Prophylaxis
(Cinryze, Haegarda, Orladeyo, Takhzyro)Human Chorionic Gonadotropin (hCG) - Pre-Pubertal Cryptorchidism
(Novarel, Pregnyl, Ovidrel, Chorionic Gonadotropin)Inbrija, Nourianz, Ongentys, Tolcapone, Tasmar
Infertility Drugs (Group Specific Benefit)
Inflammatory Bowel Disease Drugs
(budesonide ER 9mg, Dipentum, Mesalamine DR 800mg)Inhaled Corticosteroid (ICS) with Long-Acting Beta-2 Agonist (LABA) Inhalers
(AirDuo Digihaler, AirDuo RespiClick, Budesonide-Formoterol, Dulera, Fluticasone-Salmeterol, Fluticasone Furoate-Vilanterol, Wixela Inhub)Inhaled Corticosteroids (ICS) (Non-Preferred)
(Alvesco, ArmonAir Digihaler, Aasmanex, Flovent Diskus/HFA, fluticasone propionate Diskus/HFA)Insomnia Drugs
(Belsomra, Dayvigo, doxepin, quazepam (Doral), Quviviq, ramelteon (Rozerem))Insulins (Non-Preferred Long-Acting and Short-Acting)
Ivermectin, Stromectol Tablets
Javygtor, Sapropterin Dihydrochloride, Kuvan
Long-Acting Muscarinic Antagonist (LAMA) Inhalers
(Lonhala Magnair, Tudorza Pressair, Yupelri)Metyrosine, Demser, Phenoxybenazmine, Dibenzyline
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 Calcitonin Gene-Related Peptide (CGRP) Antagonists
(Preferred: Nurtec ODT, Qulipta) (Non-Preferred: Reyvow, Ubrelvy, Zavzpret)Multiple Sclerosis Drugs
(Bafiertam, Extavia, Gilenya 0.5mg, Kesimpta, Mavenclad, Mayzent, Ponvory, Vumerity, Zeposia)Nasal Corticosteroids
(azelastine HCL-fluticasone propionate (Dymista), Beconase AQ, flunisolide nasal spray, mometasone (Nasonex), Omnaris, Qnasl, Xhance, Zetonna)Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (Oral)
Nucala SQ - CRSWNP (Chronic Rhinosinusitis with Nasal Polyps)
Nucala SQ - Eosinophilic Granulomatosis Polyangiitis (EGPA)
Nucala SQ - Hypereosinophilic Syndome (HES)
Nucala SQ - Severe Eosinophilic Asthma (SEA)
Odactra House Dust Mite Allergen Extract
Oncology Drugs (Pharmacy Benefit)
Ophthalmic Drugs - Antihistamines
(Alocril, Alomide, Bepotastine Besilate 1.5%, Bepreve, Lastacaft, Zerviate)Ophthalmic Drugs - Dry Eye
(Cequa, Lacrisert, Miebo, Restasis Multidose, Tyrvaya)Overactive Bladder Drugs
(Gemtesa, Myrbetriq, Fesoterodine, Toviaz)Pancreatic Enzymes
(Pancreaze, Pertzye, Viokace)Parathyroid Hormone Analogs
(Forteo, Tymlos, Teriparatide)Pitavastatin, Livalo, Zypitamag
Posaconazole DR Tablets, Noxafil DR Tablets, Noxafil IR/DR suspension
Potassium Binders
(Lokelma, Veltassa)Proton Pump Inhibitors (PPI) Drugs (Non-Preferred)
(Dexlansoprazole, Omeprazole/Sodium Bicarbonate, Voquezna)Pulmonary Arterial Hypertension (PAH) Drugs
Pulmonary Hypertension associated with Interstitial Lung Disease (PH-ILD)
(Tyvaso)Recombinant Growth Hormone (rhGH)
(Preferred: Omnitrope, Norditropin)
(Non-Preferred: Genotropin, Humatrope, Ngenla, Nutropin, Nutropin AQ, Saizen, Sogroya, Skytrofa, Zomacton)Repository Corticotropin Drugs - Infantile Spasms
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)Repository Corticotropin Drugs - Myositis
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)Repository Corticotropin Drugs - Nephrotic Syndrome
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)Repository Corticotropin Drugs - Ocular Diseases
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)Repository Corticotropin Drugs - Other Indications
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)Repository Corticotropin Drugs - Sarcoidosis
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)Repository Corticotropin Drugs - Systemic Lupus Erythematosus
(Preferred: Purified Cortrophin Gel) (Non-Preferred: HP Acthar Gel)Saliva Substitutes
(Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx)Skyrizi SQ - Crohn's Disease & Ulcerative Colitis
Skyrizi SQ - Plaque Psoriasis & Psoriatic Arthritis
Sodium Oxbate Drugs
(Lumryz, Sodium Oxbate Oral Solution, Xyrem, Xywav)Sodium Phenylbutyrate Drugs
(Sodium Phenylbutyrate, Buphenyl, Olpruva, Pheburane)Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors (Non-Preferred)
Somatostatin Analog Drugs
(Bynfezia SQ, Sandostatin LAR Depot, Signafor SQ, Somavert SQ, Mycapssa Tablet)Stelara SQ - Crohn's Disease & Ulcerative Colitis
Stelara SQ - Plaque Psoriasis & Psoriatic Arthritis
Stendra, Vardenafil (Group Specific Benefit)
Testosterone Replacement Therapy
(Preferred: Testosterone Gel, Testosterone Injection, Testosterone Solution, Kyzatrex)
(Non-Preferred: Androderm, Natesto, Vogelxo)Topical Antibiotics Drugs
(Altabax, Xepi)Topical Antifungal Drugs
(Ertaczo, luliconazole (Luzu), Mentax, naftifine (Naftin), oxiconazole (Oxistat), sulconazole (Exelderm))Topical Immunomodulator Drugs
(Zyclara, Imiquimod 3.75% , Picato, Klisyri)Topical Phosphodiesterase 4 inhibitors
(Eucrisa 2%, Zoryve 0.15%)Topical Psoriasis Drugs
(Vtama, Zoryve Cream)Topical Retinoids and Acne Drugs - Skin Conditions
Topical Rosacea Drugs
(Brimonidine, Mirvaso, Rhofade, Ivermectin Cream, Soolantra, Zilxi)Topical Seborrheic Dermatitis Drugs
(Zoryve Foam)Vigabatrin Products
(Sabril, Vigadrone, vigabatrin, Vigafyde, Vigpoder)Wegovy - Cardiovascular Event Risk Reduction
Weight Management Drugs (Group Specific Benefit)
Zolmitriptan (Zomig) Nasal Spray
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