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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
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)
Fetzima, Trintellix, Vilazodone, Viibryd
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)
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)
Irritable Bowel Disease (Non-Preferred)
(Mesalamine DR 800 mg, Dipentum, Budesonide ER 9mg, Uceris)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)PCSK9 Inhibitors
(Preferred: Repatha) (Non-preferred: Praluent)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)Sabril, Vigadrone, Vigabatrin, Vigpoder
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 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)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