-
Behavioral Health
-
Care Coordination
TBD
-
Claims & CPT Codes
-
Continuation of Care
-
Contracting
-
Member Related
-
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
-
Prior Authorization Medical Drugs – Commercial
Medical Drug Authorizations - Commercial
Actemra IV for diagnosis of Cytokine Release Syndrome (CRS) (Medical)
Alpha Proteinase Inhibitors (Medical)
Botox Injection-Type A (Chronic Migraine Headache Prophylaxis) (Medical)
Botox Injection-Type A (Hyperhidrosis) (Medical)
Botox Injections-Type A (Upper Limb Spasticity (ULS) | Lower Limb Spasticity (LLS) (Medical)
Casgevy - β - Thalassemia (Medical)
Cimzia Lyophilized IV (Medical)
Duchenne Muscular Dystrophy Medications (Medical)
Dysport (Botox Injections) (Medical) (Cosmetic indications Excluded)
edaravone IV (Radicava IV) (Medical)
Eylea - Retinopathy of Prematurity (ROP) (Medical)
Gaucher Disease Drugs (Enzyme Replacement Therapy) (Medical)
Gonadotropin-releasing Hormone Agonists (GnRH) (Medical)
Hemophilia Factors (IV) (Medical)
Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors (Medical)
icatibant (Firazyr) | sajazir (Firazyr) (Medical)
Ilaris (sJIA | AOSD) (Medical) (Non-Preferred)
Ilaris (TRAPS | HIDS/MKD | FMF diseases | CAPS) (Medical)
Immune Globulin Intravenous (IVIG) (immunodeficiency) (CIDP) (Medical)
Immune Globulin Intravenous (IVIG) (Miscellaneous Disorders) (Medical)
Immune Globulin Intravenous (IVIG) (Miscellaneous Sjögren’s Syndrome Neuropathies) (Medical)
Immune Globulin Intravenous (IVIG) (Multifocal Motor Neuropathy (MMN)) (Medical)
Immune Globulin Intravenous (IVIG) (Primary Immunodeficiency Disorder (PID)) (Medical)
Immune Globulin SQ (Primary Immunodeficiency Disorder) (Medical)
Infliximab Products (Medical)
(PREFERRED: Renflexis & unbranded Infliximab) (Non-Preferred: Avsola | Inflectra | Remicade| Zymfrentra)Intravitreal Compliement Inhibitors
Macular Degeneration Drugs (Medical)
(Avastin, bevacizumab 1.25 mg/0.05 mL, Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Susvimo, Vabysmo)Mometasone Sinus Implants (Medical)
Nexviazyme | Pombiliti (Medical)
Noninfectious Uveitis Drugs (Medical)
(Retisert, Yutiq)Nucala - Chronic Rhinosinusitis with Nasal Polyps (CRSWNP) (Medical)
Nucala - Eosinophilic Granulomatosis Polyangiitis (EGPA) (Medical)
Nucala - Hypereosinophilic Syndrome (HES) (Medical)
Nucala - Severe Eosinophilic Asthma (SEA) (Medical)
Ocrevus | Ocrevus Zunovo (Medical)
Ophthalmic Corticosteroid Injections (Medical)
Orencia - Graft Versus Host Disease (GVHD) (Medical)
Orencia IV (Infusion only) (Medical)
PiaSky-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
plerixafor (Mozobil) (Medical)
Prophylaxis Hereditary Angiodema Drugs (Medical)
Pulmonary Arterial Hypertension Drugs (Medical)
Riabni | Rituxan IV | Ruxience | Truxima (Medical) (Non-Preferred)
Simponi ARIA IV (Medical) (Non-Preferred)
Soliris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
Soliris IV - Generalized Myasthenia Gravis (gMG) (Medical)
Soliris IV-Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)
Soliris IV-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
Somatostatin Analog Drugs (Medical)
Tegsedi SQ Injection (Medical)
Testosterone Replacement Therapy Injectables
(Aveed, Azmiro, Testopel)Tocilizumab products IV (Medical)
Ultomiris IV - Atypical Hemolytic Uremic Syndrome (aHUS) (Medical)
Ultomiris IV - Generalized Myasthenia Gravis (gMG) (Medical)
Ultomiris IV - Neuromyelitis Optica Spectrum Disorder (NMOSD) (Medical)
Ultomiris IV-Paroxysmal Nocturnal Hemoglobinuria (PNH) (Medical)
Vyvgart Hytrulo - Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)(Medical)
Vyvgart_Vyvgart Hytrulo (Medical)
Xofigo (Medical)
Zevalin (Medical)
-
Prior Authorization Pharmacy Drugs – Commercial
Drug Authorization
ACA Copay Waiver - Aspirin 81 mg
ACA Copay Waiver - Breast Cancer Prevention Drugs
ACA Copay Waiver - High Dose Statins
Actemra SQ - Systemic Sclerosis-Associated Interstitial Lung Disease
Adalimumab Preferred Products
(Commercial Preferreds: Cyltezo, Humira, Yuflyma) (Small Group/Individual Product/Exchange Preferred: adalimumab-adbm, Simlandi)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)Antiparkinson Agents
(Crexont, Inbrija, Lodosyn, Neupro, Nourianz, Ongentys , tolcapone, Rytary, Xadago)Antipsychotics (Children Ages 0 to 17)
Apokyn, Apomorphine Hydrochoride, Kynmobi
Arformoterol Nebulizer Solution
(Generic Brovana & ABA)Atypical Antipsychotics
(Asenapine, Caplyta, Cobenfy, Fanapt, lurasidone, paliperidone, 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)
Gastric Acid Suppression Drugs (Non-Preferred)
(Dexlansoprazole, Omeprazole/Sodium Bicarbonate, Voquezna)Gastrointestinal Motility Drugs
(Ibsrela, Prucalopride (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, Nypozi, 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)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
Long-Acting Muscarinic Antagonist (LAMA) Inhalers
(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 - Non-injectable Drugs
(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) (Pharmacy)
Nucala SQ - Hypereosinophilic Syndome (HES)
Nucala SQ - Severe Eosinophilic Asthma (SEA)
Odactra House Dust Mite Allergen Extract
Oncology Drugs (Pharmacy Benefit)
Ophthalmic Corticosteroid Injections (Medical)
(Ozurdex, Iluvien, Xipere)Ophthalmic Drugs - Antihistamines
(Alocril, Alomide, Bepotastine Besilate 1.5%, Bepreve, Lastacaft, Zerviate)Ophthalmic Drugs - Dry Eye
(Cequa, Lacrisert, Miebo, Restasis Multidose, Tyrvaya)Ophthalmic Drugs - Glaucoma
(Betoptic-S, brimonidine 0.1%, Rhopressa, Rocklatan, Simbrinza, tafluprost, timolol, travoprost 0.004%, Vyzulta)Overactive Bladder Drugs
(fesoterodine (Toviaz), Gemtesa, mirabegron (Myrbetriq))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)Primary Biliary Cholangitis Drugs
(Iqirvo, Livdelzi, Ocaliva)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)Roflumilast (Generic Daliresp)
Saliva Substitutes
(Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx)Sapropterin Products
(Saproterin Dihydrochloride (generic Kuvan) | Javygtor)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)SQ Tocilizumab Products - Other Indications (Actemra SQ, Tyenne SQ)
SQ Tocilizumab Products - Giant Cell Arteritis (Actemra SQ, Tyenne SQ)
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)Tiopronin Products
(Tiopronin (Thiola), tiopronin delayed-release (Thiola EC), venxxiva (Thiola))Topical Acne Drugs
(Preferred: adapalene (generic Differin) | treinoin cream 0.025%, 0.05%, 0.1%, 0.025% (generic Retin-A)) (Non-Preferred: adapalene 0.3%/benzoyl peroxide 2.5% gel (generic Epiduo Forte) | Altreno lotion 0.05% | Aklief | Amzeeq | Azelex | clindamycin 1.2%/benzoyl peroxide 2.5% gel (generic Acanya) | dapsone gel 5% (generic Aczone) | erythromycin 3%/benzoyl 5% gel (generic Benzamycin) | Retin-A Micro gel 0.06%, 0.08% | tazarotene foam 0.1% (generic Fabior) | tretinoin gel 0.05% (generic Atralin) | tretinoin microsphere gel 0.04%, 0.1% (generic Retin-A Micro) | Winlevi cream 1%)Topical Antibiotics Drugs
(Altabax, Xepi)Topical Antifungal Drugs
(Ertaczo, luliconazole (Luzu), Mentax, naftifine 1% cream, naftifine 2% cream, Naftin 1% gel, Naftin 2% gel 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 Zoryve Products
(Zoryve 0.15% cream, Zoryve 0.3% cream, Zoryve topical foam, 0.3%)Transthyretin Stabilizers
(Attruby, Vyndamax, Vyndaqel)Tremfya - Plaque Psoriasis & Psoriatic Arthritis
Vigabatrin Products
(Sabril, Vigadrone, vigabatrin, Vigafyde, Vigpoder)Wegovy – Cardiovascular Event Risk Reduction (Group Specific Benefit)
Weight Management Drugs (Group Specific Benefit)
Zepbound – Obstructive Sleep Apnea [OSA] (Group Specific Benefit)
Zolmitriptan (Zomig) Nasal Spray
Medication Exception
Maximum Daily Dosage Limit Exceptions Request Form
Pharmacy Medical Necessity Request Form
Prior Authorization
-
Prior Authorization Pharmacy and Medical Drugs – Medicare
-
Quality Measures - HEDIS & Stars
-
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