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Medication Policies

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View associated prior authorization forms.

View recent prior authorization changes.

IMPORTANT REMINDER

Medication Policies have been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medication policy is to provide a guide to coverage. Medication Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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Medication Name	Medication Policy	Position Summary
A
Aciphex^®, rabeprazoe	Medication Policy	Position Summary
Actiq^®, fentanyl citrate oral transmucosal lozenges	Medication Policy	Position Summary
Actonel^®, risedronate-Containing Medications (Actonel, Actonel with Calcium)	Medication Policy	Position Summary
ACTOplus met^™, pioglitazone-metformin	Medication Policy	Position Summary
Actos^®, pioglitazone	Medication Policy	Position Summary
Actos^®, pioglitazone-Containing Medications (Actos^®, ACTOplus Met^™, Duetact^™)	Medication Policy	Position Summary
Adcirca^™ (tadalafil) 20 mg	Medication Policy	Position Summary
Afinitor^®, everolimus	Medication Policy	Position Summary
Allernaze^™, triamcinolone nasal	Medication Policy	Position Summary
Aloxi^®, palonosetron	Medication Policy	Position Summary
Altinac^®, tretinoin topical	Medication Policy	Position Summary
Ambien^®, zolpidem	Medication Policy	Position Summary
Ambien CR^™, zolpidem MR	Medication Policy	Position Summary
Amerge^®, naratriptan	Medication Policy	Position Summary
Amevive^®, alefacept	Medication Policy	Position Summary
Amphetamine-dextroamphetamine ER capsules	Medication Policy	Position Summary
Antineoplaston Cancer Therapy	Medication Policy	Position Summary
Anzemet^®, dolasetron	Medication Policy	Position Summary
Arcalyst^®, rilonacept	Medication Policy	Position Summary
Arzerra™, ofatumumab	Medication Policy	Position Summary
Atralin^®, topical tretinoin	Medication Policy	Position Summary
Avandamet^®, rosiglitizone/metformin	Medication Policy	Position Summary
Avandia^®, rosiglitazone	Medication Policy	Position Summary
Avandaryl^™, rosiglitazone/glimepiride	Medication Policy	Position Summary
Avandia^®, rosiglitazone-Containing Medications (Avandia^®, Avandamet^®, Avandaryl^™)	Medication Policy	Position Summary
Avita^®, tretinoin topical	Medication Policy	Position Summary
Axert^®, almotriptan	Medication Policy	Position Summary
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B
Baygaym^®, (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Beconase AQ^®, beclomethasone nasal	Medication Policy	Position Summary
Betaseron^®, interferon beta-1b	Medication Policy	Position Summary
Boniva^®, ibandronate injection	Medication Policy	Position Summary
Boniva^®, ibandronate oral	Medication Policy	Position Summary
Botox^®, botulinum toxin Type A Injection	Medication Policy	Position Summary
Byetta^®, exenatide	Medication Policy	Position Summary
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C
Carimune NF (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Celebrex^®, celecoxib	Medication Policy	Position Summary
Cerezyme^®, imglucerase	Medication Policy	Position Summary
Cialis^®, tadalafil	Medication Policy	Position Summary
Cimzia^®, certolizumab pegol	Medication Policy	Position Summary
Cinryze^™, C1 inhibitor (human)	Medication Policy	Position Summary
Compounded Medications	Medication Policy	Position Summary
Crestor^®, rosuvastatin	Medication Policy	Position Summary
Cymbalta^®, duloxetine	Medication Policy	Position Summary
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D
Duetact^™, pioglitazone-glimepiride	Medication Policy	Position Summary
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E
Edluar^®, zolpidem sublingual tablets	Medication Policy	Position Summary
Effexor XR^®, venlafaxine extended-release capsules	Medication Policy	Position Summary
Embeda™, morphine/naltrexone	Medication Policy	Position Summary
Emend^®, aprepitant	Medication Policy	Position Summary
Enbrel^®, etanercept	Medication Policy	Position Summary
Erbitux^®, cetuximab, effective date February 1, 2010	Medication Policy	Position Summary
Extavia^®, interferon beta-1b	Medication Policy	Position Summary
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F
Fentora^®, fentanyl citrate buccal tablet	Medication Policy	Position Summary
Flebogamma^®	Medication Policy	Position Summary
Folotyn™, pralatrexate	Medication Policy	Position Summary
Forteo^®, teriparatide	Medication Policy	Position Summary
Frova^®, frovatriptan	Medication Policy	Position Summary
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G
Gamastan^®, (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Gammagard S/D^®, (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Gammimune N^®, (IVIG, Intravenous Immunoglobulins)	Medication Policy	Position Summary
Gamunex^®, (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Genotropin^®, somatropin	Medication Policy	Position Summary
Gleevec^®, imatinib mesylate	Medication Policy	Position Summary
Growth Hormone (GH)	Medication Policy	Position Summary
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H
Humatrope^®, somatropin	Medication Policy	Position Summary
Humira^®, adalimumab	Medication Policy	Position Summary
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I
Ilaris^®, canakinumab	Medication Policy	Position Summary
Increlex^®, mecasermin	Medication Policy	Position Summary
Imitrex^®, sumatriptan	Medication Policy	Position Summary
Infergen^® interferon alfocan-1	Medication Policy	Position Summary
Istodax^®, romidepsin	Medication Policy	Position Summary
Iveegam^®, (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
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J
Januvia^™, sitagliption	Medication Policy	Position Summary
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K
Kapidex^™, dexlansoprazole	Medication Policy	Position Summary
Kineret^®, anakinra	Medication Policy	Position Summary
Kuvan^®, sapropterin dihydrochloride	Medication Policy	Position Summary
Kytril^®, granisetron	Medication Policy	Position Summary
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L
Lamisil^®, terbinafine oral	Medication Policy	Position Summary
Levitra^®, vardenafil	Medication Policy	Position Summary
Levonorgestrel-containing Intrauterine System (LNG-IUS) for Medical Conditions	Medication Policy	Position Summary
Lexapro^®, escitalopram	Medication Policy	Position Summary
Lipitor^®, atorvastatin	Medication Policy	Position Summary
Livalo^®, pitavastatin	Medication Policy	Position Summary
Lunesta^®	Medication Policy	Position Summary
Luvox^® CR, fluvoxamine extended-release capsules	Medication Policy	Position Summary
Lyrica^®, pregabalin	Medication Policy	Position Summary
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M
Maxalt^®, rizatriptan	Medication Policy	Position Summary
Medication Policy Manual Introduction	Medication Policy	Position Summary
Mirena^®, Levonorgestrel-containing Intrauterine System (LNG-IUS) for Medical Conditions	Medication Policy	Position Summary
MyoBloc^®, botulinum toxin Type B	Medication Policy	Position Summary
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N
Nasacort AQ^®, triamcinolone nasal	Medication Policy	Position Summary
Nasonex^®, mometasone nasal	Medication Policy	Position Summary
Nexavar^®, sorafenib	Medication Policy	Position Summary
Nexium^®, esomeprazole	Medication Policy	Position Summary
Nplate^®, romiplostim	Medication Policy	Position Summary
Non-Formulary Medications, Medical Exception Criteria for Closed Pharmacy Benefit Designs	Medication Policy	Position Summary
Norditropin^®, somatropin	Medication Policy	Position Summary
Nutropin^®, somatropin	Medication Policy	Position Summary
Nutropin AQ^®, somatropin	Medication Policy	Position Summary
Nuvigil^®, armodafinil	Medication Policy	Position Summary
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O
Octagam^® (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Off-Label Drug Use of FDA Approved Drugs	Medication Policy	Position Summary
Omnaris^™, ciclesonide nasal	Medication Policy	Position Summary
Onglyza^®, saxagliptin	Medication Policy	Position Summary
Onsolis^™ fentanyl buccal soluble film	Medication Policy	Position Summary
Opana^® ER, oxymorphone, Extended Release	Medication Policy	Position Summary
Opioids for Chronic Noncancer Pain	Medication Policy	Position Summary
Oral Contraceptives for Medical Conditions	Medication Policy	Position Summary
Orencia^®, abatacept	Medication Policy	Position Summary
OxyContin^®, oxycodone CR	Medication Policy	Position Summary
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P
Pegasys^®, peginterferon alfa-2a	Medication Policy	Position Summary
PEG-Intron^®, peginterferon alfa-2b	Medication Policy	Position Summary
Penlac^®, ciclopirox	Medication Policy	Position Summary
Polygam S/D^®, (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Prevacid^®, lansoprazole	Medication Policy	Position Summary
Pristiq^™, desvenlafaxine	Medication Policy	Position Summary
Privigen^®, Immune Globulin Replacement Therapy	Medication Policy	Position Summary
Promacta^®, eltrombopag	Medication Policy	Position Summary
Protonix^®, pantoprazole	Medication Policy	Position Summary
Provigil^®, modafinil	Medication Policy	Position Summary
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Q
Qualaquin^®, quinine	Medication Policy	Position Summary
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R
Reclast^®, zoledronic acid	Medication Policy	Position Summary
Relenza^®, zanamivir	Medication Policy	Position Summary
Relistor^®, methylnaltrexone	Medication Policy	Position Summary
Relpax^®, eletriptan	Medication Policy	Position Summary
Remicade^®, infliximab	Medication Policy	Position Summary
Renova^®, tretinoin topical	Medication Policy	Position Summary
Retin A^®, tretinoin topical	Medication Policy	Position Summary
Retin A Micro^®, tretinoin topical	Medication Policy	Position Summary
Revatio™, sildenafil 20mg	Medication Policy	Position Summary
Revlimid^®, lenalidomide	Medication Policy	Position Summary
Rhinocort Aqua^®, budesonide nasal	Medication Policy	Position Summary
Rozerem^®, ramelteon	Medication Policy	Position Summary
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S
Saizen^®, somatropin	Medication Policy	Position Summary
Sancuso^®, granisetron topical patches	Medication Policy	Position Summary
Savella^™, milnacipran	Medication Policy	Position Summary
Self-Administered Injectables	Medication Policy	Position Summary
Serostim^®, somatropin	Medication Policy	Position Summary
Simponi^®, golimumab	Medication Policy	Position Summary
Solage^®, tretinoin topical	Medication Policy	Position Summary
Sonata^®, zaleplon	Medication Policy	Position Summary
Sporanox^®, itraconazole oral	Medication Policy	Position Summary
Sprycel^®, dasatinib	Medication Policy	Position Summary
Stelara^™, ustekinumab	Medication Policy	Position Summary
Sumavel^™ DosePro^™, sumatriptan	Medication Policy	Position Summary
Sutent^®, sunitinib	Medication Policy	Position Summary
Symlin^®, pramlinitide	Medication Policy	Position Summary
Synagis^®, respiratory syncytial virus prophylaxis	Medication Policy	Position Summary
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T
Tamiflu^®, oseltamivir	Medication Policy	Position Summary
Tarceva^®, erlotinib	Medication Policy	Position Summary
Tasigna^®, nilotinib	Medication Policy	Position Summary
Tev-Tropin^®, somatropin	Medication Policy	Position Summary
Treximet^™, sumatriptan/naproxen	Medication Policy	Position Summary
Tykerb^®, lapatinib	Medication Policy	Position Summary
Tysabri^®, natalizumab	Medication Policy	Position Summary
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V
Velcade^®, bortezomib, effective date February 1, 2010	Medication Policy	Position Summary
Venoglobulin^®, (IVIG, Intravenous Immunoglobulins)	Medication Policy	Position Summary
Veramyst^®, fluticasone furoate nasal	Medication Policy	Position Summary
Viagra^®, sildenafil	Medication Policy	Position Summary
Vivaglobin^®, subcutaneous immunoglobulin (Immune Globulin Replacement Therapy)	Medication Policy	Position Summary
Votrient™, pazopanib	Medication Policy	Position Summary
Vytorin^®, simvastatin/ezetimibe	Medication Policy	Position Summary
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X
Xenazine^®, tetrabenazine	Medication Policy	Position Summary
Xolair^®, omalizumab	Medication Policy	Position Summary
Xyrem^®, sodium oxybate	Medication Policy	Position Summary
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Z
Zavesca^®, miglustat	Medication Policy	Position Summary
Zofran^®, ondansetron	Medication Policy	Position Summary
Zolinza^™, vorinostat	Medication Policy	Position Summary
ZolpiMist^®, zolpidem	Medication Policy	Position Summary
Zomig^®, zolmitriptan	Medication Policy	Position Summary
Zorbtive^®, somatropin	Medication Policy	Position Summary
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