Prior authorization required — follow product-specific PA criteria

Many drugs in this formulary require prior authorization. Providers must submit indication-specific documentation (diagnosis confirmation), prior trial(s) or intolerance to alternative therapies where required, prescriber specialty and age information, and any other required medical information listed for the product requested. Follow the individual product entries for exact PA criteria and required supporting documentation.

• Diagnosis confirmation required per product-specific criteria
• Documentation of prior therapy trials or documented intolerance when specified
• Prescriber specialty and age restrictions must be provided when listed
• Additional required medical information (labs, imaging, susceptibility results) as specified per drug

Austedo prior authorization requirements

Austedo and Austedo XR require prior authorization with documentation of the specific sleep disorder diagnosis. Narcolepsy and OSAHS generally require confirmation by a sleep study unless the prescriber documents why a sleep study is not feasible. Prescriptions should be from or in consultation with a neurologist or sleep specialist.

• Narcolepsy: sleep study confirmation unless infeasible
• OSAHS: sleep study confirmation with ≥5 obstructive events/hour plus symptoms unless infeasible
• Prescribed by or in consultation with a neurologist or sleep specialist

Cayston prior authorization specifics

Cayston PA requires documentation of a diagnosis of cystic fibrosis, evidence of Pseudomonas aeruginosa in the lungs with susceptibility showing sensitivity to aztreonam, and FEV1 between 25% and 75% predicted. Prescriptions must be by or in consultation with a pulmonologist, infectious disease specialist, or CF center specialist.

• CF diagnosis and Pseudomonas aeruginosa evidence with aztreonam susceptibility
• FEV1 documented between 25%–75% predicted
• Prescriber: pulmonologist, infectious disease specialist, or CF center specialist

Dupixent prior authorization specifics

Dupixent prior authorization requires indication-specific documentation: e.g., for atopic dermatitis an inadequate response/intolerance to one medium+ potency topical steroid or topical tacrolimus/pimecrolimus/crisaborole; for asthma meet eosinophil/exacerbation criteria and concurrent medium–high dose ICS plus another controller; for EoE provide biopsy with ≥15 eosinophils/HPF and prior PPI or topical steroid trial. Concurrent use with other biologic agents is excluded.

• AD: inadequate response/intolerance to specified topical therapies
• Asthma: eosinophil thresholds and exacerbation history, plus use with medium–high dose ICS + another controller
• EoE: ≥15 eos/HPF, symptoms, exclusion of other causes, and failed ≥8-week PPI or topical esophageal corticosteroid
• Concurrent biologic therapy is an exclusion

PA submissions — include indication-specific documentation

Prior authorization submissions must include the indication-specific documentation listed in the product entry: diagnosis confirmation, required prior therapy trials or documented intolerance, age and prescriber specialty information, and any required objective test results or labs.

• Provide required prior therapy trials or justification why trials are inappropriate
• Include age and prescriber specialty per product requirements
• Attach objective supporting data (labs, imaging, pulmonary function, biopsy, susceptibility testing) when specified

Growth therapy PA duration and annual re-evaluation

Growth-related therapies are authorized for 12 months for initial and continuation approvals; continuation typically requires annual clinical re-evaluation by the treating endocrinologist and documentation of increased growth velocity or other indication-specific response measures.

• Initial and continuation PA durations: 12 months
• Annual clinical re-evaluation by treating endocrinologist required for continuation
• Continuation requires objective evidence of response (e.g., increased growth velocity)

High-dose opioid continuation — documentation required

Continuing high-dose opioid therapy (morphine-equivalent ≥90 mg/day) requires documentation that the member's pain was assessed within the last 6 months, there is clinically meaningful improvement in pain and function outweighing risks, and the member is not being treated for substance abuse.

• Pain assessment within prior 6 months
• Clinically meaningful improvement in pain/function documented
• No current treatment for substance abuse

Lidocaine patch prior authorization

Lidocaine 5% patches require prior authorization with documentation of the qualifying diagnosis (post-herpetic neuralgia or diabetic peripheral neuropathy) per the product entry.

• Document diagnosis of PHN or DPN
• Provide any other required supporting information as listed in the product entry

Livtencity (CMV) prior authorization requirements

Livtencity (letermovir) prior authorization requires documentation of CMV infection/disease in a hematopoietic stem cell or solid organ transplant recipient, failure or intolerance to at least 2 weeks of IV ganciclovir, oral valganciclovir, IV foscarnet, or IV cidofovir, and the member must weigh ≥35 kg and be ≥12 years old.

• Diagnosis of CMV infection/disease in transplant recipient
• Inadequate response or intolerance to ≥2 weeks of listed antivirals
• Age ≥12 years and weight ≥35 kg

Nuedexta prior authorization and cardiac exclusion

Nuedexta for pseudobulbar affect requires PA with documentation of PBA and an underlying qualifying neurologic condition; providers must note the exclusion for prolonged QT, congenital long QT syndrome, or torsades de pointes.

• Document diagnosis of PBA and qualifying neurologic condition (e.g., ALS, MS, stroke, traumatic brain injury)
• Provide prescriber specialty (neurologist or psychiatrist) as requested
• Do not approve if prolonged QT, congenital long QT syndrome, or torsades de pointes is documented

Onychomycosis — PA documentation and prior therapy requirement

Onychomycosis prior authorization requires confirmatory diagnostic testing (KOH, culture, or histology), documentation that the condition causes debility or ADL disruption, and evidence of inadequate response or intolerance to oral terbinafine and either oral itraconazole or topical ciclopirox before approval.

• Confirm diagnosis with KOH, culture, or histology
• Document functional impact or ADL disruption
• Provide prior treatment trials showing failure or intolerance to required agents

PAH agents — PA and specialist documentation

PA for pulmonary arterial hypertension agents requires documentation of WHO Group I PAH with NYHA Functional Class II–IV, confirmatory right-heart catheterization or echocardiography including mean pulmonary artery pressure ≥25 mm Hg at rest (or >30 with exertion), and specialist involvement; initial approvals commonly 6 months with continuation 12 months contingent on stabilization or improvement.

• PAH WHO Group I diagnosis with NYHA II–IV documented
• Confirmatory catheterization or echocardiography and mPAP ≥25 mm Hg at rest
• Prescribed by or in consultation with a cardiologist or pulmonologist
• Initial coverage typically 6 months; continuation 12 months with stabilization/improvement

Praluent prior authorization — LDL and statin trial documentation

Praluent prior authorization requires LDL-C values meeting the specified thresholds after a minimum 8-week trial of at least moderate-intensity statin therapy, or documented statin intolerance per criteria. Initial authorizations are commonly 6 months with 12-month continuation contingent on positive clinical response.

• LDL‑C ≥70 mg/dL after ≥8-week moderate‑intensity statin trial (or meet HoFH thresholds as specified)
• Document statin intolerance per listed CK/AST/ALT or clinical criteria if applicable
• Initial 6 months; continuation 12 months with evidence of LDL‑C reduction

Promacta continuation — document clinical response

Promacta (eltrombopag) continuation requires evidence of a positive clinical response appropriate to the indication, such as an increase in platelet count sufficient to avoid clinically important bleeding; continuation durations vary by indication (commonly 12 months).

• Provide objective evidence of platelet count increase for ITP
• For hepatitis C/interferon-related use, meet specified interferon therapy continuation criteria

Skyrizi induction required before maintenance; Part B note

Skyrizi maintenance dosing for Crohn's disease and ulcerative colitis is approved only following IV induction; note that Part B may apply for MA‑PD beneficiaries for infusion-related portions of therapy.

• SC maintenance use permitted only after IV induction for CD/UC
• Site-of-care/benefit (Part B vs Part D) may apply for MA‑PD beneficiaries

Osteoporosis PA — severity, prior therapy, and lifetime limits

Osteoporosis (PMO/OSTm) prior authorization requires member ≥18 years and documentation of severe osteoporosis or high fracture risk (e.g., multiple vertebral fractures or BMD T-score ≤ -2.5) and prior inadequate response or intolerance to listed therapies; cumulative lifetime therapy limits may apply to certain agents on reauthorization.

• Document BMD T-score ≤ -2.5 or history of osteoporotic fracture or multiple vertebral fractures
• Provide prior therapy trials or intolerance documentation
• Cumulative lifetime therapy limits (e.g., 2 years) apply for certain agents on reauth

Biologics (PsO/PsA/UC/CD) — PA and sequencing requirements

Biologics for psoriasis, psoriatic arthritis, UC, and Crohn's require prior authorization documenting diagnosis, specialist prescribing/consultation, and inadequate response or intolerance to the specified alternative agents (typically two agents or as listed); concurrent use with other biologic DMARDs or TNF antagonists is excluded.

• Document failure/intolerance to required prior biologic or systemic agents (typically two)
• Prescriber specialty (dermatology, rheumatology, or gastroenterology) per indication
• Concurrent biologic DMARD therapy is excluded

Prior authorization — general provider actions

Prior authorization is required for many specialty agents; providers must supply indication‑specific documentation, required prior therapy trials or intolerance evidence, age and prescriber specialty, and any objective tests or labs specified in the product entry.

• Follow individual product entries for the exact list of required documents
• Include age, prescriber specialty, and objective test results when requested
• If the product page is an index entry, consult the full product policy for PA rules

Index-only — consult individual product pages for PA rules

This index is an index-only section and does not contain prior authorization rules. Providers must review the individual drug policy pages referenced for each product to find PA requirements and documentation instructions.

• Index entries list product names and page references only
• Locate the full product policy page for PA criteria and required documentation

Step therapy used — document required prior trials

Step therapy is applied to selected drugs. For migraine CGRP inhibitors and other listed agents, prior trials of specified oral prophylactic medications or alternative agents must be documented before approval.

• CGRP inhibitors: document trials of specified oral prophylactic medications per migraine frequency
• Follow product-specific step therapy tables for required agents and durations

Auvelity — step therapy requirement

Auvelity for major depressive disorder requires documentation of inadequate response or intolerance to two formulary antidepressants prior to approval.

• Document trials and inadequate response or intolerance to two formulary antidepressants

Lybalvi — step therapy requirement

Lybalvi new starts require documentation of trials of two generic formulary antipsychotics before approval.

• Provide records of two generic antipsychotic trials and inadequate response or intolerance

Caplyta — step therapy requirement

Caplyta requires inadequate response or intolerance to two antipsychotics (schizophrenia) or two medications for bipolar depression as applicable prior to approval.

• Document two failed or intolerant antipsychotic trials (or bipolar depression alternatives) for new starts

Required prior medication trials — document failures/intolerance

Prior medication trials are commonly required: many indications require documented inadequate response or intolerance to specified alternative therapies (examples include two prophylactic agents for migraine or one DMARD for RA) before specialty therapy is approved.

• Document specific prior agents and trials per indication
• Provide justification if trials are inappropriate

Rheumatology biologics — step requirements

Rheumatology biologics often require inadequate response or intolerance to oral methotrexate or specific prior biologics (e.g., adalimumab, etanercept) before coverage; prescriber specialty (rheumatologist) is typically required.

• Document methotrexate and other prior therapy failures/intolerance as specified
• Prescribed by or in consultation with a rheumatologist when listed

Nexletol/Nexlizet — statin and ezetimibe step requirements

Nexletol/Nexlizet initial approval requires at least an 8‑week trial of maximally tolerated statin therapy and 8–12 weeks of ezetimibe when applicable, with LDL‑C documentation per the policy.

• Document ≥8 weeks of statin therapy at maximally tolerated dose
• Document ezetimibe trial of 8–12 weeks or provide contraindication/intolerance
• Include LDL‑C values within required timeframe

GLP‑1 step therapy — two preferred GLP‑1 trials required

GLP‑1 receptor agonist coverage requires documentation of type 2 diabetes and inadequate response or intolerance to a minimum 90‑day supply of two preferred GLP‑1 brands before approval.

• Submit diagnostic labs confirming T2DM (A1C/FPG/OGTT) and medical records
• Provide evidence of two 90‑day trials of preferred GLP‑1s with inadequate response or intolerance

Nurtec — step therapy requirements (acute and preventive)

Nurtec preventive use requires failure or intolerance to two 4‑week trials of listed prophylactic medications prior to approval; acute use requires failure or intolerance to one generic triptan.

• Preventive: document two 4‑week prophylactic trials with inadequate response/intolerance
• Acute: document inadequate response/intolerance to one generic triptan

Antipsychotic step requirements — aripiprazole products

Aripiprazole products require documentation of inadequate response or intolerance to aripiprazole and additional generic formulary antipsychotics depending on indication (e.g., schizophrenia, adjunctive MDD, autism irritability, Tourette's) before approval.

• Document trials of aripiprazole and the other required generic antipsychotic(s)
• Provide indication-specific supporting documentation

Required trials of alternative therapies for biologics/specialty agents

Many biologic and specialty agents require trials of specified alternative therapies and documentation of inadequate response or intolerance (e.g., required trials of TNF inhibitors or other named biologics) before approval.

• Provide records of the specified prior biologic/systemic agent trials and outcomes
• If trials are inappropriate, provide clinical justification

Xifaxan — step requirements and quantity limits for IBS‑D

Xifaxan for IBS‑D requires documentation of inadequate response or intolerance to both (A) one tricyclic antidepressant or SSRI and (B) dicyclomine, and course limits apply (≤3 total courses/42 days).

• Document failure/intolerance to one TCA or SSRI and to dicyclomine
• Adhere to quantity limit: up to 3 courses (42 days total)

Chronic urticaria — step therapy requirement

For chronic urticaria, prior inadequate response, contraindication, or intolerance to one second‑generation H1 antihistamine at maximally tolerated dose plus adjuncts (leukotriene receptor antagonist, H2 antagonist, switching antihistamines, systemic steroids, or cyclosporine) is required before approval.

• Document failure/intolerance/contraindication to one maximally tolerated second‑generation H1 antihistamine
• Document trials of or consideration of listed adjunct therapies

Index-only — no step therapy rules listed here

No step therapy rules are present in this index excerpt; consult the individual product policy pages for step therapy requirements.

• Index entries only — see full product pages for ST rules

Denial risk — missing prior authorization

Failure to obtain a required prior authorization may result in the plan not covering the drug. Providers should obtain PA before dispensing to avoid coverage denial.

• Submit PA prior to fill to avoid non‑coverage
• Follow product-specific PA instructions and provide requested documentation

Cayston — denial triggers for missing microbiology or FEV1 criteria

Cayston requests lacking evidence of Pseudomonas aeruginosa in the lungs, susceptibility showing sensitivity to aztreonam, or with FEV1 outside the required 25%–75% predicted range may be denied.

• Ensure documented Pseudomonas culture or other evidence and aztreonam susceptibility
• Provide FEV1 within 25%–75% predicted

Biologic therapy denial triggers — concurrent use or missing prior trials

Concurrent therapy with other biologic DMARDs or TNF antagonists, or failure to document required prior therapy trials, may trigger denial for multiple biologic agents (e.g., Cimzia, Cosentyx, other listed products).

• Do not request approval if member is on another biologic DMARD unless policy explicitly allows
• Provide documentation of required prior biologic or systemic therapy trials

Denial risk — concurrent biologic therapy excluded

Concurrent therapy with any other biologic agent is an exclusion for multiple indications; do not request overlapping biologic therapies as they will be denied.

• Confirm member is not receiving another biologic for the same or related indication
• If concurrent therapy is clinically necessary, document rationale and check policy exceptions

Denial trigger — concomitant injectable CGRP inhibitors

For CGRP inhibitors and related migraine biologics, documented concomitant use of another injectable CGRP inhibitor is an exclusion and may result in denial.

• Do not co‑prescribe multiple injectable CGRP inhibitors
• Provide medication history showing absence of other injectable CGRP agents

High‑dose opioid prerequisite — denial risk if prerequisites missing

New-to‑high‑dose opioid requests that do not document cancer‑related pain or, for chronic non‑cancer pain, opioid tolerance and prior evaluation for non‑opioid pharmacologic treatments may be denied.

• For new high‑dose starts, document cancer pain OR opioid tolerance AND prior non‑opioid evaluation
• Provide evidence of opioid tolerance per the policy example dosing

Growth disorder denial triggers — missing diagnostic thresholds or specialist involvement

For growth hormone gene deletion or severe primary IGF‑1 deficiency, requests missing required diagnostic thresholds (e.g., SDS values) or lacking endocrinologist involvement may be denied.

• Include height and IGF‑1 SDS values when applicable
• Prescriber should be an endocrinologist or document specialist consultation

Nuedexta — cardiac exclusion may cause denial

Nuedexta is excluded for patients with documented prolonged QT interval, congenital long QT syndrome, or torsades de pointes on cardiac testing; presence of these findings may trigger denial.

• Provide ECG/cardiac test results; do not approve if prolonged QT or related conditions are present

Posaconazole — denial risk if prior voriconazole trial not documented

For posaconazole prophylaxis, failure to document an inadequate response or intolerance to voriconazole when required may result in denial of posaconazole for prophylaxis.

• For prophylaxis use, document prior voriconazole failure/intolerance when specified
• Include indication and relevant specialist consultation (ID/transplant)

Nexletol/Nexlizet — LDL and prior therapy denial triggers

Nexletol/Nexlizet requests lacking documentation of required LDL‑C thresholds or failure/intolerance to statins and ezetimibe per the policy may be denied.

• Provide LDL‑C values and evidence of ≥8‑week statin trial at maximally tolerated dose
• Document ezetimibe trial (8–12 weeks) or justification for not using ezetimibe

Onychomycosis — denial triggers for missing diagnostics or prior therapy

Onychomycosis PA requests missing confirmatory diagnostic testing (KOH/culture/histology), lack of documentation of ADL impact, or missing prior failure/intolerance to required systemic/topical therapies may be denied.

• Attach KOH, culture, or histology confirming dermatophyte infection
• Document functional impact and prior therapy failures/intolerance

PAH — denial risk if diagnostic hemodynamics or WHO Group I not documented

PAH agent requests without documented WHO Group I PAH diagnosis with NYHA II–IV, confirmatory catheterization/echocardiography, and mean pulmonary artery pressure ≥25 mm Hg at rest (or >30 with exertion) may be denied.

• Provide right‑heart catheterization or echocardiography and mPAP data
• Include NYHA functional class and specialist consultation

PCSK9/Praluent — LDL and statin trial documentation required to avoid denial

For PCSK9 inhibitors (e.g., Praluent), missing documentation of LDL‑C thresholds after an adequate statin trial or lack of documented statin intolerance per specified criteria may lead to denial.

• Include LDL‑C values and evidence of ≥8‑week moderate‑intensity statin trial
• If statin‑intolerant, document clinical criteria (rhabdomyolysis, CK elevations, hepatotoxicity) as specified

Concurrent biologic/JAK therapy excluded — denial risk

Concurrent therapy with other biologic DMARDs or JAK inhibitors is an exclusion for multiple indications and may trigger denial if such concomitant use is documented.

• Verify patient's current biologic/JAK therapy prior to PA submission
• If concurrent therapy is present, the request will generally be denied

Concomitant nitrate use exclusion — sildenafil/PAH

Documentation of concomitant nitrate use is an exclusion for sildenafil (PAH) and can trigger denial; confirm medication list for nitrates before submission.

• Check for concurrent nitrates or nitric oxide donors
• Provide documentation that nitrates are not being used

Concurrent biologic therapy excluded for PsO/PsA/UC/CD

Concurrent therapy with biological DMARDs or TNF antagonists for indications such as psoriasis, psoriatic arthritis, UC, and CD is an exclusion and will result in denial unless the policy permits otherwise.

• Do not request overlapping biologic therapies for listed indications
• Provide evidence patient is not on another biologic for the same disease

PAH — combination with prostanoid/prostacyclin excluded

Use of PAH agents in combination with a prostanoid/prostacyclin analogue is an exclusion and may result in denial; verify current prostanoid therapy before requesting PAH medications covered here.

• Confirm patient is not receiving prostanoid/prostacyclin analogues
• If combined use is clinically required, include justification and check policy exceptions

Asthma/allergy biologics — concurrent biologic therapy excluded

Concurrent therapy with any other biologic agents for asthma/allergic conditions (e.g., benralizumab, dupilumab, mepolizumab, omalizumab) is excluded and may trigger denial for those products.

• Ensure no concurrent biologic for asthma/allergic conditions is being used
• Provide documentation of lack of overlapping biologic therapy

Site-of‑care — Part B vs Part D review for infusion/clinic/home

Site-of-care determinations may affect benefit coverage (Part B vs Part D). For products administered in infusion center, office, or home settings, Part B vs Part D review and billing determinations should be considered when submitting requests.

• Confirm site of care and whether Part B or Part D applies for the product and patient
• Include documentation of administration setting when relevant

PAH prescribing specialty — cardiology/pulmonology requirement

Pulmonary arterial hypertension agents should be prescribed by or in consultation with a cardiologist or pulmonologist; include specialist involvement in the PA submission.

• Document cardiology or pulmonology prescriber or consultation
• Specialist evaluation supports PA approval and continuation assessments

Orkambi — prescribing specialty requirement

Orkambi should be prescribed by or in consultation with a pulmonologist or cystic fibrosis specialist; include this specialty documentation with the prior authorization request.

• Provide pulmonologist or CF specialist prescriber/consultation note
• Attach relevant CF diagnostic and mutation testing information if requested

Specialty prescriber and site-of-care — include specialist and setting

Many specialty products require specialist prescribing or consultation (infusion center, clinic, or provider‑specified specialty). For certain agents, specify the infusion/clinic/specialty site and include the prescribing specialist in the PA documentation.

• For transplant, infectious disease, or GI specialty agents include relevant specialist consultation
• Document site-of-care if product is administered in infusion center, clinic, or specialty setting

Infusion center — Part B vs Part D billing/site‑of‑care note

When the product is administered in an infusion center, Part B vs Part D review may apply; include site-of-care and billing preference information to support correct benefit routing.

• Indicate infusion center administration and whether Part B billing is expected
• Attach documentation supporting site-of-care billing determination where specified