Acitretin — prior authorization required (1 year)

Acitretin is subject to prior authorization. Coverage is provided when the PA criteria are met and, per the Acitretin entry, authorization is granted for one year; no prerequisite Part D drug is required.

Augtyro — PA: 1 year; no prerequisite Part D drug

Augtyro requires prior authorization for all medically-accepted indications; coverage duration is 1 year and the entry indicates no prerequisite Part D drug is required.

Auryxia — PA: one year; no prerequisite Part D drug

Auryxia (ferric citrate) requires prior authorization for all medically‑accepted indications; coverage duration is one year and no prerequisite Part D drug is required.

Auvelity — PA: MDD requires trial of bupropion + one other agent

Auvelity requires prior authorization for all medically‑accepted indications. For major depressive disorder, the entry requires a trial of bupropion and one other agent (prerequisite Part D drug trial required).

Braftovi — PA: combination therapy and prior therapy requirements

Braftovi is subject to prior authorization; coverage for listed oncology indications requires specified combination use (e.g., vemurafenib + cobimetinib for BRAF-mutant melanoma, cetuximab + fluorouracil-based chemotherapy for CRC) and some indications require prior systemic therapy (prerequisite Part D drug required).

Brukinsa — PA: prerequisite trials or combination therapy

Brukinsa requires prior authorization; certain hematologic indications require trials of or combination with specified agents (e.g., trial of Calquence for MCL; anti‑CD20 regimens or obinutuzumab for other lymphomas).

Bysanti — PA: antipsychotic prerequisite trials required

Bysanti is subject to prior authorization. Coverage for schizophrenia in adults requires trials of lurasidone and paliperidone; for other antipsychotic indications coverage requires trials of at least two listed generic antipsychotics. Coverage duration is listed as plan year.

PA required — general note

Prior authorization is required for many products listed in this document; individual product entries specify whether prerequisite Part D drug trials are required and most PA authorizations are for one year (or plan year) where noted.

Cabometyx — PA: prior trials / combination requirements

Cabometyx requires prior authorization; first‑line advanced renal cell carcinoma coverage requires combination use with nivolumab, hepatocellular carcinoma coverage requires a trial of sorafenib, and certain differentiated thyroid cancer indications require prior VEGFR‑targeted therapy (prerequisite Part D drug required).

Prior Authorization required — 1 year (common)

Several products on the formulary require prior authorization and list a coverage duration of one year; providers must meet the PA criteria referenced for each product to obtain coverage.

Cystaran — PA: all indications; 1 year

Cystaran requires prior authorization for all medically‑accepted indications; coverage duration is one year per the product entry.

Dalfampridine — PA: baseline T25FW required; wheelchair exclusion

Dalfampridine ER requires prior authorization. For multiple sclerosis the PA requires documentation of a baseline Timed 25‑Foot Walk (T25FW) prior to initiation and the product is excluded if the patient is wheelchair‑bound or becomes wheelchair‑bound.

• Document baseline T25FW prior to initiation
• Do not initiate or continue if patient is wheelchair‑bound

Danyelza — PA: requires prior response/stable disease to prior therapy

Danyelza requires prior authorization for relapsed or refractory high‑risk neuroblastoma; coverage is contingent on response or stable disease to prior therapy (prerequisite therapy noted).

Daurismo — PA: combination therapy required for newly diagnosed AML

Daurismo requires prior authorization; coverage for newly diagnosed acute myeloid leukemia explicitly requires combination therapy per the product entry.

Deferasirox — PA: all indications; 1 year

Deferasirox (tablets/TBSO) requires prior authorization for all medically‑accepted indications; the product entry lists a one‑year coverage duration and does not note prerequisite Part D drug trials.

Diacomit — PA: trial of 2 generics + clobazam combination required

Diacomit requires prior authorization; coverage requires trial of two generic anticonvulsants and use in combination with clobazam for the listed indication.

• Trial of 2 generic anticonvulsants required
• Combination use with clobazam required

Dihydroergotamine — PA: trial of oral + non‑oral triptan required

Dihydroergotamine mesylate solution requires prior authorization; coverage requires trials of two triptans on the formulary: one oral triptan and one non‑oral triptan prior to approval.

• Trial of one oral triptan and one non‑oral triptan required

Doptelet — PA: prior therapy required for chronic ITP

Doptelet requires prior authorization for chronic immune thrombocytopenia and the entry specifies a trial of a previous therapy is required before coverage.

Drizalma — PA: all indications; 1 year

Drizalma Sprinkle requires prior authorization for all medically‑accepted indications; coverage duration is one year.

Dulera — PA: diagnosis + prior therapy trial required

Dulera requires prior authorization for asthma coverage; the entry requires a diagnosis of asthma and trial of one of the listed agents prior to approval (prerequisite therapy required).

Dupixent — PA: indication‑specific trials, exclusions, reauth requirements

Dupixent requires prior authorization across multiple indications. PA criteria include indication‑specific prior therapy trials, diagnostic thresholds (e.g., eosinophil counts), age/weight minimums, an exclusion against combination use with another biologic/targeted DMARD for the same condition, and a one‑year coverage duration.

• Cannot be used with another biologic/targeted DMARD for the same condition
• Reauthorization requires documentation of positive clinical response

Ebglyss — PA: age/weight limits, prior trials, combination exclusion, 1 year

Ebglyss requires prior authorization for patients ≥12 years old and who weigh at least 40 kg; coverage duration is one year. The entry prohibits combination use with another biologic/targeted DMARD for the same condition and requires prior therapy trials for atopic dermatitis; reauthorization requires documentation of positive clinical response.

• Patient must weigh ≥40 kg
• Age ≥12 years for indicated approvals
• Cannot be used with another biologic/targeted DMARD for same condition
• Reauthorization requires documentation of positive clinical response

PA, coverage duration, age limit — general

PA criteria apply to the products in this section; where stated, coverage duration is one year and age limits (e.g., ≥12 years) are enforced per product entries.

Emgality — PA: 1 year

Emgality requires prior authorization; the product entry lists a one‑year coverage duration.

Ensacove — PA: 1 year

Ensacove requires prior authorization with a one‑year coverage duration per the product entry.

Erleada — PA: all indications; 1 year

Erleada requires prior authorization for all medically‑accepted indications; coverage duration is one year per the product entry.

Esbriet — PA: all indications; 1 year

Esbriet (pirfenidone) requires prior authorization; coverage duration is one year and indications are all medically‑accepted indications per the entry.

Fasenra — PA: eosinophil/EGPA criteria; reauth requires clinical response

Fasenra requires prior authorization with indication‑specific criteria (e.g., eosinophil thresholds for eosinophilic asthma, EGPA criteria). Reauthorization requires documentation of positive clinical response.

• Eosinophil count thresholds and EGPA diagnostic criteria required
• Reauthorization requires documentation of clinical response

Firazyr (Icatibant) — PA: all indications; no prerequisite Part D drug

Firazyr (icatibant acetate) requires prior authorization for all medically‑accepted indications; no prerequisite Part D drug is required per the product entry.

Firdapse — PA: all indications; 1 year; no prerequisite Part D drug

Firdapse requires prior authorization for all medically‑accepted indications; authorization is granted for one year and no prerequisite Part D drug is required.

Forteo — PA: BMD T‑score ≤ −2.5 and prerequisite therapy documentation

Forteo (teriparatide) requires prior authorization. Documentation of bone mineral density with a T‑score ≤ −2.5 is required and two‑year coverage requires trials of the specified agents (or inability to be treated with them).

• BMD documentation: T‑score ≤ −2.5 required
• Two‑year coverage requires trials of the named agents (or documented inability to use them)

Fotivda — PA: prior systemic therapy required for advanced RCC

Fotivda requires prior authorization; coverage for advanced renal cell carcinoma requires prior systemic therapy trials (trial of two or more prior systemic agents).

Fruzaqla — PA: prior chemo + anti‑VEGF required for mCRC

Fruzaqla requires prior authorization for metastatic colorectal cancer; coverage requires prior fluoropyrimidine‑, oxaliplatin‑, irinotecan‑based chemotherapy and anti‑VEGF therapy per the product entry.

Fulphila — PA: 1 year; no prerequisite Part D drug

Fulphila requires prior authorization and is authorized for one year; no prerequisite Part D drug is required per the product entry.

Gattex — PA: documentation of parenteral support ≥12 months required

Gattex requires prior authorization and documentation that the patient has been dependent on parenteral support for 12 months or greater; authorization is for one year.

• Document dependence on parenteral support ≥12 months

Gavreto — PA: RET fusion‑positive thyroid cancer; prior therapy considerations

Gavreto requires prior authorization for RET fusion–positive thyroid cancer and the entry notes appropriate prior therapy (e.g., radioactive iodine when appropriate) per the PA details.

Fingolimod (Gilenya) — PA: all indications; no prerequisite Part D drug

Gilenya (fingolimod) requires prior authorization for all medically‑accepted indications; no prerequisite Part D drug is required per the product entry.

GLP‑1 agonists — PA: T2DM documentation required; weight‑loss only excluded; 1 year

GLP‑1 agonists (including Mounjaro, Ozempic, Rybelsus, Trulicity) require prior authorization; they are excluded if used solely for weight loss and, for ongoing T2DM treatment, require submission of medical records or labs demonstrating T2DM (A1c ≥6.5% OR FPG ≥126 mg/dL OR 2‑hour OGTT ≥200 mg/dL). Coverage duration is one year.

• Do not cover if used for weight loss only
• For T2DM, submit chart notes or labs: A1c ≥6.5% OR FPG ≥126 mg/dL OR 2‑hr OGTT ≥200 mg/dL
• Coverage duration: 1 year

Growth hormone — PA: pediatric 1 year; adult may be lifetime

Growth hormone products (Genotropin and Genotropin Miniquick) require prior authorization; pediatric coverage is authorized for one year and adult coverage may be lifetime as indicated.

Humira — PA: indication‑specific prerequisites; reauth requires clinical response

Humira (adalimumab products) requires prior authorization with indication‑specific diagnostic and prerequisite therapy requirements; reauthorization requires documentation of a positive clinical response to therapy.

• Reauthorization requires documentation of positive clinical response
• Cannot be used in combination with another biologic/targeted DMARD for same condition

Product-specific prior authorization — provide indicated documentation

Many listed products are subject to product‑specific prior authorization. Providers must supply the required indication, required medical information, and any prerequisite trial documentation noted in the product PA criteria.

Ivermectin — PA required; risk of denial if criteria not met

Ivermectin TABS 3 mg requires prior authorization per the PA criteria reference; coverage may be denied if PA criteria are not met.

Deferasirox — PA: 1 year; denial risk if PA criteria not met

Deferasirox tablets require prior authorization; coverage duration is limited to one year and coverage may be denied if PA criteria are not satisfied.

Joenja — PA: genetic + clinical documentation required; 1 year

Joenja requires prior authorization for APDS with specific genetic and clinical documentation: a diagnosis of APDS with associated PI3Kδ mutation, documented variant in PIK3CD or PIK3R1, and documented APDS‑related symptoms; coverage duration is one year and the product cannot be used in combination with an immunosuppressive medication for APDS.

• Document PI3Kδ mutation and variant in PIK3CD or PIK3R1
• Document associated APDS symptoms (e.g., lymphoproliferation, recurrent oto‑sino‑pulmonary infections, organ dysfunction)
• Cannot be used with immunosuppressive medication for APDS

Kerendia — PA: SGLT2 trial required for HF with LVEF ≥40% (unless contraindicated)

Kerendia requires prior authorization; coverage for CKD associated with T2DM is provided, and coverage for heart failure with LVEF ≥40% requires a trial of an SGLT2 inhibitor (e.g., empagliflozin or dapagliflozin) unless contraindicated or intolerant (prerequisite Part D drug required).

• For HF with LVEF ≥40%: document trial of an SGLT2 inhibitor or a contraindication/intolerance

Liraglutide — PA: T2DM documentation required; excluded for weight‑loss only; 1 year

Liraglutide (INJ 6 mg/mL) requires prior authorization and is excluded if used solely for weight loss. For ongoing treatment of type 2 diabetes, submit medical records/chart notes confirming T2DM or lab evidence (A1c ≥6.5% OR FPG ≥126 mg/dL OR 2‑hour OGTT ≥200 mg/dL); coverage duration is one year.

• Excluded if used for weight‑loss only
• For T2DM: submit chart notes OR labs (A1c ≥6.5% OR FPG ≥126 mg/dL OR 2‑hr OGTT ≥200 mg/dL)
• Coverage duration: 1 year

General PA duration/prerequisites — 1 year common; check product PA for trials

General PA durations and prerequisite patterns: many products list a one‑year coverage duration and some require prior trials of specified Part D therapies before approval; refer to each product's PA criteria for details.

Step therapy — general; Acitretin exempt from prerequisite Part D drug

Some formulary drugs are subject to step therapy and may require prior treatment with one or more formulary drugs before coverage; the Acitretin entry explicitly states it does not require a prerequisite Part D drug.

• Acitretin: no prerequisite Part D drug required

Briviact — step/prerequisite: trial of levetiracetam + one other agent

Briviact requires a trial of levetiracetam and one other antiseizure medication prior to coverage per the product PA entry (prerequisite Part D drug required).

Step therapy/prerequisite trials — providers must document required prior trials

Many products require prerequisite therapy trials (examples in the PA list include trials of second‑generation antipsychotics, sorafenib for HCC, generic topical trials for calcipotriene, and prior systemic therapy lines for oncology agents); providers must document these prior trials as specified.

Diacomit — prerequisite trial + combination requirement

Diacomit requires trial of two generic anticonvulsants and combination use with clobazam prior to coverage; absence of documented trials may lead to denial.

• Trial of 2 generic anticonvulsants
• Combination with clobazam required

Dihydroergotamine — prerequisite triptan trials required

Dihydroergotamine mesylate solution requires trial of two triptans (one oral and one non‑oral) on the formulary prior to approval; providers must document these trials.

• Trial one oral triptan and one non‑oral triptan required

Dupixent — prerequisite therapy trials vary by indication; document trials and diagnostics

Dupixent's indication‑specific PA entries require documented trials of specific prior therapies (e.g., high‑potency topical corticosteroid or listed systemic agents for atopic dermatitis; systemic corticosteroids and additional controller meds for eosinophilic asthma); providers must document prior trials and diagnostic criteria.

Ebglyss — prerequisite therapy and documentation for AD in ≥12 years

Ebglyss requires prior trials of listed topical or systemic agents for atopic dermatitis coverage in patients ≥12 years; providers must document prior trial failure and patient weight (≥40 kg).

• Document trial and failure of listed topical/systemic agents for AD
• Document patient weight ≥40 kg

Provider help desk — contact for PA/ST requests

Providers can contact the pharmacy help desk listed on the member ID card to request prior authorization or step therapy; use the customer service number for questions about drug coverage or claims.

Bronchitol — required medical information: tolerance test

Bronchitol coverage requires documentation that the member has passed the Bronchitol tolerance test; include that documentation with the PA request.

• Submit Bronchitol tolerance test documentation

General documentation — document prior trials and required medical information

General documentation note: product PA entries list required prior trials, required medical information, and other criteria; providers should document prior use of required medications, diagnostics, and response information where specified to avoid denial.

Cosentyx — reauthorization requires positive clinical response documentation

Cosentyx reauthorization requires documentation of a positive clinical response to therapy; include objective evidence of improvement when submitting continuation requests.

Dupixent — reauthorization requires clinical response documentation

Reauthorization for Dupixent requires documentation of positive clinical response to therapy; ensure continuation requests include measures of clinical improvement per the indication.

Ebglyss — reauth requires clinical response; prior trial documentation for AD

Ebglyss reauthorization requires documentation of positive clinical response; for AD in patients ≥12 years, providers must document prior trials of listed therapies and treatment failure.

Weight requirement — document patient weight where required (e.g., ≥40 kg)

Weight requirement: several products (e.g., Ebglyss) require patient weight documentation; for Ebglyss the patient must weigh at least 40 kilograms.

• Document patient weight (≥40 kg for Ebglyss)

Reauthorization — document positive clinical response for biologics

Reauthorization for biologics such as Enbrel and Kevzara requires documentation of a positive clinical response to therapy; include objective evidence of improvement when requesting continuation.

Fasenra — document eosinophil/EGPA criteria and clinical response at reauth

Fasenra reauthorization requires documentation of positive clinical response; initial PA also requires documentation of indication‑specific criteria such as eosinophil counts or EGPA features.

Eucrisa — prerequisite documentation: generic topical steroid trial

Eucrisa coverage for atopic dermatitis requires documentation of a trial of a generic topical steroid prior to approval; providers must include evidence of that trial.

• Document trial of a generic topical steroid

Forteo — BMD and prior trial documentation required; denial risk if missing

Forteo coverage requires BMD documentation with a T‑score ≤ −2.5 and documentation of prior trials of the specified agents (or inability to tolerate them); failure to provide prerequisite trial documentation may trigger denial.

Isotretinoin — step requirement: trial of antibiotic or benzoyl peroxide topical

Isotretinoin coverage requires a documented trial of either an oral antibiotic or a benzoyl peroxide topical prior to approval; include that trial documentation with the PA request.

• Document trial of oral antibiotic OR benzoyl peroxide topical

Inqovi — prerequisite: trial with azacitidine required

Inqovi coverage requires a documented trial with azacitidine prior to approval; failure to document this prerequisite may lead to denial.

Livtencity — prerequisite antiviral trial required for post‑transplant CMV

Livtencity coverage for post‑transplant CMV infection/disease requires a trial of valganciclovir, cidofovir, or foscarnet prior to approval; document the antiviral trial to support PA.

• Document trial of valganciclovir, cidofovir, or foscarnet

Lonsurf — prerequisite chemo + anti‑VEGF and bevacizumab combination required

Lonsurf coverage for metastatic colorectal cancer requires prior combination use with bevacizumab and trials of fluoropyrimidine‑, oxaliplatin‑, irinotecan‑based chemotherapy and an anti‑VEGF; document prior chemotherapy and targeted therapy as specified.

Lumakras — prerequisite: at least one prior systemic therapy for KRAS G12C NSCLC

Lumakras coverage for KRAS G12C‑mutated NSCLC requires documentation of at least one prior systemic therapy; include prior systemic therapy history with the PA request.

Combination biologic/targeted DMARD exclusion — may trigger denial

Combination biologic/targeted DMARD exclusion: multiple product entries (e.g., Cosentyx, Dupixent, Enbrel, Kevzara, Humira, Fasenra) explicitly prohibit use in combination with another biologic or targeted DMARD for the same condition; use of combination therapy may trigger denial.

• Do not use with another biologic/targeted DMARD indicated for the same condition — may trigger denial

Tadalafil — exclusion with concurrent nitrate therapy

Tadalafil is explicitly excluded when patients are receiving nitrate therapy; coverage will not be provided in that situation.

Dalfampridine — exclusion if patient is wheelchair‑bound

Dalfampridine is excluded for use if the patient is wheelchair‑bound or becomes wheelchair‑bound; do not authorize treatment for wheelchair‑bound patients.

General documentation note — submit required tests, labs, and prior trial records

Providers must document required medical information and prior trials as specified in each product's PA criteria (examples: Bronchitol tolerance test, baseline T25FW for dalfampridine, BMD for Forteo, lab evidence for GLP‑1 agonists) to support authorization requests and avoid denial.

• Bronchitol tolerance test documentation (Bronchitol)
• Baseline T25FW (Dalfampridine)
• BMD T‑score documentation (Forteo)
• A1c/FPG/OGTT labs or T2DM chart notes (GLP‑1 agonists)

Prerequisite trial/documentation missing — denial risk

Failure to provide documentation of prerequisite trials, diagnostic thresholds, or required tests (e.g., prior therapy trials for oncology agents, antiviral trials for Livtencity, azacitidine for Inqovi) may result in denial of coverage; verify and include all required information on the PA request.