Aimovig: document ≥4 migraine days/month; no concurrent CGRP therapy

Initial Aimovig requests must document at least four migraine days per month and must not be used with another CGRP antagonist; reauthorization requires documentation of a decrease in migraine days per month. Initial approval is 1 year; reauthorization 2 years.

Amvuttra: submit mutation, PND, and indication-specific confirmation

For Amvuttra initial requests provide diagnostic confirmation: TTR mutation, baseline PND ≤ IIIb and clinical signs for hATTR‑PN; for ATTR‑CM document prior failure/intolerance/contraindication to tafamidis, NYHA class I–III, ECHO/CMR showing cardiac involvement, and confirmatory biopsy, genetic testing, or radionuclide imaging (Grade 2–3 uptake if radionuclide used). Initial and reauthorization coverage durations are one year; reauth requires demonstration of clinical response versus baseline.

Arikayce: sputum culture + specialist prescriber required

Arikayce initial requests must include a sputum culture confirming MAC lung disease, documentation of failure to obtain negative cultures after ≥6 months of an appropriate multidrug regimen, and the drug must be prescribed by or in consultation with an infectious disease specialist or pulmonologist. Initial approval is 6 months; reauthorization 12 months and requires a negative sputum culture within the last 30 days and clinical response documentation.

ACTHAR: provide prior-therapy documentation and limit to FDA dosing

ACTHAR requests must include documentation of prior therapies and responses; dosing and quantity are limited to FDA‑supported dosing. Initial coverage duration is 6 weeks; reauthorization requires demonstrated clinical benefit. Note exclusions for acute gouty arthritis, severe psoriasis, and atopic dermatitis.

BRAFTOVI: document BRAF V600 mutation

BRAFTOVI coverage requires submitted documentation of BRAF V600 mutation status prior to approval.

BRUKINSA: provide rationale if substituting for Calquence/Imbruvica

When requesting BRUKINSA for certain hematologic malignancies, the prescriber must provide rationale explaining why alternative agents (Calquence or Imbruvica) cannot be used in place of BRUKINSA.

Colistimethate: ID specialist plus culture/susceptibility required; no nebulization

Prescribe colistimethate IV or IM only and ensure an infectious disease specialist prescribes or is consulted; submit culture and susceptibility data or local epidemiology demonstrating the organism is susceptible. Nebulized/inhalation administration is not covered.

CORTROPHIN: meet FDA duration and submit indication‑specific prior trials

CORTROPHIN initial requests must follow FDA labeling (or max 3 months if unspecified) and include indication‑specific prerequisite trials (e.g., parenteral plus oral glucocorticoid for MS exacerbations); infantile spasms are exempt. Reauthorization requires demonstrated clinical benefit and quantity limited to FDA‑supported dosing.

Cosentyx: no concomitant biologics/JAKi; document indication‑specific prior trials

Cosentyx must not be used in combination with other biologics, Otezla, or JAK inhibitors. Providers must document prior therapy trials specific to the indication (e.g., NSAID for ankylosing spondylitis; traditional immunomodulator for psoriasis) and be a specialist or consult one.

Dalfampridine ER: exclude seizure history, CrCl >50 mL/min, baseline T25FW

Dalfampridine ER requests must confirm no history of seizure, creatinine clearance >50 mL/min, and provide a baseline timed 25‑foot walk demonstrating ambulatory status; reauthorization requires stability or improvement in walking speed. Initial and reauthorization coverage are 1 year.

Duloxetine alternative: document inability to use duloxetine + trial/failure of another generic

For duloxetine alternatives (e.g., Drizalma), submit documentation that the patient is unable to use duloxetine and has trialed and failed one other generic antidepressant.

Ebglyss: failed Rinvoq and Dupixent, specialist prescriber, maintenance dosing limits

Ebglyss initial coverage for atopic dermatitis requires documentation of moderate‑to‑severe disease, trial and failure of Rinvoq and Dupixent, and specialist prescriber involvement; initial dosing limited to 4 doses first month then 2 doses monthly, and reauthorization requires documented positive clinical response versus baseline.

Dupixent: provide diagnosis confirmation and prior‑therapy documentation

Submit indication‑specific documentation for Dupixent (diagnosis confirmation and required prior therapy trials). For chronic urticaria initial requests, document urticaria >6 weeks and trial/failure of one H1 antihistamine; reauthorization requires clinical benefit versus baseline.

Eltrombopag: platelet thresholds plus prior therapy trials and no concurrent TPO‑R agents

Eltrombopag prior authorization requires current platelet count meeting thresholds (<30,000/mcL or <50,000/mcL with bleeding/risk), documentation of inadequate response or intolerance to steroids/IVIG and to rituximab or splenectomy, and it must not be combined with other maintenance thrombopoietic agents; reauth requires platelet <400 x10^9/L and evidence of response.

Emgality: ≥4 migraine days/month (migraine) or verapamil trial (cluster); no concurrent CGRP therapy

Emgality for migraine prevention requires at least four migraine days per month; for cluster headache, document trial of verapamil with intolerance or failure. Emgality must not be used with another CGRP antagonist. Reauthorization requires documentation of decreased frequency/intensity.

Enbrel: document required prior non‑biologic trials; no concomitant biologics/JAKi

Enbrel prior authorization requires documentation of prior therapies and trial/failure of specified non‑biologic agents per indication (e.g., methotrexate for RA; NSAID for ankylosing spondylitis). Enbrel must not be used with other biologics, Otezla, or JAK inhibitors; prescriber should be a specialist or consult one.

Fasenra: submit eosinophil counts and failed ICS/LABA; specialist involvement required

Fasenra requests must include blood eosinophil counts (≥150 cells/µL within 6 weeks or ≥300 cells/µL in prior 12 months), documentation of trial and failure of an ICS/LABA in the past 6 months, and specialist involvement; reauthorization requires documentation of clinical benefit.

Many specialty drugs: prior authorization per product‑specific criteria

The listed specialty products require prior authorization per their product‑specific criteria; providers must supply the specified documentation, prescriber specialty (when required), and meet the stated coverage durations.

Kalydeco: genetic test confirming ivacaftor‑responsive CFTR mutation required

Kalydeco coverage requires laboratory confirmation of an ivacaftor‑responsive CFTR mutation prior to approval.

Krazati: submit records showing NCCN‑aligned use

Krazati prior authorization requires medical records demonstrating use follows current NCCN recommendations; coverage duration is two years.

Levetiracetam ODT/soluble: document inability to use generic tablet + trial/failure

Levetiracetam ODT/soluble requests must include documentation of inability to use generic levetiracetam tablet and trial/failure with one other generic anticonvulsant; absence of this documentation may result in denial.

Livtencity: baseline CMV DNA and prior antiviral trial/failure required; no concomitant CMV antivirals

Livtencity prior authorization requires baseline CMV DNA confirming diagnosis, documentation of trial and failure with ganciclovir/valganciclovir/cidofovir or foscarnet, and it must not be used concomitantly with other CMV antivirals; reauthorization requires evidence of response (e.g., CMV DNA level).

Nexletol/Nexlizet: recent LDL‑C and statin/ezetimibe step documentation; no PCSK9/Juxtapid

Nexletol and Nexlizet require submission of the most recent LDL‑C and documentation of prior statin/ezetimibe therapy and response: either high‑intensity statin plus ezetimibe ≥4 weeks with LDL‑C ≥70 mg/dL, or ezetimibe ≥4 weeks with statin intolerance (≥2 statin trials with symptoms). Do not use concomitantly with PCSK9 inhibitors or Juxtapid.

Orgovyx: document trial/failure with Firmagon (degarelix)

Orgovyx prior authorization requires documentation of trial and failure with Firmagon (degarelix) before coverage; prerequisite therapy must be documented.

Prior authorization required for listed specialty drugs

Prior authorization is required for many listed specialty drugs; providers must submit indication‑specific documentation, prior therapy trials, prescriber specialty evidence (when required), and meet product durations (commonly two years unless noted).

Radicava: baseline ALS criteria (%FVC, ALSFRS‑R) and reauth evidence of slowed progression

Radicava prior authorization requires ALS diagnosis per revised El Escorial/Arlie House criteria (definite or probable), diagnosis ≤2 years, baseline ALSFRS‑R item scores ≥2 (total ≥24), %FVC ≥80%, and dosing within specified volume limits; reauthorization requires documentation that Radicava is slowing progression.

Per‑product prior authorization: follow each product's documented requirements

All products in the list require prior authorization per their specific entries; providers must follow the product‑level criteria for documentation, prescriber specialty, and coverage duration as specified.

Tofacitinib: prior auth and indication‑specific prior therapy documentation required

Tofacitinib entries require prior authorization and documentation of prerequisite therapies per indication (e.g., RA: trial and failure of one traditional non‑biologic immunomodulator; AS: trial and failure of one NSAID; JIA: specified prerequisites). Providers should document specialist involvement.

Vowst: document recurrent CDI after antibiotic failures; one 12‑capsule course only

Vowst prior authorization requires documentation of at least two recurrent CDI episodes (three or more total) after failure of appropriate antibiotics; limited to one treatment course (12 capsules over 3 days); initial coverage duration one year.

Tolvaptan: submit indication‑specific labs and limit dosing to FDA‑labeled maxima

Tolvaptan prior authorization requires indication‑specific documentation: for hyponatremia confirm hypervolemic/euvolemic hyponatremia with serum sodium <125 mEq/L or symptomatic nonresponse to fluid restriction (dosing up to 60 mg/day); for ADPKD document risk of rapid progression (dosing up to 120 mg/day). Coverage durations vary by indication.

Voydeya: PNH confirmation, active complement inhibitor therapy, and EVH criteria required

Voydeya prior authorization requires PNH diagnosis by flow cytometry, active treatment with ravulizumab or eculizumab, and evidence of symptomatic extravascular hemolysis (fatigue or dyspnea plus Hgb <9.5 g/dL or ARC >120 x10^9/L). Initial and reauthorization coverage are one year.

Tryngolza: FCS confirmation (TG>880 mg/dL) and prior Redemplo trial required

Tryngolza prior authorization requires confirmation of familial chylomicronemia syndrome (fasting triglycerides >880 mg/dL and exclusion of secondary causes with genetic testing or clinical diagnosis) and documentation of prior Redemplo trial with inadequate response or intolerance; initial coverage one year, reauthorization two years with evidence of benefit.

Vyndamax: multi‑modality ATTR‑CM confirmation; exclude primary (light‑chain) amyloidosis

Vyndamax (tafamidis) initial and reauthorization require NYHA class I–III, ECHO or CMR demonstrating cardiac involvement, and diagnosis confirmation by biopsy, genetic testing, or radionuclide imaging (Grade 2–3 uptake if radionuclide used); Vyndamax will not be approved for primary (light‑chain) amyloidosis. Reauthorization requires documentation of positive clinical response versus baseline.

Xolair: indication‑specific documentation (IgE, allergen testing, weight) for PA

Xolair prior authorization is required for asthma, food allergy, chronic urticaria, and nasal polyps; submit indication‑specific documentation (e.g., baseline IgE ≥30 IU/mL and positive perennial aeroallergen test for asthma, current weight, trial/failure of an ICS/LABA within 6 months) and evidence of benefit on reauthorization.

Xifaxan: follow indication limits (IBS‑D ≤3 courses; TD ≤3 days); SIBO not covered

Xifaxan prior authorization requires adherence to indication‑specific limits and prerequisites: IBS‑D limited to no more than three 14‑day courses; traveler’s diarrhea limited to three days with prior azithromycin trial/failure; SIBO coverage is not provided.

Biologics: do not combine with other biologics, Otezla, or JAK inhibitors

Use of other biologic drugs, Otezla, or JAK inhibitors in combination with specified biologics will trigger exclusion/denial; providers must not request combination biologic/JAKi therapy for these products.

Depression agents: SSRI/SNRI + one atypical antidepressant trial required

For certain depression agents (e.g., AUVELITY) try and fail an SSRI or SNRI and one atypical antidepressant (e.g., bupropion or mirtazapine) before approval; document trials and outcomes.

Asenapine/Secuado: two generic antipsychotic trials (≥28 days each) required

Asenapine (Secuado) requires documented trial and failure with two specified generic antipsychotics for at least 28 days each prior to coverage.

Brivaracetam: prior levetiracetam + another generic anticonvulsant trial required

Brivaracetam (oral) requires documentation of trial and failure with generic levetiracetam plus at least one other generic anticonvulsant (failure defined as inadequate seizure control) before approval.

Calcipotriene‑betamethasone (scalp): trial of generic steroid + calcipotriene required

For calcipotriene‑betamethasone suspension (scalp), document trial and failure of a generic topical steroid (e.g., fluocinonide or clobetasol solution) plus generic calcipotriene solution prior to approval.

Caplyta: document required prior antipsychotic trials per indication

Caplyta requests must include documentation of prior therapies and required indication‑specific antipsychotic trial/failure patterns (e.g., two generic atypical antipsychotics for schizophrenia).

Cosentyx: indication‑specific non‑biologic trials required before biologic

Cosentyx requires prior non‑biologic therapy trials per indication (e.g., NSAID for ankylosing spondylitis; traditional immunomodulator for psoriasis) before biologic initiation; providers must document trials and responses.

Ebglyss: must have failed Rinvoq and Dupixent

Ebglyss initial therapy requires prior failure of Rinvoq and Dupixent for atopic dermatitis before approval.

Enbrel: trial/failure of traditional non‑biologic therapy (e.g., methotrexate) required

Enbrel (and Enbrel Mini) requires trial and failure of one traditional non‑biologic immunomodulator (e.g., methotrexate) for RA and psoriasis prior to approval; for ankylosing spondylitis a trial and failure of one NSAID is required.

Endari: trial and failure of hydroxyurea required

Endari prior authorization requires documentation that the patient tried and failed hydroxyurea (continued pain episodes despite appropriate dosing or intolerance) before approval.

Biologics/JAKi: document trial/failure of conventional therapies per indication

Many biologic/JAKi indications require trial and failure of one or more specified conventional therapies (examples include methotrexate, NSAIDs, cyclosporine); providers must document prior trials unless exceptions apply.

Nexletol/Nexlizet: statin+ezetimibe or ezetimibe with statin‑intolerance evidence required

Nexletol/Nexlizet step requirement: patient must have tried a high‑intensity statin (or maximally‑tolerated statin) plus ezetimibe for ≥4 weeks with LDL‑C ≥70 mg/dL OR ezetimibe ≥4 weeks with statin intolerance (trial of ≥2 statins with symptoms); submit recent LDL‑C and prior therapy documentation.

Antidepressant step: two generic antidepressant trials required

For certain antidepressant approvals (e.g., Marplan) providers must document trial and failure with two generic antidepressants (SNRIs, SSRIs, mirtazapine, or bupropion).

Livtencity: prior CMV antiviral trial + baseline CMV DNA required

Livtencity requires trial and failure with ganciclovir, valganciclovir, cidofovir, or foscarnet prior to approval; baseline CMV DNA must be submitted and reauthorization requires documented response.

Psoriasis: try and fail one traditional non‑biologic immunomodulator before biologic

For moderate to severe psoriasis agents (examples Yesintek, ustekinumab), providers must document trial and failure of one traditional non‑biologic immunomodulator (e.g., methotrexate, cyclosporine, acitretin) before biologic/JAKi coverage.

RA/axial spondyloarthritis: document required prior non‑biologic trials (e.g., methotrexate, NSAID)

Rheumatoid arthritis and axial spondyloarthritis prior authorization/step requirements: providers must document trial and failure of one traditional non‑biologic immunomodulator (e.g., methotrexate) for RA and one NSAID for axial spondyloarthritis before coverage of specified agents.

Prior therapy documentation: submit records showing trial/failure or intolerance

For many products, providers must submit supporting documentation of prior drug trials and responses demonstrating inadequate response, intolerance, or FDA‑labeled contraindication; missing prior‑therapy documentation can trigger denial.

Amvuttra: submit mutation test, baseline PND, and confirmatory diagnostics

For Amvuttra provide mutation testing, baseline PND score, clinical signs, and confirmatory diagnostics (biopsy, genetic testing, or radionuclide imaging); for ATTR‑CM include NYHA class and imaging showing cardiac involvement.

Arikayce: provide initial and reauth sputum culture documentation

Arikayce initial review requires submission of a sputum culture confirming MAC and documentation of failure to obtain negative cultures after ≥6 months of a multidrug background regimen; reauthorization requires a negative sputum culture within 30 days and clinical response documentation.

Nexletol/Nexlizet: submit recent LDL‑C and prior therapy records or risk denial

Nexletol/Nexlizet documentation must include the most recent LDL‑C and records of prior statin/ezetimibe therapy and response; lack of recent LDL‑C or prior‑therapy documentation may result in denial.

Redemplo: fasting TG >880 mg/dL + genetic or clinical confirmation required

Redemplo initial requests must include fasting triglyceride >880 mg/dL (10 mmol/L) and genetic testing or clinical diagnosis per guidance; dosing must align with FDA labeling and prescriber should be a specialist.

Vowst: document ≥2 recurrences after antibiotics; one 12‑capsule course only

For Vowst, submit documentation of at least two recurrent CDI episodes (three or more total) after failure of appropriate antibiotics; limited to one treatment course (12 capsules over 3 days).

Vyndamax: submit NYHA, imaging, and diagnostic confirmation; exclude primary amyloidosis

Vyndamax initial documentation requires NYHA class I–III, ECHO or CMR showing cardiac involvement, and diagnosis confirmation by biopsy, genetic testing, or radionuclide imaging (Grade 2–3 uptake if radionuclide used); Vyndamax will not be approved for primary (light‑chain) amyloidosis.

Xifaxan: follow course limits (IBS‑D ≤3×14 days; TD ≤3 days); SIBO not covered

Xifaxan for IBS‑D is limited to up to three 14‑day courses; traveler’s diarrhea limited to three days (requires azithromycin trial/failure); coverage for SIBO is not provided.

Combination biologic/JAKi exclusion: do not request concurrent biologic/JAKi therapy

Biologic products must not be used in combination with other biologic drugs, Otezla, or JAK inhibitors for the same condition; requests that propose such combinations will be denied.

CGRP agents: no concurrent CGRP antagonist therapy; meet indication thresholds

CGRP antagonists (Aimovig, Emgality) must not be combined with another CGRP antagonist; providers must document single‑agent use and meet migraine frequency or other indication‑specific prerequisites.

Colistimethate: inhalation not supported — IV/IM only with culture/susceptibility

Colistimethate requests for inhalation/nebulization will not be supported; IV or IM administration only and must include culture/susceptibility or local epidemiology showing likely susceptibility to justify use.

PAH agents: right heart cath confirmation required or risk denial

When requesting PAH agents providers must submit documentation confirming pulmonary arterial hypertension (WHO Group 1) by right heart catheterization; absence of right heart catheterization documentation may lead to denial.

Oxervate: lifetime limit 8 weeks and ophthalmologist prescriber required

Oxervate requests exceeding an 8‑week lifetime treatment will not be covered; initial approval requires documentation of Stage 2 or 3 neurotrophic keratitis and ophthalmologist prescriber or consultation.

Sodium oxybate: MSLT/PSG required; no sedative hypnotics or SSADH deficiency

For sodium oxybate, do not prescribe with concurrent sedative hypnotics or in patients with succinic semialdehyde dehydrogenase deficiency; provide MSLT and polysomnography documentation confirming narcolepsy.

Vyndamax denial risk: exclude primary (light‑chain) amyloidosis

Vyndamax will not be approved if the patient has primary (light‑chain) amyloidosis; providers must confirm ATTR‑CM diagnostic pathway and exclude primary amyloidosis.

Index: follow referenced product entry for exact prior‑auth rules

Index entries point to the main policy locations for detailed prior authorization rules; use the referenced product entry in the policy for exact documentation and prior‑therapy requirements.

HAE: submit C4 and C1‑INH labs; ACEI co‑use not covered for icatibant/SAJAZIR

HAE treatments require submission of C4, C1‑INH protein, and C1‑INH function lab results confirming diagnosis; concurrent ACE inhibitor use is not covered for icatibant/SAJAZIR.

IVIG: submit weight, dose rationale, and records; adjust dose if BMI≥30 or weight ≥20% over ideal

IVIG requests must include current weight and requested dose, documentation that dosing follows FDA labeling or accepted practice, and weight‑adjusted dosing if BMI ≥30 or actual weight ≥20% above ideal; provide supporting medical records for diagnosis and dose.

Nulibry: genetic confirmation of MoCD Type A required

Nulibry requests require confirmed genetic testing demonstrating MoCD Type A; lack of genetic confirmation may result in denial and reauthorization requires evidence of neurologic/functional benefit.

PAH/Winrevair: specialist prescriber + right heart cath and prior therapy documentation

For PAH, specialty agents and Winrevair must be prescribed by or in consultation with a specialist and include right heart catheterization documentation and prior therapy history (e.g., failure of dual PDE inhibitor + endothelin receptor antagonist where required).

Arikayce: specialist prescriber or consult required

Arikayce must be prescribed by or in consultation with an infectious disease specialist or pulmonologist (site‑of‑care requirement).

Colistimethate: IV/IM only, ID specialist consult and infection documentation required

Colistimethate is covered only for IV or IM administration; nebulization/inhalation is not covered and an infectious disease specialist must prescribe or be consulted; provide culture/susceptibility or local epidemiology to support use.

Part B vs Part D: submit diagnosis and administration info to determine benefit

Providers must review whether administration qualifies as a Part B or Part D benefit by submitting diagnosis and administration information where indicated.

Livtencity: no concomitant CMV antivirals; baseline CMV DNA and prior antiviral trial required

Livtencity must not be used concomitantly with other CMV antivirals (e.g., ganciclovir, valganciclovir); baseline CMV DNA must be provided and prior antiviral trial/failure documented.

Oxervate: ophthalmologist prescriber/consult and stage documentation required

Oxervate must be prescribed by or in consultation with an ophthalmologist; documentation of Stage 2 or 3 neurotrophic keratitis is required for coverage.

Pirfenidone: pulmonologist prescriber/consult and HRCT or biopsy required

Pirfenidone requests must be prescribed by or in consultation with a pulmonologist and include HRCT confirming diagnosis (surgical lung biopsy or UIP pattern where IPF is suspected); provide reauthorization evidence of improvement.

Redemplo: specialist prescriber and FCS confirmation required

Redemplo must be prescribed by or in conjunction with a specialist (specialty clinic) and include FCS confirmation (fasting TG >880 mg/dL and genetic testing or clinical diagnosis).

General site‑of‑care: office acceptable unless specialist prescriber required

When no specific site‑of‑care restriction is listed, office administration is acceptable unless a specialist prescriber is required; always verify product entry for exceptions.

Verquvo: cardiologist prescriber/consult and EF <45% documentation required

Verquvo must be prescribed by or in consultation with a cardiologist; providers must submit EF <45% within 12 months and documentation of prior guideline‑directed therapies and symptomatic worsening.

Tryngolza: specialist prescriber/consult and FCS + prior Redemplo documentation required

Tryngolza must be prescribed by or in consultation with a cardiologist, endocrinologist, or other specialist; initial requests must include FCS confirmation and prior Redemplo trial documentation.

Winrevair: specialist prescriber + right heart cath and prior therapy evidence required

Winrevair for PAH must be prescribed by or in consultation with a specialist for pulmonary arterial hypertension and include right heart catheterization confirmation and prior dual‑therapy failure where applicable.

Xolair: submit diagnosis/administration details to determine Part B vs Part D benefit

Xolair administration coverage may be Part B or Part D depending on diagnosis and administration details; submit diagnosis and administration information to determine benefit.