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Pharmacy Policies



Name Type State
Kyprolis Medical & Pharmacy PA Medicaid
Interleukin-5 Inhibitors Non Formulary Policy PA Medicaid
Enbrel Prior Authorization Form PA Medicaid
Enbrel Prior Authorization Form PA Medicaid
Exelon Prior Authorization Form PA Medicaid
First Generation Antipsychotics Prior Authorization Form PA Medicaid
Gleevec Prior Authorization Form PA Medicaid
Hemophilia / Blood Factor Products Prior Authorization Form PA Medicaid
Hemophilia and Blood Factor Products Prior Authorization Form PA Medicaid
Hepatitis C Treatment Prior Authorization Form PA Medicaid
Hereditary Angioedema (HAE) Agents Prior Authorization Form PA Medicaid
Hereditary Angioedema Acute Treatment Prior Authorization Form PA Medicaid
Hereditary Angioedema Prophylaxis Prior Authorization Form PA Medicaid
Humira Prior Authorization Form PA Medicaid
Humira Prior Authorization Form PA Medicaid
Lupron Prior Authorization Form PA Medicaid
Lupron Prior Authorization Form PA Medicaid
Lupron Depot Prior Authorization Form PA Medicaid
Lyrica Prior Authorization Form PA Medicaid
Lyrica Prior Authorization Form PA Medicaid
Makena Pharmacy PA Medicaid
Makena Prior Authorization Form PA Medicaid
Neupogen Prior Authorization Form PA Medicaid
Norditropin Prior Authorization Form PA Medicaid
PCSK9 Inhibitors Pharmacy PA Medicaid
PCSK9 Inhibitor Initial Authorization Prior Authorization Form PA Medicaid
PCSK9 Inhibitor Reauthorization Prior Authorization Form PA Medicaid
Peg-Intron Prior Authorization Form PA Medicaid
Pegasys Prior Authorization Form PA Medicaid
Pulmozyme Pharmacy PA Medicaid
Pulmozyme Prior Authorization Form PA Medicaid
Remicade Prior Authorization Form PA Medicaid
Remicade Prior Authorization Form PA Medicaid
Restasis Pharmacy PA Medicaid
Restasis Prior Authorization Form PA Medicaid
Second Generation Antipsychotics for Children less than 18 Prior Authorization Form PA Medicaid
Opioid Analgesics Prior Authorization Form PA Medicaid
Opioid Analgesics Prior Authorization Form PA Medicaid
Buprenorphine SL Prior Authorization Form PA Medicaid
Buprenorphine SL Prior Authorization Form PA Medicaid
Synagis Pharmacy PA Medicaid
Synagis Prior Authorization Form PA Medicaid
Synvisc and Synvisc-One Pharmacy PA Medicaid
Synvisc and Synvisc-One Prior Authorization Form PA Medicaid
Voltaren Gel Pharmacy PA Medicaid
Voltaren Gel Prior Authorization Form PA Medicaid
Xolair Prior Authorization Form PA Medicaid
Xolair Prior Authorization Form PA Medicaid
Daraprim Prior Authorization Policy PA Medicaid
H.P. Acthar Gel Non-Formulary Policy PA Medicaid
Keytruda Non-Formulary Policy PA Medicaid
Entresto Non-Formulary Policy PA Medicaid
Opdivo Non-Formulary Policy PA Medicaid
Portrazza Non-Formulary Policy PA Medicaid
Soliris Non-Formulary Policy PA Medicaid
Yervoy Non-Formulary Policy PA Medicaid
Adcetris Non-Formulary Policy PA Medicaid
Alimta Non-Formulary Policy PA Medicaid
Erbitux Non-Formulary Policy PA Medicaid
Herceptin Non-Formulary Policy PA Medicaid
Perjeta Non-Formulary Policy PA Medicaid
Granulocyte Colony Stimulating Factors(GCS- F) Non-Formulary Policy PA Medicaid
Esbriet Non-Formulary Policy PA Medicaid
Faslodex Non-Formulary Policy PA Medicaid
Rituxan Non-Formulary Policy PA Medicaid
Velcade Non-Formulary Policy PA Medicaid
Xgeva and Prolia Non-Formulary Policy PA Medicaid
Vimizim Non-Formulary Policy PA Medicaid
Tysabri Non-Formulary Policy PA Medicaid
Botox Prior Authorization Policy PA Medicaid
Cerdelga Prior Authorization Policy PA Medicaid
Cough and Cold Medications for Children less than 4 Non-Formulary Policy PA Medicaid
Depen Prior Authorization Policy PA Medicaid
Gilenya Prior Authorization Policy PA Medicaid
Hepatitis B Non-Formulary Policy PA Medicaid
Latuda Step Therapy Policy PA Medicaid
Modafinil Prior Authorization Policy PA Medicaid
Tecfidera Prior Authorization Policy PA Medicaid
Victoza Step Therapy Policy PA Medicaid
Zyvox Prior Authorization Policy PA Medicaid
Copaxone Prior Authorization Policy PA Medicaid
Enbrel Prior Authorization Policy PA Medicaid
Humira Prior Authorization Policy PA Medicaid
Lupron Prior Authorization Policy PA Medicaid
Lyrica Prior Authorization Policy PA Medicaid
Makena Prior Authorization Policy PA Medicaid
Pulmozyme Prior Authorization Policy PA Medicaid
Remicade Prior Authorization Policy PA Medicaid
Restasis Step Therapy Policy PA Medicaid
Synagis Prior Authorization Policy PA Medicaid
Synvisc and Synvisc One Prior Authorization Policy PA Medicaid
Voltaren Gel Prior Authorization Policy PA Medicaid
Spinraza Non-Formulary Policy PA Medicaid
Xolair Non-Formulary Policy PA Medicaid
Emflaza Non-Formulary Policy PA Medicaid
Ocrevus Non-Formulary Policy PA Medicaid
Sublingual Immunotherapy Medications Non-Formulary Policy PA Medicaid
Opioid Analgesics Non-Formulary Policy PA Medicaid
Non-TNF Biologics Non-Formulary Policy PA Medicaid
Exondys-51 Non-Formulary Policy PA Medicaid
Brineura Non-Formulary Policy PA Medicaid
Avonex Prior Authorization Policy PA Medicaid
Hereditary Angioedema (HAE) Management Non-Formulary Policy PA Medicaid
Hemophilia and Blood Factor Products Non-Formulary Policy PA Medicaid
Intravenous and Subcutaneous Immune Globulin (IVIG & SCIG) Non-Formulary Policy PA Medicaid
Oral Oncology Medications Prior Authorization Policy PA Medicaid
PCSK9 Inhibitors Non-Formulary Policy PA Medicaid
Pulmonary Arterial Hypertension(PAH) Agents Non-Formulary Policy PA Medicaid
Lidocaine Patch Prior Authorization Policy PA Medicaid
Eucrisa Step Therapy Policy PA Medicaid
Xeljanz and Xeljanz XR Prior Authorization Policy PA Medicaid
Tacrolimus Ointment Prior Authorization Policy PA Medicaid
Duzallo Step Therapy Policy PA Medicaid
Avastin Prior Authorization Policy PA Medicaid
Hepatitis C Medications Non-Formulary Policy PA Medicaid
Hepatitis C Medications Non-Formulary Policy PA Medicaid
Prialt Non-Formulary Policy PA Medicaid
Injectafer Non-Formulary Policy PA Medicaid
Erythropoiesis Stimulating Agents Non-Formulary Policy PA Medicaid
Buprenorphine SL Prior Authorization Policy PA Medicaid
IV/Injectable Oncology Agents Prior Authorization Policy PA Medicaid
Ezetimibe Prior Authorization Policy PA Medicaid
Growth Hormones Non-Formulary Policy PA Medicaid
Luxturna Non-Formulary Policy PA Medicaid
Photofrin Non-Formulary Policy PA Medicaid
Supprelin LA and Vantas Non-Formulary Policy PA Medicaid
Fabrazyme Non Formulary Policy PA Medicaid
Ozempic Step Therapy Policy PA Medicaid
Trogarzo Non Formulary Policy PA Medicaid
Trogarzo Pharmacy PA Medicaid
Trogarzo Prior Authorization Form PA Medicaid
Cystic Fibrosis Biologic Response Modifiers Non Formulary Policy PA Medicaid
Luxturna Pharmacy PA Medicaid
Luxturna Prior Authorization Form PA Medicaid
Photofrin Prior Authorization Form PA Medicaid
Radicava Non-Formulary Policy PA Medicaid
Antipsychotics for Children Less than 18 Non-Formulary Policy PA Medicaid
DDP-4 and SGLT2 Inhibitors Step Therapy Policy PA Medicaid
Simponi/Simponi Aria Non-Formulary Policy PA Medicaid
Topical Retinoid Prior Authorization Policy PA Medicaid
Cimzia Non-Formulary Policy PA Medicaid
Idiopathic Pulmonary Fibrosis(IPF) Medications Non-Formulary Policy PA Medicaid
Freestyle Libre Prior Authorization Policy PA Medicaid
Crysvita Non-Formulary Policy PA Medicaid
Xifaxan Non-Formulary Policy PA Medicaid