Prior Authorization Drug Guidelines
High Level Drug Policies
- Diabetes – Continuous Glucose Monitoring Systems Care Value Policy
- Diabetes – Glucagon-Like Peptide-1 Agonists Care Value Policy
- Diabetic Drug Guideline
- Dispense as Written
- Hepatitis C Prescription Requirement Drug Policy
- Length of Authorization Drug Policy
- New to Market Medical and Pharmacy Benefit Products
- Non-Formulary Exception Criteria
- Opioids Long-Acting Products
- Weight Loss- Glucagon-Like Peptide-1 Antagonists Care Value Policy
Preferred Specialty Management Policies
Drug Policies
- Abecma
- Actemra SC
- Acthar Gel
- Actiq
- Adagen
- Adakveo
- Adcetris
- Adbry
- Adempas
- Adipex-P
- Adlarity
- Adstiladrin
- Aduhelm
- Advate
- Adynovate
- Afstyla
- Aimovig
- Ajovy
- Akeega
- Aklief
- Alecensa
- Alhemo
- Alimta
- Aliqopa
- Aloxi IV
- Alphanate
- AlphaNine SD
- Alprolix
- Altuviiio
- Amondys 45
- Amvuttra
- Alyq
- Aptivus
- AlphaNine
- Alyftrek
- Altreno
- Alunbrig
- Anzupgo
- Aphexda
- Aqneursa
- Aqvesme
- Aralast NP
- Aranesp
- Arcalyst
- Arsenic Trioxide
- Arzerra
- Asceniv
- Asparlas
- Atgam
- Attruby
- Aubagio
- Austedo
- Aveed
- Avmapki Fakzynja
- Avsola
- Avita
- Avonex
- Ayvakit
- Azedra
- Balversa
- Bavencio
- Beleodaq
- Belrapzo
- Bendamustine
- Bendeka
- BeneFIX
- Benlysta
- Beovu
- Berinert
- Besponsa
- Betaine Anhydrous
- Betaseron
- Bimzelx
- Bivigam
- Blincyto
- Boniva IV (Ibandronate IV)
- Bortezomib
- Bosulif
- Botox
- Braftovi
- Breyanzi
- Brineura
- Brinsupri
- Briviact
- Bronchitol
- Brukinsa
- Buphenyl
- Bylvay
- Byooviz
- Cablivi
- Cabometyx
- Calquence
- Camzyos
- Capecitabine
- Caprelsa
- Carbaglu
- Cardamyst
- Carimune
- Carmustine
- Carvykti
- Caverject
- Caverject Impulse
- Ceprotin
- Cequa
- Cerdelga
- Cerezyme
- Chenodal
- Cholbam
- Cibinqo
- Cimerli
- Cimzia
- Cinqair
- Cinryze
- Coagadex
- Columvi
- Cometriq
- Copaxone
- Copegus
- Copiktra
- Corifact
- Cortrophin Gel
- Cosela
- Cotellic
- Crenessity
- Crysvita
- Ctexli
- Cuvitru
- Cyltezo
- Cyramza
- Cystadane
- Cytogam
- Dacogen
- Danyelza
- Darzalex Faspro
- Darzalex IV
- Dawnzera
- Daxxify
- Decitabine
- Delatestryl
- Depo – Testosterone
- Diacomit
- Docefrez
- Dojolvi
- Doptelet
- Doptelet Sprinkle
- Dupixent
- Durolane
- Durysta
- Dysport
- Ebglyss
- Edex
- Egrifta
- Elahere
- Elaprase
- Elelyso
- Elepsia XR
- Elfabrio
- Eligard
- Eloctate
- Elrexfio
- Elzonris
- Emgality
- Empaveli
- Empliciti
- Enbrel
- Encelto
- Endari
- Endothelin Receptor Antagonists PA Policy – Pulmonary Arterial Hypertension
- Enhertu
- Enjaymo
- Ensacove
- Epkinly
- Epogen
- Epoprostenol
- Epsolay
- Erbitux
- Erwinaze
- Esbriet
- Enspryng
- Epclusa
- Epidiolex
- Erivedge
- Erleada
- Esperoct
- Euflexxa
- Evenity
- Evkeeza
- Evrysdi
- Exdensur
- Exjade
- Exondys51
- Exkivity
- Eylea
- Eylea HD
- Eysuvis
- Fabhalta
- Fabrazyme
- Farydak
- Fasenra
- Faslodex
- FEIBA
- Fensolvi
- Feraheme
- Ferriprox
- Ferrlecit
- Fibryga
- Filspari
- Filsuvez
- Firazyr
- Firmagon
- Flebogamma
- Flolan
- Folotyn
- Forteo
- Forzinity
- Fulphila
- Fulvestrant(Faslodex)
- Fusilev
- Fyarro
- Fylnetra
- Gamifant
- Gammagard Liquid – IV
- Gammagard Liquid – SubQ
- Gammagard SD IV
- Gamunex -C – IV
- Gamunex -C – SubQ
- Gavreto
- Gazyva
- Gelsyn 3
- Genotropin
- GenVisc
- Gilenya
- Gilotrif
- Givlaari
- Glassia
- Glatopa
- Gomekli
- Granix
- Haegarda
- Halaven
- Harvoni
- Helixate
- Hemgenix
- Hemlibra
- Hemofil M
- Herceptin
- Herceptin Hylecta
- Hernexeos
- Hetlioz
- Hetlioz LQ
- Hizentra
- Humate-P
- Humira
- Hyalgan
- Hyftor
- Hymovis
- HyQvia
- Hyrimoz
- Ibandronate IV
- Ibrance
- Ibtrozi
- Icatibant
- Iclusig
- Icotyde
- Idelvion
- Idhifa
- Ilaris
- Ilumya
- Imbruvica
- Imcivree
- Imfinzi
- Imjudo
- Imlygic
- Increlex
- INFeD
- Inflectra
- Infliximab IV
- Injectafer
- Inlexzo
- Inluriyo
- Inlyta
- Invega
- Iressa
- Itvisma
- Istodax
- Iwilfin
- Ixempra
- Ixinity
- Izervay
- Jadenu
- Jadenu Sprinkle
- Jakafi
- Jascayd
- Jelmyto
- Jesduvroq
- Jivi
- Juxtapid
- Jynarque
- Kadcyla
- Kajinti
- Kalbitor
- Kalydeco
- Kanuma
- Keppra
- Keppra XR
- Kerendia
- Kesimpta
- Keveyis
- Keytruda
- Keytruda Qlex
- Khapzory
- Kimmtrak
- Koate
- Kogenate
- Komzifti
- Koselugo
- Kovaltry
- Krystexxa
- Kuvan
- Kygevvi
- Kymriah
- Kynamro
- Kynmobi
- Kyprolis
- Lamzede
- Latruvo
- Ledipasvir/Sofosbuvir
- Lemtrada
- Lenalidomide
- Lenvima
- Leqembi
- Leqselvi
- Leqvio
- Lerochol
- Leukine
- Levoleucovorin IV
- Libtayo
- Livdelzi
- Livmarli
- Livtencity
- Loargys
- Lodoco
- Lomaira
- Lonsurf
- Lorbrena
- Lucentis
- Lumakras
- Lumizyme
- Lumoxiti
- Lumryz
- Lunsumio
- Lunsumio Velo
- Lupaneta Pack
- Lupron Depot
- Lupron Depot-Ped
- Lutathera
- Luxturna
- Lymphir
- Lynozyfic
- Lynparza
- Makena
- Margenza
- Mavenclad
- Mayzent
- Mekinist
- Mektovi
- Mepsevii
- Mifepristone
- Mircera
- Moderiba
- Modeyso
- Monjuvi
- Monoclate-P
- Monoferric
- Mononine
- Monovisc
- Muse
- Myalept
- Mvasi
- Mylotarg
- Myobloc
- Naglazyme
- Natpara
- Nemluvio
- Nerlynx
- Neupogen
- Neulasta
- Nexavar
- Nexviazyme
- Ngenla
- Ninlaro
- Nipent
- Nityr
- Nivestym
- Norditropin
- NovoEight
- Nplate
- Nubeqa
- Nucala
- Nulibry
- Nulojix
- Nuplazid
- Nurtec
- Nuwiq
- Nypozi
- Nyvepria
- Ocaliva
- Ocrevus
- Ocrevus Zunovo
- Octagam
- Odomzo
- Ofev
- Ogivri
- Ogsiveo
- Ojemda
- Olpruva
- Omisirge
- Omvoh
- Oncaspar
- Onivyde
- Onpattro
- Opdivo
- Opdivo Qvantig
- Opdualag
- Opfolda
- Opsumit
- Oralair
- Orencia IV
- Orenitram
- Orfadin
- Oriahnn
- Orkambi
- Orladeyo
- Orthovisc
- Osenvelt
- Osmolex ER
- Otezla
- Otezla XR
- Oxervate
- Oxlumo
- Paclitaxel Alubmin-Bound
- Padcev
- Palsonify
- Palynziq
- Panhematin
- Panzyga
- Papzimeos
- Pedmark
- Pegasys
- PegIntron
- Pemazyre
- Pemetrexed
- Pemfexy
- Perjeta
- Pheburane
- Phesgo
- Phendimetrazine Tartrate
- Pirfenidone
- Plegridy
- Pluvicto
- Polivy
- Pomalyst
- Ponvory
- Portrazza
- Poteligeo
- Pralatrexate
- Privigen Liquid
- Procrit
- Profilnine
- Prolastin C and Prolastin C Liquid
- Prolia
- Proleukin
- Promacta
- Provenge
- Pulmonary – Corticosteroid Inhalers Care Value Policy
- Pyrukynd
- Qalsody
- Qsymia
- Qulipta
- Radicava
- Ravicti
- Rebetol Capsule
- Rebetol Oral
- Rebif
- Rebinyn
- Reblozyl
- Reclast
- Recombinate
- Redemplo
- Regranex
- Releuko
- Remodulin
- Renflexis
- Repatha
- Restasis
- Retacrit
- Retevmo
- Retin-A
- Retin-A Micro
- Retin-A Micro Pump
- Revatio
- Revcovi
- Revlimid
- Revuforj
- Reyvow
- Rezdiffra
- Rezurock
- Rhapsido
- Riabni IV
- RiaSTAP
- Ribasphere
- Ribavirin
- Rinvoq
- Rinvoq LQ
- Rituxan Hycela
- Rituxan IV
- Rixubis
- Roctavian
- Rolvedon
- Romidepsin injection IV
- Romvimza
- Rozlytrek
- Rubraca
- Ruconest
- Ruxience IV
- Rybrevant Faspro
- Rybrevant IV
- Rydapt
- Rylaze
- Ryplazim
- Rystiggo
- Sabril
- Sajazir
- Samsca
- Sandostatin
- Saphnelo
- Sarclisa
- Scenesse
- Selzentry
- Sephience
- Serostim
- Sevenfact
- Signifor LAR
- Simponi
- Simponi Aria
- Skyrizi
- Skysona
- Sodium hyaluronate 1% injection
- Sohonos
- Solaraze
- Soliris
- Somatuline Depot
- Sotyktu
- Spevigo
- Spinraza
- Spiritam
- Spravato
- Sprycel
- Stelara IV
- Stimufend
- Stivarga
- Sunosi
- Supartz FX
- Supprelin LA
- Susvimo
- Sutent
- Syfovre
- Sylatron
- Sylvant
- Symdeko
- Symlin
- Synagis
- Synercid
- SynoJoynt
- Synvisc
- Synvisc One
- Tabrecta
- Tafinlar
- Tagrisso
- Takhzyro
- Taltz
- Talvey
- Tarceva
- Tarpeyo
- Tasigna
- Taxotere
- Tazverik
- Tecartus
- Tecentriq
- Tecentriq Hybreza
- Technivie
- Tecvayli
- Tegsedi
- Temodar
- Temozolomide
- Temozolomide IV
- Tepadina
- Tepezza
- Teriparatide
- Testopel
- Testosterone Enanthate IM
- Tetrabenazine
- Thalomid
- Thiola
- Thiola EC
- Thiotepa
- Tibsovo
- Tivdak
- Tolvaptan
- Topetocan IV
- Topical Retinoids-Trentinoin Products
- Torisel
- Tracleer
- Tramadol
- Trazimera
- Treanda
- Trelstar
- Tremfya
- Tretin-X
- Tretten
- Trikafta
- Triluron
- Triptodur
- Trisenox
- TriVisc
- Trodelvy
- Truvada
- Truxima IV
- Tryngolza
- Tryptyr
- Tukysa
- Tyenne
- Tykerb
- Tymlos
- Tysabri
- Tyvaso
- Tyvaso DPI
- Tzield
- Ubrelvy
- Udenyca
- Ukoniq
- Ultomiris
- Unituxin
- Unloxcyt
- Uptravi
- Vabysmo
- Valrubicin
- Valstar
- Valtoco
- Vanflyta
- Vanrafia
- Vantas
- Vectibix
- Velcade
- Veletri
- Venclexta
- Ventavis
- Veopoz
- Venofer
- Verzenio
- Vevye
- Vfend
- Viekira
- Vigabatrin
- Vijoice
- Vimizim
- Visco-3
- Vivjoa
- Vonjo
- Vonvendi
- Voquezna Dual Pack
- Voquezna Triple Pack
- Voranigo
- Vosevi
- Votrient
- Voydeya
- Voyxact
- Voxzogo
- Vpriv
- Vtama
- Vumerity
- Vyepti
- Vyjuvek
- Vykat
- Vyondys 53
- Vyvgart IV
- Vyvgart Hytrulo
- Vyxeos
- Wakix
- Wayrilz
- Welireg
- Wilate
- Winrevair
- Xalkori
- Xeljanz
- Xeljanz XR
- Xeloda
- Xembify
- Xenical
- Xenpozyme
- Xeomin
- Xermelo
- Xgeva
- Xiaflex
- Xolair
- Xtandi
- Xyosted
- Xywav
- Yargesa
- Yartemlea
- Yervoy
- Yescarta
- Yondelis
- Yonsa
- Yorvipath
- Yutrepia
- Zaltrap
- Zarxio
- Zejula
- Zelboraf
- Zemaira
- Zepatier
- Zeposia
- Zepzelca
- Zevaskyn
- Ziana
- Ziextenzo
- Zilretta
- Zirabev
- Zokinvy
- Zoladex
- Zoledronic Acid
- Zolgensma
- Zorbtive
- Ztalmy
- Zulresso
- Zurzuvae
- Zycubo
- Zydelig
- Zykadia
- Zymfentra
- Zynlonta
- Zynteglo
- Zynyz
Due to proprietary reasons, we are unable to post the Milliman Care Guidelines on our website, but a hard copy of an individual guideline can be provided as requested.
Milliman Care Guidelines (MCG) but not limited to:
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VCHCP Custom Drug Policies:
- Abilify
- Addyi
- Adriamycin
- Adrucil
- Alkeran
- Amifostine
- Arranon
- Arixtra
- Armodafinil
- Atripla
- Bicnu
- Blenoxane
- Calcipotriene
- Calcium Folinate
- Cetrotide
- Chorionic Gonadotropin
- Clomid
- Crixivan
- Cuvposa
- Cystagon
- Deferoxamine
- Epivir
- Fotivda
- Fragmin
- Fuzeon
- Gemcitabine
- Gonal F
- Hepatitis B Immune Globulin
- Infed
- Invega
- Kebilidi
- Lantidra
- Lipodox
- Menopur
- Mesnex
- Modafinil
- Mugard
- Ovidrel
- Panretin
- Pradaxa
- Prialt
- Progesterone
- Qutenza
- Rebetron
- Repronex
- Rilutek
- Simulect
- Solesta
- Sublocade
- Sucraid
- Taxol
- Thymoglobulin
- Vandetanib
- Varubi
- Visudyne
- Vowst
- Xdemvy
Formulary Exclusions -For Exception Review Use Only:
- Abrilada
- Abstral
- Adalimumab
- Adcirca
- Afinitor
- Alymsys
- Amjevita
- Ampyra
- Andembry
- Apokyn
- Aralast
- Arazlo
- Aranesp
- Atralin
- Augtyro
- Auvelity
- Avastin
- Aveed
- Avsola
- Azmiro
- Beqvez
- Berinert
- Besremi
- Bravelle
- Briumvi
- Bynfezia Pen
- Cabenuva
- Camcevi
- Cialis
- Cimzia
- Cinqair
- Clobetasol Propionate
- Columvi
- Complera
- Contrave
- Cosentyx
- Cutaquig
- Durolane
- Ekterly
- Elelyso
- Elevidys
- Emflaza
- Emrelis
- Entyvio
- Epogen
- Eohilia
- Erbitux
- Evenity
- Everolimus
- Exjade
- Exondys 51
- Extavia
- Fabior
- Fensolvi
- Fentora
- Firazyr
- Fotiva
- Gammaked – IV
- Gammaked – SubQ
- Ganirelix Acetat
- Gel-One
- Gelsyn-3
- GenVisc
- Glassia
- Gleevec
- Gocovri
- Granix
- Grastek
- Hadlima
- Harliku
- Hercessi
- Herzuma
- Hizentra
- Humatrope
- Herceptin Hylecta
- Herceptin
- Hulio
- Hyalgan
- Hympavzi
- Hymovis
- Idacio
- Imaavy
- Isbrela
- Ilumya
- Ingrezza
- Injectable Antibiotics
- Inqovi
- Isturisa
- Itovebi
- Jadenu
- Jadenu Sprinkle
- Jublia
- Kevzara
- Kineret
- Kisqali
- Kisqali Femara Co-Pack
- Kisunla
- Korlym
- Krazati
- LanreotideSC
- Lazanda
- Leqvio
- Letairis
- Levitra
- Lidoderm Patch
- Loqtorzi
- Lovenox
- Lupkynis
- Mavyret
- Miplyffa
- Mircera
- Mycapssa
- Myfembree
- Neulasta
- Neupogen
- Northera
- NovoSeven RT
- Nutropin
- Nutropin AQ
- Nuwiq
- Qbrexza
- Ogivri
- Olumiant
- Olysio
- Omnitrope
- Ongentys
- Onpattro
- Ontruzant
- Onureg
- Orencia IV
- Orencia SC
- Orgovyx
- Osmolex ER
- Otulfi IV
- Palforzia
- Phexxi
- Piasky
- Piqray
- Plavix
- Praluent
- Privigen IV
- Prolia
- Provigil
- Pyzchiva IV
- Qelbree
- Qfitlia
- Qinlock
- Quviviq
- Recombinate
- Recorlev
- Remicade
- Renflexis
- Riabni
- Rituxan Hycela
- Rituxan IV
- Rolvedon
- Rukobia
- Rystiggo
- Ryzneuta
- Saizen
- Sandostatin LAR
- Scemblix
- Signifor LAR
- Siliq
- Sivextro
- Skytrofa
- Sodium Hyaluronate
- Sovaldi
- Spravato
- Staxyn
- Stendra
- Steqeyma
- Stribild
- Subsys
- Supartz FX
- Supprelin LA
- Synvisc
- Synvisc One
- Targretin Oral
- Tavalisse
- Tavneos
- Tazorac
- Tecentriq
- Tecfidera
- Tepmetko
- Tespopel
- Trelstar
- TriVisc
- Truseltiq
- Truxima IV
- Tryvio
- Tyrvaya
- Udenyca
- Uplizna
- Upneeq
- Ustekinumab IV
- Vabysmo
- Vegzelma
- Veltin
- Veregen
- Verkazia
- Viagra
- Viltepso
- Vimpat
- Visco 3
- Vivimusta
- Vyalev
- Wezlana
- Winlevi
- Xelstrym
- Xenazine
- Xpovio
- Xyntha
- Xyrem
- Yuflyma
- Zavesca
- Ziihera
- Zomacton
- Zoryve
- Zusduri
- Zytiga
ChloroqineCoronavirusInfectionDrugs
KaletraCoronavirusInfectionDrugs
Plaquenil(hydroxychloroquine)CoronavirusInfectionDrugs
ProAirHFA(albuterolsulfateaerosolmetered)CoronavirusInfectionDrugs
PreferredSpecialtyManagement(PSM)Policy
Pulmonary – Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers Care Value Policy
Step Therapy Policies
- Angiotensin Receptor Blocker Step Therapy Policy
- Antidepressants Step Therapy Policy
- Diabetes – Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy
- Diabetes – Sodium Glucose Co-Transporter-2 and Dipeptidyl Peptidase-4 Inhibitors Step Therapy Policy
- Diabetes – Sodium Glucose Co-Transporter-2 Inhibitors Step Therapy Policy
- Enbumyst Step Therapy Policy
- Myqorzo Step Therapy Policy
- Nasal Steroids Step Therapy Policy
- Nonsteroidal Anti-Inflammatory Drugs Step Therapy Policy
- Proton Pump Inhibitors Step Therapy Policy
- Sedative Hypnotics Step Therapy Policy
- Statins Step Therapy Policy
- Tetracyclines (Oral) Step Therapy Policy
- Tonmya Step Therapy Policy
- Wakix Step Therapy Policy
Medication-Related Policies