QP35-22 Commercial Pharmacy Benefit Update – Revised Drug-Related Prior Authorization (PA) Requirement Notification – Effective June 14, 2022

OTC COVID-19 At-Home Test - Medicaid

Quantity Limit

Interleukin-4 (IL-4) Inhibitors - Medicaid

Prior Authorization, Quantity Limit

Interleukin-4 (IL-4) Inhibitors - Commercial

Prior Authorization, Quantity Limit

Growth Hormone - Commercial

Prior Authorization

Arikayce (amikacin liposome inhalation suspension) - Medicaid

Prior Authorization, Quantity Limit

Arikayce - Commercial

Prior Authorization, Quantity Limit

Antifungals - Medicaid

Prior Authorization, Quantity Limit

Interstitial Lung Disease - Commercial

Prior Authorization, Quantity Limit

Interleukin-5 (IL-5) Inhibitors - Medicaid

Prior Authorization, Quantity Limit