Proton Pump Inhibitors (PPI's) - Commercial

Step Therapy, Quantity Limit

Phenylketonuria - Commercial - Effective Date 02/01/2025

Prior Authorization

Opzelura™ (ruxolitinib) - Commercial

Prior Authorization, Quantity Limit

Zeposia® (ozanimod) - Medicaid

Prior Authorization, Quantity Limit

Zeposia® (ozanimod) - Commercial

Prior Authorization, Quantity Limit

Symlin® (pramlintide) - Medicaid

Step Therapy, Quantity Limit

Sodium-glucose Co-transporter (SGLT) Inhibitors and Combinations - Commercial

Step Therapy, Quantity Limit

Otezla® (apremilast) - Commercial

Prior Authorization, Quantity Limit

Oral Nonsteroidal Anti-Inflammatory Drugs (NSAID) - Commercial

Step Therapy

QP21-22 Reminder: Replacement Claim, Adjustment Request or Appeal Submission