Anti-Influenza Agents - Commercial

Quantity Limit

Angiotensin II Receptor Antagonists (ARBs), Renin Inhibitors and Combinations - Commercial

Step Therapy, Quantity Limit

QP75-21 MHCP Pharmacy Benefit Update – New Drug-Related Prior Authorization (PA) with Quantity Limit (QL) Criteria: Weight Loss Agents

QP73-21 Medical Drug Update – RSV Health Alert and Palivizumab (Synagis)

Endari™ (Pharmaceutical Grade L-Glutamine (PGLG)) - Commercial

Prior Authorization

Elmiron® (pentosan polysulfate sodium) - Medicaid

Prior Authorization

Elmiron® (pentosan polysulfate sodium) - Commercial

Prior Authorization

Combination Non-Steroidal Anti-Inflammatory Drugs (NSAID) - Medicaid

Prior Authorization, Quantity Limit

Opioids Extended Release (ER) - Commercial

Prior Authorization, Quantity Limit

Northera® (droxidopa) - Medicaid

Prior Authorization, Quantity Limit