QP95-24 Commercial Pharmacy Benefit Exclusion for lanreotide, Ultomiris® and Visudyne®

Alternative Dosage Form - Commercial

Prior Authorization, Quantity Limit

Hepatitis C Direct Acting Antivirals - Medicaid

Prior Authorization, Quantity Limit

IBS-D (Lotronex, Viberzi) - Medicaid

Prior Authorization, Quantity Limit

Resmetirom - Commercial

Prior Authorization, Quantity Limit

Peginterferon and Ribavirin - Medicaid

Prior Authorization

Xolremdi (mavorixafor) - Commercial

Prior Authorization, Quantity Limit

Xolremdi (mavorixafor) - Medicaid

Prior Authorization, Quantity Limit

Commercial Pharmacy Program Policy Activity Provider Notification

MHCP Pharmacy Program Policy Activity Provider Notification