Elmiron - Commercial

Prior Authorization

Combination NSAID - Medicaid

Prior Authorization, Quantity Limit

Alinia - Medicaid

Quantity Limit

QP29-16 Implementation of New Utilization Management Platform

IBS-D (Lotronex, Viberzi) - Medicaid

Prior Authorization, Quantity Limit

Peginterferon and Ribavirin - Medicaid

Prior Authorization

Xolremdi (mavorixafor) - Commercial

Prior Authorization, Quantity Limit

Xolremdi (mavorixafor) - Medicaid

Prior Authorization, Quantity Limit

Topiramate ER - Medicaid

Quantity Limit

P2-17 Updated: Change in Coverage for Detoxification Services for Minnesota Health Care Programs Subscribers