Clinical coverage guidelines

To view clinical coverage guidelines, select the corresponding link below and select Ctrl F to search by drug name. 

Prior Authorization Guidelines

Step Therapy Guidelines

Note: Clinical coverage guidelines are developed by a team of health care professionals based on standards of practice at the time of approval. Guidelines are used as a basis for making coverage decisions and do not serve as medical advice. Coverage of medications is subject to plan provisions. Additional coverage restrictions not listed in the guidelines may apply.