Medicaid Medication Policies


Pharmacy Prior Authorization with CoverMyMeds
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Policy Name
Category
Anticonvulsants Statewide PDL Prior Authorization Criteria
Anticoagulants Statewide PDL Prior Authorization Criteria Policy
Growth Hormones Statewide PDL Prior Authorization Criteria policy
Glucocorticoids, Oral Statewide PDL Prior Authorization Criteria policy
Glucocorticoids, Inhaled Statewide PDL Prior Authorization Criteria policy
GI Motility, Chronic Statewide PDL Prior Authorization Criteria policy
Fluoroquinolones, Oral Statewide PDL Prior Authorization Criteria policy
Zeposia Statewide PDL Prior Authorization Criteria Policy
VMAT2 Inhibitors Statewide PDL Prior Authorization Criteria Policy
Vitamin D Analogs Statewide PDL Prior Authorization Criteria Policy
Vaginal Anti-Infectives Statewide PDL Prior Authorization Criteria Policy
Urinary Anti-Infectives Statewide PDL Prior Authorization Criteria Policy
Urea Cycle Disorder Agents Statewide PDL Prior Authorization Criteria Policy
Ulcerative Colitis Agents Statewide PDL Prior Authorization Criteria Policy
Estrogens Statewide PDL Prior Authorization Criteria policy
Erythropoiesis Stimulating Proteins Statewide PDL Prior Authorization Criteria policy
Epinephrine, Self-Injected Statewide PDL Prior Authorization Criteria policy
Enzyme Replacements, Gaucher Disease Statewide PDL Prior Authorization Criteria policy
Dupixent Statewide PDL Prior Authorization Criteria policy
Cytokine and CAM Antagonists Statewide PDL Prior Authorization Criteria policy
COPD Agents Statewide PDL Prior Authorization Criteria policy
Contraceptives, Oral Statewide PDL Prior Authorization Criteria policy
Contraceptives, Other Statewide PDL Prior Authorization Criteria policy
Colony Stimulating Factors Statewide PDL Prior Authorization Criteria policy
Cephalosporins Statewide PDL Prior Authorization Criteria policy
Beta Blockers Statewide PDL Prior Authorization Criteria policy
Calcium Channel Blockers Statewide PDL Prior Authorization Criteria policy
Bronchodilators, Beta Agonists Statewide PDL Prior Authorization Criteria policy
BPH Treatments Statewide PDL Prior Authorization Criteria policy
Botulinum Toxins Statewide PDL Prior Authorization Criteria policy
Bone Density Regulators Statewide PDL Prior Authorization Criteria policy
Blood Glucose Meters and Test Strips Statewide PDL Prior Authorization Criteria
Bladder Relaxant Preparations Statewide PDL Prior Authorization Criteria
Bile Salts Statewide PDL Prior Authorization Criteria
Tysabri Statewide PDL Prior Authorization Criteria Policy
Thyroid Hormones Statewide PDL Prior Authorization Criteria Policy
Thrombopoietics Statewide PDL Prior Authorization Criteria Policy
Thalidomide and Derivatives Statewide PDL Prior Authorization Criteria Policy
Tetracyclines Statewide PDL Prior Authorization Criteria Policy
Stimulants and Related Agents Statewide PDL Prior Authorization Criteria Policy
Steroids, Topical Statewide PDL Prior Authorization Criteria Policy
Smoking Cessation Statewide PDL Prior Authorization Criteria Policy
Skeletal Muscle Relaxants Statewide PDL Prior Authorization Criteria Policy
Sickle Cell Anemia Agents Statewide PDL Prior Authorization Criteria Policy
Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled Statewide PDL Prior Authorization Criteria Policy
Proton Pump Inhibitors Statewide PDL Prior Authorization Criteria policy
Progestational Agents Statewide PDL Prior Authorization Criteria Policy
Prenatal Vitamins Statewide PDL Prior Authorization Criteria Policy
Potassium Removing Agents Statewide PDL Prior Authorization Criteria Policy
Platelet Aggregation Inhibitors Statewide PDL Prior Authorization Criteria Policy
Pitutiary Suppressive Agents, LHRH Statewide PDL Prior Authorization Criteria Policy
Anxiolytics Statewide PDL Prior Authorization Criteria policy
Antivirals, Influenza Statewide PDL Prior Authorization Criteria policy
Phosphate Binders Statewide PDL Prior Authorization Criteria Policy
Antivirals, Herpes Statewide PDL Prior Authorization Criteria policy
Penicillins Statewide PDL Prior Authorization Criteria Policy
Antivirals, CMV Statewide PDL Prior Authorization Criteria policy
Pancreatic Enzymes Statewide PDL Prior Authorization Criteria Policy
Antipsychotics Statewide PDL Prior Authorization Criteria policy
Zulresso Highmark Wholecare Non-PDL Prior Authorization Criteria
Xyrem & Xywav Highmark Wholecare Non-PDL Prior Authorization Criteria
Antipsoriatics, Topical Statewide PDL Prior Authorization Criteria policy
Antipsoriatics, Oral Statewide PDL Prior Authorization Criteria policy
Xiaflex Highmark Wholecare Non-PDL Prior Authorization Criteria
Vyndaqel & Vyndamax Highmark Wholecare Non-PDL Prior Authorization Criteria
Antiparkinson's Agents Statewide PDL Prior Authorization Criteria policy
Uplizna Highmark Wholecare Non-PDL Prior Authorization Criteria
Tepezza Highmark Wholecare Non-PDL Prior Authorization Criteria
Antiparasitics, Topical Statewide PDL Prior Authorization Criteria policy
Synagis Highmark Wholecare Non-PDL Prior Authorization Criteria
Sucraid Highmark Wholecare Non-PDL Prior Authorization Criteria
Antimalarials Statewide PDL Prior Authorization Criteria policy
Sublingual Immunotherapy Medications Highmark Wholecare Non-PDL Prior Authorization Criteria
Strensiq Highmark Wholecare Non-PDL Prior Authorization Criteria
Somatuline Depot Highmark Wholecare Non-PDL Prior Authorization Criteria
Spinal Muscular Atrophy Medications Highmark Wholecare Non-PDL Prior Authorization Criteria
Sandostatin LAR Depot Highmark Wholecare Non-PDL Prior Authorization Criteria
Rituxan & Rituximab Biosimilars Highmark Wholecare Non-PDL Prior Authorization Criteria
Radicava Highmark Wholecare Non-PDL Prior Authorization Criteria
Quantity Limits Highmark Wholecare Non-PDL Prior Authorization Criteria
Qbrexza Highmark Wholecare Non-PDL Prior Authorization Criteria
Pulmozyme Highmark Wholecare Non-PDL Prior Authorization Criteria
Phenylketonuria Medications Highmark Wholecare Non-PDL Prior Authorization Criteria
Palforzia Highmark Wholecare Non-PDL Prior Authorization Criteria
Pulmonary Arterial Hypertension (PAH) Agents, Injectable Highmark Wholecare Non-PDL Prior Authorization Criteria
Onpattro & Tegsedi Highmark Wholecare Non-PDL Prior Authorization Criteria
Oncology Agents, Oral Statewide PDL Prior Authorization Criteria Policy
Oncology, IV/Injectable Highmark Wholecare Non-PDL Prior Authorization Criteria
Oncology Agents, Breast Cancer Statewide PDL Prior Authorization Criteria Policy
Nuedexta Highmark Wholecare Non-PDL Prior Authorization Criteria
Non-Formulary Medical Necessity Highmark Wholecare Non-PDL Prior Authorization Criteria
Myalept Highmark Wholecare Non-PDL Prior Authorization Criteria
Isturisa Highmark Wholecare Non-PDL Prior Authorization Criteria
Immune Globulin Products Highmark Wholecare Non-PDL Prior Authorization Criteria
Corticotropin (H.P. Acthar, Purified Cortrophin Gel) Highmark Wholecare Non-PDL Prior Authorization Criteria
Givlaari Highmark Wholecare Non-PDL Prior Authorization Criteria
Gattex Highmark Wholecare Non-PDL Prior Authorization Criteria
Gamifant Highmark Wholecare Non-PDL Prior Authorization Criteria
Continuous Glucose Monitor Systems Highmark Wholecare Non-PDL Prior Authorization Criteria
Firdapse and Ruzurgi Highmark Wholecare Non-PDL Prior Authorization Criteria
Fabry Disease Medications Highmark Wholecare Non-PDL Prior Authorization Criteria
Enspryng Highmark Wholecare Non-PDL Prior Authorization Criteria
Antihyperuricemics Statewide PDL Prior Authorization Criteria policy
Antihypertensives, Sympatholytic Statewide PDL Prior Authorization Criteria policy
Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides Highmark Wholecare Non-PDL Prior Authorization Criteria
Antihistamines, Minimally Sedating Statewide PDL Prior Authorization Criteria policy
Antihemophilia Agents Statewide PDL Prior Authorization Criteria policy
Daraprim Highmark Wholecare Non-PDL Prior Authorization Criteria
Antifungals, Topical Statewide PDL Prior Authorization Criteria policy
Crysvita Highmark Wholecare Non-PDL Prior Authorization Criteria
Antifungals, Oral Statewide PDL Prior Authorization Criteria policy
Antiemetic-Antivertigo Agents Statewide PDL Prior Authorization Criteria policy
Cough and Cold Medications for Children less than 4 Highmark Wholecare Non-PDL Prior Authorization Criteria
Antidepressants, SSRI Statewide PDL Prior Authorization Criteria policy
Compounds Highmark Wholecare Non-PDL Prior Authorization Criteria
Antidepressants, Other Statewide PDL Prior Authorization Criteria policy
Chimeric Antigen Receptor T-cell (CAR-T) Immunotherapy Highmark Wholecare Non-PDL Prior Authorization Criteria
Antibiotics, GI and related Statewide PDL Prior Authorization Criteria policy
C5b Complement Inhibitors Highmark Wholecare Non-PDL Prior Authorization Criteria
Brineura Highmark Wholecare Non-PDL Prior Authorization Criteria
Cystic Fibrosis Biologic Response Modifiers Highmark Wholecare Non-PDL Prior Authorization Criteria
Antibiotics, Topical Statewide PDL Prior Authorization Criteria policy
Avastin & Bevacizumab Biosimilars Highmark Wholecare Non-PDL Prior Authorization Criteria
Alpha-1 Proteinase Inhibitors Highmark Wholecare Non-PDL Prior Authorization Criteria
Antibiotics, Inhaled Statewide PDL Prior Authorization Criteria policy
Aduhelm Highmark Wholecare Non-PDL Prior Authorization Criteria
Otic Antibiotics Statewide PDL Prior Authorization Criteria Policy
Opioid Overdose Agents Statewide PDL Prior Authorization Criteria Policy
Opioid Dependence Treatments Statewide PDL Prior Authorization Criteria Policy
Ophthalmics, Immunomodulators Statewide PDL Prior Authorization Criteria Policy
Ophthalmics, Glaucoma Statewide PDL Prior Authorization Criteria Policy
Antianginal Agent Statewide PDL Prior Authorization Criteria policy
Ophthalmics, Antibiotic-Steroid Combinations Statewide PDL Prior Authorization Criteria Policy
Angiotensin Modulators Statewide PDL Prior Authorization Criteria policy
Ophthalmics, Antibiotics Statewide PDL Prior Authorization Criteria Policy
Angiotensin Modulator Combinations Statewide PDL Prior Authorization Criteria policy
Androgenic Agents Statewide PDL Prior Authorization Criteria policy
Ophthalmics, Anti-inflammatories Statewide PDL Prior Authorization Criteria Policy
Analgesics, Opioid Short-Acting Statewide PDL Prior Authorization Criteria policy
Ophthalmics, Allergic Conjunctivitis Statewide PDL Prior Authorization Criteria Policy
Analgesics, Opioid Long-Acting Statewide PDL Prior Authorization Criteria policy
Analgesics, Non-Opioid Barbituate Combinations Statewide PDL Prior Authorization Criteria Policy
NSAIDS Statewide PDL Prior Authorization Criteria Policy
Neuropathic Pain Agents Statewide PDL Prior Authorization Criteria Policy
Alzheimer's Agents Statewide PDL Prior Authorization Criteria policy
Multiple Sclerosis Agents Statewide PDL Prior Authorization Criteria Policy
Migraine Prevention Agents Statewide PDL Prior Authorization Criteria Policy
Migraine Acute Treatment Agents Statewide PDL Prior Authorization Criteria Policy
Methotrexate Statewide PDL Prior Authorization Criteria Policy
Macular Degeneration Agents Statewide PDL Prior Authorization Criteria Policy
Macrolides Statewide PDL Prior Authorization Criteria Policy
Monoclonal Antibodies (MABs)- Anti-IL, Anti-IgE Statewide PDL Prior Authorization Criteria Policy
Local Anesthetics, Topical Statewide PDL Prior Authorization Criteria Policy
Lipotropics, Statins Statewide PDL Prior Authorization Criteria Policy
Lipotropics, Other Statewide PDL Prior Authorization Criteria Policy
Leukotriene Modifiers Statewide PDL Prior Authorization Criteria Policy
Iron, Parenteral Statewide PDL Prior Authorization Criteria Policy
Iron Chelating Agents Statewide PDL Prior Authorization Criteria Policy
Intranasal Rhinitis Agents Statewide PDL Prior Authorization Criteria Policy
Intra-Articular Hyaluronates Statewide PDL Prior Authorization Criteria Policy
Acne Agents, Topical Statewide PDL Prior Authorization Criteria Policy
Acne Agents, Oral Statewide PDL Prior Authorization Criteria Policy
Immunosuppressives, Oral Statewide PDL Prior Authorization Criteria Policy
Immunomodulators, Topical Statewide PDL Prior Authorization Criteria Policy
Immunomodulators, Atopic Dermatitis Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, TZDs Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, Sulfonylureas Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, SGLT2 Inhibitors Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, Metformins Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, Meglitinides Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, Insulin and Related Agent Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, Incretin Mimetics/Enhancers Statewide PDL Prior Authorization Criteria Policy
Hypoglycemics, Alpha-Glucosidase Inhibitors Statewide PDL Prior Authorization Criteria Policy
Hypoglycemia Treatments Statewide PDL Prior Authorization Criteria Policy
HIV/AIDS Antiretrovirals Statewide PDL Prior Authorization Criteria Policy
Histamine 2 Receptor Blockers Statewide PDL Prior Authorization Criteria Policy
Hereditary Angioedema Agents Statewide PDL Prior Authorization Criteria Policy
Hepatitis C Agents Statewide PDL Prior Authorization Criteria Policy
Hepatitis B Agents Statewide PDL Prior Authorization Criteria Policy
Hematopoietic Mixtures Statewide PDL Prior Authorization Criteria Policy
H. Pylori Treatments Statewide PDL Prior Authorization Criteria Policy
Sedative Hypnotics Statewide PDL Prior Authorization Criteria
Idiopathic Pulmonary Fibrosis Agents Statewide PDL Prior Authorization Criteria
Systemic Lupus Erythematosus (SLE) Agents Highmark Wholecare Non-PDL Prior Authorization Criteria
Enzyme Replacement Therapy, Pompe Disease Highmark Wholecare Non-PDL Prior Authorization Criteria
Luxturna Highmark Wholecare Non-PDL Prior Authorization Criteria
Bylvay Highmark Wholecare Non-PDL Prior Authorization Criteria
Vyvgart Highmark Wholecare Non-PDL Prior Authorization Criteria
Livmarli Highmark Wholecare Non-PDL Prior Authorization Criteria
Leqvio Highmark Wholecare Non-PDL Prior Authorization Criteria
Tezspire Highmark Wholecare Non-PDL Prior Authorization Criteria
Adbry Highmark Wholecare Non-PDL Prior Authorization Criteria
Gene Therapy Agents Highmark Wholecare Non-PDL Prior Authorization Criteria


This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 27 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

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