Medication Policies

Policy Name

Category

Acne Agents, Oral

Statewide PDL Prior Authorization Criteria Policy

Acne Agents, Topical

Statewide PDL Prior Authorization Criteria Policy

Alcohol Use Disorder Agents

Statewide PDL Prior Authorization Criteria Policy

Alpha-1 Proteinase Inhibitors

Highmark Wholecare Non-PDL Prior Authorization Criteria

Alzheimer's Agents

Statewide PDL Prior Authorization Criteria Policy

Alzheimer's Antiamyloid Monoclonal Antibodies

Highmark Wholecare Non-PDL Prior Authorization Criteria

Amyotrophic lateral sclerosis (ALS) Medications

Highmark Wholecare Non-PDL Prior Authorization Criteria

Analgesics, Acute Pain Agents

Statewide PDL Prior Authorization Criteria Policy

Analgesics, Non-Opioid Barbituate Combinations

Statewide PDL Prior Authorization Criteria Policy

Analgesics, Opioid Long-Acting

Statewide PDL Prior Authorization Criteria policy

Analgesics, Opioid Short-Acting

Statewide PDL Prior Authorization Criteria Policy

Androgenic Agents

Statewide PDL Prior Authorization Criteria Policy

Angiotensin Modulator Combinations

Statewide PDL Prior Authorization Criteria Policy

Angiotensin Modulators

Statewide PDL Prior Authorization Criteria Policy

Antianginal Agent

Statewide PDL Prior Authorization Criteria Policy

Antibiotics, GI and related

Statewide PDL Prior Authorization Criteria Policy

Antibiotics, Inhaled

Statewide PDL Prior Authorization Criteria policy

Antibiotics, Topical

Statewide PDL Prior Authorization Criteria policy

Anticoagulants

Statewide PDL Prior Authorization Criteria Policy

Anticonvulsants

Statewide PDL Prior Authorization Criteria Policy

Antidepressants, Other

Statewide PDL Prior Authorization Criteria Policy

Antidepressants, SSRI

Statewide PDL Prior Authorization Criteria Policy

Antiemetic-Antivertigo Agents

Statewide PDL Prior Authorization Criteria Policy

Antifibrotic Respiratory Agents

Statewide PDL Prior Authorization Criteria Policy

Antifungals, Oral

Statewide PDL Prior Authorization Criteria Policy

Antifungals, Topical

Statewide PDL Prior Authorization Criteria Policy

Antihemophilia Agents

Statewide PDL Prior Authorization Criteria Policy

Antihistamines, Minimally Sedating

Statewide PDL Prior Authorization Criteria policy

Antihypertensives, Sympatholytic

Statewide PDL Prior Authorization Criteria Policy

Antihyperuricemics

Statewide PDL Prior Authorization Criteria Policy

Antimalarials

Statewide PDL Prior Authorization Criteria Policy

Antiparasitics, Topical

Statewide PDL Prior Authorization Criteria Policy

Antiparkinson's Agents

Statewide PDL Prior Authorization Criteria Policy

Antipsoriatics, Oral

Statewide PDL Prior Authorization Criteria Policy

Antipsoriatics, Topical

Statewide PDL Prior Authorization Criteria Policy

Antipsychotics

Statewide PDL Prior Authorization Criteria Policy

Antivirals, CMV

Statewide PDL Prior Authorization Criteria Policy

Antivirals, Herpes

Statewide PDL Prior Authorization Criteria Policy

Antivirals, Influenza

Statewide PDL Prior Authorization Criteria Policy

Anxiolytics

Statewide PDL Prior Authorization Criteria Policy

Beta Blockers

Statewide PDL Prior Authorization Criteria Policy

Bladder Relaxant Preparations

Statewide PDL Prior Authorization Criteria Policy

Blood Glucose Meters and Test Strips

Statewide PDL Prior Authorization Criteria Policy

Bone Density Regulators

Statewide PDL Prior Authorization Criteria Policy

Botulinum Toxins

Statewide PDL Prior Authorization Criteria Policy

BPH Treatments

Statewide PDL Prior Authorization Criteria Policy

Brineura

Highmark Wholecare Non-PDL Prior Authorization Criteria

Bronchodilators, Beta Agonists

Statewide PDL Prior Authorization Criteria Policy

Bylvay

Highmark Wholecare Non-PDL Prior Authorization Criteria

C5b and C3 Complement Inhibitors

Highmark Wholecare Non-PDL Prior Authorization Criteria

Calcium Channel Blockers

Statewide PDL Prior Authorization Criteria Policy

Casgevy

Statewide PDL Prior Authorization Criteria Policy

Cephalosporins

Statewide PDL Prior Authorization Criteria Policy

Chimeric Antigen Receptor T-cell (CAR-T) Immunotherapy

Highmark Wholecare Non-PDL Prior Authorization Criteria

Colony Stimulating Factors

Statewide PDL Prior Authorization Criteria Policy

Complement Inhibitors

Highmark Wholecare Non-PDL Prior Authorization Criteria

Compounds

Highmark Wholecare Non-PDL Prior Authorization Criteria

Continuous Glucose Monitoring Products

Statewide PDL Prior Authorization Criteria Policy

Contraceptives, Oral

Statewide PDL Prior Authorization Criteria Policy

Contraceptives, Other

Statewide PDL Prior Authorization Criteria Policy

COPD Agents

Statewide PDL Prior Authorization Criteria Policy

Corticotropin (H.P. Acthar, Purified Cortrophin Gel)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Cough and Cold Medications for Children less than 4

Highmark Wholecare Non-PDL Prior Authorization Criteria

Crysvita

Highmark Wholecare Non-PDL Prior Authorization Criteria

Cystic Fibrosis Biologic Response Modifiers

Highmark Wholecare Non-PDL Prior Authorization Criteria

Cytokine and CAM Antagonists

Statewide PDL Prior Authorization Criteria Policy

Daraprim

Highmark Wholecare Non-PDL Prior Authorization Criteria

Daybue (trofinetide)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Dry Eye Treatments

Statewide PDL Prior Authorization Criteria Policy

Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides

Highmark Wholecare Non-PDL Prior Authorization Criteria

Dupixent

Statewide PDL Prior Authorization Criteria Policy

Duvyzat (givinostat)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Enspryng (satralizumab-mwge) and Uplizna (inebilizumab-cdon)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Enzyme Replacement Therapy, Pompe Disease

Highmark Wholecare Non-PDL Prior Authorization Criteria

Enzyme Replacements, Gaucher Disease

Statewide PDL Prior Authorization Criteria Policy

Epidermolysis Bullosa Products

Highmark Wholecare Non-PDL Prior Authorization Criteria

Epinephrine, Self-Injected

Statewide PDL Prior Authorization Criteria Policy

Erythropoiesis Stimulating Proteins

Statewide PDL Prior Authorization Criteria Policy

Estrogens

Statewide PDL Prior Authorization Criteria Policy

Fabry Disease Medications

Highmark Wholecare Non-PDL Prior Authorization Criteria

Filspari

Highmark Wholecare Non-PDL Prior Authorization Criteria

Firdapse

Highmark Wholecare Non-PDL Prior Authorization Criteria

Fluoroquinolones, Oral

Statewide PDL Prior Authorization Criteria Policy

Forzinity (elamipretide)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Gamifant

Highmark Wholecare Non-PDL Prior Authorization Criteria

Gattex

Highmark Wholecare Non-PDL Prior Authorization Criteria

Gene Therapy Agents

Highmark Wholecare Non-PDL Prior Authorization Criteria

GI Motility, Chronic

Statewide PDL Prior Authorization Criteria Policy

Givlaari

Highmark Wholecare Non-PDL Prior Authorization Criteria

GLP-1 Receptor Agonists

Statewide PDL Prior Authorization Criteria Policy

Glucocorticoids, Inhaled

Statewide PDL Prior Authorization Criteria Policy

Glucocorticoids, Oral

Statewide PDL Prior Authorization Criteria Policy

Growth Hormones

Statewide PDL Prior Authorization Criteria Policy

H. Pylori Treatments

Statewide PDL Prior Authorization Criteria Policy

Hematopoietic Mixtures

Statewide PDL Prior Authorization Criteria Policy

Hepatic and Biliary Agents

Statewide PDL Prior Authorization Criteria Policy

Hepatitis B Agents

Statewide PDL Prior Authorization Criteria Policy

Hepatitis C Agents

Statewide PDL Prior Authorization Criteria Policy

Hereditary Angioedema Agents

Statewide PDL Prior Authorization Criteria Policy

Histamine 2 Receptor Blockers

Statewide PDL Prior Authorization Criteria Policy

HIV/AIDS Antiretrovirals

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemia Treatments

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, Alpha-Glucosidase Inhibitors

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, DPP-4 Inhibitors

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, Insulin and Related Agent

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, Meglitinides

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, Metformins

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, SGLT2 Inhibitors

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, Sulfonylureas

Statewide PDL Prior Authorization Criteria Policy

Hypoglycemics, TZDs

Statewide PDL Prior Authorization Criteria Policy

Imcivree (setmelanotide)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Immune Globulin Products

Highmark Wholecare Non-PDL Prior Authorization Criteria

Immunomodulators, Dermatologics

Statewide PDL Prior Authorization Criteria Policy

Immunomodulators, Topical

Statewide PDL Prior Authorization Criteria Policy

Immunosuppressives, Oral

Statewide PDL Prior Authorization Criteria Policy

Intra-Articular Hyaluronates

Statewide PDL Prior Authorization Criteria Policy

Intranasal Rhinitis Agents

Statewide PDL Prior Authorization Criteria Policy

Iron Chelating Agents

Statewide PDL Prior Authorization Criteria Policy

Iron, Parenteral

Statewide PDL Prior Authorization Criteria Policy

Isturisa

Highmark Wholecare Non-PDL Prior Authorization Criteria

Joenja

Highmark Wholecare Non-PDL Prior Authorization Criteria

Lantidra

Highmark Wholecare Non-PDL Prior Authorization Criteria

Leukotriene Modifiers

Statewide PDL Prior Authorization Criteria Policy

Lipotropics, Other

Statewide PDL Prior Authorization Criteria Policy

Lipotropics, Statins

Statewide PDL Prior Authorization Criteria Policy

Livmarli

Highmark Wholecare Non-PDL Prior Authorization Criteria

Local Anesthetics, Topical

Statewide PDL Prior Authorization Criteria Policy

Luxturna

Highmark Wholecare Non-PDL Prior Authorization Criteria

Lyfgenia

Statewide PDL Prior Authorization Criteria Policy

Macrolides

Statewide PDL Prior Authorization Criteria Policy

Macular Degeneration Agents

Statewide PDL Prior Authorization Criteria Policy

Methotrexate

Statewide PDL Prior Authorization Criteria Policy

Migraine Acute Treatment Agents

Statewide PDL Prior Authorization Criteria Policy

Migraine Prevention Agents

Statewide PDL Prior Authorization Criteria Policy

Monoclonal Antibodies (MABs)- Anti-IL, Anti-IgE, Anti-TSLP

Statewide PDL Prior Authorization Criteria Policy

Multiple Sclerosis Agents

Statewide PDL Prior Authorization Criteria Policy

Myalept

Highmark Wholecare Non-PDL Prior Authorization Criteria

Myasthenia Gravis Medications

Highmark Wholecare Non-PDL Prior Authorization Criteria

Natalizumab

Statewide PDL Prior Authorization Criteria Policy

Neuropathic Pain Agents

Statewide PDL Prior Authorization Criteria Policy

Non-Formulary Medical Necessity

Highmark Wholecare Non-PDL Prior Authorization Criteria

NSAIDS

Statewide PDL Prior Authorization Criteria Policy

Nuedexta

Highmark Wholecare Non-PDL Prior Authorization Criteria

Obesity Treatment Agents

Statewide PDL Prior Authorization Criteria Policy

Oncology Agents, Breast Cancer

Statewide PDL Prior Authorization Criteria Policy

Oncology Agents, Oral

Statewide PDL Prior Authorization Criteria Policy

Oncology, IV/Injectable

Highmark Wholecare Non-PDL Prior Authorization Criteria

Onpattro,Tegsedi and Amvuttra

Highmark Wholecare Non-PDL Prior Authorization Criteria

Ophthalmics, Allergic Conjunctivitis

Statewide PDL Prior Authorization Criteria Policy

Ophthalmics, Antibiotics

Statewide PDL Prior Authorization Criteria Policy

Ophthalmics, Antibiotic-Steroid Combinations

Statewide PDL Prior Authorization Criteria Policy

Ophthalmics, Anti-inflammatories

Statewide PDL Prior Authorization Criteria Policy

Ophthalmics, Glaucoma

Statewide PDL Prior Authorization Criteria Policy

Opioid Overdose Agents

Statewide PDL Prior Authorization Criteria Policy

Opioid Use Disorder Treatments

Statewide PDL Prior Authorization Criteria Policy

Otic Antibiotics

Statewide PDL Prior Authorization Criteria Policy

Palforzia

Highmark Wholecare Non-PDL Prior Authorization Criteria

Pancreatic Enzymes

Statewide PDL Prior Authorization Criteria Policy

Papzimeos (zopapogene imadenoved-drba)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Penicillins

Statewide PDL Prior Authorization Criteria Policy

Phenylketonuria Medications

Highmark Wholecare Non-PDL Prior Authorization Criteria

Phosphate Binders

Statewide PDL Prior Authorization Criteria Policy

Pituitary Suppressive Agents, LHRH

Statewide PDL Prior Authorization Criteria Policy

Platelet Aggregation Inhibitors

Statewide PDL Prior Authorization Criteria Policy

Potassium Removing Agents

Statewide PDL Prior Authorization Criteria Policy

Prenatal Vitamins

Statewide PDL Prior Authorization Criteria Policy

Progestational Agents

Statewide PDL Prior Authorization Criteria Policy

Proton Pump Inhibitors

Statewide PDL Prior Authorization Criteria policy

Pulmonary Arterial Hypertension (PAH) Agents, Injectable

Highmark Wholecare Non-PDL Prior Authorization Criteria

Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled

Statewide PDL Prior Authorization Criteria Policy

Pulmozyme

Highmark Wholecare Non-PDL Prior Authorization Criteria

Qbrexza

Highmark Wholecare Non-PDL Prior Authorization Criteria

Quantity Limits

Highmark Wholecare Non-PDL Prior Authorization Criteria

Rezdiffra (resmetirom)

Highmark Wholecare Non-PDL Prior Authorization Criteria

Rituxan

Highmark Wholecare Non-PDL Prior Authorization Criteria

Sandostatin LAR Depot

Highmark Wholecare Non-PDL Prior Authorization Criteria

Sedative Hypnotics

Statewide PDL Prior Authorization Criteria

Selective Transthyretin (TTR) Stabilizers

Highmark Wholecare Non-PDL Prior Authorization Criteria

Sickle Cell Anemia Agents

Statewide PDL Prior Authorization Criteria Policy

Skeletal Muscle Relaxants

Statewide PDL Prior Authorization Criteria Policy

Skyclarys

Highmark Wholecare Non-PDL Prior Authorization Criteria

Smoking Cessation

Statewide PDL Prior Authorization Criteria Policy

Sohonos

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

Steroids, Topical

Statewide PDL Prior Authorization Criteria Policy

Stimulants and Related Agents

Statewide PDL Prior Authorization Criteria Policy

Strensiq

Highmark Wholecare Non-PDL Prior Authorization Criteria

Sublingual Immunotherapy Medications

Highmark Wholecare Non-PDL Prior Authorization Criteria

Sucraid

Highmark Wholecare Non-PDL Prior Authorization Criteria

Systemic Lupus Erythematosus (SLE) Agents

Highmark Wholecare Non-PDL Prior Authorization Criteria

Tepezza

Highmark Wholecare Non-PDL Prior Authorization Criteria

Tetracyclines

Statewide PDL Prior Authorization Criteria Policy

Thalidomide and Derivatives

Statewide PDL Prior Authorization Criteria Policy

Thrombopoietics

Statewide PDL Prior Authorization Criteria Policy

Thyroid Hormones

Statewide PDL Prior Authorization Criteria Policy

Tubeless Insulin Delivery Devices

Statewide PDL Prior Authorization Criteria Policy

Tzield

Highmark Wholecare Non-PDL Prior Authorization Criteria

Ulcerative Colitis Agents

Statewide PDL Prior Authorization Criteria Policy

Urea Cycle Disorder Agents

Statewide PDL Prior Authorization Criteria Policy

Urinary Anti-Infectives

Statewide PDL Prior Authorization Criteria Policy

Vaginal Anti-Infectives

Statewide PDL Prior Authorization Criteria Policy

Vanrafia

Highmark Wholecare Non-PDL Prior Authorization Criteria

Vitamin D Analogs

Statewide PDL Prior Authorization Criteria Policy

VMAT2 Inhibitors

Statewide PDL Prior Authorization Criteria Policy

Xenpozyme

Highmark Wholecare Non-PDL Prior Authorization Criteria

Xiaflex

Highmark Wholecare Non-PDL Prior Authorization Criteria

Xyrem, Xywav, and Lumryz

Highmark Wholecare Non-PDL Prior Authorization Criteria

Zeposia

Statewide PDL Prior Authorization Criteria Policy

Zynteglo

Statewide PDL Prior Authorization Criteria Policy