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, 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
Bile Salts	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	Highmark Wholecare Non-PDL Prior Authorization Criteria
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
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
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
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
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, Incretin Mimetics/Enhancers	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)
Immune Globulin Products	Highmark Wholecare Non-PDL Prior Authorization Criteria
Immunomodulators, Atopic Dermatitis	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
Journavx (Suzetrigine)	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
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
Uplizna	Highmark Wholecare Non-PDL Prior Authorization Criteria
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
Vitamin D Analogs	Statewide PDL Prior Authorization Criteria Policy
VMAT2 Inhibitors	Statewide PDL Prior Authorization Criteria Policy
Vyjuvek	Highmark Wholecare Non-PDL Prior Authorization Criteria
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

Medication Policies

Policy Name

Category