For Advantage U Part D Requests, please visit: Advantage U Medicare Provider Documents & Forms

Policy Name Effective Date Revision Date Next Review Date
ALL
PHARM-PA General Pharmacy Prior Authorization FormN/AN/AN/A
PHARM-FE Pharmacy Formulary Exception Request FormN/AN/AN/A
PHARM-MHCFE MHC Formulary Exception FormN/AN/AN/A
PHARM-MHCPA MHC General Pharmacy Prior Authorization FormN/AN/AN/A
A
Pharm-088Acute Migraine MedicationsJune 01, 2020June 01, 2020May 20, 2021
pharm-001Acne RosaceaNovember 01, 2020October 28, 2020October 28, 2021
PHARM-002Alpha-1-Proteinase-InhibitorsSeptember 01, 2020November 01, 2020August 19, 2021
pharm-003Ankylosing SpondylitisJune 1, 2020May 20, 2020May 20, 2021
pharm-m018Ankylosing Spondylitis- Medical Infused DrugsNovember 01, 2020October 28, 2020October 28, 2021
pharm-004AnthelminticNovember 01, 2020October 28, 2020October 28, 2021
pharm-005AntidepressantsMarch 26, 2020March 25, 2020March 25, 2021
pharm-006Antiemetics for Chemotherapy Induced Nausea and VomitingSeptember 01, 2020August 19, 2020August 19, 2021
pharm-m028Antiemetics for Chemotherapy Induced Nausea and Vomiting- Medical Infused DrugsAugust 27, 2020August 19, 2020August 19, 2021
pharm-m017Antineoplastics - Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
pharm-007Antineoplastics - RetailJuly 06, 2020June 30, 2020June 30, 2021
pharm-008AranespSeptember 01, 2020August 19, 2020August 19, 2021
pharm-009Atopic DermatitisNovember 01, 2020October 28, 2020October 28, 2021
B
pharm-010Brand Atypical AntipsychoticsNovember 01, 2020October 28, 2020October 28, 2021
pharm-011Basal InsulinJanuary 01, 2021December 22, 2020December 22, 2021
pharm-012Biosimilar PolicyJune 01, 2020May 20, 2020May 20, 2021
pharm-013Brand Name MedicationsJune 1, 2020May 20, 2020May 20, 2021
pharm-081BenlystaNovember 01, 2020October 28, 2020October 28, 2021
pharm-095Brand AnticonvulsantsFebruary 27, 2020March 25, 2020March 25, 2021
pharm-m014BrineuraJanuary 01, 2021December 22, 2020December 22, 2021
pharm-m015Botulinum ToxinsJanuary 10, 2020March 25, 2020March 25, 2021
C
Pharm-094CabliviJune 01, 2020April 15, 2020May 20, 2021
pharm-096Carisoprodol for Healthy USeptember 01, 2020August 19, 2020August 19, 2021
pharm-015C. Difficile DrugsFebruary 20, 2019February 13, 2019February 20, 2020
pharm-016Calcitonin Gene-Related Peptide (CGRP) Receptor AntagonistsDecember 01, 2020November 23, 2020November 23, 2021
pharm-017ConstipationNovember 01, 2020October 28, 2020October 28, 2021
pharm-108Continuous Glucose Monitor (CGM)- Retail PharmacyNovember 01, 2020October 28, 2020October 28, 2021
pharm-018CorlanorMarch 26, 2020March 25, 2020March 25, 2021
pharm-019Crohn's DiseaseJune 1, 2020May 20, 2020May 20, 2021
pharm-m019Crohn’s Disease- Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
pharm-098CuvposaAugust 10, 2020August 19, 2020August 19, 2021
pharm-104Cystadrops and Cystaran for Ocular CystinosisNovember 01, 2020October 28, 2020October 28, 2021
pharm-014Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) AgentsJanuary 23, 2020January 22, 2020January 23, 2021
D
pharm-020DalirespMarch 26, 2020March 25, 2020March 25, 2021
pharm-111DescovyJanuary 01, 2021November 23, 2020November 23, 2021
pharm-022DupixentNovember 01, 2020October 28, 2020October 28, 2021
E
pharm-023EntrestoMarch 26, 2020March 25, 2020March 25, 2021
pharm-024EpidiolexAugust 01, 2020May 20, 2019May 20, 2021
pharm-091Esbriet/OFEVNovember 01, 2020October 28, 2020October 28, 2021
G
pharm-026Gonadotropin Releasing Hormone (GnRH) Agonists and AntagonistsMarch 26, 2020March 25, 2020March 25, 2021
pharm-027Growth Hormones- AdultJune 1, 2020May 29, 2020May 29, 2021
pharm-028Growth Hormones- ChildJune 1, 2020May 29, 2020May 29, 2021
H
pharm-030Hepatitis C Direct Acting AntiviralsSeptember 01, 2020August 19, 2020August 19, 2021
pharm-110Hemophilia and Blood ProductsJanuary 01, 2021November 23, 2020November 23, 2021
pharm-031Hereditary AngioedemaNovember 01, 2020October 28, 2020October 28, 2021
pharm-032Hidradenitis SuppurativaJune 1, 2020May 20, 2020May 20, 2021
pharm-m020Hidradenitis Supperativa- Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
pharm-101Humira for UveitisJune 18, 2020August 19, 2020August 19, 2021
pharm-033HyperkalemiaJanuary 23, 2020January 22, 2020January 23, 2021
pharm-m001Hyaluronic AcidSeptember 01, 2020August 19, 2020August 19, 2021
I
pharm-034Irritable Bowel Syndrome with Diarrhea (IBS-D)March 26, 2020March 25, 2020March 25, 2021
pharm-035Interleukin-5 Receptor Antagonists for Asthma- IL5 (Eosinophilic asthma)January 23, 2020January 22, 2020January 23, 2021
pharm-036IncrelexAugust 01, 2020May 20, 2020May 20, 2021
pharm-038Chronic InsomniaJanuary 23, 2020January 22, 2020January 23, 2021
pharm-039Interstitial CystitisJanuary 23, 2020January 22, 2020January 23, 2021
pharm-082Iron Chelation TherapyNovember 01, 2020October 28, 2020October 28, 2021
pharm-091Idiopathic Pulmonary FibrosisNovember 01, 2020October 28, 2020October 28, 2021
pharm-m002Intravenous IronNovember 01, 2020October 28, 2020October 28, 2021
pharm-105IsturisaNovember 01, 2020October 28, 2020October 28, 2021
J
pharm-041Juvenile Idiopathic ArthritisJune 1, 2020May 20, 2020May 20, 2021
pharm-m021Juvenile Idiopathic Arthritis - Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
K
pharm-m029KrystexxaNovember 01, 2020October 28, 2020October 28, 2021
pharm-m003KymriahJune 1, 2020May 20, 2020May 20, 2021
L
pharm-043Long Acting TacrolimusJanuary 23, 2020January 22, 2020January 23, 2021
pharm-m004LutatheraJanuary 23, 2020January 22, 2020January 23, 2021
M
pharm-044Multiple Sclerosis AgentsNovember 01, 2020October 28, 2020October 28, 2021
pharm-045MucolyticsJune 1, 2020May 20, 2020May 20, 2021
pharm-046MyrbetriqFebruary 27, 2019February 20, 2019February 27, 2020
N
pharm-102Nayzilam® and Valtoco® Nasal SprayJune 01, 2020May 20, 2020May 21, 2021
pharm-099Nexletol and NexlizetAugust 10, 2020August 19, 2020August 19, 2021
pharm-047NeuproAugust 01, 2020May 20, 2020May 20, 2021
pharm-m027Neuromyelitis Optica Spectrum Disorder November 01, 2020October 28, 2020October 28, 2021
PHARM-048NucalaSeptember 01, 2020November 01, 2020August 19, 2021
pharm-106Nucala for Hypereosinophilic SyndromeNovember 01, 2020October 28, 2020October 28, 2021
pharm-083NuedextaNovember 01, 2020October 28, 2020October 28, 2021
O
pharm-068OcalivaJanuary 23, 2020January 22, 2020January 23, 2021
pharm-049Off Label UseJune 1, 2020May 20, 2020May 20, 2021
pharm-050Opioid Dependence AgentsJanuary 23, 2020January 22, 2020January 23, 2021
pharm-051Opioids - ChronicMarch 5, 2020January 23, 2021March 5, 2020
pharm-052Opioids - LimitationsSeptember 01, 2020August 19, 2020August 19, 2021
pharm-054OsteoprosisJune 1, 2020May 20, 2020May 20, 2021
pharm-m005Ophthalmic VEGF AntagonistsMay 9, 2019May 6, 2019May 9, 2020
pharm-097Overactive BladderApril 29, 2020June 28, 2020April 29, 2021
P
Pharm-M026Place of Service for Pharmaceutical InfusionsMarch 24, 2020June 24, 2020August 24, 2020
pharm-056Prior Authorization and Medical Necessity PolicyAugust 21, 2019April 22, 2019August 21, 2020
pharm-057Phosphodiesterase Type 5 (PDE-5) InhibitorSeptember 01, 2020August 19, 2020August 19, 2021
pharm-058PhenylbutyratesJune 1, 2020May 20, 2020May 20, 2021
pharm-059Phenylketonuria (PKU)November 01, 2020October 28, 2020October 28, 2021
pharm-100PrevymisAugust 05, 2020August 19, 2020August 19, 2021
pharm-060PromactaJune 1, 2020May 20, 2020May 20, 2021
pharm-061PsoriasisJune 1, 2020May 20, 2020May 20, 2021
pharm-m022Psoriasis- Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
pharm-062Psoriatic ArthritisNovember 01, 2020October 28, 2020October 28, 2021
pharm-m023Psoriatic Arthritis- Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
pharm-063Pulmonary Arterial HypertensionSeptember 01, 2020August 19, 2020August 19, 2021
pharm-080Pancreatic EnzymesJanuary 1, 2021December 22, 2020December 22, 2021
pharm-089Parkinson's AgentsSeptember 01, 2020August 19, 2020August 19, 2021
pharm-m006Branded Denosumab Products (Prolia, Xgeva)June 1, 2020May 20, 2020May 20, 2021
R
PHARM-064RevcoviSeptember 01, 2020November 01, 2020August 19, 2021
pharm-065Rheumatoid ArthritisJune 1, 2020May 20, 2020May 20, 2021
pharm-m024Rheumatoid Arthritis-Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
pharm-084Ruzurgi- FirdapseNovember 01, 2020October 28, 2020October 28, 2021
S
pharm-066SandostatinMarch 1, 2020February 27, 2020February 27, 2021
pharm-067SavellaJanuary 23, 2020January 22, 2020January 23, 2021
pharm-109SigniforNovember 01, 2020October 28, 2020October 28, 2021
pharm-m013Soliris & UltomirisNovember 01, 2020October 28, 2020October 28, 2021
pharm-069Spavato-KetamineSeptember 01, 2020August 19, 2020August 19, 2021
pharm-m007SpinrazaNovember 06, 2019November 01, 2019November 06, 2020
pharm-071Brand StatinsJune 28, 2020March 25, 2020March 25, 2021
pharm-070Subcutaneous MethotrexateJanuary 23, 2020January 22, 2020January 23, 2021
pharm-107SunosiNovember 01, 2020October 28, 2020October 28, 2021
pharm-073SynagisJune 1, 2020May 20, 2020May 20, 2021
T
pharm-m031TecartusNovember 01, 2020October 28, 2020October 28, 2021
pharm-m016TepezzaMarch 25, 2020March 25, 2020March 25, 2021
pharm-m008TestopelSeptember 01, 2020August 19, 2020August 19, 2021
pharm-074Topiramate ER Sprinkle CapsulesSeptember 01, 2020August 19, 2020August 19, 2021
U
pharm-075Ulcerative ColitisJune 1, 2020May 20, 2020May 20, 2021
pharm-m025Ulcerative Colitis - Medical Infused DrugsJune 30, 2020July 6, 2020June 30, 2021
V
pharm-077VMAT-2 InhibitorsAugust 01, 2020May 20, 2020May 20, 2021
pharm-085Vasopressin Receptor Antagonists (VRA)November 01, 2020October 28, 2020October 28, 2021
pharm-m032VyeptiNovember 01, 2020October 28, 2020October 28, 2021
X
pharm-078XifaxanJune 28, 2020March 25, 2020March 25, 2021
pharm-079XolairSeptember 01, 2020August 19, 2020August 19, 2021
pharm-086XHANCENovember 01, 2020October 28, 2020October 28, 2021
pharm-m011XiaflexNovember 01, 2020October 28, 2020October 28, 2021
Y
pharm-m009YescartaJune 1, 2020May 20, 2020May 20, 2021
pharm-087YupelriDecember 01, 2020November 23, 2020November 23, 2021
Z
pharm-m010ZilrettaJune 1, 2020May 20, 2020May 20, 2021
pharm-m012ZolgensmaJanuary 01, 2021December 22, 2020December 22, 2021