Pharmacy Policy Criteria for ConnectiCare Commercial Members
These preauthorization criteria apply to members with ConnectiCare’s commercial plans (other than Large Group Plan Select members which have their own criteria) when they obtain prescription drugs covered by retail or specialty pharmacy benefits.
The same policy criteria apply to EmblemHealth’s members.
This page is under construction. More policy criteria are being prepared and will be added to the table soon.
| Title | Download (PDF) |
|---|---|
| Allergen Immunotherapy Grass Pollen Sublingual Products | Download (PDF) |
| Allergen Immunotherapy Odactra | Download (PDF) |
| Allergen Immunotherapy Palforzia | Download (PDF) |
| Allergen Immunotherapy Ragwitek | Download (PDF) |
| Alpha1 Proteinase Inhibitor Products | Download (PDF) |
| Amifampridine Products | Download (PDF) |
| Amyloidosis Onpattro | Download (PDF) |
| Antibiotics (Inhaled) Arikayce | Download (PDF) |
| Antibiotics (Inhaled) TOBI Podhaler | Download (PDF) |
| Antibiotics (Inhaled) Tobramycin Inhalation Solution | Download (PDF) |
| Antibiotics Linezolid (Zyvox) Sivextro | Download (PDF) |
| Antibiotics Vancomycin Capsules | Download (PDF) |
| Anticoagulants Savaysa | Download (PDF) |
| Antiepileptics Banzel | Download (PDF) |
| Antiepileptics Clobazam Products | Download (PDF) |
| Antiepileptics Fintepla |
Download (PDF) |
| Antiepileptics Nayzilam |
Download (PDF) |
| Antiepileptics Vigabatrin |
Download (PDF) |
| Antifungals (Azoles) Intravenous Products |
Download (PDF) |
| Antifungals Cresemba (Oral) | Download (PDF) |
| Antiseizure: Diacomit (stiripentol capsules and powder for oral suspension) | Download (PDF) |
| Antiseizure: Epidiolex (cannabidiol oral solution) | Download (PDF) |
| Antiseizure: Valtoco (diazepam nasal spray) | Download (PDF) |
| Antivirals - Ribavirin Oral Products | Download (PDF) |
| Attention Deficit Hyperactivity Disorder Non-Stimulant Medications | Download (PDF) |
| Attention Deficit Hyperactivity Disorder Stimulant Medications | Download (PDF) |
| Bone Modifiers: Evenity (romosozumab-aqqg subcutaneous injection) | Download (PDF) |
| Bone Modifiers: Boniva (ibandronate intravenous infusion) | Download (PDF) |
| Bone Modifiers: Prolia (denosumab subcutaneous injection) | Download (PDF) |
| Bone Modifiers: Forteo (teriparatide subcutaneous injection and Teriparatide subcutaneous injection) | Download (PDF) |
| Bone Modifiers: Tymlos (abaloparatide subcutaneous injection) | Download (PDF) |
| Bone Modifiers: Xgeva (denosumab subcutaneous injection) | Download (PDF) |
| Bone Modifiers: Zoledronic Acid/Reclast IV | Download (PDF) |
| Botulinum toxin: Dysport (abobotulinumtoxinA) | Download (PDF) |
| Botulinum toxin: Myobloc (rimabotulinumtoxinB injection) | Download (PDF) |
| Calcitonin Gene-Related Peptide Inhibitors: Aimovig (erenumab-aooe subcutaneous injection) | Download (PDF) |
| Calcitonin Gene-Related Peptide Inhibitors: Ajovy (fremanezumab-vfrm subcutaneous injection) | Download (PDF) |
| Calcitonin Gene-Related Peptide Inhibitors: Emgality (galcanezumab-gnlm subcutaneous injection) | Download (PDF) |
| Calcitonin Gene-Related Peptide Inhibitors: Vyepti (eptinezumab-jjmr intravenous infusion) | Download (PDF) |
| Cardiology: Corlanor (ivabradine tablets and oral solution) | Download (PDF) |
| Cardiology: Zontivity (vorapaxar) | Download (PDF) |
| Chelating Agents: Chemet (succimer capsules) | Download (PDF) |
| Chelating Agents: Cuprimine and Depen (penicillamine) | Download (PDF) |
| Chelating Agents: Syprine (trientine hydrochloride capsules) | Download (PDF) |
| Cholbam (cholic acid capsules) | Download (PDF) |
| Colony Stimulating Factors: Filgrastim Products | Download (PDF) |
| Colony Stimulating Factors: Granix (tbo-filgrastim) | Download (PDF) |
| Colony Stimulating Factors: Pegfilgrastim, Products | Download (PDF) |
| Complement Inhibitors: Soliris (eculizumab intravenous infusion) | Download (PDF) |
| Complement Inhibitors: Ultomiris Intravenous (ravulizumab-cwvz) | Download (PDF) |
| Cystic Fibrosis: Bronchitol (mannitol) | Download (PDF) |
| Diabetes: Symlin (pramlintide subcutaneous injection) | Download (PDF) |
| Marinol, Syndros (dronabinol) | Download (PDF) |
| Enspryng (satralizumab-mwge subcutaneous injection) | Download (PDF) |
| Enzyme Replacement Therapy - Strensiq (asfotase alfa subcutaneous injection) | Download (PDF) |
| Erectile Dysfunction - Caverject, Caverject Impulse, Edex, Muse (alprostadil) | Download (PDF) |
| Erectile Dysfunction - Viagra (sildenafil tablets) | Download (PDF) |
| Erectile Dysfunction - Stendra (avanafil) | Download (PDF) |
| Erectile Dysfunction - Cialis (tadalafil) | Download (PDF) |
| Erectile Dysfunction - Levitra, Staxyn (vardenafil) | Download (PDF) |
| Erythropoiesis-Stimulating Agents – Aranesp (darbepoetin alfa) | Download (PDF) |
| Erythropoiesis-Stimulating Agents – Epoetin Alfa Products (Epogen, Procrit, Retacrit) | Download (PDF) |
| Erythropoiesis: Stimulating Agents Mircera (ivabradine) | Download (PDF) |
| Fabry Disease - Galaford (migalasta) | Download (PDF) |
| Gamifant (emapalumab-lzsg) | Download (PDF) |
| Enzyme Replacement Thereapy - Cerezyme (imiglucerase) | Download (PDF) |
| Gaucher Disease - Substrate Reduction Therapy - Cerdelga (eliglustat) | Download (PDF) |
| Gonadotropin-Releasing Hormone Antagonists - Orilissaa (elagolix) | Download (PDF) |
| Gonadotropin-Releasing Hormone Agonists - Implants (Supprelin LA, Vantas, Zoladex) | Download (PDF) |
| Gonadotropin-Releasing Hormone Antagonists - Oriahnn (elagolix, estradiol, and norethindrone acetate; elagolix) | Download (PDF) |
| Growth Disorders Growth Hormone - Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive | Download (PDF) |
| Growth Disorders – Increlex | Download (PDF) |
| Hematology - Coagadex (coagulation Factor X [human]) | Download (PDF) |
| Hematology - Corifact (Factor XIII Concentrate [human]) | Download (PDF) |
| Hematology: Reblozyl (luspatercept-aamt) | Download (PDF) |
| Hematology: Vonvendi (von Willebrand factor [recombinant]) | Download (PDF) |
| Hemophilia - Factor IX Products (Alprolix, Idelvion, Rebinyn, BeneFIX, Ixinity, Rixubis, AlphaNine SD, Mononine, Profilnine | Download (PDF) |
| Hemophilia: Factor Viii (Nuwiq, Recombinate, Xyntha, etc) | Download (PDF) |
| Hemophilia - Hemlibra (emicizumab-kxwh) | Download (PDF) |
| Hepatology - Givlaari (givosiran) | Download (PDF) |
| Hyperlipidemia – Omega-3 Fatty Acid Products: Lovaza and Vascepa | Download (PDF) |
| Sensipar (cinacalcet tablets) | Download (PDF) |
