Switch to:
  • members
  • brokers
  • employers
  • Sign in
  • Contact Us

Pharmacy Policy Criteria

Switch to:
Switch to:
  • members
  • brokers
  • employers
  • Provider Manual
  • Our Policies
    • Coverage Guidelines
    • Medical
    • Pharmacy
      • Pharmacy Policy Criteria
      • New Century Health - Medical Oncology Policies
        • Oncology Drug Management Program
        • Go to
      • Go to
    • Reimbursement Policies
    • Payment Integrity Policies
    • Go to Our Policies
  • Billing and Claims
    • Eligibility and Benefits
    • Fee Schedule
    • Go to Billing and Claims
  • Provider Resources
    • Clinical Information
      • Clinical Practice Guidelines
      • Preauthorization Lists
      • Special Programs
      • Go to
    • Provider Toolkit
      • Improving the Patient Experience
      • Forms and Documents
      • Resources
      • Credentialing
      • Go to
    • Help & Support
    • News and Updates
      • Provider resource: 2020 changes to Medicare Advantage plans
      • Dual special needs plan member information available through provider website
      • New 2020 codes
      • Reminders about caring for our Medicare Advantage members
      • Medical policies updated for 2020
      • Changes to claims payment for Medicare Advantage inpatient stays
      • Update on Medicare Beneficiary Identifiers (MBIs)
      • 2020 updates to Medicare Advantage plans
      • Preauthorization updates for 2020
      • Go to
    • Office Visit Newsletter
    • Medicare Advantage Plans
    • Providers
    • Go to Provider Resources
  • Find a Doctor
  • COVID-19
  • Sign in
  • Contact Us

Search

Popular Tasks

  • Forms
  • Policies and Criteria
  • Preauthorization
  • News
  • Reimbursement Policies
Contact Us

Visit a ConnectiCare Center

  • Farmington
  • Manchester
  • Provider Manual
  • Our Policies
    • Coverage Guidelines
    • Medical
    • Pharmacy
    • Reimbursement Policies
    • Payment Integrity Policies
    • Go to Our Policies
  • Billing and Claims
    • Eligibility and Benefits
    • Fee Schedule
    • Go to Billing and Claims
  • Provider Resources
    • Clinical Information
    • Provider Toolkit
    • Help & Support
    • News and Updates
    • Office Visit Newsletter
    • Medicare Advantage Plans
    • Providers
    • Go to Provider Resources
  • Find a Doctor
  • COVID-19
  • Sign in

Pharmacy

  1. Home
  2. Home
  3. Our Policies
  4. Pharmacy
  5. Policy Criteria
  1. Commercial
  2. Large Group Plan Select
  3. Medicare

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)

Large Group Select Pharmacy Policy Criteria

These preauthorization criteria apply to ConnectiCare’s Large Group Plan Select members (other ConnectiCare commercial members and EmblemHealth members follow their own criteria) when they obtain prescription drugs covered by retail or specialty pharmacy benefits.

 
Title Download (PDF)
Absorica LD PA CCI Download (PDF)
Absorica PA CCI Download (PDF)
Accrufer Download (PDF)
ACE-ARB ST CCI Download (PDF)
Acitretin PA CCI Download (PDF)
Acne Oral Download (PDF)
Acne Topicals Download (PDF)
Actemra SQ PA CCI Download (PDF)
Acthar Download (PDF)
Actimmune Download (PDF)
Acyclovir Topical PA CCI Download (PDF)
Adalimumab PA CCI Download (PDF)
Adempas PA CCI Download (PDF)
Adcirca PA CCI Download (PDF)
ADHD PA CCI Download (PDF)
Adbry Download (PDF)
Aemcolo PA CCI Download (PDF)
Aemcolo QL CCI Download (PDF)
Afrezza (test 1) Download (PDF)
Aimovig QL CCI Download (PDF)
Aimovig Download (PDF)
Ajovy PA CCI Download (PDF)
Ajovy QL CCI Download (PDF)
Aklief PA CCI Download (PDF)
Alcortin PA CCI Download (PDF)
Alecensa PA CCI Download (PDF)
Alferon N Download (PDF)
Alkindi  PA CCI Download (PDF)
Alunbrig PA CCI Download (PDF)
Alyq PA CCI Download (PDF)
Amantadine ER PA CCI Download (PDF)
Amitiza-Motegrity PA CCI Download (PDF)
Amrix-Fexmid PA CCI Download (PDF)
Annovera QL CCI Download (PDF)
Anticoagulants Download (PDF)
Antidepressants ST CCI Download (PDF)
Antihistamines PA CCI Download (PDF)
Antimalarials PA CCI Download (PDF)
Apadaz QL CCI Download (PDF)
Aplenzin-Forfivo XL PA CCI Download (PDF)
Apretude  Download (PDF)
Aptiom PA CCI Download (PDF)
Arazlo PA CCI Download (PDF)
Arikayce QL Download (PDF)
Arikayce Download (PDF)
Aspirin Products PA CCI Download (PDF)
Atypicals Download (PDF)
Aubagio PA CCI Download (PDF)
Auryxia PA CCI Download (PDF)
Austedo PA CCI Download (PDF)
Auvelity Download (PDF)
Auvi Q-Symjepi Download (PDF)
Avonex PA CCI Download (PDF)
Ayvakit PA CCI Download (PDF)
Ayvakit QL CCI Download (PDF)
Azedra (iobenguane I-131) Download (PDF)
Bafiertam PA CCI Download (PDF)
Barfiertam QL CCI Download (PDF)
Balversa PA Download (PDF)
Baqsimi QL CCI Download (PDF)
Baxdela PA CCI Download (PDF)
BCG Download (PDF)
Belbuca PA CCI Download (PDF)
Belsomra-Quviviq Download (PDF)
Benlysta SQ Download (PDF)
Benznidazole PA CCI Download (PDF)
Besremi PA CCI Download (PDF)
Betaseron PA CCI Download (PDF)
Bosulif PA CCI Download (PDF)
Bowel Preparation PA CCI Download (PDF)
BPH_Silodosin ST CCI Download (PDF)
Braftovi QL Download (PDF)
Braftovi Download (PDF)
Brand Oral Baclofen Download (PDF)
Breast Cancer Primary Prevention Download (PDF)
Brexafemme  Download (PDF)
Breztri Aerosphere PA CCI Download (PDF)
Breztri Aerosphere QL CCI Download (PDF)
Briviact PA CCI Download (PDF)
Bronchitol PA CCI Download (PDF)
Brukinsa PA CCI Download (PDF)
Brukinsa QL CCI Download (PDF)
Budesonide Capsules PA Download (PDF)
Bunavail CCI Exchange PA Download (PDF)
Bylvay  Download (PDF)
Cabometyx PA CCI Download (PDF)
Calquence Download (PDF)
Cambia PA CCI Download (PDF)
Campath (alemtuzumab) Download (PDF)
Camzyos Download (PDF)
Caplyta PA CCI Download (PDF)
Caplyta QL CCI Download (PDF)
Carbinoxamine PA CCI Download (PDF)
Carvedilol ER PA CCI Download (PDF)
Cayston PA CCI Download (PDF)
Cequa QL Download (PDF)
Cyclosporine Ophthalmic Download (PDF)
Cerdelga PA CCI Download (PDF)
Cesamet PA CCI Download (PDF)
Chenodal Download (PDF)
Chlorzoxazone PA CCI Download (PDF)
Cholbam PA CCI Download (PDF)
Cholinesterase Inhibitors PA CCI Download (PDF)
Cibinqo Download (PDF)
Cimzia PA CCI Download (PDF)
Cinacalcet (Sensipar) PA CCI Download (PDF)
Clobazam PA CCI Download (PDF)
Cometriq PA CCI Download (PDF)
Conjupri PA CCI Download (PDF)
Consensi PA CCI Download (PDF)
Consensi QL CCI Download (PDF)
Copiktra QL Download (PDF)
Copiktra Download (PDF)
Corlanor Download (PDF)
Cosentyx PA CCI Download (PDF)
Cotellic PA CCI Download (PDF)
Cresemba PA CCI Download (PDF)
Curvrior Download (PDF)
Cuvposa PA CCI Download (PDF)
Cystadrops-Cystaran PA CCI Download (PDF)
Dalfampridine PA CCI Download (PDF)
Dapsone Topical PA CCI Download (PDF)
Daurismo QL Download (PDF)
Daurismo Download (PDF)
Daybue Download (PDF)
Dayvigo PA CCI Download (PDF)
Dayvigo QL CCI Download (PDF)
Delstrigo QL Download (PDF)
Dexamethasone Packs PA CCI Download (PDF)
Dexcom QL Download (PDF)
Diabetic Oral Medications CCI Download (PDF)
Diabetic Test Strips Download (PDF)
Diacomit PA CCI Download (PDF)
Diacomit QL CCI Download (PDF)
Dificid PA CCI Download (PDF)
Dihydroergotamine spray PA CCI Download (PDF)
Doptelet QL Download (PDF)
Doptelet Download (PDF)
Dovato QL Download (PDF)
Doxepin Creams PA CCI Download (PDF)
Drizalma Sprinkle PA CCI Download (PDF)
Dronabinol PA CCI Download (PDF)
Duaklir Pressair PA CCI Download (PDF)
Duexis PA CCI Download (PDF)
Dojolvi PA CCI Download (PDF)
Duobrii QL CCI Download (PDF)
Dupixent PA CCI Download (PDF)
Dymista PA CCI Download (PDF)
Ecoza Luzu CCI PA Download (PDF)
Egrifta Download (PDF)
Eletriptan PA CCI Download (PDF)
Elliot's B Download (PDF)
Elyxyb  Download (PDF)
Emflaza Download (PDF)
Emgality PA CCI Download (PDF)
Emgality QL CCI. Download (PDF)
Emsam PA CCI Download (PDF)
Enbrel PA CCI Download (PDF)
Endari PA CCI Download (PDF)
Endari QL Download (PDF)
Enspryng PA CCI Download (PDF)
Entadfi Download (PDF)
Epclusa PA CCI Download (PDF)
Epidiolex CCI Download (PDF)
Epoprostenol PA CCI Download (PDF)
Equetro PA CCI Download (PDF)
Erectile Dysfunction Download (PDF)
Erivedge (vismodegib) Download (PDF)
Erleada PA CCI Download (PDF)
Esbriet Download (PDF)
Eucrisa PA CCI Download (PDF)
Evekeo Download (PDF)
Evekeo-ODT Download (PDF)
Evrysdi PA CCI Download (PDF)
Exelderm PA CCI Download (PDF)
Exkivity Download (PDF)
Extavia PA CCI Download (PDF)
Eysuvis PA CCI Download (PDF)
Fasenra Download (PDF)
Farydak PA CCI Download (PDF)
Febuxostat ST CCI Download (PDF)
Fenofibrates Brand ST CCI Download (PDF)
Fenofibrates Brand PA CCI Download (PDF)
Fentanyls Download (PDF)
Fertility PA CCI Download (PDF)
Filspari Download (PDF)
Fintepla PA CCI Download (PDF)
Firdapse - Ruzurgi PA CCI Download (PDF)
Firdapse QL CCI Download (PDF)
Flector Download (PDF)
Fotivda PA CCI Download (PDF)
Freedom Calcium Channel Blockers PA CCI Download (PDF)
Freedom Contraceptives PA CCI Download (PDF)
FREEDOM Lachydrin Download (PDF)
Freestyle Libre QL Download (PDF)
Furoscix CCI PA Download (PDF)
Fuzeon PA CCI Download (PDF)
Galafold QL Download (PDF)
Galafold Download (PDF)
Gavreto PA CCI Download (PDF)
Gavreto QL CCI Download (PDF)
Gilenya PA CCI Download (PDF)
Gimoti PA CCI Download (PDF)
Glaucoma ST CCI Download (PDF)
Gloperba PA CCI Download (PDF)
GLP-2 Analog Download (PDF)
Glucagon Products PA CCI Download (PDF)
Gluten Intolerance PA CCI Download (PDF)
Glycopyrrolate Download (PDF)
Gralise PA CCI Download (PDF)
Grastek PA CCI Download (PDF)
Growth Hormone PA CCI Download (PDF)
Gvoke QL CCI Download (PDF)
Hepatitis C Download (PDF)
Hemady PA CCI Download (PDF)
Hetlioz Download (PDF)
Horizant PA CCI Download (PDF)
Hyaluronic Acids Download (PDF)
Hycamtin PA CCI Download (PDF)
Hyftor Download (PDF)
Iclusig PA CCI Download (PDF)
Ilumya Download (PDF)
Imbruvica Download (PDF)
Imcivree PA CCI Download (PDF)
Impavido PA CCI Download (PDF)
Inbrija PA CCI Download (PDF)
Inbrija QL CCI Download (PDF)
Increlex PA CCI Download (PDF)
Ingrezza PA CCI Download (PDF)
Inlyta Download (PDF)
Inpefa Download (PDF)
Inqovi PA CCI Download (PDF)
Inqovi QL CCI Download (PDF)
Inrebic PA CCI Download (PDF)
Inrebic QL CCI Download (PDF)
Insulins PA CCI Download (PDF)
Intron-A Download (PDF)
Iressa Download (PDF)
Iron Chelators PA CCI Download (PDF)
Isturisa PA CCI Download (PDF)
IVIG-Subcutaneous Download (PDF)
Jakafi Download (PDF)
Jatenzo QL CCI Download (PDF)
Jaypirca Download (PDF)
Joenja Download (PDF)
Jublia PA CCI Download (PDF)
Juxtapid Download (PDF)
Jynarque QL Download (PDF)
Jynarque PA CCI Download (PDF)
Kalydeco Download (PDF)
Katerzia PA CCI Download (PDF)
Kerendia  Download (PDF)
Kerydin PA CCI Download (PDF)
Kesimpta PA CCI Download (PDF)
Ketoprofen PA CCI Download (PDF)
Keveyis PA CCI Download (PDF)
Kevzara Download (PDF)
Kineret Download (PDF)
Klisyri CCI PA Download (PDF)
Kloxxado  Download (PDF)
Korlym PA CCI Download (PDF)
Koselugo PA CCI Download (PDF)
Krazati Download (PDF)
Kuvan Download (PDF)
Kynamro Download (PDF)
Kynmobi PA CCI Download (PDF)
Lactulose Download (PDF)
Lampit PA CCI Download (PDF)
Letairis PA CCI Download (PDF)
Lidocaines Download (PDF)
Livmarli Download (PDF)
Livtencity  Download (PDF)
Lokelma Download (PDF)
Long Acting Hydrocodones Download (PDF)
Long Acting Opioids Download (PDF)
Long Acting Insulin Semglee Degludec Rezvoglar Download (PDF)
Long-acting muscarinic antagonist CCI Exchange PA Download (PDF)
Long-Acting Muscarinic Antagonist-Long-Acting Beta-Agonist Combo PA CCI Download (PDF)
Lonsurf PA CCI Download (PDF)
Lorbrena Download (PDF)
Lucemyra QL Download (PDF)
Lucemyra Download (PDF)
Lumakras  Download (PDF)
Lupkynis PA CCI Download (PDF)
Lybalvi Download (PDF)
Lynparza PA CCI Download (PDF)
Lyrica Download (PDF)
Lytgobi CCI PA Download (PDF)
Matulane PA CCI Download (PDF)
Mavenclad PA CCI Download (PDF)
Mavyret PA CCI Download (PDF)
Mayzent PA CCI Download (PDF)
Medical Exception Policy Download (PDF)
Mekinist Download (PDF)
Mektovi QL Download (PDF)
Mektovi Download (PDF)
Mepron Download (PDF)
Metformin (Liquids) PA CCI Download (PDF)
Metformin Extended Release (Osmotic & Gastric Retention) PA CCI Download (PDF)
Methotrexates Download (PDF)
Metoprolol HCTZ Download (PDF)
Metyrosine PA CCI Download (PDF)
Minocycline topical foam PA CCI Download (PDF)
Morphines Download (PDF)
Mulpleta QL Download (PDF)
Mulpleta Download (PDF)
Myalept PA CCI Download (PDF)
Mycapssa PA CCI Download (PDF)
Myfembree  Download (PDF)
Mytesi Download (PDF)
Naproxen ER PA CCI Download (PDF)
Nasal Steroids Download (PDF)
Natpara Download (PDF)
Nayzilam PA CCI Download (PDF)
Nayzilam QL CCI Download (PDF)
Needlephobia Download (PDF)
Nexletol and Nexlizet PA CCI Download (PDF)
Nexletol QL CCI Download (PDF)
Nexlizet QL CCI Download (PDF)
Nexviazyme Download (PDF)
Nilutamide PA CCI Download (PDF)
Nitisinone PA CCI Download (PDF)
Nocdurna QL Download (PDF)
Noctiva QL Download (PDF)
Noctiva-Nocdurna Download (PDF)
Non-Preferred GLP1 PA CCI Download (PDF)
Northera PA CCI Download (PDF)
Nourianz PA CCI Download (PDF)
Noxafil (posaconazole) PA CCI Download (PDF)
NSAID Download (PDF)
Nubeqa PA CCI Download (PDF)
Nubeqa QL CCI Download (PDF)
Nucala Download (PDF)
Nuedexta PA CCI Download (PDF)
Nuedexta QL CCI Download (PDF)
Nuplazid PA CCI Download (PDF)
Nurtec ODT PA CCI Download (PDF)
Nurtec ODT QL CCI Download (PDF)
Nuvigil PA CCI Download (PDF)
Nuzyra PA CCI Download (PDF)
Ocaliva PA CCI Download (PDF)
Odactra Download (PDF)
Ofev PA CCI Download (PDF)
Off Label Download (PDF)
Olumiant QL Download (PDF)
Olumiant Download (PDF)
Omega 3's Download (PDF)
Oncology Download (PDF)
Ongentys PA CCI Download (PDF)
Ongentys QL CCI Download (PDF)
Onmel Download (PDF)
Onureg PA CCI Download (PDF)
Onureg QL CCI Download (PDF)
Ophthalmic Anti-Allergy ST CCI Download (PDF)
Ophthalmic Glaucoma PA CCI Download (PDF)
Ophthalmic NSAIDs ST CCI Download (PDF)
Ophthalmic Steroid ST CCI Download (PDF)
Opioids MME CCI Download (PDF)
Opzeulra  Download (PDF)
Opsumit PA CCI Download (PDF)
Oracea Download (PDF)
Oral Contraceptives Download (PDF)
Oralair Download (PDF)
Oravig Download (PDF)
Orencia IV Medical PA CCI Download (PDF)
Orencia PA CCI Download (PDF)
Orenitram PA CCI Download (PDF)
Orgovyx PA CCI Download (PDF)
Oriahnn PA CCI Download (PDF)
Orilissa Download (PDF)
Orkambi QL Download (PDF)
Orkambi Download (PDF)
Orladeyo PA CCI Download (PDF)
Orphenadrine-Citrate-Aspirin Download (PDF)
Orserdu Download (PDF)
Oseni (alogliptin benzoate-pioglitazone hydrochloride) PA CCI Download (PDF)
Otezla PA CCI Download (PDF)
Ovace Plus Download (PDF)
Overactive Bladder ST CCI Download (PDF)
Oxandrin PA CCI Download (PDF)
Oxbryta PA CCI Download (PDF)
Oxbryta QL CCI Download (PDF)
Oxervate CCI PA Download (PDF)
Oxervate QL CCI Download (PDF)
Oxiconazole cream PA CCI Download (PDF)
Oxtellar XR Download (PDF)
Oxycodones Download (PDF)
Palforzia PA CCI Download (PDF)
Palynziq Download (PDF)
Pancreatic Enzymes ST CCI Download (PDF)
Panretin PA CCI Download (PDF)
Pantoprazole Suspension PA CCI Download (PDF)
Patanase Download (PDF)
Pegasys-PegIntron Download (PDF)
Pemazyre PA CCI Download (PDF)
Pemazyre QL CCI Download (PDF)
Penicillamine PA CCI Download (PDF)
Pennsaid Download (PDF)
Phenoxybenzamine PA CCI Download (PDF)
Phosphate Binder ST CCI Download (PDF)
Pifeltro QL Download (PDF)
Piqray PA CCI Download (PDF)
Piqray QL CCI Download (PDF)
Plegridy PA CCI Download (PDF)
Pomalyst CCI PA Policy Download (PDF)
Ponvory PA CCI Download (PDF)
PPI's Download (PDF)
Praluent Download (PDF)
Preferred GLP1 ST CCI Download (PDF)
Prestalia PA CCI Download (PDF)
Pretomanid PA CCI Download (PDF)
Prevymis Download (PDF)
Prialt Download (PDF)
Procysbi Download (PDF)
Promacta Download (PDF)
Provigil Download (PDF)
Psoriasis Topicals CCI Download (PDF)
Pyrimethamine Download (PDF)
Pyrukynd Download (PDF)
Qbrelis--Epaned Download (PDF)
Qbrexa QL Download (PDF)
Qbrexza Download (PDF)
Qdolo PA CCI Download (PDF)
Qelbree QL CCI Download (PDF)
Qinlock PA CCI Download (PDF)
Qinlock QL CCI Download (PDF)
QL Policy Download (PDF)
Qtern PA CCI Download (PDF)
Qtern QL Download (PDF)
Qualaquin PA CCI Download (PDF)
Qudexy-Trokendi Download (PDF)
Qulipta Download (PDF)
Ragwitek Download (PDF)
Ravicti Download (PDF)
Rayaldee PA CCI Download (PDF)
Rayos Download (PDF)
Rebif PA CCI Download (PDF)
Recorlev Download (PDF)
Regranex PA CCI Download (PDF)
Relistor Download (PDF)
Reltone ST CCI Download (PDF)
Relyvrio Download (PDF)
Remodulin PA CCI Download (PDF)
Repatha Download (PDF)
Retevmo PA CCI Download (PDF)
Retevmo QL CCI Download (PDF)
Revlimid Download (PDF)
Rexulti Download (PDF)
Reyvow PA CCI Download (PDF)
Reyvow QL CCI Download (PDF)
Rezlidhia Download (PDF)
Rezurock Download (PDF)
Rhopressa_Rocklatan PA CCI Download (PDF)
Rinvoq PA CCI Download (PDF)
Rinvoq QL CCI Download (PDF)
Rosacea Topicals Download (PDF)
Roszet PA CCI Download (PDF)
Rozlytrek PA CCI Download (PDF)
Rozlytrek QL CCI Download (PDF)
Rubraca CCI PA Download (PDF)
Rukobia QL CCI Download (PDF)
Ruzurgi QL CCI Download (PDF)
Ryaltris Download (PDF)
Rybelsus QL CCI Download (PDF)
Rydapt Download (PDF)
Rylaze Download (PDF)
Scemblix  Download (PDF)
Secuado PA CCI Download (PDF)
Secuado QL CCI Download (PDF)
Sedative Hypnotics ST CCI Download (PDF)
Seglentis Download (PDF)
Sertraline Capsule  Download (PDF)
Short Acting Bronchodilators PA CCI Download (PDF)
Short Acting Opioids Download (PDF)
Signifor PA CCI Download (PDF)
Siklos PA CCI Download (PDF)
Sildenafil  Download (PDF)
Silenor PA CCI Download (PDF)
Siliq Download (PDF)
Simponi PA CCI Download (PDF)
Simvastatin/Atorvastatin Oral Suspension Download (PDF)
Sirturo PA CCI Download (PDF)
Sitavig Download (PDF)
Sivextro PA CCI Download (PDF)
Skyrizi PA CCI Download (PDF)
Skyrizi QL CCI Download (PDF)
Skyclarys  Download (PDF)
Skytrofa  Download (PDF)
Sodium Oxybate Download (PDF)
Sodium Phenylbutyrate PA CCI Download (PDF)
Solodyn (minocycline extended release) PA CCI Download (PDF)
Solosec Download (PDF)
Somavert Download (PDF)
Sotyktu Download (PDF)
Sprix Download (PDF)
Stadol-QL Download (PDF)
Statin Step Download (PDF)
Steglujan PA CCI Download (PDF)
Stelara PA CCI Download (PDF)
Steroid Beta Agonist Combo Inhalers PA CCI Download (PDF)
Steroid Inhalers PA CCI Download (PDF)
Strensiq PA CCI Download (PDF)
Sucraid PA CCI Download (PDF)
Sumatriptan_Naproxen(Treximet) PA CCI Download (PDF)
Sumatriptans Download (PDF)
Sumavel Dose Pro PA CCI Download (PDF)
Sunlenca Download (PDF)
Sunosi PA CCI Download (PDF)
Sylatron PA CCI Download (PDF)
Symapzan Download (PDF)
Symdeko QL Download (PDF)
Symdeko Download (PDF)
SymlinPen PA CCI Download (PDF)
Sympazan PA CCI Download (PDF)
Synarel PA CCI Download (PDF)
Syndros PA CCI Download (PDF)
Tabrecta PA CCI Download (PDF)
Tabrecta QL CCI Download (PDF)
Tafamidis PA CCI Download (PDF)
Tafinlar Download (PDF)
Tagrisso Download (PDF)
Taltz PA CCI Download (PDF)
Talzenna QL Download (PDF)
Talzenna Download (PDF)
Targretin Gel PA Download (PDF)
Targretin Oral Capsules PA Download (PDF)
Tasigna Download (PDF)
Tavalisse Download (PDF)
Tavneos Download (PDF)
Tazverik PA CCI Download (PDF)
Tazverik QL CCI Download (PDF)
Tecartus (brexucabtagene autoleucel) Download (PDF)
Tecfidera PA CCI Download (PDF)
Testosterones Download (PDF)
Testosterone Undecanoate Capsules Download (PDF)
Tetrabenazine PA CCI Download (PDF)
Tezpire Download (PDF)
Thyrogen Download (PDF)
Tibsovo QL Download (PDF)
Tibsovo Download (PDF)
Tiglutik QL Download (PDF)
Tiglutik and Exservan Download (PDF)
Tirosint-SOL Download (PDF)
Tivicay QL CCI Download (PDF)
Tobramycin PA CCI Download (PDF)
Tolsura PA CCI Download (PDF)
Tolsura QL CCI Download (PDF)
Topical Antibiotic PA CCI Download (PDF)
Topical Steroids PA CCI Download (PDF)
Tosymra QL CCI Download (PDF)
Tracleer PA CCI Download (PDF)
Tramadol Biphasic Download (PDF)
Trelstar PA CCI Download (PDF)
Tremfya Download (PDF)
Tretin-X Download (PDF)
Tretinoin PA CCI Download (PDF)
Trientine PA CCI Download (PDF)
Trikafta PA CCI Download (PDF)
Trikafta QL CCI Download (PDF)
Trintellix PA CCI Download (PDF)
Triptan Nasal Sprays PA CCI Download (PDF)
Triptans QL Download (PDF)
Tudorza Download (PDF)
Tukysa PA CCI Download (PDF)
Tukysa QL CCI Download (PDF)
Turalio PA CCI Download (PDF)
Turalio QL CCI Download (PDF)
Tuzistra XR PA CCI. Download (PDF)
Tykerb Download (PDF)
Tyrvaya  Download (PDF)
Tyvaso PA CCI Download (PDF)
Ubrelvy PA CCI Download (PDF)
Ubrelvy QL CCI Download (PDF)
Uceris Rectal Foam PA CCI Download (PDF)
Ulcerative Colitis ST CCI Download (PDF)
Upneeq PA CCI Download (PDF)
Uptravi PA CCI Download (PDF)
Utopic Download (PDF)
Valchlor PA CCI Download (PDF)
Valtoco PA CCI Download (PDF)
Veltassa Download (PDF)
Vemlidy PA CCI Download (PDF)
Ventavis PA CCI Download (PDF)
Veozah Download (PDF)
Verquvo PA CCI Download (PDF)
Vijoice PA CCI Download (PDF)
Vimovo PA CCI Download (PDF)
Vitamin D2 Analogs PA CCI Download (PDF)
Vitrakvi QL Download (PDF)
Vitrakvi Download (PDF)
Vivjoa  Download (PDF)
Vizimpro QL Download (PDF)
Vizimpro Download (PDF)
Vonjo Download (PDF)
Voraxaze Download (PDF)
Vowst  Download (PDF)
Voxzogo  Download (PDF)
Vuity  Download (PDF)
Vumerity PA CCI Download (PDF)
Vusion Download (PDF)
Vyndaqel QL CCI Download (PDF)
Wakix PA CCI Download (PDF)
Welireg Download (PDF)
Wellbutrin XL QL CCI Download (PDF)
Xadago Download (PDF)
Xcopri PA CCI Download (PDF)
Xeljanz Download (PDF)
Xenleta PA CCI Download (PDF)
Xenleta QL CCI Download (PDF)
Xerese PA CCI Download (PDF)
Xermelo Download (PDF)
Xhance ST CCI Download (PDF)
Xifaxan PA CCI Download (PDF)
Xofluza QL CCI Download (PDF)
Xolair Download (PDF)
Xospata QL Download (PDF)
Xospata Download (PDF)
Xpovio PA CCI Download (PDF)
Xtandi PA CCI Download (PDF)
Xuriden PA CCI Download (PDF)
Xywav PA CCI Download (PDF)
Yonsa Download (PDF)
Zavesca Download (PDF)
Zejula PA CCI Download (PDF)
Zelboraf PA CCI Download (PDF)
Zelnorm PA CCI Download (PDF)
Zeposia PA CCI Download (PDF)
Zokinvy PA CCI Download (PDF)
Zolinza (vorinostat) Download (PDF)
Zolpidem Download (PDF)
Zonisade Download (PDF)
Zontivity PA CCI Download (PDF)
Zortress Download (PDF)
Ztalmy Download (PDF)
Zurampic--Duzallo Download (PDF)
Zyflo PA CCI Download (PDF)

Medicare Pharmacy Policy Criteria

Review ConnectiCare's preauthorization criteria on various prescription medications.

Please note, by downloading or viewing any of the criteria below, you have agreed to accept
ConnectiCare’s Preauthorization Criteria User Agreement.

 

Title Download (PDF)
Sandostatin SQ & LAR depot and Somatuline
Download (PDF)
SCIG Download (PDF)
provider
  • blog
  • facebook
  • instagram
  • linkedin
  • twitter
  • youtube
  • Provider Manual
  • Our Policies
  • Billing and Claims
  • Provider Resources
  • Find a Doctor
  • Media Center
  • ConnectiCare Centers
  • Blog
  • Contact Us
  • Legal Information
  • Careers
  • Glossary

Access the ConnectiCare Portal

Sign in
  • Legal
  • Nondiscrimination Policy
  • Important Legal Notice
  • Site Requirements
  • Social Media Policy
  • Privacy Policy

Language Assistance:

  • Español
  • Português
  • Polski
  • 中文
  • Italiano
  • Français
  • Kreyòl Ayisyen
  • Русский
  • Tiếng Việt
  • العربية
  • العربية
  • 한국어
  • Shqip
  • हिंदी
  • Tagalog
  • λληνικά
  • ខ្មែរ
  • ગુજરાતી

©2021 ConnectiCare. All Rights Reserved.

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your  plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.

Enter your ZIP code:
Continue