Medical and Behavioral Health Policy Activity Effective October 31, 2022

q42022-utilization-management-updates-10-1-22-final.pdf

Application for Individual Dental/Vision Insurance

Ryplazim® (plasminogen,human-tvmh) - Medicaid

Prior Authorization, Quantity Limit

Tarpeyo™ (budesonide) - Commercial

Prior Authorization, Quantity Limit

Recorlev® (levoketoconazole) - Commercial - Effective Date 02/01/2025

Prior Authorization, Quantity Limit

Pyrukynd® (mitapivat) - Medicaid - Effective Date 02/01/2025

Prior Authorization, Quantity Limit

Cibinqo™ (abrocitinib) - Medicaid

Prior Authorization, Quantity Limit

Cibinqo™ (abrocitinib) - Commercial

Prior Authorization, Quantity Limit

Tarpeyo™ (budesonide) - Medicaid

Prior Authorization, Quantity Limit