Prior Authorization Drug Guidelines

High Level Drug Policies

• Diabetes - Glucagon-Like Peptide-1 Agonists Care Value Policy
• Diabetic Drug Guideline
• Dispense as Written
• Hepatitis C Prescription Requirement Drug Policy
• Length of Authorization Drug Policy
• New to Market Medical and Pharmacy Benefit Products
• Non-Formulary Exception Criteria

Preferred Specialty Management Policies

• Inflammatory Conditions PSM Policy - Care Value Policy
• Hepatitis C Virus (HCV) Direct-Acting Antivirals (DAAs) PSM Policy
• Multiple Sclerosis PSM Policy
• Oncology Care Value – Breast Cancer (Oral) Agents

Express Scripts Drug Policies

Adopted Express Scripts QLL Policies

• Depression - SSRI DQM - Per Rx
• Diflucan 150 mg(fluconazole) DQM - Per Rx

Due to proprietary reasons, we are unable to post the Milliman Care Guidelines on our website, but a hard copy of an individual guideline can be provided as requested.

Milliman Care Guidelines (MCG) but not limited to:

VCHCP Custom Drug Policies:

Market Events Program:

Market Events Program Policy For Exception Review of Excluded Drugs

• Zavesca

National Preferred Formulary Exclusions List

National Preferred Formulary Exception Criteria for Exception Review Only

Formulary Exclusions -For Exception Review Use Only:

Step Therapy

• Step Therapy Document

Medication-Related Policies

• Coverage of Prescription Medication for Off-Label Use
• Pain Management for Terminally Ill Patients
• Prior Authorization of Medications

VCHCP Custom Drug Policies – Medical Benefit