Oscar Clinical Guidelines: Pharmacy
Clinical guidelines are developed and adopted to establish evidence-based clinical criteria for utilization management decisions. Oscar may delegate utilization management decisions of certain services to third-party delegates who may develop and adopt their own clinical criteria. The clinical guidelines are applicable to all commercial policies. Coverage of services is subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law. Please reference the member’s policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or to confirm coverage contact 855-672-2755 for Oscar Plans and 855-672-2789 for Cigna+Oscar Plans. Looking for medical guidelines?Click hereLooking for our Archived guidelines? Click here.
Upcoming Policy Changes
- Summary of Changes
- 2026 Q3 (August) P&T Summary of Changes
- 2026 Q3 (July) P&T Summary of Changes
- 2026 Q2 (June) P&T Summary of Changes
- 2026 Q2 (May) P&T Summary of Changes
- 2026 Q2 (Apr) P&T Summary of Changes
- 2026 Q1 (March) P&T Summary of Changes
- 2026 Q1 (February) P&T Summary of Changes
- 2026 Q1 (January) P&T Summary of Changes
- Effective 10/1/2026
- Intravitreal Corticosteroid Injections or Implants (PG271, Ver. 2)
- Non-Formulary Antiretroviral Products Criteria (PG268, Ver. 2)
- Spevigo (spesolimab-sbzo) (CG071, Ver. 6)
- Tepezza (teprotumumab-trbw) (PG273, Ver. 2)
- Vykat XR (diazoxide choline) (PG267, Ver. 2)
- Yescarta (axicabtagene ciloleucel) (CG063, Ver. 10)
- Effective 11/2/2026
- Beyfortus (nirsevimab-alip) and Enflonsia (clesrovimab-cfor) (PG180, Ver. 4)
- Dupixent (dupilumab) (PG026, Ver. 16)
- Imcivree (PG088, Ver. 8)
- Lanthanum Carbonate Chewable tablet (Fosrenol) (PG177, Ver. 4)
- Non-Formulary Mental Health Products Criteria (PG265, Ver. 2)
- Restasis (cyclosporine ophthalmic emulsion 0.05%) (PG025, Ver. 9)
- Rivastigmine (Exelon) (PG212, Ver. 3)
- Sirturo (bedaquiline) (PG242, Ver. 3)
- Varubi (rolapitant) (PG178, Ver. 4)
- Verkazia (cyclosporine ophthalmic emulsion) 0.1% (PG236, Ver. 3)
- Effective 12/1/2026
- brimonidine/timolol (Combigan) (PG103, Ver. 7)
- Dipentum (olsalazine sodium) (PG244, Ver. 3)
- Doxylamine/Pyridoxine (Bonjesta, Diclegis) (PG096, Ver. 7)
- Emverm (mebendazole) (PG001, Ver. 8)
- Ivermectin 1% Topical Cream (PG239, Ver. 3)
- Miebo (perfluorohexyloctane) (PG166, Ver. 4)
- oxiconazole (Oxistat 1%) (PG100, Ver. 7)
- Pancreatic Digestive Enzymes - pancrelipase (Brand Names: Creon; Pancreaze; Pertzye; Viokace; Zenpep) (PG027, Ver. 8)
- Vemlidy (tenofovir alafenamide) (PG010, Ver. 8)
- Xiidra (lifitegrast) (PG197, Ver. 4)
- Zortress (everolimus) (PG033, Ver. 8)
- Effective 1/4/2027
- Accelerated Approval Products (PG289, Ver. 1)
- adefovir dipivoxil (Hepsera) (PG081, Ver. 8)
- albendazole (Albenza) (PG101, Ver. 7)
- Alvesco (ciclesonide) (PG105, Ver. 7)
- Aptiom (eslicarbazepine acetate) (PG174, Ver. 4)
- Briviact (brivaracetam) Tablet, Solution (PG172, Ver. 5)
- Daybue (trofinetide) (PG148, Ver. 4)
- Duaklir (aclidinium/formoterol) (PG107, Ver. 7)
- Entecavir (Baraclude) (PG085, Ver. 8)
- Fycompa (perampanel) (PG176, Ver. 4)
- HIV (Human Immunodeficiency Virus) PrEP (Pre-exposure Prophylaxis) Zero Copay Exception-REG (PG288, Ver. 1)
- Luxturna (voretigene neparvovec-rzyl) (CG060, Ver. 8)
- Natalizumab and Natalizumab Biosimilars (Tysabri, Tyruko) (PG195, Ver. 7)
- Osphena (ospemifene) (PG169, Ver. 4)
- Preventive Services Statins Zero Copay Exception-REG (PG159, Ver. 4)
- Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors (PG144, Ver. 4)
- Xdemvy (lotilaner) (PG161, Ver. 4)
Pharmacy Guidelines
- Adakveo (crizanlizumab) (PG193, Ver. 3)
- Adbry (tralokinumab) (PG110, Ver. 8)
- Adefovir Dipivoxil (Hepsera) (PG081, Ver. 7)
- albendazole (Albenza) (PG101, Ver. 6)
- Alvesco (ciclesonide) (PG105, Ver. 6)
- Amvuttra (vutrisiran) (PG264, Ver. 3)
- Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 9)
- Antidiabetic Agents - Soliqua, Xultophy (PG153, Ver. 5)
- Anti-migraine Agents: Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008, Ver. 10)
- Aptiom (eslicarbazepine acetate) (PG174, Ver. 3)
- Approved and Accepted Off-label Medical Necessity Criteria for Products, Drugs and Biologicals (PG136, Ver. 4)
- Aripiprazole oral disintegrating tablet, solution (PG173, Ver. 5)
- armodafinil (Nuvigil) (PG036, Ver. 9)
- asenapine (Saphris) (PG058, Ver. 8)
- Authorization Duration Exception-REG (PG269, Ver. 2)
- Autoimmune Conditions Exceptions Criteria For Certain States (PG286, Ver. 8)
- Autoimmune Conditions Exceptions Criteria For All Other States (PG287, Ver. 1)
- Auvelity (dextromethorphan and bupropion) (PG128, Ver. 5)
- Avonex (interferon beta-1a) (PG218, Ver. 3)
- azelaic acid 15% gel (PG059, Ver. 8)
- Azstarys (serdexmethylphenidate and dexmethylphenidate) (PG130, Ver. 4)
- Bafiertam (monomethyl fumarate) (PG219, Ver. 3)
- Belsomra (suvorexant) (PG064, Ver. 7)
- Benlysta (belimumab) (PG014, Ver. 9)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG254, Ver. 6)
- Betaseron (interferon beta-1b) (PG220, Ver. 3)
- Beqvez (fidanacogene elaparvovec) (CG118)
- Beyfortus (nirsevimab-alip) and Enflonsia (clesrovimab-cfor) (PG180, Ver. 3)
- Botulinum Toxin (CG033, Ver. 16)
- Brand Medically Necessary Drugs (PG186, Ver. 4)
- Brimonidine/Timolol (Combigan) (PG103, Ver. 6)
- Briumvi (ublituximab) (PG134, Ver. 6)
- Briviact (brivaracetam) Tablet, Solution (PG172, Ver. 4)
- Caplyta (lumateperone) (PG175, Ver. 5)
- Cardamyst (etripamil) (PG285, Ver. 1)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 7)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 4)
- CeQur Simplicity Insulin Delivery System (PG192, Ver. 5)
- Cibinqo (abrocitinib) (PG111, Ver. 6)
- Cobenfy (xanomeline and trospium) (PG253, Ver. 3)
- Collagenase Ointment (Santyl) (PG141, Ver. 4)
- Combination products for treatment of helicobacter pylori (PG199, Ver. 2)
- Continuous Glucose Monitors (CGMs) Prescription Products (PG121, Ver. 8)
- Cromolyn Sodium 100mg/5mL Solution (PG087, Ver. 7)
- Dalfampridine (Ampyra) (PG217, Ver. 3)
- Dapsone 7.5% Topical Gel (Aczone) (PG214, Ver. 3)
- Daybue (trofinetide) (PG148, Ver. 3)
- Dexlansoprazole (Dexilant) (PG047, Ver. 9)
- Difluprednate ophthalmic drops (Durezol) (PG079, Ver. 7)
- Dimethyl Fumarate (Tecfidera) (PG222, Ver. 3)
- Dipentum (olsalazine sodium) (PG244, Ver. 2)
- Direct Acting Antiviral Agents for Hepatitis C (PG045, Ver. 8)
- Disposable Insulin Pump Devices (PG127, Ver. 5)
- Doxylamine/Pyridoxine (Bonjesta, Diclegis) (PG096, Ver. 6)
- Duaklir (aclidinium/formoterol) (PG107, Ver. 6)
- Dupixent (dupilumab) (PG026, Ver. 15)
- Ekterly (sebetralstat) (PG278, Ver. 1)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160, Ver. 3)
- Emverm (mebendazole) (PG001, Ver. 7)
- Entecavir (Baraclude) (PG085, Ver. 7)
- Eohilia (budesonide) (PG216, Ver. 3)
- Eucrisa (crisaborole) (PG023, Ver. 8)
- Ezetimibe (Zetia) (PG073, Ver. 7)
- Febuxostat (Uloric) (PG066, Ver. 7)
- Fetzima (levomilnacipran) (PG063, Ver. 7)
- Filsuvez (birch triterpenes) (PG211, Ver. 3)
- fingolimod (Gilenya, Tascenso ODT) (PG224, Ver. 3)
- Fleqsuvy (baclofen oral suspension) (PG112, Ver. 4)
- Forzinity (elamipretide) (PG274, Ver. 1)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132, Ver. 6)
- Fycompa (perampanel) (PG176, Ver. 3)
- Glatiramer Acetate (Copaxone, Glatopa) (PG221, Ver. 4)
- Growth Hormones (Lonapegsomatropin, Somapacitan, Somatropin, Somatrogon) (PG049, Ver. 8)
- Hemangeol (propranolol hydrochloride oral solution) (PG135, Ver. 4)
- Hormonal Therapy for Gender Dysphoria Zero Copay Exception-REG (PG184, Ver. 3)
- Icosapent ethyl (Vascepa) (PG125, Ver. 5)
- Ilaris (canakinumab) (PG185, Ver. 3)
- Imcivree (setmelanotide) (PG088, Ver. 7)
- Immune Globulin Weight-Based Dosing Criteria (PG256, Ver. 2)
- Infertility Injectable Agents (PG119, Ver. 5)
- Injectable Iron Supplements (PG196, Ver. 5)
- Intravitreal Corticosteroid Injections or Implants (PG271, Ver. 1)
- Ivermectin 1% Topical Cream (PG239, Ver. 2)
- Izervay (avancincaptad pegol) (PG168, Ver. 3)
- Journavx (suzetrigine) Quantity Limit Exceptions Criteria (PG260, Ver. 2)
- Kebilidi (eladocagene exuparvovec-tneq) (PG259, Ver. 2)
- Kerendia (finerenone) (PG263, Ver. 2)
- Kesimpta (ofatumumab) (PG225, Ver. 5)
- Kisunla (donanemab-azbt) (PG238, Ver. 2)
- Kymriah (tisagenlecleucel) (CG058, Ver. 9)
- Lamzede (velmanase alfa-tycv) (PG146, Ver. 3)
- Lanthanum Carbonate Chewable tablet (Fosrenol) (PG177, Ver. 3)
- Lantidra (donislecel-jujn) (PG167, Ver. 4)
- Lasix ONYU (furosemide injection) (PG282, Ver. 1)
- Lazcluze (lazertinib) (PG251, Ver. 3)
- Lemtrada (Alemtuzumab) (PG226, Ver. 4)
- Lenmeldy (atidarsagene autotemcel) (CG117, Ver. 3)
- Leqembi (lecanemab-irmb) (PG138, Ver. 5)
- Lidocaine topical system (PG124, Ver. 5)
- Livtencity (maribavir) (PG113, Ver. 5)
- Lokelma (sodium zirconium cyclosilicate) (PG143, Ver. 4)
- Lumryz (sodium oxybate) (PG246, Ver. 3)
- Luxturna (voretigene neparvovec-rzyl) (CG060)
- Lybalvi (olanzapine/samidorphan) (PG283, Ver. 1)
- Lyfgenia (lovotibeglogene autotemcel) (CG114, Ver. 3)
- Lynkuet (elinzanetant) (PG281, Ver. 1)
- Mayzent (siponimod) (PG228, Ver. 3)
- Mavenclad (cladribine) (PG227, Ver. 3)
- Medical Necessity Prior Authorization Criteria for Formulary Products (PG076, Ver. 8)
- Medications for Cosmetic Purposes (PG080, Ver. 7)
- Mesalamine DR 800 mg (Asacol HD) (PG024, Ver. 8)
- Methotrexate Injectable Solution (PG249, Ver. 4)
- Miebo (perfluorohexyloctane) (PG166, Ver. 3)
- Mitoxantrone (Novantrone) (PG126, Ver. 5)
- Modafinil (Provigil) (PG035, Ver. 7)
- Myrbetriq (mirabegron) (PG181, Ver. 3)
- Natalizumab and Natalizumab Biosimilars (Tysabri, Tyruko) (PG195, Ver. 6)
- Neffy (epinephrine nasal spray) (PG243, Ver.3)
- Nevanac (nepafenac) ophthalmic suspension (PG078, Ver. 7)
- NexoBrid (anacaulase-bcdb) (CG112, Ver. 3)
- Niktimvo (axatilimab) (PG252, Ver. 3)
- Non-Formulary Antiretroviral Products Criteria (PG268, Ver. 1)
- Non-Formulary Products Criteria (PG069, Ver. 8)
- Non-Formulary Mental Health Products Criteria (PG265, Ver. 1)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235, Ver. 6)
- Ohtuvayre (ensifentrine) (PG237, Ver. 3)
- Omega-3-acid ethyl esters (Lovaza) (PG005, Ver. 8)
- Omisirge (omidubicel-onlv) (PG149, Ver. 3)
- Opioids (PG018, Ver. 8)
- Orgovyx (relugolix) (PG089, Ver. 7)
- Orilissa (elagolix) (PG261, Ver. 2)
- Orladeyo (PG090, Ver. 8)
- Osphena (ospemifene) (PG169, Ver. 3)
- Oxiconazole (Oxistat 1%) (PG100, Ver. 6)
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245, Ver. 2)
- Pancreatic Digestive Enzymes - pancrelipase (Brand Names: Creon; Pancreaze; Pertzye; Viokace; Zenpep) (PG027, Ver. 7)
- Papzimeos (zopapogene imadenovec-drba) (PG275, Ver. 1)
- paroxetine 7.5 mg capsule (PG272, Ver. 2)
- Pedmark (sodium thiosulfate) (PG133)
- Phenoxybenzamine Hydrochloride (Dibenzyline) (PG054, Ver. 7)
- Plegridy (peginterferon beta-1a) (PG229, Ver. 3)
- Ponvory (ponesimod) (PG230, Ver. 3)
- Potassium Chloride Oral solution (PG086, Ver. 7)
- Prenatal Vitamins Zero Copay Exception-REG (PG258, Ver. 2)
- Prescription Digital Therapeutics (PG142, Ver. 3)
- Prescription Drugs for Serious Mental Illnesses-REG (PG171, Ver. 4)
- Preventive Services Statins Zero Copay Exception-REG (PG159, Ver. 3)
- Prevymis (letermovir) (PG280, Ver. 1)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors (PG068, Ver. 9)
- Qalsody (tofersen) (PG151, Ver. 5)
- Quantity Limit Exception Criteria (PG200, Ver. 4)
- Rasagiline 1mg Oral tablet (PG065, Ver. 7)
- Rebif (interferon beta-1a) (PG231, Ver. 3)
- Rebyota (fecal microbiota, live - jslm) (PG240, Ver. 2)
- Recorlev (levoketoconazole) (PG115, Ver. 5)
- Restasis (cyclosporine 0.05% ophthalmic emulsion) (PG025, Ver. 8)
- Revuforj (revumenib) (PG284, Ver. 1)
- Rexulti (brexpiprazole) (PG074, Ver. 8)
- Rezdiffra (resmetirom) (PG198, Ver. 5)
- Rezzayo (rezafungin) (PG145)
- Rivastigmine (Exelon) (PG212, Ver. 2)
- Roctavian (valoctocogene roxaparvovec-rvox) (PG163)
- Rosuvastatin (Crestor) (PG006, Ver. 8)
- Sancuso (granisetron) Patch (PG007, Ver. 9)
- Savella (milnacipran) (PG062, Ver. 7)
- sildenafil (PAH, Viagra) (PG051, Ver. 8)
- Sirturo (bedaquiline) (PG242, Ver. 2)
- sodium oxybate (Xyrem) (PG009, Ver. 9)
- Sohonos (palovarotene) (PG183, Ver. 3)
- Spevigo (spesolimab-sbzo) (CG071, Ver. 5)
- Spravato (esketamine) (PG257, Ver. 2)
- Step Therapy Exception-REG (PG270, Ver. 2)
- Sublingual Allergy Immunotherapy (SLIT) (PG093, Ver. 7)
- Sunosi (solriamfetol) (PG097, Ver. 6)
- Syfovre (pegcetacoplan injection) (PG150, Ver. 4)
- Tadalafil (Adcirca, Alyq, Chewtadzy, Cialis, Tadliq) (PG052, Ver. 9)
- Tarpeyo (budesonide delayed release capsules) (PG116, Ver. 7)
- Tepezza (teprotumumab-trbw) (PG273, Ver. 1)
- Teriflunomide (Aubagio) (PG232, Ver. 3)
- Testosterone Replacement Therapy (PG122, Ver. 6)
- Tevimbra (tislelizumab) (PG210, Ver. 3)
- Tezspire (tezepelumab) (PG118, Ver. 7)
- Thyrogen (thyrotropin alfa) (PG140, Ver. 3)
- Tzield (teplizumab-mzwv) (CG072, Ver. 5)
- Urea Cycle Disorder (UCD) Treatment Agents (PG187, Ver. 4)
- Varubi (rolapitant) (PG178, Ver. 3)
- Velphoro (sucroferric oxyhydroxide) (PG179, Ver. 4)
- Vemlidy (tenofovir alafenamide) (PG010, Ver. 7)
- Veozah (fezolinetant) (PG215, Ver. 3)
- Verkazia (cyclosporine ophthalmic emulsion) 0.1% (PG236, Ver. 2)
- Verquvo (vericiguat) (PG091, Ver. 7)
- Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors (PG144, Ver. 3)
- Viscosupplementation for Osteoarthritis (CG054, Ver. 10)
- Vowst (fecal microbiota spores, live-brpk) (PG241, Ver. 2)
- Vumerity (diroximel fumarate) (PG233, Ver. 3)
- Vyjuvek (beremagene geperpavec-svdt) (PG147, Ver. 4)
- Vykat XR (diazoxide choline) (PG267, Ver. 1)
- Vyvanse (lisdexamfetamine) (PG098, Ver. 8)
- Wakix (pitolisant hydrochloride) (PG247, Ver. 2)
- Wegovy (semaglutide) for Cardiovascular Risk Reduction or Metabolic Dysfunction-Associated Steatohepatitis (MASH) (PG194, Ver. 6)
- Weight Loss Agents (PG070, Ver. 10)
- Winrevair (sotatercept-csrk) (PG207, Ver. 3)
- Xarelto (rivaroxaban) 1mg/mL Granules for Suspension (PG137, Ver. 4)
- Ycanth (cantharidin) (PG162, Ver. 5)
- Xdemvy (lotilaner) (PG161, Ver. 3)
- Xifaxan (rifaximin) 550 mg Tablets (PG022, Ver. 9)
- Xiidra (lifitegrast) (PG197, Ver. 3)
- Xywav (calcium, magnesium, potassium, and sodium oxybates) (PG248, Ver. 3)
- Yescarta (axicabtagene ciloleucel) (CG063, Ver. 9)
- Zelsuvmi (berdazimer topical gel, 10.3%) (PG201, Ver. 3)
- Zepbound (tirzepatide) for the Treatment of Obstructive Sleep Apnea (PG255, Ver. 4)
- Zepbound (tirzepatide) for the Treatment of Obstructive Sleep Apnea - New York (PG276, Ver. 2)
- Zeposia (ozanimod) (PG234, Ver. 5)
- Zokinvy (lonafarnib) (PG092, Ver. 7)
- Zolgensma (onasemnogene abeparvovec-xioi) (CG061)
- Zortress (everolimus) (PG033, Ver. 7)
- Zurzuvae (zuranolone) (PG182, Ver. 3)
- Zynteglo (betibeglogene autotemcel) (CG073)
Adopted Guidelines
- Caremark Prior Authorization Criteria