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 Q1 (January) P&T Summary of Changes
- 2025 Q4 (December) P&T Summary of Changes
- 2025 Q4 (November) P&T Summary of Changes
- 2025 Q4 (October) P&T Summary of Changes
- Effective 3/2/2026
- Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 8)
- Briviact (brivaracetam) Tablet, Solution (PG172, Ver. 4)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 7)
- CeQur Simplicity Insulin Delivery System (PG192, Ver. 4)
- Difluprednate ophthalmic drops (Durezol) (PG079, Ver. 7)
- Disposable Insulin Pump Devices (PG127, Ver. 5)
- Hormonal Therapy for Gender Dysphoria Zero Copay Exception-REG (PG184, Ver. 3)
- Kerendia (finerenone) (PG263, Ver. 1)
- Kymriah (tisagenlecleucel) (CG058, Ver. 9)
- Lumryz (sodium oxybate) (PG246, Ver. 3)
- Lynkuet (elinzanetant) (PG281, Ver. 1)
- Medical Necessity Prior Authorization Criteria (PG076, Ver. 7)
- Myrbetriq (mirabegron) (PG181, Ver. 3)
- Non-Formulary Products Criteria (PG069, Ver. 8)
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245, Ver. 2)
- Potassium Chloride Oral solution (PG086, Ver. 7)
- sodium oxybate (Xyrem) (PG009, Ver. 9)
- Testosterone Replacement Therapy (PG122, Ver. 6)
- Urea Cycle Disorder (UCD) Treatment Agents (PG187, Ver. 4)
- Veozah (fezolinetant) (PG215, Ver. 3)
- Wegovy (semaglutide) for Cardiovascular Risk Reduction or Metabolic Dysfunction-Associated Steatohepatitis (MASH) (PG194, Ver. 5)
- Weight Loss Agents (PG070, Ver. 8)
- Winrevair (sotatercept-csrk) (PG207, Ver. 3)
- Xifaxan (rifaximin) 550 mg Tablets (PG022, Ver. 9)
- Xywav (calcium, magnesium, potassium, and sodium oxybates) (PG248, Ver. 3)
- Yescarta (axicabtagene ciloleucel) (CG063, Ver. 9)
- Zepbound (tirzepatide) for the Treatment of Obstructive Sleep Apnea (PG255, Ver. 3)
- Zokinvy (lonafarnib) (PG092, Ver. 7)
- Effective 4/1/2026
- Antidiabetic Agents - Soliqua, Xultophy (PG153, Ver. 5)
- Belsomra (suvorexant) (PG064, Ver. 7)
- Brand Medically Necessary Drugs (PG186, Ver. 4)
- Cobenfy (xanomeline and trospium) (PG253, Ver. 2)
- Ilaris (canakinumab) (PG185, Ver. 3)
- Intravitreal Corticosteroid Injections or Implants (PG271, Ver. 1)
- Medications for Cosmetic Purposes (PG080, Ver. 7)
- Orladeyo (berotralstat) (PG090, Ver. 7)
- Rasagiline 1mg Oral tablet (PG065, Ver. 7)
- Syfovre (pegcetacoplan injection) (PG150, Ver. 4)
- Tepezza (teprotumumab-trbw) (PG273, Ver. 1)
- Effective 5/1/2026
- Ekterly (sebetralstat) (PG278, Ver. 1)
- Lantidra (donislecel-jujn) (PG167, Ver. 3)
- Papzimeos (zopapogene imadenovec-drba) (PG275, Ver. 1)
- Prescription Digital Therapeutics (PG142, Ver. 3)
- Rezdiffra (resmetirom) (PG198, Ver. 4)
- Sohonos (palovarotene) (PG183, Ver. 3)
- Effective 6/1/2026
- Antidiabetic Agent - SymlinPen (pramlintide acetate) (PG156, Ver. 5)
- Continuous Glucose Monitors (CGMs) Prescription Products (PG121, Ver. 8)
- Non-Solid Oral Dosage Formulations (PG279, Ver. 1)
- Prevymis (letermovir) (PG280, Ver. 1)
- Rezdiffra (resmetirom) (PG198, Ver. 5)
- sildenafil (PAH, Viagra) (PG051, Ver. 8)
- Tadalafil (Adcirca, Alyq, Chewtadzy, Cialis, Tadliq) (PG052, Ver. 9)
- Ycanth (cantharidin) (PG162, Ver. 5)
- Xarelto (rivaroxaban) 1mg/mL Granules for Suspension (PG137, Ver. 4)
Pharmacy Guidelines
- Adakveo (crizanlizumab) (PG193, Ver. 2)
- Adbry (tralokinumab-ldrm) (PG110, Ver. 7)
- Adefovir Dipivoxil (Hepsera) (PG081, Ver. 7)
- albendazole (Albenza) (PG101, Ver. 6)
- Allergen Sublingual Immunotherapy (SLIT) (PG093, Ver. 6)
- Alvesco (ciclesonide) (PG105, Ver. 6)
- Amvuttra (vutrisiran) (PG264, Ver. 2)
- Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 7)
- Antidiabetic Agents - Soliqua, Xultophy (PG153)
- Antidiabetic Agent - SymlinPen (pramlintide acetate) (PG156, Ver. 4)
- Anti-migraine Agents: Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008, Ver. 9)
- Approved and Accepted Off-label Medical Necessity Criteria for Products, Drugs and Biologicals (PG136, Ver. 3)
- Aptiom (eslicarbazepine acetate) (PG174, Ver. 3)
- Armodafinil (Nuvigil) (PG036, Ver. 8)
- Aripiprazole oral disintegrating tablet, solution (PG173, Ver. 4)
- Asenapine (Saphris) (PG058, Ver. 7)
- Authorization Duration Exception-REG (PG269, Ver. 2)
- Autoimmune Conditions Exception Criteria (2026, Ver. 6)
- Auvelity (Dextromethorphan and Bupropion) (PG128, Ver. 4)
- Avonex (interferon beta-1a) (PG218, Ver. 2)
- Azelaic acid 15% gel (PG059, Ver. 7)
- Azstarys (serdexmethylphenidate and dexmethylphenidate) (PG130, Ver. 3)
- Bafiertam (monomethyl fumarate) (PG219, Ver. 2)
- Belsomra (suvorexant) (PG064)
- Benlysta (belimumab) (PG014, Ver. 8)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG254, Ver. 5)
- Betaseron (interferon beta-1b) (PG220, Ver. 2)
- Beqvez (fidanacogene elaparvovec) (CG118)
- Beyfortus (nirsevimab-alip) and Enflonsia (clesrovimab-cfor) (PG180, Ver. 3)
- Botulinum Toxin (CG033, Ver. 15)
- Brand Medically Necessary Drugs (PG186)
- Brimonidine/Timolol (Combigan) (PG103, Ver. 6)
- Briumvi (ublituximab) (PG134, Ver. 5)
- Briviact (brivaracetam) Tablet, Solution (PG172, Ver. 3)
- Budesonide 3mg Delayed-Release Capsule (Entocort EC) (PG082, Ver. 7)
- Caplyta (lumateperone) (PG175, Ver. 4)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 6)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 4)
- CeQur Simplicity Insulin Delivery System (PG192, Ver. 3)
- Cibinqo (abrocitinib) (PG111, Ver. 5)
- Cobenfy (xanomeline and trospium) (PG253)
- Collagenase Ointment (Santyl) (PG141, Ver. 3)
- Combination products for treamtent of helicobacter pylori (PG199, Ver. 2)
- Continuous Glucose Monitors (CGMs) (PG121, Ver. 7)
- Cromolyn Sodium 100mg/5mL Solution (PG087, Ver. 7)
- Dalfampridine (Ampyra) (PG217, Ver. 2)
- Dapsone 7.5% topical Gel (Aczone) (PG214, Ver. 2)
- Daybue (trofinetide) (PG148, Ver. 3)
- Dexlansoprazole (dexilant) (PG047, Ver. 8)
- Difluprednate (Durezol) Ophthalmic Drops (PG079)
- Dimethyl Fumarate (Tecfidera) (PG222, Ver. 2)
- Dipentum (olsalazine sodium) (PG244, Ver. 2)
- Direct Acting Antiviral Agents for Hepatitis C (PG045, Ver. 7)
- Disposable Insulin Pump Devices (PG127, Ver. 4)
- Doxylamine/Pyridoxine (Bonjesta, Diclegis) (PG096, Ver. 6)
- Duaklir (aclidinium/formoterol) (PG107, Ver. 6)
- Dupixent (dupilumab) (PG026, Ver. 15)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160)
- Emverm (mebendazole) (PG001, Ver. 7)
- Entecavir (Baraclude) (PG085, Ver. 7)
- Eohilia (budesonide) (PG216, Ver. 2)
- Eucrisa (crisaborole) (PG023, Ver. 7)
- Extavia (interferon beta-1b) (PG223, Ver. 2)
- Exemestane (Aromasin) (PG084, Ver. 8)
- Ezetimibe (Zetia) (PG073, Ver. 7)
- Febuxostat (Uloric) (PG066, Ver. 7)
- Fesoterodine (Toviaz) (PG102, Ver. 6)
- Fetzima (levomilnacipran) (PG063, Ver. 7)
- Filsuvez (birch triterpenes) (PG211, Ver. 2)
- Fingolimod (Gilenya, Tascenso ODT) (PG224, Ver. 2)
- Fleqsuvy (baclofen oral suspension) (PG112, Ver. 4)
- Forzinity (elamipretide) (PG274, Ver. 1)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132, Ver. 5)
- Fycompa (perampanel) (PG176, Ver. 3)
- Glatiramer Acetate (Copaxone, Glatopa) (PG221, Ver. 3)
- 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 (PG184)
- Icosapent ethyl (Vascepa) (PG125, Ver. 4)
- Ilaris (canakinumab) (PG185)
- Imcivree (setmelanotide) (PG088, Ver. 7)
- Immune Globulin Weight-Based Dosing Criteria (PG256, Ver. 1)
- Infertility Injectable Agents (PG119, Ver. 4)
- Injectable Iron Supplements (PG196, Ver. 5)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 15)
- Ivermectin 1% Topical Cream (PG239, Ver. 2)
- Izervay (avancincaptad pegol) (PG168, Ver. 3)
- Journavx (suzetrigine) Quantity Limit Exceptions Criteria (PG260, Ver. 1)
- Kebilidi (eladocagene exuparvovec-tneq) (PG259, Ver. 1)
- Kesimpta (ofatumumab) (PG225, Ver. 3)
- Kisunla (donanemab-azbt) (PG238, Ver. 2)
- Kymriah (tisagenlecleucel) (CG058, Ver. 8)
- Lacosamide (Vimpat) (PG056, Ver. 7)
- lamotrigine extended release (Lamictal XR) (PG055, Ver7)
- Lamotrigine Orally Disintegrating Tablet (PG083, Ver. 7)
- Lamzede (velmanase alfa-tycv) (PG146, Ver. 3)
- Lanthanum Carbonate Chewable tablet (Fosrenol) (PG177, Ver. 3)
- Lantidra (donislecel-jujn) (PG167)
- Lazcluze (lazertinib) (PG251, Ver. 3)
- Lemtrada (Alemtuzumab) (PG226, Ver. 2)
- Lenmeldy (atidarsagene autotemcel) (CG117, Ver. 2)
- Leqembi (lecanemab-irmb) (PG138)
- Lidoderm (lidocaine) 5% Transdermal Patch (PG124, Ver. 4)
- Livtencity (maribavir) (PG113, Ver. 4)
- Lokelma (sodium zirconium cyclosilicate) (PG143, Ver. 3)
- Lumryz (sodium oxybate) (PG246, Ver. 2)
- lurasidone (Latuda) (PG057, Ver. 7)
- Luxturna (voretigene neparvovec-rzyl) (CG060)
- Lyfgenia (lovotibeglogene autotemcel) (CG114)
- Mavenclad (cladribine) (PG227, Ver. 2)
- Mayzent (siponimod) (PG228, Ver. 2)
- Medications for Cosmetic Purposes (PG080)
- Medical Necessity Prior Authorization Criteria (PG076)
- Memantine (Namenda) (PG213, Ver. 2)
- Mesalamine DR 800 (Asacol HD) (PG024, Ver. 7)
- Methotrexate Injectable Solution (PG249, Ver. 3)
- Miebo (perfluorohexyloctane) (PG166, Ver. 3)
- Mitoxantrone (Novantrone) (PG126, Ver. 4)
- Modafinil (Provigil) (PG035, Ver. 7)
- Myrbetriq (mirabegron) (PG181)
- Neffy (epinephrine nasal spray) (PG243, Ver. 2)
- Nevanac (nepafenac) ophthalmic suspension (PG078, Ver. 7)
- NexoBrid (anacaulase-bcdb) (CG112, Ver. 3)
- Niktimvo (axatilimab) (PG252, Ver. 2)
- Non-Formulary Antiretroviral Products Criteria (PG268, Ver. 1)
- Non-Formulary Mental Health Products Criteria (PG265, Ver. 1)
- Non-Formulary Products Criteria (PG069)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235, Ver. 4)
- Ohtuvayre (ensifentrine) (PG237, Ver. 2)
- Omega-3-acid ethyl esters (Lovaza) (PG005, Ver. 7)
- Omisirge (omidubicel-onlv) (PG149, Ver. 3)
- Opioids (PG018, Ver. 8)
- Orgovyx (relugolix) (PG089, Ver. 7)
- Orladeyo (berotralstat) (PG090)
- Orilissa (elagolix) (PG261, Ver. 1)
- Osphena (ospemifene) (PG169, Ver. 3)
- Oxiconazole (Oxistat 1%) (PG100, Ver. 6)
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245)
- Pancreatic Digestive Enzymes - pancrelipase (Brand Names: Creon; Pancreaze; Pertzye; Viokace; Zenpep) (PG027, Ver. 7)
- paroxetine 7.5 mg capsule (PG272, Ver. 1)
- Pedmark (sodium thiosulfate) (PG133)
- Prescription Digital Therapeutics (PG142)
- Phenoxybenzamine Hydrochloride (Dibenzyline) (PG054, Ver. 7)
- Plegridy (peginterferon beta-1a) (PG229, Ver. 2)
- Ponvory (ponesimod) (PG230, Ver. 2)
- Potassium Chloride Oral Solution (PG086)
- Prenatal Vitamins Zero Copay Exception-REG (PG258, Ver. 1)
- Prescription Drugs for Serious Mental Illnesses-REG (PG171, Ver. 3)
- Preventive Services Statins Zero Copay Exception-REG (PG159, Ver. 3)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors (PG068, Ver. 7)
- Qalsody (tofersen) (PG151, Ver. 4)
- Quantity Limit Exception Criteria (PG200, Ver. 3)
- Rasagiline 1mg (PG065)
- Rebif (interferon beta-1a) (PG231, Ver. 2)
- Rebyota (fecal microbiota, live - jslm) (PG240, Ver. 2)
- Recorlev (levoketoconazole) (PG115, Ver. 4)
- Restasis (cyclosporine 0.05% ophthalmic emulsion) (PG025, Ver. 8)
- Rexulti (brexpiprazole) (PG074, Ver. 7)
- Rezdiffra (resmetirom) (PG198, Ver. 3)
- Rezzayo (rezafungin) (PG145)
- Rivastigmine (Exelon) (PG212, Ver. 2)
- Roctavian (valoctocogene roxaparvovec-rvox) (PG163)
- Rosuvastatin (Crestor) (PG006, Ver. 8)
- Sancuso (granisetron) Patch (PG007, Ver. 8)
- Savella (milnacipran) (PG062, Ver. 7)
- Sildenafil (PAH, Viagra) (PG051, Ver. 7)
- Sirturo (bedaquiline) (PG242, Ver. 2)
- Sodium oxybate (Xyrem) (PG009, Ver. 8)
- Sohonos (palovarotene) (PG183)
- Spevigo (spesolimab-sbzo) (CG071, Ver. 5)
- Spravato (esketamine) (PG257, Ver. 1)
- Step Therapy Exception-REG (PG270, Ver. 2)
- Sunosi (solriamfetol) (PG097, Ver. 6)
- Syfovre (pegcetacoplan injection) (PG150)
- Tadalafil (Adcirca, Alyq, Chewtadzy, Cialis, Tadliq) (PG052, Ver. 8)
- Tarpeyo (budesonide delayed release capsules) (PG116, Ver. 5)
- Teriflunomide (Aubagio) (PG232, Ver. 2)
- Testosterone replacement therapy (PG122, Ver. 5)
- Tevimbra (tislelizumab) (PG210, Ver. 2)
- Tezspire (tezepelumab) (PG118, Ver. 6)
- Thyrogen (thyrotropin alfa) (PG140)
- Tysabri (natalizumab) (PG195, Ver. 4)
- Tzield (teplizumab-mzwv) (CG072)
- Urea Cycle Disorder (UCD) Treatment Agents (PG187, Ver. 3)
- Varubi (rolapitant) (PG178, Ver. 3)
- Velphoro (sucroferric oxyhydroxide) (PG179, Ver. 3)
- Vemlidy (tenofovir alafenamide) (PG010, Ver. 7)
- Veozah (fezolinetant) (PG215, Ver. 2)
- Verkazia (cyclosporine ophthalmic emulsion) 0.1% (PG236, Ver. 2)
- Verquvo (vericiguat) (PG091, Ver. 7)
- Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors (PG144, Ver. 3)
- Vowst (fecal microbiota spores, live-brpk) (PG241, Ver. 2)
- Vumerity (diroximel fumarate) (PG233, Ver. 2)
- Vyvanse (lisdexamfetamine) (PG098, Ver. 7)
- Vyjuvek (beremagene geperpavec-svdt) (PG147, Ver. 3)
- Vykat XR (diazoxide choline) (PG267, Ver. 1)
- Wakix (pitolisant hydrochloride) (PG247, Ver. 2)
- Wegovy (semaglutide) for Cardiovascular Risk Reduction or Metabolic Dysfunction-Associated Steatohepatitis (MASH) (PG194, Ver. 4)
- Weight Loss Agents (PG070, Ver. 7)
- Winrevair (sotatercept-csrk) (PG207, Ver. 2)
- Xarelto (rivaroxaban) 1mg/mL Granules for Suspension (PG137, Ver. 3)
- Xdemvy (lotilaner) (PG161, Ver. 3)
- Xifaxan (rifaximin) 550 mg Tablets (PG022, Ver. 8)
- Xiidra (lifitegrast) (PG197, Ver. 3)
- Xywav (calcium, magnesium, potassium, and sodium oxybates) (PG248, Ver. 2)
- Ycanth (cantharidin) (PG162, Ver. 4 )
- Yescarta (axicabtagene ciloleucel) (CG063)
- Zelsuvmi (berdazimer topical gel, 10.3%) (PG201, Ver. 2)
- Zepbound (tirzepatide) for the Treatment of Obstructive Sleep Apnea - New York (PG276, Ver. 1)
- Zepbound (tirzepatide) for the Treatment of Obstructive Sleep Apnea (PG255, Ver. 2)
- Zeposia (ozanimod) (PG234, Ver. 3)
- Zokinvy (lonafarnib) (PG092)
- 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