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 here.
Pharmacy Guidelines
- Acyclovir 5% ointment (Zovirax) (PG099)
- Adbry (tralokinumab-ldrm) (PG110)
- Adakveo (crizanlizumab) (PG193)
- Adefovir Dipivoxil (Hepsera) (PG081)
- Albendazole (Albenza) (PG101)
- Allergen Sublingual Immunotherapy (SLIT) (PG093)
- Alvesco (ciclesonide)(PG105)
- Antidiabetic Agents - Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & DPP-4 Antidiabetic Combinations (PG155)
- Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152)
- Antidiabetic Agents - Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors & SGLT2 Antidiabetic Combinations (PG154)
- Antidiabetic Agents - Soliqua, Xultophy (PG153)
- Antidiabetic Agent - SymlinPen (pramlintide acetate) (PG156)
- Anti-migraine Agents/ Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008)
- Approved and Accepted Off-label Medical Necessity Criteria for Products, Drugs and Biologicals (PG136)
- Aptiom (eslicarbazepine acetate) (PG174)
- Aripiprazole oral disintegrating tablet, solution (PG173)
- Armodafinil (Nuvigil) (PG036)
- Asenapine (Saphris) (PG058)
- Auvelity (Dextromethorphan and Bupropion) (PG128)
- Azelaic acid 15% gel (PG059)
- Azstarys (serdexmethylphenidate and dexmethylphenidate) (PG130)
- Belsomra (suvorexant) (PG064)
- Benlysta (belimumab) (PG014)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG181)
- Brand Medically Necessary Drugs (PG186)
- Brimonidine/Timolol (Combigan) (PG103)
- Briviact (brivaracetam) Tablet, Solution (PG172)
- Budesonide 3mg Capsule (Entocort EC) (PG082)
- Caplyta (lumateperone) (PG175)
- CeQur Simplicity Insulin Delivery System (PG192)
- Cibinqo (abrocitinib) (PG111)
- Clomiphene (Clomid) (PG104)
- Collagenase Ointment (Santyl) (PG141)
- Continuous Glucose Monitors (CGMs) (PG121)
- Cromolyn Sodium Oral Concentrate (PG087)
- Daybue (trofinetide) (PG148)
- Descovy (emtricitabine/tenofovir alafenamide) (PG004)
- Descovy (emtricitabine/tenofovir alafenamide) (PG004-NP)
- Desvenlafaxine Succinate ER (PG072)
- Difluprednate (Durezol) Ophthalmic Drops (PG079)
- Direct Acting Antiviral Agents for Hepatitis C (PG045)
- Disposable Insulin Pump Devices (PG127)
- Doxylamine/Pyridoxine (Bonjesta, Diclegis) (PG096)
- Duaklir (aclidinium/formoterol) (PG107)
- Dupixent (dupilumab) (PG026)
- Emverm (mebendazole) (PG001)
- Entecavir Tablets (PG085)
- Epidiolex (cannabidiol) (PG050)
- Eucrisa (crisaborole) (PG023)
- Exemestane (PG084)
- Ezetimibe (Zetia) (PG073)
- Febuxostat (Uloric) (PG066)
- Fesoterodine (Toviaz) (PG102)
- Fetzima (levomilnacipran) (PG063)
- Fleqsuvy (baclofen oral suspension) (PG112)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132)
- Fycompa (perampanel) (PG176)
- Growth Hormones (PG049)
- Hemangeol (propranolol hydrochloride oral solution) (PG135)
- Hormonal Therapy for Gender Dysphoria Zero Copay Exception (PG184)
- Imcivree (setmelanotide) (PG088)
- Infertility Injectable Agents (PG119)
- Lacosamide (Vimpat) (PG056)
- Lamotrigine ER (Lamictal XR) (PG055)
- Lamotrigine Orally Disintegrating Tablet (PG083)
- Lanthanum Carbonate Chewable tablet (Fosrenol) (PG177)
- Lidocaine Transdermal Patch (PG124)
- Livtencity (maribavir) (PG113)
- Lokelma (sodium zirconium cyclosilicate) (PG143)
- Lurasidone (Latuda) (PG057)
- Medications for Cosmetic Purposes (PG080)
- Medical Necessity Criteria for Non-Formulary Products (PG069)
- Medical Necessity Prior Authorization Criteria (PG076)
- Mesalamine DR 800 mg (PG024)
- Miebo (perfluorohexyloctane) (PG166)
- mitoxantrone (Novantrone) (PG126)
- Modafinil (Provigil) (PG035)
- Multiple Sclerosis Agents (PG094)
- Myrbetriq (mirabegron) (PG181)
- Nevanac (nepafenac) Ophthalmic Suspension (PG078)
- Omega-3-acid Ethyl Esters (Lovaza) (PG005)
- Opioids (PG018)
- Oral Retinoids for Acne (PG123)
- Orgovyx (relugolix) (PG089)
- Orgovyx (relugolix) (PG089-REG)
- Orladeyo (berotralstat) (PG090)
- Osphena (ospemifene) (PG169)
- Oxbryta (voxelotor) (PG114)
- Oxiconazole (Oxistat 1%) (PG100)
- Pancreatic Digestive Enzymes (pancrelipase) (PG027)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors (PG068)
- Phenoxybenzamine (PG054)
- Phenoxybenzamine (PG054-REG)
- Potassium Chloride Oral Solution (PG086)
- Pregabalin Immediate-Release (Lyrica) (PG060)
- Prescription Drugs for Serious Mental Illnesses-REG (PG171)
- Preventive Services Statins Zero Copay Exception (PG159)
- Proton Pump Inhibitors - Esomeprazole and Rabeprazole (PG047)
- Rasagiline 1mg (PG065)
- Recorlev (levoketoconazole) (PG115)
- Relyvrio (sodium phenylbutyrate and taurursodiol) (PG129)
- Restasis (cyclosporine ophthalmic emulsion 0.05%) (PG025)
- Rexulti (brexipiprazole) (PG074)
- Rosuvastatin (Crestor) (PG006)
- Sancuso (granisetron) Patch (PG007)
- Sancuso (granisetron) Patch (PG007-REG)
- Savella (milnacipran) (PG062)
- Sildenafil (LiQrev, Revatio, Viagra) (PG051)
- Sodium oxybate (Xyrem) (PG009)
- Sohonos (palovarotene) (PG183)
- Sunosi (solriamfetol) (PG097)
- Tadalafil (Adcirca, Alyq, Cialis, Tadliq) (PG052)
- Tarpeyo (budesonide DR) (PG116)
- Tascenso ODT (fingolimod) (PG117)
- Testosterone Replacement Therapy (PG122)
- Tezspire (tezepelumab) (PG118)
- Urea Cycle Disorder (UCD) Treatment Agents (PG187)
- Vascepa (icosapent ethyl) (PG125)
- Velphoro (sucroferric oxyhydroxide) (PG179)
- Vemlidy (tenofovir alafenamide) (PG010)
- Verquvo (vericiguat) (PG091)
- Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors (PG144)
- Vilazodone (Viibryd) (PG071)
- Vyvanse (lisdexamfetamine) (PG098)
- Weight Loss Agents (PG070)
- Xarelto (rivaroxaban) 1mg/mL Granules for Suspension (PG137)
- Xdemvy (lotilaner) (PG161)
- Xifaxan (rifaximin)(PG022)
- Zokinvy (lonafarnib) (PG092)
- Zortress (everolimus) (PG033)
- Zurzuvae (zuranolone) (PG182)
Adopted Guidelines
- Caremark Prior Authorization Criteria