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 (PG099)
- Adbry (tralokinumab-ldrm) (PG110)
- Albenza (albendazole) (PG101)
- Alvesco (ciclesonide)(PG105)
- Arcapta (indacaterol) (PG106)
- Armodafinil (PG036)
- Azelaic acid 15% gel (PG059)
- Belsomra (suvorexant) (PG064)
- Benlysta (belimumab) (PG014)
- Bonjesta (doxylamine/pyridoxine extended-release) & Diclegis (doxylamine/pyridoxine delayed-release) (PG096)
- Budesonide 3mg Capsule (PG082)
- Buprenorphine (PG011)
- CGRP Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008)
- Cibinqo (abrocitinib) (PG111)
- Clomid (clomiphene) (PG104)
- Clomipramine (PG109)
- Combigan (brimonidine/timolol) (PG103)
- Creon, Viokace, Zenpep (pancrelipase) (PG027)
- Cromolyn Sodium Oral Concentrate (PG087)
- Descovy (emtricitabine/tenofovir alafenamide)(PG004)
- Desvenlafaxine Succinate ER (PG072)
- Duaklir (aclidinium/formoterol) (PG107)
- Dupixent (dupilumab) (PG026)
- Durezol (difluprednate) Ophthalmic Drops (PG079)
- Emverm (mebendazole) (PG001)
- Entecavir Tablets (PG085)
- Epidiolex (cannabidiol) (PG050)
- Eucrisa (crisaborole) (PG023)
- Exemestane (PG084)
- Ezetimibe (PG073)
- Febuxostat (PG066)
- Fetzima (levomilnacipran) (PG063)
- Growth Hormone (PG049)
- Hepatitis C (PG045)
- Hepsera (adefovir dipivoxil) (PG081)
- Imcivree (setmelanotide) (PG088)
- Lamotrigine ER (PG055)
- Lamotrigine ODT (PG083)
- Latuda (lurasidone) (PG057)
- Livtencity (maribavir) (PG113)
- Medications for Cosmetic Purposes (PG080)
- Medical Necessity Criteria for Non-Formulary Drugs (PG069)
- Medical Necessity Prior Authorization Criteria (PG076)
- Mesalamine DR 800 mg (PG024)
- Modafinil (PG035)
- Multiple Sclerosis (PG094)
- Nevanac (nepafenac) Ophthalmic Suspension (PG078)
- Olopatadine Eye Drops (PG067)
- Omega-3 Dyslipidemic Agents (PG005)
- Opioids (PG018)
- Orgovyx (relugolix) (PG089)
- Orgovyx (relugolix)(PG089-REG)
- Orladeyo (berotralstat)(PG090)
- Oxbryta (voxelotor) (PG114)
- Oxiconazole (PG100)
- PCSK9 Inhibitors (PG068)
- Phenoxybenzamine (PG054)
- Phenoxybenzamine (PG054-REG)
- Potassium Chloride Oral Solution (PG086)
- Pregabalin capsules (PG060)
- Proton Pump Inhibitors (PG047)
- Rasagiline 1mg (PG065)
- Recorlev (levoketoconazole) (PG115)
- Restasis (cyclosporine ophthalmic emulsion 0.05%) (PG025)
- Rexulti (brexipiprazole) (PG074)
- Rosuvastatin (PG006)
- Sancuso (granisetron) Patch (PG007)
- Sancuso (granisetron) Patch (PG007-REG)
- Saphris (asenapine) (PG058)
- Savella (milnacipran) (PG062)
- Sildenafil (PG051)
- Sklice (ivermectin) (PG061)
- Sublingual Allergy Immunotherapy (SLIT) (PG093)
- Sunosi (solriamfetol) (PG097)
- Tadalafil (PG052)
- Tarpeyo (budesonide DR) (PG116)
- Tascenso ODT (fingolimod) (PG117)
- Tezspire (tezepelumab) (PG118)
- Toviaz (fesoterodine) (PG102)
- Utibron (glycopyrrolate/indacaterol)(PG108)
- Vemlidy (tenofovir alafenamide) (PG010)
- Verquvo (vericiguat)(PG091)
- Viibryd (vilazodone) (PG071)
- Vimpat (lacosamide) (PG056)
- Vyvanse (lisdexamfetamine)(PG098)
- Weight Loss Agents (PG070)
- Xifaxan (rifaximin)(PG022)
- Xyrem (sodium oxybate) (PG009)
- Zokinvy (lonafarnib) (PG092)
- Zortress (everolimus) (PG033)
Adopted Guidelines
- Caremark Prior Authorization Criteria