Oscar Clinical Guidelines: Pharmacy

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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

          • Effective 11/1/2025
            • Anti-migraine Agents: Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008, Ver. 9)
            • Armodafinil (Nuvigil) (PG036, Ver. 8)
            • Cibinqo (abrocitinib) (PG111, Ver. 4)
            • Dexlansoprazole (dexilant) (PG047, Ver. 8)
            • Fesoterodine (Toviaz) (PG102, Ver. 6)
            • Filsuvez (birch triterpenes) (PG211, Ver. 2)
            • Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132, Ver. 5)
            • Icosapent ethyl (Vascepa) (PG125, Ver. 4)
            • Injectable Iron Supplements (PG196, Ver. 4)
            • Mitoxantrone (Novantrone) (PG126, Ver. 4)
            • Orilissa (elagolix) (PG261, Ver. 1)
            • Pancreatic Digestive Enzymes - pancrelipase (Brand Names: Creon; Pancreaze; Pertzye; Viokace; Zenpep) (PG027, Ver. 7)
            • Quantity Limit Exception Criteria (PG200, Ver. 2)
            • Spevigo (spesolimab-sbzo) (CG071, Ver. 5)
            • Sunosi (solriamfetol) (PG097, Ver. 6)
            • Vyvanse (lisdexamfetamine) (PG098, Ver. 6)
            • Wakix (pitolisant hydrochloride) (PG247, Ver. 2)
            • Wegovy (semaglutide) for Cardiovascular Risk Reduction or Metabolic Dysfunction-Associated Steatohepatitis (MASH) (PG194, Ver. 4)
            • Zortress (everolimus) (PG033, Ver. 7)
          • Effective 12/1/2025
            • 2025 Q3 (July) P&T Summary of Changes
            • Amvuttra (vutrisiran) (PG264, Ver. 1)
            • Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 6)
            • Aptiom (eslicarbazepine acetate) (PG174, Ver. 3)
            • Azelaic acid 15% gel (PG059, Ver. 7)
            • Benlysta (belimumab) (PG014, Ver. 8)
            • Briviact (brivaracetam) Tablet, Solution (PG172, Ver. 3)
            • Continuous Glucose Monitors (CGMs) (PG121, Ver. 7)
            • Dipentum (olsalazine sodium) (PG244, Ver. 2)
            • Direct Acting Antiviral Agents for Hepatitis C (PG045, Ver. 7)
            • Doxylamine/Pyridoxine (Bonjesta, Diclegis) (PG096, Ver. 6)
            • Fycompa (perampanel) (PG176, Ver. 3)
            • lamotrigine extended release (Lamictal XR) (PG055, Ver7)
            • Lamotrigine Orally Disintegrating Tablet (PG083, Ver. 7)
            • Memantine (Namenda) (PG213, Ver. 2)
            • Methotrexate Injectable Solution (PG249, Ver. 3)
            • Non-Formulary Mental Health Products Criteria (PG265, Ver. 1)
            • Prescription Drugs for Serious Mental Illnesses-REG (PG171, Ver. 3)
            • Rebyota (fecal microbiota, live - jslm) (PG240, Ver. 2)
            • Restasis (cyclosporine 0.05% ophthalmic emulsion) (PG025, Ver. 8)
            • Rivastigmine (Exelon) (PG212, Ver. 2)
            • Tysabri (natalizumab) (PG195, Ver. 4)
            • Varubi (rolapitant) (PG178, Ver. 3)
            • Verkazia (cyclosporine ophthalmic emulsion) 0.1% (PG236, Ver. 2)
            • Vowst (fecal microbiota spores, live-brpk) (PG241, Ver. 2)

          Pharmacy Guidelines

                                                                                                                                                                                                                                                                                                                                                                                                                                      Adopted Guidelines