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.
Upcoming Policy Changes
- 2025 Q1 Pharmacy & Therapeutics Summary of Changes
- Effective 10/1/2025
- armodafinil (Nuvigil) (PG036_v7)
- Avonex (interferon beta-1a) (PG218)_v2
- Bafiertam (monomethyl fumarate) (PG219)_v2
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG254)_v3
- Betaseron (interferon beta-1b) (PG220)_v2
- Briumvi (ublituximab) (PG134)_v5
- Casgevy (exagamglogene autotemcel) (CG113)_v3
- Collagenase Ointment (Santyl) (PG141)_v3
- Dalfampridine (Ampyra) (PG217)_v2
- Dapsone 7.5% topical Gel (Aczone) (PG214)_v2
- Dimethyl Fumarate (Tecfidera) (PG222)_v2
- Eohilia (budesonide) (PG216)_v2
- Eucrisa (crisaborole) (PG023)_v7
- Extavia (interferon beta-1b) (PG223)_v2
- Ezetimibe (Zetia) (PG073)_v7
- Fingolimod (Gilenya, Tascenso ODT) (PG224)_v2
- Glatiramer Acetate (Copaxone, Glatopa) (PG221)_v3
- Journavx (suzetrigine) Quantity Limit Exceptions Criteria (PG260)_v1
- Kesimpta (ofatumumab) (PG225)_v3
- Lemtrada (Alemtuzumab) (PG226)_v2
- Lidoderm (lidocaine) 5% Transdermal Patch (PG124)_v4
- Lokelma (sodium zirconium cyclosilicate) (PG143)_v3
- Mavenclad (cladribine) (PG227)_v2
- Mayzent (siponimod) (PG228)_v2
- Mesalamine DR 800 (Asacol HD) (PG024)_v7
- Modafinil (Provigil) (PG035)_v7
- Neffy (epinephrine nasal spray) (PG243)_v2
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235)_v4
- Omega-3-acid ethyl esters (Lovaza) (PG005)_v7
- Plegridy (peginterferon beta-1a) (PG229)_v2
- Ponvory (ponesimod) (PG230)_v2
- Prenatal Vitamins Zero Copay Exception-REG (PG258)_v1
- Quantity Limit Exception Criteria (PG200)_v2
- Rebif (interferon beta-1a) (PG231)_v2
- Rezdiffra (resmetirom) (PG198)_v2
- Rosuvastatin (Crestor) (PG006)_v8
- Sancuso (granisetron) Patch (PG007-REG)_v7
- Sancuso (granisetron) Patch (PG007)_v7
- Teriflunomide (Aubagio) (PG232)_v2
- Tevimbra (tislelizumab) (PG210)_v2
- Veozah (fezolinetant) (PG215)_v2
- Vumerity (diroximel fumarate) (PG233)_v2
- Zelsuvmi (berdazimer topical gel, 10.3%) (PG201)_v2
- Zeposia (ozanimod) (PG234)_v3
Pharmacy Guidelines
- Adbry (tralokinumab-ldrm) (PG110)
- Adakveo (crizanlizumab) (PG193)
- Adefovir Dipivoxil (Hepsera) (PG081)
- Albendazole (Albenza) (PG101)
- Allergen Sublingual Immunotherapy (SLIT) (PG093)
- Alvesco (ciclesonide)(PG105)
- Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152)
- 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)
- Avonex (interferon beta-1a) (PG218)
- Azelaic acid 15% gel (PG059)
- Azstarys (serdexmethylphenidate and dexmethylphenidate) (PG130)
- Bafiertam (monomethyl fumarate) (PG219)
- Belsomra (suvorexant) (PG064)
- Benlysta (belimumab) (PG014)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG1254)
- Betaseron (interferon beta-1b) (PG220)
- Brand Medically Necessary Drugs (PG186)
- Brimonidine/Timolol (Combigan) (PG103)
- Briumvi (ublituximab) (PG134)
- 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)
- Cobenfy (xanomeline and trospium) (PG253)
- Collagenase Ointment (Santyl) (PG141)
- Combination Products for Treatment of Helicobacter pylori (PG199)
- Continuous Glucose Monitors (CGMs) (PG121)
- Cromolyn Sodium Oral Concentrate (PG087)
- Dalfampridine (Ampyra) (PG217)
- Dapsone 7.5% Topical Gel (PG214)
- Daybue (trofinetide) (PG148)
- Difluprednate (Durezol) Ophthalmic Drops (PG079)
- Dipentum (olsalazine sodium) (PG244)
- Dimethyl Fumarate (Tecfidera) (PG222)
- 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)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160)
- Emverm (mebendazole) (PG001)
- Entecavir Tablets (PG085)
- Eohilia (budesonide) (PG216)
- Eucrisa (crisaborole) (PG023)
- Exemestane (PG084)
- Extavia (interferon beta-1b) (PG223)
- Febuxostat (Uloric) (PG066)
- Fesoterodine (Toviaz) (PG102)
- Fetzima (levomilnacipran) (PG063)
- Filsuvez (birch triterpenes) (PG211)
- fingolimod (Gilenya, Tascenso ODT) (PG224)
- Fleqsuvy (baclofen oral suspension) (PG112)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132)
- Fycompa (perampanel) (PG176)
- Glatiramer Acetate (Copaxone, Glatopa) (PG221)
- Growth Hormones (PG049)
- Hemangeol (propranolol hydrochloride oral solution) (PG135)
- Hormonal Therapy for Gender Dysphoria Zero Copay Exception (PG184)
- Ilaris (canakinumab) (PG185)
- Imcivree (setmelanotide) (PG088)
- Immune Globulin Weight-Based Dosing Criteria (PG256, Ver. 1)
- Infertility Injectable Agents (PG119)
- Injectable Iron Supplements (PG196)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 15)
- Ivermectin 1% Topical Cream (PG239)
- Izervay (avancincaptad pegol) (PG168)
- Kesimpta (ofatumumab) (PG225)
- Kisunla (donanemab-azbt) (PG238)
- Lacosamide (Vimpat) (PG056)
- Lamotrigine ER (Lamictal XR) (PG055)
- Lamotrigine Orally Disintegrating Tablet (PG083)
- Lanthanum Carbonate Chewable tablet (Fosrenol) (PG177)
- Lazcluze (lazertinib) (PG251)
- Lemtrada (Alemtuzumab) (PG226)
- Leqembi (lecanemab-irmb) (PG138)
- Lidocaine Transdermal Patch (PG124)
- Livtencity (maribavir) (PG113)
- Lokelma (sodium zirconium cyclosilicate) (PG143)
- Lumryz (sodium oxybate) (PG246)
- Lurasidone (Latuda) (PG057)
- Mavenclad (cladribine) (PG227)
- Mayzent (siponimod) (PG228)
- Medications for Cosmetic Purposes (PG080)
- Medical Necessity Prior Authorization Criteria (PG076)
- Memantine (Namenda) (PG213)
- Mesalamine DR 800 mg (PG024)
- Methotrexate Injectable Solution (PG249)
- Miebo (perfluorohexyloctane) (PG166)
- mitoxantrone (Novantrone) (PG126)
- Myrbetriq (mirabegron) (PG181)
- Neffy (epinephrine nasal spray) (PG243)
- Nevanac (nepafenac) Ophthalmic Suspension (PG078)
- Non-Formulary Products Criteria (PG069)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235)
- Ohtuvayre (ensifentrine) (PG237)
- Omega-3-acid Ethyl Esters (Lovaza) (PG005)
- Opioids (PG018)
- Orgovyx (relugolix) (PG089)
- Orgovyx (relugolix) (PG089-REG)
- Orladeyo (berotralstat) (PG090)
- Osphena (ospemifene) (PG169)
- Oxiconazole (Oxistat 1%) (PG100)
- Pancreatic Digestive Enzymes (pancrelipase) (PG027)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors (PG068)
- Phenoxybenzamine (PG054)
- Phenoxybenzamine (PG054-REG)
- Plegridy (peginterferon beta-1a) (PG229)
- Ponvory (ponesimod) (PG230)
- Potassium Chloride Oral Solution (PG086)
- Prescription Drugs for Serious Mental Illnesses-REG (PG171)
- Preventive Services Statins Zero Copay Exception (PG159)
- Proton Pump Inhibitors - Esomeprazole and Rabeprazole (PG047)
- Qalsody (tofersen) (PG151)
- Quantity Limit Exception Criteria (PG200)
- Rasagiline 1mg (PG065)
- Rebif (interferon beta-1a) (PG231)
- Rebyota (fecal microbiota, live - jslm) (PG240)
- Recorlev (levoketoconazole) (PG115)
- Restasis (cyclosporine ophthalmic emulsion 0.05%) (PG025)
- Rexulti (brexipiprazole) (PG074)
- Rezdiffra (resmetirom) (PG198)
- Rivastigmine (Exelon) (PG212)
- Sancuso (granisetron) Patch (PG007)
- Sancuso (granisetron) Patch (PG007-REG)
- Savella (milnacipran) (PG062)
- Sildenafil (LiQrev, Revatio, Viagra) (PG051)
- Sirturo (bedaquiline) (PG242)
- Sodium oxybate (Xyrem) (PG009)
- Sohonos (palovarotene) (PG183)
- Spevigo (spesolimab-sbzo) (CG071)
- Spravato (esketamine) (PG257, Ver. 1)
- Sunosi (solriamfetol) (PG097)
- Tadalafil (Adcirca, Alyq, Cialis, Tadliq) (PG052)
- Tarpeyo (budesonide DR) (PG116)
- Teriflunomide (Aubagio) (PG232)
- Testosterone Replacement Therapy (PG122)
- Tevimbra (tislelizumab) (PG210)
- Tezspire (tezepelumab) (PG118)
- Thyrogen (thyrotropin alfa) (PG140)
- Tysabri (natalizumab) (PG195)
- Tremfya (guselkumab) (PG250)
- Urea Cycle Disorder (UCD) Treatment Agents (PG187)
- Varubi (rolapitant) (PG178)
- Vascepa (icosapent ethyl) (PG125)
- Velphoro (sucroferric oxyhydroxide) (PG179)
- Vemlidy (tenofovir alafenamide) (PG010)
- Veozah (fezolinetant) (PG215)
- Verkazia (cyclosporine ophthalmic emulsion) 0.1% (PG236)
- Verquvo (vericiguat) (PG091)
- Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors (PG144)
- Vowst (fecal microbiota spores, live-brpk) (PG241)
- Vumerity (diroximel fumarate) (PG233)
- Vyvanse (lisdexamfetamine) (PG098)
- Wakix (pitolisant hydrochloride) (PG247)
- Wegovy (semaglutide) for Cardiovascular Risk Reduction (PG194)
- Weight Loss Agents (PG070)
- Winrevair (sotatercept-csrk) (PG207)
- Xarelto (rivaroxaban) 1mg/mL Granules for Suspension (PG137)
- Xdemvy (lotilaner) (PG161)
- Xifaxan (rifaximin)(PG022)
- Xiidra (lifitegrast) (PG197)
- Xywav (calcium, magnesium, potassium, and sodium oxybate) (PG248)
- Ycanth (cantharidin) (PG162)
- Zelsuvmi (berdazimer topical gel, 10.3%) (PG201)
- Zepbound (tirzepatide) for the Treatment of Obstructive Sleep Apnea (PG255)
- Zeposia (ozanimod) (PG234)
- Zokinvy (lonafarnib) (PG092)
- Zortress (everolimus) (PG033)
- Zurzuvae (zuranolone) (PG182)
Adopted Guidelines
- Caremark Prior Authorization Criteria