Medication Prior Authorization Criteria

Name
Type
General Drug Exception Form (Prior Authorization Form) Form
Home Infusion Form  Form
Acthar Pharmacy
Adcetris Medical & Pharmacy
Adult Stimulants (ADHD and Narcolepsy) Pharmacy
Alimta Medical & Pharmacy
Aloxi Medical & Pharmacy
Ampyra Pharmacy
Antidepressants Pediatric Pharmacy
Antipsychotics For Children Younger than 18 years old Medical & Pharmacy
Antiobesity drug Pharmacy
Atovaquone Pharmacy
Austedo and Ingrezza Pharmacy
Avastin Medical & Pharmacy
Benlysta Medical & Pharmacy
Bone Resorption Suppression and Related Agents Pharmacy
Botulinum Toxin (Botox) Medical & Pharmacy
Brineura  Medical & Pharmacy
Calcitonin Gene Related Peptide Receptor Inhibitors Pharmacy
Carisoprodol Pharmacy
Cerezyme Medical & Pharmacy
Chantix Pharmacy
Cholinesterase Inhibitor Pharmacy
Chronic GI Motility Agents Pharmacy
Cimzia Pharmacy
Cinacalcet Pharmacy
Crysvita Pharmacy
Cystic Fibrosis Biologic Response Modifiers Pharmacy
Daraprim Pharmacy
Diacomit Pharmacy
Dutasteride Pharmacy
Emflaza Pharmacy
Enbrel Pharmacy
Epidiolex Pharmacy
Erbitux Medical & Pharmacy
Erythropoetin Stimulating Agents  Pharmacy
Exondys Medical & Pharmacy
Eylea Medical & Pharmacy
Fabry Disease Medications Pharmacy
Faslodex Medical & Pharmacy
Fentanyl transmucosal transbuccal Pharmacy
Gleevec Pharmacy
Gralise Pharmacy
Granulocyte Colony-Stimulating Factors Medical & Pharmacy
Growth Hormone Pharmacy
Hemophilia/Blood Factor Products  Pharmacy
Hepatitis C Agents Pharmacy
Herceptin Medical & Pharmacy
Hereditary Angioedema (HAE) Agents Pharmacy
Humira Pharmacy
Incretin Mimetics Pharmacy
Inhaled LABA Corticosteroid Combination Medications Pharmacy
Intravenous Immunoglobulin (IVIG) and Subcutaneous Immunoglobulin (SCIG) Medical & Pharmacy
Intravenous Interleukin 5 Inhibitors Medical & Pharmacy
Isotretinoin Pharmacy
IV/Injectable Iron Medications Medical & Pharmacy
Keytruda Medical & Pharmacy
Krystexxa Medical & Pharmacy
Kyprolis Medical & Pharmacy
Lidocaine Topical Patch Pharmacy
Long-acting Injectable Atypical Antipsychotics  Pharmacy
Lucemyra Pharmacy
Lucentis Medical & Pharmacy
Lumizyme Medical & Pharmacy
Lupron Medical & Pharmacy
Luxturna Medical & Pharmacy
Lyrica Pharmacy
Macugen Pharmacy
Makena (hydroxyprogesterone) Pharmacy
Megestrol Oxandrolone Pharmacy
Mozobil Medical & Pharmacy
Multiple Sclerosis Medications Medical & Pharmacy
Nplate Medical & Pharmacy
Oncology Medications Medical & Pharmacy
Opdivo Medical & Pharmacy
Opioid Analgesics Pharmacy
-CDC Clinical Tools for Opioid Prescribing
 
Perjeta Medical & Pharmacy
PCSK9 Inhibitor Therapy Pharmacy
Phenylketonuria Medications - Kuvan and Palynziq Pharmacy
Phosphorous Binders Pharmacy
Photofrin Medical & Pharmacy
Pimecrolimus and Tacrolimus Pharmacy
Portrazza Medical & Pharmacy
Prialt Medical & Pharmacy
Provigil® (modafinil) and Nuvigil® (armodafinil) Pharmacy
Pulmonary Arterial Hypertension Pharmacy
Pulmozyme Pharmacy
Radicava Pharmacy
Regranex Pharmacy
Remicade Medical & Pharmacy
Restasis Pharmacy
Rhopressa Pharmacy
Rituxan Medical & Pharmacy
Sandostatin LAR Medical & Pharmacy
Selective COX-2 inhibitors Pharmacy
Simponi Aria/Simponi Pharmacy
SGLT2 Inhibitors Pharmacy
Soliris Medical & Pharmacy
Somatuline Depot Medical & Pharmacy
Spinraza Medical & Pharmacy
Strensiq Pharmacy
Sublingual Immunotherapy Medications  Pharmacy
Sublocade Pharmacy
Supprelin/Vantas Medical & Pharmacy
Synagis Pharmacy
Synvisc and Synvisc-One (intra-articular hyaluronan injection) Pharmacy
Tavalisse Pharmacy
Testosterone Supplementation Pharmacy
Thrombopoietin (TPO) Receptor Agonists Pharmacy
Trogarzo Pharmacy
Tysabri Medical & Pharmacy
Veltassa Pharmacy
Vimizim Medical & Pharmacy
Visudyne Pharmacy
Vyvanse for Binge Eating Disorder Pharmacy
Weight Gain Promoting Agents Pharmacy
Xolair Medical & Pharmacy
Yervoy Medical & Pharmacy
Zyvox linezolid Pharmacy