Pharmacy Prior Authorization Approval Criteria

General Drug Exception Form (Prior Authorization Form)
Home Infusion Form 

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

 

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