Medication Prior Authorization Criteria

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

Name	Type
Acthar	Pharmacy
Adcetris	Medical & Pharmacy
Stimulants (ADHD and Narcolepsy)	Pharmacy
Alimta	Medical & Pharmacy
Aloxi	Medical & Pharmacy
Ampyra	Pharmacy
Antidepressants Pediatric	Pharmacy
Antipsychotics For Children Younger than 18 years old	Pharmacy
Antiobesity drug	Pharmacy
Atovaquone	Pharmacy
Austedo and Ingrezza	Pharmacy
Avastin & Bevacizumab Biosimilars	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
Chimeric Antigen Receptor T cell (CAR-T) Immunotherapy	Pharmacy
Cholinesterase Inhibitor	Pharmacy
Chronic GI Motility Agents	Pharmacy
Cimzia	Pharmacy
Cinacalcet	Pharmacy
Cough and Cold Medications for Children Less than 4 Years	Pharmacy
Crysvita	Medical & 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
Fabry Disease Medications	Pharmacy
Faslodex	Medical & Pharmacy
Gralise	Pharmacy
Granulocyte Colony-Stimulating Factors	Medical & Pharmacy
Growth Hormone	Pharmacy
Hemophilia/Blood Factor Products	Pharmacy
Hepatitis C Agents	Pharmacy
Herceptin & Trastuzumab Biosimilars	Medical & Pharmacy
Hereditary Angioedema (HAE) Agents	Pharmacy
Humira	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
Lidocaine Topical Patch	Pharmacy
Lucemyra	Pharmacy
Lumizyme	Medical & Pharmacy
Lupron	Medical & Pharmacy
Luxturna	Medical & Pharmacy
Lyrica	Pharmacy
Macular Degeneration Agents	Medical & Pharmacy
Makena (hydroxyprogesterone)	Pharmacy
Multiple Sclerosis Medications	Medical & Pharmacy
Oncology Medications	Medical & Pharmacy
Opioid Analgesics -CDC Clinical Tools for Opioid Prescribing	Pharmacy
Mozobil	Medical & Pharmacy
PCSK9 Inhibitor Therapy	Pharmacy
Phenylketonuria Medications - Kuvan and Palynziq	Pharmacy
Phosphorous Binders	Pharmacy
Photofrin	Medical & Pharmacy
Prialt	Medical & Pharmacy
Provigil® (modafinil) and Nuvigil® (armodafinil)	Pharmacy
Pulmonary Arterial Hypertension	Pharmacy
Pulmozyme	Pharmacy
Radicava	Pharmacy
Regranex	Pharmacy
Remicade & Infliximab Biosimilars	Medical & Pharmacy
Restasis	Pharmacy
Ocular Rho Kinase Inhibitors	Pharmacy
Rituxan & Rituximab Biosimilars	Medical & Pharmacy
Sandostatin LAR	Medical & Pharmacy
Simponi Aria/Simponi	Pharmacy
SGLT2 Inhibitors and Incretin Mimetics	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
Topical Immunomodulators	Pharmacy
Transmucosal Immediate Release Fentanyl Formulations	Pharmacy
Trogarzo	Pharmacy
Tysabri	Medical & Pharmacy
Vimizim	Medical & Pharmacy
Vyvanse for Binge Eating Disorder	Pharmacy
Xifaxan	Pharmacy
Xolair	Medical & Pharmacy
Xyrem	Pharmacy
Yervoy	Medical & Pharmacy
Zyvox linezolid	Pharmacy
Qbrexa	Pharmacy
Firdapse	Pharmacy
Hyperkalemia Agents	Pharmacy
Nuedextra	Pharmacy
Non-TNF Biologic Therapies	Medical & Pharmacy
Dupixent	Pharmacy
Fentanyl transmucosal transbuccal	Pharmacy
Freestyle Libre	Pharmacy
Tobramycin Inhalation Products	Pharmacy
Spravato	Pharmacy
Compounds	Pharmacy
Zulresso	Pharmacy and Medical
Evenity	Pharmacy
Actimmune	Pharmacy
Gattex	Pharmacy
Zolgensma	Pharmacy
Vyndamax and Vyndaqel	Pharmacy
C5b Complement Inhibitors (Soliris & Ultomiris)	Pharmacy
Ravicti	Pharmacy
Xiaflex	Pharmacy
Duplicate Therapy	Pharmacy
Alpha1-Proteinase Inhibitors	Medical & Pharmacy
Gamifant	Medical & Pharmacy
Myalept	Pharmacy
Onpattro and Tegsedi	Pharmacy
Zoladex	Medical & Pharmacy
Megace(megestrol)	Pharmacy
Marinol(dronabinol)	Pharmacy
Substance P Neurokinin-1 (NKI) Receptor Antagonists	Pharmacy
Advakeo	Pharmacy

Medication Prior Authorization Criteria

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