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Medication Prior Authorization Criteria

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

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 and Serotonin (5-HT)1F Receptor Pharmacy
Carisoprodol Pharmacy
Gauche Disease: Enzyme Replacement and Substrate Reduction Therapy 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
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
Latuda Pharmacy
Lidocaine Topical Patch Pharmacy
Lucemyra Pharmacy
Lumizyme Medical & Pharmacy
Leuprolide Acetate Products 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
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
Oxbryta Pharmacy
COVID-19 Pharmacy
Duchenne Muscular Dystrophy Antisense Oligonucleotides Medical & Pharmacy
Reblozyl Pharmacy
Non-Formulary Medication/Medical Necessity Medical & Pharmacy
Palforzia Medical & Pharmacy
Tepezza Medical & Pharmacy
Givlaari Medical & Pharmacy
Orilissa Pharmacy
Uplizna Medical & Pharmacy
Cidofovir Medical & Pharmacy
Oriahnn Pharmacy
Koselugo Pharmacy
Isturisa Pharmacy

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