05/19/22 |
15 Day Limitation Fiscal Edit |
05/19/22 |
15 Day Supply - Oral Oncology |
01/06/22 |
ACE Inhibitors and ACE Inhibitors Diuretic Combinations PDL |
01/06/22 |
ACE Inhibitors/ACE Inhibitors-Calcium Channel Blocker Combinations PDL |
05/05/22 |
Acetaminophen Cumulative Dose Clinical Edit |
08/05/21 |
Acne and Rosacea - Select Topical Agents Step Therapy Edit |
07/01/21 |
Actinic Keratosis Agents – Topical PDL |
01/27/22 |
Aduhelm Clinical Edit |
02/03/22 |
ADHD Amphetamines – Long Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form |
02/03/22 |
ADHD Amphetamines – Short Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form |
03/03/22 |
ADHD Methylphenidate – Long Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form |
02/03/22 |
ADHD Methylphenidate – Short Acting
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form |
02/03/22 |
ADHD Non-Stimulant Agents
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
Adult ADD/ADHD Prior Authorization Form |
10/14/21 |
Alpha-Glucosidase Inhibitors |
04/07/22 |
Alzheimer’s Agents & Cholinesterase Inhibitors PDL |
11/11/21 |
Ampyra |
10/14/21 |
Amylin Analogs PDL |
07/01/21 |
Androgenic Agents – PDL |
01/06/22 |
Angiotensin Receptor Blockers and Angiotensin Receptor Blocker/Diuretic Combinations PDL |
01/06/22 |
Angiotensin Receptor Blocker-Calcium Channel Blocker Combinations PDL |
04/07/22 |
Antiandrogenic Agents |
07/01/21 |
Antibiotic Agents – Inhaled PDL |
10/14/21 |
Antibiotics, Mupirocin Topical PDL |
01/06/22 |
Anticoagulants Agents: Oral and Subcutaneous PDL |
06/01/22 |
Anticonvulsants, Dravet Syndrome PDL Edit |
01/06/22 |
Anticonvulsants, Rescue Agents PDL |
04/07/22 |
Antiemetic 5-HT3, NK1 & Other Select Agents, Non-Injectable PDL |
04/07/22 |
Antiemetic 5-HT3, NK1 Agents, Injectable PDL |
04/07/22 |
Antiemetics–THC Derivative Agents PDL |
07/01/21 |
Antifungal Agents - Oral PDL |
07/01/21 |
Antifungal Agents – Topical PDL |
07/01/21 |
Antihistamine Decongestant Combination - 2nd Generation |
07/01/21 |
Antihistamines – Intranasal PDL |
02/03/22 |
Antihistamines - Ophthalmic |
10/14/21 |
Antihyperuricemic Agents PDL |
04/07/22 |
Anti-Migraine, Alternative Oral Agents PDL |
04/07/22 |
Anti-Migraine, Serotonin (5-HT1) Receptor Agents PDL |
07/29/21 |
Antiparasitic Agents – Topical PDL |
04/07/22 |
Anti-Parkinsonism MAOB Inhibitors PDL |
04/28/22 |
Anti-Parkinsonism Non-Ergot Dopamine Agonists PDL |
01/06/22 |
Antiplatelet Agents |
04/07/22 |
Antipsychotics - 1st Gen (Typical) Clinical Edit
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old |
04/07/22 |
Antipsychotics – 2nd Generation (Atypicals) Reference Drug List
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old |
07/01/21 |
Antivirals – Herpes Oral PDL |
05/12/22 |
Antiretroviral Therapy (ART) PDL |
07/01/21 |
Antivirals - Topical PDL |
07/01/21 |
Atopic Dermatitis Agents (Immunomodulators) |
10/14/21 |
Benign Prostatic Hyperplasia Agents PDL Edit |
04/28/22 |
Benzodiazepines (Select Oral) Clinical Edit |
07/01/21 |
Benzoyl Peroxide-Antibiotic Combination PDL |
07/08/21 |
Beta Adrenergic Agents Long Acting PDL |
07/01/21 |
Beta Adrenergic Agents/Nebulized PDL |
07/01/21 |
Beta Adrenergic Agents – Short Acting PDL |
01/06/22 |
Beta Adrenergic Blockers and Beta Adrenergic Blockers-Diuretic Combinations PDL |
04/28/22 |
BiDil® Tablets Clinical Edit |
04/07/22 |
Bile Salts Agents PDL |
05/19/22 |
Biosimilar vs Reference Products Fiscal Edit |
10/14/21 |
Bone Ossification Suppression Agents |
02/10/22 |
Botulinum Toxin Clinical Edit |
06/09/22 |
Brand Over Generic |
04/21/22 |
Butalbital Combo Clinical Edit |
04/21/22 |
Butalbital Combo Excessive Therapy |
04/07/22 |
Calcitonin Gene-Related Peptide (CGRP) Inhibitors PDL |
05/26/22 |
Calcium Channel Blockers (Dihydropyridines) PDL |
01/06/22 |
Calcium Channel Blockers (Non-Dihydropyridines) PDL |
06/16/22 |
Car T Cell Clinical Edit |
10/14/21 |
Cephalosporin Antibiotics – Oral PDL |
08/05/21 |
Clobazam Agents Clinical Edit |
10/14/21 |
Colony Stimulating Factors |
02/10/22 |
Continuous Glucose Monitors (CGMs) Clinical Edit |
07/01/21 |
COPD Anticholinergic Agents PDL |
04/28/22 |
Corlanor® Clinical Edit |
07/01/21 |
Corticosteroids Oral – Inhaled PDL
Asthma SMART Therapy |
07/01/21 |
Corticosteroids - Intranasal PDL |
10/14/21 |
Corticosteroids - Ophthalmic PDL |
11/04/21 |
Corticosteroids-Topical PDL |
07/01/21 |
Cough and Cold PDL |
10/14/21 |
Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL |
10/28/21 |
Crysvita Clinical Edit |
04/07/22 |
Cyclin-Dependent Kinase (CDK) 4-6 Inhibitors PDL Edit |
07/15/21 |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulator Clinical Edit |
05/12/22 |
Diabetic Supply Quantity Limit Fiscal Edit |
01/06/22 |
Direct Renin Inhibitors and Combinations PDL |
05/26/22 |
Dose Optimization Fiscal Edit |
10/14/21 |
DPP-IV Inhibitors PDL |
02/24/22 |
Dry Eye Disease Agents PDL |
11/18/21 |
Duchenne Muscular Dystrophy (DMD) Clinical Edit |
10/14/21 |
Electrolyte Depleters – Phosphate Lowering Agents PDL |
10/14/21 |
Electrolyte Depleters – Potassium Lowering Agents PDL |
04/21/22 |
Empaveli Clinical Edit |
02/10/22 |
Emsam® Clinical Edit |
10/21/21 |
Entresto Clinical Edit |
07/01/21 |
Epinephrine Self-Injectable Agents PDL |
02/17/22 |
Equetro® Clinical Edit |
10/14/21 |
Erythropoiesis Stimulating Agents PDL |
05/12/22 |
Extended Supply Fiscal Edit |
07/29/21 |
Fabry Disease Clinical Edit |
05/26/22 |
Fibromyalgia Agents PDL |
10/14/21 |
Fluoroquinolones PDL |
07/01/21 |
Fluoroquinolones – Ophthalmic PDL |
07/01/21 |
Fluoroquinolones – Otic PDL |
11/18/21 |
Gamifant Clinical Edit |
10/14/21 |
Gastrointestinal (GI) Antibiotics – Oral PDL |
04/07/22 |
GI Motility Agents PDL |
07/29/21 |
Givlaari Clinical Edit |
07/01/21 |
Glaucoma Agents PDL |
11/18/21 |
GLP-1 Receptor Agonist PDL |
04/07/22 |
Glucagon Agents PDL |
11/11/21 |
Gonadotropin Releasing Hormone (GnRH) Antagonists – Oral Clinical Edit (formerly known as Elagolix Clinical Edit) |
10/14/21 |
Growth Hormones & Growth Hormone Releasing Factors, Select Agents PDL |
10/14/21 |
Growth Hormones Somatropin Agents PDL
Growth Hormones, Somatropin Agents Prior Authorization Form |
11/04/21 |
HBV Nucleotide Analog Fiscal Edit |
07/01/21 |
Hep C (HCV) Therapy
Hepatitis C Treatment Prior Authorization |
04/07/22 |
Hereditary Angioedema Treatment Agents PDL |
04/07/22 |
High Risk Therapies Clinical Edit |
04/07/22 |
Homozygous Familial Hypercholesterolemia (HFHC) Products PDL |
03/03/22 |
Hospice Fiscal Edit |
11/18/21 |
Imcivree Clinical Edit |
02/10/22 |
Immunoglobulins Clinical Edit |
02/03/22 |
Insulin Pumps - Tubeless Clinical Edit
|
06/01/22 |
Insulins Long Acting PDL |
10/14/21 |
Insulins Mix PDL |
10/14/21 |
Insulins-Non-Analog PDL |
10/14/21 |
Insulins Rapid Acting PDL |
11/11/21 |
Iron – Injectable Step Therapy Edit |
04/22/21 |
Isturisa Clinical Edit |
04/28/22 |
Kerendia Clinical Edit |
11/18/21 |
Koselugo Clinical Edit |
02/17/22 |
Lambert-Eaton Myasthenic Syndrome (LEMS) Clinical Edit |
10/14/21 |
Leukotriene Modifiers PDL |
10/14/21 |
Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Non-Oral PDL |
11/18/21 |
Luxturna Clinical Edit |
10/14/21 |
Macrolides PDL |
05/26/22 |
Manufacturers Requiring Prior Authorization Fiscal Edit |
07/01/21 |
Mast Cell Stabilizers - Ophthalmic PDL |
07/29/21 |
Megestrol Acetate Clinical Edit |
10/14/21 |
Methotrexate Products |
04/07/22 |
Morphine Milligram Equivalent Accumulation |
10/14/21 |
Multiple Sclerosis, Injectable Agents PDL |
04/21/22 |
Multiple Sclerosis, Oral Agents PDL |
02/03/22 |
Narcolepsy Inhibitors |
02/10/22 |
Neuromyelitis Optica Spectrum Disorder (NMOSD) Clinical Edit |
04/07/22 |
Neuropathic Pain Agents PDL |
01/06/22 |
Niacin Derivatives |
05/05/22 |
Non-Oral Contraceptives Fiscal Edit |
04/07/22 |
NSAID Agents PDL |
07/01/21 |
NSAIDs – Ophthalmic PDL |
02/17/22 |
Nuedexta Clinical Edit |
11/18/21 |
Nulibry Clinical Edit |
04/07/22 |
Opioid Dependence Agents PDL Alcohol Use Disorder Fact Sheet |
04/07/22 |
Opioid Emergency Reversal Agents PDL |
04/07/22 |
Opioid - Long Acting PDL Opioid Prior Authorization Process for Prescribers Opioid Prior Authorization Process for Pharmacy Opioid Prior Authorization Form
|
07/15/21 |
Opioids, Combination Short-Acting Clinical Edit
|
04/07/22 |
Opioids, Short Acting Clinical Edits
Opioid Prior Authorization Form |
10/14/21 |
Oral AntiDiabetic: Biguanides PDL |
10/14/21 |
Oral AntiDiabetic: Meglintinides PDL |
05/05/22 |
Out-of-State, Non-Bordering Pharmacies Fiscal Edit |
01/27/22 |
Oxandrin® Clinical Edit |
10/28/21 |
Oxazolidinone Fiscal Edit |
11/18/21 |
Oxervate Clinical Edit |
07/29/21 |
Oxlumo Clinical Edit |
02/10/22 |
Palforzia Clinical Edit |
11/18/21 |
Palynziq Clinical Edit |
07/01/21 |
Pancreatic Enzyme Agents PDL |
11/04/21 |
Parathyroid Hormone and Bone Resorption Suppression Related Agents Clinical Edit |
10/14/21 |
Penicillins PDL |
04/21/22 |
Pompe Disease Clinical Edit |
06/17/21 |
PrEP Fiscal Edit |
05/19/22 |
Prior Authorization Required Fiscal Edit |
01/06/22 |
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Binder PDL |
01/20/22 |
Proton Pump Inhibitors PDL |
07/01/21 |
Psoriasis Agents - Oral PDL |
07/01/21 |
Psoriasis Agents – Topical PDL |
07/22/21 |
Psychotropic Medications Polypharmacy Clinical Edit
Psychotropic Medications Polypharmacy Prior Authorization Form
|
01/06/22 |
Pulmonary Arterial Hypertension (PAH) Agents – Oral Endothelin Receptor Antagonists (ETRAs) |
01/06/22 |
Pulmonary Arterial Hypertension (PAH) Agents – Oral Phosphodiesterase-5 (PDE5) |
01/06/22 |
Pulmonary Arterial Hypertension (PAH) Agents – Prostacyclin Pathway Agonist, Inhaled |
01/06/22 |
Pulmonary Arterial Hypertension (PAH) Agents – Prostacyclin Pathway Agonist, Injectable |
01/06/22 |
Pulmonary Arterial Hypertension (PAH) Agents – Prostacyclin Pathway Agonist, Oral |
02/17/22 |
Ranexa® Clinical Edit |
11/18/21 |
Reblozyl Clinical Edit |
12/09/21 |
Respiratory Monoclonal Antibodies PDL |
10/14/21 |
Retinoids – Topical PDL |
11/18/21 |
Second Generation Sulfonylureas PDL |
04/07/22 |
Sedative Hypnotics PDL
|
05/05/22 |
Selzentry® (Maraviroc) |
01/20/22 |
Sickle Cell Disease Clinical Edit |
04/07/22 |
Skeletal Muscle Relaxants PDL |
05/26/22 |
SNRI Clinical Edit |
10/14/21 |
Sodium - Glucose Co - Transporter 2 (SGLT2) PDL |
04/07/22 |
Somatostatin Analogs PDL Edit |
04/21/22 |
Spinal Muscular Atrophy (SMA) Clinical Edit |
07/22/21 |
Spravato® Clinical Edit |
01/20/22 |
SSRI Clinical Edit |
01/06/22 |
Statins (HMG Co-A Reductase Inhibitors) and Combination Products PDL |
01/06/22 |
Sympatholytic Agents PDL |
10/14/21 |
Synagis® Clinical Edit |
07/22/21 |
Systemic Antifungals Clinical Edit |
10/14/21 |
Targeted Immune Modulators, IL17 Receptor Antagonists PDL |
05/19/22 |
Targeted Immune Modulators, IL23-12 Inhibitors PDL |
10/14/21 |
Targeted Immune Modulators, Interleukin-6 (IL-6) Receptor Inhibitors PDL |
10/14/21 |
Targeted Immune Modulators, Janus Kinase (JAK) Inhibitors PDL |
10/14/21 |
Targeted Immune Modulators, Select Agents PDL |
12/09/21 |
Targeted Immune Modulators, Tumor Necrosis Factor (TNF) Inhibitors PDL |
11/18/21 |
Tepezza Clinical Edit |
10/14/21 | Tetracyclines PDL |
10/14/21 |
Thiazolidinediones & Combination Agents PDL |
10/14/21 |
Thromobocytopenia Treatment Agents PDL |
10/28/21 |
Tolvaptan Clinical Edit |
04/07/22 |
Tramadol - Like Agents PDL |
04/07/22 |
Transmucosal Immediate Release Fentanyl (TIRF) Clinical Edit |
02/03/22 |
Transthyretin-Mediated Amyloidosis (ATTR) Clinical Edit |
01/06/22 |
Triglyceride Lowering Agents PDL |
07/01/21 |
Ulcerative Colitis Oral Agents PDL |
07/01/21 |
Ulcerative Colitis - Rectal PDL |
10/14/21 |
Urinary Tract Antispasmodics PDL |
10/14/21 |
Vaginal Antibiotics PDL |
10/21/21 |
Verquvo Clinical Edit |
05/13/21 |
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors PDL Edit |
02/03/22 |
Xcopri Clinical Edit |
11/18/21 |
Zokinvy Clinical Edit |
11/04/21 |
Zometa® (zoledronic acid) |
07/22/21 |
Zulresso Clinical Edit |