01/12/23 |
ACE Inhibitors and ACE Inhibitors/Diuretic Combinations PDL |
01/12/23 |
ACE Inhibitor/Calcium Channel Blocker Combinations PDL |
05/25/23 |
Acetaminophen Cumulative Dose Clinical Edit |
07/28/22 |
Acne and Rosacea - Select Topical Agents Step Therapy Edit |
07/07/22 |
Actinic Keratosis Agents – Topical PDL |
05/04/23 |
Anti-Amyloid Monoclonal Antibody Clinical Edit (formerly the Aduhelm Clinical Edit) |
05/18/23 |
ADHD, Amphetamines Long Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
|
05/18/23 |
ADHD, Amphetamines Short Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
|
05/18/23 |
ADHD, Methylphenidate Long Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
|
05/18/23 |
ADHD, Methylphenidate Short Acting PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
|
05/18/23 |
ADHD, Non-Stimulants PDL
ADHD Medication Prior Authorization Form - Children Less Than 6 Years Old
|
01/12/23 |
Alpha-Glucosidase Inhibitors |
01/12/23 |
Alpelisib Clinical Edit |
06/02/23 |
Alzheimer’s Agents & Cholinesterase Inhibitors PDL |
10/20/22 |
Ampyra |
01/12/23 |
Amylin Analogs PDL |
07/07/22 |
Androgenic Agents PDL |
01/12/23 |
Angiotensin Receptor Blockers and Angiotensin Receptor Blocker/Diuretic Combinations PDL |
01/12/23 |
Angiotensin Receptor Blocker-Calcium Channel Blocker Combinations PDL |
04/06/23 |
Antiandrogenic Agents PDL |
07/07/2022 |
Antibiotic Agents – Inhaled PDL |
01/12/23 |
Antibiotics, Gastrointestinal (GI) Oral PDL |
01/12/23 |
Antibiotics, Mupirocin Topical PDL |
01/12/23 |
Antibiotics, Vaginal PDL |
07/07/22 |
Anticholinergics, Long Acting Beta Adrenergic(LABA) Combinations PDL Edit |
11/03/22 |
Anticholinergics, Long Acting Beta Adrenergic (LABA)-Inhaled Corticosteroid (ICS) Combinations and Phosphodiesterase 4 (PDE4) Inhibitors PDL Edit |
07/07/22 |
Anticholinergics, Long Acting Inhaled PDL Edit |
07/07/22 |
Anticholinergics, Short Acting and Combinations Inhaled PDL Edit |
03/02/2023 |
Anticoagulants: Oral and Subcutaneous PDL |
04/06/23 |
Anticonvulsants, Dravet Syndrome PDL Edit |
01/12/23 |
Anticonvulsants, Rescue Agents PDL |
04/06/23 |
Antiemetic 5-HT3, NK1 & Other Select Agents, Non-Injectable PDL |
04/06/23 |
Antiemetic 5-HT3, NK1 Agents, Injectable PDL |
02/09/23 |
Antifungal Agents - Oral PDL |
07/07/22 |
Antifungal Agents – Topical PDL |
07/07/22 |
Antihistamines and Antihistamine/Decongestant Combinations, Second Generation PDL |
09/01/22 |
Antihistamines, Intranasal PDL |
07/07/22 |
Antihistamines, Ophthalmic PDL |
01/12/23 |
Antihyperuricemic Agents PDL |
04/06/23 |
Anti-Migraine, Alternative Oral Agents PDL |
04/06/23 |
Anti-Migraine, Serotonin (5-HT1) Receptor Agents PDL |
10/06/22 |
Antiparasitics, Topical PDL Edit |
04/06/23 |
Anti-Parkinsonism MAO-B Inhibitors PDL |
04/06/23 |
Anti-Parkinsonism Non-Ergot Dopamine Agonists PDL |
01/12/23 |
Antiplatelet Agents PDL |
04/06/2023 |
Antipsychotics - 1st Gen (Typical) Clinical Edit
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old |
04/06/23 |
Antipsychotics - 2nd Generation (Atypical) Depot Agents Resource List
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old |
04/06/23 |
Antipsychotics - 2nd Generation (Atypical) Oral & Transdermal Agents Resource List Edit
Atypical Antipsychotic Prior Authorization Form - Children Less Than 9 Years Old |
07/07/22 |
Antivirals – Herpes Oral PDL |
04/06/23 |
Antiretroviral Therapy (ART) PDL |
02/17/23 |
Antivirals - Topical PDL |
07/07/22 |
Atopic Dermatitis Agents, Immunomodulators PDL Edit |
01/12/23 |
Benign Prostatic Hyperplasia Agents PDL Edit |
04/20/23 |
Benzodiazepines (Select Oral) Clinical Edit |
07/07/22 |
Benzoyl Peroxide-Antibiotic Combination PDL |
10/20/22 |
Besremi Clinical Edit |
03/17/22 |
Beta Adrenergic Agents Long Acting PDL |
08/25/22 |
Beta Adrenergic Agents/Nebulized PDL |
09/01/22 |
Beta Andrenergic Agents - Short Acting
Albuterol Limit for Pharmacists
Albuterol Limit for Prescribers |
01/12/23 |
Beta Adrenergic Blockers and Beta Adrenergic Blockers-Diuretic Combinations PDL |
01/12/23 |
Biguanides & Combination Agents PDL |
01/12/23 |
Bile Salts Agents PDL |
05/18/23 |
Biosimilar vs Reference Products Fiscal Edit |
01/12/23 |
Bone Ossification Agents PDL |
10/20/22 |
Botulinum Toxin Clinical Edit |
06/01/23 |
Brand Over Generic Fiscal Edit |
04/20/23 |
Butalbital Combinations without Codeine Clinical Edit |
04/06/23 |
Calcitonin Gene-Related Peptide (CGRP) Inhibitors PDL |
01/12/23 |
Calcium Channel Blockers (Dihydropyridines) PDL |
01/12/23 |
Calcium Channel Blockers (Non-Dihydropyridines) PDL |
04/27/23 |
Camyzos Clinical Edit |
01/19/23 |
Carbamoyl Phosphate Synthetase 1 Activators PDL |
10/20/22 |
Car T Cell Clinical Edit |
01/12/23 |
Cephalosporin Agents PDL |
01/12/23 |
Colony Stimulating Factors PDL |
03/30/2023 |
Continuous Glucose Monitors (CGMs) Clinical Edit
Continuous Glucose Monitoring Device & Tubeless Insulin Pump Prior Authorization |
04/27/23 |
Corlanor® Clinical Edit |
03/16/2023 |
Corticosteroids Oral – Inhaled PDL
Asthma SMART Therapy |
12/08/22 |
Corticosteroids - Ophthalmic PDL |
12/08/22 |
Corticosteroids-Topical PDL |
04/13/23 |
Cough and Cold PDL |
01/12/23 |
Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL |
10/20/22 |
Crysvita Clinical Edit |
04/06/23 |
Cyclin-Dependent Kinase (CDK) 4-6 Inhibitors PDL Edit |
05/04/23 |
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulator Clinical Edit
Cystic Fibrosis Treatment Request |
08/04/22 |
C5 Complement Inhibitors Clinical Edit |
04/06/23 |
Diabetic Supply Quantity Limit Fiscal Edit |
01/12/23 |
Direct Renin Inhibitors and Combinations PDL |
12/01/22 |
DisposeRx Excessive Therapy Edit |
04/06/23 |
Dose Optimization Fiscal Edit |
01/12/23 |
DPP-IV Inhibitors PDL |
10/20/22 |
Duchenne Muscular Dystrophy (DMD) Clinical Edit |
01/12/23 |
Electrolyte Depleting Agents, Phosphate Lowering PDL |
02/16/23 |
Electrolyte Depleting Agents, Potassium Lowering PDL |
05/04/23 |
Empaveli Clinical Edit |
10/20/22 |
Emsam® Clinical Edit |
05/04/23 |
Enjaymo Clinical Edit |
01/12/23 |
Entresto Clinical Edit |
05/04/23 |
Enzyme Deficiency, Select Agents Clinical Edit |
01/26/23 |
Epinephrine Self-Injectable Agents PDL |
01/12/23 |
Erythropoiesis Stimulating Agents PDL |
05/25/23 |
Extended Supply Fiscal Edit |
08/04/22 |
Fabry Disease Clinical Edit |
04/06/23 |
Fibromyalgia Agents PDL |
01/12/23 |
Fluoroquinolones, Oral PDL |
07/07/22 |
Fluoroquinolones – Ophthalmic PDL |
07/07/22 |
Fluoroquinolones – Otic PDL |
10/20/22 |
Gamifant Clinical Edit |
04/06/23 |
GI Motility Agents PDL |
05/11/23 |
Givlaari Clinical Edit |
12/08/22 |
Glaucoma Agents PDL |
01/12/23 |
GLP-1 Receptor Agonists & Combination Agents PDL |
04/06/23 |
Glucagon Agents PDL |
02/23/23 |
Growth Hormones & Growth Hormone Releasing Factors, Select Agents PDL |
02/02/2023 |
Growth Hormones Somatropin Agents PDL
Growth Hormones, Somatropin Agents Prior Authorization Form |
05/11/23 |
HBV Nucleotide Analog Fiscal Edit |
07/07/22 |
Hepatitis C Agents PDL Edit
Hepatitis C Treatment Prior Authorization |
04/06/23 |
Hereditary Angioedema Treatment Agents PDL |
04/20/23 |
High Risk Therapies Clinical Edit |
04/27/23 |
Homozygous Familial Hypercholesterolemia (HoFH) Agents PDL |
03/03/22 |
Hospice Fiscal Edit |
08/04/22 |
Imcivree Clinical Edit |
10/20/22 |
Immunoglobulins (IVIG and SCIG) Clinical Edit |
03/30/2023 |
Insulin Pumps - Tubeless Clinical Edit
|
02/09/23 |
Insulins Long Acting PDL |
01/12/23 |
Insulins Mix PDL |
01/12/23 |
Insulins-Non-Analog PDL |
01/12/23 |
Insulins Rapid Acting PDL |
10/20/22 |
Iron – Injectable Step Therapy Edit |
08/04/22 |
Isturisa Clinical Edit |
01/12/23 |
Keratoconjunctivitis Agents PDL (formerly Dry Eye Disease Agents) |
04/27/23 |
Kerendia Clinical Edit |
10/20/22 |
Koselugo Clinical Edit |
10/20/22 |
Lambert-Eaton Myasthenic Syndrome (LEMS) Clinical Edit |
7/7/22 |
Leukotriene Modifiers PDL |
01/12/23 |
Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Non-Oral PDL |
01/12/23 |
Luteinizing Hormone Releasing Hormone (LHRH)/Gonadotropin Releasing Hormone (GnRH) Agents, Oral PDL |
10/20/22 |
Luxturna Clinical Edit |
01/12/23 |
Macrolides PDL |
04/27/23 |
Manufacturers Requiring Prior Authorization Fiscal Edit |
07/07/22 |
Mast Cell Stabilizers - Ophthalmic PDL |
01/12/23 |
Meglitinide Agents PDL |
07/21/22 |
Megestrol Acetate Clinical Edit |
01/12/23 |
Methotrexate Agents PDL |
04/06/23 |
Mitogen-activated Extracellular Kinase Inhibitors (MEKi) & B-raf Kinase Inhibitors (BRAFi) PDL Edit |
04/20/23 |
Morphine Milligram Equivalent Accumulation Clinical Edit |
01/12/23 |
Multiple Sclerosis, Injectable Agents PDL |
04/27/23 |
Multiple Sclerosis, Oral Agents PDL |
10/20/22 |
Narcolepsy Inhibitors Clinical Edit |
10/20/22 |
Neuromyelitis Optica Spectrum Disorder (NMOSD) Clinical Edit |
04/06/23 |
Neuropathic Pain Agents PDL
Gabapentin |
01/12/23 |
Niacin Derivatives PDL |
05/11/23 |
Non-Oral Contraceptives Fiscal Edit |
04/06/23 |
NSAID Agents PDL |
07/07/22 |
NSAIDs – Ophthalmic PDL |
10/20/22 |
Nuedexta Clinical Edit |
08/04/22 |
Nulibry Clinical Edit |
04/06/23 |
Opioid Emergency Reversal Agents PDL |
04/06/23 |
Opioid - Long Acting PDL
Opioid Prior Authorization Form
|
04/06/23 |
Opioid and Select Alcohol Dependence Agents PDL Edit |
04/20/23 |
Opioids, Short Acting Clinical Edits
Opioid Prior Authorization Form |
05/04/23 |
Out-of-State, Non-Bordering Pharmacies Fiscal Edit |
10/20/22 |
Oxandrin® Clinical Edit |
05/11/23 |
Oxazolidinone Fiscal Edit |
08/04/22 |
Oxervate Clinical Edit |
11/17/22 |
Oxlumo Clinical Edit |
10/20/22 |
Palforzia Clinical Edit |
10/20/22 |
Palynziq Clinical Edit |
01/12/23 |
Pancreatic Enzyme Agents PDL Edit |
01/05/23 |
Parathyroid Hormone and Bone Resorption Suppression Related Agents Clinical Edit |
01/12/23 |
Penicillin Agents PDL |
05/04/23 |
Pompe Disease Clinical Edit |
05/18/23 |
Prior Authorization Required Fiscal Edit |
01/12/23 |
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Binder PDL |
01/12/23 |
Proton Pump Inhibitors PDL |
07/07/22 |
Psoriasis Agents - Oral PDL |
12/08/22 |
Psoriasis Agents – Topical PDL |
02/23/23 |
Psychotropic Medications Polypharmacy Clinical Edit
Psychotropic Medications Polypharmacy Prior Authorization Form
|
01/12/23 |
Pulmonary Arterial Hypertension (PAH) Agents, Endothelin Receptor Antagonists (ETRAs) PDL |
03/02/2023 |
Pulmonary Arterial Hypertension (PAH) Agents, Phosphodiesterase-5 (PDE5) and Soluble Guanylate Cyclase (SGC) Stimulators PDL) |
01/12/23 |
Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Inhaled PDL |
01/12/23 |
Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Injectable PDL |
01/12/23 |
Pulmonary Arterial Hypertension (PAH) Agents, Prostacyclin Pathway Agonists, Oral PDL |
10/20/22 |
Ranolazine Clinical Edit (formerly Ranexa® Clinical Edit) |
10/20/22 |
Reblozyl Clinical Edit |
12/08/22 |
Retinoids – Topical PDL |
08/04/22 |
Scenesse Clinical Edit |
04/06/23 |
Sedative Hypnotics PDL
|
05/11/23 |
Selzentry Clinical Edit |
07/28/22 |
Sickle Cell Disease Clinical Edit |
05/18/23 |
Skeletal Muscle Relaxants PDL |
05/04/23 |
Skysona Clinical Edit |
10/20/22 |
SNRI Clinical Edit |
01/12/23 |
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors & Combination Agents PDL |
04/06/23 |
Somatostatin Analogs PDL Edit |
01/12/23 |
Spinal Muscular Atrophy (SMA) Clinical Edit |
07/21/22 |
Spravato® Clinical Edit |
10/20/22 |
SSRI Clinical Edit |
01/12/23 |
Statins (HMG Co-A Reductase Inhibitors) and Combination Products PDL |
01/12/23 |
Sulfonylurea Agents, Second Generation PDL |
01/12/23 |
Sympatholytics PDL Edit |
08/25/22 |
Synagis® Clinical Edit
Synagis Prior Authorization Form |
01/26/23 |
Systemic Antifungals Clinical Edit |
01/12/23 |
Targeted Immune Modulators, IL-17A Antibody/IL-17 Receptor Antagonists PDL |
01/12/23 |
Targeted Immune Modulators, IL-23 Inhibitors & IL-23/IL-12 Inhibitors PDL |
01/12/23 |
Targeted Immune Modulators, Interleukin-6 (IL-6) Receptor Inhibitors PDL |
02/02/2023 |
Targeted Immune Modulators, Janus Kinase (JAK) Inhibitors PDL |
03/02/2023 |
Targeted Immune Modulators, Misc. Allergy and Asthma Related Monoclonal Antibodies PDL (formerly Respiratory Monoclonal Antibody PDL)
Target Immune Modulators, Misc. Allergy and Asthma Related Monoclonal Antibodies Prior Authorization |
01/12/23 |
Targeted Immune Modulators, Select Agents PDL |
01/12/23 |
Targeted Immune Modulators, Tumor Necrosis Factor (TNF) Inhibitors PDL |
10/20/22 |
Targeted Immune Modulators, Small Molecule JAK Clinical Edit |
08/04/22 |
Tavneos Clinical Edit |
05/04/23 |
Tepezza Clinical Edit |
01/12/23 | Tetracyclines PDL |
01/12/23 |
Thiazolidinediones & Combination Agents PDL |
01/12/23 |
Thromobocytopenia Agents PDL |
10/20/22 |
Tolvaptan Clinical Edit |
04/06/23 |
Tramadol - Like Agents PDL |
04/20/23 |
Transmucosal Immediate Release Fentanyl (TIRF) Clinical Edit |
01/12/23 |
Transthyretin-Mediated Amyloidosis (ATTR) Clinical Edit |
01/12/23 |
Triglyceride Lowering Agents PDL |
07/07/22 |
Ulcerative Colitis Oral Agents PDL |
05/04/23 |
Ulcerative Colitis - Rectal PDL |
01/12/23 |
Urinary Tract Antispasmodics PDL |
04/27/23 |
Verquvo Clinical Edit |
04/06/23 |
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors PDL Edit |
08/04/22 |
Voxzogo Clinical Edit |
10/20/22 |
Vyvgart Clinical Edit |
10/20/22 |
Xcopri Clinical Edit |
08/04/22 |
Zokinvy Clinical Edit |
10/20/22 |
Zometa Clinical Edit |
05/04/23 |
Ztalmy Clinical Edit |
05/04/23 |
Zynteglo Clinical Edit |
07/28/22 |
Zulresso Clinical Edit |
05/18/23 |
15 Day Supply – Oral Oncology Fiscal Edit |