Please utilize the appropriate PA form listed under Prior Authorization Packets located on the main Prior Authorization web page.
| Manual Prior Authorization Criteria | Updated |
|---|---|
| Akynzeo | 2/1/2019 |
| Antipsychotics | 2/1/2019 |
| Austedo | 9/1/2019 |
| CGRPs | 10/1/2019 |
| Corlanor | 9/16/2019 |
| Cosentyx | 2/1/2019 |
| Cresemba | 9/1/2019 |
| Dupixent – Asthma | 2/1/2019 |
| Dupixent – Atopic Dermatitis | 10/16/2019 |
| Dupixent – Nasal Polyposis | 10/1/2019 |
| Emflaza | 2/1/2019 |
| Endari | 8/1/2019 |
| Eucrisa | 10/1/2019 |
| Exondys | 4/1/2019 |
| Farydak | 2/1/2019 |
| Ingrezza | 9/1/2019 |
| Jadenu | 8/7/2019 |
| Juxtapid | 10/16/2019 |
| Kaledyco | 2/1/2019 |
| Lotronex | 8/7/2019 |
| Lynparza | 2/1/2019 |
| Mavenclad | 10/1/2019 |
| Mayzent | 10/1/2019 |
| Ocrevus | 9/1/2019 |
| Orkambi | 2/1/2019 |
| Praluent | 10/16/2019 |
| Probuphine | 2/1/2019 |
| Repatha | 10/16/2019 |
| Sivexto | 2/1/2019 |
| Stribild | 2/1/2019 |
| Sublocade | 2/1/2019 |
| Symdeko | 8/1/2019 |
| Tybost | 2/1/2019 |
| Varubi | 2/1/2019 |
| Vivitrol | 2/1/2019 |
| Zontivity | 2/1/2019 |
| Zyvox | 8/7/2019 |
