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Manual Prior Authorization Criteria

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 2/3/2020
Antipsychotics 2/3/2020
Austedo 6/10/2020
CGRPs 5/26/2021
Corlanor 2/3/2020
Cresemba 2/3/2020
Dupixent – Asthma 2/3/2020
Dupixent – Atopic Dermatitis 2/3/2020
Dupixent – Nasal Polyposis 2/3/2020
Emflaza 2/3/2020
Endari 2/3/2020
Eucrisa 4/1/2020
Evrysdi 4/6/2021
Exondys 2/3/2020
Farydak 2/3/2020
Hemlibra 2/3/2020
Ingrezza 2/3/2020
Jadenu 2/3/2020
Juxtapid 2/3/2020
Kalydeco 1/27/2021
Lotronex 2/3/2020
Lynparza 6/3/2020
Mavenclad 2/3/2020
Mayzent 2/3/2020
Ocrevus 2/3/2020
Orkambi 2/3/2020
Oxbryta 2/28/2020
Palforzia 12/16/2020
Praluent 10/16/2019
Probuphine 2/3/2020
Repatha 10/16/2019
Sivexto 2/3/2020
Stribild 2/3/2020
Sublocade 2/3/2020
Symdeko 1/27/2021
Trikafta 7/9/2021
Tybost 2/3/2020
Varubi 2/3/2020
Viltepso 1/21/2021
Vivitrol 2/3/2020
Vyepti 2/10/2021
Vyondys 53 1/22/2021
Zontivity 2/3/2020
Zyvox 2/3/2020