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 | 2/3/2020 |
| 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 | 1/28/2021 |
| 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 |
