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 | 10/27/2019 |
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 |