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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 2/1/2019
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