Drug Criteria

Abecma Criteria [ 119.2 kB ] Added 5/7/2021

Abilify Mycite Criteria [ 125.6 kB ] Updated 7/18/2023

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys Criteria [ 333.5 kB ] Updated 03/2018

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys PA Form [ 1001.5 kB ] Updated 11/28/2023

Adakveo Criteria [ 74.6 kB ] Updated 1/24/2024

Adbry Criteria [ 125.1 kB ] Updated 2/8/2024

Adlarity Criteria [ 113.4 kB ]  Added 11/15/2022

Aduhelm Criteria [ 198.3 kB ] Updated 10/2/2023

Adult High Dose Antipsychotic Criteria [ 134.1 kB ] Updated 1/24/2024

Adult High Dose Antipsychotic PA Form [ 545.7 kB ] Updated 11/28/2023

Adzynma Criteria [ 208.4 kB ] Updated 3/11/2024

Aemcolo Criteria [ 150.6 kB ] Added 3/13/2023

Afrezza Criteria [ 183.1 kB ] Updated10/2/2023

Agamree Criteria [ 115.1 kB ] Added 7/1/2024

Albumin PA Form [ 968.7 kB ] Updated 11/28/2023

Alinia Criteria [ 138.3 kB ] Updated 6/16/2022

Amifampridine Criteria [ 121 kB ] Updated 7/19/2023

Amlodipine (NORLIQVA® and KATERZIA®) oral solution/suspension Criteria [ 143.5 kB ] Added 3/13/2023

Amondys 45 Criteria [ 150.9 kB ] Updated 4/14/2023

Anti-Parkinson’s Agents for “Off” Episodes [ 156.6 kB ] Updated 7/28/2022

Antidepressants (Age < 6 years) PA Form [ 1.4 MB ] Updated 11/28/2023

Antipsychotic (Age <6) PA Form [ 1.4 MB ] Updated 10/14/2020

Antipsychotic (Age 6 to <18) PA Form [ 1.9 MB ] Updated 11/28/2023

Antipsychotic Non-Preferred Criteria [ 145.5 kB ] Updated 1/24/2024

Antipsychotic Polypharmacy Criteria [ 383 kB ] Added 7/7/2020

Aplenzin [ 300.6 kB ] New 6/5/2015

Arikayce Criteria [ 117.4 kB ] Added 4/30/2021

Automated Prior Authorizations and Bypass Lists [ 1.8 MB ] Updated 11/25/2024

Auvelity Criteria [ 174.1 kB ] Added 6/27/2023

Benlysta Criteria [ 148.8 kB ] Updated 12/29/2021

Besremi Criteria [ 138 kB ] Updated 9/8/2022

Bile Salts Agents Criteria [ 146.3 kB ] Added 1/7/2022

Blincyto Criteria [ 70.2 kB ] Added 6/16/2022

Boniva Injection Criteria [ 181.5 kB ] Updated 1/24/2024

Botulinum Criteria [ 113.6 kB ] Updated 1/24/2024

Brexafemme Criteria [ 114.2 kB ] Added 11/15/2022

Breyanzi Criteria [ 161.6 kB ] Updated 10/14/2022

Brineura Criteria [ 155 kB ] Added 1/27/2023

Brisdelle Criteria [ 295.9 kB ] Updated 2/28/2018

Bronchitol Criteria [ 118.3 kB ] Added 4/30/2021

Buprenorphine Agents for Pain [ 75.6 kB ] Updated 11/30/2023

Butalbital Criteria [ 100.9 kB ] Updated 4/22/2022

Camzyos Criteria [ 178 kB ] Added 10/14/2022

Carbaglu Critieria [ 168.1 kB ] Updated 9/17/2021

Carvykti Criteria [ 177.1 kB ] Added 6/16/2022

Casgevy Criteria [ 151.4 kB ] Added 8/14/2024

Cayston Criteria [ 300.3 kB ] Updated 2/24/2015

Ceprotin Criteria [ 295.1 kB ] Updated 11/16/2015

Cerdelga Criteria [ 125.1 kB ] Updated 2/9/2024

Cerezyme Criteria [ 137.5 kB ] Updated 6/16/2022

Chantix Criteria [ 112.4 kB ] Updated 1/21/2022

Chemet Criteria [ 145.7 kB ]  Updated 6/27/2023

Chorionic Gonadotropin Criteria [ 194.8 kB ] Updated 11/16/2015

Cibinqo Criteria [ 146 kB ] Updated 10/2/2023

CII-V Edit Override Criteria [ 175.9 kB ] Updated April 4, 2024

Cinqair Criteria [ 147.9 kB ] Updated 8/9/2022

Cinryze Criteria [ 322 kB ] Added 4/12/2019

Cobenfy Criteria [ 118 kB ]  Added 10/11/2024

Colchicine Agents Criteria [ 140.3 kB ] Added 4/22/2022

Colony Stimulating Factors Form [ 1.3 MB ] Updated 8/16/2023

Concomitant Drug Therapy Criteria [ 364.4 kB ] Added 7/7/2020

Constipation Agents [ 154.6 kB ] Updated 3/26/2024

Corlanor Criteria [ 131.2 kB ] Updated 1/24/2024

Cough and Cold Antitussive Medications Criteria [ 70.6 kB ] Updated 4/21/2021

Cresemba Criteria [ 142.6 kB ] Added 11/13/2024​​​​​

Crysvita Criteria [ 98 kB ] Updated 7/1/2024

Cubicin Criteria [ 281 kB ] Updated 10/3/2019

Cyanocobalamin Criteria [ 23.5 kB ] Updated 4/22/2022

Cyramza Criteria [ 344.3 kB ] Updated 6/14/2019

Cytokines and CAM Antagonists Criteria [ 255.8 kB ] Updated 11/13/2024

Cytogam PA Form [ 1015.2 kB ] Updated 11/28/2023

Daliresp Criteria [ 190.7 kB ] Added 6/27/2018

Dalvance Criteria [ 75.9 kB ] Updated 12/10/2021

Daraprim Criteria [ 119.1 kB ] Updated 12/29/2021

Daybue Criteria [ 189.3 kB ] Updated 11/08/2023​​​​​

Diacomit Criteria [ 138.3 kB ] Updated 10/14/2022

Dibenzyline Criteria [ 135.9 kB ] Updated 7/7/2022

Dificid Criteria [ 256.4 kB ] Updated 6/22/2022

Dojolvi Criteria [ 126.9 kB ] Added 10/29/2020

Dupixent Criteria [ 176.1 kB ] Updated 11/13/2024

Elfabrio Criteria [ 120.8 kB ] Added 2/27/2024

Elmiron Criteria [ 182 kB ] Updated 11/16/2015

Emflaza Criteria [ 229.2 kB ] Updated 6/28/2019

Empaveli Criteria [ 141.2 kB ] Added 9/21/2021

Enjaymo Criteria [ 117 kB ]  Updated 10/2/2023

Enspryng Criteria [ 143.3 kB ] Added 9/2/2020

Entadfi Criteria [ 179 kB ] Added 5/5/2023

Epaned Criteria [ 197.9 kB ] Updated 1/24/2024

Erwinaze and Rylaze Criteria [ 142.6 kB ]  Updated 4/12/2024

Erythropoeisis Stimulating Agents Criteria [ 235.4 kB ] Updated 1/24/2024

Erythropoeisis Stimulating Agents Form [ 1 MB ] Updated 11/28/2023

Esbriet Criteria [ 339.7 kB ] Updated 5/19/2020

Evenity Criteria [ 151.1 kB ] Updated 5/8/2024

Evrysdi Criteria [ 150.7 kB ] Updated 10/14/2022

Exjade Criteria [ 170 kB ] Updated 10/15/2021

Exondys 51 Criteria [ 152.7 kB ] Updated 3/31/2022

Exondys PA Form [ 1008.8 kB ] Updated 11/28/2023

Fabhalta Criteria [ 145.5 kB ] Added 2/28/2024

Fasenra Criteria [ 185.5 kB ]  Updated 8/19/2024

Ferriprox Criteria [ 159.8 kB ] Updated 3/11/2022

Fetzima Criteria [ 338.1 kB ] Updated 6/15/2016

Filspari Criteria [ 161.3 kB ] Added 1/26/2024

Filsuvez Criteria [ 123.9 kB ] Added 9/19/2024

Fintepla Criteria [ 122.1 kB ] Updated 6/16/2022

Firvanq Criteria [ 69.9 kB ] Updated 6/16/2022

Fleqsuvy Criteria [ 172.6 kB ] Added 7/8/2022

Forteo Criteria [ 159.7 kB ] Updated 1/24/2024

Fuzeon PA Form [ 1016 kB ] Updated 11/28/2023

Galafold Criteria [ 397.5 kB ] Added 1/18/2019

Gamifant Criteria [ 69.2 kB ] Added 9/25/2020

Gattex Criteria [ 334 kB ] Updated 6/3/2019

Gemtesa Criteria [ 121.7 kB ] Added 2/27/2024

Gimoti Criteria [ 112.4 kB ] Added 8/4/2021

Givlaari Criteria [ 145.7 kB ] Added 8/4/2021

H.P. Acthar Gel Criteria [ 143.5 kB ] Updated 3/11/2022

Haegarda Criteria [ 119 kB ] Updated 10/30/2020

Hemady Criteria [ 114.1 kB ] Added 8/4/2021

Hemangeol Criteria [ 173.8 kB ] Updated 1/27/2023

Hepatitis C Agents Criteria [ 117.6 kB ] Updated 3/13/2023

Hepatitis C Agents Form [ 1.9 MB ] Updated 11/28/2023

Hetlioz Criteria [ 188.6 kB ] Updated 1/13/2022

HIV Auto PA Form [ 144.1 kB ] Updated 12/7/2021

HIV Diagnosis Verification or Prophylaxis of HIV Form [ 1.3 MB ] Updated 11/28/2023

Human Growth Hormone Criteria [ 288.9 kB ] Updated 8/19/2024

Human Growth Hormone PA Form [ 1.6 MB ] Updated 8/26/2024

Hyftor Criteria [ 171.4 kB ] Added 5/2/2023

Hyperlipidemia Agents Criteria [ 250.5 kB ] Updated 11/7/2024

Ibsrela Criteria [ 122.6 kB ] Added 2/27/2024

iDose TR Criteria [ 141.1 kB ] Added 8/19/2024

​​​​ Ileal Bile Acid Transporter Inhibitor Agents Criteria [ 151 kB ] Updated 7/10/2024

Imcivree Criteria [ 147.6 kB ] Added 4/30/2024

Immune Globulin Criteria [ 421.8 kB ] Updated 10/11/2024

Increlex PA Form [ 1.3 MB ] Updated 11/28/2023

Injectable and Intravenous Iron Agents Criteria [ 174.1 kB ] Updated 7/20/2023

Isturisa Criteria [ 122 kB ] Added 6/9/2021

Joenja Criteria [ 132 kB ] Updated 4/9/2024

Kadcyla Criteria [ 144.9 kB ] Updated 10/14/2022

Kalbitor Criteria [ 224.4 kB ] Added 3/20/2020

Kalydeco Critieria [ 176.2 kB ] Updated 9/9/2024

Kanuma Criteria [ 69.8 kB ] Added 3/30/2022

Kapvay Critieria [ 319.3 kB ] Updated 11/19/2015

Kepivance Critieria [ 42.9 kB ] Updated 9/8/2022

Kerendia Criteria [ 143.2 kB ] Added 12/10/2021

Kimmtrak Criteria [ 135.9 kB ] Added 6/16/2022

Korlym Criteria [ 115.2 kB ] Updated 7/7/2022

Krystexxa Criteria [ 140 kB ] Updated 10/14/2022

Kymriah Criteria [ 165.3 kB ] Updated 10/14/2022

Lacrisert Criteria [ 156.7 kB ] Updated 7/7/2022

Lampit Criteria [ 120.8 kB ] Updated 1/24/2024

Lamzede Criteria [ 92.9 kB ] Added 1/26/2024

Leqembi Criteria [ 189.3 kB ] Added 6/15/2023

Lioresal/Gablofen Criteria [ 143.3 kB ] Updated 7/7/2022

Livtencity Criteria [ 117.2 kB ] Added 3/30/2022

Long Acting Beta 2 Agonists Criteria [ 135.5 kB ] Updated 7/9/2021

Long Acting Stimulants in Children Criteria [ 114 kB ]  Updated 5/11/2023

Lucemyra Criteria [ 118 kB ] Added 1/11/2021

Lumryz Criteria [ 172.9 kB ] Added 1/26/2024

Lupkynis Criteria [ 152.2 kB ] Added 6/9/2021

Luxturna Criteria [ 378.4 kB ] Added 3/27/2018

Lybalvi Criteria [ 186.9 kB ] Updated 11/15/2024​​​​​​

Lyfgenia Criteria [ 151.7 kB ] Added 8/14/2024

Marinol Criteria [ 180.9 kB ] Updated 6/8/2016

Methadone Criteria [ 510.7 kB ] Update 3/15/2018

Miscellaneous Drug Criteria [ 123 kB ] Updated 6/27/2023

Miscellaneous Pharmacy Prior Authorization Requests [ 813.6 kB ] Updated 11/28/2023

Mounjaro Criteria [ 142.9 kB ] Updated 4/26/2024

Mozobil Criteria [ 308.1 kB ] Updated 11/6/2017

Mucopolysaccharidosis Agents Criteria [ 154.7 kB ] Added 3/13/2023

Multi Source Brand Drug PA Form [ 1001.6 kB ] Updated 11/28/2023

Multiple Sclerosis Oral Agents Criteria [ 146.3 kB ] Updated 2/5/2024

Myalept Criteria [ 119.9 kB ] Updated 4/12/2024

Myfembree Criteria [ 142.9 kB ] Updated 4/13/2023

Myrbetriq Criteria [ 145.1 kB ] Added 2/27/2024

Mytesi Criteria [ 183.1 kB ] Added 11/20/2020

Namenda XR Criteria [ 123.8 kB ] Updated 1/24/2024

Natacyn Criteria [ 292.6 kB ]

Neupro Criteria [ 441 kB ] Updated 11/19/2015

Nitisinone PA Form [ 1.3 MB ] Updated 10/13/2020

Nucala Criteria [ 166.8 kB ] Updated 8/9/2022

Nuplazid Criteria [ 290.8 kB ] Updated 8/8/2018

Ocreotides & Related Agents Criteria [ 159.3 kB ] Added 1/19/2022

Ofev Criteria [ 140.7 kB ] Updated 7/1/2024

Off Label Use Criteria [ 93.1 kB ] Updated 6/27/2023

Olpruva Criteria [ 182.6 kB ] Updated 8/19/2024

Opioid PA Form [ 587.6 kB ] Updated 11/28/2023

Opzelura Criteria [ 144.3 kB ] Updated 9/19/2024

Oralair [ 135.5 kB ] Added 2/1/2022

Oral Oncology Criteria [ 496.3 kB ] Updated 11/13/2024

Oral Oncology PA Form [ 1.2 MB ] Updated 11/28/2023

Oriahnn Criteria [ 136.5 kB ] Added 9/21/2020

Orilissa Criteria [ 324.1 kB ] Added 1/18/2019

Oritavancin Criteria [ 156.1 kB ] Updated 1/27/2023

Orkambi Criteria [ 158.7 kB ] Updated 5/11/2023

Orladeyo Criteria [ 111.2 kB ] Added 4/2/2021

Ortikos Criteria [ 134.6 kB ] Added 8/4/2021

Otrexup Criteria [ 197.1 kB ] Added 7/27/2016

Overactive Bladder Agents Criteria [ 74.6 kB ] Updated 3/26/2024

Oxalosis Agents Criteria [ 186 kB ] Updated 7/1/2024

Oxandrin Criteria [ 127.4 kB ] Updated 12/22/2016

Oxbryta Criteria [ 123 kB ] Updated 8/14/2024

Palforzia Criteria [ 165.5 kB ] Updated 11/12/2021

Panretin PA Form [ 1.3 MB ] Updated 11/28/2023

Pheburane Criteria [ 70.8 kB ]  Updated 11/14/2024​​​​​​

Phenylketonuria Treatments Criteria [ 90.9 kB ] Added 3/13/2023

Pompe Disease Agents [ 143.9 kB ] Added 12/10/2021

Prevymis Criteria [ 149.6 kB ] Updated 1/24/2024

ProCentra Criteria [ 127.2 kB ] Updated 7/18/2023

Proleukin PA Form [ 1.3 MB ] Updated 11/28/2023

Prolia Criteria [ 174.5 kB ] Updated 1/24/2024

Proton Pump Inhibitors [ 488.3 kB ] Added 7/11/2016

Pulmonary Hypertension Agent Criteria [ 168.8 kB ] Updated 11/13/2024

Pyrukynd Criteria [ 141.3 kB ] Added 6/16/2022

Qalsody Criteria [ 161.2 kB ] Added 1/26/2024

Qutenza Criteria [ 144 kB ] Added 11/13/2024​​​​​​

Radicava/Radicava ORS Criteria [ 151.1 kB ] Added 10/14/2022

Rasuvo Criteria [ 197.2 kB ] Added 7/27/2016

Ravicti Criteria [ 85.3 kB ] Updated 8/19/2024

Reblozyl Criteria [ 379.7 kB ] Added 7/10/2020

Recorlev Criteria [ 115.6 kB ] Added 6/16/2022

Rectiv Criteria [ 353.2 kB ]

Regranex Criteria [ 227 kB ] Updated 11/6/2018

Relyvrio Criteria [ 148.1 kB ] Added 5/11/2023

Revcovi Criteria [ 88.7 kB ] Added 1/7/2022

Reyvow Criteria [ 135.1 kB ] Added 10/29/2021

Rezdiffra Criteria [ 181.4 kB ] Added 9/19/2024

Rezurock Criteria [ 115.3 kB ] Added 12/17/2021

Rinvoq ER Criteria [ 127.4 kB ] Updated 11/13/2024

Ruconest Criteria [ 321.4 kB ] Added 4/12/2019

Sancuso Criteria [ 195.2 kB ] Updated 1/15/2015

Saphnelo Criteria [ 115.9 kB ] Added 12/17/2021

Saphris Criteria [ 147.5 kB ] Updated 1/24/2024

Sedative Hypnotic Criteria [ 115.1 kB ] Updated 11/13/2024

Selzentry PA Form [ 966.2 kB ] Updated 11/28/2023

Serostim PA Form [ 1 MB ] Updated 11/28/2023

Sirturo Criteria [ 120.4 kB ] Updated 9/8/2022

Skyclarys Criteria [ 187.2 kB ] Updated 5/8/2024

Sodium-Glucose Co-Transporter (SGLT-2) Inhibitor Agents [ 160.3 kB ] Updated 9/9/2024

Soliris Criteria [ 80.6 kB ] Updated 6/10/2021

Soma PA Form [ 2 MB ] Updated 2/9/2024

Spinraza Criteria [ 158.2 kB ] Updated 4/23/2021

Spinraza PA Form [ 965.6 kB ] Updated 11/28/2023

Spravato Criteria [ 180.8 kB ] Updated 8/11/2020

Stimulants and Strattera (<6 years of age) PA Form [ 936.2 kB ] Updated 11/28/2023

Sunosi Criteria [ 123.6 kB ]  Updated 6/27/2023

Supprelin LA Criteria [ 94.8 kB ] Updated 7/7/2022

Supprelin LA PA Form [ 684.4 kB ] Updated 4/12/2024

Symdeko Criteria [ 312.1 kB ] Updated 9/17/2021

Synagis Criteria [ 446 kB ] Updated 4/3/2020

Synagis - All Florida Regions Combined PA Form [ 1.4 MB ] Updated 11/28/2023

Synagis - Weight Change PA Form [ 1007.8 kB ] Updated 11/28/2023

Synribo Criteria [ 300.3 kB ] Updated 11/23/2015

Takhzyro Criteria [ 119.8 kB ] Updated 1/24/2024

Tarpeyo Criteria [ 121.7 kB ] Updated 9/13/2022

Tavneos Criteria [ 167.8 kB ] Added 3/30/2022

Tecartus Criteria [ 69.3 kB ] Updated 3/11/2022

Tepezza Criteria [ 122.8 kB ] Updated 1/24/2024

Testosterone Criteria [ 215.7 kB ] Updated 5/8/2024

Tezspire Criteria [ 146.1 kB ] Updated 8/19/2024

Thrombopoiesis Stimulating Agents Criteria [ 161.4 kB ] Updated 7/18/2023

Tolvaptan Criteria [ 190.2 kB ] Updated 8/19/2024

Toujeo Criteria [ 178.3 kB ] Added 8/27/2024

Transthyretin Mediated Amyloidosis Agents Criteria [ 125.2 kB ] Updated 10/14/2022

Trikafta Criteria [ 190.9 kB ] Updated 8/19/2024

Trudhesa Criteria [ 148.2 kB ] Updated 5/6/2022

Tygacil Criteria [ 78.6 kB ] Updated 7/7/2022

Tymlos Criteria [ 149.8 kB ]  Updated 1/24/2024

Tzield Criteria [ 152.3 kB ] Added 3/28/2023

Ultomiris Criteria [ 171.1 kB ] Updated 5/8/2024

Uplizna Criteria [ 146.5 kB ] Added 9/2/2020

Vecamyl Criteria [ 312.4 kB ] Updated 3/14/2018

Veozah Criteria [ 172.1 kB ] Added 8/27/2024

Veregen Criteria [ 120.3 kB ] Updated 7/7/2022

Verkazia Criteria [ 142.7 kB ] Added 11/15/2022

Verquvo Criteria [ 127.8 kB ] Updated 1/24/2024

Vfend PA Form [ 1 MB ] Updated 11/28/2023

Vibativ Criteria [ 146.2 kB ] Updated 7/7/2022

Viberzi Criteria [ 192.5 kB ] Added 4/5/2018

Viltepso Criteria [ 149.8 kB ] Updated 4/14/2023

Vijoice Criteria [ 117.2 kB ] Updated 7/1/2024

Vivjoa Criteria [ 105.1 kB ] Added 1/29/2024

Voquezna Criteria [ 115.2 kB ] Added 5/10/2024

Vowst Criteria [ 159.8 kB ] Added 1/29/2024

Voxzogo Criteria [ 142.7 kB ]  Updated 12/28/2023

Vpriv Criteria [ 333 kB ] Added 1/18/2019

Vtama Criteria [ 138.3 kB ]  Updated 5/8/2024

Vyepti Criteria [ 143.2 kB ] Updated 10/29/2021

Vyjuvek Criteria [ 159.4 kB ] Added 9/19/2024

Vyondys 53 Criteria [ 97.3 kB ] Updated 3/31/2022

Vyvgart Criteria [ 117.7 kB ] Added 3/30/2022

Wakix Criteria [ 142.4 kB ] Updated 6/27/2023

Xenazine Criteria [ 213.1 kB ] Updated 7/16/2018

Xenpozyme Criteria [ 128.8 kB ] Added 11/15/2022

Xermelo Criteria [ 247.4 kB ] Added 12/21/2017

Xgeva Criteria [ 146.8 kB ] Updated 4/15/2024

Xiaflex Criteria [ 185.4 kB ] Added 6/16/2022

Xifaxan Criteria [ 358.7 kB ] Updated 11/23/2015

Xphozah Criteria [ 121.3 kB ] Added 5/10/2024

Xolair Criteria [ 171.9 kB ] Updated 9/19/2024

Xopenex Criteria [ 38.1 kB ] Updated 2/9/2024

Xyrem Criteria [ 163.2 kB ] Updated 11/24/2020

Xywav Criteria [ 137.3 kB ] Updated 10/23/2024

Ycanth Criteria [ 202.4 kB ] Added 5/10/2024

Yescarta Criteria [ 71.6 kB ] Updated 6/16/2022

Zavzpret Criteria [ 156.2 kB ] Added 2/9/2024

Zeposia Criteria [ 146.9 kB ] Updated 4/5/2023​​​​​​

Zokinvy Criteria [ 146.6 kB ] Added 8/4/2021

Zolgensma Criteria [ 152 kB ] Updated 1/24/2024

Zortress Criteria [ 83.1 kB ] Updated 9/8/2022

Zoryve Criteria [ 146.6 kB ] Added 5/10/2024

Ztalmy Criteria [ 154.3 kB ] Added 1/29/2024

Zulresso Criteria [ 145.7 kB ] Updated 10/14/2022

Zurzuvae Criteria [ 156.1 kB ] Added 7/2/2024

Zyprexa Relprevv [ 170.9 kB ] Updated 1/24/2024