Drug Criteria

Miscellaneous Drug Criteria [227KB] Updated 5/16/2017

5-ASA Derivatives Criteria [213KB]

Abilify Maintena [222KB] Updated 8/17/2017

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys Criteria [391KB] Updated 3/25/2016

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys PA Form [667KB] Updated 8/4/2014

Abuse-Deterrent Products Criteria [56KB] New 11/28/2016

Actemra Critera [219KB] Updated 6/8/2017

Adult High Dose Antipsychotic Criteria [180KB] Updated 2/27/2017

Adult High Dose Antipsychotic PA Form [471KB] New 5/11/2015

Albumin PA Form [1.49MB] Updated 8/4/2014

Aldurazyme Criteria [212KB]

Alinia Criteria [198KB] Updated 11/10/2015

Aloxi Crtieria [176KB] Updated 11/10/2015

Altabax Criteria [138KB] Updated 11/10/2015

Amitiza Criteria [211KB] Updated 1/7/2015

Ampyra Criteria [186KB] Updated 12/19/2016

Antidepressants (Age < 6 years) PA Form [120KB] Updated 12/11/2014

Antimigraine Agents Criteria [270KB] New 6/23/2015

Antipsychotic (Age <6) PA Form [101KB] Updated 12/11/2014

Antipsychotic (Age 6 to <18) PA Form [155KB] Updated 12/11/2014

Aplenzin [202KB] New 6/5/2015

Apokyn Criteria [191KB]

Aranesp Criteria [426KB] Updated 7/21/2017

Arcalyst Criteria [112KB]

Aristada Criteria [146KB] New 4/29/2016

Atrovent (nasal) Criteria [208KB] Updated 11/10/2015

Automated Prior Authorizations and Bypass [1.01MB] Updated 8/17/2017

Banzel Criteria [210KB] Updated 4/23/2015

Benlysta Criteria [142KB] Updated 4/11/2017

Bone Resorption Inhibitor Criteria [261KB]

Boniva Injection Criteria [293KB] Updated 11/13/2015

Brisdelle Criteria [179KB] New 5/15/2015

Buprenorphine Agents Criteria [435KB] Updated 5/23/2017

Buprenorphine Agents PA Form [1.9MB] Updated 5/24/2017

Butalbital Criteria [145KB]

Carbaglu Crtieria [153KB]

Cayston Criteria [181KB] Updated 2/24/2015

Ceprotin Criteria [179KB] Updated 11/16/2015

Chantix Criteria [168KB]

Chemet [180KB] Added 10/15/2015

Chorionic Gonadotropin Criteria [115KB] Updated 11/16/2015

CII-V Edit Override Criteria [237KB] Updated 11/16/2015

Cimzia Criteria [290KB] Updated 8/8/2016

Colcrys Criteria [208KB]

Cough and Cold Codeine Containing Products Criteria [171KB] New 4/18/2017

Cubicin Criteria [281KB] Added 12/16/2015

Cyanocablamin Criteria [84KB]

Cyramza Criteria [243KB] Updated 6/11/2015

Cytogam PA Form [81KB]

Daklinza Criteria [581KB] Updated 2/17/2017

Dalvance Criteria [276KB] Updated 1/29/2016

Daraprim Criteria [175KB] New 10/8/2015

Detrol Criteria [112KB]

Diastat Criteria [261KB]

Dibenzyline Criteria [112KB]

Diclegis Criteria [180KB] Updated 11/12/2014

Dificid Criteria [204KB] Updated 11/16/2015

Edurant Criteria [226KB] Updated 11/16/2015

Elaprase Criteria [197KB]

Elelyso Criteria [213KB] Updated 11/16/2015

Elmiron Criteria [178KB] Updated 11/16/2015

Emflaza Criteria [198KB] Updated 7/10/2017

Epaned Criteria [195KB] Updated 8/7/2017

Erwinaze Criteria [113KB]

Erythromycin Criteria [183KB] New 4/20/2016

Esbriet Criteria [300KB] Updated 6/5/2017

Exjade Criteria [113KB] Updated 3/30/2015

Exondys 51 Criteria [316KB] New 5/8/2017

Farydak [185KB] New 4/20/2015

Ferriprox Criteria [108KB] Update 8/7/2015

Fetzima Criteria [ 204KB] Updated 6/15/2016

Folbalin and Folbic Criteria [98KB]

Forteo Criteria [532KB] Updated 8/17/2017

Fulyzaq Criteria [185KB]

Fuzeon PA Form [244KB]

Fycompa Criteria [345KB] Updated 8/17/2017

Gattex Criteria [191KB] Updated 11/20/2014

Glucocorticoids Oral Criteria [192KB]

H.P. Acthar Gel Criteria [285KB]

Hemangeol Criteria [340KB] New 12/3/2014

Hepatitis C Agents Criteria [256KB] Updated 5/1/2017

Hepatitis C Agents Form [737KB] Updated 2/22/2017

Hepatitis C Retreatment Criteria [148KB PDF] New 5/1/2017

Hetlioz Criteria [189KB] New 8/28/2014

HIV Auto PA Form [182KB] Updated 4/12/2016

HIV Diagnosis Verification Form [1.47MB] Updated 8/4/2014

Human Growth Hormone Criteria [781KB] Updated 8/18/2017

Human Growth Hormone PA Form [623KB] Updated 3/3/2017

Hydroxyprogesterone Caproate Injection Criteria

Iclusig Critieria [201KB] Updated 11/18/2015

Ilaris Criteria [218KB] Updated 7/11/2016

Increlex PA Form [2.32MB] Updated 1/18/2017

Invega Oral Criteria [142KB] Updated 6/5/2015

Invega Sustenna Criteria [138KB] Updated 2/24/2016

Invega Trinza [232KB] New 6/5/2015

IVIG Criteria [592KB] Updated 7/21/2017

Jadenu Criteria [235KB] New 6/1/2015

Jardiance [186KB] Updated 12/19/2016

Juxtapid Criteria [182KB] Updated 12/19/2016

Kadcyla Criteria [182KB] Updated 11/18/2015

Kalydeco Critieria [350KB] Updated 5/23/2017

Kapvay Critieria [199KB] Updated 11/19/2015

Kepivance Critieria [85KB]

Kineret Criteria [195KB] Updated 8/8/2016

Korlym Criteria [216KB]

Kuvan Criteria [185KB] Updated 5/13/2015

Kynamro Criteria [174KB]

Lacrisert Criteria [186KB]

Lamotrigine XR Criteria [182KB] Updated 8/20/2014

Lioresal/Gablofen Criteria [176KB]

Long Acting Beta 2 Agonists Criteria [247KB]

Long Acting Stimulants in Children Criteria [183KB] New 6/18/2015

Lovaza Criteria [139KB] New 12/1/2016

Makena Criteria [180KB] Updated 12/22/2016

Marinol Criteria [103KB] Updated 6/8/2016

Metadate CD Criteria [119KB] Updated 8/4/2015

Methadone Criteria [310KB] Update 1/15/2016

Miscellaneous Pharmacy Prior Authorization Requests [1.02MB] Updated 5/18/2015

Morphine Sulfate ER Criteria [249KB] Update 3/3/2016

Mozobil Criteria [296KB]

Multi Source Brand Drug PA Form [1.72MB] Updated 6/8/2015

Multiple Sclerosis Oral Agents Criteria [176KB] Updated 12/19/2016

Myrbetriq Criteria [66KB] Updated 11/19/2015

Naglazyme Criteria [277KB]

Namenda XR Criteria [213KB] New 6/23/2015

Natacyn Criteria [175KB]

Neumega Criteria [178KB]

Neupogen/Leukine/Neulasta/Granix/Zarxio PA Form [618MB] Updated 7/21/2017

Neupro Criteria [277KB] Updated 11/19/2015

Nucynta Criteria [176KB]

Nuedexta Criteria [181KB] Updated 6/5/2015

Ofev Criteria [182KB] New 10/22/2015

Off Label Use Criteria [101KB] New 4/1/2015

Olysio Criteria [391KB] Updated 2/17/2017

Onfi Criteria [212KB] Updated 8/20/2014

Oral Oncology Criteria [658KB] Updated 7/12/2017

Oral Oncology PA Form [1.03MB] Updated 8/4/2014

Oravig Criteria [112KB]

Orbactiv Criteria [195KB] New 5/21/2015

Orencia Criteria [238KB] Updated 8/8/2016

Orfadin PA Form [1.32MB] Updated 8/4/2014

Orkambi Criteria [239KB] Updated 10/24/2016

Otezla Criteria [152KB] Updated 7/11/2016

Otrexup Criteria [120KB] New 7/27/2016

Oxandrin Criteria [153KB] Updated 12/22/2016

Oxtellar XR Criteria [176KB] Updated 8/20/2014

Oxycodone ER Oxycontin PA Form [1.32MB] Updated 8/4/2014

Panretin PA Form [59KB] Updated 5/18/2015

Pomalyst Criteria [180KB] Updated 12/18/2015

Praluent Criteria [203KB] New 10/8/2015

ProCentra Criteria [179KB] Updated 11/20/2015

Procrit Criteria [464KB] Updated 7/21/2017

Procrit/Aranesp PA Form [1.48MB] Updated 8/11/2017

Proleukin PA Form [73KB]

Prolia Criteria [571KB] Updated 8/17/2017

Promacta Criteria [164KB] Updated 10/9/2015

Proton Pump Inhibitors [298KB] New 7/11/2016

Provigil PA Form [177KB] Updated 6/2/2016

Pulmonary Hypertension Agent Criteria [229KB] Updated 2/22/2016

Qudexy XR Criteria [215KB] Updated 5/16/17

Rasuvo Criteria [120KB] New 7/27/2016

Ravicti Criteria [77KB]

Rectiv Criteria [219KB]

Regranex Criteria [190KB]

Relistor Criteria [243KB] Updated 11/23/2015

Remicade Criteria [294KB] Updated 8/8/2016

Repatha Criteria [204KB] New 10/22/2015

Rexulti Criteria [245KB] New 11/29/2016

Risperdal Consta Criteria [342KB] Updated 8/17/2017

Sabril Criteria [321KB] Updated 8/10/2016

Samsca Criteria [446KB] Updated 7/10/2017

Sanctura Criteria [113KB] Updated 10/8/2015

Sancuso Criteria [150KB] Updated 1/15/2015

Sandostatin LAR Criteria [216KB] Updated 4/6/2015

Saphris Criteria [220KB] Updated 11/6/2015

Sedative Hypnotic Criteria [301KB] Updated 11/2/2016

Selzentry PA Form [139KB]

Sensipar Criteria [223KB]

Serostim PA Form [245KB]

Simponi Criteria [225KB] Updated 8/8/2016

Sirturo Criteria [223KB]

Soliris Criteria [47KB] Updated 11/23/2015

Soma PA Form [481KB] Updated 6/13/2016

Sovaldi Criteria [771KB] Updated 6/7/2017

Spinraza Criteria [444KB] New 7/21/17

Stelara Criteria [278KB] Updated 12/1/2016

Stimulants and Strattera (<6 years of age) PA Form [499KB] New 8/18/2015

Supprelin LA Criteria [1.45MB] Updated 11/4/2015

Supprelin LA PA Form [62KB] Updated 8/4/2014

Sylatron Criteria [199KB]

Synagis Criteria [238KB] Updated 6/30/2015

Synagis - All Florida Regions Combined PA Form [1.32MB] Updated 6/30/2015

Synagis - Weight Change PA Form [1.32MB] Updated 8/4/2014

Synribo Criteria [183KB] Updated 11/23/2015

Taltz Criteria [141KB] New 1/11/2017

Testosterone Criteria [298KB] Updated 2/24/2016

Trokendi XR Criteria [221KB] Updated 5/16/2017

Tygacil Criteria [100KB]

Valcyte Criteria [156KB] Updated 5/16/2017

Valcyte Form [1.01MB] Updated 3/20/2017

Vecamyl Criteria [261KB]

Veregen Criteria [113KB]

Vfend PA Form [107KB]

Vibativ Criteria [192KB]

Victoza Criteria [220KB] Updated 12/22/2016

Viekira Pak beyond 12 weeks Criteria [437KB] New 11/29/2016

Vimizim Criteria [133KB]

Vivitrol [187KB] Updated 2/1/2017

Xalkori Criteria [180KB] Updated 8/10/2016

Xenazine Criteria [149KB]

Xgeva Criteria [193KB] Updated 11/23/2015

Xifaxan Criteria [222KB] Updated 11/23/2015

Xolair Criteria [130KB] Updated 3/30/2017

Xopenex Criteria [235KB] Updated 3/30/2015

Xyrem Criteria [141KB]

Zepatier Criteria [570KB] Updated 2/20/2017

Zortress Criteria [180KB]

Zykadia Criteria [186KB]

Zyprexa Relprevv [156KB] Updated 11/23/2015

Zyvox Criteria [154KB]