Drug Criteria
5-ASA Derivatives Criteria [388KB] Updated 05/2012
Abecma Criteria [120KB] Added 5/7/2021
Abilify Mycite Criteria [229KB] Updated 07/2019
Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys Criteria [334KB] Updated 03/2018
Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys PA Form [1.54MB] Updated 1/7/2019
Adakveo Criteria [73KB] Updated 10/13/2021
Aduhelm Criteria [197KB] Updated 8/4/2021
Adult High Dose Antipsychotic Criteria [335KB] Updated 02/2017
Adult High Dose Antipsychotic PA Form [632KB] Updated 1/7/2019
Afrezza Criteria [335KB] Added 6/11/2020
Albumin PA Form [1.39MB] Updated 1/7/2019
Aldurazyme Criteria [297KB]
Alinia Criteria [329KB] Updated 11/10/2015
Aloxi Crtieria [193KB] Updated 11/10/2015
Amifampridine Criteria [138KB] Added 9/22/2020
Amondys 45 Criteria [148KB] Updated 10/4/2021
Anti-Parkinson’s Agents for “Off” Episodes [152KB] Added 6/11/2021
Antidepressants (Age < 6 years) PA Form [1.40MB] Updated 10/14/2020
Antipsychotic (Age <6) PA Form [1.41MB] Updated 10/14/2020
Antipsychotic (Age 6 to <18) PA Form [1.89MB] Updated 3/17/2021
Antipsychotic Polypharmacy Criteria [383KB] Added 7/7/2020
Aplenzin [3012KB] New 6/5/2015
Arikayce Criteria [116KB] Added 4/30/2021
Automated Prior Authorizations and Bypass Lists [1.56MB] Updated 10/21/2021
Benlysta Criteria [274KB] Updated 5/16/2019
Bone Resorption Inhibitor Criteria [441KB]
Boniva Injection Criteria [182KB] Updated 9/25/2020
Botulinum Criteria [109KB] Updated 9/8/2021
Breyanzi Criteria [87KB] Updated 4/21/2021
Brisdelle Criteria [299KB] Updated 2/28/2018
Bronchitol Criteria [119KB] Added 4/30/2021
Buprenorphine Agents for Pain [73KB] Added 8/6/2021
Butalbital Criteria [241KB]
Cabenuva Criteria [139KB] Added 2/9/2021
Carbaglu Crtieria [169KB] Updated 9/17/2021
Cayston Criteria [301KB] Updated 2/24/2015
Ceprotin Criteria [296KB] Updated 11/16/2015
Cerdelga Criteria [326KB] Added 1/27/2020
Cerezyme Criteria [338KB] Added 1/18/2019
Chantix Criteria [317KB]Updated 4/12/2019
Chemet [296KB] Added 10/15/2015
Chorionic Gonadotropin Criteria [195KB] Updated 11/16/2015
CII-V Edit Override Criteria [381KB] Updated 11/16/2015
Cinqair Criteria [340KB] Added 5/9/2018
Cinryze Criteria [323KB] Added 4/12/2019
Colcrys Criteria [341KB]
Colony Stimulating Factors Form [1.00MB] Updated 8/9/2021
Concomitant Drug Therapy Criteria [365KB] Added 7/7/2020
Constipation Agents [144KB] Added 7/21/2021
Corlanor Criteria [366KB] Added 4/24/2020
Cough and Cold Antitussive Medications Criteria [71KB] Updated 4/21/2021
Crysvita Criteria [294KB] Updated 6/30/2020
Cubicin Criteria [282KB] Updated 10/3/2019
Cyanocobalamin Criteria [129KB]
Cyramza Criteria [345KB] Updated 6/14/2019
Cytokines and CAM Antagonists Criteria [230KB] Updated 8/26/2021
Cytogam PA Form [1.93MB] Updated 1/7/2019
Daliresp Criteria [191KB] Added 6/27/2018
Dalvance Criteria [302KB] Updated 6/8/2018
Daraprim Criteria [273KB] Added 10/8/2015
Dibenzyline Criteria [190KB]
Dificid Criteria [146KB] Updated 9/28/2021
Dojolvi Criteria [127KB] Added 10/29/2020
Dupixent Criteria [374KB] Updated 6/12/2020
Edurant Criteria [371KB] Updated 11/16/2015
Elaprase Criteria [290KB]
Elmiron Criteria [307KB] Updated 11/16/2015
Emflaza Criteria [231KB] Updated 6/28/2019
Empaveli Criteria [143KB] Added 9/21/2021
Endari Criteria [71KB] Added 10/13/2021
Enspryng Criteria [144KB] Added 9/2/2020
Epaned Criteria [195KB] Updated 8/7/2017
Erwinaze Criteria [331KB]
Erythropoeisis Stimulating Agents Criteria [228KB] Added 8/18/2021
Erythropoeisis Stimulating Agents Form [969KB] Updated 7/23/2021
Esbriet Criteria [340KB] Updated 5/19/2020
Evkeeza Criteria [153KB] Added 6/21/2021
Evrysdi Criteria [150KB] Updated 12/15/2020
Exjade Criteria [170KB] Updated 10/15/2021
Exondys 51 Criteria [153KB] Updated 10/4/2021
Exondys PA Form [1.48MB] Updated 1/7/2019
Fasenra Criteria [424KB] Added 5/9/2018
Fensolvi Criteria [70KB] Added 1/11/2021
Ferriprox Criteria [140KB] Updated 10/15/2021
Fetzima Criteria [ 339KB] Updated 6/15/2016
Fintepla Criteria [140KB] Added 1/11/2021
Firvanq Criteria [118KB] Added 1/11/2021
Forteo Criteria [157KB] Updated 9/25/2020
Fuzeon PA Form [1.45MB] Updated 1/7/2019
Galafold Criteria [398KB] Added 1/18/2019
Gamifant Criteria [70KB] Added 9/25/2020
Gattex Criteria [334KB] Updated 6/3/2019
Gimoti Criteria [113KB] Added 8/4/2021
Givlaari Criteria [146KB] Added 8/4/2021
Gloperba Criteria [227KB] Added 6/24/2020
H.P. Acthar Gel Criteria [118KB] Updated 9/25/2020
Haegarda Criteria [120KB] Updated 10/30/2020
Hemady Criteria [115KB] Added 8/4/2021
Hemangeol Criteria [481KB] Added 12/3/2014
Hepatitis C Agents Criteria [266KB] Updated 9/17/2021
Hepatitis C Agents Form [1.78MB] Updated 8/4/2020
Hetlioz Criteria [187KB] Updated 8/5/2021
HIV Auto PA Form [358KB] Updated 5/16/2018
HIV Diagnosis Verification or Prophylaxis of HIV Form [1.34MB] Updated 7/9/2021
Human Growth Hormone Criteria [289KB] Updated 9/28/2021
Human Growth Hormone PA Form [1.26MB] Updated 1/7/2019
Increlex PA Form [1.65MB] Updated 1/9/2019
Invega Oral Criteria [217KB] Updated 6/5/2015
Immune Globulin Criteria [396KB] Updated 9/28/2021
Isturisa Criteria [123KB] Added 6/9/2021
Jadenu Criteria [130KB] Updated 10/15/2021
Juxtapid Criteria [152KB] Updated 6/21/2021
Jynarque Criteria [404KB] Added 1/18/2019
Kadcyla Criteria [300KB] Updated 11/18/2015
Kalbitor Criteria [225KB] Added 3/20/2020
Kalydeco Critieria [310KB] Updated 9/17/2021
Kapvay Critieria [320KB] Updated 11/19/2015
Katerzia Criteria [458KB] Added 2/14/2020
Kepivance Critieria [124KB]
Korlym Criteria [389KB]
Krystexxa Criteria [138KB] Added 6/9/2021
Kuvan Criteria [304KB] Updated 5/13/2015
Kymriah Criteria [316KB] Updated 7/16/2020
Kynamro Criteria [295KB]
Lacrisert Criteria [314KB]
Lampit Criteria [119KB] Added 10/29/2020
Lioresal/Gablofen Criteria [295KB]
Long Acting Beta 2 Agonists Criteria [136KB] Updated 7/9/2021
Long Acting Stimulants in Children Criteria [282KB] Added 6/18/2015
Lovaza Criteria [161KB] Updated 6/21/2021
Lucemyra Criteria [119KB] Added 1/11/2021
Lumizyme Criteria [282KB] Added 2/21/2018
Lupkynis Criteria [153KB] Added 6/9/2021
Luxturna Criteria [379KB] Added 3/27/18
Makena Criteria [159KB] Updated 10/13/2020
Marinol Criteria [181KB] Updated 6/8/2016
Mepsevii Criteria [279KB] New 7/19/2018
Methadone Criteria [511KB] Update 3/15/2018
Miscellaneous Drug Criteria [327KB] Updated 6/4/2020
Miscellaneous Pharmacy Prior Authorization Requests [867KB] Updated 2/3/2020
Mozobil Criteria [309KB] Updated 11/6/2017
Multi Source Brand Drug PA Form [1.36MB] Updated 1/9/2019
Multiple Sclerosis Oral Agents Criteria [194KB] Updated 9/17/2021
Myalept Criteria [330KB] Added 6/24/2020
Mycapssa Criteria [118KB] Added 10/29/2020
Mytesi Criteria [184KB] Added 11/20/2020
Naglazyme Criteria [498KB]
Namenda XR Criteria [348KB] Added 6/23/2015
Natacyn Criteria [293KB]
Neumega Criteria [300KB]
Neupro Criteria [441KB] Updated 11/19/2015
Nexletol/Nexlizet Criteria [157KB] Added 9/25/2020
Nitisinone PA Form [1.25MB] Updated 10/13/2020
Nucala Criteria [165KB] Updated 9/28/2021
Nucynta Criteria [70KB] Updated 7/13/2021
Nuplazid Criteria [291KB] Updated 8/8/2018
Ofev Criteria [347KB] Updated 5/19/2020
Off Label Use Criteria [219KB] Updated 1/31/2020
Opioid PA Form [2.03MB] Updated 7/29/2019
Oral Oncology Criteria [515KB] Updated 9/17/2021
Oral Oncology PA Form [1.66MB] Updated 1/9/2019
Oravig Criteria [190KB]
Orbactiv Criteria [309KB] Added 5/21/2015
Oriahnn Criteria [137KB] Added 9/21/2020
Orilissa Criteria [325KB] Added 1/18/2019
Orkambi Criteria [391KB] Updated 11/20/2019
Orladeyo Criteria [112KB] Added 4/2/2021
Ortikos Criteria [135KB] Added 8/4/2021
Otrexup Criteria [198KB] Added 7/27/2016
Overactive Bladder Agents Criteria [73KB] Added 8/6/2021
Oxandrin Criteria [153KB] Updated 12/22/2016
Oxbryta Criteria [152KB] Udpated 10/13/2021
Oxlumo Criteria [158KB] Added 6/9/2021
Palforzia Criteria [487KB] Added 4/14/20
Palynziq Criteria [414KB] Added 1/18/2019
Panretin PA Form [1.66MB] Updated 1/9/2019
Praluent Criteria [133KB] Updated 6/21/2021
ProCentra Criteria [295KB] Updated 11/20/2015
Proleukin PA Form [1.23MB] Updated 1/11/2019
Prolia Criteria [174KB] Updated 9/25/2020
Promacta Criteria [442KB] Updated 1/18/2019
Proton Pump Inhibitors [489KB] Added 7/11/2016
Pulmonary Hypertension Agent Criteria [124KB] Updated 1/11/2021
Rasuvo Criteria [98KB] Added 7/27/2016
Ravicti Criteria [353KB] Updated 10/3/2019
Reblozyl Criteria [330KB] Added 7/10/2020
Rectiv Criteria [354KB]
Regranex Criteria [227KB] Updated 11/6/2018
Repatha Criteria [140KB] Updated 6/21/2021
Rexulti Criteria [245KB] Added 11/29/2016
Ruconest Criteria [322KB] Added 4/12/2019
Samsca Criteria [446KB] Updated 7/10/2017
Sancuso Criteria [196KB] Updated 1/15/2015
Sandostatin LAR Criteria [354KB] Updated 4/6/2015
Saphris Criteria [358KB] Updated 11/6/2015
Sedative Hypnotic Criteria [165KB] Updated 9/28/2021
Selzentry PA Form [997KB] Updated 9/13/2021
Sensipar Criteria [316KB]
Serostim PA Form [1.59MB] Updated 1/11/2019
Sirturo Criteria [334KB] Updated 8/19/2019
Soliris Criteria [81KB] Updated 6/10/2021
Soma PA Form [647KB] Updated 1/11/2019
Spinraza Criteria [159KB] Updated 4/23/2021
Spinraza PA Form [1.43MB] Updated 1/11/2019
Spravato Criteria [181KB] Updated 8/11/2020
Stimulants and Strattera (<6 years of age) PA Form [1.43KB] Updated 1/11/2019
Sunosi Criteria [413KB] Added 3/25/2020
Supprelin LA Criteria [298KB] Updated 11/4/2015
Supprelin LA PA Form 1.58MB] Updated 1/11/2019
Sylatron Criteria [445KB]
Symdeko Criteria [313KB] Updated 9/17/2021
Synagis Criteria [447KB] Updated 4/3/2020
Synagis - All Florida Regions Combined PA Form [1.24MB] Updated 10/3/2019
Synagis - Weight Change PA Form [1.42MB] Updated 1/11/2019
Synribo Criteria [301KB] Updated 11/23/2015
Takhzyro Criteria [323KB] Updated 4/12/2019
Tecartus Criteria [69KB] Added 8/11/2020
Tepezza Criteria [124KB] Added 1/28/2021
Testosterone Criteria [526KB] Updated 2/24/2016
Trikafta Criteria [226KB] Updated 9/17/2021
Trogarzo Criteria [429KB] Updated 8/6/2018
Tygacil Criteria [141KB]
Tymlos Criteria [341KB] Added 4/3/2018
Ultomiris Criteria [209KB] Added 6/9/2021
Uplizna Criteria [147KB] Added 9/2/2020
Vascepa Criteria [154KB] Added 8/4/2021
Vecamyl Criteria [313KB] Updated 3/14/2018
Veregen Criteria [194KB]
Verquvo Criteria [160KB] Added 4/30/2021
Vfend PA Form [1.57MB] Updated 1/11/2019
Vibativ Criteria [310KB]
Viberzi Criteria [193KB] Added 4/5/2018
Viltepso Criteria [147KB] Updated 3/17/2021
Victoza Criteria [336KB] Updated 7/2/2019
Vimizim Criteria [232KB]
Vpriv Criteria [334KB] Added 1/18/2019
Vyepti Criteria [199KB] Updated 4/8/2021
Vyondys 53 Criteria [94KB] Updated 10/4/2021
Wakix Criteria [144KB] Updated 11/24/2020
Xenazine Criteria [214KB] Updated 7/16/2018
Xermelo Criteria [248KB] Added 12/21/2017
Xgeva Criteria [348KB] Updated 10/21/2019
Xifaxan Criteria [359KB] Updated 11/23/2015
Xolair Criteria [146KB] Updated 9/8/2021
Xopenex Criteria [228KB] Updated 3/30/2015
Xyrem Criteria [164KB] Updated 11/24/2020
Xywav Criteria [146KB] Added 10/29/2020
Yescarta Criteria [89KB] Updated 3/17/2021
Zeposia Criteria [200KB] Added 9/17/2021
Zokinvy Criteria [147KB] Added 8/4/2021
Zolgensma Criteria [153KB] Updated 12/15/2020
Zortress Criteria [109KB]
Zulresso Criteria [454KB] Added 3/20/2020
Zyprexa Relprevv [230KB] Updated 9/8/2017