Drug Criteria
5-ASA Derivatives Criteria [388KB] Updated 05/2012
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 [227KB] Updated 12/2019
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
Amitiza Criteria [344KB] Updated 1/7/2015
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 10/14/2020
Antipsychotic Polypharmacy Criteria [383KB] Added 7/7/2020
Aplenzin [3012KB] New 6/5/2015
Apokyn Criteria [290KB]
Aranesp Criteria [391KB] Updated 7/24/2019
Automated Prior Authorizations and Bypass [1.36MB] Updated 10/19/2020
Benlysta Criteria [274KB] Updated 5/16/2019
Bone Resorption Inhibitor Criteria [441KB]
Boniva Injection Criteria [182KB] Updated 9/25/2020
Botulinum Criteria [283KB] Added 7/27/2020
Brisdelle Criteria [299KB] Updated 2/28/2018
Buprenorphine Agents Criteria [141KB] Updated 10/19/2020
Buprenorphine Agents PA Form [935KB] Updated 1/29/2020
Butalbital Criteria [241KB]
Carbaglu Crtieria [248KB]
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 [158KB] Updated 6/12/2020
Concomitant Drug Therapy Criteria [365KB] Added 7/7/2020
Corlanor Criteria [366KB] Added 4/24/2020
Cough and Cold Codeine Containing Products Criteria [192KB] Updated 5/10/2018
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 [510KB] Updated 7/7/2020
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
Detrol Criteria [191KB]
Diastat Criteria [432KB]
Dibenzyline Criteria [190KB]
Dificid Criteria [335KB] Updated 11/16/2015
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
Enspryng Criteria [144KB] Added 9/2/2020
Epaned Criteria [195KB] Updated 8/7/2017
Epidiolex Criteria [120KB] Updated 8/11/2020
Epogen Criteria [502KB] Updated 7/7/2020
Erwinaze Criteria [331KB]
Erythropoeisis Stimulating Agents Form [989KB] Added 7/10/2020
Esbriet Criteria [340KB] Updated 5/19/2020
Evrysdi Criteria [147KB] Added 9/30/2020
Exjade Criteria [387KB] Updated 3/30/2015
Exondys 51 Criteria [414KB] Updated 1/18/2019
Exondys PA Form [1.48MB] Updated 1/7/2019
Fasenra Criteria [424KB] Added 5/9/2018
Ferriprox Criteria [318KB] Update 8/7/2015
Fetzima Criteria [ 339KB] Updated 6/15/2016
Forteo Criteria [157KB] Updated 9/25/2020
Fulyzaq Criteria [382KB]
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
Gloperba Criteria [227KB] Added 6/24/2020
H.P. Acthar Gel Criteria [118KB] Updated 9/25/2020
Haegarda Criteria [323KB] Updated 4/12/2019
Hemangeol Criteria [481KB] Added 12/3/2014
Hepatitis C Agents Criteria [202KB] Updated 8/3/2020
Hepatitis C Agents Form [1.78MB] Updated 8/4/2020
Hetlioz Criteria [436KB] Added 8/28/2014
HIV Auto PA Form [358KB] Updated 5/16/2018
HIV Diagnosis Verification Form [598KB] Updated 10/30/2017
Human Growth Hormone Criteria [296KB] Updated 9/25/2020
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
IVIG Criteria [399KB] Updated 10/6/2020
Jadenu Criteria [330KB] Updated 3/31/2020
Jardiance [304KB] Updated 12/19/2016
Juxtapid Criteria [298KB] Updated 12/19/2016
Jynarque Criteria [404KB] Added 1/18/2019
Kadcyla Criteria [300KB] Updated 11/18/2015
Kalbitor Criteria [225KB] Added 3/20/2020
Kalydeco Critieria [393KB] Updated 11/20/2019
Kapvay Critieria [320KB] Updated 11/19/2015
Katerzia Criteria [458KB] Added 2/14/2020
Kepivance Critieria [124KB]
Korlym Criteria [389KB]
Kuvan Criteria [304KB] Updated 5/13/2015
Kymriah Criteria [316KB] Updated 7/16/2020
Kynamro Criteria [295KB]
Lacrisert Criteria [314KB]
Lioresal/Gablofen Criteria [295KB]
Long Acting Beta 2 Agonists Criteria [354KB] Updated 1/23/2018
Long Acting Stimulants in Children Criteria [282KB] Added 6/18/2015
Lovaza Criteria [139KB] Added 12/1/2016
Lumizyme Criteria [282KB] Added 2/21/2018
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
Mircera Criteria [359KB] Updated 7/7/2020
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 [126KB] Updated 9/25/2020
Myalept Criteria [330KB] Added 6/24/2020
Myrbetriq Criteria [294KB] Updated 11/19/2015
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 [164KB] Updated 10/1/2020
Nucynta Criteria [290KB]
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 [474KB] Updated 10/1/2020
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
Otrexup Criteria [198KB] Added 7/27/2016
Oxandrin Criteria [153KB] Updated 12/22/2016
Oxbryta Criteria [451KB] Added 1/21/2020
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 [323KB] Added 10/8/2015
ProCentra Criteria [295KB] Updated 11/20/2015
Procrit Criteria [417KB] Updated 7/7/2020
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 [468KB] Updated 1/27/2020
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
Relistor Criteria [301KB] Updated 11/23/2015
Repatha Criteria [331KB] Updated 7/16/2018
Retacrit Criteria [504KB] Added 7/7/2020
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 [511KB] Updated 2/27/2019
Selzentry PA Form [1.53MB] Updated 1/11/2019
Sensipar Criteria [316KB]
Serostim PA Form [1.59MB] Updated 1/11/2019
Sirturo Criteria [334KB] Updated 8/19/2019
Soliris Criteria [93KB] Updated 7/31/2019
Soma PA Form [647KB] Updated 1/11/2019
Spinraza Criteria [169KB] Updated 9/30/2020
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 [475KB] Updated 11/20/2019
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
Testosterone Criteria [526KB] Updated 2/24/2016
Trikafta Criteria [464KB] Added 11/20/2019
Trogarzo Criteria [429KB] Updated 8/6/2018
Tygacil Criteria [141KB]
Tymlos Criteria [341KB] Added 4/3/2018
Uplizna Criteria [147KB] Added 9/2/2020
Vecamyl Criteria [313KB] Updated 3/14/2018
Veregen Criteria [194KB]
Vfend PA Form [1.57MB] Updated 1/11/2019
Vibativ Criteria [310KB]
Viberzi Criteria [193KB] Added 4/5/2018
Victoza Criteria [336KB] Updated 7/2/2019
Vimizim Criteria [232KB]
Vpriv Criteria [334KB] Added 1/18/2019
Vyondys 53 Criteria [353KB] Added 1/2/2020
Wakix Criteria [329KB] Updated 7/10/2020
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 [344KB] Updated 11/28/2018
Xopenex Criteria [228KB] Updated 3/30/2015
Xyrem Criteria [396KB] Updated 11/28/2018
Yescarta Criteria [401KB] Updated 7/16/2020
Zolgensma Criteria [384KB] Updated 7/24/2019
Zortress Criteria [109KB]
Zulresso Criteria [454KB] Added 3/20/2020
Zyprexa Relprevv [230KB] Updated 9/8/2017