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