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Drug Criteria

5-ASA Derivatives Criteria [325KB]

Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys Criteria [297KB] Updated 3/15/2018

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

Adult High Dose Antipsychotic Criteria [300KB] Updated 2/27/2017

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

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

Aldurazyme Criteria [297KB]

Alinia Criteria [329KB] Updated 11/10/2015

Aloxi Crtieria [193KB] Updated 11/10/2015

Amitiza Criteria [344KB] Updated 1/7/2015

Ampyra Criteria [308KB] Updated 5/24/2018

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

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

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

Aplenzin [3012KB] New 6/5/2015

Apokyn Criteria [290KB]

Aranesp Criteria [444KB] Updated 6/8/2018

Austedo Criteria [290KB] Added 4/25/2018

Automated Prior Authorizations and Bypass [1.25MB] Updated 9/7/2018

Banzel Criteria [343KB] Updated 4/23/2015

Benlysta Criteria [235KB] Updated 4/11/2017

Bone Resorption Inhibitor Criteria [441KB]

Boniva Injection Criteria [487KB] Updated 11/13/2015

Brisdelle Criteria [299KB] Updated 2/28/2018

Buprenorphine Agents Criteria [303KB] Updated 3/15/2018

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

Butalbital Criteria [241KB]

Carbaglu Crtieria [248KB]

Cayston Criteria [301KB] Updated 2/24/2015

Ceprotin Criteria [296KB] Updated 11/16/2015

Chantix Criteria [285KB]Updated 2/28/2018

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

Colcrys Criteria [341KB]

Cough and Cold Codeine Containing Products Criteria [192KB] Updated 5/10/2018

Crysvita Criteria [235KB] New 7/19/2018

Cubicin Criteria [300KB] Added 12/16/2015

Cyanocobalamin Criteria [129KB]

Cyramza Criteria [308KB] Updated 6/11/2015

Cytokines and CAM Antagonists Criteria [453KB] Updated 7/23/2018

Cytogam PA Form [589KB] Updated 10/24/2017

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 [178KB] Added 1/8/2018

Edurant Criteria [371KB] Updated 11/16/2015

Elaprase Criteria [290KB]

Elmiron Criteria [307KB] Updated 11/16/2015

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

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

Erwinaze Criteria [331KB]

Esbriet Criteria [303KB] Updated 3/28/2018

Exjade Criteria [387KB] Updated 3/30/2015

Exondys 51 Criteria [387KB] Updated 8/28/2017

Exondys PA Form [1.79MB] Added 10/24/2017

Fasenra Criteria [424KB] Added 5/9/2018

Ferriprox Criteria [318KB] Update 8/7/2015

Fetzima Criteria [ 339KB] Updated 6/15/2016

Forteo Criteria [348KB] Updated 4/3/2018

Fulyzaq Criteria [382KB]

Fuzeon PA Form [244KB]

Gattex Criteria [304KB] Updated 11/20/2014

H.P. Acthar Gel Criteria [358KB] Updated 2/28/2018

Hemangeol Criteria [481KB] Added 12/3/2014

Hepatitis C Agents Criteria [435KB] Updated 9/7/2018

Hepatitis C Agents Form [1.52MB] Updated 2/16/2018

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 [778KB] Updated 3/6/2018

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

Ingrezza Criteria [285KB] Added 4/25/2018

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

Invega Oral Criteria [217KB] Updated 6/5/2015

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

Jadenu Criteria [382KB] Added 6/1/2015

Jardiance [304KB] Updated 12/19/2016

Juxtapid Criteria [298KB] Updated 12/19/2016

Kadcyla Criteria [300KB] Updated 11/18/2015

Kalydeco Critieria [386KB] Updated 8/28/2018

Kapvay Critieria [320KB] Updated 11/19/2015

Kepivance Critieria [124KB]

Korlym Criteria [389KB]

Kuvan Criteria [304KB] Updated 5/13/2015

Kymriah Criteria [281KB] Updated 7/27/2018

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 [298KB] Updated 11/6/2017

Marinol Criteria [181KB] Updated 6/8/2016

Mepsevii Criteria [279KB] New 7/19/2018

Methadone Criteria [511KB] Update 3/15/2018

Mircera Criteria [306KB] Updated 6/12/2018

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

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

Morphine Sulfate ER Criteria [464KB] Update 3/15/2018

Mozobil Criteria [309KB] Updated 11/6/2017

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

Multiple Sclerosis Oral Agents Criteria [294KB] Updated 5/24/2018

Myrbetriq Criteria [294KB] Updated 11/19/2015

Naglazyme Criteria [498KB]

Namenda XR Criteria [348KB] Added 6/23/2015

Natacyn Criteria [293KB]

Neumega Criteria [300KB]

Neupogen/Leukine/Neulasta/Granix/Zarxio/Fulphia PA Form [1.49MB] Updated 7/23/2018

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

Nityr PA Form [591KB] Added 3/27/2018

Nucala Criteria [346KB] Added 5/9/2018

Nucynta Criteria [290KB]

Nuedexta Criteria [299KB] Updated 6/5/2015

Nuplazid Criteria [291KB] Updated 8/8/2018

Ofev Criteria [298KB] Added 10/22/2015

Off Label Use Criteria [182KB] Updated 8/30/2017

Opioid PA Form [2.26MB] Updated 7/02/2018

Oral Oncology Criteria [742KB] Updated 8/28/2018

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

Oravig Criteria [190KB]

Orbactiv Criteria [309KB] Added 5/21/2015

Orfadin PA Form [591KB] Updated 3/27/2018

Orkambi Criteria [309KB] Updated 8/10/2018

Otrexup Criteria [198KB] Added 7/27/2016

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

Oxycontin PA Form [1.40MB] Updated 4/5/2018

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

Praluent Criteria [323KB] Added 10/8/2015

ProCentra Criteria [295KB] Updated 11/20/2015

Procrit/Retacrit Criteria [466KB] Updated 7/9/2018

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

Proleukin PA Form [73KB]

Prolia Criteria [575KB] Updated 6/5/2018

Promacta Criteria [404KB] Updated 7/31/2018

Proton Pump Inhibitors [489KB] Added 7/11/2016

Pulmonary Hypertension Agent Criteria [392KB] Updated 2/22/2016

Rasuvo Criteria [98KB] Added 7/27/2016

Ravicti Criteria [314KB] Updated 6/29/2018

Rectiv Criteria [354KB]

Regranex Criteria [195KB]

Relistor Criteria [301KB] Updated 11/23/2015

Repatha Criteria [331KB] Updated 7/16/2018

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

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 [476KB] Updated 11/2/2016

Selzentry PA Form [139KB]

Sensipar Criteria [316KB]

Serostim PA Form [245KB]

Sirturo Criteria [297KB]

Soliris Criteria [70KB] Updated 11/15/2017

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

Spinraza Criteria [454KB] Updated 8/28/2017

Spinraza PA Form [1.81MB] Added 10/24/2017

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

Supprelin LA Criteria [298KB] Updated 11/4/2015

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

Sylatron Criteria [445KB]

Symdeko Criteria [434KB] Updated 6/18/2018

Synagis Criteria [365KB] Updated 6/15/2018

Synagis - All Florida Regions Combined PA Form [1.94MB] Updated 8/27/2018

Synagis - Weight Change PA Form [1.40MB] Updated 8/27/2018

Synribo Criteria [301KB] Updated 11/23/2015

Testosterone Criteria [526KB] Updated 2/24/2016

Trogarzo Criteria [429KB] Updated 8/6/2018

Tygacil Criteria [141KB]

Tymlos Criteria [341KB] Added 4/3/2018

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

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

Vecamyl Criteria [313KB] Updated 3/14/2018

Venofer Criteria [277KB] Added 1/8/2018

Veregen Criteria [194KB]

Vfend PA Form [107KB]

Vibativ Criteria [310KB]

Viberzi Criteria [193KB] Added 4/5/2018

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

Vimizim Criteria [232KB]

Xenazine Criteria [214KB] Updated 7/16/2018

Xermelo Criteria [248KB] Added 12/21/2017

Xgeva Criteria [311KB] Updated 11/23/2015

Xifaxan Criteria [359KB] Updated 11/23/2015

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

Xopenex Criteria [228KB] Updated 3/30/2015

Xyrem Criteria [205KB] Updated 10/25/2017

Yescarta Criteria [512KB] Added 12/22/2017

Zortress Criteria [109KB]

Zyprexa Relprevv [230KB] Updated 9/8/2017

Zyvox Criteria [218KB]