Clinical Prior Authorization Edit Criteria

ADD/ADHD Agents 1/30/2019
Alinia (Nitazoxanide) 5/27/2016
Aliskiren-Containing Agents (Except Valturna) 5/31/2016
Allergen Extracts 11/9/2018
Altabax (Retapamulin) 5/27/2016
Antiemetics 5/27/2016
Antipsychotics 1/21/2019
Anxiolytics and Sedatives/Hynotics 10/12/2018
Buprenorphine Agents 3/26/2018
Carisoprodol 11/20/2017
Copaxone (Glatiramer) 8/1/2018
Cough/Cold Medications 2/12/2018
COX-2 Inhibitors 4/3/2015
Cystic Fibrosis Agents 1/30/2019
Desmopressin 5/8/2017
Dextromethorphan Overutilization 7/17/2018
Drug Regimen Optimization 4/3/2015
Dupixent 1/3/2019
Emflaza 7/28/2017
Erythropoiesis-Stimulating Agents 10/3/2017
Fentanyl Agents 5/30/2017
Cyclobenzaprine 5/8/2017
Forteo 5/8/2017
GI Motility Agents 2/12/2018
GLP-1 Receptor Agonists 4/6/2018
Growth Hormone 5/11/2017
H.P. Acthar 10/12/2018
Hepatitis C Virus (Initial) 3/2018
Hepatitis C Virus (Refill) 3/2018
Imiquimod 12/10/2018
Increlex (Mecasermin) 5/8/2017
Injectable Pulmonary HTN Agents 10/11/2018
Ketorolac (Toradol) 8/11/2017
Leukotriene Modifiers 2/1/2016
Lidocaine Patches 2/15/2018
Lovaza (Omega-3-Acid Ethyl Esters) Capsules 4/3/2015
Makena 8/22/2018
Morphine Equivalent Dose (MED) Limit 1/30/2019
Opiate Overutilization 1/21/2019
Opiate/Benzodiazepine/Muscle Relaxant Combinations 1/21/2019
OxyContin (Oxycodone ER) 11/20/2017
PCSK9 Inhibitors 11/17/2016
Promethazine/Promethazine Containing Products 2/12/2018
Propylthiouracil 8/11/2017
Provigil (Modafinil) 10/5/2017
Ranexa 11/20/2017
Revatio (Sildenafil) 6/25/2018
Savella 11/30/2015
Symlin (Pramlintide Acetate) 4/12/2018
Synagis (Palivizumab) 11/16/2018
Topical Immunomodulators 5/31/2017
VMAT2 Inhibitors 7/23/2018
Xenical (Orlistat) 1/2018
Xifaxan (Rifaximin) 4/12/2018
Xyrem 1/21/2019
Zelboraf 4/12/2018