Drug name |
Criteria |
PA form |
| Abilify (aripiprazole) |
Abilify criteria |
Abilify PA form and worksheet |
| Abstral (fentanyl) |
Abstral criteria |
PA form |
Acanya (benzoyl peroxide +
clindamycin topical) |
Acanya criteria |
Acanya PA form and worksheet |
| Aciphex (rabeprazole) |
Aciphex criteria |
Aciphex PA form and worksheet |
| Actiq (fentanyl citrate) |
Actiq criteria |
PA form |
| Actemra (tocilizumab) |
Actemra criteria |
PA form |
| Aczone (dapsone) |
Aczone criteria |
Aczone PA form and worksheet |
| Adcetris (brentuximab) |
Adcetris criteria |
PA form |
| Adcirca (tadalafil) |
Adcirca criteria |
Adcirca PA form and worksheet |
| Adriamycin (doxorubicin) |
Adriamycin criteria |
PA form |
| Advate (antihemophilic factor VIII, recombinant) |
Advate criteria |
PA form |
| Afinitor (everolimus) |
Afinitor criteria |
PA form |
| Agrylin (anagrelide) |
Agrylin criteria |
PA form |
| Aldurazyme (laronidase) |
Aldurazyme criteria |
PA form |
| Alphanate (antihemophilic factor VIII, human) |
Alphanate criteria |
PA form |
| Alvesco (ciclesonide) |
Alvesco criteria |
PA form |
Ambien CR (zolpidem extended
release) |
Ambien CR criteria |
Ambien CR PA form and worksheet |
| Amerge (naratriptan) |
Amerge criteria |
PA form |
| Amevive (alefacept) |
Amevive criteria |
PA form |
| Amitiza (lubiprostone) |
Amitiza criteria |
Amitiza PA form and worksheet |
| Ampyra (dalfampridine) |
Ampyra criteria |
Ampyra PA form and worksheet |
| Amrix (cyclobenzaprine extended-release) |
Amrix criteria |
PA form |
| Amturnide (aliskiren, amlodipine, and hydrochlorothiazide) |
Amturnide criteria |
PA form |
| Andadrol-50 (oxymetholone) |
Andadrol-50 criteria |
PA form |
| Antagon (ganirelix) |
Antagon criteria |
PA form |
| Antihemophilic Factor VIII (human) |
Antihemophilic Factor VIII criteria |
PA form |
| Antihemophilic Factor VIII (recombinant) |
Antihemophilic Factor VIII criteria |
PA form |
| Antara (fenofibrate) |
Step therapy medications criteria |
Antara PA form and worksheet |
| Aplenzin (bupropion hydrobromide) |
Aplenzin criteria |
PA form |
| Apokyn (apomorpine) |
Apokyn criteria |
PA form |
| Apriso (mesalamine) |
Apriso criteria |
PA form |
| Aralast (alpha-1 proteinase inhibitor) |
Aralast criteria |
PA form |
| Aranesp (darbepoetin) |
Aranesp criteria |
Aranesp PA form and worksheet |
| Arcalyst (rilonacept) |
Arcalyst criteria |
PA form |
| Arranon (nelarabine) |
Arranon criteria |
PA form |
| Arzerra (ofatumumab) |
Arzerra criteria |
PA form |
| AutoPlex (anti-inhibitor coagulant complex) |
AutoPlex criteria |
PA form |
| Banzel (rufinamide) |
Banzel criteria |
PA form |
| Baraclude (entecavir) |
Baraclude criteria |
PA form |
| Beconase AQ (beclomethasone) |
Step therapy medications criteria |
Steroid nasal sprays PA form and worksheet |
| Benlysta (belimumab) |
Benlysta criteria |
PA form |
| Benzaclin (benzoyl peroxide + clindamycin topical) |
Benzaclin criteria |
Benzaclin PA form and worksheet |
| Benzefoam (benzoyl peroxide 5.3%) |
Benzefoam criteria |
PA form |
BiDil (isosorbide
dinitrate/hydralazine) |
BiDil criteria |
PA form |
| Boniva (ibandronate) |
Boniva criteria |
Boniva PA form and worksheet |
| Botox (botulinium toxin A) |
Botox criteria |
Botox PA form and worksheet |
| Brilinta (Ticagrelor) |
Brilinta criteria |
PA form |
| Brovana (arformoterol) |
Brovana criteria |
PA form |
| Butrans (buprenorphine) |
Butrans criteria |
PA form |
| Byetta (exenatide) |
Byetta criteria |
Byetta PA form and worksheet |
| Bystolic (nebivolol) |
Bystolic criteria |
PA form |
| Calomist (cyanocobalamin) |
Calomist criteria |
PA form |
| Carbaglu (carglumic acid) |
Carbaglu criteria |
PA form |
| Cambia (diclofenac) |
Cambia criteria |
PA form |
| Campral (acamprosate) |
Campral criteria |
Campral PA form and worksheet |
| Caprelsa (vandetanib) |
Caprelsa criteria |
PA form |
| Cayston (aztreonam) |
Cayston criteria |
PA form |
| Celebrex (celecoxib) |
Celebrex criteria |
Celebrex PA form and worksheet |
| Cerezyme (imigluterase) |
Cerezyme criteria |
PA form |
| Cesamet (nabilone) |
Cesamet criteria |
PA form |
| Cetrotide (cetrorelix) |
Cetrotide criteria |
PA form |
| Chorionic gonadotropin |
Chorionic gonadotropin criteria |
PA form |
| Cimzia (certolizumab) |
Cimzia criteria |
Cimzia PA form and worksheet |
| Cinryze (C1 inhibitor human) (pdf, 67KB) |
Cinryze criteria |
PA form |
| Clobex Lotion (clobetasol lotion) |
Clobex Lotion criteria |
Clobex PA form and worksheet |
| Clobex Shampoo (clobetasol) |
Clobex Shampoo criteria |
Clobex PA form and worksheet |
| Clobex Spray (clobetasol propionate spray) |
Clobex Spray criteria |
Clobex PA form and worksheet |
| Clolar (clofarabine) |
Clolar criteria |
PA form |
| Copegus (ribavirin) |
Copegus criteria |
Copegus (inital fill) PA form
Copegus (renewal) PA form |
| Coreg (carvedilol) |
Coreg criteria |
Coreg PA form and worksheet |
| Crestor (rosuvastatin) |
Step therapy medications criteria |
Crestor PA form and worksheet |
| Crinone (progesterone gel) |
Crinone criteria |
PA form |
| Cubicin (daptomycin) |
Cubicin criteria |
PA form |
| Cuvposa (glycopyrrolate) |
Cuvposa criteria |
PA form |
| Cymbalta (duloxetine) |
Cymbalta criteria |
Cymbalta PA form and worksheet |
| Dacogen (decitabine) |
Dacogen criteria |
PA form |
| Daytrana (methylphenidate) |
Daytrana criteria |
Daytrana PA form and worksheet |
| Desonate gel (desonide gel) |
Desonate gel criteria |
PA form |
| Dificid (fidaxomicin) |
Dificid criteria |
PA form |
| Diflucan (fluconazole) |
Diflucan criteria |
PA form |
| Diflucan VC (fluconazole) |
Diflucan VC criteria |
PA form |
| Duac Gel (benzoyl peroxide + clindamycin) |
Duac Gel criteria |
Duac PA form and worksheet |
| Dysport (abobotulinumtoxin A) |
Dysport criteria |
PA form |
| Edluar (zolpidem sublingual) |
Edluar criteria |
PA form |
| Effexor XR (venlafaxine) |
Effexor XR criteria |
Effexor XR PA form and worksheet |
| Effient (prasugrel) |
Effient criteria |
Effient PA form and worksheet |
| Egrifta (tesamorelin) |
Egrifta criteria |
PA form |
| Elaprase (idursulfase) |
Elaprase criteria |
PA form |
| Embeda (morphine naltrexone extended release) |
Embeda criteria |
PA form |
| Emsam (selegiline) |
Emsam criteria |
PA form |
| Entereg (alvimopan) |
Entereg criteria |
PA form |
Epiduo (adapalene/benzoyl
peroxide topical gel) |
Epiduo criteria |
Epiduo PA form and worksheet |
| Epogen (epoetin) |
Epogen criteria |
Epogen PA form and worksheet |
| Ethyol (amifostine) |
Ethyol criteria |
PA form |
| Euflexxa (sodium hyaluronate) |
Euflexxa criteria |
Euflexxa PA form and worksheet |
| Evoclin (clindamycin foam) |
Evoclin criteria |
Evoclin PA form and worksheet |
| Exalgo (hydromorphone) |
Exalgo criteria |
PA form |
| Excess quantity limit criteria |
Excess quantity limit criteria criteria |
PA form |
| Extina (ketoconazole foam) |
Extina criteria |
PA form |
| Fabrazyme (agalsidase) |
Fabrazyme criteria |
PA form |
| Factive (gemifloxacin) |
Factive criteria |
PA form |
| Factor IX Complex (Human) |
Factor IX Complex (Human) criteria |
PA form |
| Fanapt (iloperidone) |
Fanapt criteria |
PA form |
| Feiba VH (anti-inhibitor coagulant complex) |
Feiba VH criteria |
PA form |
| Fentora (fentanyl citrate) |
Fentora criteria |
PA form |
| Flector (diclofenac) |
Flector criteria |
Flector PA form and worksheet |
| Flonase (fluticasone) |
Step therapy medications criteria |
Steroid nasal sprays PA form and worksheet |
| FluMist (influenza virus vaccine live intranasal) |
FluMist criteria |
PA form |
| Follistim AQ (follitropin) |
Follistim AQ criteria |
Follistim AQ (inital fill) PA form and worksheet
Follistim AQ (mid-cycle increase) PA form and worksheet |
Fortamet (metformin
extended-release) |
Fortamet criteria |
PA form |
| Forteo (teriparatide) |
Forteo criteria |
PA form |
| Fortesta (testosterone) |
Fortesta criteria |
PA form |
| Fosrenol (lanthanum) |
Fosrenol criteria |
PA form |
| Fotolyn (pralatrexate) |
Fotolyn criteria |
PA form |
| Fusilev (levoleucovorin) |
Fusilev criteria |
PA form |
| Fuzeon (enfuvirtide) |
Fuzeon criteria |
PA form |
| Gelnique (oxybutynin) |
Gelnique criteria |
PA form |
| Gilenya (fingolimod) |
Gilenya criteria |
Gilenya PA form and worksheet |
| Glassia (alpha-1 proteinase inhibitor) |
Glassia criteria |
PA form |
| Gonadotropin-releasing hormones |
Gonadotropin-releasing hormones criteria |
PA form |
| Gonal F (follitropin) |
Gonal F criteria |
Gonal-F (inital fill) PA form and worksheet
Gonal-F (mid-cycle increase) PA form and worksheet |
| Growth hormone (adults) |
Growth hormone (adults) criteria |
PA form |
| Growth hormone (children) |
Growth hormone (children) criteria |
PA form |
| Halaven (eribulin) |
Halaven criteria |
PA form |
| Helidac (bismuth metronidazole tetracycline) |
Helidac criteria |
PA form |
| Hepsera (adefovir) |
Hepsera criteria |
PA form |
| Herceptin (trastuzumab) |
Herceptin criteria |
PA form |
| Hizentra (immunoglobulin SCIG) |
Hizentra criteria |
PA form |
| Horizant (gabapentin extended release) |
Horizant criteria |
PA form |
| Hyalgan (sodium hyaluronate) |
Hyalgan criteria |
Hyalgan PA form and worksheet |
| Hycamtin (oral topotecan) |
Hycamtin criteria |
PA form |
| Ilaris (canakinumab) |
Ilaris criteria |
PA form |
| Imitrex (sumatriptan) |
Imitrex criteria |
PA form |
| Immunoglobulin IVIG and SCIG |
Immunoglobulin IVIG and SCIG criteria |
PA form |
| Incivek (telaprevir) |
Coming soon |
Incivek (inital fill) PA form
Incivek (renewal) PA form |
| Increlex (mecasermin) |
Increlex criteria |
PA form |
| Infertility medication |
Not applicable |
Infertility Services Prior Authorization Request Form (Medical and Pharmacy) |
| Inspra (eplerenone) |
Inspra criteria |
PA form |
| Insulin Pen |
Insulin Pen criteria |
Insulin Pen PA form and worksheet |
| Intron A (interferon alpha-2b) |
Intron A criteria |
PA form |
| Intuniv (guanfacine) |
Intuniv criteria |
Intuniv PA form and worksheet |
| Invega (paliperidone) |
Invega criteria |
Invega PA form and worksheet |
| Iprivask (desirudin) |
Iprivask criteria |
PA form |
| Istodax (romidepsin) |
Istodax criteria |
PA form |
| Ixempra (ixabepilone) |
Ixempra criteria |
PA form |
| Janumet (sitagliptin, sitagliptin, and metformin) |
Step therapy medications criteria |
Janumet PA form and worksheet |
| Januvia (sitagliptin) |
Januvia criteria |
Januvia PA form and worksheet |
| Jevtana (cabazitaxel) |
Jevtana criteria |
PA form |
| Kadian (morphine extended release) |
Kadian criteria |
PA form |
| Kalbitor (ecallantide) |
Kalbitor criteria |
PA form |
| Kapvay (clonidine extended release) |
Kapvay criteria |
PA form |
| Kepivance (palifermin) |
Kepivance criteria |
PA form |
| Krystexxa (pegloticase) |
Krystexxa criteria |
PA form |
| Kuvan (sapropterin) |
Kuvan criteria |
PA form |
| Latuda (lurasidone) |
Latuda criteria |
PA form |
| Letairis (ambrisentan) |
Letairis criteria |
Letairis PA form and worksheet |
| Lexapro (escitalopram) |
Lexapro criteria |
Lexapro PA form and worksheet |
| Lialda (mesalamine) |
Lialda criteria |
PA form |
| Livalo (pitavastatin) |
Step therapy medications criteria |
Livalo PA form and worksheet |
| Lotronex (alosetron) |
Lotronex criteria |
PA form |
| Lovaza (omega-3-acid ethyl esters) |
Lovaza criteria |
Lovaza PA form and worksheet |
| Lumizyme (alglucosidase alfa) |
Lumizyme criteria |
PA form |
| Lunesta (eszopiclone) |
Lunesta criteria |
Lunesta PA form and worksheet |
| Luveris (lutropin-alpha) |
Luveris criteria |
PA form |
| Luxiq (betamethasone foam) |
Luxiq criteria |
Luxiq PA form and worksheet |
| Lyrica (pregabalin) |
Lyrica criteria |
Lyrica PA form and worksheet |
| Marinol (dronabinol) |
Marinol criteria |
PA form |
| Meridia (sibutramine) |
Meridia criteria |
PA form |
| Metozolv (metoclopramide) |
Metozolv criteria |
PA form |
| Mirapex ER (pramipexole) |
Mirapex ER criteria |
PA form |
| Mobic (meloxicam) |
Mobic criteria |
PA form |
| Moxatag™ (amoxicillin extended-release) |
Moxatag™ criteria |
PA form |
| Mozobil (plerixafor) |
Mozobil criteria |
Mozobil PA form and worksheet |
| Multaq (dronedarone) |
Multaq criteria |
Multaq PA form and worksheet |
| Mylotarg (gemtuzumab ozogamicin) |
Mylotarg criteria |
PA form |
| Myobloc (botulinum toxin B) |
Myobloc criteria |
Myobloc PA form and worksheet |
| Myozyme (aglucosidase alfa) |
Myozyme criteria |
PA form |
| Naglazyme (galsulfase) |
Naglazyme criteria |
PA form |
| Nasacort AQ (triamcinolone) |
Step therapy medications criteria |
Steroid nasal sprays PA form and worksheet |
| Nascobal (cyanocobalmin) |
Nascobal criteria |
PA form |
| Natroba (spinosad) |
Natroba criteria |
PA form |
| Neupro (rotigotine) |
Neupro criteria |
PA form |
| Nexavar (sorafenib) |
Nexavar criteria |
PA form |
| Nexiclon XR (clonidine extended release) |
Nexiclon XR criteria |
PA form |
| Nexium (esomeprazole) |
Nexium criteria |
Nexium PA form and worksheet |
| Nicotrol Inhaler (nicotine inhalation) |
Nicotrol Inhaler criteria |
PA form |
| Non-sedating antihistamines (for MassHealth only) |
Non-sedating antihistamines criteria |
PA form |
| Novarel (chorionic gonodatropin) |
Novarel criteria |
PA form |
| Novolog (insulin aspart) |
Novolog criteria |
Novolog PA form and spreadsheet |
| NovoSeven (human coagulation factor VIIa) |
NovoSeven criteria |
PA form |
| Noxafil (posaconazole) |
Noxafil criteria |
PA form |
| Nplate (romiplostim) |
Nplate criteria |
PA form |
| Nucynta (tapentadol) |
Nucynta criteria |
PA form |
| Nuedexta (dextromethorphan/Quinidine) |
Nuedexta criteria |
PA form |
| Nuvigil (armodafinil) |
Nuvigil criteria |
Nuvigil PA form and spreadsheet |
| Oleptro (trazodone extended release) |
Oleptro criteria |
PA form |
| Olux Foam and Olux-E Foam (clobetasol propionate) |
Olux Foam and Olux-E Foam criteria |
Olux PA form and worksheet |
| Omnaris (ciclesonide) |
Step therapy medications criteria |
Steroid nasal sprays PA form and worksheet |
| Onsolis (fentanyl buccal soluble film) |
Onsolis criteria |
PA form |
| Ontak (denileukin diftitox) |
Ontak criteria |
PA form |
| Opana ER (oxymorphone) |
Opana ER criteria |
PA form |
| Oracea (doxycycline) |
Oracea criteria |
Oracea PA form and worksheet |
| Oravig (miconazole) |
Oravig criteria |
PA form |
| Orencia (abatacept) |
Orencia criteria |
Orencia PA form and worksheet |
| Orfadin (nitisinone) |
Orfadin criteria |
PA form |
| Orthovisc (hyaluronic acid) |
Orthovisc criteria |
Orthovisc PA form and worksheet |
| Ovide (malathion) |
Ovide criteria |
PA form |
| Oxandrin (oxandrolone) |
Oxandrin criteria |
PA form |
| OxyContin (oxycodone extended-release) |
OxyContin criteria |
OxyContin ER PA form and worksheet |
| Pacnex (benzoyl peroxide 7%) |
Pacnex criteria |
PA form |
| Pamine Forte (methscopolamine) |
Pamine Forte criteria |
PA form |
| Panhematin (hemin) |
Panhematin criteria |
PA form |
| PEG-Intron, Pegasys (peginterferon alfa-2b, Peginterferon alfa-2a) |
PEG-Intron, Pegasys criteria |
PEG-Intron, Pegasys (inital fill) PA form
PEG-Intron, Pegasys (renewal) PA form |
| Penlac (ciclopirox) |
Penlac criteria |
Penlac PA form and worksheet |
| Pepcid (famotidine) |
Pepcid criteria |
PA form |
| Perforomist (formoterol) |
Perforomist criteria |
PA form |
| Plasma volume expander |
Plasma volume expander criteria |
PA form |
| Plenaxis (abarelix) |
Plenaxis criteria |
PA form |
| Pradaxa (dabigatran) |
Pradaxa criteria |
Pradaxa PA form and worksheet |
| Pregnyl (chorionic gonodatropin) |
Pregnyl criteria |
PA form |
| Pristiq (desvenlafaxine) |
Pristiq criteria |
Pristiq PA form and worksheet |
| Proamatine (midodrine) |
Proamatine criteria |
PA form |
| Prochieve (progesterone gel) |
Prochieve criteria |
PA form |
| Procrit (epoetin) |
Procrit criteria |
Procrit PA form and worksheet |
| Prolastin (alpha-1 proteinase inhibitor) |
Prolastin criteria |
PA form |
| Prolia (denosumab) |
Prolia criteria |
PA form |
| Promacta (eltrombopag) |
Promacta criteria |
PA form |
| Prosom (estazolam) |
Prosom criteria |
PA form |
| Provigil (modafinil) |
Provigil criteria |
Provigil PA form and worksheet |
| Prozac 40mg (fluoxetine 40mg) |
Prozac 40mg criteria |
Prozac 40mg PA form and worksheet |
| Prozac Weekly |
Prozac Weekly criteria |
PA form |
| Pulmicort respules (budesonide) |
Pulmicort respules criteria |
PA form |
Pylera (biskalcitrate/metronidazole/
tetracycline) |
Pylera criteria |
PA form |
| Qualaquin (quinine sulfate) |
Qualaquin criteria |
PA form |
| Qutenza (capsaicin) |
Qutenza criteria |
PA form |
| Ranexa (ranolazine) |
Ranexa criteria |
Renaxa PA form and worksheet |
| Rapaflo (silodosin) |
Rapaflo criteria |
PA form |
| Rebetol (ribavirin) |
Rebetol criteria |
Rebatol (inital fill) PA form
Rebatol (renewal) PA form |
| Rebif (interferon beta 1a) |
Rebif criteria |
Rebif PA form and worksheet |
| Reclast (zoledronic acid) |
Reclast criteria |
Reclast PA form and worksheet |
| Regranex (becaplermin) |
Regranex criteria |
PA form |
| Relistor (methylnaltrexone) |
Relistor criteria |
PA form |
| Remicade (infliximab) |
Remicade criteria |
Remicade PA form |
| Restasis (cyclosporine ophth) |
Restasis criteria |
PA form |
| Retisert (fluocinolone acetonide) |
Retisert criteria |
PA form |
| Revatio (sildenafil) |
Revatio criteria |
Revatio PA form and worksheet |
| Revlimid (lenalidomide) |
Revlimid criteria |
PA form |
| Rhinocort AQ (budesonide) |
Step therapy medications criteria |
Steroid nasal sprays PA form and worksheet |
| Ribasphere (ribavirin) |
Ribasphere criteria |
Ribasphere (inital fill) PA form
Ribasphere (renewal) PA form |
| Rozerem (ramelteon) |
Rozerem criteria |
PA form |
| Rythmol SR (propafenone extended release) |
Rythmol SR criteria |
PA form |
| Ryzolt (tramadol extended release) |
Ryzolt criteria |
PA form |
| Sabril (vigabatrin) |
Sabril criteria |
PA form |
| Samsca (tolvaptan) |
Samsca criteria |
PA form |
| Saphris (asenapine) |
Saphris criteria |
PA form |
| Savella (milnacipran) |
Savella criteria |
PA form |
| Sancuso (granisetron) |
Sancuso criteria |
PA form |
| Sandostatin (octreotide) |
Sandostatin criteria |
PA form |
| Sarafem (fluoxetine) |
Sarafem criteria |
PA form |
| Selzentry (maraviroc) |
Selzentry criteria |
PA form |
| Sensipar (cinacalcet) |
Sensipar criteria |
Sensipar PA form and worksheet |
| Short-acting agents for insomnia |
Short-acting agents for insomnia criteria |
PA form |
| Silenor (doxepin) |
Silenor criteria |
PA form |
| Simponi (golimumab) |
Simponi criteria |
PA form |
| Singulair Allergy (montelukast) |
Singulair Allergy criteria |
Singulair PA form and worksheet |
| Solaraze (diclofenac) |
Solaraze criteria |
PA form |
| Soliris (eculizumab) |
Soliris criteria |
PA form |
| Solodyn (minocycline) |
Solodyn criteria |
Solodyn PA form and worksheet |
| Somatuline Depot (lanreotide) |
Somatuline Depot criteria |
PA form |
| Sonata (zalpelon) |
Sonata criteria |
PA form |
| Sporanox (itraconazole) |
Sporanox criteria |
PA form |
| Sprix (ketorolac tromethamine) |
Sprix criteria |
PA form |
| Sprycel (dasatinib) |
Sprycel criteria |
PA form |
| Stadol NS (butorphanol) |
Stadol NS criteria |
PA form |
| Stalevo (carbidopa levodopa entacapone) |
Stalevo criteria |
PA form |
| Stavzor (valproic acid) |
Stavzor criteria |
PA form |
| Stelara (ustekinumab) |
Stelara criteria |
Stelara PA form and worksheet |
| Step therapy medications |
Step therapy medications criteria |
PA form |
| Strattera (atomoxetine) |
Strattera criteria |
PA form |
| Striant (testosterone) |
Striant criteria |
PA form |
| Suboxone Film (buprenorphine/naloxone) |
Suboxone Film criteria |
PA form |
| Subutex Suboxone (buprenorphine, buprenorphine/naloxone) |
Subutex Suboxone criteria |
PA form |
| Supartz (hyaluronic acid) |
Supartz criteria |
Supartz PA form and worksheet |
| Supprelin LA (histrelin) |
Supprelin LA criteria |
PA form |
| Sutent (sunitinib) |
Sutent criteria |
PA form |
| Sylatron (peginterferon alfa-2b) |
Sylatron criteria |
PA form |
| Symbyax (olanzapine and fluoxetine) |
Symbyax criteria |
PA form |
| Symlin (pramlintide) |
Symlin criteria |
PA form |
| Synagis (palivizumab) |
Synagis criteria |
PA form |
| Synercid (dalfopristin/quinupristin) |
Synercid criteria |
PA form |
| Synvisc (hyaluronic acid) |
Synvisc criteria |
Synvisc PA form and worksheet |
| Taclonex (calcipotriene and betamethasone dipropionate) |
Taclonex criteria |
PA form |
| Tamiflu (oseltamivir) |
Tamiflu criteria |
PA form |
| Tarceva (erlotinib) |
Tarceva criteria |
PA form |
| Tasigna (nilotinib) |
Tasigna criteria |
PA form |
| Tekamlo (aliskiren and amlodipine) |
Tekamlo criteria |
PA form |
| Tekturna (aliskiren) |
Tekturna criteria |
PA form |
| Tekturna HCT (aliskiren/ hydrochlorothiazide) |
Tekturna HCT criteria |
PA form |
| Tersifoam (selenium sulfide) |
Tersifoam criteria |
PA form |
| Testim (testosterone gel) |
Testim criteria |
PA form |
| Tev-Tropin (growth hormone) |
Tev-Tropin criteria |
PA form |
| Thalomid (thalidomide) |
Thalomid criteria |
PA form |
| Thrombate III (antithrombin III) |
Thrombate III criteria |
PA form |
| Toradol (ketorolac) |
Toradol criteria |
PA form |
| Toviaz (fesoterodine fumarate) |
Toviaz criteria |
PA form |
| Tracleer (bosentan) |
Tracleer criteria |
Tracleer PA form and worksheet |
| Treanda (bendamustine) |
Treanda criteria |
PA form |
| Tretinoin |
Tretinoin criteria |
PA form |
| Treximet (sumatriptan/naproxen sodium) |
Treximet criteria |
Treximet PA form and worksheet |
| Tribenzor (olmesartan, amlodipine, and hydrochlorothiazide) |
Tribenzor criteria |
PA form |
| Tricor (fenofibrate) |
Step therapy medications criteria |
Tricor PA form and worksheet |
| Trilipix (fenofibric acid) |
Trilipix criteria |
Trilipix PA form and worksheet |
| Tygacil (tigecycline) |
Tygacil criteria |
PA form |
| Tykerb (lapatinib) |
Tykerb criteria |
PA form |
| Tysabri (natalizumab) |
Tysabri criteria |
PA form |
| Tyvaso (treprostinil) |
Tyvaso criteria |
PA form |
| Tyzeka (telbivudine) |
Tyzeka criteria |
PA form |
| Uloric (febuxostat) |
Uloric criteria |
PA form |
| Ultracet (tramadol acetaminophen) |
Ultracet criteria |
PA form |
| Valturna (aliskiren and valsartan) |
Valturna criteria |
PA form |
| Vancocin (vancomycin) |
Vancocin criteria |
PA form |
| Vectibix (panitumumab) |
Vectibix criteria |
PA form |
| Vectical (calcitriol) |
Vectical criteria |
PA form |
| Veltin Gel (clindamycin/tretinoin) |
Veltin Gel criteria |
PA form |
| Ventavis (iloprost) |
Ventavis criteria |
PA form |
| Veramyst (fluticasone) |
Step therapy medications criteria |
Steroid nasal sprays PA form and worksheet |
| Verdeso (desonide) |
Verdeso criteria |
PA form |
| Veregen (sinecatechins) |
Veregen criteria |
PA form |
| Vfend (voriconazole) |
Vfend criteria |
PA form |
| Victoza (liraglutide) |
Victoza criteria |
Victoza PA form and worksheet |
| Victrelis (boceprevir) |
Coming soon |
Victrelis (inital fill) PA form
Victrelis (renewal) PA form |
| Vidaza (azacitidine) |
Vidaza criteria |
PA form |
| Viibryd (vilazodone) |
Viibryd criteria |
PA form |
| Vimpat (lacosamide) |
Vimpat criteria |
PA form |
| Vimovo (naproxen and esomeprazole) |
Vimovo criteria |
PA form |
| Vivitrol (naltrexone) |
Vivitrol criteria |
PA form |
| Votrient (pazopanib) |
Votrient criteria |
PA form |
| Vpriv (velaglucerase) |
Vpriv criteria |
PA form |
| Vyvanse (lisdexamfetamine dimesylate) |
Vyvanse criteria |
Vyvanse PA form and worksheet |
| Xalkori (crizotinib) |
Xalkori criteria |
PA form |
| Xarelto (rivaroxaban) |
Xarelto criteria |
PA form |
| Xenazine (tetrabenazine) |
Xenazine criteria |
PA form |
| Xenical (orlistat) |
Xenical criteria |
PA form |
| Xeomin (incobotulinumtoxin A) |
Xeomin criteria |
PA form |
| Xerese (acyclovir 5% and hydrocortisone 1%) |
Xerese criteria |
PA form |
| Xgeva (denosumab) |
Xgeva criteria |
PA form |
| Xiaflex (collagenase clostridium histolyticum) |
Xiaflex criteria |
PA form |
| Xifaxan (rifaximin) |
Xifaxan criteria |
PA form |
| Xigris (drotrecogin alfa) |
Xigris criteria |
PA form |
| Xolair (omalizumab) |
Xolair criteria |
Xolair (initial fill) PA form and worksheet
Xolair (renewal) PA form and worksheet
|
| Xopenex (levalbuterol) |
Xopenex criteria |
Xopenex PA form and worksheet |
| Xyrem (sodium oxybate) |
Xyrem criteria |
PA form |
| Xyzal (levocetirizine) |
Xyzal criteria |
PA form |
| Yervoy (ipilimumab) |
Yervoy criteria |
PA form |
| Zanaflex (tizanidine) |
Zanaflex criteria |
Zanaflex PA form and worksheet |
| Zelapar (selegiline) |
Zelapar criteria |
PA form |
| Zelboraf (vemurafenib) |
Zelboraf criteria |
PA form |
| Zemaira (alpha-1 antiproteinase inhibitor) |
Zemaira criteria |
PA form |
| Zemplar (paricalcitol) |
Zemplar criteria |
PA form |
| Ziana Gel (clindamycin/tretinoin) |
Ziana Gel criteria |
PA form |
| Zinecard (dexrazoxane) |
Zinecard criteria |
PA form |
| Zithromax (azithromycin) |
Zithromax criteria |
PA form |
| Zofran (ondansetron) |
Zofran criteria |
Zofran PA form and worksheet |
| Zolinza (vorinostat) |
Zolinza criteria |
PA form |
| Zorbtive (somatropin) |
Zorbtive criteria |
PA form |
| Zytiga (abiraterone) |
Zytiga criteria |
PA form |
| Zyvox (linezolid) |
Zyvox criteria |
Zyvox PA form and worksheet |
| All other medications |
Standard Criteria for Medications without Specific Written Requirements |
PA form |