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Documents

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Documents

Title
Title
Dose Optimization Program
Maintenance Medications
Non-Legend Drug List
Preferred Drug List - effective 09/01/2022
Quantity Limit Program

Fax Forms

Title	Revision Date
Title	Revision Date
Adenosine Triphosphate-Citrate Lyase Medications Prior Authorization Drug Approval Form	07/12/2022
Allergen Extract Medications Prior Authorization Drug Approval Form	08/13/2021
Anti-Fungal Medication for Onychomycosis Prior Authorization/Non-Preferred Drug Approval Form	07/12/2022
Asthma/Allergy Immunomodulators Prior Authorization Drug Approval Form	07/12/2022
Atopic Dermatitis Prior Authorization Drug Approval Form	07/12/2022
Benign Prostatic Hyperplasia Prior Authorization/Non-Preferred Drug Approval Form	08/13/2021
Bowel Disorder Drugs Prior Authorization Drug Approval Form	08/13/2021
Brand Name Multiple Source Prescription Drugs Prior Authorization/Non-Preferred Drug Approval Form	07/12/2022
Buprenorphine/Naloxone and Buprenorphine (Oral) Prior Authorization Drug Approval Form	07/12/2022
Calcitonin Gene-Related Peptide (CGRP) Inhibitor Prior Authorization Drug Approval Form	01/14/2022
Carisoprodol and Combination Medications Prior Authorization Drug Approval Form	07/12/2022
CNS Stimulant and ADHD/ADD Medication Prior Authorization Drug Approval Form	07/12/2022
Codeine for Pediatric Use Prior Authorization Drug Approval Form	01/14/2022
Convenience Kits Prior Authorization Drug Approval Form	01/14/2022
Direct Renin Inhibitors and Combinations Prior Authorization Drug Approval Form	08/13/2021
Duchenne Muscular Dystrophy Medications Prior Authorization Drug Approval Form	08/13/2021
Duloxetine Prior Authorization Drug Approval Form	07/12/2022
Dupixent Prior Authorization Drug Approval Form	01/14/2022
Evrysdi Prior Authorization Drug Approval Form	08/13/2021
Fibromyalgia Prior Authorization Drug Approval Form	07/12/2022
Growth Hormones Prior Authorization Drug Approval Form	07/12/2022
Hematopoietic Agent Prior Authorization Drug Approval Form	08/13/2021
Hepatitis C Medications Prior Authorization Drug Approval Form	01/14/2022
Hetlioz Prior Authorization Drug Approval Form	07/12/2022
Horizant Prior Authorization Drug Approval Form	07/12/2022
Hyaluronic Acid Derivatives Injection Prior Authorization Drug Approval Form	01/14/2022
Inhaled Insulin Medications Prior Authorization Drug Approval Form	07/12/2022
Juxtapid Prior Authorization Drug Approval Form	01/14/2022
Long Acting Opioid Analgesics Prior Authorization Drug Approval Form	07/12/2022
Methadone Prior Authorization Drug Approval Form	02/24/2021
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease Prior Authorization Drug Approval Form	07/12/2022
Morphine Milligram Equivalent (MME) Prior Authorization Drug Approval Form	07/12/2022
Movement Disorder Medications Prior Authorization Drug Approval Form	07/12/2022
New Drug Product Medication Request Prior Authorization Drug Approval Form	07/12/2022
Non-Preferred Drug Approval Form	04/09/2019
Oral Isotretinoin Medications Prior Authorization Drug Approval Form	07/12/2022
Pregabalin Prior Authorization Drug Approval Form	07/12/2022
Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Prior Authorization Drug Approval Form	07/12/2022
Psychoactive Medications for Children (5 years of age or younger) Prior Authorization Drug Approval Form	07/12/2022
Psychotropic Medications Duplicate Therapy (6 years of age or older) Prior Authorization Drug Approval Form	07/12/2022
Pulmonary Arterial Hypertension (Phosphodiesterase type-5 (PDE-5) Inhibitors only) Prior Authorization/Non-Preferred Drug Approval Form	01/14/2022
Rho Kinase Inhibitor Prior Authorization Drug Approval Form	01/14/2022
Second-Line Antifungal Prior Authorization Drug Approval Form	07/12/2022
Short Acting Fentanyl Analgesic Prior Authorization Drug Approval Form	08/13/2021
Spinraza Prior Authorization Drug Approval Form	01/14/2022
Spravato Prior Authorization Drug Approval Form	08/13/2021
Stromectol Prior Authorization Drug Approval Form	01/14/2022
Symlin Prior Authorization Drug Approval Form	07/12/2022
Synagis Prior Authorization Drug Approval Form	07/12/2022
Systemic Immunomodulators Medications Prior Authorization Drug Approval Form	07/12/2022
Verquvo Prior Authorization Drug Approval Form	07/12/2022
Vuity Prior Authorization Drug Approval Form	07/12/2022
Weight Management Prior Authorization Drug Approval Form	01/14/2022
Zolgensma Prior Authorization Drug Approval Form	07/12/2022

Clinical PA Criteria

Title	Date
Title	Date
Adenosine Triphosphate-Citrate Lyase Criteria	07/12/2022
Allergen Extract Criteria	08/13/2021
Anti-Fungal Medication for Onychomycosis Criteria	07/12/2022
Asthma/Allergy Immunomodulator Criteria	07/12/2022
Atopic Dermatitis Criteria	07/12/2022
Benign Prostatic Hyperplasia Criteria	08/13/2021
Bowel Disorders/GI Motility, Chronic Criteria	08/13/2021
Brand Name Multiple Source Prescription Drug Product Criteria	07/12/2022
Buprenorphine/Naloxone and Buprenorphine (Oral) Criteria	07/12/2022
Calcitonin Gene-Related Peptide (CGRP) Inhibitor Criteria	01/14/2022
Carisoprodol and Combination Medication Criteria	07/12/2022
CNS Stimulant and ADHD/ADD Medications Criteria	07/12/2022
Codeine for Pediatric Use Criteria	01/14/2022
Convenience Kits Criteria	01/14/2022
Direct Renin Inhibitor and Combination Criteria	08/13/2021
Duchenne Muscular Dystrophy Criteria	08/13/2021
Duloxetine Criteria	07/12/2022
Dupixent Criteria	01/14/2022
Evrysdi Criteria	08/13/2021
Fibromyalgia Criteria	07/12/2022
Hematopoietic Agent Criteria	08/13/2021
Hepatitis C Criteria	01/14/2022
Hetlioz Criteria	07/12/2022
Horizant Criteria	07/12/2022
Human Growth Hormones Criteria	07/12/2022
Hyaluronic Acid Derivatives Injection Criteria	01/14/2022
Inhaled Insulin Criteria	07/12/2022
Juxtapid Criteria	01/14/2022
Long-Acting Opioid Analgesic Criteria	07/12/2022
Methadone (Pain Management Only) Criteria	07/12/2022
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease Criteria	07/12/2022
Morphine Milligram Equivalent Criteria	07/12/2022
Movement Disorders Criteria	07/12/2022
New Drug Product Criteria	07/12/2022
Oral Isotretinoin Criteria	07/12/2022
Pregabalin Criteria	07/12/2022
Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Criteria	07/12/2022
Psychoactive Medication for Children (5 Years of Age or Younger) Criteria	07/12/2022
Psychotropic Medication Duplicate Therapy (Patients 6 Years and Older) Criteria	07/12/2022
Pulmonary Arterial Hypertension Criteria Phosphodiesterase Type 5 (PDE-5) Inhibitors Only	01/14/2022
Rho Kinase Inhibitor Criteria	01/14/2022
Second-Line Antifungal Criteria	07/12/2022
Short-Acting Fentanyl Analgesic Criteria	08/13/2021
Spinraza (nusinersen) Criteria	01/14/2022
Spravato Criteria	08/13/2021
Stromectol Criteria	01/14/2022
Symlin Criteria	07/12/2022
Synagis Criteria	07/12/2022
Systemic Immunomodulator Criteria	07/12/2022
Verquvo Criteria	07/12/2022
Vuity Criteria	07/12/2022
Weight Management Criteria	01/14/2022
Zolgensma Criteria	07/12/2022