Clinical Prior Authorization Edit Criteria


 
ADD/ADHD Medications 7/15/2013
Agents for Cystic Fibrosis 4/3/2013
Alinia (Nitazoxanide) 1/31/2011
Aliskiren-Containing Agents (Except Valturna) 6/18/2012
Allergen Extracts - Grastek/Oralair/Ragwitek 10/3/2013
Altabax (Retapamulin) 1/31/2011
Amitiza (Lubiprostone) 4/12/2012
Antiemetics 1/31/2011
Antipsychotics 6/14/2011
Anxiolytics and Sedatives/Hynotics 1/31/2011
Opiate/Benzodiazepine/Muscle Relaxant Combinations 10/3/2013
Byetta (Exenatide Injection) 1/31/2011
Carisoprodol 1/31/2011
Copaxone (Glatiramer) 7/7/2014
Cough/Cold Medications 8/6/2015
COX-2 Inhibitors 1/31/2011
Desmopressin 5/24/2012
Dextromethorphan Overutilization 7/18/2012
Drug Regimen Optimization 1/31/2011
Erythropoiesis-Stimulating Agents 8/23/2013
Fentanyl Agents 1/20/2017
Flexeril/Amrix (Cyclobenzaprine) 1/31/2011
Forteo 8/16/2015
Fosrenol (Lanthanum) 1/31/2011
Growth Hormone 1/31/2011
H.P. Acthar 11/24/2014
Hepatitis C Virus (Initial) 1/13/2017
Hepatitis C Virus (Refill) 1/13/2017
Imiquimod 4/11/2012
Increlex (Mecasermin) 1/31/2011
Injectable Pulmonary HTN Agents 11/24/2014
Ketorolac (Toradol) 7/12/2012
Leukotriene Modifiers 4/23/2015
Lidocaine Patches 1/29/2015
Lovaza (Omega-3-Acid Ethyl Esters) Capsules 6/5/2012
Makena 6/6/2015
Methylnaltrexone Bromide (Relistor) 8/23/2013
Neurontin (Gabapentin) 1/31/2011
Nuedexta (Dextromethorphan/Quinidine) 1/27/2017
Opiate Overutilization 1/31/2011
OxyContin (Oxycodone) 1/31/2011
PCSK9 Inhibitors 11/17/2016
Phenergan/Phenergan Containing Products (Promethazine) 1/31/2011
Propylthiouracil 3/9/2011
Provigil (Modafinil) 1/31/2011
Ranexa 4/3/2012
Revatio (Sildenafil) 1/31/2011
Savella 10/22/2015
Sitagliptin (Januvia) 1/31/2011
Suboxone/Subutex 3/27/2013
Symlin (Pramlintide Acetate) 1/31/2011
Synagis (Palivizumab) 1/31/2011
Thiazolidinediones 1/31/2011
Topical Immunomodulators 1/31/2011
Victoza (Liraglutide) Solution for Injection 7/8/2012
Xenazine 3/3/2014
Xenical (Orlistat) 2/9/2004
Xifaxan (Rifaximin) 1/31/2011
Xyrem 3/9/2011
Zelboraf 1/8/2014