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Retired Criteria
-
Amitiza and Linzess Criteria |
Form |
ePA |
Effective thru 12/31/23 -
Belsomra Criteria |
Form |
ePA |
Effective thru 6/14/20
-
Bimzelx Criteria
-
Benlysta Criteria |
Form |
ePA
-
Botulinum Toxin Products (JCode only) Criteria |
Form,
Service Auth |
ePA |
Effective thru 10/2/16
-
Calcium Criteria (retired) |
ePA
-
Celebrex Criteria (retired) [NSAID] |
Form |
ePA
-
CGRP Inhibitors Criteria |
Form |
ePA |
Effective thru 11/15/20
-
Corlanor Criteria (retired) |
Form |
ePA
-
Cosentyx Criteria (retired) |
Form |
ePA
-
Diclegis Criteria |
Form |
ePA |
Effective thru 5/31/22
-
Dupixent Criteria |
Form |
ePA
-
Dupixent Criteria |
Form |
ePA |
Effective 11/1/22
-
Eliquis Criteria (retired) |
ePA
-
Entyvio Criteria |
Form |
ePA |
Effective thru 12/31/23
-
Entyvio Criteria |
Form |
ePAEffective thru 2/28/23
-
Epidiolex Criteria |
Form |
ePA |
Effective thru 11/15/20
-
Eucrisa Criteria (retired) |
Form |
ePA |
Effective thru 3/14/21
-
Eucrisa Criteria (retired)|
Form |
ePA |
Effective 3/15/21
-
Firadapse/Ruzurgi Criteria |
Form |
ePA |
Effective thru 1/1/23
-
Folic acid 1mg Criteria (retired) |
ePA
-
Hepatitis C Direct Acting Antivirals for Chronic Hepatitis C Criteria - All Products and Genotypes |
Form |
ePA |
Effective 1/4/22
-
Hetlioz Criteria |
Form |
ePA
-
H.P. Acthar Gel Criteria |
Form |
ePA |
Effective thru 10/2/16
-
H.P. Acthar Gel Criteria |
Form |
ePA |
Effective thru 1/14/19
-
Human Growth Hormone Criteria |
Form |
ePA |
Effective through 1/1/23
-
Hydromorphone Criteria |
Form |
ePA |
Effective thru 1/5/20
-
Interleukin-5 inhibitor Criteria |
Form |
ePA |
Effective thru 1/10/21
-
Interleukin-5 Inhibitors Criteria |
Form |
ePA |
Effective thru 3/1/22
-
Interleukin-5 Inhibitor Criteria (Nucala, Cinqair, Fasenra) |
Form |
ePA |
Effective 1/11/21
-
Jynarque Criteria |
Form |
ePA |
Effective thru 5/31/22
-
Kalydeco Criteria |
Form |
ePA |
Effective thru 10/2/16
-
Kerendia Criteria |
Form |
ePA |
Effective thru 12/31/23
-
Lidoderm (lidocaine) patch Criteria (retired) |
Form |
ePA | Effective thru 10/2/16
-
Lidoderm (lidocaine) patch Criteria (retired) |
Form |
ePA |
Effective thru 10/2/16
-
Lidoderm (lidocaine) patch Criteria (retired) |
Form |
ePA |
Effective thru 10/2/16
-
Long-acting Beta Agonist Criteria [BRONCHODILATORS]
(retired) |
Form |
ePA
-
Lovaza Criteria |
Form |
ePA |
Effective thru 3/14/21
-
Magnesium Criteria (retired) |
ePA
-
MAT Provider Attestation Form,
Form |
ePA |
Effective thru 5/31/23
-
Makena Criteria |
Form |
ePA
-
Mayzent Criteria |
Form |
ePA
- Ocrevus Criteria | Form | ePA
-
Onfi Criteria |
Form |
ePAEffective 3/1/23
-
Onfi Criteria [ANTICONV] |
Form |
ePA |
Effective thru 11/19/19
-
Onsolis (fentanyl) Criteria |
Form |
ePA
-
Opzelura Criteria |
Form |
ePA
-
Oral Buprenorphine-based Medication Assisted Therapy (MAT) Criteria;
Office-Based Opioid Treatment (OBOT) (e.g., Bunavail, Suboxone, Subutex, Zubsolv) |
Effective thru 5/31/23
-
Orexn Criteria |
Form |
ePA |
Effective thru 5/31/22
-
Orilissa, Orihann, Myfembree Criteria |
Form |
ePA |
-
Orkambi Criteria |
Form |
ePA |
Effective thru 6/9/19
-
Oxbryta Criteria |
Form |
ePA
-
Oxycodone Criteria,
immediate release |
Form |
ePA |
Effective thru 1/5/20
-
PCSK9 Inhibitors (Praluent and Repatha) Criteria |
Form |
ePA
-
Pradaxa Criteria (retired) |
ePA
-
Proton Pump Inhibitors Criteria(retired) |
Form |
ePA
-
Relistor (methylnaltrexone) Criteria |
Form |
ePA |
Effective thru 11/19/19
-
Second Generation Non-Sedating Antihistamines Criteria (retired) |
Form |
ePA
-
Serostim Criteria |
Form |
ePA |
Effective thru 10/2/16
-
Soliris, Ultomiris Criteria |
Form |
ePA |
-
Sphingosine 1-phosphate receptor modulators Criteria |
Form |
ePA
-
Stelara Criteria [CAM] |
Form |
ePA |
Effective thru 6/9/19
-
Strensiq Criteria |
Form |
ePA |
Effective thru 12/31/23
-
Suboxone and Subutex Criteria (retired) |
ePA |
Effective thru 11/11/18+
-
Synagis, 2023-2024 Criteria |
Form |
ePA
-
Tecfidera (dimethyl fumarate) Criteria (retired) |
Form |
ePA
-
TOBI Podhaler Criteria (retired) |
Form |
ePA
-
Vancocin (vancomycin) Criteria (retired) |
Form |
ePA
-
Vascepa and Lovaza Criteria |
Form |
ePA |
Effective thru 3/14/21
-
Vesicular Monoamine Transporter 2 Inhibitors Criteria
(Austedo, Austedo XR, Ingrezza, Xenazine) |
Form |
ePA -
Victrelis Criteria (retired) |
ePA
-
Vitamin E Criteria (retired) |
ePA
-
Xarelto Criteria (retired) |
ePA
-
Xifaxan (rifaximin) Criteria |
Form |
ePA |
Effective thru 10/2/16
-
Xolair Criteria (retired) |
Form |
ePA
-
Xolair Criteria (retired) |
Form |
ePA |
Effective 11/1/22
-
Xyrem Criteria |
Form |
ePA |
Effective thru 1/10/21
-
Zyvox (linezolid) Criteria(retired) |
Form |
ePA