Class-Specific Clinical Criteria

  1. ADHD Medications - Safe Use for All Ages (PDF)
  2. ADHD Medications (PDF)
  3. Adult Rheumatoid Arthritis Agents (PDF)
  4. Alpha1-Proteinase Inhibitors (PDF)
  5. Ankylosing Spondylitis Agents (PDF)
  6. Anti-Constipation Agents (PDF)
  7. Antidepressant Medications - Safe Use for All Ages (PDF)
  8. Antidepressant Medications (PDF)
  9. Anti-Emetics Cannabinoids (PDF)
  10. Antipsychotic Medications - Safe Use for All Ages (PDF)
  11. Antipsychotic Medications (PDF)
  12. Asthma Agents (PDF)
  13. Atopic Dermatitis Agents (PDF)
  14. Benzodiazepine Medications - Safe Use for All Ages (PDF)
  15. Benzodiazepine Medications (PDF)
  16. Beta Thalassemia Agents (PDF)
  17. Botulinum Toxins (PDF)
  18. Brand Medical Necessity (PDF)
  19. Calcimimetic Agents (PDF)
  20. Carisoprodol Containing Products (PDF)
  21. Chimeric Antigen Receptor T-Cell (CAR-T) Therapy Agents (PDF)
  22. Crohns Disease Agents PA Criteria (PDF)
  23. Diabetes Mellitus Type 2 Agents (PDF)
  24. Duchenne Muscular Dystrophy (DMD) Agents (PDF)
  25. Enzyme Replacement Therapy (PDF)
  26. Growth Hormone PA Criteria (PDF)
  27. Hemophilia Factors - Long-Acting (PDF)
  28. Hepatitis C Agents (PDF)
  1. High Cost Compounds PA Criteria (PDF)
  2. Hypercholesterolemia Agents (PDF)
  3. Intravenous Immune Globulins (IVIG) (PDF)
  4. Juvenile Idiopathic Arthritis (JIA) Agents (PDF)
  5. Migraine Acute Treatment Agents (PDF)
  6. Migraine Prophylaxis Agents (PDF)
  7. Minimum Requirements Prior Authorization (PDF)
  8. Monoamine Depletor (VMAT2 Inhibitors) (PDF)
  9. Multiple Sclerosis Agents (PDF)
  10. Narcolepsy Agents (PDF)
  11. Neuromyelitis Optica Spectrum Disorder (NMOSD) Agents (PDF)
  12. Oncology - Auxiliary Treatment Agents (PDF)
  13. Oncology Agents PA (PDF)
  14. Opioid Induced Constipation Agents (PDF)
  15. Opioid PA Criteria (PDF)
  16. Opioid Use Disorder (PDF)
  17. PCSK9 Inhibitors (PDF)
  18. Plaque Psoriasis (PsO) Agents (PDF)
  19. Psoriatic Arthritis Agents (PDF)
  20. Pulmonary Arterial Hypertension Agents (PDF)
  21. Rosacea Agents (PDF)
  22. Spinal Muscular Atrophy (SMA) (PDF)
  23. Systemic Lupus Erythematosus (SLE) Agents (PDF)
  24. Thyroid Eye Disease Agents (PDF)
  25. Topical and Buccal Androgen Hormone Agents (PDF)
  26. Tuberculosis Treatments (PDF)
  27. Ulcerative Colitis (UC) Agents (PDF)
  28. Weight Loss Drugs (PDF)