Class-Specific Clinical Criteria

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