List of Drugs Under Review

Medication must meet Package Insert requirements for FDA-approved indication, age, dose, and frequency, as well as the additional requirements outlined.

Drugs & Prior Authorization Criteria Number

DrugAdditional PA Approval Criteria Number
Brexafemme ® 
6
Bylvay ™ 
Package Insert Only
Dhivy™  tabs
6
Dyanavel® ER (tabs)
1
Elyxyb2
Gemtesa® 
1
Leqvio3
Livtencity™
6
Mavyret®  (pellets)
Package Insert
Myfembree®  
Package Insert
Myrbetriq® oral granules for suspension Package Insert
Opzelura™ 1% cream
1
Ozobax® solution
1
Saphnelo™ 
Package Insert
Skytrofa® 
1
TepezzaPackage Insert
Tezspire3
Thyquidity oral solution
6
Trudhesa™ 
2
Tyrvaya™ Nasal Spray
6
Voxzogo™ 
Package Insert
Winlevi® 1% cream
6
Xarelto suspensionPackage Insert


Criteria Descriptions

Criteria Number
Abbreviated Description
1
Falls into existing class/category on Preferred Drug List (PDL), subject to non-preferred PA process.
2
Falls into the existing Step Therapy class PA process.
3
Falls into both PDL and Step Therapy requirements (1 and 2).
4
Chemical drugs available in alternate existing dosage forms to be tried first.
5
Product is a racemic mix, single enantiomer or diastereomer, or isomer of available medication, or prodrug metabolized to available medication or active metabolite of available medication.
6
If the drug does not fall into mentioned categories, the patient must have an inadequate response to two or more medications FDA-approved for the same indication and/or medications that are considered the standard of care for the indication, when such agents exist.