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
| Drug | Additional PA Approval Criteria Number |
|---|---|
| Adlarity | 4 |
| Altuviio™ | 6 |
| Amjevita™ | 3 |
| Amvuttra | 6 |
| Aspruzyo Sprinkle™ | 6 |
| Briumvi | Package Insert |
| Carvykti | Package Insert |
| Dartisla ODT | 6 |
| Demser | Package Insert |
| Enjaymo™ | 6 |
| Entadfi™ | 6 |
| Ermeza | 1 |
| Fylnetra® | 1 |
| Givlaari | Package Insert |
| Hemgenix | Package Insert |
| Hyftor™ gel | Package Insert |
| Imcivree | Package Insert |
| Konvomep™ | 1 |
| Leqembi™ | 6 |
| Mounjaro™ | 2 |
| Pheburane® oral pellets | 6 |
| Pyrukynd | Package Insert |
| Quviviq™ | 1 |
| Radicava oral suspension | Package Insert |
| Recorlev® | Package Insert |
| Relyvrio oral suspension | Package Insert |
| Ryaltris® | 6 |
| Ryplazim | Package Insert |
| Spevigo® | Package Insert |
| Syfovre ™ | Package Insert |
| Tarpeyo | Package Insert |
| Tascenso ODT | 6 |
| Tezspire® Autoinjector | 3 |
| Tzield | Package Insert |
| Vegzelma® | 6 |
| Verkazia | 6 |
| Vijoice® | Package Insert |
| Vtama® | 6 |
| Xarelto suspension | Package Insert |
| Zoryve™ cream | 6 |
| Ztalmy® suspension | Package 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. |