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- List of Drugs Under Review
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.
AMHMR Prior Authorization Criteria (PDF)
Drugs & Prior Authorization Criteria Number
Drug | Additional PA Approval Criteria Number |
---|---|
Adlarity | 4 |
Adstiladrin® | Package Insert |
Airsupra™ | 6 |
Ala-Scalp® | 1 |
Altuviio™ | 6 |
Aspruzyo Sprinkle™ | 6 |
Austedo® XR | 4 |
Clemastine syrup | 4 |
Cosentyx® UnoReady | 2 |
Cuvrior™ | 6 |
Cyltezo® | 3 |
Demser | Package Insert |
Elevidys™ | Package Insert |
Enjaymo™ | 6 |
Entadfi™ | 6 |
Fiasp® PumpCart | 1 |
Hadlima™ | 3 |
Hulio® | 3 |
Hyftor™ gel | Package Insert |
Hyrimoz® | 3 |
Idacio® | 3 |
Imcivree | Package Insert |
Inpefa™ | 6 |
Joenja® | Package Insert |
Lumryz™ | 2 |
Lymepak™ | 1 |
Lyuzeh™ | 1 |
Metformin 625mg tablet | 1 |
Miembo™ | 1 |
Ngenla® | 1 |
Olpruva™ | 6 |
Omisirge® | Package Insert |
Pheburane® oral pellets | 6 |
Pradaxa® sprinkle | 4 |
Pyrukynd | Package Insert |
Qalsody™ | Package Insert |
Relyvrio oral suspension | Package Insert |
Roctavian™ | Package Insert |
Ryaltris® | 6 |
Ryplazim | Package Insert |
Rystiggo® | Package Insert |
Skyclarys® | Package Insert |
Skysona® | Package Insert |
Sogroya® | 3 |
Sohonos™ | Package Insert |
Spevigo® | Package Insert |
Suflave™ | 1 |
Syfovre ™ | Package Insert |
Trikafta® packets | Package Insert |
Tzield | Package Insert |
Valsartan solution | 4 |
Vegzelma® | 6 |
Veopoz® | Package Insert |
Veozah™ | 6 |
Verkazia | 6 |
Vijoice® | Package Insert |
Vtama® | 6 |
Vyjuvek™ | Package Insert |
Vyvgart® Hytrulo | Package Insert |
Yuflyma™ | 3 |
Zavzpret™ | 3 |
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. |