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
Adlarity4
Brexafemme ® 6
Bylvay  Package Insert 
CarvyktiPackage Insert
Cibingo2
Dartisla ODT6
DemserPackage Insert
Dhivy  tabs6
Dyanavel® ER (tabs)1
Elyxyb2
Enjaymo™ 6
Fleqsuvy1
Gemtesa1
Leqvio3
LivtencityPackage Insert
Mounjaro™ 2
Myrbetriq® oral granules for suspension Package Insert
PyrukyndPackage Insert
Recorlev®Package Insert
RyplazimPackage Insert
TarpeyoPackage Insert
TepezzaPackage Insert
Trudhesa2
Twyneo1
Tyvaso DPI1
Vijoice®Package Insert
Voxzogo Package Insert
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.