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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. |