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
Amvuttra6
Aspruzyo Sprinkle™ 
6
Calquence tabletsPackage Insert
CarvyktiPackage Insert
Dartisla ODT6
DemserPackage Insert
Enjaymo™ 6
Entadfi6
Fylnetra®1
Hyftor™ gelPackage Insert
Imbruvica suspensionPackage Insert
Mounjaro™ 2
Pheburane® oral pellets6
PyrukyndPackage Insert
Quviviq1
Recorlev®Package Insert
Rolvedon3
Ryaltris®6
RyplazimPackage Insert
Sotyktu3
Spevigo®Package Insert
TarpeyoPackage Insert
TepezzaPackage Insert
Verkazia6
Vijoice®Package Insert
Vtama® 6
Xarelto suspensionPackage Insert
Xelstrym1
XenopozymePackage Insert
Zoryve™ cream6
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.