Pharmacy Prior Authorization Guidelines

Acne Agents, Topical

Alpha-1 Proteinase Inhibitors

Alzheimer's Agents

Analgesics, Narcotic, Long-Acting

Analgesics, Narcotic, Short-Acting

Analgesics, Non-Narcotic Barbiturate Combinations

Androgenic Agents

Angiotensin Modulators

Angiotensin Modulators Combinations

Anti-Allergens, Oral

Antibiotics, GI  

Antibiotics, Inhaled

Antibiotics, Topical

Antibiotics, Vaginal


Anticonvulsants, Oral

Antidepressants, Other

Antidepressants, SSRIs

Antiemetics/Antivertigo Agents

Antifungals, Oral

Antifungals, Topical

Antihistamines, Minimally Sedating

Antihypertensives, Sympatholytic


Antimigraine Agents, Other

Antimigraine Agents, Triptans

Antiparasitics, Topical

Antiparkinson's Agents

Antipsoriatics, Oral

Antipsoriatics, Topical


Antivirals, Oral

Antivirals, Topical


Benign Prostatic Hyperplasia (BPH) Treatment


Bile Salts

Bladder Relaxant Preparations

Bone Resorption Suppression and Related Agents

Botulinum Toxins

Bronchodilators, Beta Agonist

Calcium Channel Blockers

Cephalosporins and Related Agents

Colony Stimulating Factors

Compounded Prescriptions

Contraceptives, Oral

Contraceptives, Other

COPD Agents

Corlanor (ivabradine)

Cough and Cold Medications

Cytokine and CAM Antagonists

Diabetic Meters

Diabetic Strips

Early Refill of Prescriptions


Enzyme Replacement, Gauchers Disease

Epinephrine, Self-Injected

Erythropoiesis Stimulating Proteins

Fluoroquinolones, Oral

G.I. Motility, Chronic Agents (Formerly Irritable Bowel Syndrome Agents)

Glucocorticiods, Inhaled

Glucocorticiods, Oral

Growth Factors

Growth Hormones

H.P. Acthar Gel (corticotropin)

H. Pylori Treatments

Hepatitis B Agents

Hepatitis C Agents

Hereditary Angioedema (HAE) Agents

Histamine II Receptor Blockers

HIV/AIDS Medications

Hypoglycemics, Alpha-Glucosidase Inhibitors

Hypoglycemics, Incretin Mimetics/Enhancers

Hypoglycemics, Insulins and Related Agents

Hypoglycemics, Meglitinides

Hypoglycemics, Metformins

Hypoglycemics, SGLT2 Inhibitors

Hypoglycemics, Sulfonylureas

Hypoglycemics, TZDs

Idiopathic Pulmonary Fibrosis Agents

Immune Globulins

Immunomodulators, Atopic Dermatitis

Immunomodulators, Topical

Immunosuppressive, Oral

Intra-Articular Hyaluronic Acid Agents

Intranasal Rhinitis Agents

Iron, Oral

Iron, Parenteral

Kalydeco (ivacaftor)

Korlym (mifepristone)

Leukotriene Modifiers

Lipotropics, Other Than Statins



Macular Degeneration Agents

Makena (hydroxyprogesterone caproate)


Mozobil (plerixafor)

Multiple Sclerosis Agents

Neuopathic Pain Agents

Nitrofuran Derivatives

Nplate (romiplostim)


Nucala (mepolizumab)

Nuedexta (dextromethorphan/quinidine)

Oncology Agents, Breast Cancer

Oncology Agents, Oral

Ophthalmics for Allergic Conjunctivitis

Ophthalmic Antibiotics

Ophthalmics, Antibiotic-Steroid Combinations

Ophthalmics for Glaucoma

Ophthalmic Anti-Inflammatories

Orkambi (lumacaftor/ivacaftor)

Opiate Dependence Treatments

Opiate Overdose Agents

Otic Antibiotic Preparations

Otic Anti-Infectives & Anesthetics

Pancreatic Enzymes

Phosphate Binders

Pituitary Suppressive Agents, LHRH

Platelet Aggregation Inhibitors

Prenatal Vitamins

Promacta (eltrombopag)

Progestational Agents

Proton Pump Inhibitors (PPIs)

Provenge (sipuleucel-T)

Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled

Quantity Limits/Daily Dose Limits

Ranexa (ranolazine)

Rilutek (riluzole)

Santyl Ointment (collagenase)

Sedative Hypnotics

Skeletal Muscle Relaxants

Smoking Cessation

Soliris (eculizumab)

Steroids, Topical High

Steroids, Topical Low

Steroids, Topical Medium

Steroids, Topical Very High

Stimulants and Related Agents

Synagis (palivizumab)


Thalidomide and Derivatives

Thyroid Hormones

Tysabri (natalizumab)

Ulcerative Colitis Agents

Vasodilators, Coronary

Vecamyl (mecamylamine)

Xenazine (tetrabenazine)

Xofigo (radium Ra 223 dichloride)

Xolair (omalizumab)

Xyrem (sodium oxybate)