Clinical Criteria
Select the starting letter of the medication to find the desired form. Drug coverage is dependent on member’s formulary.
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Exceptions
Select the starting letter of the medication to find the desired form. Drug coverage is dependent on member’s formulary.
A
B
C
E
F
G
H
J
K
L
M
N
O
P
Q
R
S
T
V
W
X
Y
Z
State-Specific Criteria
The following medications may need approval:
- Aimovig
- Ajovy
- Emgality
- Ubrelvy
- Nurtec
- Aptivus
- Invirase
- Prezista
- Penicillamine
- Zonalon
Use the links below to access the criteria by state.