Prior Authorization Criteria
Select the starting letter of the medication to find the desired form. Drug coverage is dependent on member’s formulary.
A
B
D
F
H
I
J
K
L
N
O
Q
R
S
U
W
X
Y
Z
Exceptions
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
V
W
X
Y
Z
Criteria Effective Dates
State-Specific Criteria
Universal States Mandate Stage IV Cancer (AR, LA, MD, MN, GA, CT, CO, IL, ND, PA, TX, OH)