Prior Authorization Criteria

Prior Authorization Files

File Description Date
PA Criteria Chart Effective June 1, 2017 867.39 KB 2017/05/01

Prior Authorization Files Archive

File Description Date
PA Criteria Chart Effective April 1, 2017 870.9 KB 2017/02/20
PA Criteria Chart Effective March 1, 2017 855.2 KB 2017/02/07
PA Criteria Chart Effective January 1, 2017 853.17 KB 2017/01/09
PA Criteria Chart Effective January 1, 2017 853.13 KB 2016/11/22
PA Criteria Chart Effective October 1, 2016 833.69 KB 2016/08/23
PA Criteria Chart Effective August 1, 2016 853.91 KB 2016/08/03
PA Criteria Chart Effective June 1, 2016 803.52 KB 2016/05/25
PA Criteria Chart Effective June 1, 2016 809.89 KB 2016/05/02
PA Criteria Chart Effective April 11, 2016 763 KB 2016/03/28
PA Criteria Chart Effective April 11, 2016 763.19 KB 2016/03/09
PA Criteria Chart Effective January 7, 2016 753.38 KB 2016/01/07
PA Criteria Chart Effective January 1, 2016 751.52 KB 2015/12/01
PA Criteria Chart Effective October 1, 2015 339.76 KB 2015/09/02
PA Criteria Chart Effective August 4, 2015 686.05 KB 2015/08/04
PA Criteria Chart Effective July 6, 2015 686.26 KB 2015/06/10
PA Criteria Chart Effective June 1, 2015 756.41 KB 2015/04/23
PA Criteria Chart Effective January 9, 2015 303.25 KB 2015/01/05
PA Criteria Chart Effective January 1, 2015 303.01 KB 2014/11/24
PA Criteria Chart Effective November 3, 2014 287.67 KB 2014/11/03
PA Criteria Chart Effective October 14, 2014 277.23 KB 2014/10/15
PA Criteria Chart Effective October 1, 2014 280.37 KB 2014/08/22
PA Criteria Chart Effective July 21, 2014 217.07 KB 2014/06/17
PA Criteria Chart Effective June 1, 2014 441.48 KB 2014/04/24
PA Criteria Chart Effective April 1, 2014 213.49 KB 2014/02/27
PA Criteria Chart Effective January 1, 2014. 426.97 KB 2013/12/02
PA Criteria Chart Effective October 1, 2013 200.73 KB 2013/09/03
PA Criteria Chart Effective July 1, 2013 190.26 KB 2013/05/21
PA Criteria Chart Effective May 1, 2013 187.7 KB 2013/03/18
PA Chart Effective March 4, 2013 233.86 KB 2013/02/06
PA Criteria Chart Effective January 1, 2013 174.4 KB 2012/11/21
Preferred / Recommended Drug List Effective October 22, 2012 217.31 KB 2012/09/14
PA Criteria Chart Effective July 30, 2012 167.76 KB 2012/06/26
PA Criteria Chart Effective April 9, 2012 164.42 KB 2012/03/12
PA Criteria Chart Effective January 30, 2012 162.92 KB 2011/12/28
PA Criteria Chart Effective January 30, 2012 162.92 KB 2011/12/28
PA Criteria Chart Effective November 1, 2011 159.3 KB 2011/12/28
PA Criteria Chart Effective November 1, 2011 156.16 KB 2011/12/05
Intuniv1 6.52 KB 2011/11/01
Levemir 12.08 KB 2011/10/28
Viibryd 31.29 KB 2011/09/19
PA Criteria Chart Effective August 1, 2011 152.25 KB 2011/07/11
PA Criteria Chart Effective July 18, 2011 151.59 KB 2011/06/22
PA Criteria Chart Effective July 18, 2011 150.97 KB 2011/06/15
PA Criteria Chart Effective March 14, 2011 150.82 KB 2011/02/23
PA Criteria Chart Effective January 1, 2011 142.77 KB 2010/12/14
PA Criteria Chart Effective October 18, 2010 202.62 KB 2010/10/06
PA Criteria Chart Effective May 24, 2010 161.04 KB 2010/05/12
PA Criteria Chart Effective May 24, 2010 161.42 KB 2010/05/12
PA Criteria Chart Effective April 5, 2010 157.63 KB 2010/03/01
PA Criteria Chart Effective January 1, 2010 153.95 KB 2009/12/08
PA Criteria Chart Effective January 1, 2010 153.93 KB 2009/12/08
PA Criteria Chart Effective November 1, 2009 146.38 KB 2009/09/24
PA Criteria Chart Effective August 3, 2009 143.22 KB 2009/07/27
PA Criteria Chart Effective June 15, 2009 142.87 KB 2009/05/13
PA Criteria Chart Effective February 27,2009 141.03 KB 2009/02/25
PA Criteria Chart Effective January 1, 2009 140.99 KB 2009/02/25
PA Criteria Chart Effective January 1, 2009 140.9 KB 2009/01/19
PA Criteria Chart Effective October 27, 2008 139.99 KB 2008/11/20
PA Criteria Chart Effective October 27, 2008 139.99 KB 2008/11/20
PA Criteria Chart Effective October 27, 2008 141.17 KB 2008/10/29
PA Criteria Chart Effective July, 28 2008 139.93 KB 2008/07/21
PA Criteria Chart Effective April 30, 2008 140.1 KB 2008/04/16
PA Criteria Chart Effective February 18, 2008 71.53 KB 2008/04/16
PA Criteria Chart Effective October 29, 2007 145.93 KB 2008/04/16
PA Criteria Chart Effective07-30-2007 68.74 KB 2007/07/23
PA Criteria Chart Effective April 16, 2007 68.66 KB 2007/06/13
PA Criteria Chart Effective January 1, 2007 181.75 KB 2006/12/14
PA Criteria Chart Effective October 30, 2006 181.15 KB 2006/12/08
PA Criteria Chart Effective July 17, 2006 62.92 KB 2006/09/22
Prior Authorization Criteria Chart - 3-09-06 62.82 KB 2006/03/09
PA Criteria Chart Effective 1-16-06 59.99 KB 2006/02/16
Prior Authorization Criteria Chart 109.42 KB 2005/08/23