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Home
PDL / PA
expand_more
Preferred Drug Lists
PA Forms
Prior Authorization Criteria
New Drug Process
Policy for Review of Drug Status
Appeals & Exception to Policy
CDC Guidelines
(External link)
Info Letters / Provider Info
expand_more
Informational Letters
Latest news
Listserv
Fax Confidentiality Certificate
Billing Information
expand_more
Billing / Quantity Limits
340B
Frequently Asked Questions
Payer Sheet
Committee / Public Comments
expand_more
P&T Committee Information
Public Comments
Drugs for Rare Diseases
Rebate Info
expand_more
expand_more
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Section
Prior Authorization Criteria
Current
PA Criteria Chart Effective January 1, 2025
Archive
PA Criteria Chart Effective January 1, 2025
PA Criteria Chart Effective October 1, 2024
PA Criteria chart - effective July 1, 2024
PA Criteria chart - Effective June 1, 2024
PA Criteria chart - Effective January 1, 2024
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