Drug Criteria
Miscellaneous Drug Criteria [403KB PDF]
5-ASA Derivatives Criteria [213KB PDF]
Abilify Maintena [141KB PDF]
Actemra Critera [136KB PDF]
Adcetris Criteria [176KB PDF]
Albumin PA Form [61KB PDF]
Aldurazyme Criteria [212KB PDF]
Alinia Criteria [195KB PDF]
Aloxi Crtieria [176KB PDF]
Altabax Criteria [137KB PDF]
Amerge Criteria [180KB PDF]
Amitiza Criteria [203KB PDF] Updated 5/15/2013
Ampyra Criteria [179KB PDF]
Androgel Criteria [194KB PDF]
Anticonvulsants Auto PA Form [239KB PDF]
Antidepressants (Age < 6 years) PA Form [111KB PDF]
Antipsychotic (Age 6 to <18) PA Form [137KB PDF]
Antipsychotic (Age <6) PA Form [99KB PDF]
Apokyn Criteria [191KB PDF]
Aralast Criteria [173KB PDF]
Aranesp Criteria [289KB PDF]
Arcalyst Criteria [112KB PDF]
Atrovent (nasal) Criteria [202KB PDF]
Aubagio Criteria [174KB PDF]
Axert Criteria [234KB PDF]
Banzel Criteria [208KB PDF]
Benlysta Criteria [111KB PDF]
Bepreve Directive [44KB PDF]
Bone Resorption Inhibitor Criteria [261KB PDF]
Boniva Injection Criteria [395KB PDF]
Botox PA Form [52KB PDF]
Brilinta Criteria [191KB PDF]
Butalbital Criteria [145KB PDF]
Butrans Crtieria [209KB PDF]
Carbaglu Crtieria [153KB PDF]
Carbamazepine ER Criteria Equetro and Carbatrol [180KB PDF]
Cayston Criteria [181KB PDF]
Ceprotin Criteria [168KB PDF]
Ceredase Criteria [199KB PDF]
Cerezyme Criteria [200KB PDF]
Chantix Criteria [168KB PDF]
Chorionic Gonadotropin Criteria [111KB PDF]
Cialis Criteria [197KB PDF]
CII-V Edit Override Criteria [234KB PDF]
Cinryze Criteria [174KB PDF]
Colcrys Criteria [208KB PDF]
Complera Criteria [100KB PDF]
Corifact Criteria [210KB PDF]
Cyanocablamin [84KB PDF]
Cystadene Criteria [59KB PDF]
Cytogam PA Form [75KB PDF]
Detrol Criteria [112KB PDF]
Diastat Criteria [261KB PDF]
Dibenzyline Criteria [112KB PDF]
Dificid Criteria [202KB PDF]
Duexis Criteria [97KB PDF]
Dulera Criteria [155KB PDF]
Edurant Critera [100KB PDF]
Effient Criteria [211KB PDF]
Elaprase Criteria [197KB PDF]
Elelyso Criteria [213KB PDF]
Eliquis Criteria [210KB PDF]
Elmiron Criteria [178KB PDF]
Embeda Criteria Recall [84KB PDF]
Emend Auto PA Form [180KB PDF]
Erwinase Criteria [113KB PDF]
Exjade Criteria [113KB PDF]
Extavia Criteria [96KB PDF]
Fabrazyme Criteria [212KB PDF]
Famciclovir Criteria [158KB PDF]
Fentanyl Criteria [112KB PDF]
Fentanyl (Transmucosal Immediate Release) Criteria [384KB PDF]
Fentanyl (Transmucosal Immediate Release) PA Form [55KB PDF]
Ferriprox Criteria [108KB PDF]
Firazyr Criteria [177KB PDF]
Folbalin and Folbic Criteria [98KB PDF]
Forteo Criteria [428KB PDF]
Frova Criteria [180KB PDF]
Fulzaq Criteria [185KB PDF]
Fuzeon PA Form [79KB PDF]
Gablofen Criteria [176KB PDF] New 5/7/2013
Gattex Criteria [174KB PDF]
Gilenya Criteria [175KB PDF] Updated 5/16/2013
Glucocorticoids Oral Criteria [192KB PDF]
Human Growth Hormone PA Form [89KB PDF] New 5/15/2013
H.P. Acthar Gel Criteria [285KB PDF]
HIV Auto PA Form [182KB PDF]
HIV Diagnosis Verification Form [76KB PDF]
Hizentra Criteria [333KB PDF]
Iclusig Criteria [175KB PDF]
Incivek and Victrelis Auto PA Form [177KB PDF]
Increlex PA Form [73KB PDF]
Infergen Auto PA Form [240KB PDF]
Inlyta Criteria [186KB PDF]
Invega Oral Criteria [141KB PDF]
Invega Sustenna Criteria [163KB PDF]
Istalol Directive [44KB PDF]
IVIG Letter [106KB PDF]
Jakafi Criteria [195KB PDF]
Jetrea Criteria [41KB PDF]
Juxtapid Criteria [174KB PDF]
Kalydeco Criteria [204KB PDF]
Kapvay Critieria [199KB PDF]
Kepivance Critieria [85KB PDF]
Kineret Criteria [111KB PDF]
Korlym Criteria [216KB PDF]
Kuvan Criteria [181KB PDF]
Kynamro Criteria [174KB PDF}
Kyprolis Criteria [41KB PDF]
LABA Criteria [247KB PDF]
Lacrisert Criteria [186KB PDF]
Leukine PA Form [152KB PDF]
Linzess Criteria [202KB PDF] New 5/15/2013
Lioresal Criteria [176KB PDF] Updated 5/7/2013
Makena Criteria [180KB PDF]
Maxalt Criteria [234KB PDF]
Metadate CD Criteria [117KB PDF]
Multi Source Brand Drug PA Form [48KB PDF]
Mozobil Criteria [296KB PDF]
Myobloc Criteria [31KB PDF]
Myfortic and Cellcept Criteria [112KB PDF]
Myrbetriq Criteria [66KB PDF]
Naglazyme Criteria [277KB PDF]
Natamycin Criteria [175KB PDF]
Natroba Crtieria [281KB PDF]
Neulasta PA Form [152KB PDF]
Neupogen PA Form [85KB PDF]
Neupro Criteria [246KB PDF]
Nimotop Criteria [175KB PDF]
Nplate Criteria [110KB PDF]
Nucynta Criteria [176KB PDF]
Nuedexta Criteria [184KB PDF]
Omontys Criteria [110KB PDF]
Onfi Criteria [208KB PDF]
Oral Oncology Criteria [389KB PDF}
Oral Oncology PA Form [56KB PDF]
Oravig Criteria [112KB PDF]
Orencia Criteria [224KB PDF]
Orfadin PA Form [74KB PDF]
Oxandrolone Criteria [153KB PDF]
Oxycontin Auto PA Form [236KB PDF]
Oxycontin PA Form [74KB PDF]
Panretin PA Form [59KB PDF]
Perjeta Criteria [171KB PDF]
Pomalyst Criteria [175KB PDF]
Potiga Criteria [238KB PDF] Updated 5/14/2013
Pradaxa Auto PA Form[175KB PDF]
Prevacid Criteria [309KB PDF]
Pristiq Criteria [21KB PDF]
ProCentra Criteria [178KB PDF]
Procrit Criteria [295KB PDF]
Prolastin-C Criteria [61KB PDF]
Proleukin PA Form [60KB PDF]
Prolia Criteria [313KB PDF]
Procrit/Aranesp PA Form [147KB PDF]
Promacta Criteria [46KB PDF]
Provigil PA Form [150KB PDF]
Pulmicort Criteria [223KB PDF]
Pulmonary Hypertension Agent Criteria [217KB PDF]
Pylera Criteria [13KB PDF]
Quillivant Criteria [177KB PDF]
Ravicti Criteria [77KB PDF]
Reclast Criteria [385KB PDF]
Rectiv Criteria [219KB PDF]
Regranex Criteria [190KB PDF]
Relistor Criteria [237KB PDF]
Relpax Criteria [235KB PDF]
Remicade Criteria [258KB PDF]
Risperdal Consta Criteria [96KB PDF]
Sabril Criteria [311KB PDF] Updated 5/8/2013
Samsca Criteria [202KB PDF]
Sanctura Criteria [113KB PDF]
Sancuso Criteria [150KB PDF]
Sandostatin LAR Criteria [216KB PDF]
Sedative Hypnotic Criteria [300KB PDF]
Selzentry PA Form [69KB PDF]
Sensipar Criteira [223KB PDF]
Seroquel Criteria [244KB PDF]
Serostim PA Form [86KB PDF]
Simponi Criteria [190KB PDF]
Skeletal Muscle Relaxants Criteria [224KB PDF]
Soliris Criteria [46KB PDF]
Soma PA Form [117KB PDF]
Stelara Criteria [276KB PDF]
Stivarga Criteria [109KB PDF]
Stribild Criteria [100KB PDF]
Suboxone PA Form [132KB PDF]
Sumatriptan Criteria [235KB PDF]
Supprelin LA Criteria [175KB PDF]
Supprelin LA PA Form [62KB PDF]
Sylatron Criteria [199KB PDF]
Synagis PA Form [96KB PDF]
Synagis Weight PA Form [116KB PDF]
Synribo Criteria [176KB PDF]
Targretin Criteria [205KB PDF]
Tecfidera Criteria [135KB PDF] Updated 5/20/2013
Tobi PA Form [75KB PDF]
Treximet Criteria [180KB PDF]
Tudorza Criteria [42KB PDF]
Tygacil Criteria [100KB PDF]
Valcyte Criteria [218KB PDF]
Valcyte PA Form [72KB PDF]
Veregen Criteria [113KB PDF]
Vfend PA Form [84KB PDF]
Vibativ Criteria [192KB PDF]
Victoza Criteria [220KB PDF]
Vimovo Criteria [180KB PDF]
Vitrase Directive [43KB PDF]
Vivitrol Criteria [9KB PDF]
Vpriv Criteria [212KB PDF]
Xalkori Criteria [178KB PDF]
Xarelto Criteria [218KB PDF]
Xeljanz Criteria [111KB PDF]
Xenazine Criteria [149KB PDF]
Xgeva Criteria [169KB PDF]
Xifaxan Criteria [222KB PDF]
Xolair Criteria [97KB PDF]
Xopenex Criteria [235KB PDF]
Xyrem Criteria [141KB PDF]
Xyzal Criteria [101KB PDF]
Yervoy Criteria [178KB PDF]
Zavesca Critieria [112KB PDF]
Zelboraf Criteria [178KB PDF]
Zemaira Criteria [60KB PDF]
Zetia Criteria [47KB PDF]
Zomig Criteria [180KB PDF]
Zortress Criteria [180KB PDF]
Zostavax Criteria [110KB PDF]
Zovirax Criteria [173KB PDF]
Zyperxa Relprevv [146KB PDF]
Zytiga Criteria [194KB PDF]
Zyvox Criteria [154KB PDF]
