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Use the Formulary Search function to search for formulary drugs and view the criteria used to evaluate a prior authorization for a specific drug and the alternate therapies (where applicable) that are allowed.

To begin, type the name of the drug you wish to search for in the Search field. If necessary, you may type partial text, for example, type res to display a list of drugs containing the letters “res” anywhere in its name. Click Search to view a list of drugs matching your search description.

For each drug that is displayed in the list, you may:

  • Click Alternatives to view a list of all associated alternatives for the drug and the PDL status of each alternative.
  • Click Criteria Rules to view the criteria used to evaluate a prior authorization request for the selected drug.

Clinical Criteria
ADD/ADHD Agents (Revised March 2, 2021)*
Alinia (Revised February 17, 2021)*
Aliskiren Containing Agents (Pending Implementation) (Revised February 17, 2021)
Aliskiren Containing Agents (Revised March 21, 2019)*
Allergen Extracts (Revised December 10, 2019)*
Altabax (Revised February 17, 2021)*
Amantadine ER (Pending Implementation) (Revised January 27, 2021)*
Androgenic Agents (Pending Implementation) (Revised March 21, 2019)*
Antiemetic Agents (Revised February 17, 2021)*
Antipsychotic Agents (Revised February 17, 2021)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised April 30, 2021)*
Anxiolytics and Sedative-Hypnotics (Revised March 22, 2019)*
Arikayce (Pending Implementation) (Revised February 17, 2021)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised March 1, 2021)*
Buprenorphine Agents (Revised March 22, 2019)*
Carisoprodol Overuse (Revised March 26, 2019)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised May 23, 2019)*
CGRP Antagonists, Acute (Pending Implementation) (Revised October 28, 2020)*
CGRP Antagonists, Chronic (Pending Implementation) (Revised August 29, 2019)*
CNS Stimulants (Revised October 29, 2019)*
Colcrys (Pending Implementation) (Revised February 17, 2021)*
Cough & Cold Agents (Revised March 10, 2020)*
COX-2 Inhibitors (Revised February 18, 2021)*
Cyclobenzaprine (Revised March 27, 2019)*
Cymbalta (Pending Implementation) (Revised January 30, 2020)*
Cystic Fibrosis Agents (Revised January 20, 2021)
Cytokine and CAM Antagonists (Revised March 2, 2021)*
Desmopressin (Revised December 21, 2020)*
Dextromethorphan Overutilization (Revised December 30, 2019)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diacomit (Pending Implementation) (Revised August 20, 2020)*
Diclofenac (Pending Implementation) (Revised March 27, 2019)*
Dopamine Agonists (Pending Implementation) (Revised January 22, 2021)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised October 29, 2019)*
DPP4 Inhibitors (Revised March 27, 2019)*
Drug Regimen Optimization (Pending Implementation) (Revised November 11, 2019)*
Drug Regimen Optimization (Revised September 16, 2019)*
Dupixent (Revised March 3, 2021)*
Duplicate Therapy (Revised April 27, 2021)*
Emflaza (Revised July 3, 2019)*
Enzymes (Pending Implementation) (Revised April 5, 2021)*
Enzymes (Revised September 11, 2019)*
Epidiolex (Pending Implementation May 11, 2021) (Revised February 25, 2021)*
Erythropoiesis-Stimulating Agents (Revised October 7, 2020)*
Evrysdi (Pending Implementation) (Revised January 22, 2021)*
Fentanyl Agents (Revised February 18, 2021)*
Forteo (Pending Implementation) (Revised March 28, 2019)*
Gabapentin Agents (Revised March 29, 2019)*
Gaucher's Disease Agents (Pending Implementation) (Revised July 15, 2019)*
GI Motility Agents (Pending Implementation) (Revised July 30, 2019)*
GI Motility Agents (Revised March 29, 2019)*
Glatiramer Acetate Injection (Pending Implementation) (Revised July 15, 2019)*
GLP-1 Receptor Agonists (Revised April 12, 2021)*
Growth Hormone Agents (Revised February 20, 2020)*
Growth Hormone Quick Reference Guide
HAE Agents (Pending Implementation) (Revised April 23, 2021)*
Hemady (Pending Implementation) (Revised March 29, 2021)*
HP Acthar (Pending Implementation) (Revised July 24, 2020)*
HP Acthar (Revised July 15, 2019)*
Hyperlipidemia Agents (Formerly PCSK9 Inhibitors) (Revised March 29, 2019)*
Hyperlipidemia Agents (Pending Implementation) (Revised April 23, 2021)*
Imiquimod (Revised March 29, 2019)*
Increlex (Revised March 29, 2019)*
Inhaled Antibiotics (Pending Implementation) (Revised February 13, 2020)*
Ketorolac (Revised March 29, 2019)*
Keveyis (Pending Implementation) (Revised March 29, 2019)*
Leukotriene Modifiers (Revised July 15, 2019)*
Lidocaine Patches (Pending Implementation) (Revised July 15, 2019)*
Lovaza (Revised April 30, 2021)*
Lyrica (Pending Implementation) (Revised June 26, 2020)*
Makena (Revised May 14, 2019)*
Monoclonal Antibody Agents for Asthma (Revised February 1, 2021)*
Multiple Sclerosis Agents (Pending Implementation) (Revised April 23, 2021)*
Nuedexta (Revised March 29, 2019)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Ophthalmic Immunomodulators (Pending Implementation) (Revised June 30, 2020)*
Opiate Overutilization (Revised July 27, 2020)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised January 30, 2020)*
Opioid Policy Criteria (Formerly MME criteria) (Revised July 20, 2020)*
Oriahnn (Pending Implementation) (Revised October 28, 2020)*
Orilissa (Pending Implementation) (Revised March 29, 2019)*
Oxervate (Pending Implementation) (Revised July 24, 2020)*
Oxycontin / Narcotic Analgesic (Revised March 29, 2019)*
Palforzia (Pending Implementation) (Revised August 24, 2020)*
PDE5-Inhibitors (Revised November 8, 2019)*
Phosphate Binders (Revised January 30, 2020)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Promethazine Utilization (Revised March 29, 2019)*
Propylthiouracil (Revised March 29, 2019)*
Proton Pump Inhibitors (Pending Implementation) (Revised March 29, 2019)*
Pulmonary Hypertension Agents (Pending Implementation) (Revised February 13, 2020)*
Ranexa (Revised March 29, 2019)*
Retinoids (Pending Implementation) (Revised July 15, 2020)*
Savella (Pending Implementation) (Revised March 29, 2019)*
SGLT2 Agents (Pending Implementation) (Revised May 1, 2019)
Sickle Cell Agents (Revised January 30, 2020)*
Symlin (Revised March 29, 2019)*
Synagis (Revised August 11, 2020)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised February 1, 2021)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised April 24, 2020)
Urea Cycle Disorder Agents (Pending Implementation) (Revised April 26, 2019)
Valturna (Retired) (Revised August 23, 2017)*
VMAT2 Inhibitors (Revised June 24, 2020)*
Wakix (Pending Implementation) (Revised October 28, 2020)*
Xifaxan (Revised March 29, 2019)*
Xyrem (Revised March 29, 2019)*
Xyrem/Xywav (Pending Implementation) (Revised October 28, 2020)*
Zelboraf (Pending Implementation) (Revised March 29, 2019)*
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Formulary Search
12HR NASAL DECONGEST ER 120 MG
PDL Status:N/A N/A
1ST TIER COMFORTOUCH 28G LANCT
PDL Status:N/A N/A
1ST TIER COMFORTOUCH 30G LANCT
PDL Status:N/A N/A
1ST TIER UNIFINE PENTP 5MM 31G
PDL Status:N/A N/A
1ST TIER UNIFINE PNTIP 4MM 32G
PDL Status:N/A N/A
1ST TIER UNIFINE PNTIP 6MM 31G
PDL Status:N/A N/A
1ST TIER UNIFINE PNTIP 8MM 31G
PDL Status:N/A N/A
1ST TIER UNIFINE PNTIP 8MM 31G
PDL Status:N/A N/A
1ST TIER UNIFINE PNTP 12MM 29G
PDL Status:N/A N/A
1ST TIER UNIFINE PNTP 29GX1/2
PDL Status:N/A N/A
1ST TIER UNIFINE PNTP 31GX1/4
PDL Status:N/A N/A
1ST TIER UNIFINE PNTP 31GX3/16
PDL Status:N/A N/A
1ST TIER UNIFINE PNTP 31GX5/16
PDL Status:N/A N/A
1ST TIER UNIFINE PNTP 32GX5/32
PDL Status:N/A N/A
24HR ALLERGY(LEVOCETIRZN) 5 MG
PDL Status:Non Preferred Non Preferred
row(s) 1 - 15 of more than 500