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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 21, 2019)*
ADD/ADHD Agents (Revised September 16, 2019)*
Alinia (Revised March 21, 2019)*
Aliskiren Containing Agents (Revised March 21, 2019)*
Allergen Extracts (Revised July 15, 2019)*
Altabax (Revised March 21, 2019)*
Androgenic Agents (Pending Implementation) (Revised March 21, 2019)*
Antiemetic Agents (Revised March 21, 2019)*
Antipsychotic Agents (Revised September 4, 2019)*
Anxiolytics and Sedative-Hypnotics (Revised March 22, 2019)*
Arikayce (Pending Implementation) (Revised April 26, 2019)*
Buprenorphine Agents (Revised March 22, 2019)*
Carisoprodol Overuse (Revised March 26, 2019)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised May 23, 2019)*
CGRP Antagonists (Pending Implementation) (Revised August 29, 2019)*
CNS Stimulants (Formerly Provigil and Nuvigil) (Revised March 29, 2019)*
CNS Stimulants (Pending Implementation) (Revised October 29, 2019)*
Colcrys (Pending Implementation) (Revised March 26, 2019)*
Cough & Cold (Revised September 26, 2019)*
COX-2 Inhibitors (Revised March 26, 2019)*
Cyclobenzaprine (Revised March 27, 2019)*
Cymbalta (Revised March 27, 2019)*
Cystic Fibrosis Agents (Revised July 10, 2019)*
Cytokine and CAM Antagonists (Pending Implementation) (Revised November 7, 2019)*
Cytokine and CAM Antagonists (Revised August 7, 2019)*
Desmopressin (Revised March 27, 2019)*
Dextromethorphan Overutilization (Revised November 20, 2019)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diacomit (Pending Implementation) (Revised November 4, 2019)*
Diclofenac (Pending Implementation) (Revised March 27, 2019)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised October 29, 2019)*
DPP4 Inhibitors (Revised March 27, 2019)*
Drug Regimen Optimization (Revised September 16, 2019)*
Dupixent (Pending Implementation) (Revised September 13, 2019)*
Dupixent (Revised March 28, 2019)*
Duplicate Therapy (September 26, 2019)*
Emflaza (Revised July 3, 2019)*
Enzymes (Revised September 11, 2019)*
Epidiolex (Pending Implementation) (Revised March 28, 2019)*
Erythropoiesis-Stimulating Agents (Revised March 28, 2019)*
Fentanyl Agents (Revised March 28, 2019)*
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 July 5, 2019)*
Growth Hormone Agents (Pending Implementation) (Revised March 29, 2019)*
Growth Hormone Agents (Revised March 29, 2019)*
Growth Hormone Quick Reference Guide
HAE Agents (Pending Implementation) (Revised July 15, 2019)*
HP Acthar (Revised July 15, 2019)*
Imiquimod (Revised March 29, 2019)*
Increlex (Revised March 29, 2019)*
Inhaled Antibiotics (Pending Implementation) (Revised April 26, 2019)*
Injectable Agents for PAH (Pending Implementation) (Revised July 15, 2019)*
Ketorolac (Revised March 29, 2019)*
Keveyis (Pending Implementation) (Revised March 29, 2019)*
Leukotriene Modifiers (Revised July 15, 2019)*
Lidocaine Patches (Revised July 15, 2019)*
Lovaza (Revised March 29, 2019)*
Lyrica (Pending Implementation) (Revised May 30, 2019)*
Makena (Revised May 14, 2019)*
Morphine Milligram Equivalent Criteria (Revised July 1, 2019)*
Nuedexta (Revised March 29, 2019)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Opiate Overutilization (Revised July 1, 2019)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised July 1, 2019)*
Orilissa (Pending Implementation) (Revised March 29, 2019)*
Oxycontin / Narcotic Analgesic (Revised March 29, 2019)*
PCSK9 Inhibitors (Revised March 29, 2019)*
PDE5-Inhibitors (Revised November 8, 2019)*
Phosphate Binders (Revised March 29, 2019)*
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)*
Ranexa (Revised March 29, 2019)*
Savella (Pending Implementation) (Revised March 29, 2019)*
SGLT2 Agents (Pending Implementation) (Revised May 1, 2019)
Symlin (Revised March 29, 2019)*
Synagis (Pending Implementation) (Revised October 4, 2019)*
Synagis (Revised August 8, 2019)*
Thiazolidinediones (Revised March 29, 2019)*
Topical Acne Agents (Pending Implementation) (Revised March 29, 2019)*
Topical Immunomodulators (Revised March 29, 2019)*
Topical Retinoids (Pending Implementation) (Revised March 29, 2019)*
Urea Cycle Disorder Agents (Pending Implementation) (Revised April 26, 2019)
Valturna (Retired) (Revised August 23, 2017)*
VMAT2 Inhibitors (Revised March 29, 2019)*
Xifaxan (Revised March 29, 2019)*
Xyrem (Revised March 29, 2019)*
Zelboraf (Pending Implementation) (Revised March 29, 2019)*
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Formulary Search
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:No Auto PA No Auto PA
A THRU Z ADVANCED FORMULA TAB
PDL Status:N/A N/A
row(s) 1 - 15 of more than 500