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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 (Pending Implementation) (Revised July 11, 2022)*
ADD/ADHD Agents (Revised December 2, 2021)*
Aliskiren Containing Agents (Pending Implementation) (Revised February 17, 2021)
Aliskiren Containing Agents (Revised March 21, 2019)*
Allergen Extracts (Pending Implementation) (Revised July 25, 2022)*
Allergen Extracts (Revised December 10, 2019)*
Altabax (Revised February 17, 2021)*
Amantadine ER (Pending Implementation) (Revised November 11, 2021)*
Androgenic Agents (Pending Implementation) (Revised March 21, 2019)*
Antiemetic Agents (Revised February 17, 2021)*
Antifungal Agents, Topical (Pending Implementation) (Revised October 22, 2021)*
Antimigraine Agents, Triptans (Pending Implementation) (Revised January 21, 2022)*
Antipsychotic Agents (Pending Implementation) (Revised June 2, 2022)*
Antipsychotic Agents (Revised February 17, 2021)*
Antiseizure Agents (Epidiolex and Fintepla) (Pending Implementation) (July 25, 2022)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised July 8, 2022)*
Anxiolytics and Sedative-Hypnotics (Revised February 4, 2022)*
Arikayce (Pending Implementation) (Revised February 17, 2021)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised November 11, 2021)*
Buprenorphine Agents (Revised July 19, 2021)*
Carisoprodol Overuse (Revised March 26, 2019)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised May 23, 2019)*
CGRP Antagonists, Acute (Pending Implementation) (Revised January 24, 2022)*
CGRP Antagonists, Prophylaxis (Pending Implementation) (Revised February 17, 2022)*
Cholestatic Pruritis Agents (Pending Implementation) (Revised April 28, 2022)*
CNS Stimulants (Revised October 29, 2019)*
Colcrys (Pending Implementation) (Revised February 17, 2021)*
Cough & Cold Agents (Revised January 13, 2022)*
COX-2 Inhibitors (Revised February 18, 2021)*
Cyclobenzaprine (Revised October 6, 2020)*
Cymbalta (Pending Implementation) (Revised January 30, 2020)*
Cystic Fibrosis Agents (Pending Implementation) (Revised July 1, 2021)*
Cystic Fibrosis Agents (Revised January 20, 2021)
Cytokine and CAM Antagonists (Pending Implementation) (Revised May 23, 2022)*
Cytokine and CAM Antagonists (Revised January 28, 2022)*
Desmopressin (Revised December 21, 2020)*
Dextromethorphan Overutilization (Revised March 12, 2020)*
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, 2021)*
Drug Regimen Optimization (Revised September 16, 2019)*
Dupixent (Revised March 10, 2022)*
Duplicate Therapy (Revised June 9, 2022)*
Emflaza (Revised October 7, 2021)*
Enzymes (Pending Implementation) (Revised April 5, 2021)*
Enzymes (Revised September 11, 2019)*
Erythropoiesis-Stimulating Agents (Revised October 7, 2020)*
Evrysdi (Pending Implementation) (Revised June 9, 2022)*
Fentanyl Agents (Revised July 19, 2021)*
Forteo (Pending Implementation) (Revised March 29, 2019)*
Gabapentin Agents (Revised March 29, 2019)*
Gaucher's Disease Agents (Pending Implementation) (Revised July 15, 2019)*
GI Motility Agents (Pending Implementation) (Revised July 25, 2022)*
GI Motility Agents (Revised March 29, 2019)*
Glatiramer Acetate Injection (Pending Implementation) (Revised July 15, 2019)*
GLP-1 Receptor Agonists (Pending Implementation) (Revised August 9, 2021)*
GLP-1 Receptor Agonists (Revised June 1, 2021)*
Growth Hormone Agents (Pending Implementation) (Revised June 8, 2022)*
Growth Hormone Agents (Revised January 12, 2022)*
Growth Hormone Quick Reference Guide
HAE Agents (Pending Implementation) (Revised July 1, 2021)*
Hemady (Pending Implementation) (Revised March 29, 2021)*
HP Acthar (Pending Implementation) (Revised July 24, 2020)*
HP Acthar (Revised July 15, 2019)*
Hyperlipidemia Agents (Revised October 7, 2021)*
Imiquimod (Revised March 29, 2019)*
Immunomodulator Agents for Dry Eye (Formerly Ophthalmic Immunomodulators) (Pending Implementation) (Revised April 28, 2022)*
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 November 7, 2019)*
Lovaza (Revised February 17, 2022)*
Lupus Agents (Pending Implementation) (Revised October 22, 2021)*
Lyrica (Pending Implementation) (Revised March 7, 2022)*
Makena (Revised November 11, 2021)*
Monoclonal Antibody Agents (Pending Implementation) (Revised July 25, 2022)*
Monoclonal Antibody Agents (Revised August 9, 2021)*
Multiple Sclerosis Agents (Pending Implementation) (Revised July 23, 2021)*
Nitazoxanide (Formerly Alinia) (Revised September 7, 2021)*
Nuedexta (Revised November 11, 2021)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Opiate Overutilization (Revised July 27, 2020)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised January 30, 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 October 8, 2021)*
PDE5-Inhibitors (Revised October 6, 2021)*
Phosphate Binders (Revised February 2, 2022)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Promethazine Utilization (Revised October 19, 2021)*
Propylthiouracil (Revised March 29, 2019)*
Proton Pump Inhibitors (Pending Implementation) (Revised March 29, 2019)*
Pulmonary Hypertension Agents (Pending Implementation) (Revised February 13, 2020)*
Pulmozyme (Pending Implementation) (Revised January 24, 2022)*
Qelbree (Pending Implementation) (Revised July 28, 2021)*
Ranexa (Revised March 29, 2019)*
Recorlev (Pending Implementation) (Revised April 22, 2022)*
Retinoids (Pending Implementation) (Revised July 19, 2021)*
Savella (Pending Implementation) (Revised March 29, 2019)*
SGLT2 Agents (Pending Implementation) (Revised August 1, 2022)*
Sickle Cell Agents (Revised February 17, 2022)*
Symlin (Revised March 29, 2019)*
Synagis (Revised June 1, 2022)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised July 19, 2021)*
Topical Immunomodulators (Pending Implementation) (Revised March 24, 2022)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised October 8, 2021)*
Urea Cycle Disorder Agents (Pending Implementation) (Revised April 26, 2019)
Valturna (Retired) (Revised August 23, 2017)*
VMAT2 Inhibitors (Revised October 15, 2021)*
Voxzogo (Pending Implementation) (Revised April 22, 2022)*
Wakix (Pending Implementation) (Revised October 8, 2021)*
Xifaxan (Revised March 29, 2019)*
Xyrem (Revised October 8, 2021)*
Xyrem/Xywav (Pending Implementation) (Revised October 8, 2021)*
Zelboraf (Pending Implementation) (Revised October 8, 2021)*
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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:No Auto PA No Auto PA
row(s) 1 - 15 of more than 500