Help

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 (Pending Implementation) (Revised September 14, 2023)*
ADD/ADHD Agents (Revised December 2, 2021)*
Aliskiren Containing Agents (Pending Implementation) (Revised July 5, 2022)*
Aliskiren Containing Agents (Revised March 21, 2019)*
Allergen Extracts (Pending Implementation) (Revised September 20, 2023)*
Allergen Extracts (Revised December 10, 2019)*
ALS Agents (Pending Implementation) (Revised July 21, 2023)*
Altabax (Revised July 5, 2022)*
Amantadine ER (Pending Implementation) (Revised October 18, 2022)*
Androgenic Agents (Pending Implementation) (Revised December 20, 2022)*
Antiemetic Agents (Revised July 5, 2022)*
Antifungal Agents, Topical (Pending Implementation) (Revised October 22, 2021)*
Antimigraine Agents, Ergot Derivatives (Revised April 28, 2023)*
Antimigraine Agents, Triptans (Revised February 8, 2023)*
Antipsychotic Agents (Pending Implementation) (Revised July 27, 2023)*
Antipsychotic Agents (Revised February 17, 2021)*
Antiseizure Agents (Diacomit, Epidiolex and Fintepla) (Pending Implementation) (Revised February 8, 2023)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised July 18, 2023)*
Anxiolytics and Sedative-Hypnotics (Revised February 4, 2022)*
Arikayce (Pending Implementation) (Revised July 5, 2022)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised November 11, 2021)*
Buprenorphine Agents (Revised February 28, 2023)*
Carisoprodol Overuse (Revised October 20, 2022)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised October 20, 2022)*
CGRP Antagonists, Acute (Revised December 1, 2022)*
CGRP Antagonists, Prophylaxis (Revised May 18, 2023)*
CNS Stimulants (Pending Implementation) (Revised February 1, 2023)*
CNS Stimulants (Revised October 29, 2019)*
Colchicine (Pending Implementation) (Revised May 24, 2022)*
Cough & Cold Agents (Revised February 28, 2023)*
COX-2 Inhibitors (Revised May 24, 2022)*
Cyclobenzaprine (Revised October 18, 2022)*
Cymbalta (Pending Implementation) (Revised October 18, 2022)*
Cystic Fibrosis Agents (Pending Implementation) (Revised September 13, 2023)*
Cystic Fibrosis Agents (Revised September 21, 2022)
Cytokine and CAM Antagonists (Revised August 11, 2023)*
Daybue (Pending Implementation) (Revised July 21, 2023)*
Desmopressin (Revised February 1, 2023)*
Dextromethorphan Overutilization (Revised February 28, 2023)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diclofenac (Pending Implementation) (Revised October 20, 2022)*
Dopamine Agonists (Pending Implementation) (Revised October 18, 2022)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised October 29, 2019)*
DPP4 Inhibitors (Revised March 27, 2019)*
Drug Regimen Optimization (Retired)*
Duplicate Therapy (Revised November 18, 2022)*
Emflaza (Revised October 7, 2021)*
Enzymes (Revised October 18, 2022)*
Erythropoiesis-Stimulating Agents (Pending Implementation) (Revised April 28, 2023)*
Erythropoiesis-Stimulating Agents (Revised October 28, 2022)*
Evrysdi (Pending Implementation) (Revised June 9, 2022)*
Fentanyl Agents (Revised March 21, 2023)*
FMT Agents (Pending Implementation) (Revised July 26, 2023)*
Forteo (Pending Implementation) (Revised October 18, 2022)*
Gabapentin Agents (Revised October 28, 2022)*
Gattex (Revised April 28, 2023)*
Gaucher's Disease Agents (Pending Implementation) (Revised December 1, 2022)*
GI Motility Agents (Pending Implementation) (Revised July 7, 2023)*
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, 2023)*
GLP-1 Receptor Agonists (Revised August 2, 2023)*
Gonadotropin Releasing Hormone (GnRH) Receptor Antagonists (Pending Implementation) (Revised September 12, 2022)*
Growth Hormone Agents (Pending Implementation) (Revised July 21, 2023)*
Growth Hormone Agents (Revised January 12, 2022)*
Growth Hormone Quick Reference Guide
HAE Agents (Revised March 23, 2023)*
Hemady (Pending Implementation) (Revised October 28, 2022)*
HP Acthar (Pending Implementation) (Revised December 2, 2022)*
HP Acthar (Revised July 15, 2019)*
Hyperlipidemia Agents (Revised October 7, 2021)*
Ileal Bile Acid Transporter (IBAT) Inhibitors (Formerly Cholestatic Pruritis Agents) (Pending Implementation) (Revised March 30, 2023)*
Imiquimod (Revised October 19, 2022)*
Immunomodulator Agents for Dry Eye (Formerly Ophthalmic Immunomodulators) (Pending Implementation) (Revised April 28, 2022)*
Increlex (Revised October 19, 2022)*
Inhaled Antibiotics (Revised October 28, 2022)*
Ketorolac (Revised September 13, 2023)*
Keveyis (Pending Implementation) (Revised October 28, 2022)*
Leukotriene Modifiers (Revised December 2, 2022)*
Lidocaine Patches (Pending Implementation) (Revised January 17, 2023)*
Lupus Agents (Pending Implementation) (Revised October 22, 2021)*
Lyrica (Pending Implementation) (Revised March 7, 2022)*
Monoclonal Antibody Agents (Pending Implementation) (Revised March 23, 2023)*
Monoclonal Antibody Agents (Revised August 9, 2021)*
Monoclonal Antibody Agents - Dupixent (Revised March 10, 2022)*
Multiple Sclerosis Agents (Pending Implementation) (Revised June 1, 2023)*
Nitazoxanide (Formerly Alinia) (Revised September 7, 2021)*
Nitazoxanide (Pending Implementation) (Revised May 24, 2022)*
Nuedexta (Revised November 11, 2021)*
Nuplazid (Pending Implementation) (Revised March 29, 2019)*
Omega-3 Fatty Acids (Pending Implementation) (Revised September 13, 2023)*
Omega-3 Fatty Acids (Revised January 3, 2023)*
Opiate Overutilization (Revised March 22, 2023)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Pending Implementation) (Revised July 26, 2023)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised February 28, 2023)*
Orilissa (Pending Implementation) (Revised March 29, 2019)*
Oxervate (Pending Implementation) (Revised December 2, 2022)*
Oxycodone Extended-Release Agents (Revised March 22, 2023)*
Palforzia (Pending Implementation) (Revised October 19, 2022)*
PDE5-Inhibitors (Revised May 15, 2023)*
Phosphate Binders (Revised February 1, 2023)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Preferred Drug List (July 2023)
Promethazine Utilization (Revised October 19, 2022)*
Propylthiouracil (Revised October 31, 2022)*
Proton Pump Inhibitors (Pending Implementation) (Revised March 29, 2019)*
Pulmonary Hypertension Agents (Revised May 18, 2023)*
Pulmozyme (Pending Implementation) (Revised January 24, 2022)*
Ranexa (Revised October 31, 2022)*
Recorlev (Pending Implementation) (Revised April 22, 2022)*
Recurrent Vulvovaginal Candidiasis (RVVC) Agents (Vivjoa) (Pending Implementation) (Revised October 22, 2022)*
Retinoids (Pending Implementation) (Revised July 19, 2021)*
Savella (Pending Implementation) (Revised March 29, 2019)*
SGLT2 Agents (Pending Implementation) (Revised September 12, 2023)*
SGLT2 Agents (Revised February 1, 2023)*
Sickle Cell Agents (Revised October 19, 2022)*
Symlin (Revised March 29, 2019)*
Synagis (Revised September 15, 2022)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised July 19, 2021)*
Topical Immunomodulators (Pending Implementation) (Revised May 17, 2023)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised October 8, 2021)*
Urea Cycle Disorder Agents (Pending Implementation) (Revised July 7, 2023)
Valturna (Retired) (Revised August 23, 2017)*
Veozah (Pending Implementation) (Revised August 14, 2023)*
VMAT2 Inhibitors (Pending Implementation) (Revised June 1, 2023)*
VMAT2 Inhibitors (Revised October 15, 2021)*
Voxzogo (Pending Implementation) (Revised April 22, 2022)*
Xifaxan (Revised March 29, 2019)*
Xyrem (Revised October 8, 2021)*
Xyrem/Xywav (Pending Implementation) (Revised October 8, 2021)*
Zelboraf (Revised October 8, 2021)*
Ztalmy (Pending Implementation) (Revised January 20, 2023)*
1 - 134
Search
Search Reset
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:No Auto PA No Auto PA
row(s) 1 - 15 of more than 500