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 January 9, 2024)*
Allergen Extracts (Revised December 10, 2019)*
ALS Agents (Pending Implementation) (Revised July 21, 2023)*
Altabax (Revised July 5, 2022)*
Amantadine ER (Pending Implementation) (Revised February 28, 2024)*
Androgenic Agents (Pending Implementation) (Revised December 20, 2022)*
Antiemetic Agents (Revised July 5, 2022)*
Antifungal Agents, Topical (Pending Implementation) (Revised December 8, 2023)*
Antimigraine Agents, Ergot Derivatives (Revised January 9, 2024)*
Antimigraine Agents, Triptans (Pending Implementation) (Revised January 26, 2024)*
Antimigraine Agents, Triptans (Revised March 7, 2024)*
Antipsychotic Agents (Pending Implementation) (Revised January 26, 2024)*
Antipsychotic Agents (Revised October 13, 2023)*
Antiseizure Agents (Diacomit, Epidiolex, and Fintepla) (Pending Implementation) (Revised December 8, 2023)*
Anxiolytics and Sedative-Hypnotics (Pending Implementation) (Revised February 13, 2024)*
Anxiolytics and Sedative-Hypnotics (Revised July 18, 2023)*
Arikayce (Pending Implementation) (Revised July 5, 2022)*
Binge Eating Disorder (BED) Agents (Pending Implementation) (Revised February 13, 2024)*
Buprenorphine Agents (Revised December 8, 2023)*
Carisoprodol Overuse (Revised October 20, 2022)*
Carisoprodol-Containing Agents (Pending Implementation) (Revised October 30, 2023)*
CGRP Antagonists, Acute (Pending Implementation) (Revised January 9, 2024)*
CGRP Antagonists, Acute (Revised December 1, 2022)*
CGRP Antagonists, Prophylaxis (Revised January 9, 2024)*
CNS Stimulants (Pending Implementation) (Revised October 30, 2023)*
CNS Stimulants (Revised October 29, 2019)*
Colchicine (Pending Implementation) (Revised January 26, 2024)*
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 (Revised December 8, 2023)*
Cytokine and CAM Antagonists (Pending Implementation) (Revised February 13, 2024)*
Cytokine and CAM Antagonists (Revised August 11, 2023)*
Daybue (Pending Implementation) (Revised July 21, 2023)*
Desmopressin (Revised February 1, 2023)*
Dextromethorphan Overutilization (Revised December 8, 2023)*
Diabetic Test Strips (Pending Implementation) (Revised March 27, 2019)*
Diclofenac (Pending Implementation) (Revised February 20, 2024)*
Dopamine Agonists (Pending Implementation) (Revised October 18, 2022)*
Doxylamine/Pyridoxine (Pending Implementation) (Revised December 8, 2023)*
DPP4 Inhibitors (Revised December 8, 2023)*
Drug Regimen Optimization (Retired)*
Duplicate Therapy (Revised March 11, 2024)*
Emflaza (Revised December 8, 2023)*
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)*
Filspari (Pending Implementation) (Revised October 13, 2023)*
FMT Agents (Pending Implementation) (Revised July 26, 2023)*
Forteo (Pending Implementation) (Revised October 18, 2022)*
Gabapentin Agents (Revised October 30, 2023)*
Gattex (Revised February 13, 2024)*
Gaucher's Disease Agents (Revised January 9, 2024)*
GI Motility Agents (Revised October 10, 2023)*
Glatiramer Acetate Injection (Pending Implementation) (Revised January 9, 2024)*
GLP-1 Receptor Agonists (Revised August 9, 2023)*
Gonadotropin Releasing Hormone (GnRH) Receptor Antagonists (Pending Implementation) (Revised September 12, 2022)*
Growth Hormone Agents (Pending Implementation) (Revised February 13, 2024)*
Growth Hormone Agents (Revised January 12, 2022)*
Growth Hormone Quick Reference Guide
HAE Agents (Revised January 11, 2024)*
Hemady (Pending Implementation) (Revised October 30, 2023)*
Hormonal Therapy Agents (Revised December 26, 2023)*
HP Acthar (Pending Implementation) (Revised December 2, 2022)*
HP Acthar (Revised January 9, 2024)*
Hyperlipidemia Agents (Revised January 9, 2024)*
Ileal Bile Acid Transporter (IBAT) Inhibitors (Pending Implementation) (Revised January 9, 2024)*
Imcivree (Pending Implementation) (Revised October 13, 2023)*
Imiquimod (Revised December 13, 2023)*
Immunomodulator Agents for Dry Eye (Formerly Ophthalmic Immunomodulators) (Pending Implementation) (Revised April 28, 2022)*
Increlex (Revised October 19, 2022)*
Inhaled Antibiotics (Revised October 31, 2023)*
Ketorolac (Revised October 31, 2023)*
Keveyis (Pending Implementation) (Revised October 31, 2023)*
Leukotriene Modifiers (Revised January 9, 2024)*
Lidocaine Patches (Pending Implementation) (Revised January 9, 2024)*
Lupus Agents (Pending Implementation) (Revised February 14, 2024)*
Lyrica (Pending Implementation) (Revised December 8, 2023)*
Monoclonal Antibody Agents (Pending Implementation) (Revised March 12, 2024)*
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 February 14, 2024)*
Nuplazid (Pending Implementation) (Revised December 8, 2023)*
Omega-3 Fatty Acids (Revised September 13, 2023)*
Opiate Overutilization (Revised November 8, 2023)*
Opiate/Benzodiazepine/Muscle Relaxant Combinations (Revised February 13, 2024)*
Orilissa (Pending Implementation) (Revised February 16, 2024)*
Oxervate (Pending Implementation) (Revised January 10, 2024)*
Oxybate Products (formerly Xyrem/Xywav) (Pending Implementation) (Revised December 8, 2023)*
Oxycodone Extended-Release Agents (Revised November 9, 2023)*
Palforzia (Pending Implementation) (Revised October 19, 2022)*
PDE5-Inhibitors (Revised February 28, 2024)*
Phosphate Binders (Revised February 7, 2024)*
Plavix (Pending Implementation) (Revised March 29, 2019)*
Preferred Drug List (January 2024)*
Promethazine Utilization (Revised October 19, 2022)*
Propylthiouracil (Revised October 31, 2022)*
Proton Pump Inhibitors (Pending Implementation) (Revised February 16, 2024)*
Pulmonary Hypertension Agents (Revised January 10, 2024)*
Pulmozyme (Pending Implementation) (Revised February 16, 2024)*
Ranexa (Revised October 31, 2022)*
Recorlev (Pending Implementation) (Revised December 13, 2023)*
Recurrent Vulvovaginal Candidiasis (RVVC) Agents (Pending Implementation) (Revised December 8, 2023)*
Retinoids (Pending Implementation) (February 23, 2024)*
Rezurock (Pending Implementation) (Revised October 13, 2023)*
Savella (Pending Implementation) (Revised February 20, 2024)*
SGLT2 Agents (Pending Implementation) (Revised February 20, 2024)*
SGLT2 Agents (Revised August 1, 2023)*
Sickle Cell Agents (Revised October 19, 2022)*
Skyclarys (Pending Implementation) (Revised October 13, 2023)*
Symlin (Revised December 8, 2023)*
Synagis (Revised January 11, 2024)*
Thiazolidinediones (Revised November 11, 2020)*
Topical Acne Agents (Pending Implementation) (Revised February 23, 2024)*
Topical Immunomodulators (Pending Implementation) (Revised March 7, 2024)*
Topical Immunomodulators (Revised June 24, 2020)*
Transthyretin Agents (Pending Implementation) (Revised January 10, 2024)*
Urea Cycle Disorder Agents (Pending Implementation) (Revised February 23, 2024)*
Valturna (Retired) (Revised August 23, 2017)*
Veozah (Pending Implementation) (Revised August 14, 2023)*
VMAT2 Inhibitors (Pending Implementation) (Revised February 23, 2024)*
VMAT2 Inhibitors (Revised June 1, 2023)*
Voxzogo (Pending Implementation) (Revised February 20, 2024)*
Xifaxan (Revised December 8, 2023)*
Xyrem (Revised February 1, 2023)*
Zelboraf (Revised December 8, 2023)*
Ztalmy (Pending Implementation) (Revised February 23, 2024)*
1 - 137
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