Statewide PDL Prior Authorization Guidelines
- Acne Agents, Oral
- Acne Agents, Topical
- Alcohol Use Disorder Agents
- Alzheimer’s Agents
- Analgesics, Non-Opioid Barbiturate Combinations
- Analgesics, Opioid Long-Acting
- Analgesics, Opioid Short-Acting
- Androgenic Agents
- Angiotensin Modulator Combinations
- Angiotensin Modulators
- Antianginal Agents
- Antibiotics, GI and Related Agents
- Antibiotics, Inhaled
- Antibiotics, Topical
- Anticoagulants
- Anticonvulsants
- Antidepressants, Other
- Antidepressants, SSRIs
- Antiemetics/Antivertigo Agents
- Antifibrotic Respiratory Agents
- Antifungals, Oral
- Antifungals, Topical
- Antihemophilia Agents
- Antihistamines, Minimally Sedating
- Antihypertensives, Sympatholytic
- Antihyperuricemics
- Antimalarials
- Antiparasitics, Topical
- Antiparkinson’s Agents
- Antipsoriatics, Oral
- Antipsoriatics, Topical
- Antipsychotics
- Antivirals, CMV
- Antivirals, Herpes
- Antivirals, Influenza
- Anxiolytics
- Benign Prostatic Hyperplasia (BPH) Treatments
- Beta Blockers
- Bladder Relaxant Preparations
- Blood Glucose Meters and Test Strips
- Bone Density Regulators
- Botulinum Toxins
- Bronchodilators, Beta Agonists
- Calcium Channel Blockers
- Cephalosporins
- Colony Stimulating Factors
- Continuous Glucose Monitoring Products
- Contraceptives, Oral
- Contraceptives, Other
- COPD Agents
- Cytokine and CAM Antagonists
- Dry Eye Treatments (formerly Ophthalmics, Immunomodulators)
- Dupixent (dupilumab)
- Enzyme Replacements, Gaucher Disease
- Epinephrine, Self-Injected
- Erythropoiesis Stimulating Agents
- Estrogens
- Fluoroquinolones, Oral
- GI Motility, Chronic Agents
- Glucocorticoids, Inhaled
- Glucocorticoids, Oral
- Growth Hormones
- H. Pylori Treatments
- Hematopoietic Mixtures (formerly Iron, Oral)
- Hepatic and Bilary Agents
- Hepatitis B Agents
- Hepatitis C Agents
- Hereditary Angioedema (HAE) Agents
- Histamine 2 Receptor Blockers
- HIV/AIDS Antiretrovirals
- Hypoglycemia Treatments
- Hypoglycemics, Alpha-Glucosidase Inhibitors
- Hypoglycemics, Incretin Mimetics/Enhancers
- Hypoglycemics, Insulin and Related Agents
- Hypoglycemics, Meglitinides
- Hypoglycemics, Metformins
- Hypoglycemics, SGLT2 Inhibitors
- Hypoglycemics, Sulfonylureas
- Hypoglycemics, TZDs
- Immunomodulators, Atopic Dermatitis
- Immunomodulators, Topical
- Immunosuppressives, Oral
- Intra-Articular Hyaluronates
- Intranasal Rhinitis Agents
- Iron Chelating Agents
- Iron, Parenteral
- Leukotriene Modifiers
- Lipotropics, Other
- Lipotropics, Statins
- Local Anesthetics, Topical
- Macrolides
- Macular Degeneration Agents
- Methotrexate
- Migraine Acute Treatment Agents
- Migraine Prevention Agents
- Monoclonal Antibodies (MABs) – Anti-IL, Anti-IgE, Anti-TSLP
- Multiple Sclerosis Agents
- Natalizumab
- Neuropathic Pain Agents
- NSAIDs
- Obesity Treatment Agents
- Oncology Agents, Breast Cancer
- Oncology Agents, Oral
- Ophthalmics, Allergic Conjunctivitis
- Ophthalmics, Antibiotics
- Ophthalmics, Antibiotic-Steroid Combinations
- Ophthalmics, Anti-Inflammatories
- Ophthalmics, Glaucoma
- Opioid Overdose Agents
- Opioid Use Disorder Treatments
- Otic Antibiotic Preparations
- Pancreatic Enzymes
- Penicillins
- Phosphate Lowering Agents
- Pituitary Suppressive Agents, LHRH
- Platelet Aggregation Inhibitors
- Potassium Removing Agents
- Prenatal Vitamins
- Progestational Agents
- Proton Pump Inhibitors (PPIs)
- Pulmonary Hypertension Agents, Oral and Inhaled
- Radicava
- Sedative Hypnotics
- Sickle Cell Anemia Agents
- Skeletal Muscle Relaxants
- Smoking Cessation Products
- Steroids, Topical
- Stimulants and Related Agents
- Stimulants and Related Agents — Analeptics (e.g., Provigil, Nuvigil, Sunosi, Wakix)
- Tetracyclines
- Thalidomide and Derivatives
- Thrombopoietics
- Thyroid Hormones
- Tubeless Insulin Delivery Devices
- Ulcerative Colitis Agents
- Urea Cycle Disorder Agents
- Urinary Anti-Infectives (formerly Nitrofuran Derivatives)
- Vaginal Anti-Infectives (formerly Antibiotics, Vaginal)
- Vitamin D Analogs
- VMAT2 Inhibitors
Fee-for-Service Non-PDL Prior Authorization Guidelines
- Abecma
- Adstiladrin
- Alpha-1 Proteinase Inhibitors (Aralast-NP, Glassia, Prolastin-C, Zemaira)
- Amvuttra
- Amyloid-Targeted Monoclonal Antibodies (MABs) (Kisunla, Leqembi)
- Anti-Allergens, Oral (Grastek, Odactra, Oralair, Ragwitek)
- Benlysta
- Breyanzi
- Brineura
- Camzyos
- Carvykti
- Casgevy
- Clinical Prior Authorization of Non-PDL Drugs
- Complement Inhibitors (Empaveli, Enjaymo, Fabhalta, Piasky, Soliris, Tavneos, Ultomiris, Voydeya, Zilbrysq)
- Compounded Prescriptions
- Corlanor
- Corticotropin (formerly H.P. Acthar Gel)
- Cough and Cold Medications
- Crysvita
- Cystic Fibrosis Transmembrane Regulator (CFTR) Modulators (Kalydeco, Orkambi, Symdeko, Trikafta)
- DefenCath
- Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides (Amondys-45, Exondys 51, Viltepso, Vyondys 53)
- Early Refills of Prescriptions
- Elevidys
- Elitek
- Evrysdi
- Filspari
- Filsuvez
- Growth Factors
- Hyftor
- Imcivree
- Immune Globulins
- Joenja
- Jynarque
- Kanuma
- Korlym
- Kuvan/sapropterin
- Kymriah
- Lyfgenia
- Mozobil
- Nuedexta
- Omisirge
- Onpattro
- Palforzia
- Palynziq
- Provenge
- Quantity Limits/Daily Dose Limits
- Radicava
- Rezdiffra
- Roctavian
- Rystiggo
- Skyclarys
- Skysona
- Spinraza
- Synagis
- Tecartus
- Tegsedi
- Tepezza
- Tzield
- Uplizna
- Vecamyl
- Veozah
- Vijoice
- Vuity
- Vyjuvek
- Vyndamax
- Vyndaqel
- Vyvgart
- Wainua
- Winrevair
- Xermelo
- Xofigo
- Xyrem/Xywav
- Xolremdi
- Yescarta
- Zolgensma
- Zynteglo