Rx Prior Authorization

Drugs that Require Prior Authorization

Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. This approval process is called prior authorization.

Drug list/Formulary inclusion does not infer a drug is a covered benefit. Please check your schedule of benefits for coverage information.

Select an authorization document link below to review more information about a specific prior authorization.

	Pharmacy Prior Auth Criteria
Drug Name	Quantity Limit	Prior Authorization	Dosage Limit
ABC Multi Source Brand		Clinical Criteria Fax Form
Abilify		Clinical Criteria Fax Form
Abstral	Clinical Criteria Fax Form	Clinical Criteria Fax Form
AcipHex		Clinical Criteria Fax Form
Actemra		Clinical Criteria Fax Form
Actiq	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Actos	Clinical Criteria Fax Form
Adalat CC			Clinical Criteria Fax Form
Adcirca		Clinical Criteria Fax Form
Adderall		Clinical Criteria Fax Form
Adipex-P		Clinical Criteria Fax Form
Adoxa		Clinical Criteria Fax Form Clinical Criteria Fax Form
Advair	Clinical Criteria Fax Form
Advicor			Clinical Criteria Fax Form
Aerobid	Clinical Criteria Fax Form
Aerobid-M	Clinical Criteria Fax Form
Afinitor		Clinical Criteria Fax Form
Alamast	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Ala-Tet		Clinical Criteria Fax Form
Aldara	Clinical Criteria Fax Form
Allegra	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Allegra-D	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Alocril	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Alodox		Clinical Criteria Fax Form
Alomide	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Alsuma	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Altoprev		Clinical Criteria Fax Form	Clinical Criteria Fax Form
Alupent Inhaler	Clinical Criteria Fax Form
Alvesco	Clinical Criteria Fax Form
Ambien CR		Clinical Criteria Fax Form
Amerge	Clinical Criteria Fax Form
Amevive		Clinical Criteria Fax Form
Amnesteem		Clinical Criteria Fax Form
Amphetamine Salt Combination(Generic Adderall XR)		Clinical Criteria Fax Form
Ampyra	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Androderm	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Androgel	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Anexsia	Clinical Criteria Fax Form
Anzemet	Clinical Criteria Fax Form
Apidra		Clinical Criteria Fax Form
Aplenzin			Clinical Criteria Fax Form
Aranesp		Clinical Criteria Fax Form
Arestin		Clinical Criteria Fax Form
Arixtra		Clinical Criteria Fax Form
Arthrotec		Clinical Criteria Fax Form
Asmanex	Clinical Criteria Fax Form
Atacand			Clinical Criteria Fax Form
Atacand HCT			Clinical Criteria Fax Form
Atralin		Clinical Criteria Fax Form
Atrovent Nasal Spray	Clinical Criteria Fax Form
Atrovent oral inhaler	Clinical Criteria Fax Form
Atrovent Soln for inhalation	Clinical Criteria Fax Form
Avalide			Clinical Criteria Fax Form
Avandamet		Clinical Criteria Fax Form
Avandaryl		Clinical Criteria Fax Form
Avandia		Clinical Criteria Fax Form
Avapro			Clinical Criteria Fax Form
Avastin		Clinical Criteria Fax Form
Avelox	Clinical Criteria Fax Form
Avidoxy		Clinical Criteria Fax Form
Avinza	Clinical Criteria Fax Form
Avita		Clinical Criteria Fax Form
Avodart		Clinical Criteria Fax Form
Axert	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Axiron	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Azelastine Hydrochloride	Clinical Criteria Fax Form
Azelex		Clinical Criteria Fax Form
Azmacort	Clinical Criteria Fax Form
Azor			Clinical Criteria Fax Form
Balacet	Clinical Criteria Fax Form
Beconase A.Q.	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Benicar			Clinical Criteria Fax Form
Benicar HCT			Clinical Criteria Fax Form
Benlysta		Clinical Criteria Fax Form
BenzaClin		Clinical Criteria Fax Form
Benzoyl Peroxide Products		Clinical Criteria Fax Form
Bepreve	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Betaseron Only applies to commercial		Clinical Criteria Fax Form
Betaseron Only applies to closed commercial		Clinical Criteria Fax Form
Birth Control/Contraceptives		Clinical Criteria Fax Form
Boniva		Clinical Criteria Fax Form
Bontril SR		Clinical Criteria Fax Form
Botox		Clinical Criteria Fax Form
Bravelle		Clinical Criteria Fax Form
Brovana Solution	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Buphenyl		Clinical Criteria Fax Form
Bydureon		Clinical Criteria Fax Form
Byetta		Clinical Criteria Fax Form
Caprelsa		Clinical Criteria Fax Form
Caduet			Clinical Criteria Fax Form
Capital w/codeine	Clinical Criteria Fax Form
Cardene			Clinical Criteria Fax Form
Cardene S.R.			Clinical Criteria Fax Form
Cardizem CD 360mg			Clinical Criteria Fax Form
Cardizem LA			Clinical Criteria Fax Form
Carimune NF		Clinical Criteria Fax Form
Caverject	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Celebrex		Clinical Criteria Fax Form
Celexa			Clinical Criteria Fax Form
Ceredase		Clinical Criteria Fax Form
Cerezyme		Clinical Criteria Fax Form
Cetrotide		Clinical Criteria Fax Form
Chantix		Clinical Criteria Fax Form
Cialis	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Cimzia Kit		Clinical Criteria Fax Form
Ciprofloxacin (Cipro Tablets)	Clinical Criteria Fax Form
Claravis		Clinical Criteria Fax Form
Clarinex	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Clarinex D	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Clomiphene Citrate		Clinical Criteria Fax Form
Clozaril		Clinical Criteria Fax Form
Cocet	Clinical Criteria Fax Form
Cocet Plus	Clinical Criteria Fax Form
Colcrys	Clinical Criteria Fax Form
Combivent	Clinical Criteria Fax Form
Combunox	Clinical Criteria Fax Form
Concerta		Clinical Criteria Fax Form
Copaxone Only applies to closed commercial		Clinical Criteria Fax Form
Covera H.S.			Clinical Criteria Fax Form
Cozaar			Clinical Criteria Fax Form
Crestor			Clinical Criteria Fax Form
Crinone 4%		Clinical Criteria Fax Form
Crinone 8%		Clinical Criteria Fax Form
Cymbalta			Clinical Criteria Fax Form
Darvocet	Clinical Criteria Fax Form
Daytrana		Clinical Criteria Fax Form
Declomycin		Clinical Criteria Fax Form
Depo-Provera		Clinical Criteria Fax Form
Desoxyn		Clinical Criteria Fax Form
Dexedrine		Clinical Criteria Fax Form
Dexilant		Clinical Criteria Fax Form
Dextrostat		Clinical Criteria Fax Form
Diabetic Test Strips		Clinical Criteria Fax Form
Didrex		Clinical Criteria Fax Form
Diethylpropion		Clinical Criteria Fax Form
Differin		Clinical Criteria Fax Form
Dilacor XR			Clinical Criteria Fax Form
Diovan			Clinical Criteria Fax Form
Diovan HCT			Clinical Criteria Fax Form
Doryx		Clinical Criteria Fax Form Clinical Criteria Fax Form
Dose Optimization			Clinical Criteria Fax Form
Doxycycline		Clinical Criteria Fax Form
Doxy-Lemmon		Clinical Criteria Fax Form
Duexis		Clinical Criteria Fax Form
Dulera	Clinical Criteria Fax Form
Duragesic	Clinical Criteria Fax Form
Dynacin		Clinical Criteria Fax Form
Dynacirc C.R.			Clinical Criteria Fax Form
Dysport		Clinical Criteria Fax Form
Edarbi			Clinical Criteria Fax Form
Edex	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Edluar		Clinical Criteria Fax Form
Effexor XR			Clinical Criteria Fax Form
Effient			Clinical Criteria Fax Form
Egrifta		Clinical Criteria Fax Form
Elelyso		Clinical Criteria Fax Form
Elestat	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Elidel		Clinical Criteria Fax Form
Eligard		Clinical Criteria Fax Form
Emadine	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Embeda	Clinical Criteria Fax Form
Emcyt		Clinical Criteria Fax Form
Enablex		Clinical Criteria Fax Form
Enbrel		Clinical Criteria Fax Form
Endometrin		Clinical Criteria Fax Form
Enteral Nutrition		Clinical Criteria
Epinastine	Clinical Criteria Fax Form
Epogen		Clinical Criteria Fax Form
Erbitux		Clinical Criteria Fax Form
Erivedge		Clinical Criteria Fax Form
Euflexxa		Clinical Criteria Fax Form
Exalgo		Clinical Criteria Fax Form
Exforge			Clinical Criteria Fax Form
Exforge HCT			Clinical Criteria Fax Form
Extavia Only applies to commercial		Clinical Criteria Fax Form
Extavia Only applies to closed commercial		Clinical Criteria Fax Form
Fanapt		Clinical Criteria Fax Form
FazaClo		Clinical Criteria Fax Form
Fentanyl - Oral		Clinical Criteria Fax Form
Fentanyl - Transdermal	Clinical Criteria Fax Form
Fentora	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Fioricet	Clinical Criteria Fax Form
Firmagon		Clinical Criteria Fax Form
Flebogamma		Clinical Criteria Fax Form
Flector		Clinical Criteria Fax Form
Flolan		Clinical Criteria Fax Form
Flomax		Clinical Criteria Fax Form
Flonase	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Flovent	Clinical Criteria Fax Form
Flunisolide	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Fluoxetine			Clinical Criteria Fax Form
Fluvoxamine			Clinical Criteria Fax Form
Focalin		Clinical Criteria Fax Form
Focalin/XR		Clinical Criteria Fax Form
Follistim AQ		Clinical Criteria Fax Form
Foradil	Clinical Criteria Fax Form
Forteo		Clinical Criteria Fax Form
Fortesta	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Fragmin		Clinical Criteria Fax Form
Frova	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Gamastan		Clinical Criteria Fax Form
Gammagard		Clinical Criteria Fax Form
Gammaked		Clinical Criteria Fax Form
Gammaplex		Clinical Criteria Fax Form
Gamunex		Clinical Criteria Fax Form
Ganirelix		Clinical Criteria Fax Form
Gelnique		Clinical Criteria Fax Form
Genotropin		Clinical Criteria Fax Form
Geodon		Clinical Criteria Fax Form
Gilenya	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Gleevec		Clinical Criteria Fax Form
Gonal-F		Clinical Criteria Fax Form
Granisetron	Clinical Criteria Fax Form
Granisol	Clinical Criteria Fax Form
Halaven		Clinical Criteria Fax Form
Haldol		Clinical Criteria Fax Form
Herceptin		Clinical Criteria Fax Form
Hizentra		Clinical Criteria Fax Form
HP Acthar		Clinical Criteria Fax Form
Humatrope		Clinical Criteria Fax Form
Humira		Clinical Criteria Fax Form
Hyalgan		Clinical Criteria Fax Form
Hycet	Clinical Criteria Fax Form
Hydrocodone -acetaminophen	Clinical Criteria Fax Form
Hyzaar			Clinical Criteria Fax Form
Imitrex Injection	Clinical Criteria Fax Form
Imitrex Nasal Inhaler	Clinical Criteria Fax Form
Imitrex Tablet	Clinical Criteria Fax Form
Immune Globulin		Clinical Criteria Fax Form
Incivek		Clinical Criteria Fax Form
Increlex		Clinical Criteria Fax Form
Indocin		Clinical Criteria Fax Form
Infergen		Clinical Criteria Fax Form
Inlyta		Clinical Criteria Fax Form
Innohep		Clinical Criteria Fax Form
Intron-A		Clinical Criteria Fax Form
Intuniv		Clinical Criteria Fax Form
Invega		Clinical Criteria Fax Form
Jakafi		Clinical Criteria Fax Form
Kadian	Clinical Criteria Fax Form
Kalydeco		Clinical Criteria Fax Form
Kapvay		Clinical Criteria Fax Form
Kineret		Clinical Criteria Fax Form
Kuvan		Clinical Criteria Fax Form
Kytril	Clinical Criteria Fax Form
Lansoprazole		Clinical Criteria Fax Form
Lastacaft	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Latuda		Clinical Criteria Fax Form
Lazanda	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Lescol		Clinical Criteria Fax Form	Clinical Criteria Fax Form
Leukine		Clinical Criteria Fax Form
Leuprolide Acetate		Clinical Criteria Fax Form Clinical Criteria Fax Form
Levaquin	Clinical Criteria Fax Form
Levitra	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Lexapro			Clinical Criteria Fax Form
Lipitor		Clinical Criteria Fax Form	Clinical Criteria Fax Form
Livalo		Clinical Criteria Fax Form	Clinical Criteria Fax Form
Lorcet	Clinical Criteria Fax Form
Lorcet HD	Clinical Criteria Fax Form
Lorcet Plus	Clinical Criteria Fax Form
Lortab	Clinical Criteria Fax Form
Lovastatin			Clinical Criteria Fax Form
Lovenox		Clinical Criteria Fax Form
Loxapine/Loxitane		Clinical Criteria Fax Form
Lucentis		Clinical Criteria Fax Form
Lumizyme		Clinical Criteria Fax Form
Lunesta	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Lupron		Clinical Criteria Fax Form Clinical Criteria Fax Form
Lupron Depot		Clinical Criteria Fax Form Clinical Criteria Fax Form
Lupron Depot - PED		Clinical Criteria Fax Form
Luveris		Clinical Criteria Fax Form
Luvox			Clinical Criteria Fax Form
Lyrica		Clinical Criteria Fax Form
Macugen		Clinical Criteria Fax Form
Makena		Clinical Criteria Fax Form
Maxair Autohaler	Clinical Criteria Fax Form
Maxalt	Clinical Criteria Fax Form
Maxidone 10- 750mg tab	Clinical Criteria Fax Form
Medroxyprogesterone acetate Injectable		Clinical Criteria Fax Form
Mellaril		Clinical Criteria Fax Form
Menopur		Clinical Criteria Fax Form
Metabolic Infant Formula		Clinical Criteria
Metadate		Clinical Criteria Fax Form
Methylin		Clinical Criteria Fax Form
Mevacor			Clinical Criteria Fax Form
Micardis			Clinical Criteria Fax Form
Micardis HCT			Clinical Criteria Fax Form
Minocin		Clinical Criteria (age edit) Fax Form(age edit) Clinical Criteria (step edit) Fax Form(step edit)
Minocycline HCl, ER		Clinical Criteria Fax Form Clinical Criteria Fax Form
Moban		Clinical Criteria Fax Form
Monodox		Clinical Criteria Fax Form
Morgidox		Clinical Criteria Fax Form Clinical Criteria Fax Form
Morphine Sulfate	Clinical Criteria Fax Form
MS Contin	Clinical Criteria Fax Form
MSB Medications		Clinical Criteria Fax Form
Muse	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Myobloc		Clinical Criteria Fax Form
Myozyme		Clinical Criteria Fax Form
Nalfon		Clinical Criteria Fax Form
Narcotic Analgesics Combination Products	Clinical Criteria Fax Form
Nasacort AQ	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Nasonex	Clinical Criteria Fax Form
Navane		Clinical Criteria Fax Form
Neulasta		Clinical Criteria Fax Form
Neumega		Clinical Criteria Fax Form
Neupogen		Clinical Criteria Fax Form
Nexavar		Clinical Criteria Fax Form
Nexium		Clinical Criteria Fax Form
Nicotrol Inhaler		Clinical Criteria Fax Form
Nicotrol Nasal Spray		Clinical Criteria Fax Form
Non Formulary Medications		Clinical Criteria Fax Form
Norco	Clinical Criteria Fax Form
Norditropin		Clinical Criteria Fax Form
Noroxin	Clinical Criteria Fax Form
Norvasc			Clinical Criteria Fax Form
Novarel		Clinical Criteria Fax Form
Nucynta	Clinical Criteria Fax Form
NuOx		Clinical Criteria Fax Form
Nutridox		Clinical Criteria Fax Form
Nutropin		Clinical Criteria Fax Form
Nutropin, AQ		Clinical Criteria Fax Form
Nuvigil		Clinical Criteria Fax Form
Octagam		Clinical Criteria Fax Form
Oforta		Clinical Criteria Fax Form
Omeprazole		Clinical Criteria Fax Form
Omeprazole/Sodium Bicarbonate	Clinical Criteria Fax Form
Omnaris	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Omnitrope		Clinical Criteria Fax Form
Omontys		Clinical Criteria Fax Form
Ondansetron	Clinical Criteria Fax Form
Onglyza		Clinical Criteria Fax Form	Clinical Criteria Fax Form
Onsolis	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Opana	Clinical Criteria Fax Form
Opana/ER	Clinical Criteria Fax Form
Optivar	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Oramorph SR	Clinical Criteria Fax Form
Orap		Clinical Criteria Fax Form
Oraxyl		Clinical Criteria Fax Form
Orencia		Clinical Criteria Fax Form
Orthovisc		Clinical Criteria Fax Form
Ovidrel		Clinical Criteria Fax Form
Oxandrin		Clinical Criteria Fax Form
Oxycodone	Clinical Criteria Fax Form Clinical Criteria Fax Form
Oxycontin	Clinical Criteria Fax Form
Oxymorphone	Clinical Criteria Fax Form
Oxytrol		Clinical Criteria Fax Form
Panlor DC caps	Clinical Criteria Fax Form
Panlor SS tabs	Clinical Criteria Fax Form
Pantoprazole		Clinical Criteria Fax Form
Pataday	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Patanol	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Paxil			Clinical Criteria Fax Form
Paxil CR			Clinical Criteria Fax Form
Peg-Intron		Clinical Criteria Fax Form
Pegasys		Clinical Criteria Fax Form
Pennsaid		Clinical Criteria Fax Form
Percocet	Clinical Criteria Fax Form
Perforomist		Clinical Criteria
Periostat		Clinical Criteria Fax Form
Pexeva			Clinical Criteria Fax Form
Plan B		Clinical Criteria Fax Form
Plendil			Clinical Criteria Fax Form
Pravachol			Clinical Criteria Fax Form
Pravastatin			Clinical Criteria Fax Form
Pregnyl		Clinical Criteria Fax Form
Prevacid	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Prilosec	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Pristiq			Clinical Criteria Fax Form
Privigen		Clinical Criteria Fax Form
Procardia XL			Clinical Criteria Fax Form
Prochieve 4%		Clinical Criteria Fax Form
Prochieve 8%		Clinical Criteria Fax Form
Procrit		Clinical Criteria Fax Form
Prolia		Clinical Criteria Fax Form
Prolixin/Permitil		Clinical Criteria Fax Form
Propoxyphene(Darvon and Darvocet)		Clinical Criteria Fax Form
Proscar		Clinical Criteria Fax Form
Protonix	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Protopic		Clinical Criteria Fax Form
Provenge		Clinical Criteria Fax Form
Proventil	Clinical Criteria Fax Form
Proventil HFA	Clinical Criteria Fax Form
Provigil		Clinical Criteria Fax Form
Prozac			Clinical Criteria Fax Form
Pulmicort Respules (suspension)	Clinical Criteria Fax Form
Pulmicort Turbuhaler (inhaler)	Clinical Criteria Fax Form
Pulmozyme		Clinical Criteria Fax Form
Qnasl	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Qualaquin		Clinical Criteria Fax Form
Quantity Supply	Clinical Criteria Fax Form
Quinine		Clinical Criteria Fax Form
Qvar	Clinical Criteria Fax Form
Rebif Only applies to closed commercial		Clinical Criteria Fax Form
Relpax	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Remicade		Clinical Criteria Fax Form
Remodulin		Clinical Criteria Fax Form
Renova		Clinical Criteria Fax Form
Reprexain	Clinical Criteria Fax Form
Repronex		Clinical Criteria Fax Form
Retin-A		Clinical Criteria Fax Form
Revatio		Clinical Criteria Fax Form
Revlimid		Clinical Criteria Fax Form
Rhinocort Aqua	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Risperdal		Clinical Criteria Fax Form
Ritalin		Clinical Criteria Fax Form
Rituxan		Clinical Criteria Fax Form
Roferon-A		Clinical Criteria Fax Form
Roxicet	Clinical Criteria Fax Form
Rozerem		Clinical Criteria Fax Form
Rybix ODT	Clinical Criteria Fax Form
Ryzolt	Clinical Criteria Fax Form
Saizen		Clinical Criteria Fax Form
Sanctura		Clinical Criteria Fax Form
Sanctura XR		Clinical Criteria Fax Form
Saphris		Clinical Criteria Fax Form
Sarafem			Clinical Criteria Fax Form
Semprex-D		Clinical Criteria Fax Form
Serevent Diskus	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Seroquel		Clinical Criteria Fax Form
Seroquel XR		Clinical Criteria Fax Form
Serostim		Clinical Criteria Fax Form
Silenor		Clinical Criteria Fax Form
Simponi		Clinical Criteria Fax Form
Simvastatin		Clinical Criteria Fax Form	Clinical Criteria Fax Form
Sodium sulfacetamide/sulfur		Clinical Criteria Fax Form
Solodyn		Clinical Criteria Fax Form Clinical Criteria Fax Form
Sonata		Clinical Criteria Fax Form
Sotret		Clinical Criteria Fax Form
Spiriva	Clinical Criteria Fax Form
Sporanox		Clinical Criteria Fax Form
Sprycel		Clinical Criteria Fax Form
Stadol N.S.	Clinical Criteria Fax Form
Staxyn	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Stelara		Clinical Criteria Fax Form
Stelazine		Clinical Criteria Fax Form
Stendra	Clinical Criteria Fax Form	Clinical Criteria
Strattera		Clinical Criteria Fax Form
Striant		Clinical Criteria Fax Form
Suboxone	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Subsys		Clinical Criteria Fax Form
Subutex		Clinical Criteria Fax Form
Sular			Clinical Criteria Fax Form
Sumatriptan	Clinical Criteria Fax Form
Sumavel DosePro	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Suprenza ODT		Clinical Criteria Fax Form
Supartz		Clinical Criteria Fax Form
Supprelin LA		Clinical Criteria Fax Form
Sutent		Clinical Criteria Fax Form
Symbicort Inhaler	Clinical Criteria Fax Form
Synagis		Clinical Criteria Fax Form
Synarel		Clinical Criteria Fax Form
Synvisc		Clinical Criteria Fax Form
Synvisc-One		Clinical Criteria Fax Form
Tamiflu		Clinical Criteria Fax Form
Tarceva		Clinical Criteria Fax Form
Targretin		Clinical Criteria Fax Form
Tasigna		Clinical Criteria Fax Form
Tekamlo			Clinical Criteria Fax Form
Tekturna			Clinical Criteria Fax Form
Tekturna HTC			Clinical Criteria Fax Form
Temodar		Clinical Criteria Fax Form
Testim	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Tetracycline HCl		Clinical Criteria Fax Form
Tev-Tropin		Clinical Criteria Fax Form
Thalomid		Clinical Criteria Fax Form
Thorazine (excludes suppositoriesand injectables)		Clinical Criteria Fax Form
Tiazac			Clinical Criteria Fax Form
Toradol	Clinical Criteria Fax Form
Trelstar Depot or LA		Clinical Criteria Fax Form
Tretin-X		Clinical Criteria Fax Form
Treximet	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Trilafon		Clinical Criteria Fax Form
Twynsta			Clinical Criteria Fax Form
Tykerb		Clinical Criteria Fax Form
Tylenol w/Cod	Clinical Criteria Fax Form
Tylox	Clinical Criteria Fax Form
Tyvaso		Clinical Criteria Fax Form
Uloric		Clinical Criteria Fax Form
Ultracet	Clinical Criteria Fax Form
Ultram	Clinical Criteria Fax Form
Valturna			Clinical Criteria Fax Form
Vantas Implant		Clinical Criteria Fax Form
Vectibix		Clinical Criteria Fax Form
Veletri		Clinical Criteria Fax Form
Veltin		Clinical Criteria Fax Form
Venlafaxine ER			Clinical Criteria Fax Form
Ventavis		Clinical Criteria Fax Form
Ventolin HFA	Clinical Criteria Fax Form
Veramyst	Clinical Criteria Fax Form
Verelan PM			Clinical Criteria Fax Form
Vfend		Clinical Criteria Fax Form
Viagra	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Vibramycin		Clinical Criteria Fax Form
Vicodin	Clinical Criteria Fax Form
Vicoprofen	Clinical Criteria Fax Form
Victoza		Clinical Criteria Fax Form
Victrelis		Clinical Criteria Fax Form
Viibryd		Clinical Criteria Fax Form
Vivaglobin		Clinical Criteria Fax Form
Vivitrol		Clinical Criteria Fax Form
Vopac	Clinical Criteria Fax Form
Votrient		Clinical Criteria Fax Form
VPRIV		Clinical Criteria Fax Form
Vytorin		Clinical Criteria Fax Form
Vyvanse		Clinical Criteria Fax Form
Wellbutrin XL			Clinical Criteria Fax Form
Xalkori		Clinical Criteria Fax Form
Xiaflex		Clinical Criteria Fax Form
Xeloda		Clinical Criteria Fax Form
Xenazine		Clinical Criteria Fax Form
Xenical		Clinical Criteria Fax Form
Xeomin		Clinical Criteria Fax Form
Xgeva		Clinical Criteria Fax Form
Xiaflex		Clinical Criteria Fax Form
Xifaxan		Clinical Criteria Fax Form
Xodol	Clinical Criteria Fax Form
Xolair		Clinical Criteria Fax Form
Xopenex HFA	Clinical Criteria Fax Form
Xyzal	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Yervoy		Clinical Criteria Fax Form
Zamicet	Clinical Criteria Fax Form
Zavesca		Clinical Criteria Fax Form
Zetia		Clinical Criteria Fax Form
Zegerid	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Zelboraf		Clinical Criteria Fax Form
Zerlor	Clinical Criteria Fax Form
Ziana Gel		Clinical Criteria Fax Form
Zithromax	Clinical Criteria Fax Form
Zmax	Clinical Criteria Fax Form
Zocor			Clinical Criteria Fax Form
Zofran	Clinical Criteria Fax Form
Zoladex		Clinical Criteria Fax Form
Zolinza		Clinical Criteria Fax Form
Zoloft			Clinical Criteria Fax Form
Zolpimist		Clinical Criteria Fax Form
Zomig	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Zomig nasal spray	Clinical Criteria Fax Form	Clinical Criteria Fax Form
Zorbtive		Clinical Criteria Fax Form
Zuplenz	Clinical Criteria Fax Form
Zyban		Clinical Criteria Fax Form
Zydone	Clinical Criteria Fax Form
Zyprexa		Clinical Criteria Fax Form
Zytiga		Clinical Criteria Fax Form
Zyvox		Clinical Criteria Fax Form
Myorisan		Clinical Criteria Fax Form
Beyaz		Clinical Criteria Fax Form
Safyral		Clinical Criteria Fax Form
Ovcon		Clinical Criteria Fax Form
Ortho Tri-Cyclen Lo		Clinical Criteria Fax Form
Norinyl		Clinical Criteria Fax Form
Natazia		Clinical Criteria Fax Form
Loestrin Fe		Clinical Criteria Fax Form
Lo Loestrin Fe		Clinical Criteria Fax Form
Generess Fe		Clinical Criteria Fax Form
Zetonna		Clinical Criteria Fax Form
Korlym		Clinical Criteria Fax Form
Magnacet		Clinical Criteria Fax Form
Primlev		Clinical Criteria Fax Form
Xolox		Clinical Criteria Fax Form
Eylea		Clinical Criteria Fax Form
Januvia		Clinical Criteria Fax Form
Tradjenta		Clinical Criteria Fax Form
Avonex Only applies to closed commercial		Clinical Criteria Fax Form
Bosulif		Clinical Criteria Fax Form
Xtandi		Clinical Criteria Fax Form
Relenza	Clinical Criteria Fax Form
Aubagio		Clinical Criteria Fax Form
Stivarga		Clinical Criteria Fax Form
Bontril PDM		Clinical Criteria Fax Form
Dymista		Clinical Criteria Fax Form
Isotretinoin		Clinical Criteria
Nulojix		Clinical Criteria Fax Form
Femara		Clinical Criteria Fax Form
Berinert		Clinical Criteria Fax Form
Cinryze		Clinical Criteria Fax Form
Firazyr		Clinical Criteria Fax Form
Kalibitor		Clinical Criteria Fax Form
Picato		Clinical Criteria Fax Form
Solaraze		Clinical Criteria Fax Form
Soliris		Clinical Criteria Fax Form
Xeljanz		Clinical Criteria Fax Form
Yervoy		Clinical Criteria Fax Form
Adcetris		Clinical Criteria
Eylea		Clinical Criteria Fax Form
Neutroval		Clinical Criteria
Buproban		Clinical Criteria Fax Form
Bupropion SR		Clinical Criteria Fax Form
Jetrea		Clinical Criteria
Pomalyst		Clinical Criteria Fax Form
Kyprolis		Clinical Criteria Fax Form
Perjeta		Clinical Criteria
Stivarga		Clinical Criteria
Zaltrap		Clinical Criteria Fax Form
Zyclara		Clinical Criteria Fax Form
Januvia		Clinical Criteria
Nesina		Clinical Criteria
Tradjenta		Clinical Criteria
Diltiazem ER			Clinical Criteria Fax Form
Wellbutrin SR			Clinical Criteria Fax Form
Eliphos		Clinical Criteria Fax Form
PhosLo		Clinical Criteria Fax Form
Phoslyra		Clinical Criteria Fax Form
Fosrenol		Clinical Criteria Fax Form
RenaGel		Clinical Criteria Fax Form

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