Pharmacy Prior Authorization Criteria

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Guideline	Drug Name
Erythropoietic Agents - PA, NF	Aranesp (darbepoetin alfa), Epogen (epoetin alfa), Procrit (epoetin alfa), and Retacrit (epoetin alfa-epbx), Mircera (methoxy polyethylene glycol-epoetin beta)
Evrysdi (risdiplam)	Evrysdi (risdiplam)
Extended Release Tramadol Products	Conzip, Tramadol Extended Release (ER)
Eysuvis (loteprednol etabonate ophthalmic suspension)	Eysuvis (loteprednol etabonate ophthalmic suspension)
Fabry Disease Agents	Elfabrio (pegunigalsidase alfa-iwxj), Fabrazyme (agalsidase beta)
Fecal Microbiota Agents - PA, NF	Rebyota (fecal microbiota, live-jslm) suspension, Vowst (fecal microbiota spores, live-brpk) capsule, Zinplava (bezlotoxumab) injection
Ferriprox (deferiprone)	Ferriprox (deferiprone) Oral Solution, Ferriprox (deferiprone) Tablets
Fibric Acid Derivatives	Fenoglide, Fibricor
Flurazepam	Flurazepam
Galafold (migalastat)	Galafold (migalastat)
Gamifant (emapalumab-lzsg)	Gamifant (emapalumab-lzsg)
Gattex (teduglutide)	Gattex (teduglutide)
Gaucher Disease Agents - PA, NF	Cerdelga (eliglustat), Cerezyme (imiglucerase for injection), Elelyso (taliglucerase alfa) for injection, VPRIV (velaglucerase alfa for injection), Zavesca (miglustat), Yargesa (miglustat), Generic miglustat
Generic-First Step Program	ABILIFY, ACZONE, ALPHAGAN P, ALTACE, ARIMIDEX, ARTHROTEC 50, ARTHROTEC 75, ATACAND, AVAPRO, AVODART, AZOPT, BROVANA, BYSTOLIC, CANASA, CARBATROL, CARDIZEM LA, CARNITOR, CARNITOR SF, CATAPRES-TTS-1, CATAPRES-TTS-2, CATAPRES-TTS-3, CELEXA, CIALIS, CLARINEX, CLIMARA, CLOBEX, COLESTID, COLESTID FLAVORED, COMBIGAN, COREG, COREG CR, CORTEF, COSOPT, COSOPT PF, COZAAR, DELESTROGEN, DEPAKOTE, DEPAKOTE ER, DEPAKOTE SPRINKLES, DILANTIN-125, EFFEXOR XR, EPIDUO, ESTRACE, EXFORGE, FIORICET, FIORICET/CODEINE, FLOMAX, GOLYTELY, HALOG, HYZAAR, IMITREX, IMITREX STATDOSE REFILL, IMITREX STATDOSE SYSTEM, INDERAL LA, K-TAB, KEPPRA, KEPPRA XR, KLONOPIN, LAMICTAL, LAMICTAL CHEWABLE DISPERSIBLE, LAMICTAL ODT, LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE, LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE, LAMICTAL STARTER/TAKING VALPROATE, LAMICTAL XR, LASIX, LATISSE, LATUDA, LOESTRIN 1.5/30-21, LOESTRIN 1/20-21, LOESTRIN FE 1.5/30, LOESTRIN FE 1/20, LOTREL, LYRICA, MAXALT, MAXALT-MLT, MICARDIS, MICARDIS HCT, NALFON, NATROBA, NEURONTIN, NITROSTAT, PAXIL, PAXIL CR, PLAQUENIL, PLAVIX, PRED FORTE, PREDNISOLONE ACETATE P-F, PROMETRIUM, PROPECIA, QUESTRAN, QUESTRAN LIGHT, RANEXA, RELPAX, RENAGEL, RESTORIL, RISPERDAL, RISPERDAL CONSTA, SAFYRAL, SEASONIQUE, SEROQUEL, SEROQUEL XR, SILVADENE, SOMA, SOVUNA, SUBOXONE, TEGRETOL, TEGRETOL-XR, TENORMIN, TIKOSYN, TIMOPTIC, TIMOPTIC OCUDOSE, TIMOPTIC-XE, TOPAMAX, TOPAMAX SPRINKLE, TOPICORT, TRAVATAN Z, TRICOR, TRILEPTAL, UCERIS, VALTREX, VANADOM, VECTICAL, VESICARE, VIGAMOX, VIMPAT, WELCHOL, XALATAN, YASMIN 28, ZANAFLEX, ZESTRIL, ZOLOFT, ZONEGRAN, ZOVIRAX, ZYPREXA
Gilenya (fingolimod) - PA, NF	Gilenya (fingolimod)
Gilotrif (afatinib)	Gilotrif (afatinib)
Glumetza (metformin ER tablets)	Glumetza (metformin ER tablets)
Glycopyrrolate Oral Solution	Cuvposa (glycopyrrolate oral solution)
Gonadotropin-Releasing Hormone Agonists	Camcevi (leuprolide), Leuprolide Acetate, Leuprolide Acetate Depot, Eligard (leuprolide acetate), Trelstar (triptorelin pamoate), Lupron Depot (leuprolide acetate) 1-Month 7.5 mg, Lupron Depot 3-Month 22.5 mg, Lupron Depot 4-Month 30 mg, Lupron Depot 6-Month 45 mg, Lupron Depot 1-Month 3.75 mg, Lupron Depot 3-Month 11.25 mg, Lupron Depot-PED (leuprolide acetate), Supprelin LA (histrelin acetate), Triptodur (triptorelin), Fensolvi (leuprolide acetate)
Growth Hormones - PA, NF	Genotropin and Omnitrope, Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ NuSpin, Omnitrope, and Zomacton, Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ NuSpin, Omnitrope, Saizen, and Zomacton, Genotropin, Nutropin AQ NuSpin, and Omnitrope, Genotropin, Nutropin AQ NuSpin, Omnitrope, and Saizen, Humatrope and Zomacton, Ngenla (somatrogon-ghla), Norditropin Flexpro, Norditropin Flexpro and Humatrope, Norditropin Flexpro, Humatrope, and Zomacton, Norditropin Flexpro, Humatrope, and Zomacton, Nutropin AQ NuSpin, Serostim, Skytrofa (lonapegsomatropin-tcgd), Sogroya (somapacitan-beco), Zomacton, Zorbtive

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