Pharmacy Prior Authorization Criteria

Epinephrine Injection Products

Indications for Prior Authorization

EpiPen (epinephrine injection), EpiPen Jr. (epinephrine injection), epinephrine injection

• For diagnosis of Allergic reactions
  Indicated in the emergency treatment of type I allergic reactions, including anaphylaxis, in adults and pediatric patients who weigh 15 kg or greater.

Criteria

Brand EpiPen, Brand EpiPen Jr.

Step Therapy

Length of Approval: 6 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (within the past 180 days) or intolerance to generic epinephrine

P & T Revisions

2026-04-03, 2025-12-18, 2024-04-15, 2023-10-02, 2023-04-11, 2022-06-21, 2022-05-28, 2021-06-02, 2020-05-25

References

1. EpiPen prescribing information. Mylan Specialty L.P. Morgantown, WV. March 2026.
2. EpiPen Jr prescribing information. Mylan Specialty L.P. Morgantown, WV. March 2026.

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Revision History

• 2026-04-03: 2026 Annual Review
• 2025-12-18: no criteria changes, added IL statute operational note
• 2024-04-15: 2024 Annual Review
• 2023-10-02: update guideline
• 2023-04-11: 2023 Annual Review.
• 2022-06-21: Updated criteria.
• 2022-05-28: Annual Review - No changes.
• 2021-06-02: Updated references.
• 2020-05-25: Updated references section.

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