Pharmacy Prior Authorization Criteria

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Guideline	Drug Name
Xenazine (tetrabenazine)	Xenazine (tetrabenazine)
Xenpozyme (olipudase alfa)	Xenpozyme (olipudase alfa)
Xeomin (incobotulinumtoxinA)	Xeomin (incobotulinumtoxinA)
Xermelo (telotristat ethyl)	Xermelo (telotristat ethyl)
Xiaflex (collagenase clostridium histolyticum)	Xiaflex (collagenase clostridium histolyticum)
Xifaxan (rifaximin) - PA, NF	Xifaxan (rifaximin)
Xipere (triamcinolone acetonide injectable suspension)	Xipere
Xipere (triamcinolone acetonide injectable suspension)	Xipere
Xolair (omalizumab)	Xolair (omalizumab)
Xolremdi (mavorixafor)	Xolremdi (mavorixafor)
Xospata (gilteritinib)	Xospata (gilteritinib) tablets
Xpovio (selinexor)	Xpovio (selinexor)
Xromi (hydroxyurea)	Xromi (hydroxyurea)
Xtandi (enzalutamide)	Xtandi (enzalutamide)
Xuriden (uridine triacetate)	Xuriden (uridine triacetate)
Yartemlea (narsoplimab-wuug)	Yartemlea (narsoplimab)
Yonsa (abiraterone acetate) - PA, NF	Yonsa (abiraterone acetate)
Yorvipath (palopegteriparatide)	Yorvipath (palopegteriparatide)
Zejula (niraparib)	Zejula (niraparib)
Zelboraf (vemurafenib)	Zelboraf (vemurafenib)