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Program Information
Prior Authorization Process
Hotlinks
Current Criteria
Amphetamine Products
Antibotics with >14 days supply
Growth Hormones
Home IV Therapy
Injectable Medications
Mandatory Generic Substitution
Non-Steroidal Anti-Inflammatory Drugs
Neuraminidase Inhibitors (Oral Influenza Treatment Agents)
Non-PDL Prefilled Insulin Syringes
Retin-A
Stadol Nasal Spray
Synagis
Injectable Medication
Orlistat (Xenical ã)

Forms
Diabetic Supply Form
GI Risk Scale
Home IV Form
Neuraminidase PA Form
Prior Authorization Form
Synagis Approval Form

Blank PDL Form

Preferred drug List Criteria and Prior Approval Criteria