List of Drugs Under Review
Medication must meet Package Insert requirements for FDA-approved indication, age, dose, and frequency, as well as the additional requirements outlined.
AMHMR Prior Authorization Criteria (PDF)
Drugs & Prior Authorization Criteria Number
| Drug | Additional PA Approval Criteria Number |
|---|---|
| Adstiladrin® | Package Insert |
| Adzynma™ | Package Insert |
| Agamree™ | 2 |
| Airsupra™ | 6 |
| Ala-Scalp® | 1 |
| Alvaiz™ | 1 |
| Beqvez™ | 2 |
| Clemastine syrup | 4 |
| Cuvrior™ | 6 |
| Demser | Package Insert |
| Entadfi™ | 6 |
| Eohilia™ | Package Insert |
| Fabhalta™ | 6 |
| Filsuvez® | Package Insert |
| Flolipid™ | 1, 4 |
| Focinvez™ | 4 |
| iDose® TR | 6 |
| Imcivree | Package Insert |
| Ingrezza® Sprinkle | 4 |
| Inpefa™ | 6 |
| Libervant™ | Package Insert |
| Lumryz™ | 2 |
| Lymepak™ | 1 |
| Myhibbin™ | 4 |
| Nexiclon XR | 4 |
| Ngenla® | 1 |
| Olpruva™ | 6 |
| Omisirge® | Package Insert |
| Opfolda™ | Package Insert |
| Opsynvi | 1 |
| Pokonza™ | 4 |
| Pombiliti™ | Package Insert |
| Rezdiffra™ | Package Insert |
| Rinvoq® LQ |
3, 4 |
| Rivfloza™ | 6 |
| Ryaltris® | 6 |
| Rystiggo® | Package Insert |
| Simlandi | 2 |
| Skyclarys® | Package Insert |
| Sogroya® | 3 |
| Sohonos™ | Package Insert |
| Tofidence™ | 3 |
| Trientene 500mg | 4 |
| Tryvio™ | 6 |
| Tyenne® | 3 |
| Veopoz® | Package Insert |
| Veozah™ | 6 |
| Voquezna® | 6 |
| Voquezna® Dual Pak | 6 |
| Voquezna® Triple Pak | 6 |
| Voydeya™ | Package Insert |
| Vtama® | 6 |
| Vyjuvek™ | Package Insert |
| Vyvgart® Hytrulo | Package Insert |
| Wainua™ | Package Insert |
| Winrevair™ | 6 |
| Xphozah™ | 6 |
| Zepbound™ | 6 |
| Zilbrysq® | Package Insert |
| Zoryve® foam | 6 |
| Ztalmy | Package Insert |
| Zymfentra® | 3 |
Criteria Descriptions
Criteria Number |
Abbreviated Description |
|---|---|
1 |
Falls into existing class/category on Preferred Drug List (PDL), subject to non-preferred PA process. |
2 |
Falls into the existing Step Therapy class PA process. |
3 |
Falls into both PDL and Step Therapy requirements (1 and 2). |
4 |
Chemical drugs available in alternate existing dosage forms to be tried first. |
5 |
Product is a racemic mix, single enantiomer or diastereomer, or isomer of available medication, or prodrug metabolized to available medication or active metabolite of available medication. |
6 |
If the drug does not fall into mentioned categories, the patient must have an inadequate response to two or more medications FDA-approved for the same indication and/or medications that are considered the standard of care for the indication, when such agents exist. |
Rinvoq® LQ
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