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

DrugAdditional PA Approval Criteria Number
Adstiladrin®Package Insert
AdzynmaPackage Insert
Agamree2
Airsupra6
Ala-Scalp®1
Alvaiz1
Clemastine syrup4
Cuvrior6
DemserPackage Insert
Entadfi6
EohiliaPackage Insert
Fabhalta6
Filsuvez®Package Insert
iDose® TR6
ImcivreePackage Insert
Inpefa6
Lumryz2
Lymepak1
Nexiclon XR4
Ngenla®1
Olpruva6
Omisirge®Package Insert
OpfoldaPackage Insert
Opsynvi1
Pokonza4
PombilitiPackage Insert
Rivfloza6
Ryaltris®6
Rystiggo®Package Insert
Simlandi2
Skyclarys®Package Insert
Sogroya®3
SohonosPackage Insert
Trientene 500mg4
Veopoz®Package Insert
Veozah6
Voquezna®6
Voquezna® Dual Pak
6
Voquezna® Triple Pak
6
Vtama® 6
VyjuvekPackage Insert
Vyvgart® HytruloPackage Insert
WainuaPackage Insert
Xphozah6
Zepbound6
Zilbrysq®Package Insert
Zoryve® foam
6
ZtalmyPackage 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.