|
PA Criteria Chart Effective April 1, 2023 999.11 KB |
|
2023/02/27 |
|
PA Criteria Chart Effective January 1, 2023 734.92 KB |
|
2022/11/30 |
|
PA Criteria Chart Effective October 1, 2022 716.76 KB |
|
2022/08/30 |
|
PA Criteria Chart Effective August 1, 2022 727.65 KB |
|
2022/06/22 |
|
PA Criteria Chart Effective June 1, 2022 716.29 KB |
|
2022/04/22 |
|
PA Criteria Chart Effective January 13, 2022 710.07 KB |
|
2022/01/14 |
|
PA Criteria Chart Effective January 1, 2022 709.39 KB |
|
2021/11/29 |
|
PA Criteria Chart Effective October 1, 2021 672.8 KB |
|
2021/08/25 |
|
PA Criteria Chart Effective June 1, 2021 674.43 KB |
|
2021/04/26 |
|
PA Criteria Chart Effective January 1, 2021 879.64 KB |
|
2020/11/19 |
|
PA Criteria Chart Effective November 1, 2020 861.97 KB |
|
2020/09/14 |
|
PA Criteria Chart Effective October 1, 2020 873.33 KB |
|
2020/08/24 |
|
PA Criteria Chart Effective July 1, 2020 854.78 KB |
|
2020/06/02 |
|
PA Criteria Chart Effective February 1, 2020 1020.51 KB |
|
2020/01/27 |
|
PA Criteria Chart Effective January 1, 2020 1.02 MB |
|
2019/11/25 |
|
PA Criteria Chart Effective October 1, 2019 743.06 KB |
|
2019/08/28 |
|
PA Criteria Chart Effective July 1, 2019 735.56 KB |
|
2019/05/21 |
|
PA Criteria Chart Effective June 1, 2019 763.64 KB |
|
2019/04/30 |
|
PA Criteria Chart Effective March 1, 2019 745.46 KB |
|
2019/04/01 |
|
PA Criteria Chart Effective January 1, 2019 824.08 KB |
|
2018/11/21 |
|
PA Criteria Chart Effective October 1, 2018 813.22 KB |
|
2018/08/30 |
|
PA Criteria Chart Effective July 1, 2018 858.06 KB |
|
2018/06/11 |
|
PA Criteria Chart Effective July 1, 2018 625.04 KB |
|
2018/05/24 |
|
PA Criteria Chart Effective June 1, 2018 888.89 KB |
|
2018/04/30 |
|
PA Criteria Chart Effective June 1, 2018 888.57 KB |
|
2018/04/27 |
|
PA Criteria Chart Effective April 1, 2018 876.7 KB |
|
2018/02/21 |
|
PA Criteria Chart Effective January 1, 2018 457.09 KB |
|
2017/11/20 |
|
PA Criteria Chart Effective October 1, 2017 889.6 KB |
|
2017/08/25 |
|
PA Criteria Chart Effective June 1, 2017 867.39 KB |
|
2017/05/01 |
|
PA Criteria Chart Effective April 1, 2017 870.9 KB |
|
2017/02/20 |
|
PA Criteria Chart Effective March 1, 2017 855.2 KB |
|
2017/02/07 |
|
PA Criteria Chart Effective January 1, 2017 853.17 KB |
|
2017/01/09 |
|
PA Criteria Chart Effective January 1, 2017 853.13 KB |
|
2016/11/22 |
|
PA Criteria Chart Effective October 1, 2016 833.69 KB |
|
2016/08/23 |
|
PA Criteria Chart Effective August 1, 2016 853.91 KB |
|
2016/08/03 |
|
PA Criteria Chart Effective June 1, 2016 803.52 KB |
|
2016/05/25 |
|
PA Criteria Chart Effective June 1, 2016 809.89 KB |
|
2016/05/02 |
|
PA Criteria Chart Effective April 11, 2016 763 KB |
|
2016/03/28 |
|
PA Criteria Chart Effective April 11, 2016 763.19 KB |
|
2016/03/09 |
|
PA Criteria Chart Effective January 7, 2016 753.38 KB |
|
2016/01/07 |
|
PA Criteria Chart Effective January 1, 2016 751.52 KB |
|
2015/12/01 |
|
PA Criteria Chart Effective October 1, 2015 339.76 KB |
|
2015/09/02 |
|
PA Criteria Chart Effective August 4, 2015 686.05 KB |
|
2015/08/04 |
|
PA Criteria Chart Effective July 6, 2015 686.26 KB |
|
2015/06/10 |
|
PA Criteria Chart Effective June 1, 2015 756.41 KB |
|
2015/04/23 |
|
PA Criteria Chart Effective January 9, 2015 303.25 KB |
|
2015/01/05 |
|
PA Criteria Chart Effective January 1, 2015 303.01 KB |
|
2014/11/24 |
|
PA Criteria Chart Effective November 3, 2014 287.67 KB |
|
2014/11/03 |
|
PA Criteria Chart Effective October 14, 2014 277.23 KB |
|
2014/10/15 |
|
PA Criteria Chart Effective October 1, 2014 280.37 KB |
|
2014/08/22 |
|
PA Criteria Chart Effective July 21, 2014 217.07 KB |
|
2014/06/17 |
|
PA Criteria Chart Effective June 1, 2014 441.48 KB |
|
2014/04/24 |
|
PA Criteria Chart Effective April 1, 2014 213.49 KB |
|
2014/02/27 |
|
PA Criteria Chart Effective January 1, 2014. 426.97 KB |
|
2013/12/02 |
|
PA Criteria Chart Effective October 1, 2013 200.73 KB |
|
2013/09/03 |
|
PA Criteria Chart Effective July 1, 2013 190.26 KB |
|
2013/05/21 |
|
PA Criteria Chart Effective May 1, 2013 187.7 KB |
|
2013/03/18 |
|
PA Chart Effective March 4, 2013 233.86 KB |
|
2013/02/06 |
|
PA Criteria Chart Effective January 1, 2013 174.4 KB |
|
2012/11/21 |
|
Preferred / Recommended Drug List Effective October 22, 2012 217.31 KB |
|
2012/09/14 |
|
PA Criteria Chart Effective July 30, 2012 167.76 KB |
|
2012/06/26 |
|
PA Criteria Chart Effective April 9, 2012 164.42 KB |
|
2012/03/12 |
|
PA Criteria Chart Effective January 30, 2012 162.92 KB |
|
2011/12/28 |
|
PA Criteria Chart Effective November 1, 2011 159.3 KB |
|
2011/12/28 |
|
PA Criteria Chart Effective January 30, 2012 162.92 KB |
|
2011/12/28 |
|
PA Criteria Chart Effective November 1, 2011 156.16 KB |
|
2011/12/05 |
|
Intuniv1 6.52 KB |
|
2011/11/01 |
|
Levemir 12.08 KB |
|
2011/10/28 |
|
Viibryd 31.29 KB |
|
2011/09/19 |
|
PA Criteria Chart Effective August 1, 2011 152.25 KB |
|
2011/07/11 |
|
PA Criteria Chart Effective July 18, 2011 151.59 KB |
|
2011/06/22 |
|
PA Criteria Chart Effective July 18, 2011 150.97 KB |
|
2011/06/15 |
|
PA Criteria Chart Effective March 14, 2011 150.82 KB |
|
2011/02/23 |
|
PA Criteria Chart Effective January 1, 2011 142.77 KB |
|
2010/12/14 |
|
PA Criteria Chart Effective October 18, 2010 202.62 KB |
|
2010/10/06 |
|
PA Criteria Chart Effective May 24, 2010 161.04 KB |
|
2010/05/12 |
|
PA Criteria Chart Effective May 24, 2010 161.42 KB |
|
2010/05/12 |
|
PA Criteria Chart Effective April 5, 2010 157.63 KB |
|
2010/03/01 |
|
PA Criteria Chart Effective January 1, 2010 153.95 KB |
|
2009/12/08 |
|
PA Criteria Chart Effective January 1, 2010 153.93 KB |
|
2009/12/08 |
|
PA Criteria Chart Effective November 1, 2009 146.38 KB |
|
2009/09/24 |
|
PA Criteria Chart Effective August 3, 2009 143.22 KB |
|
2009/07/27 |
|
PA Criteria Chart Effective June 15, 2009 142.87 KB |
|
2009/05/13 |
|
PA Criteria Chart Effective February 27,2009 141.03 KB |
|
2009/02/25 |
|
PA Criteria Chart Effective January 1, 2009 140.99 KB |
|
2009/02/25 |
|
PA Criteria Chart Effective January 1, 2009 140.9 KB |
|
2009/01/19 |
|
PA Criteria Chart Effective October 27, 2008 139.99 KB |
|
2008/11/20 |
|
PA Criteria Chart Effective October 27, 2008 139.99 KB |
|
2008/11/20 |
|
PA Criteria Chart Effective October 27, 2008 141.17 KB |
|
2008/10/29 |
|
PA Criteria Chart Effective July, 28 2008 139.93 KB |
|
2008/07/21 |
|
PA Criteria Chart Effective April 30, 2008 140.1 KB |
|
2008/04/16 |
|
PA Criteria Chart Effective February 18, 2008 71.53 KB |
|
2008/04/16 |
|
PA Criteria Chart Effective October 29, 2007 145.93 KB |
|
2008/04/16 |
|
PA Criteria Chart Effective07-30-2007 68.74 KB |
|
2007/07/23 |
|
PA Criteria Chart Effective April 16, 2007 68.66 KB |
|
2007/06/13 |
|
PA Criteria Chart Effective January 1, 2007 181.75 KB |
|
2006/12/14 |
|
PA Criteria Chart Effective October 30, 2006 181.15 KB |
|
2006/12/08 |
|
PA Criteria Chart Effective July 17, 2006 62.92 KB |
|
2006/09/22 |
|
Prior Authorization Criteria Chart - 3-09-06 62.82 KB |
|
2006/03/09 |
|
PA Criteria Chart Effective 1-16-06 59.99 KB |
|
2006/02/16 |
|
Prior Authorization Criteria Chart 109.42 KB |
|
2005/08/23 |