Medicaid Prior Authorization Criteria
- Accrufer
- Acitretin Non-Oncology
- Acyclovir Suspension
- Adempas
- Advair HFA/Breo/Dulera
- Age Restriction
- Ajovy/Emgality
- Aranesp Non-Oncology
- Arikayce
- Aripiprazole Injection (Abilify Maintena, Aristada, Aristada Initio)
- Austedo
- Azstarys
- Benlysta
- Benefit Exclusion
- Botox
- Breast Cancer Risk Reduction Prophylaxis Criteria
- Brexafemme
- Bronchitol
- Bylvay
- Carglumic Acid
- Cerdelga
- Chemet
- Chenodal
- Cholbam
- Cinacalcet
- Cinqair
- Constipation Drugs-Amitiza, Linzess, Motegrity, Movantik, Relistor, Symproic, Trulance
- Cosentyx
- Cresemba
- Crysvita
- Cystadrops
- Cystagon
- Dalfampridine
- Daliresp Step Therapy
- Dayvigo
- Descovy
- Diabetic Test Strip
- Diacomit
- Diclofenac Gel Prescription
- Dojolvi
- Doxylamine succinate- Pyridoxine
- DPP-4 Inhibitors (Gliptins)
- Dupixent
- Dysport
- Emend Non-Oncology
- Emflaza
- Enbrel
- Enspryng
- Entresto
- Epidiolex
- Entyvio
- Epogen-Procrit-Retacrit Non-Oncology
- Esbriet
- Eucrisa
- Evrysdi
- Fanapt
- Fasenra
- Fensolvi
- Fintepla
- Firdapse
- Freestyle Libre/Dexcom
- Fycompa
- Pulmonary Arterial Hypertension Global
- Galafold
- Gattex
- GLP-1 Agonist Step Therapy
- Haegarda
- Hemlibra
- Hemophilia Products – Factor IX
- Hemophilia Products – Factor VIII
- Hemophilia Products – von Willebrand Factor (Vonvendi)
- Hepatitis C
- Hetlioz
- HP Acthar Gel
- Humate-P
- Humira
- Humulin R U-500
- Hypodermic Needles & Syringes
- lanreotide Depot Non-Oncology
- Icatibant
- Ilumya
- Imcivree
- Impavido
- Invega Hafyera
- Invega Sustenna
- Invega Trinza
- Isotretinoins Non-Oncology
- Isturisa
- Ivermectin
- Juxtapid
- Jynarque
- Kalydeco
- Kanuma
- Kerendia
- Kesimpta
- Keveyis
- Kevzara
- Krystexxa
- Kuvan
- Latuda
- Leuprolide Non Oncology
- Livmarli
- Lokelma
- Long Acting Opioid
- Long Acting Stimulant
- Lumizyme
- Lupkynis
- Mavenclad
- Medicaid Medical Benefit Only Policy
- Medicaid Pharmacy Benefit Only Policy
- Methylphenidate Solution
- Miglustat
- Mircera
- Myalept
- Myobloc
- Myrbetriq Step Therapy
- Naproxen Suspension Step Therapy
- New To Market
- Nexviazyme
- Nicotrol
- Non-Formulary Exception
- Norditropin
- Northera
- Nourianz
- Nucala
- Nuedexta
- Nuplazid
- Nurtec/Ubrelvy
- Octreotide Non-Oncology
- Ofev
- Olopatadine Ophthalmic
- Omnipod
- Opzelura
- Orfadin-Nityr-Nitisinone
- Oriahnn Myfembree
- Orilissa
- Orkambi
- Orladeyo
- Osphena Step Therapy
- Otezla
- Oxervate Criteria
- PAH Global
- Palforzia
- Palynziq
- Pharmacy Benefit Only
- Phosphate Binders Step Therapy (Lanthanum, Sevelamer)
- Pimecrolimus
- Prevymis
- Prior Authorization Global Criteria
- Prolia Non-Oncology
- Pyrimethamine
- Quantity Limit Exception
- Ravicti
- Repatha
- Restasis Step Therapy
- Rinvoq
- Risperdal Consta
- Serostim
- Sodium-Glucose Cotransporter-2 (SGLT2)
- Medicaid Short-Acting Opioid Naïve
- Short-Acting Opioid Post Limit
- Simponi
- Skyrizi
- Sodium Phenylbutyrate
- Solosec
- Somatuline Depot
- Soriatane
- Spiriva Handihaler Step Therapy
- Stelara
- Step Therapy Exception
- Strensiq
- Sublocade
- Sucraid
- Sunosi
- Symdeko
- Synagis
- Takhzyro
- Tavneos
- Tegsedi
- Terconazole Vaginal Cream/Suppository Step Therapy
- Teriparatide
- Testosterone (topical – generic)
- Tetrabenazine
- Thalomid Non-Oncology
- Thiola EC
- Tobramycin Inhalation Solution
- Travoprost Step Therapy
- Tremfya
- Tretinoin Topical
- Trijardy XR
- Trikafta
- Trogarzo
- Tyvaso
- Uceris Rectal Foam
- Varenicline Step Therapy
- Veltassa
- Verquvo
- Vimpat Step Therapy
- Voriconazole
- Voxzogo
- Vraylar
- Vyndamax-Vyndaqel
- Wakix
- Weight Loss-Belviq-BelviqXR-Contrave-Qsymia-Saxenda
- Xcopri
- Xeljanz
- Xenleta
- Xeomin
- Xifaxan
- Xolair
- Xyrem
- Xywav
- Zeposia
- Zokinvy
- Zyprexa Relprevv Injection
Oncology/Hematology Medicaid Prior Authorization Criteria
- 5HT3 Receptor Antagonists: Zofran, Kytril, Anzemet, Aloxi, Akynzeo, Granisetron, Sancuso, Sustol
- Abiraterone
- Afinitor
- Alecensa
- Alunbrig
- Ayvakit
- Balversa
- Bone Modifying Agents: Aredia, Zometa, Xgeva/Prolia
- Bosulif
- Braftovi
- Brukinsa
- Cablivi
- Calquence
- Caprelsa
- Cometriq or Cabometyx
- Copiktra
- Cotellic
- Daurismo
- Doptelet
- Emend, Cinvanti and Varubi
- Endari
- Erythropoiesis Stimulating Agents: Epogen, Procrit, Aranesp, Mircera, Retacrit
- Erivedge
- Erleada
- Erlotinib
- Exkivity
- Farydak
- Faslodex
- Ferriprox
- Fotivda
- Gavreto
- Generic Drug Policy
- Gilotrif
- Gleevec
- Ibrance
- Iclusig
- Idhifa
- Imbruvica
- Inlyta
- Inqovi
- Inrebic
- Iressa
- Iron Products
- Jakafi
- Kisqali
- Koselugo
- Lenvima
- LHRH Agonists and Antagonist: Lupron, Lupron Depot, Eligard, Viadur
- Lonsurf
- Lorbrena
- Lumakras
- Lynparza
- Medicaid Oncology/Hematology Preferred Drug Policy
- Mekinist
- Mektovi
- Mozobil
- Mulpleta
- Myeloid Growth Factors: Neupogen, Granix, Leukine, Zarxio, Neulasta, Fulphila
- Nerlynx
- Nexavar
- Ninlaro
- Nubeqa
- Odomzo
- Onureg
- Oxbryta
- Pemazyre
- Piqray
- Pomalyst
- Promacta
- Qinlock
- Retevmo
- Revlimid
- Rozlytrek
- Rubraca
- Rydapt
- Scemblix
- Somatostatin Analog: Sandostatin SQ, LAR depot (Octreotide), and Somatuline (lanreotide)
- Sprycel
- Stivarga
- Sutent
- Tabrecta
- Tafinlar
- Tagrisso
- Talzenna
- Tarceva
- Targretin
- Tasigna
- Tavalisse
- Tazverik
- Tepmetko
- Thalomid
- Tibsovo
- Topical and Intralesional Therapies use in Non-Melanoma Skin Cancers and Primary Cutaneous Lymphomas
- Truseltiq
- Tukysa
- Turalio
- Tykerb
- Ukoniq
- Venclexta
- Verzenio
- Vitrakvi
- Vizimpro
- Votrient
- Xalkori
- Xermelo
- Xospata
- Xpovio
- Xtandi
- Zejula
- Zelboraf
- Zolinza
- Zydelig
- Zykadia
2022 Commercial Prior Authorization Criteria
- Acamprosate
- Actemra
- Actimmune
- Adapalene
- Adempas
- Alecensa
- Alpha1-Proteinase Inhibitors
- Ambrisentan-Letairis
- Anabolic Steroids
- Anadrol
- Antidiabetic Agents Step Therapy Policy
- Apokyn-Kynmobi
- Aranesp
- Arcalyst
- Aubagio
- Avonex
- Azacitidine-Vidaza
- Banzel
- Betaseron-Extavia
- Bexarotene-Targretin
- Bosentan-Tracleer
- Bosulif
- BPH Cialis
- Cabometyx
- Calquence
- Caprelsa
- Carbaglu
- Cayston
- Cetrotide-Ganirelix
- Cinacalcet-Sensipar
- Cometriq
- Copaxone-Glatopa
- Cosentyx
- Cuprimine, Depen, Syprine
- Cystadan
- Cystagon
- Cystaran-Cystadrops
- Dalfampridine-Ampyra
- Daliresp
- Daraprim
- Decitabine-Dacogen
- Dibenzyline
- Dificid
- Dimethyl fumarate
- Dipentum
- Dofetilide-Tikosyn
- Eligard
- Emflaza
- Emsam
- Enbrel
- Epclusa
- Epidiolex
- Epogen-Procrit-Retacrit
- Erbitux
- Erivedge
- Erleada
- Erlotinib-Tarceva
- Esbriet
- Everolimus-Afinitor Products
- Evrysdi
- Exelon
- Farydak
- Ferriprox
- Follitropins
- Fulvestrant-Faslodex
- Fuzeon
- Gazyva
- Gilenya
- Growth Hormone Without ISS
- Haegarda
- Harvoni
- HCG
- Hemlibra
- Hetlioz
- High Risk Medications (HRM Long List)
- Humira
- Ibrance
- Icatibant-Sajazir-Firazyr
- Iclusig
- Idhifa
- Imatinib-Gleevec
- Imbruvica
- Inbrija
- Increlex
- Inlyta
- Insomnia (Belsomra, Dayvigo)
- Intron A
- Isotretinoins
- Itraconazole (Sporanox Capsules)
- Itraconazole (Sporanox Oral Solution)
- Jakafi
- Jublia
- Kadcyla
- Kalydeco
- Kevzara
- Keytruda
- Kisqali
- Kuvan
- Lenvima
- Leuprolide
- Lidoderm
- Lorbrena
- Lotronex
- Lupaneta Pack
- Lynparza
- Mekinist
- Mircera
- Mitoxantrone
- Multaq
- Myalept
- Namenda
- Neulasta and pegfilgrastim biosimilars
- Neupogen and filgrastim biosimilars
- Nexavar
- Noxafil
- Nubeqa
- Nucala
- Nuedexta
- Nuvigil
- Octreotide products
- Odomzo
- Ofev
- Oncaspar
- Onfi Sympazan
- Opsumit
- Oral-Intranasal Fentanyl Products
- Orenitram
- Orfadin-Nityr
- Orkambi
- Osphena
- Otezla
- Oxandrolone
- Pancrelipase
- PCSK9i
- Pegasys
- Peg-Intron
- Phenylbutyrate-Buphenyl
- Plegridy
- Pomalyst
- Praluent
- Prolia
- Promacta
- Provigil
- Rebif
- Regranex
- Revlimid
- Ribavirin
- Rinvoq
- Rosacea Products
- Rydapt
- Samsca
- Signifor
- Sildenafil-Revatio
- Simponi
- Simponi Aria
- Sirturo
- Skyrizi
- Somatuline Depot
- Somavert
- Sovaldi
- Sprycel
- Stelara
- Stivarga
- Subcutaneous Immune Globulin
- Sucraid
- Sunosi
- Supprelin LA
- Sutent
- Symdeko
- Synarel
- Tadalafil Products
- Tafinlar
- Taltz
- Tazorac
- Temozolomide-Temodar
- Testosterone – Oral Methyltestosterone Non-TGC
- Testosterone Products TGC
- Tetrabenazine-Xenazine
- Thalomid
- Tobramycin Inhalation
- Tremfya
- Treprostinil-Remodulin
- Tretinoins (Topical)
- Trikafta
- Triptodur
- Tukysa
- Tykerb
- Tymlos
- Tysabri
- Tyvaso
- Uptravi
- Valcyte
- Varenicline Step Therapy
- Vemlidy
- Venclexta
- Ventavis
- Vfend
- Vigabatrin-Sabril-Vigadrone
- Vitrakvi
- Vivitrol
- Vosevi
- Votrient
- Xeloda
- Xeljanz-Xeljanz XR
- Xeloda
- Xifaxan
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Zileuton
- Zoledronic acid-Reclast
- Zoledronic acid-Zometa
- Zolinza
- Zydelig
- Zykadia
- Zytiga
2021 Commercial Prior Authorization Criteria
- 5-Alpha Reductase Inhibitors
- 5-HT1 Agonist Limit
- 5-HT1 Agonist Post Limit
- Acamprosate Calcium
- Actemra
- Actimmune
- Adapalene
- Adempas
- Afinitor Disperz
- Alecensa
- Alpha-1 Proteinase Inhibitors: Aralast Np, Glassia, Prolastin-C, Zemaira
- Ambrisentan
- Anadrol-50
- Antidiabetic Agents Step Therapy
- Antifungal Topical Step Therapy
- Apokyn & Kynmobi
- Aptiom
- Aranesp
- Arcalyst
- Atypical Antipsychotics Step Therapy
- Aubagio
- Avonex
- Azacitidine
- Benefit Exclusion
- Betaseron/Extavia
- Bexarotene
- Bosentan
- Bosulif
- Briviact
- Calquence
- Caprelsa
- Carbaglu
- Cayston
- Cerdelga
- Cetrotide/Ganirelix
- CGRP Receptor Antagonists Step Therapy
- Cialis
- Cinacalcet
- Cometriq
- Copaxone/Glatopa
- Cosentyx
- Cystadane
- Cystagon
- Cystaran/Cystadrops
- Dalfampridine
- Daliresp
- Daraprim
- Desvenlafaxine & Fetzima Step Therapy
- Dificid
- Dipentum
- Dofetilide
- DPP-4 Inhibitors Step Therapy
- Eligard
- Emsam
- Enbrel
- Epclusa
- Epidiolex
- Epogen Procrit Retacrit
- Erbitux
- Erivedge
- Erleada
- Esbriet
- Eucrisa Step Therapy
- Evrysdi
- Exchange Medical Benefit Only
- Exchange Pharmacy Benefit Only
- Farydak
- Ferriprox
- Fulvestrant
- Fuzeon
- Gazyva
- Gilenya
- Harvoni
- Hemlibra
- Hetlioz
- Human Chorionic Gonadotropin (hCG): Novarel, Pregnyl, & Ovidrel
- Humira
- Ibrance
- Icatibant
- Iclusig
- Idhifa
- Imatinib
- Imbruvica
- Increlex
- Inlyta
- Intron
- Isotretinoins
- Itraconazole (Sporanox Capsules)
- Itraconazole (Sporanox Oral Solution)
- Ivermectin
- Jakafi
- Jublia
- Jublia Limit-Post Limit
- Kadcyla
- Kalydeco
- Kevzara
- Keytruda
- Kisqali
- Kuvan
- Lenvima
- Leuprolide
- Lidoderm ZTLido
- Lorbrena
- Lupaneta Pack
- Lupron Depot-PED
- Lynparza
- Lyrica, Gralise, & Horizant Step Therapy
- Marketplace Sklice Step Therapy
- Mekinist
- Mircera
- Mitoxantrone
- Modafinil
- Multaq
- Myalept
- Namenda
- Neulasta and Pegfilgrastim Biosimilars
- Neupogen and Filgrastim Biosimilars
- Nexavar
- Non-Formulary
- Noxafil
- Nubeqa
- Nucala
- Nuedexta
- Octreotide Products: Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot
- Odomzo
- Omega-3 Fatty Acids: Epanova, Lovaza, Vascepa
- Oncaspar
- Opioids ER – Step Therapy with MME Limit and Post Limit
- Opioids IR – 7-Day Acute Pain Duration Limit with MME Limit and Post Limit
- Opioids IR – 7-Day APAP-ASA-IBU Combo Products – Acute Pain Duration Limit
- Opsumit
- Orenitram
- Orfadin & Nityr
- Orkambi
- Otezla
- Oxandrin
- Pegasys
- Phenylbutyrate-Buphenyl
- Plegridy
- Pomalyst
- Praluent
- Prolia
- Promacta
- Prudoxin & Zonalon Step Therapy
- Quantity Limit Exception
- Ranexa Step Therapy
- Rebif
- Reclast
- Regranex
- Revlimid
- Ribavirin
- Rinvoq
- Rosuvastatin Step Therapy
- Rydapt
- Samsca
- Savella Step Therapy
- Subcutaneous Immune Globulin (SCIG): Hizentra, HyQvia, Cutaquig, Cuvitru, and Xembify
- Signifor
- Sildenafil
- Simponi
- Simponi Aria
- Simvastatin 80mg, Simvastatin/Ezetimibe 10/80mg Step Therapy
- Sirturo
- Skyrizi
- Somatuline Depot
- Somavert
- Sovaldi
- Sprycel
- Stelara
- Stivarga
- Sucraid
- Sutent
- Symdeko
- Tadalafil Products
- Tafinlar
- Taltz
- Tarceva
- Tazorac
- Tecfidera
- Temozolomide
- Testosterone Products
- Tetrabenazine
- Thalomid
- Tobramycin (Inhalation)
- Tremfya
- Treprostinil
- Tretinoins (Topical)
- Treximet Step Therapy
- Trikafta
- Tukysa
- Tykerb
- Tymlos
- Tysabri
- Tyvaso
- Uloric Step Therapy
- Uptravi
- Valcyte
- Vemlidy
- Venclexta
- Ventavis
- Vigabatrin (Sabril, Vigadrone)
- Vitrakvi
- Vivitrol
- Vosevi
- Votrient
- Xalkori
- Xeljanz & Xeljanz XR
- Xeloda
- Xifaxan
- Xolair
- Xtandi
- Yonsa
- Zejula
- Zelboraf
- Zepatier
- Zolinza
- Zometa
- Zydelig
- Zykadia
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.
2020 Commercial Prior Authorization Criteria
- Abiraterone Acetate
- Acamprosate Calcium
- Actemra
- Actimmune
- Adapalene
- Adempas
- Afinitor
- Alecensa
- Alosetron
- Ambrisentan
- Amitriptyline
- Amylin Analogs Step Therapy
- Anadrol-50
- Antidepressants Step Therapy
- Apokyn
- Aptiom
- Aranesp
- ARB and Direct Renin Inhibitor Step Therapy
- Arcalyst
- Armodafinil
- Atypical Antipsychotics Step Therapy
- Aubagio
- Autoimmune Specialty Exceptions
- Avita
- Avonex
- Azacitidine
- Belbuca
- Benefit Exclusion
- Benign Prostatic Hyperplasia Step Therapy
- Betaseron
- Bexarotene
- Bisphosphonates Step Therapy
- Bosentan
- Bosulif
- Briviact
- Calquence
- Capecitabine
- Caprelsa
- Carbaglu
- Carisoprodol
- Cayston
- Cerdelga
- Chorionic Gonadotropin
- Clemastine Fumarate
- Clobazam
- Cometriq
- Copaxone Inj
- Cosentyx
- Creon
- Cyclobenzaprine
- Cystadane
- Cystagon
- Cystaran
- Dalfampridine
- Daliresp
- Daraprim
- Decitabine
- Depen
- Dermatology – Acne Step Therapy
- Desvenlafaxine / Fetzima
- Dificid
- Dipentum
- Dipyridamole
- Divigel
- Dofetilide
- Doxepin Step Therapy
- DPP-4 Step Therapy
- Elestrin
- Eligard
- Embeda cap
- Emsam
- Enbrel
- Epclusa
- Epoprostenol sodium
- Erbitux
- Erivedge
- Erlotinib
- Esbriet
- Estradiol
- Estrogel Gel
- Estropipate
- Evamist
- Exchange Medical Benefit Only Policy
- Exelderm
- Farydak
- Febuxostat
- Fentanyl
- Fentanyl Citrate
- Ferriprox
- Ganirelix Acetate
- Gazyva
- Gilenya
- Glatopa/Glatiramer Acetate
- Glyburide, Glyburide Micronized, Glyburide-Metformin
- Gonal-F, Gonal-F Rff
- Growth Hormone without ISS
- Guanfacine ER
- Harvoni
- Hemlibra
- Hepatitis C
- Hetlioz
- Humatrope
- Humira
- Hydromorphone
- Hydroxyzine
- Hydroxyzine Pamoate
- Hyqvia
- Hysingla ER
- Ibrance
- Icatibant Acetate
- Iclusig
- Idhifa
- Ilaris
- Imatinib Mesylate
- Imbruvica
- Imipramine Pamoate
- Increlex
- Incretin Mimetic Agents Step Therapy
- Incretin Mimetic Combination Agents Step Therapy
- Inlyta
- Intron A
- Isotretinoin
- Itraconazole
- Jakafi
- Jublia
- Kadcyla
- Kalydeco
- Kevzara
- Keytruda
- Kisqali
- Kuvan
- Lenvima
- Leuprolide Acetate
- Lidocaine Patch
- Lorbrena
- Lupaneta Pack
- Lupron Dep-Ped Inj
- Lynparza
- Mekinist
- Memantine Hcl
- Menest
- Metaxalone
- Methadone
- Methocarbamol
- Methscopolamine Bromide
- Methyltestosterone
- Mircera
- Mitoxantrone
- Modafinil
- Morphine Sulfate
- Morphine Sulfate beads
- Multaq
- Multiple Sclerosis
- Myalept
- Namenda XR cap titration
- Nasal Steroids
- Neulasta and pegfilgrastim biosimilars
- Neupogen and filgrastim biosimilars
- Nexavar
- Nitrofurantoin
- Nivestym
- Non-Formulary Criteria
- Nortriptyline
- Noxafil
- Nucala
- Nucynta er
- Nuedexta
- Nuplazid
- Octreotide Acetate
- Odomzo
- Omega-3-Acid Ethyl Esters
- Oncaspar
- Opsumit
- Orenitram
- Orfadin
- Orkambi
- Orphenadrine Citrate
- Otezla
- Ovidrel
- Oxandrolone
- Oxycodone hcl
- Oxycontin
- Oxymorphone hcl
- Pegasys
- Plegridy
- Pomalyst
- Pregabalin
- Premarin
- Prolastin-C inj
- Prolia
- Promacta
- Promethazine
- Prostaglandin Analogues Step Therapy
- Proton Pump Inhibitor Step Therapy
- Ranolazine
- Rebetol
- Rebif
- Regranex
- Remodulin
- Repatha
- Retacrit
- Revlimid
- Ribasphere
- Ribavirin
- Rinvoq
- Rivastigmine
- Rosuvastatin
- Rydapt
- Samsca
- Savella
- Sensipar
- SGLT2 Step Therapy
- Signifor
- Sildenafil Citrate
- Simponi
- Simponi Aria
- Skyrizi
- Sleep Agents
- Sodium phenylbutryate
- Somatuline
- Somavert
- Sovaldi
- Sprycel
- Stelara
- Stivarga
- Sutent
- Symdeko
- Synarel
- Tadalfil
- Tafinlar
- Taltz
- Targretin gel, Bexarotene capsules
- Tazarotene cream
- Tazorac gel
- Tecfidera
- Technivie
- Temodar
- Temozolomide
- Terbinafine
- Testosterone
- Tetrabenazine
- Thalomid
- Tobramycin
- Tracleer
- Tramadol
- Tremfya
- Tretinoin
- Truvada
- Tykerb
- Tymlos
- Tysabri
- Tyvaso
- Udenyca
- Uptravi
- Urinary Antispasmodics Step Therapy
- Vemlidy
- Venclexta
- Ventavis
- Vigabatrin
- Viokace
- Vitrakvi
- Vivitrol
- Voriconazole
- Vosevi
- Votrient
- Vytorin 10-80, Simvastatin 80mg
- Xalkori
- Xeljanz
- Xifaxan
- Xolair
- Xtampza ER
- Xtandi
- Zejula
- Zelboraf
- Zenpep
- Zepatier
- Zoledronic acid 4 mg/100 mL
- Zolinza
- Zydelig
- Zykadia
- Zytiga
- Zoledronic acid 5 mg/100mL
For questions and comments regarding prior authorization criteria, please contact Customer Care at 855-582-2022. After taking your information and comments, the information will be relayed to Medical Affairs.