2025 Kaiser Permanente Northwest Commercial formulary (PDF)
2024 Kaiser Permanente Northwest Commercial formulary (PDF)
Use this formulary if you have a Traditional, Deductible or High Deductible Health Plan (HDHP). This formulary also applies to KP Plus and Choice plans when you receive your prescription from a Kaiser Permanente pharmacy.
2025 Kaiser Permanente Northwest Commercial formulary (PDF)
2024 Kaiser Permanente Northwest Commercial formulary (PDF)
Use this formulary if you have a Traditional, Deductible or High Deductible Health Plan (HDHP). This formulary also applies to KP Plus and Choice plans when you receive your prescription from a Kaiser Permanente pharmacy.
2025 Oregon Marketplace (Exchange) formulary (PDF)
2025 Washington Marketplace (Exchange) formulary (PDF)
2024 Oregon Marketplace (Exchange) formulary (PDF)
2024 Washington Marketplace (Exchange) formulary (PDF)
Use this formulary if you have an Oregon or Washington Marketplace (Exchange) plan.
2025 Kaiser Permanente Northwest Self-Funded formulary (PDF)
2024 Kaiser Permanente Northwest Self-Funded formulary (PDF)
Use this formulary if you have a Self-Funded Employer plan.
2024 Oregon Medicaid formulary (PDF)
Use this formulary if you have an Oregon Medicaid plan.
Apple Health Preferred Drug List (PDL)
Use this formulary if you have a Washington Medicaid plan.
2025 FEHB formulary (PDF)
2024 FEHB formulary (PDF)
FEHB Prescription Drug Cost Lookup
Use this formulary if you have an FEHB plan offered by Kaiser Permanente.
PSHB Prescription Drug Cost Lookup
Use this formulary if you have a PSHB plan offered by Kaiser Permanente.
Kaiser Permanente Northwest medical benefit formulary (PDF)
Use this formulary if medications are administered to you in a participating medical office.
Specialty drug list (PDF)
Learn more about what Kaiser Permanente considers specialty drugs. For more information about whether this list applies to your plan, please refer to your Evidence of Coverage.
30-day drug list (PDF)
See a list of drugs that are limited to a 30-day supply each time a prescription is filled.
Quantity-limit drug list (PDF)
See a list of drugs that are limited to a maximum amount within a certain period of days.
Contraceptive benefits flyer (PDF)
Learn more about contraceptive, or birth control, methods covered under the Affordable Care Act.
The Pharmacy and Therapeutics Committee, a group of Kaiser Permanente doctors and pharmacists, chooses which drugs to include in our formulary. To make sure you always have the most effective, safe, and affordable drug options, the committee regularly reviews information about new and existing drugs. The formulary is updated monthly based on new information or when new drugs become available.
FOR PRESCRIBERS ONLY: Please prescribe formulary medication(s) for your patients with Kaiser Permanente benefits. If a formulary medication is not appropriate, complete the Drug Coverage Request form (PDF) and fax to 1-866-618-6569.
Drugs not listed on the formulary, known as nonformulary drugs, aren’t covered by your plan. If your doctor decides that a nonformulary drug is medically necessary, your doctor can request an exception. With an exception, the drug will be covered by your prescription drug benefit — if your plan has one. Without an exception, you’ll be charged the full retail price for the drug.
The most effective way to get an exception to the formulary is to send a secure email to your doctor.
You can also contact Membership Services by submitting an online form. Or you can call us, Monday through Friday, 8 a.m. to 6 p.m. at:
Portland area: 1-503-813-2000
All other areas: 1-800-813-2000
TTY Oregon : 1-800-735-2900
TTY Washington: 711
Language interpretation services: 1-800-324-8010
If you want a nonformulary drug that your doctor doesn’t believe to be medically necessary, you can file a grievance (Senior Advantage and Medicare Cost members can file a coverage determination). To start the process, call Membership Services at the numbers above.
Certain drugs may need prior authorization before they can be prescribed. For a list of these drugs and the criteria used to prescribe them, see below. For more information, please see your Evidence of Coverage.
Drugs requiring preauthorization:
Abstral – Criteria (PDF)
Actiq – Criteria (PDF)
Actemra IV – Criteria (PDF)
Actemra SC – Criteria (PDF)
Adakveo – Criteria (PDF)
Adbry – Criteria (PDF)
Adempas® – Criteria (PDF)
Admelog pen – Criteria (PDF)
Admelog vial – Criteria (PDF)
Adstiladrin – Criteria (PDF)
Adynovate – Criteria (PDF)
Aimovig – Criteria (PDF)
Airsupra – Criteria (PDF)
Ajovy – Criteria (PDF)
Alprolix – Criteria (PDF)
Altuviiio – Criteria (PDF)
Alvaiz – Criteria (PDF)
Amjevita – Criteria (PDF)
Amondys 45 – Criteria (PDF)
Amvuttra – Criteria (PDF)
Androgel 1% gel – Criteria (PDF)
Androgel 1% pump – Criteria (PDF)
Angiotensin Receptor Blocker Combinations – Criteria (PDF)
Anoro Ellipta – Criteria (PDF)
Antihemophilic Factor VIII – Criteria (PDF)
Apidra Solostar – Criteria (PDF)
Apidra vial – Criteria (PDF)
Apretude – Criteria (PDF)
Aptensio XR – Criteria (PDF)
Aptiom – Criteria (PDF)
Arcalyst – Criteria (PDF)
Arnuity Ellipta – Criteria (PDF)
Astagraf XL – Criteria (PDF)
Austedo® – Criteria (PDF)
Auvelity – Criteria (PDF)
Auvi-Q – Criteria (PDF)
Aveed – Criteria (PDF)
Avonex – Criteria (PDF)
Axert – Criteria (PDF)
Axiron – Criteria (PDF)
Ayvakit – Criteria (PDF)
Azstarys – Criteria (PDF)
Bafiertam – Criteria (PDF)
Basaglar – Criteria (PDF)
Beleodaq – Criteria (PDF)
Bevespi Aerosphere – Criteria (PDF)
Belsomra – Criteria (PDF)
Benefix - Criteria (PDF)
Benlysta IV – Criteria (PDF)
Benlysta SC – Criteria (PDF)
Bimzelx – Criteria (PDF)
Brand Product with Generic Equivalent Available – Criteria (PDF)
Brand Product with Unbranded Biologic – Criteria (PDF)
Breo Ellipta – Criteria (PDF)
Breztri Aerosphere – Criteria (PDF)
Brilinta – Criteria (PDF)
Brintellix – Criteria (PDF)
Briumvi – Criteria (PDF)
Briviact – Criteria (PDF)
Bronchitol – Criteria (PDF)
Brukinsa – Criteria (PDF)
Bydureon/BCise – Criteria (PDF)
Byetta – Criteria (PDF)
Bylvay - Criteria (PDF)
Calquence – Criteria (PDF)
Cambia – Criteria (PDF)
Camzyos – Criteria (PDF)
Caplyta – Criteria (PDF)
Cequa – Criteria (PDF)
Cerdelga – Criteria (PDF)
Cerezyme – Criteria (PDF)
Cibinqo – Criteria (PDF)
Cimzia® – Criteria (PDF)
Columvi – Criteria (PDF)
Cometriq – Criteria (PDF)
Complera – Criteria (PDF)
Concerta – Criteria (PDF)
Condylox Gel – Criteria (PDF)
Copiktra – Criteria (PDF)
Cosentyx IV – Criteria (PDF)
Cosentyx SC – Criteria (PDF)
Cotempla XR-ODT® – Criteria (PDF)
Crysvita – Criteria (PDF)
Cutaquig– Criteria (PDF)
Cuvitru– Criteria (PDF)
Daliresp – Criteria (PDF)
Darzalex – Criteria (PDF)
Darzalex Faspro – Criteria (PDF)
Daybue – Criteria (PDF)
Daytrana – Criteria (PDF)
Dayvigo – Criteria (PDF)
Demser – Criteria (PDF)
Denavir – Criteria (PDF)
Descovy – Criteria (PDF)
Desoxyn – Criteria (PDF)
Desvenlafaxine Base by Ranbaxy – Criteria (PDF)
Dexilant – Criteria (PDF)
Diacomit – Criteria (PDF)
Dibenzyline – Criteria (PDF)
Dojolvi – Criteria (PDF)
Doptelet - Criteria (PDF)
Duaklir Pressair – Criteria (PDF)
Dulera – Criteria (PDF)
Dupixent – Criteria (PDF)
Dyanavel XR® – Criteria (PDF)
Edarbi – Criteria (PDF)
Edecrin – Criteria (PDF)
Elahere – Criteria (PDF)
Elevidys – Criteria (PDF)
Elelyso – Criteria (PDF)
Elfabrio - Criteria (PDF)
Eliquis – Criteria (PDF)
Elmiron – Criteria (PDF)
Eloctate - Criteria (PDF)
Emflaza® – Criteria (PDF)
Emgality – Criteria (PDF)
Empaveli – Criteria (PDF)
Emverm – Criteria (PDF)
Enbrel – Criteria (PDF)
Endari – Criteria (PDF)
Enhertu – Criteria (PDF)
Enspryng - Criteria (PDF)
Entresto® – Criteria (PDF)
Entyvio – Criteria (PDF)
Epidiolex – Criteria (PDF)
EpiPen – Criteria (PDF)
Epkinly – Criteria (PDF)
Eprontia – Criteria (PDF)
Erivedge – Criteria (PDF)
Erleada – Criteria (PDF)
Estring – Criteria (PDF)
Eucrisa – Criteria (PDF)
Evekeo – Criteria (PDF)
Evkeeza – Criteria (PDF)
Evrysdi – Criteria (PDF)
Evzio – Criteria (PDF)
Exalgo ER – Criteria (PDF)
Exondys 51 – Criteria (PDF)
Fabhalta - Criteria (PDF)
Fanapt – Criteria (PDF)
Farxiga – Criteria (PDF)
Fasenra – Criteria (PDF)
Febuxostat – Criteria (PDF)
Fentora – Criteria (PDF)
Fetzima – Criteria (PDF)
Fiasp – Criteria (PDF)
Filspari – Criteria (PDF)
Fintepla – Criteria (PDF)
Firmagon – Criteria (PDF)
Firdapse – Criteria (PDF)
Flector Patch – Criteria (PDF)
Fleqsuvy – Criteria (PDF)
Fluvastatin – Criteria (PDF)
Folotyn – Criteria (PDF)
Forfivo XL – Criteria (PDF)
Fortamet – Criteria (PDF)
Forteo – Criteria (PDF)
Fortesta – Criteria (PDF)
Fotivda – Criteria (PDF)
Frovatriptan – Criteria (PDF)
Fulphila – Criteria (PDF)
Fycompa – Criteria (PDF)
Fylnetra - Criteria (PDF)
Gattex – Criteria (PDF)
Gemtesa – Criteria (PDF)
Givlaari – Criteria (PDF)
Glumetza – Criteria (PDF)
Glyxambi – Criteria (PDF)
Gocovri – Criteria (PDF)
Gralise – Criteria (PDF)
Hadlima – Criteria (PDF)
Hemlibra – Criteria (PDF)
Hetlioz® – Criteria (PDF)
HP Acthar – Criteria (PDF)
Horizant – Criteria (PDF)
Humira – Criteria (PDF)
Humulin R U-500/KWIKPen – Criteria (PDF)
Humulin R U-500 vial – Criteria (PDF)
Hydrocodone bitartrate extended release – Criteria (PDF)
Hydromorphone sustained release – Criteria (PDF)
Hyqvia – Criteria (PDF)
Hysingla ER – Criteria (PDF)
Ibrance – Criteria (PDF)
Ibsrela – Criteria (PDF)
Iclusig – Criteria (PDF)
Idelvion – Criteria (PDF)
Ilaris – Criteria (PDF)
Ilumya – Criteria (PDF)
Imbruvica – Criteria (PDF)
Imcivree – Criteria (PDF)
Imvexxy – Criteria (PDF)
Inbrija – Criteria (PDF)
Ingrezza – Criteria (PDF)
InPen smart insulin pen – Criteria (PDF)
Inrebic – Criteria (PDF)
Intermezzo – Criteria (PDF)
Intrarosa – Criteria (PDF)
Invokamet – Criteria (PDF)
InvokametXR – Criteria (PDF)
Invokana – Criteria (PDF)
Istodax – Criteria (PDF)
Ixinity – Criteria (PDF)
Janumet – Criteria (PDF)
Janumet XR – Criteria (PDF)
Januvia – Criteria (PDF)
Jardiance® – Criteria (PDF)
Javygtor – Criteria (PDF)
Jaypirca – Criteria (PDF)
Jelmyto – Criteria (PDF)
Jentadueto – Criteria (PDF)
Jentadueto XR – Criteria (PDF)
Joenja – Criteria (PDF)
Jornay PM – Criteria (PDF)
Jynarque – Criteria (PDF)
Kalydeco® – Criteria (PDF)
Katerzia – Criteria (PDF)
Kazano – Criteria (PDF)
Kerendia – Criteria (PDF)
Kesimpta – Criteria (PDF)
Keveyis – Criteria (PDF)
Kevzara – Criteria (PDF)
Keytruda – Criteria (PDF)
Khedezla – Criteria (PDF)
Kineret – Criteria (PDF)
Kombiglyze XR – Criteria (PDF)
Korlym – Criteria (PDF)
Koselugo – Criteria (PDF)
Krazati – Criteria (PDF)
Krystexxa – Criteria (PDF)
Kuvan – Criteria (PDF)
Kynmobi – Criteria (PDF)
Lantus – Criteria (PDF)
Lantus Solostar – Criteria (PDF)
Lazanda – Criteria (PDF)
Lenvima – Criteria (PDF)
Lescol XL – Criteria (PDF)
Levemir FlexPen – Criteria (PDF)
Levemir – Criteria (PDF)
Levitra – Criteria (PDF)
Levo-Dromoran® – Criteria (PDF)
Leqembi – Criteria (PDF)
Linzess – Criteria (PDF)
Litfulo – Criteria (PDF)
Livalo – Criteria (PDF)
Livmarli - Criteria (PDF)
Livtencity – Criteria (PDF)
Lumakras – Criteria (PDF)
Lumizyme – Criteria (PDF)
Lupkynis – Criteria (PDF)
Lonhala Magnair – Criteria (PDF)
Lorbrena – Criteria (PDF)
Lybalvi – Criteria (PDF)
Lynparza – Criteria (PDF)
Lyrica CR – Criteria (PDF)
Lyumjev – Criteria (PDF)
Lyvispah - Criteria (PDF)
Marinol – Criteria (PDF)
Mavenclad – Criteria (PDF)
Mayzent – Criteria (PDF)
Miebo – Criteria (PDF)
Monjuvi – Criteria (PDF)
Motegrity – Criteria (PDF)
Mounjaro – Criteria (PDF)
Movantik® – Criteria (PDF)
Mycapssa – Criteria (PDF)
Mydayis – Criteria (PDF)
Myrbetriq® – Criteria (PDF)
Natesto – Criteria (PDF)
Nayzilam – Criteria (PDF)
Nesina – Criteria (PDF)
Neulasta – Criteria (PDF)
Neupogen prefilled syringe – Criteria (PDF)
Neupogen vial – Criteria (PDF)
Nexium packet – Criteria (PDF)
Nexletol – Criteria (PDF)
Nexlizet – Criteria (PDF)
Nexviazyme – Criteria (PDF)
Ninlaro – Criteria (PDF)
Nityr – Criteria (PDF)
Novolin 70-30 – Criteria (PDF)
Novolin N – Criteria (PDF)
Novolin R – Criteria (PDF)
Novolog 70-30 FlexPen – Criteria (PDF)
Novolog 70-30 – Criteria (PDF)
Novolog Flexpen – Criteria (PDF)
Novolog Penfill – Criteria (PDF)
Novolog – Criteria (PDF)
Nplate – Criteria (PDF)
Nubeqa – Criteria (PDF)
Nucala – Criteria (PDF)
Nucynta ER – Criteria (PDF)
Nuplazid – Criteria (PDF)
Nurtec – Criteria (PDF)
Nyvepria – Criteria (PDF)
Ocaliva – Criteria (PDF)
Ocrevus – Criteria (PDF)
Odomzo – Criteria (PDF)
Ofev® – Criteria (PDF)
Ogsiveo – Criteria (PDF)
Ojjaara - Criteria (PDF)
Olumiant 1mg & 2mg – Criteria (PDF)
Olumiant 4mg – Criteria (PDF)
Omeprazole suspension – Criteria (PDF)
Omnipod Classic – Criteria (PDF)
Omnipod DASH – Criteria (PDF)
Omnipod 5 – Criteria (PDF)
Ongentys – Criteria (PDF)
Onglyza – Criteria (PDF)
Onpattro – Criteria (PDF)
Onsolis – Criteria (PDF)
Onureg – Criteria (PDF)
Opana – Criteria (PDF)
Opana ER® – Criteria (PDF)
Opium Tincture – Criteria (PDF)
Opsumit® – Criteria (PDF)
Opzelura – Criteria (PDF)
Oracea – Criteria (PDF)
Orencia – Criteria (PDF)
Orfadin – Criteria (PDF)
Orgovyx – Criteria (PDF)
Orkambi® – Criteria (PDF)
Orladeyo – Criteria (PDF)
Orserdu – Criteria (PDF)
Oseni – Criteria (PDF)
Osphena– Criteria (PDF)
Otezla – Criteria (PDF)
Oxbryta – Criteria (PDF)
Oxervate – Criteria (PDF)
Oxlumo – Criteria (PDF)
OxyContin – Criteria (PDF)
Ozempic – Criteria (PDF)
Ozobax DS - Criteria (PDF)
Padcev – Criteria (PDF)
Palynziq – Criteria (PDF)
Pemazyre – Criteria (PDF)
Piqray – Criteria (PDF)
Plegridy® – Criteria (PDF)
Polivy – Criteria (PDF)
Pomalyst® – Criteria (PDF)
Ponvory – Criteria (PDF)
Poteligeo – Criteria (PDF)
Praluent – Criteria (PDF)
Precision Xtra meter – Criteria (PDF)
Precision Xtra test strips – Criteria (PDF)
Prevymis – Criteria (PDF)
ProAir RespiClick – Criteria (PDF)
Promacta® – Criteria (PDF)
Protonix Oral Suspension – Criteria (PDF)
Provenge – Criteria (PDF)
Pyrukynd – Criteria (PDF)
Qalsody – Criteria (PDF)
Qbrexza – Criteria (PDF)
Qelbree – Criteria (PDF)
Qinlock – Criteria (PDF)
Qtern – Criteria (PDF)
Qualaquin – Criteria (PDF)
Qudexy XR – Criteria (PDF)
QuilliChew ER – Criteria (PDF)
Quillivant XR – Criteria (PDF)
Qulipta – Criteria (PDF)
Quviviq - Criteria (PDF)
QVAR RediHaler – Criteria (PDF)
Radicava – Criteria (PDF)
Ranbaxy (manufacturer) – Criteria (PDF)
Ravicti® – Criteria (PDF)
Rebif – Criteria (PDF)
Rebinyn – Criteria (PDF)
Reblozyl – Criteria (PDF)
Rebyota – Criteria (PDF)
Relistor injection – Criteria (PDF)
Relistor tablet – Criteria (PDF)
Relyvrio – Criteria (PDF)
Repatha – Criteria (PDF)
Restasis – Criteria (PDF)
Revlimid® – Criteria (PDF)
Rexulti – Criteria (PDF)
Reyvow – Criteria (PDF)
Rezdiffra - Criteria (PDF)
Rezvoglar KWIKPen – Criteria (PDF)
Rinvoq 15mg ER – Criteria (PDF)
Rinvoq 30mg ER – Criteria (PDF)
Rinvoq 45mg ER – Criteria (PDF)
Rixubis – Criteria (PDF)
Roszet – Criteria (PDF)
Rybelsus – Criteria (PDF)
Rybrevant – Criteria (PDF)
Rytelo – Criteria (PDF)
Samsca – Criteria (PDF)
Saphnelo – Criteria (PDF)
Sarclisa – Criteria (PDF)
Savaysa – Criteria (PDF)
Savella – Criteria (PDF)
Saxenda – Criteria (PDF)
Scemblix – Criteria (PDF)
Scenesse – Criteria (PDF)
Segluromet – Criteria (PDF)
Siliq – Criteria (PDF)
Simponi 50mg – Criteria (PDF)
Simponi 100mg – Criteria (PDF)
Simponi Aria – Criteria (PDF)
Skyclarys – Criteria (PDF)
Skyrizi 150mg/mL – Criteria (PDF)
Skyrizi 180mg/1.2mL & 360mg/2.4mL – Criteria (PDF)
Skyrizi IV – Criteria (PDF)
Soliqua – Criteria (PDF)
Soliris – Criteria (PDF)
Somavert – Criteria (PDF)
Soolantra® – Criteria (PDF)
Sotyktu – Criteria (PDF)
Spevigo IV – Criteria (PDF)
Spevigo SC – Criteria (PDF)
Spinraza – Criteria (PDF)
Spravato – Criteria (PDF)
Sprycel – Criteria (PDF)
Steglatro – Criteria (PDF)
Steglujan – Criteria (PDF)
Stelara IV – Criteria (PDF)
Stelara SQ – Criteria (PDF)
Stendra – Criteria (PDF)
Stribild – Criteria (PDF)
Subsys – Criteria (PDF)
Sunosi – Criteria (PDF)
Sutab – Criteria (PDF)
Symdeko – Criteria (PDF)
Symproic – Criteria (PDF)
Synjardy – Criteria (PDF)
Synjardy XR – Criteria (PDF)
Tabloid – Criteria (PDF)
Tabrecta – Criteria (PDF)
Takhzyro – Criteria (PDF)
Taltz – Criteria (PDF)
Targretin – Criteria (PDF)
Tarpeyo – Criteria (PDF)
Tasigna – Criteria (PDF)
Tavneos – Criteria (PDF)
Tazverik – Criteria (PDF)
Tecartus – Criteria (PDF)
Tecvayli – Criteria (PDF)
Tepezza – Criteria (PDF)
Tepmetko – Criteria (PDF)
Testim – Criteria (PDF)
Tezspire – Criteria (PDF)
Thalomid – Criteria (PDF)
Tirosint® – Criteria (PDF)
Toujeo – Criteria (PDF)
Tradjenta – Criteria (PDF)
Trelegy Ellipta – Criteria (PDF)
Tremfya – Criteria (PDF)
Tresiba – Criteria (PDF)
Treximet – Criteria (PDF)
Trijardy XR – Criteria (PDF)
Trikafta – Criteria (PDF)
Trintellix – Criteria (PDF)
Trodelvy – Criteria (PDF)
Trokendi XR – Criteria (PDF)
Trulance – Criteria (PDF)
Trulicity – Criteria (PDF)
Truqap – Criteria (PDF)
Tukysa – Criteria (PDF)
Turalio – Criteria (PDF)
Tyenne SC – Criteria (PDF)
Tymlos – Criteria (PDF)
Tyrvaya – Criteria (PDF)
Tzield – Criteria (PDF)
Ubrelvy – Criteria (PDF)
Udenyca – Criteria (PDF)
Ultomiris – Criteria (PDF)
Uptravi – Criteria (PDF)
Utibron Neohaler – Criteria (PDF)
Valtoco – Criteria (PDF)
Vascepa – Criteria (PDF)
Veozah – Criteria (PDF)
Vemlidy – Criteria (PDF)
Venclexta – Criteria (PDF)
VePesid – Criteria (PDF)
Verzenio – Criteria (PDF)
Viberzi – Criteria (PDF)
Victoza – Criteria (PDF)
Vigabatrin – Criteria (PDF)
Viltepso – Criteria (PDF)
Vitrakvi – Criteria (PDF)
Vogelxo – Criteria (PDF)
Vowst – Criteria (PDF)
Voxzogo – Criteria (PDF)
Vpriv – Criteria (PDF)
Vumerity – Criteria (PDF)
Vraylar – Criteria (PDF)
Vtama – Criteria (PDF)
Vyepti – Criteria (PDF)
Vyjuvek – Criteria (PDF)
Vyndamax/Vyndaqel – Criteria (PDF)
Vyondys 53 – Criteria (PDF)
Vyvanse – Criteria (PDF)
Vyvanse chewable – Criteria (PDF)
Vyvgart – Criteria (PDF)
Vyvgart Hytrulo - Criteria (PDF)
Wakix – Criteria (PDF)
Wegovy – Criteria (PDF)
Welireg – Criteria (PDF)
Winlevi – Criteria (PDF)
Xarelto 2.5mg – Criteria (PDF)
Xarelto 10mg/15mg/20mg – Criteria (PDF)
Xcopri – Criteria (PDF)
Xdemvy – Criteria (PDF)
Xermelo – Criteria (PDF)
Xeljanz IR 5mg – Criteria (PDF)
Xeljanz IR 10mg – Criteria (PDF)
Xeljanz oral solution – Criteria (PDF)
Xeljanz XR 11mg – Criteria (PDF)
Xeljanz XR 22mg – Criteria (PDF)
Xelstrym – Criteria (PDF)
Xembify – Criteria (PDF)
Xhance – Criteria (PDF)
Xifaxan – Criteria (PDF)
Xigduo XR – Criteria (PDF)
Xiidra – Criteria (PDF)
Xphozah – Criteria (PDF)
Xtampza ER – Criteria (PDF)
Xtandi – Criteria (PDF)
Xolair – Criteria (PDF)
Xolremdi - Criteria (PDF)
Xospata – Criteria (PDF)
Xpovio – Criteria (PDF)
Xultophy – Criteria (PDF)
Xyrem – Criteria (PDF)
Xywav – Criteria (PDF)
Ycanth – Criteria (PDF)
Yupelri – Criteria (PDF)
Zavzpret – Criteria (PDF)
Zepbound – Criteria (PDF)
Zeposia - Criteria (PDF)
Zepzelca – Criteria (PDF)
Ziextenzo – Criteria (PDF)
Zipsor – Criteria (PDF)
Zohydro ER – Criteria (PDF)
Zituvimet - Criteria (PDF)
Zituvio - Criteria (PDF)
Zokinvy – Criteria (PDF)
Zoladex – Criteria (PDF)
Zolgensma – Criteria (PDF)
Zomig nasal spray – Criteria (PDF)
Zonisade – Criteria (PDF)
Zorvolex – Criteria (PDF)
Zoryve – Criteria (PDF)
Ztalmy – Criteria (PDF)
Zurzuvae – Criteria (PDF)
Zyflo – Criteria (PDF)
Zyflo CR – Criteria (PDF)
Zykadia – Criteria (PDF)
Zynlonta – Criteria (PDF)
Zymfentra – Criteria (PDF)
Certain drugs may need prior authorization before they can be prescribed. For a list of these drugs and the criteria used to prescribe them, see below. For more information, please see your Evidence of Coverage.
Drugs requiring preauthorization:
All PA Guidelines (PDF)
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