Commercial Utilization Criteria

Brand Name (Generic Name) Utilization Criteria
Abilify (aripiprazole) PDF (8 59.63 kB)
Abstral (fentanyl)  PDF (17 64.80 kB)  
Accretropin (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Aciphex (rabeprazole) PDF (12 61.04 kB)
Actemra (tocilizumab) [SPECIALTY] PDF (07 97.06 kB)
Actiq (fentanyl citrate) PDF (17 64.80 kB)
Adcirca (tadalafil) [SPECIALTY] PDF (8 68.40 kB)
Ambien/CR (zolpidem) PDF (12 72.45 kB)
Amerge (naratriptan) PDF (02 83.81 kB)
Amevive (alefacept) [SPECIALTY] PDF (10 64.76 kB)
Antihistamines (e.g. products containing cyproheptadine, dexcholorpheniramine, diphenydramine, hydroxyzine, promethazine) PDF (17 67.98 kB)
Anzemet (dolasetron) PDF (23 82.94 kB)
Aralast NP (alpha1- proteinase inhibitor) [SPECIALTY] PDF (12 81.39 kB)
Aranesp (darbepoetin alfa-polysorbate 80) [SPECIALTY] PDF (11 111.57 kB)
Axert (almotriptan) PDF (02 83.81 kB)
Atarax (hydroxyzine HCl) *SEE ANTIHISTAMINES CRITERIA*  
Avonex (interferon beta-1a) [SPECIALTY] PDF (8 69.74 kB)
Benadryl (diphenhydramine) *SEE ANTIHISTAMINES CRITERIA*  
Benlysta (belimumab) [SPECIALTY] PDF (07 69.89 kB)
Betaseron (interferon beta-1b) [SPECIALTY] PDF (8 69.74 kB)
B & O suppository (belladonna-opium containing products) PDF (2 64.73 kB)
Botox (onabotulinumtoxin A) [SPECIALTY] PDF (8 63.91 kB)
Buprenex (buprenorphine HCl) PDF (02 69.33 kB)
Butrans (buprenorphine transdermal) PDF (02 69.33 kB)
Bydureon (exenatide ext-rel)  PDF (07 55.62 kB)
Byetta (exenatide) PDF (07 55.62 kB)
Chantix (varenicline tartrate) PDF (10 64.78 kB)
Cimzia (certolizumab pegol) [SPECIALTY] PDF (8 87.12 kB)
Compounded Medications PDF (pdf 74.98 kB)
Copaxone (glatiramer acetate) [SPECIALTY] PDF (8 69.74 kB)
Demerol (meperidine containing products) PDF (2 64.73 kB)
Dexilant (dexlansoprazole) PDF (12 61.04 kB)
Dificid (fidaxomicin)  PDF (11 79.26 kB)
Dysport (onabotulinumtoxin A) [SPECIALTY] PDF (8 63.91 kB)
Edular (zolpidem) PDF (12 72.45 kB)
Egrifta (tesamorelin) PDF (23 72.62 kB)
Emend (aprepitant) PDF (23 82.94 kB)
Enbrel (etanercept) [SPECIALTY] PDF (8 87.12 kB)
Epogen (epoetin alfa) [SPECIALTY] PDF (11 111.57 kB)
Erivedge (vismodegib) [SPECIALTY]  PDF (07 72.86 kB)
Exjade (deferasirox) [SPECIALTY] PDF (12 64.27 kB)
Extavia (interferon beta-1b) [SPECIALTY] PDF (8 69.74 kB)
Fentora (fentanyl citrate) PDF (17 64.80 kB)
Flexeril (cyclobenzaprine) *SEE SKELETAL MUSCLE RELAXANTS CRITERIA*  
Frova (frovatriptan) PDF (02 83.81 kB)
Gabitril (tiagabine HCl) PDF (27 93.36 kB)
Genotropin (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Gilenya (fingolimod HCl) [SPECIALTY] PDF (8 64.78 kB)
Glassia (alpha1- proteinase inhibitor) [SPECIALTY] PDF (12 81.39 kB)
Granisol (granisetron) PDF (23 82.94 kB)
Horizant (gabapentin enacarbil ext-rel)  PDF (8 52.44 kB)  
Humatrope (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Humira (adalimumab) [SPECIALTY] PDF (8 87.12 kB)
Imitrex (sumatriptan succinate) PDF (02 83.81 kB)
Immune Globulins PDF (11 95.92 kB)
Incivek (telaprevir)  PDF  (12 89.88 kB)
Increlex (mecasermin) [SPECIALTY] PDF (11 81.92 kB)
Intermezzo (zolpidem)  PDF (12 72.45 kB)
Kalydeco (ivacaftor) [SPECIALTY] PDF (7 71.08 kB)
Keppra/XR (levetiracetam) PDF (27 93.36 kB)
Kineret (anakinra) [SPECIALTY] PDF (07 84.22 kB)
Lamictal/XR (lamotrigine) PDF (27 93.36 kB)
Lazanda (fentanyl)  PDF (17 64.80 kB)  
Letaris (ambrisentan) [SPECIALTY] PDF (12 77.37 kB)
Leukine (sargramostim) [SPECIALTY] PDF (11 104.74 kB)
Lunesta (eszopiclone) PDF (12 72.45 kB)
Lyme Disease-IV Antibiotics PDF (12 57.65 kB)
Lyrica (pregabalin) PDF (27 93.36 kB)
Maxalt/MLT (rizatriptan) PDF (02 83.81 kB)
Myobloc (rimabotulinumtoxin B) [SPECIALTY] PDF (8 63.91 kB)
Neulasta (pegfilgrastim) [SPECIALTY] PDF (11 104.74 kB)
Neumega (oprelvekin) [SPECIALTY] PDF (12 81.47 kB)
Neupogen (filgrastim) [SPECIALTY] PDF (11 104.74 kB)
Nexium (esomeprazole) PDF (12 61.04 kB)
Nicotine Products PDF (10 64.78 kB)
Nitrofurantoin products PDF (10 60.49 kB)
Norditropin (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Nutropin/AQ (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Nuvigil (armodafinil) PDF (10 63.47 kB)
Omnitrope (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Onsolis (fentanyl citrate) PDF (17 64.80 kB)
Oral Estrogens (e.g. products containing conjugated estrogen, esterified estrogen, estropipate) PDF (10 57.66 kB)
Orencia (abatacept) [SPECIALTY] PDF (07 91.95 kB)
Ozurdex (dexamethasone intravitreal implant) PDF (17 47.20 kB)
Phenergan (promethazine) *SEE ANTIHISTAMINES CRITERIA*  
Pradaxa (dabigatran) PDF (17 60.68 kB)
Premarin (conjugated estrogen) *SEE ORAL ESTROGENS CRITERIA*  
Prempro (conjugated estrogen/medroxyprogesterone) *SEE ORAL ESTROGENS CRITERIA*  
Prevacid (lansoprazole) PDF (12 61.04 kB)
Prilosec (omeprazole) PDF (12 61.04 kB)
Procrit (epoetin alfa) [SPECIALTY] PDF (11 111.57 kB)
Prolastin (alpha1-proteinase inhibitor) [SPECIALTY] PDF (12 81.39 kB)
Protonix (pantoprazole) PDF (12 61.04 kB)
Provenge (sipuleucel-T) PDF (11 94.66 kB)
Provigil (modafinil) PDF (10 63.47 kB)
Qualaquin (quinine sulfate) PDF (12 50.06 kB)
Qutenza (capsaicin) PDF (17 39.32 kB)
Rebif (interferon beta-1a) [SPECIALTY]  PDF (8 69.74 kB)
Relpax (eletriptan) PDF (02 83.81 kB)
Remicade (infliximab) [SPECIALTY] PDF (8 87.12 kB)
Remodulin (treprostinil sodium) [SPECIALTY] PDF (8 61.13 kB)
Revatio (sildenafil citrate) [SPECIALTY] PDF (8 68.40 kB)
Rituxan (rituximab) [SPECIALTY] PDF (09 77.99 kB)
Robaxin (methocarbamol) *SEE SKELETAL MUSCLE RELAXANTS CRITERIA*  
Rozerem (ramelteon) PDF (12 72.45 kB)
Saizen (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Sandostatin/LAR (octreotide) [SPECIALTY] PDF (8 67.34 kB)
Sensipar (cinacalcet HCl) [SPECIALTY] PDF (8 56.02 kB)
Seroquel/XR (quetiapine) PDF (8 59.63 kB)
Simponi (golimumab) [SPECIALTY] PDF (8 87.12 kB)
Skelaxin (metaxalone) *SEE SKELETAL MUSCLE RELAXANTS CRITERIA*  
Skeletal Muscle Relaxants (e.g. products containing carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine) PDF (10 55.32 kB)
Smoking Cessation Products PDF (10 64.78 kB)
Soma (carisoprodol) *SEE SKELETAL MUSCLE RELAXANTS CRITERIA*  
Somatuline Depot (lanreotide) [SPECIALTY] PDF (8 67.34 kB)
Somavert (pegvisomant) [SPECIALTY] PDF (8 38.95 kB)
Sonata (zaleplon) PDF (12 72.45 kB)
Stelara (ustekinumab) [SPECIALTY] PDF (17 60.82 kB)
Suboxone (buprenorphine/naloxone ) PDF (02 69.33 kB)
Subutex (buprenorphine HCl) PDF (02 69.33 kB)
Sumavel DosePro (sumatriptan) PDF (02 83.81 kB)
Synagis (palivizumab) PDF (23 79.18 kB)
Talwin (pentazocine containing products) PDF (2 64.73 kB)
Tev-Tropin (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Topamax (topiramate) PDF (27 93.36 kB)
Tracleer (bosentan) [SPECIALTY] PDF (12 77.37 kB)
Treximet (sumatriptan/naproxen sodium) PDF (02 83.81 kB)
Trileptal (oxcarbazepine) PDF (27 93.36 kB)
Tysabri (natalizumab) PDF (07 91.36 kB)
Vancocin (vancomycin)  PDF (11 79.26 kB)
Ventavis (iloprost) [SPECIALTY] PDF (8 42.65 kB)
Victoza (liraglutide) PDF (07 55.63 kB)
Vimpat (lacosamide) PDF (27 93.36 kB)
Victrelis (boceprevir)  PDF (14 68.86 kB)
Vistaril (hydroxyzine pamoate) *SEE ANTIHISTAMINES CRITERIA*  
Vivitrol (naltrexone) [SPECIALTY] PDF (17 47.86 kB)
Xalkori (crizotinib)  [SPECIALTY] PDF (8 54.80 kB)
Xeomin (onabotulinumtoxin A) [SPECIALTY] PDF (8 63.91 kB)
Xolair (omalizumab) [SPECIALTY] PDF (8 73.79 kB)
Xgeva (denosumab) [SPECIALTY] PDF (12 64.92 kB)
Xyrem (sodium oxybate) PDF (10 50.55 kB)
Zegerid (omeprazole/sodium bicarbonate)  PDF (12 61.04 kB)
Zelboraf (vemurafenib)  [SPECIALTY] PDF (8 49.99 kB)
Zemaira (alpha1-proteinase inhibitor) [SPECIALTY] PDF (12 81.39 kB)
Ziana (clindamycin/tretinoin)  PDF (07 79.58 kB)  
Zofran/ODT (ondansetron) PDF (23 82.94 kB)
Zolpimist (zolpidem) PDF (12 72.45 kB)
Zomig/ZMT (zolmitriptan) PDF (02 83.81 kB)
Zorbtive (somatropin) [SPECIALTY] PDF (8 105.76 kB)
Zuplenz (ondansetron) PDF (23 82.94 kB)
Zyban (bupropion SR) PDF (10 64.78 kB)
Zyprexa/Zydis (olanzapine) PDF (8 59.63 kB)