To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Abecma drug criteria (PDF)

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]]> Yes - Actemra IV step therapy criteria - (MAPD) (PDF)

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]]> Yes - Wezlana IV step therapy criteria - (MAPD) (PDF)

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]]> Yes - Selarsdi step therapy criteria - (MAPD) (PDF)

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]]> Yes - Selarsdi step therapy criteria - (MA) (PDF)

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]]> To request call 1-877-212-8811 (TTY: 711)

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]]> Yes - Simponi Aria step therapy criteria - (MAPD) (PDF)

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]]> Yes - Yondelis step therapy criteria (PDF)

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]]> Yes - Universal Medicare Part B drug criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

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]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Zemaira drug criteria (PDF)

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]]> Yes - Soliris drug criteria (PDF)

]]> Yes - Soliris (aHUS/PNH) step therapy criteria (PDF)

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]]> Yes - Soliris drug criteria (PDF)

]]> Yes - Soliris (Myasthenia Gravis) step therapy criteria (PDF)

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]]> Yes - Universal Medicare Part B drug criteria (PDF)

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]]> Yes - Zilretta drug criteria (PDF)

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]]> Yes - Starjemza drug criteria (PDF)

]]> Yes - Starjemza step therapy criteria - (MAPD) (PDF)

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]]> Yes - Starjemza step therapy criteria - (MA) (PDF)

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]]> Yes - Octreotide acetate depot drug criteria (PDF)

]]> Yes - Octreotide acetate depot step therapy criteria (PDF)

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]]> Yes - Steqeyma step therapy criteria - (MAPD) (PDF)

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]]> Yes - Steqeyma drug criteria (PDF)

]]> Yes - Steqeyma step therapy criteria - (MA) (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Zynteglo drug criteria (PDF)

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]]> Yes - Stimufend drug criteria (PDF)

]]> Yes - Stimufend step therapy criteria (PDF)

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]]> Yes - Octagam drug criteria (PDF)

]]> Yes - Octagam step therapy criteria (PDF)

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]]> Yes - Stoboclo drug criteria (PDF)

]]> Yes - Stoboclo step therapy criteria (PDF)

]]> Ogivri fax form (PDF)

]]> Yes - Ogivri drug criteria (PDF)

]]> Strensiq fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Supartz FX drug criteria (PDF)

]]> Yes - Supartz FX step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

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]]> Yes - Susvimo drug criteria (PDF)

]]> Yes - Susvimo step therapy criteria (PDF)

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]]> Yes - Omvoh drug criteria (PDF)

]]> Yes - Omvoh step therapy criteria - (MAPD) (PDF)

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]]> Yes - Syfovre drug criteria (PDF)

]]> Yes - Syfovre step therapy criteria (PDF)

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]]> Yes - Onpattro drug criteria (PDF)

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]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Synojoynt drug criteria (PDF)

]]> Yes - Synojoynt step therapy criteria (PDF)

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]]> Yes - Opdivo drug criteria (PDF)

]]> Yes - Opdivo step therapy criteria (PDF)

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]]> Yes - Opdivo Qvantig step therapy criteria

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]]> Yes - Opuviz drug criteria (PDF)

]]> Yes - Opuviz step therapy criteria (PDF)

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]]> Yes - Orencia IV drug criteria (PDF)

]]> Yes - Orencia IV step therapy criteria - (MA) (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Tecartus drug criteria (PDF)

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]]> Yes - Orencia IV step therapy criteria - (MAPD) (PDF)

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]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Tecentriq drug criteria (PDF)

]]> Yes - Tecentriq step therapy criteria (PDF)

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]]> Yes - Orthovisc drug criteria (PDF)

]]> Yes - Orthovisc step therapy criteria (PDF)

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]]> Yes - Tecentriq Hybreza drug criteria (PDF)

]]> Yes - Tecentriq Hybreza step therapy criteria

]]> Osenvelt fax form (PDF)

]]> Yes - Osenvelt drug criteria (PDF)

]]> Yes - Osenvelt step therapy criteria (PDF)

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]]> Yes - Tecvayli drug criteria (PDF)

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]]> Yes - Hymovis One drug criteria (PDF)

]]> Yes - Hymovis One step therapy criteria (PDF)

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]]> Yes - Ospomyv drug criteria (PDF)

]]> Yes - Ospomyv step therapy criteria (PDF)

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]]> Yes - Tepezza drug criteria (PDF)

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]]> Yes - HyQvia drug criteria (PDF)

]]> Yes - HyQvia step therapy criteria (PDF)

]]> Osvyrti fax form (PDF)

]]> Yes - Osvyrti drug criteria (PDF)

]]> Yes - Osvyrti step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Teriparatide drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Idelvion drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Otarmeni drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Tevimbra drug criteria (PDF)

]]> Ilaris fax form (PDF)

]]> Yes - Ilaris drug criteria (PDF)

]]> Otulfi fax form (PDF)

]]> Yes - Otulfi drug criteria (PDF)

]]> Yes - Otulfi step therapy criteria - (MAPD) (PDF)

]]> Tezspire fax form (PDF)

]]> Yes - Tezspire drug criteria (PDF)

]]> Yes - Tezspire step therapy criteria - (MAPD) (PDF)

]]> Ilumya fax form (PDF)

]]> Yes - Ilumya drug criteria (PDF)

]]> Yes - Ilumya step therapy criteria - (MA) (PDF)

]]> Otulfi fax form (PDF)

]]> Yes - Otulfi drug criteria (PDF)

]]> Yes - Otulfi step therapy criteria - (MA) (PDF)

]]> Tivdak fax form (PDF)

]]> Yes - Tivdak drug criteria (PDF)

]]> Ilumya fax form (PDF)

]]> Yes - Ilumya drug criteria (PDF)

]]> Yes - Ilumya step therapy criteria - (MAPD) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> tocilizumab-aazg (unbranded) fax form (PDF)

]]> Yes - tocilizumab-aazg (unbranded) drug criteria (PDF)

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]]> Yes - Imaavy drug criteria (PDF)

]]> Yes - Imaavy step therapy criteria (PDF)

]]> Oxlumo fax form (PDF)

]]> Yes - Oxlumo drug criteria (PDF)

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]]> Yes - Tofidence step therapy criteria (MA)

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]]> Yes - Tofidence step therapy criteria (MAPD)

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]]> Yes - Imfinzi drug criteria (PDF)

]]> Yes - Imfinzi step therapy criteria (PDF)

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]]> Yes - Paclitaxel protein-bound drug criteria (PDF)

]]> Yes - Paclitaxel protein-bound step therapy criteria (PDF)

]]> Imjudo fax form (PDF)

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]]> Yes - Universal Medicare Part B drug criteria (PDF)

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]]> Yes - Padcev drug criteria (PDF)

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]]> Yes - Trazimera drug criteria (PDF)

]]> Yes - Trazimera step therapy criteria (PDF)

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]]> Yes - Imlygic drug criteria (PDF)

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]]> Yes - Panzyga drug criteria (PDF)

]]> Yes - Panzyga step therapy criteria (PDF)

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]]> Yes - Universal Medicare Part B criteria (PDF)

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]]> Yes - Imuldosa drug criteria (PDF)

]]> Yes - Imuldosa step therapy criteria - (MAPD) (PDF)

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]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Trelstar drug criteria (PDF)

]]> Yes - Trelstar step therapy criteria (PDF)

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]]> Yes - Inflectra drug criteria (PDF)

]]> Yes - Inflectra step therapy criteria - (MAPD) (PDF)

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]]> Yes - Pavblu drug criteria (PDF)

]]> Yes - Pavblu step therapy criteria

]]> Tremfya IV fax form (PDF)

]]> Yes - Tremfya IV drug criteria (PDF)

]]> Infliximab-abda fax form (PDF)

]]> Yes - Infliximab-abda drug criteria (PDF)

]]> Pedmark fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Tretten drug criteria (PDF)

]]> Infliximab (unbranded) fax form (PDF)

]]> Yes - Infliximab (unbranded) drug criteria (PDF)

]]> Yes - Infliximab (unbranded) step therapy criteria - (MA) (PDF)

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]]> Yes - Pemfexy drug Criteria (PDF)

]]> Yes - Pemfexy step therapy criteria (PDF)

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]]> Yes - Triluron drug criteria (PDF)

]]> Yes - Triluron step therapy criteria (PDF)

]]> Infliximab (unbranded) fax form (PDF)

]]> Yes - Infliximab (unbranded) drug criteria (PDF)

]]> Yes - Infliximab (unbranded) step therapy criteria - (MAPD) (PDF)

]]> Pemrydi RTU fax form (PDF)

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]]> Yes - Pemrydi RTU step therapy criteria

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]]> Yes - TriVisc drug criteria (PDF)

]]> Yes - TriVisc step therapy criteria (PDF)

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]]> Yes - Injectafer step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

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]]> Yes - Trodelvy drug criteria (PDF)

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]]> Yes - Perjeta drug criteria (PDF)

]]> Yes - Perjeta step therapy criteria (PDF)

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]]> Yes - Truxima drug criteria (PDF)

]]> Yes - Truxima step therapy criteria - (MAPD) (PDF)

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]]> Yes - Truxima step therapy criteria - (MA) (PDF)

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]]> Yes - Tyruko drug criteria (PDF)

]]> Yes - Tyruko step therapy criteria - (MA) (PDF)

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]]> Yes - Darzalex Faspro drug criteria (PDF)

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]]> Yes - Tyruko step therapy criteria - (MAPD) (PDF)

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]]> Yes - Tysabri step therapy criteria - (MA) (PDF)

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]]> Yes - Jobevne step therapy criteria (PDF)

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]]> Yes - Tysabri step therapy criteria - (MAPD) (PDF)

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]]> Yes - Jubbonti step therapy criteria (PDF)

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]]> Yes - Jubereq step therapy criteria (PDF)

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]]> Yes - Denosumab-bnht step therapy criteria (unbranded Prolia biosimilar) (PDF)

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]]> Yes - Kadcyla drug criteria (PDF)

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]]> Yes - Udenyca step therapy criteria (PDF)

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]]> Yes - Ultomiris drug criteria (PDF)

]]> Yes - Ultomiris (aHUS/PNH) step therapy criteria (PDF)

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]]> Yes - Ultomiris (Myasthenia Gravis) step therapy criteria (PDF)

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]]> Yes - Ultomiris (NMOSD) step therapy criteria (PDF)

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]]> Yes - Prolia step therapy criteria (PDF)

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]]> Yes - Dysport step therapy criteria (PDF)

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]]> Yes - Keytruda step therapy criteria (PDF)

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]]> Yes - Pyzchiva IV drug criteria (PDF)

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]]> Yes - ustekinumab (unbranded) step therapy criteria - (MAPD) (PDF)

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]]> ustekinumab (unbranded) fax form (PDF)

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]]> Yes - ustekinumab (unbranded) step therapy criteria - (MA) (PDF)

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]]> Yes - ustekinumab-aauz (unbranded) step therapy criteria - (MAPD) (PDF)

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]]> Yes - Radicava drug criteria (PDF)

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]]> Yes - ustekinumab-aauz (unbranded) step therapy criteria - (MA) (PDF)

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]]> Yes - Kogenate FS drug criteria (PDF)

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]]> Yes - Kovaltry drug criteria (PDF)

]]> Adynovate fax form (PDF)

]]> Yes - Adynovate drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Adzynma drug criteria (PDF)

]]> Afstyla fax form (PDF)

]]> Yes - Afstyla drug criteria (PDF)

]]> Yes - Afstyla step therapy criteria (PDF)

]]> Ahzantive fax form (PDF)

]]> Yes - Ahzantive drug criteria (PDF)

]]> Yes - Ahzantive step therapy criteria (PDF)

]]> Aldurazyme fax form (PDF)

]]> Yes - Aldurazyme drug criteria (PDF)

]]> Alphanate fax form (PDF)

]]> Yes - Alphanate drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - AlphaNine SD drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Alprolix drug criteria (PDF)

]]> Altuviiio fax form (PDF)

]]> Yes - Altuviiio drug criteria (PDF)

]]> ustekinumab-aekn (unbranded) fax form (PDF)

]]> Yes - ustekinumab-aekn (unbranded) drug criteria (PDF)

]]> Yes - ustekinumab-aekn (unbranded) step therapy criteria - (MAPD) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B criteria (PDF)

]]> ustekinumab-aekn (unbranded) fax form (PDF)

]]> Yes - ustekinumab-aekn (unbranded) drug criteria (PDF)

]]> Yes - ustekinumab-aekn (unbranded) step therapy criteria - (MA) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Kresladi drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Rebinyn drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - ustekinumab-auub (unbranded) drug criteria (PDF)

]]> Eloctate fax form (PDF)

]]> Yes - Eloctate drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Krystexxa drug criteria (PDF)

]]> Reblozyl fax form (PDF)

]]> Yes - Reblozyl drug criteria (PDF)

]]> Yes - Reblozyl step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - ustekinumab-srlf (unbranded) drug criteria (PDF)

]]> Elrexfio fax form (PDF)

]]> Yes - Elrexfio drug criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Kymriah drug criteria (PDF)

]]> Recombinate fax form (PDF)

]]> Yes - Recombinate drug criteria (PDF)

]]> ustekinumab-stba (unbranded) fax form (PDF)

]]> Yes - ustekinumab-stba drug criteria (PDF)

]]> Yes - ustekinumab-stba (unbranded) step therapy criteria - (MAPD) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Elzonris drug criteria (PDF)

]]> Kyprolis fax form (PDF)

]]> Yes - Kyprolis drug criteria (PDF)

]]> Yes - Kyprolis step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug criteria (PDF)

]]> ustekinumab-stba (unbranded) fax form (PDF)

]]> Yes - ustekinumab-stba drug criteria (PDF)

]]> Yes - ustekinumab-stba (unbranded) step therapy criteria - (MA) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Emrelis drug criteria (PDF)

]]> Kyxata fax form (PDF)

]]> Yes - Kyxata step therapy criteria (PDF)

]]> Releuko fax form (PDF)

]]> Yes - Releuko drug criteria (PDF)

]]> Yes - Releuko step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - ustekinumab-ttwe (unbranded) drug criteria (PDF)

]]> Empliciti fax form (PDF)

]]> Yes - Empliciti drug criteria (PDF)

]]> Yes - Empliciti step therapy criteria (PDF)

]]> Lamzede fax form (PDF)

]]> Yes - Lamzede drug criteria (PDF)

]]> Remicade fax form (PDF)

]]> Yes - Remicade drug criteria (PDF)

]]> Yes - Remicade step therapy criteria - (MA) (PDF)

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]]> Yes - Vabysmo drug criteria (PDF)

]]> Yes - Vabysmo step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Encelto drug criteria (PDF)

]]> Lanreotide (Cipla) fax form (PDF)

]]> Yes - Lanreotide (Cipla) drug criteria (PDF)

]]> Remicade fax form (PDF)

]]> Yes - Remicade drug criteria (PDF)

]]> Yes - Remicade step therapy criteria - (MAPD) (PDF)

]]> Vafseo fax form (PDF)

]]> Yes - Vafseo drug criteria (PDF)

]]> Yes - Vafseo step therapy criteria (PDF)

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]]> Yes - Enhertu drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Remodulin drug criteria (PDF)

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]]> Yes - Vectibix drug criteria (PDF)

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]]> Yes - Enjaymo drug criteria (PDF)

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]]> Yes - Lemtrada drug criteria (PDF)

]]> Yes - Lemtrada step therapy criteria (PDF)

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]]> Yes - Renflexis drug criteria (PDF)

]]> Yes - Renflexis step therapy criteria - (MAPD) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

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]]> Yes - Enoby drug criteria (PDF)

]]> Yes - Enoby step therapy criteria (PDF)

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]]> Yes - Alyglo drug criteria (PDF)

]]> Yes - Alyglo step therapy criteria (PDF)

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]]> Yes - Alymsys drug criteria (PDF)

]]> Yes - Alymsys step therapy criteria (PDF)

]]> Amondys 45 fax form (PDF)

]]> Yes - Amondys 45 drug criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Amtagvi drug criteria (PDF)

]]> Amvuttra fax form (PDF)

]]> Yes - Amvuttra drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Anktiva drug criteria (PDF)

]]> Aralast NP fax form (PDF)

]]> Yes - Aralast NP drug criteria (PDF)

]]> Yes - Aralast NP step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Armlupeg drug criteria (PDF)

]]> Vegzelma fax form (PDF)

]]> Yes - Vegzelma drug criteria (PDF)

]]> Yes - Vegzelma step therapy criteria (PDF)

]]> Retacrit (ESRD) fax form (PDF)

]]> Yes - Retacrit (ESRD) drug criteria (PDF)

]]> Yes - Retacrit (ESRD) step therapy criteria (PDF)

]]> Leqembi fax form (PDF)

]]> Yes - CMS NCD Criteria

]]> Retacrit (non-ESRD) fax form (PDF)

]]> Yes - Retacrit (non-ESRD) drug criteria (PDF)

]]> Yes - Retacrit (non-ESRD) step therapy criteria (PDF)

]]> Veletri fax form (PDF)

]]> Yes - Veletri drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Ventavis drug criteria (PDF)

]]> Entyvio IV fax form (PDF)

]]> Yes - Entyvio IV drug criteria (PDF)

]]> Leqvio fax form (PDF)

]]> Yes - Leqvio drug criteria (PDF)

]]> Yes - Leqvio step therapy criteria - (MAPD) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug criteria (PDF)

]]> Veopoz fax form (PDF)

]]> Yes - Veopoz drug criteria (PDF)

]]> Enzeevu fax form (PDF)

]]> Yes - Enzeevu drug criteria (PDF)

]]> Yes - Enzeevu step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

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]]> Yes - Riabni (other indications) drug criteria (PDF)

]]> Yes - Riabni (other indications) step therapy criteria (PDF)

]]> Viltepso fax form (PDF)

]]> Yes - Viltepso drug criteria (PDF)

]]> Epkinly fax form (PDF)

]]> Yes - Epkinly drug criteria (PDF)

]]> Leukine fax form (PDF)

]]> Yes - Leukine drug criteria (PDF)

]]> Yes - Leukine step therapy criteria (PDF)

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]]> Yes - Riabni (RA only) drug criteria (PDF)

]]> Yes - Riabni (RA only) step therapy criteria - (MAPD) (PDF)

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]]> Yes - Vimizim drug criteria (PDF)

]]> Epogen (ESRD) fax form (PDF)

]]> Yes - Epogen (ESRD) drug criteria (PDF)

]]> Yes - Epogen (ESRD) step therapy criteria (PDF)

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]]> Yes - Riabni (RA only) drug criteria (PDF)

]]> Yes - Riabni (RA only) step therapy criteria - (MA) (PDF)

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]]> Yes - Visco-3 drug criteria (PDF)

]]> Yes - Visco-3 step therapy criteria (PDF)

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]]> Yes - Epogen (non-ESRD) drug criteria (PDF)

]]> Yes - Epogen (non-ESRD) step therapy criteria (PDF)

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]]> Yes - Libtayo drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - RiaSTAP drug criteria (PDF)

]]> Vivimusta fax form (PDF)

]]> Yes - Vivimusta drug criteria (PDF)

]]> Yes - Vivimusta step therapy criteria (PDF)

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]]> Yes - Epoprostenol sodium drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Loargys drug criteria (PDF)

]]> Rituxan (other indications) fax form (PDF)

]]> Yes - Rituxan (other indications) drug criteria (PDF)

]]> Yes - Rituxan (other indications) step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Vonvendi drug criteria (PDF)

]]> Epysqli fax form (PDF)

]]> Yes - Epysqli drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Loqtorzi drug criteria (PDF)

]]> Rituxan (RA only) fax form (PDF)

]]> Yes - Rituxan (RA only) drug criteria (PDF)

]]> Yes - Rituxan (RA only) step therapy criteria - (MA) (PDF)

]]> Epysqli fax form (PDF)

]]> Yes - Epysqli drug criteria (PDF)

]]> Yes - Epysqli (Myasthenia Gravis) step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Lutathera drug criteria (PDF)

]]> Epysqli fax form (PDF)

]]> Yes - Epysqli drug criteria (PDF)

]]> Yes - Epysqli (NMOSD) step therapy criteria (PDF)

]]> Asceniv fax form (PDF)

]]> Yes - Asceniv drug criteria (PDF)

]]> Yes - Asceniv step therapy criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Aucatzyl drug criteria (PDF)

]]> Aukelso fax form (PDF)

]]> Yes - Aukelso drug criteria (PDF)

]]> Yes - Aukelso step therapy criteria (PDF)

]]> Avastin (oncology) fax form (PDF)

]]> Yes - Avastin (oncology) drug criteria (PDF)

]]> Yes - Avastin (oncology) step therapy criteria (PDF)

]]> Aveed fax form (PDF)

]]> Yes - Aveed drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Avlayah drug criteria (PDF)

]]> Avsola fax form (PDF)

]]> Yes - Avsola drug criteria (PDF)

]]> Yes - Avsola step therapy criteria - (MA) (PDF)

]]> Avsola fax form (PDF)

]]> Yes - Avsola drug criteria (PDF)

]]> Yes - Avsola step therapy criteria - (MAPD) (PDF)

]]> Avtozma IV fax form (PDF)

]]> Yes - Avtozma IV drug criteria (PDF)

]]> Yes - Avtozma IV step therapy criteria - (MAPD) (PDF)

]]> Rituxan (RA only) fax form (PDF)

]]> Yes - Rituxan (RA only) drug criteria (PDF)

]]> Yes - Rituxan (RA only) step therapy criteria - (MAPD) (PDF)

]]> Lucentis fax form (PDF)

]]> Yes - Lucentis drug criteria (PDF)

]]> Yes - Lucentis step therapy criteria (PDF)

]]> Rituxan Hycela fax form (PDF)

]]> Yes - Rituxan Hycela drug criteria (PDF)

]]> Yes - Rituxan Hycela step therapy criteria (PDF)

]]> Erbitux fax form (PDF)

]]> Yes - Erbitux drug criteria (PDF)

]]> Lumizyme fax form (PDF)

]]> Yes - Lumizyme drug criteria (PDF)

]]> Rivfloza fax form (PDF)

]]> Yes - Rivfloza drug criteria (PDF)

]]> Esperoct fax form (PDF)

]]> Yes - Esperoct drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Rixubis drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Lunsumio drug criteria (PDF)

]]> Roctavian fax form (PDF)

]]> Yes - Roctavian drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Lunsumio Velo drug criteria (PDF)

]]> Rolvedon fax form (PDF)

]]> Yes - Rolvedon drug criteria (PDF)

]]> Yes - Rolvedon step therapy criteria (PDF)

]]> Evenity fax form (PDF)

]]> Yes - Evenity drug criteria (PDF)

]]> Yes - Evenity step therapy criteria (PDF)

]]> Lupron Depot fax form (PDF)

]]> Yes - Lupron Depot drug criteria (PDF)

]]> Yes - Lupron Depot step therapy criteria (PDF)

]]> Ruconest fax form (PDF)

]]> Yes - Ruconest drug criteria (PDF)

]]> Evkeeza fax form (PDF)

]]> Yes - Evkeeza drug criteria (PDF)

]]> Lupron Depot fax form (PDF)

]]> Yes - Lupron Depot drug criteria (PDF)

]]> Yes - Lupron Depot step therapy criteria (PDF)

]]> Ruxience fax form (PDF)

]]> Yes - Ruxience drug criteria (PDF)

]]> Yes - Ruxience step therapy criteria - (MAPD) (PDF)

]]> Exondys 51 fax form (PDF)

]]> Yes - Exondys 51 drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Lutrate drug criteria (PDF)

]]> Ruxience fax form (PDF)

]]> Yes - Ruxience drug criteria (PDF)

]]> Yes - Ruxience step therapy criteria - (MA) (PDF)

]]> Eydenzelt fax form (PDF)

]]> Yes- Eydenzelt drug criteria (PDF)

]]> Yes- Eydenzelt step therapy criteria (PDF)

]]> Luxturna fax form (PDF)

]]> Yes - Luxturna drug criteria (PDF)

]]> Rybrevant fax form (PDF)

]]> Yes - Rybrevant drug criteria (PDF)

]]> Eylea fax form (PDF)

]]> Yes - Eylea drug criteria (PDF)

]]> Yes - Eylea step therapy criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Lyfgenia drug criteria (PDF)

]]> Eylea HD fax form (PDF)

]]> Yes - Eylea HD drug criteria (PDF)

]]> Yes - Eylea HD step therapy criteria (PDF)

]]> Avtozma IV fax form (PDF)

]]> Yes - Avtozma IV drug criteria (PDF)

]]> Yes - Avtozma IV step therapy criteria - (MA) (PDF)

]]> Avzivi fax form (PDF)

]]> Yes - Avzivi drug criteria (PDF)

]]> Yes - Avzivi step therapy criteria (PDF)

]]> Axtle fax form (PDF)

]]> Yes - Axtle drug criteria (PDF)

]]> Yes - Axtle step therapy criteria

]]> Bavencio fax form (PDF)

]]> Yes - Bavencio drug criteria (PDF)

]]> Beizray fax form (PDF)

]]> Yes - Beizray step therapy criteria (PDF)

]]> Belrapzo fax form (PDF)

]]> Yes - Belrapzo drug criteria (PDF)

]]> Yes - Belrapzo step therapy criteria (PDF)

]]> Bendamustine HCl (Apotex) fax form (PDF)

]]> Yes - Bendamustine HCl (Apotex) drug criteria (PDF)

]]> Yes - Bendamustine (Apotex) step therapy criteria (PDF)

]]> Bendamustine HCl (Baxter) fax form (PDF)

]]> Yes - Bendamustine HCl (Baxter) drug criteria (PDF)

]]> Yes - Bendamustine (Baxter) step therapy criteria (PDF)

]]> Bendeka fax form (PDF)

]]> Yes - Bendeka drug criteria (PDF)

]]> Yes - Bendeka step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - BeneFix drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Rybrevant Faspro drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Lymphir drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Ryoncil drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Exdensur drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Lynozyfic drug criteria (PDF)

]]> Ryplazim fax form (PDF)

]]> Yes - Ryplazim drug criteria (PDF)

]]> Fabrazyme fax form (PDF)

]]> Yes - Fabrazyme drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Rystiggo fax form (PDF)

]]> Yes - Rystiggo drug criteria (PDF)

]]> Yes - Rystiggo step therapy criteria (PDF)

]]> Fasenra fax form (PDF)

]]> Yes - Fasenra drug criteria (PDF)

]]> Margenza fax form (PDF)

]]> Yes - Margenza drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Rytelo drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Feiba drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Ryzneuta fax form (PDF)

]]> Yes - Ryzneuta drug criteria (PDF)

]]> Yes - Ryzneuta step therapy criteria (PDF)

]]> Feraheme (ESRD) fax form (PDF)

]]> Yes - Feraheme (ESRD) step therapy criteria (PDF)

]]> Mepsevii fax form (PDF)

]]> Yes - Mepsevii drug criteria (PDF)

]]> Sandostatin fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Feraheme (non-ESRD) fax form (PDF)

]]> Yes - Feraheme (non-ESRD) step therapy criteria (PDF)

]]> Metastron fax form (PDF)

]]> Yes - Metastron drug criteria (PDF)

]]> Sandostatin LAR fax form (PDF)

]]> Yes - Sandostatin LAR drug criteria (PDF)

]]> Yes - Sandostatin LAR step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Fesilty drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Miacalcin drug criteria (PDF)

]]> Saphnelo fax form (PDF)

]]> Yes - Saphnelo drug criteria (PDF)

]]> Yes - Saphnelo step therapy criteria - (MA) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Fibryga drug criteria (PDF)

]]> Saphnelo fax form (PDF)

]]> Yes - Saphnelo drug criteria (PDF)

]]> Yes - Saphnelo step therapy criteria - (MAPD) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Filkri drug criteria (PDF)

]]> Benlysta fax form (PDF)

]]> Yes - Benlysta drug criteria (PDF)

]]> Beovu fax form (PDF)

]]> Yes - Beovu drug criteria (PDF)

]]> Yes - Beovu step therapy criteria (PDF)

]]> Berinert fax form (PDF)

]]> Yes - Berinert drug criteria (PDF)

]]> Besponsa fax form (PDF)

]]> Yes - Besponsa drug criteria (PDF)

]]> Bildyos fax form (PDF)

]]> Yes - Bildyos drug criteria (PDF)

]]> Yes - Bildyos step therapy criteria (PDF)

]]> Bilprevda fax form (PDF)

]]> Yes - Bilprevda drug criteria (PDF)

]]> Yes - Bilprevda step therapy criteria (PDF)

]]> Bivigam fax form (PDF)

]]> Yes - Bivigam drug criteria (PDF)

]]> Yes - Bivigam step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Bizengri drug criteria (PDF)

]]> Bkemv fax form (PDF)

]]> Yes - Bkemv drug criteria (PDF)

]]> Bkemv fax form (PDF)

]]> Yes - Bkemv drug criteria (PDF)

]]> Yes - Bkemv (Myasthenia Gravis) step therapy criteria (PDF)

]]> Monjuvi fax form (PDF)

]]> Yes - Monjuvi drug criteria (PDF)

]]> Flebogamma fax form (PDF)

]]> Yes - Flebogamma drug criteria (PDF)

]]> Yes - Flebogamma step therapy criteria (PDF)

]]> Monoferric fax form (PDF)

]]> Yes - Monoferric step therapy criteria (PDF)

]]> Flolan fax form (PDF)

]]> Yes - Flolan drug criteria (PDF)

]]> Monovisc fax form (PDF)

]]> Yes - Monovisc drug criteria (PDF)

]]> Yes - Monovisc step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Mvasi fax form (PDF)

]]> Yes - Mvasi drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Forteo drug criteria (PDF)

]]> Myobloc fax form (PDF)

]]> Yes - Myobloc drug criteria (PDF)

]]> Yes - Myobloc step therapy criteria (PDF)

]]> Naglazyme fax form (PDF)

]]> Yes - Naglazyme drug criteria (PDF)

]]> Fyarro fax form (PDF)

]]> Yes - Fyarro drug criteria (PDF)

]]> Neupogen fax form (PDF)

]]> Yes - Neupogen drug criteria (PDF)

]]> Yes - Neupogen step therapy criteria (PDF)

]]> Fylnetra fax form (PDF)

]]> Yes - Fylnetra drug criteria (PDF)

]]> Yes - Fylnetra step therapy criteria (PDF)

]]> Nexviazyme fax form (PDF)

]]> Yes - Nexviazyme drug criteria (PDF)

]]> GamaSTAN S/D fax form (PDF)

]]> Yes - GamaSTAN S/D drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Niktimvo drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Bkemv fax form (PDF)

]]> Yes - Bkemv drug criteria (PDF)

]]> Yes - Bkemv (NMOSD) step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Blenrep drug criteria (PDF)

]]> Bomyntra fax form (PDF)

]]> Yes - Bomyntra drug criteria (PDF)

]]> Yes - Bomyntra step therapy criteria (PDF)

]]> Boncresa fax form (PDF)

]]> Yes - Boncresa drug criteria (PDF)

]]> Boruzu fax form (PDF)

]]> Yes - Boruzu Part B drug Criteria (PDF)

]]> Yes - Boruzu step therapy criteria (PDF)

]]> Bosaya fax form (PDF)

]]> Yes - Bosaya drug criteria (PDF)

]]> Yes - Bosaya step therapy criteria (PDF)

]]> Nivestym fax form (PDF)

]]> Yes - Nivestym drug criteria (PDF)

]]> Yes - Nivestym step therapy criteria (PDF)

]]> Gammagard Liquid fax form (PDF)

]]> Yes - Gammagard Liquid drug criteria (PDF)

]]> Yes - Gammagard Liquid step therapy criteria (SC) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Gammagard Liquid fax form (PDF)

]]> Yes - Gammagard Liquid drug criteria (PDF)

]]> Yes - Gammagard Liquid step therapy criteria (IV) (PDF)

]]> Novoeight fax form (PDF)

]]> Yes - NovoEight drug criteria (PDF)

]]> Yes - NovoEight step therapy criteria (PDF)

]]> Gammagard Liquid ERC fax form (PDF)

]]> Yes - Gammagard Liquid ERC drug criteria (PDF)

]]> Yes - Gammagard Liquid ERC step therapy criteria (IV) (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - NovoSeven RT drug criteria (PDF)

]]> Gammagard Liquid ERC fax form (PDF)

]]> Yes - Gammagard Liquid ERC drug criteria (PDF)

]]> Yes - Gammagard Liquid ERC step therapy criteria (SC) (PDF)

]]> Nucala fax form (PDF)

]]> Yes - Nucala drug criteria (PDF)

]]> Yes - Nucala step therapy criteria - (MAPD) (PDF)

]]> Gammagard S/D fax form (PDF)

]]> Yes - Gammagard S/D drug criteria (PDF)

]]> Yes - Gammagard S/D step therapy criteria (IV) (PDF)

]]> Nucala fax form (PDF)

]]> Yes - Nucala drug criteria (PDF)

]]> Yes - Nucala step therapy criteria - (MA) (PDF)

]]> Gammaked fax form (PDF)

]]> Yes - Gammaked drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug criteria (PDF)

]]> Gammaplex fax form (PDF)

]]> Yes - Gammaplex drug criteria (PDF)

]]> Yes - Gammaplex step therapy criteria (PDF)

]]> Nulibry fax form (PDF)

]]> Yes - Nulibry drug criteria (PDF)

]]> Gamunex-C fax form (PDF)

]]> Yes - Gamunex-C drug criteria (PDF)

]]> Nuwiq fax form (PDF)

]]> Yes - Nuwiq drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Nypozi fax form (PDF)

]]> Yes - Nypozi drug criteria (PDF)

]]> Yes - Nypozi step therapy criteria (PDF)

]]> Gattex fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Breyanzi drug criteria (PDF)

]]> Brineura fax form (PDF)

]]> Yes - Brineura drug criteria (PDF)

]]> Briumvi fax form (PDF)

]]> Yes - Briumvi drug criteria (PDF)

]]> Byooviz fax form (PDF)

]]> Yes - Byooviz drug criteria (PDF)

]]> Yes - Byooviz step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Cablivi drug criteria (PDF)

]]> Camcevi fax form (PDF)

]]> Yes - Camcevi drug criteria (PDF)

]]> Camcevi ETM fax form (PDF)

]]> Yes - Camcevi ETM drug criteria (PDF)

]]> Carimune NF fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Carvykti drug criteria (PDF)

]]> To request call 1-877-212-8811 (TTY: 711)

]]> Yes - Casgevy drug criteria (PDF)

]]> Gel-One fax form (PDF)

]]> Yes - Gel-One drug criteria (PDF)

]]> Yes - Gel-One step therapy criteria (PDF)

]]> Gelsyn3 fax form (PDF)

]]> Yes - Gelsyn3 drug criteria (PDF)

]]> Yes - Gelsyn3 step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Genvisc fax form (PDF)

]]> Yes - Genvisc drug criteria (PDF)

]]> Yes - Genvisc step therapy criteria (PDF)

]]> Givlaari fax form (PDF)

]]> Yes - Givlaari drug criteria (PDF)

]]> Glassia fax form (PDF)

]]> Yes - Glassia drug criteria (PDF)

]]> Yes - Glassia step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Granix fax form (PDF)

]]> Yes - Granix drug criteria (PDF)

]]> Yes - Granix step therapy criteria (PDF)

]]> Hemgenix fax form (PDF)

]]> Yes - Hemgenix drug criteria (PDF)

]]> Cerezyme fax form (PDF)

]]> Yes - Cerezyme drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Universal Medicare Part B drug Criteria (PDF)

]]> Cimerli fax form (PDF)

]]> Yes - Cimerli drug criteria (PDF)

]]> Yes - Cimerli step therapy criteria (PDF)

]]> Cimzia fax form (PDF)

]]> Yes - Cimzia drug criteria (PDF)

]]> Yes - Cimzia step therapy criteria - (MA) (PDF)

]]> Cimzia fax form (PDF)

]]> Yes - Cimzia drug criteria (PDF)

]]> Yes - Cimzia step therapy criteria - (MAPD) (PDF)

]]> Cinqair fax form (PDF)

]]> Yes - Cinqair drug criteria (PDF)

]]> Yes - Cinqair step therapy criteria - (MAPD) (PDF)

]]> Cinqiar fax form (PDF)

]]> Yes - Cinqair drug criteria (PDF)

]]> Yes - Cinqair step therapy criteria - (MA) (PDF)

]]> Cinryze fax form (PDF)

]]> Yes - Cinryze drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Coagadex drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Hemlibra drug criteria (PDF)

]]> Hemofil M fax form (PDF)

]]> Yes - Hemofil M drug criteria (PDF)

]]> Hercessi fax form (PDF)

]]> Yes - Hercessi drug criteria (PDF)

]]> Yes - Hercessi step therapy criteria (PDF)

]]> Herceptin fax form (PDF)

]]> Yes - Herceptin drug criteria (PDF)

]]> Yes - Herceptin step therapy criteria (PDF)

]]> Herceptin Hylecta fax form (PDF)

]]> Yes - Herceptin Hylecta drug criteria (PDF)

]]> Yes - Herceptin Hylecta step therapy criteria (PDF)

]]> Herzuma fax form (PDF)

]]> Yes - Herzuma drug criteria (PDF)

]]> Yes - Herzuma step therapy criteria (PDF)

]]> Hizentra fax form (PDF)

]]> Yes - Hizentra drug criteria (PDF)

]]> Humate-P fax form (PDF)

]]> Yes - Humate-P drug criteria (PDF)

]]> Hyalgan fax form (PDF)

]]> Yes - Hyalgan drug criteria (PDF)

]]> Yes - Hyalgan step therapy criteria (PDF)

]]> Hymovis fax form (PDF)

]]> Yes - Hymovis drug criteria (PDF)

]]> Yes - Hymovis step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Columvi drug criteria (PDF)

]]> Connexxence fax form (PDF)

]]> Yes - Conexxence drug criteria (PDF)

]]> Yes - Conexxence step therapy criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Corifact drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Cortrophin Gel drug criteria (PDF)

]]> Cosela fax form (PDF)

]]> Yes - Cosela drug criteria (PDF)

]]> Specialty medication fax form (PDF)

]]> Yes - Cosentyx IV drug criteria (PDF)

]]> Crysvita fax form (PDF)

]]> Yes - Crysvita drug criteria (PDF)

]]> Cutaquig fax form (PDF)

]]> Yes - Cutaquig drug criteria (PDF)

]]> Yes - Cutaquig step therapy criteria (PDF)

]]> Cuvitru fax form (PDF)

]]> Yes - Cuvitru drug criteria (PDF)

]]> Yes - Cuvitru step therapy criteria (PDF)

]]> Cyramza fax form (PDF)

]]> Yes - Cyramza drug criteria (PDF)

]]> Yes - Cyramza step therapy criteria (PDF)

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