Avastin & Bevacizumab Biosimilars |
Gateway Health Non-PDL Prior Authorization Criteria |
Benlysta |
Gateway Health Non-PDL Prior Authorization Criteria |
Brineura |
Gateway Health Non-PDL Prior Authorization Criteria |
Cidofovir |
Gateway Health Non-PDL Prior Authorization Criteria |
Cough and Cold Medications for Children Under 4 Years of Age |
Gateway Health Non-PDL Prior Authorization Criteria |
Crysvita |
Gateway Health Non-PDL Prior Authorization Criteria |
Cystic Fibrosis Biologic Response Modifiers |
Gateway Health Non-PDL Prior Authorization Criteria |
Daraprim |
Gateway Health Non-PDL Prior Authorization Criteria |
Strensiq |
Gateway Health Non-PDL Prior Authorization Criteria |
Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides |
Gateway Health Non-PDL Prior Authorization Criteria |
FreeStyle Libre Continuous Glucose Monitor Systems |
Gateway Health Non-PDL Prior Authorization Criteria |
H.P. Acthar Gel |
Gateway Health Non-PDL Prior Authorization Criteria |
Intravenous and Subcutaneous Immune Globulin (IVIG & SCIG) |
Gateway Health Non-PDL Prior Authorization Criteria |
Lumizyme |
Gateway Health Non-PDL Prior Authorization Criteria |
Luxturna |
Gateway Health Non-PDL Prior Authorization Criteria |
Pulmonary Arterial Hypertension (PAH) Agents, Injectable |
Gateway Health Non-PDL Prior Authorization Criteria |
Pulmozyme |
Gateway Health Non-PDL Prior Authorization Criteria |
Radicava |
Gateway Health Non-PDL Prior Authorization Criteria |
Rituxan & Rituximab Biosimilars |
Gateway Health Non-PDL Prior Authorization Criteria |
Somatuline Depot |
Gateway Health Non-PDL Prior Authorization Criteria |
Sublingual Immunotherapy Medications |
Gateway Health Non-PDL Prior Authorization Criteria |
Synagis |
Gateway Health Non-PDL Prior Authorization Criteria |
Vimizim |
Gateway Health Non-PDL Prior Authorization Criteria |
Zyvox |
Gateway Health Non-PDL Prior Authorization Criteria |
Sandostatin LAR Depot Kit | Gateway Health Non-PDL Prior Authorization Criteria |
Quantity Limits |
Gateway Health Non-PDL Prior Authorization Criteria |
Non-Formulary Medication/Medical Necessity |
Gateway Health Non-PDL Prior Authorization Criteria |
Zulresso |
Gateway Health Non-PDL Prior Authorization Criteria |
Gamifant |
Gateway Health Non-PDL Prior Authorization Criteria |
Actimmune |
Gateway Health Non-PDL Prior Authorization Criteria |
Myalept |
Gateway Health Non-PDL Prior Authorization Criteria |
Diacomit |
Gateway Health Non-PDL Prior Authorization Criteria |
Fabry Disease Medications (Fabrazyme & Galafold) |
Gateway Health Non-PDL Prior Authorization Criteria |
Qbrexza |
Gateway Health Non-PDL Prior Authorization Criteria |
Xyrem |
Gateway Health Non-PDL Prior Authorization Criteria |
Phenylketonuria Medications (Kuvan & Palynziq) | Gateway Health Non-PDL Prior Authorization Criteria |
C5b Complement Inhibitors (Soliris & Ultomiris) |
Gateway Health Non-PDL Prior Authorization Criteria |
Firdapse |
Gateway Health Non-PDL Prior Authorization Criteria |
Nuedexta |
Gateway Health Non-PDL Prior Authorization Criteria |
Xiaflex |
Gateway Health Non-PDL Prior Authorization Criteria |
Sucraid |
Gateway Health Non-PDL Prior Authorization Criteria |
Alpha1-Proteinase Inhibitors |
Gateway Health Non-PDL Prior Authorization Criteria |
Gattex |
Gateway Health Non-PDL Prior Authorization Criteria |
Vyndaqel & Vyndamax |
Gateway Health Non-PDL Prior Authorization Criteria |
Onpattro & Tegsedi |
Gateway Health Non-PDL Prior Authorization Criteria |
Compounds | Gateway Health Non-PDL Prior Authorization Criteria |
Oncology Medications, IV/Injectable | Gateway Health Non-PDL Prior Authorization Criteria |
Acne Agents, Oral | Statewide PDL Prior Authorization Criteria |
Acne Agents, Topical | Statewide PDL Prior Authorization Criteria |
Alzheimer's Agents | Statewide PDL Prior Authorization Criteria |
Analgesics, Non-Opioid Barbituate Combinations | Statewide PDL Prior Authorization Criteria |
Analgesics, Opioid Long Acting | Statewide PDL Prior Authorization Criteria |
Analgesics, Opioid Short Acting | Statewide PDL Prior Authorization Criteria |
Androgenic Agents | Statewide PDL Prior Authorization Criteria |
Angiotensin Modulator Combinations | Statewide PDL Prior Authorization Criteria |
Angiotensin Modulators | Statewide PDL Prior Authorization Criteria |
Antianginal Agents | Statewide PDL Prior Authorization Criteria |
Antibiotics, GI and Related Agents | Statewide PDL Prior Authorization Criteria |
Antibiotics, Inhaled | Statewide PDL Prior Authorization Criteria |
Antibiotics, Topical | Statewide PDL Prior Authorization Criteria |
Antibiotic-Steroid Combinations | Statewide PDL Prior Authorization Criteria |
Anticoagulants | Statewide PDL Prior Authorization Criteria |
Anticonvulsants | Statewide PDL Prior Authorization Criteria |
Antidepressants, Other | Statewide PDL Prior Authorization Criteria |
Antidepressants, SSRIs | Statewide PDL Prior Authorization Criteria |
Antiemetics-Antivertigo Agents | Statewide PDL Prior Authorization Criteria |
Antifungals, Oral | Statewide PDL Prior Authorization Criteria |
Antifungals, Topical | Statewide PDL Prior Authorization Criteria |
Antihemophilia Agents | Statewide PDL Prior Authorization Criteria |
Antihistamines, Minimally Sedating | Statewide PDL Prior Authorization Criteria |
Antihypertensives, Sympatholytic | Statewide PDL Prior Authorization Criteria |
Antihyperuricemics | Statewide PDL Prior Authorization Criteria |
Antimalarials | Statewide PDL Prior Authorization Criteria |
Antiparasitics, Topical | Statewide PDL Prior Authorization Criteria |
Antiparkinson's Agents | Statewide PDL Prior Authorization Criteria |
Antipsoriatics, Oral | Statewide PDL Prior Authorization Criteria |
Antipsoriatics, Topical | Statewide PDL Prior Authorization Criteria |
Antipsychotics | Statewide PDL Prior Authorization Criteria |
Antivirals, CMV | Statewide PDL Prior Authorization Criteria |
Antivirals, Herpes | Statewide PDL Prior Authorization Criteria |
Antivirals, Influenza | Statewide PDL Prior Authorization Criteria |
Anxiolytics | Statewide PDL Prior Authorization Criteria |
Beta-Blockers | Statewide PDL Prior Authorization Criteria |
Bile Salts | Statewide PDL Prior Authorization Criteria |
Bladder Relaxant Preparations | Statewide PDL Prior Authorization Criteria |
Blood Glucose Meters and Test Strips | Statewide PDL Prior Authorization Criteria |
Bone Density Regulators | Statewide PDL Prior Authorization Criteria |
Botulinum Toxins | Statewide PDL Prior Authorization Criteria |
BPH Treatments | Statewide PDL Prior Authorization Criteria |
Bronchodilators, Beta Agonists | Statewide PDL Prior Authorization Criteria |
Calcium Channel Blockers | Statewide PDL Prior Authorization Criteria |
Cephalosporins | Statewide PDL Prior Authorization Criteria |
Colony Stimulating Factors | Statewide PDL Prior Authorization Criteria |
Contraceptives, Oral | Statewide PDL Prior Authorization Criteria |
Contraceptives, Other | Statewide PDL Prior Authorization Criteria |
COPD Agents | Statewide PDL Prior Authorization Criteria |
Cytokine and CAM Antagonists | Statewide PDL Prior Authorization Criteria |
Dupixent | Statewide PDL Prior Authorization Criteria |
Enzyme Replacements, Gaucher Disease | Statewide PDL Prior Authorization Criteria |
Epinephrine, Self-Injected | Statewide PDL Prior Authorization Criteria |
Erythropoiesis Stimulating Proteins | Statewide PDL Prior Authorization Criteria |
Estrogens | Statewide PDL Prior Authorization Criteria |
Fluoroquinolones, Oral | Statewide PDL Prior Authorization Criteria |
GI Motility, Chronic | Statewide PDL Prior Authorization Criteria |
Glucocorticoids, Inhaled | Statewide PDL Prior Authorization Criteria |
Glucocorticoids, Oral | Statewide PDL Prior Authorization Criteria |
Growth Hormones | Statewide PDL Prior Authorization Criteria |
H. Pylori Treatments | Statewide PDL Prior Authorization Criteria |
Hepatitis B Agents | Statewide PDL Prior Authorization Criteria |
Hepatitis C Agents | Statewide PDL Prior Authorization Criteria |
Hereditary Angioedema Treatments | Statewide PDL Prior Authorization Criteria |
Histamine 2 Receptor Blockers | Statewide PDL Prior Authorization Criteria |
HIV/AIDS Antiretrovirals | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, Alpha-Glucosidase Inhibitors | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, Incretin Mimetics/Enhancers | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, Insulin and Related Agents | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, Meglitinides | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, Metformins | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, SGLT2 Inhibitors | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, Sulfonylureas | Statewide PDL Prior Authorization Criteria |
Hypoglycemics, TZDs | Statewide PDL Prior Authorization Criteria |
Immunomodulators, Atopic Dermatitis | Statewide PDL Prior Authorization Criteria |
Immunomodulators, Topical | Statewide PDL Prior Authorization Criteria |
Immunosuppressives, Oral | Statewide PDL Prior Authorization Criteria |
Intra-Articular Hyaluronates | Statewide PDL Prior Authorization Criteria |
Intranasal Rhinitis Agents | Statewide PDL Prior Authorization Criteria |
Iron Chelating Agents | Statewide PDL Prior Authorization Criteria |
Iron, Parenteral | Statewide PDL Prior Authorization Criteria |
Leukotriene Modifiers | Statewide PDL Prior Authorization Criteria |
Lipotropics, Other | Statewide PDL Prior Authorization Criteria |
Lipotropics, Statins | Statewide PDL Prior Authorization Criteria |
Local Anesthetics, Topical | Statewide PDL Prior Authorization Criteria |
Macrolides | Statewide PDL Prior Authorization Criteria |
Macular Degeneration Agents | Statewide PDL Prior Authorization Criteria |
Methotrexates | Statewide PDL Prior Authorization Criteria |
Monoclonal Antibodies (MABs) - Anti-IL, Anti-IgE | Statewide PDL Prior Authorization Criteria |
Multiple Sclerosis Agents | Statewide PDL Prior Authorization Criteria |
Neuropathic Pain | Statewide PDL Prior Authorization Criteria |
NSAIDs | Statewide PDL Prior Authorization Criteria |
Oncology Agents, Breast Cancer | Statewide PDL Prior Authorization Criteria |
Oncology Agents, Oral | Statewide PDL Prior Authorization Criteria |
Ophthalmics, Allergic Conjunctivitis | Statewide PDL Prior Authorization Criteria |
Ophthalmics, Antibiotics | Statewide PDL Prior Authorization Criteria |
Ophthalmics, Anti-Inflammatories | Statewide PDL Prior Authorization Criteria |
Ophthalmics, Glaucoma | Statewide PDL Prior Authorization Criteria |
Ophthalmics, Immunomodulators | Statewide PDL Prior Authorization Criteria |
Opioid Dependence Treatments | Statewide PDL Prior Authorization Criteria |
Opioid Overdose Agents | Statewide PDL Prior Authorization Criteria |
Otic Antibiotics | Statewide PDL Prior Authorization Criteria |
Pancreatic Enzymes | Statewide PDL Prior Authorization Criteria |
Penicillins | Statewide PDL Prior Authorization Criteria |
Phosphate Binders | Statewide PDL Prior Authorization Criteria |
Pituitary Suppressive Agents, LHRH | Statewide PDL Prior Authorization Criteria |
Platelet Aggregation Inhibitors | Statewide PDL Prior Authorization Criteria |
Potassium Removing Agents | Statewide PDL Prior Authorization Criteria |
Prenatal Vitamins | Statewide PDL Prior Authorization Criteria |
Progestational Agents | Statewide PDL Prior Authorization Criteria |
Proton Pump Inhibitors | Statewide PDL Prior Authorization Criteria |
Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled | Statewide PDL Prior Authorization Criteria |
Sedative Hypnotics | Statewide PDL Prior Authorization Criteria |
Skeletal Muscle Relaxants | Statewide PDL Prior Authorization Criteria |
Smoking Cessation | Statewide PDL Prior Authorization Criteria |
Steroids, Topical | Statewide PDL Prior Authorization Criteria |
Stimulants and Related Agents | Statewide PDL Prior Authorization Criteria |
Tetracyclines | Statewide PDL Prior Authorization Criteria |
Thalidomide and Derivatives | Statewide PDL Prior Authorization Criteria |
Thrombopoietics | Statewide PDL Prior Authorization Criteria |
Thyroid Hormones | Statewide PDL Prior Authorization Criteria |
Tysabri | Statewide PDL Prior Authorization Criteria |
Ulcerative Colitis Agents | Statewide PDL Prior Authorization Criteria |
Urea Cycle Disorder Agents | Statewide PDL Prior Authorization Criteria |
Urinary Anti-Infectives | Statewide PDL Prior Authorization Criteria |
Vaginal Anti-Infectives | Statewide PDL Prior Authorization Criteria |
Vitamin D Analogs | Statewide PDL Prior Authorization Criteria |
VMAT2 Inhibitors | Statewide PDL Prior Authorization Criteria |
Palforzia | Gateway Health Non-PDL Prior Authorization Criteria |
Givlaari | Gateway Health Non-PDL Prior Authorization Criteria |
Elaprase | Gateway Health Non-PDL Prior Authorization Criteria |
Lioresal | Gateway Health Non-PDL Prior Authorization Criteria |
MACI | Gateway Health Non-PDL Prior Authorization Criteria |
Naglazyme | Gateway Health Non-PDL Prior Authorization Criteria |
Quzyttir | Gateway Health Non-PDL Prior Authorization Criteria |
Tepezza | Gateway Health Non-PDL Prior Authorization Criteria |
Idiopathic Pulmonary Fibrosis (IPF) Agents | Statewide PDL Prior Authorization Criteria |
Celestone Soluspan | Gateway Health Non-PDL Prior Authorization Criteria |
Integrilin | Statewide PDL Prior Authorization Criteria |
Kenalog | Gateway Health Non-PDL Prior Authorization Criteria |
Mepsevii | Gateway Health Non-PDL Prior Authorization Criteria |
Scenesse | Gateway Health Non-PDL Prior Authorization Criteria |
Reblozyl | Gateway Health Non-PDL Prior Authorization Criteria |
Uplizna | Gateway Health Non-PDL Prior Authorization Criteria |
Enspryng | Gateway Health Non-PDL Prior Authorization Criteria |
Monoferric |
Gateway Health Non-PDL Prior Authorization Criteria |
Bafiertam |
Gateway Health Non-PDL Prior Authorization Criteria |
Kesimpta |
Gateway Health Non-PDL Prior Authorization Criteria |
Spinal Muscular Atrophy Medications |
Gateway Health Non-PDL Prior Authorization Criteria |
Isturisa |
Gateway Health Non-PDL Prior Authorization Criteria |
Migraine Prevention | Statewide PDL Prior Authorization Criteria |
Sickle Cell Agents | Statewide PDL Prior Authorization Criteria |
Hematopoietic Mixtures | Statewide PDL Prior Authorization Criteria |
Migraine Acute Treatment | Statewide PDL Prior Authorization Criteria |
Hypoglycemia Treatments | Statewide PDL Prior Authorization Criteria |