Physician-Administered Drug Prior Authorization Criteria

Physician-Administered Drug guidelines Adopted by CalOptima Health’s Pharmacy and Therapeutics Committee

Criteria by Topic A to F

Browse the documents below for Physician-Administered Drug guidelines Adopted by CalOptima Health’s Pharmacy and Therapeutics Committee.

Beremagene geperpavec-svdt (Vyjuvek)—PAD PA Criteria
Physician-administered drug prior authorization criteria for beremagene geperpavec-svdt (Vyjuvek)
Biologics and Immunologics—PAD PA Criteria
Physician-administered drug prior authorization criteria for biologics and immunologics
Botulinum Toxins—PAD PA Criteria
Physician-administered drug prior authorization criteria for botulinum toxins
Brexucabtagene autoleucel (Tecartus)—PAD PA Criteria
Physician-administered drug prior authorization criteria for brexucabtagene autoleucel (Tecartus)
Cantharidin (Ycanth)—PAD PA Criteria
Physician-administered drug prior authorization criteria for cantharidin (Ycanth)
Corticosteroid Intravitreal Implants—PAD PA Criteria
Physician-administered drug prior authorization criteria for corticosteroid intravitreal implants
Collagenase, clostridium histolyticum (Xiaflex)—PAD PA Criteria
Physician-administered drug prior authorization criteria for collagenase, clostridium histolyticum (Xiaflex)
Delandistrogene moxeparvovec (Elevidys)—PAD PA Criteria
Physician-administered drug prior authorization criteria for delandistrogene moxeparvovec (Elevidys)
Denosumab—PAD PA Criteria
Physician-administered drug prior authorization criteria for denosumab
Depemokimab-ulaa (Exdensur)—PAD PA Criteria
Physician-administered drug prior authorization criteria for depemokimab-ulaa (Exdensur)
Efgartigimod alfa fcab (Vyvgart_Vyvgart Hytrulo)—PAD PA Criteria
Physician-administered drug prior authorization criteria for efgartigimod alfa fcab (Vyvgart_Vyvgart Hytrulo)
Eptinezumab-jjmr (Vyepti)—PAD PA Criteria
Physician-administered drug prior authorization criteria for eptinezumab-jjmr (Vyepti)
Esketamine (Spravato)—PAD PA Criteria
Physician-administered drug prior authorization criteria for esketamine (Spravato)
Etranacogene dezaparvovec-drlb (Hemgenix)—PAD PA Criteria
Physician-administered drug prior authorization criteria for etranacogene dezaparvovec-drlb (Hemgenix)
Exagamglogene autotemecl (Casgevy)—PAD PA Criteria
Physician-administered drug prior authorization criteria for exagamglogene autotemecl (Casgevy)
Evinacumab-dgnb (Evkeeza)—PAD PA Criteria
Physician-administered drug prior authorization criteria for evinacumab-dgnb (Evkeeza)

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Criteria by Topic G to M

Browse the documents below for Physician-Administered Drug guidelines Adopted by CalOptima Health’s Pharmacy and Therapeutics Committee.

Gonadotropin Releasing Hormone Analog—PAD PA Criteria
Physician-administered drug prior authorization criteria for gonadotropin releasing hormone analog
Hyaluronic Acid—PAD PA Criteria
Physician-administered drug prior authorization criteria for hyaluronic acid
Immune Globulin—PAD PA Criteria
Physician-administered drug prior authorization criteria for immune globulin
Inclisiran (Leqvio)—PAD PA Criteria
Physician-administered drug prior authorization criteria for inclisiran (Leqvio)
Intra-Dialytic Parenteral Nutrition (IDPN)—PAD PA Criteria
Physician-administered drug prior authorization criteria for intra-dialytic parenteral nutrition (IDPN)
Intravitreal Vascular Endothelial Growth Factor Antagonist (VEGF-A)—PAD PA Criteria
Physician-administered drug prior authorization criteria for intravitreal vascular endothelial growth factor antagonist (VEGF-A)
Iron Products—PAD PA Criteria
Physician-administered drug prior authorization criteria for iron products
Lovotibeglogene Autotemcel (Lyfgenia)—PAD PA Criteria
Physician-administered drug prior authorization criteria for lovotibeglogene autotemcel (Lyfgenia)

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Criteria by Topic N to Z

Browse the documents below for Physician-Administered Drug guidelines Adopted by CalOptima Health’s Pharmacy and Therapeutics Committee.

Nusinersen (Spinraza)—PAD PA Criteria
Physician-administered drug prior authorization criteria for nusinersen (Spinraza)
Onasemnogene (Itvisma, Zolgensma)—PAD PA Criteria
Physician-administered drug prior authorization criteria for onasemnogene (Itvisma, Zolgensma)
Ophthalmic riboflavin (Epioxa, Photrexa)—PAD PA Criteria
Physician-administered drug prior authorization criteria for ophthalmic riboflavin (Epioxa, Photrexa)
Pegloticase (Krystexxa)—PAD PA Criteria
Physician-administered drug prior authorization criteria for pegloticase (Krystexxa)
Pegzilarginase-nbln (Loargys)—PAD PA Criteria
Physician-administered drug prior authorization criteria for pegzilarginase-nbln (Loargys)
Prademagene zamikeracel (Zevaskyn)—PAD PA Criteria
Physician-administered drug prior authorization criteria for prademagene zamikeracel (Zevaskyn)
Revakinagene taroretcel-lwey (Encelto)—PAD PA Criteria
Physician-administered drug prior authorization criteria for revakinagene taroretcel-lwey (Encelto)
Remestemcel-L-rknd (Ryoncil)—PAD PA Criteria
Physician-administered drug prior authorization criteria for remestemcel-L-rknd (Ryoncil)
Reslizumab (Cinqair)—PAD PA Criteria
Physician-administered drug prior authorization criteria for reslizumab (Cinqair)
Romiplostim (Nplate)—PAD PA Criteria
Physician-administered drug prior authorization criteria for romiplostim (Nplate)
Romosozumab-aqqg (Evenity)—PAD PA Criteria
Physician-administered drug prior authorization criteria for romosozumab-aqqg (Evenity)
Teprotumumab-trbw (Tepezza)—PAD PA Criteria
Physician-administered drug prior authorization criteria for teprotumumab-trbw (Tepezza)
Tisagenlecleucel (Kymriah)—PAD PA Criteria
Physician-administered drug prior authorization criteria for tisagenlecleucel (Kymriah)
Triamcinolone extended-release (Zilretta)—PAD PA Criteria
Physician-administered drug prior authorization criteria for triamcinolone extended-release (Zilretta)
Voretigene neparvovec-rzyl (Luxturna)—PAD PA Criteria
Physician-administered drug prior authorization criteria for voretigene neparvovec-rzyl (Luxturna)