Pharmacy prior authorizations

  • PA process
  • Pharmacy benefit criteria (patient-administered)
  • Medical benefit criteria (physician-administered)

Prior authorization process

Fallon Health Weinberg partners with CVS Caremark (Fallon's Pharmacy Benefit Manager) for pharmacy prior authorization. CVS Caremark reviews pharmacy benefit drugs (patient self-administered drugs, including oral medications), and Fallon Health Weinberg reviews medical benefit drugs (physician-administered drugs, including home infusion).

Patient-administered drugs (pharmacy benefit)

You can call in your prior authorization to 1-866-412-5394, or fax it to 1-855-633-7673. Please use the CVS Caremark prior authorization form if submitting your request by fax.

Physician-administered drugs (medical benefit)

For physician-administered drugs that require prior authorization, fax a completed Prior authorization form for medical benefit drugs to us at 1-716-810-1909.

Patient-administered drugs (pharmacy benefit)

You can submit a prior authorization request by phone to 1-866-412-5394, or by fax to 1-855-633-7673. Please use the CVS Caremark prior authorization form if submitting your request by fax.

Drug name

Criteria

PA form

Abilify (aripiprazole) Abilify criteria PA form
Actimmune (gamma interferon) Actimmune criteria PA form
Actiq (fentanyl citrate) Actiq criteria PA form
Adcirca (tadalafil)  Adcirca criteria PA form
Adempas (riociguat) Adempas criteria PA form
Afinitor (everolimus) Afinitor criteria PA form
Aldurazyme (laronidase) Aldurazyme criteria PA form
Alecensa (alectinib) Alecensa criteria PA form
Alunbrig (brigatinib) Alunbrig criteria PA form
Ampyra (dalfampridine) Ampyra criteria PA form
Anadrol-50 (oxymetholone) Anadrol-50 criteria PA form
Apokyne (apomorphine) Apokyn criteria PA form
Aptiom (eslicarbazepine acetate) Aptiom criteria PA form
Aralast (alpha-1 proteinase inhibitor) Aralast criteria PA form
Arcalyst (rilonacept) Arcalyst criteria PA form
Aubagio (teriflunomide) Aubagio criteria PA form
Banzel (rufinamide) Banzel criteria PA form
Baraclude (entecavir) Baraclude criteria PA form
Bavencio (avelumab) Bavencio criteria PA form
Beleodaq (belinostat) Beleodaq criteria PA form
Benlysta (belimumab) Benlysta criteria PA form
Bosulif (bosutinib) Bosulif criteria PA form
Briviact (brivaracetam) Briviact criteria PA form
Byetta (exenatide) Byetta criteria PA form
Cabometyx (cabozantinib) Cabometyx criteria PA form
Campral (acamprosate) Campral criteria PA form
Caprelsa (vandetanib) Caprelsa criteria PA form
Carbaglu (carglumic acid) Carbaglu criteria PA form
Carisoprodol Carisoprodol criteria PA form
Cayston (aztreonam) Cayston criteria PA form
Celebrex (celecoxib) Celebrex criteria PA form
Cerezyme (imiglucerase) Cerezyme criteria PA form
Cinryze (C1 inhibitor human) Cinryze criteria PA form
Cometriq (cabozantinib) Cometriq criteria PA form
Cotellic (cobimetinib) Cotellic criteria PA form
Crinone (progesterone gel) Crinone criteria PA form
Cubicin (daptomycin)‎ Cubicin criteria PA form
Cyclobenzaprine Cyclobenzaprine criteria PA form
Cyclophosphamide Medicare Part B versus Part D determination PA form
Cystaran (cysteamine ophthalmic solution)  Cystaran criteria PA form
Daklinza (daclatasvir) Daklinza criteria PA form
Darzalex (daratumumab) Darzalex criteria PA form
Emend (aprepitant) Emend criteria PA form
Empliciti (elotuzumab) Empliciti criteria PA form
Emsam (selegiline) Emsam criteria PA form
Entresto (sacubitril/valsartan) Entresto criteria PA form
Epclusa (sofosbuvir/velpatasvir) Epclusa criteria PA form
Epoetin Epoetin criteria PA form
Erivedge (vismodegib) Erivedge criteria PA form
Erwinaze (asparaginase Erwinia chrysanthemi) Erwinaze criteria PA form
Esbriet (pirfenidone) Esbriet criteria PA form
ESRD Drugs (Access/Anemia/Bone Mineral Metabolism/Cellular Management) Medicare Part B versus Part D determination PA form
Fabrazyme (agalsidase) Fabrazyme criteria PA form
Fanapt (iloperidone) Fanapt criteria PA form
Farxiga (dapagliflozen) Farxiga criteria PA form
Farydak (panobinostat) Farydak criteria PA form
Ferriprox (deferiprone) Ferriprox criteria PA form
Fetzima (levomilnacipran) Fetzima criteria PA form
Firazyr (icatibant) Firayzr criteria PA form
Formulary exception Formulary exception PA form
Forteo (teriparatide) Forteo criteria PA form
Fycompa (perampanel) Fycompa criteria PA form
Gattex (teduglutide) Gattex criteria PA form
Gilenya (fingolimod) Gilenya criteria PA form
Gilotrif (afatinib) Gilotrif criteria PA form
Gleevec (imatinib) Gleevec criteria PA form
Growth hormone Growth hormone criteria PA form
Harvoni (ledipasvir and sofosbuvir) Harvoni criteria PA form
Hepatitis B vaccine Medicare Part B versus Part D determination PA form
Hepsera (adefovir) Hepsera criteria PA form
Herceptin (trastuzumab) Herceptin criteria PA form
Hetlioz (tasimelteon) Hetlioz criteria PA form
Hopsice drugs Medicare Part B versus Part D determination PA form
Ibrance (palbociclib) Ibrance criteria PA form
Iclusig (ponatinib) Iclusig criteria PA form
Idhifa (enasidenib) Idhifa criteria PA form
Ilaris (canakinumab) Ilaris criteria PA form
Imbruvica (ibrutinib) Imbruvica criteria PA form
Imfinzi (durvalumab) Imfinzi criteria PA form
Immune globulin Immune globulin criteria PA form
Immunosuppressant agents Medicare Part B versus Part D determination PA form
Increlex (mecasermin) Increlex criteria PA form
Infusion pump medications Medicare Part B versus Part D determination PA form
Ingrezza (valbenazine) Ingrezza criteria PA form
Inhalation solutions – beta 2 adrenergic agonists and anticholinergics and corticosteroids and mast cell stabilizers Medicare Part B versus Part D determination PA form
Inhalation Solutions – Mucolytics Medicare Part B versus Part D determination PA form
Inhalation Solutions – Nebupent (pentamidine) Medicare Part B versus Part D determination PA form
Inhalation Solutions – Tobramycin Medicare Part B versus Part D determination PA form
Injectibles Medicare Part B versus Part D determination PA form
Inlyta (axitinib) Inlyta criteria PA form
Intron A (interferon alpha-2b) Intron A criteria PA form
Intuniv (guanfacine extended release) Intuniv criteria PA form
Invega (paliperidone) Invega criteria PA form
Iressa (gefitinib) Iressa criteria PA form
Jakafi (ruxolitinib) Jakafi criteria PA form
Janumet (sitagliptin/metformin HCl) Janumet criteria PA form
Januvia (sitagliptin) Januvia criteria PA form
Juxtapid (lomitapide) Juxtapid criteria PA form
Kadcyla (ado-trastuzumab emtansine) Kadcyla criteria PA form
Kalydeco (ivacaftor) Kalydeco criteria PA form
Keveyis (dichlorphenamide) Keveyis criteria PA form
Keytruda (pembrolizumab) Keytruda criteria PA form
Kineret (anakinra) Kineret criteria PA form
Kisqali (ribociclib) Kisqali criteria PA form
Korlym (mifepristone) Korlym criteria PA form
Kuvan (sapropterin dihydrochloride) Kuvan criteria PA form
Kynamro (mipomersen sodium) Kynamro criteria PA form
Kyprolis (carfilzomib) Kyprolis criteria PA form
Lartruvo (olaratumab)  Lartruvo criteria PA form
Latuda (lurasidone) Latuda criteria PA form
Lenvima (lenvatinib) Lenvima criteria PA form
Letairis (ambrisentan) Letairis criteria PA form
Levemir  (insulin detemir)  Levemir criteria PA form
Lidoderm (lidocaine patch) Lidoderm criteria PA form
Lonsurf (trifluridine and tipiracil) Lonsurf criteria PA form
Lotronex (alosetron) Lotronex criteria PA form
Lumigan (bimatoprost ophthalmic solution) Ophthalmaic prostaglandin criteria PA form
Lumizyme (alglucosidase alfa) Lumizyme criteria PA form
Lynparza (olaparib) Lynparza criteria PA form
Lyrica (pregabalin) Lyrica criteria PA form
Mekinist (trametinib) Mekinist criteria PA form
Movantik (naloxegol) Movantik criteria PA form
Mozobil (plerixafor) Mozobil criteria PA form
Multaq (dronedarone) Multaq criteria PA form
Myrbetriq (mirabegron) Myrbetriq criteria PA form
Mytesi (crofelemer) Mytesi criteria PA form
Naglazyme (galsulfase) Naglazyme criteria PA form
Natpara (parathyroid horomone) Natpara criteria PA form
Nerlynx (neratinib) Nerlynx criteria PA form
Neupro (rotigotine) Neupro criteria PA form
Nexavar (sorafenib) Nexavar criteria PA form
Ninlaro (ixazomib) Ninlaro criteria PA form
Northera (droxidopa) Northera criteira PA form
Noxafil (posaconazole) Noxafil criteria PA form
Nucala (mepolizumab) Nucala criteria PA form
Nuedexta (dextromethorphan/Quinidine) Nuedexta criteria PA form
Nuplazid (pimavanserin) Nuplazid criteria PA form
Odomzo (sonidegib) Odomzo criteria PA form
Ofev (nintedanib) Ofev criteria PA form
Olysio (simeprevir)‎ Olysio criteria PA form
Onfi (clobazam) Onfi criteria PA form
Opdivo (nivolumab) Opdivo criteria PA form
Opsumit (macitentan) Opsumit criteria PA form
Oral antiemetic agents (except Akynzeo and Emend) Medicare Part B versus Part D determination PA form
Oral chemotherapy agents Medicare Part B versus Part D determination PA form
Orencia (abatacept) Orencia criteria PA form
Orfadin (nitisinone) Orfadin criteria PA form
Orkambi (lumacaftor/ivacaftor)  Orkambi criteria PA form
Oxandrin (oxandrolone) Oxandrin criteria PA form
OxyContin (oxycodone extended-release) OxyContin ER criteria PA form
Parenteral nutrition Medicare Part B versus Part D determination PA form
PEG‐Intron (peginterferon alfa‐2b) PEG‐Intron criteria PA form
Perjeta (pertuzumab) Perjeta criteria PA form
Pomalyst (pomalidomide) Pomalyst criteria PA form
Potiga (ezogabine) Potiga criteria PA form
Pristiq (desvenlafaxine) Pristiq criteria PA form
Prolia (denosumab)‎ Prolia criteria PA form
Promacta (eltrombopag) Promacta criteria PA form
Provigil (modafinil) Provigil criteria PA form
Radicava (edaravone) Radicava criteria PA form
Ranexa (ranolazine) Ranexa criteria PA form
Ravicti (glycerol phenylbutyrate) Ravicti criteria PA form
Rebif (interferon beta-1a) Rebif criteria PA form
Relistor (methylnaltrexone) Relistor criteria PA form
Remicade (infliximab) Remicade criteria PA form
Repatha (evolocumab) Repatha criteria PA form
Revatio (sildenafil) Revatio criteria PA form
Revlimid (lenalidomide) Revlimid criteria PA form
Rexulti (brexpiprazole) Rexulti criteria PA form
Risperdal Consta (risperidone) Risperdal criteria PA form
Rozerem (ramelteon) Rozerem criteria PA form
Rubraca (rucaparib)  Rubraca criteria PA form
Rydapt (midostaurin) Rydapt criteria PA form
Sabril (vigabatrin) Sabril criteria PA form
Saphris (asenapine maleate) Saphris criteria PA form
Serostim (somatropin) Serostim criteria PA form
Signifor (pasireotide) Signifor criteria PA form
Sirturo (bedaquiline) Sirturo criteria PA form
Somatuline Depot (lanreotide) Somatuline Depot criteria PA form
Sovaldi (sofosbuvir) Sovaldi criteria PA form
Sprycel (dasatinib) Sprycel criteria PA form
Stivarga (regorafenib) Stivarga criteria PA form
Strattera (atomoxetine) Strattera criteria PA form
Sutent (sunitinib) Sutent criteria PA form
Sylatron (peginterferon alfa-2b) Sylatron criteria PA form
Symlin (pramlintide) Symlin criteria PA form
Synagis (palivizumab) Synagis criteria PA form
Synribo (omacetaxine mepesuccinate) Synribo criteria PA form
Tafinlar (dabrafenib) Tafinlar criteria PA form
Tagrisso (osimertinib) Tagrisso criteria PA form
Tarceva (erlotinib) Tarceva criteria PA form
Tasigna (nilotinib) Tasigna criteria PA form
Tecentriq (atezolizumab) Tecentriq criteria PA form
Tecfidera (dimethyl fumarate) Tecfidera criteria PA form
Technivie (ombitasvir, paritaprevir and ritonavir) Technivie criteria PA form
Testim (testosterone gel) Testim criteria PA form
Thalomid (thalidomide) Thalomid criteria PA form
Tracleer (bosentan) Tracleer criteria PA form
Travatan Z (travoprost ophthalmic solution) Ophthalmaic prostaglandin criteria PA form
Trintellix (vortioxetine) Trintellix criteria PA form
Tygacil (tigecycline) Tygacil criteria PA form
Tykerb (lapatinib) Tykerb criteria PA form
Tysabri (natalizumab) Tysabri criteria PA form
Tyzeka (telbivudine) Tyzeka criteria PA form
Uptravi (selexipag) Uptravi criteria PA form
Valchlor (mechlorethamine) Valchor criteria PA form
Vancocin (vancomycin) Vancocin criteria PA form
Vancomycin IV Medicare Part B versus Part D determination PA form
Venclexta (venetoclax) Venclexta criteria PA form
Ventavis (iloprost) Ventavis criteria PA form
Vfend (voriconazole) Vfend criteria PA form
Vidaza (azacitidine) Vidaza criteria PA form
Viekira (ombitasvir/paritaprevir/ritonavir with dasabuvir) Viekira criteria PA form
Viibryd (vilazodone) Viibryd criteria PA form
Vimpat (lacosamide) Vimpat criteria PA form
Virazole Medicare Part B versus Part D determination PA form
Votrient (pazopanib) Votrient criteria PA form
Vraylar (cariprazine) Vraylar criteria PA form
Xalkori (crizotinib) Xalkori criteria PA form
Xarelto (rivaroxaban) Xarelto criteria PA form
Xenazine (tetrabenazine) Xenazine criteria PA form
Xgeva (denosumab) Xgeva criteria PA form
Xolair (omalizumab) Xolair criteria PA form
Xtandi (enzalutamide) Xtandi criteria PA form
Xyrem (sodium oxybate) Xyrem criteria PA form
Yervoy (ipilimumab) Yervoy criteria PA form
Yondelis (trabectedin) Yondelis criteria PA form
Zaltrap (ziv-aflibercept) Zaltrap criteria PA form
Zejula (niraparib) Zejula criteria PA form
Zelboraf (vemurafenib) Zelboraf criteria PA form
Zemplar (paricalcitol) Zemplar criteria PA form
Zofran (ondansetron) Medicare Part B versus Part D determination PA form
Zolinza (vorinostat) Zolinza criteria PA form
Zydelig (idelalisib) Zydelig criteria PA form
Zykadia (ceritinib) Zykadia criteria PA form
Zytiga (abiraterone) Zytiga criteria PA form
Zyvox (linezolid) Zyvox criteria PA form
Non-formulary medications Formulary exception PA form

Physician-administered drugs (medical benefit)

For physician-administered drugs that require prior authorization, fax a completed Prior authorization form for medical benefit drugs to us at 1-716-810-1909.

Drug name Criteria PA form
Acthar (corticotropin) Acthar criteria PA form
Actemra (tocilizumab) Actemra criteria PA form
Adcetris (brentuximab) Adcetris criteria PA form
Aldurazyme (laronidase) Aldurazyme criteria PA form
Amevive (alefacept) Amevive criteria PA form
Aralast (alpha-1 proteinase inhibitor) Aralast criteria PA form
Aranesp (darbepoetin) Aranesp criteria PA form
Arranon (nelarabine) Arranon criteria PA form
Arzerra (ofatumumab) Arzerra criteria PA form

Bavencio (avelumab)

Bavencio criteria PA form
Beleodaq (belinostat) Beleodaq criteria PA form
Bendeka (bendamustine hydrochloride) Bendeka criteria PA form
Benlysta (belimumab) Benlysta criteria PA form
Berinert (C1 esterase inhibitor [Human]) Berinert criteria PA form
Botox (botulinium toxin A) Botox criteria PA form
Cerezyme (imiglucerase) Cerezyme criteria PA form
Cimzia (certolizumab pegol) Cimzia criteria PA form
Cinqair (reslizumab) Cinqair criteria PA form
Cinryze (C1 inhibitor human) Cinryze criteria PA form
Clolar (clofarabine) Clolar criteria PA form
Cosentyx (secukinumab) Cosentyx criteria PA form
Cresemba (isavuconazonium sulfate) Cresemba criteria PA form
Cubicin (daptomycin) Cubicin criteria PA form
Cyramza (ramucirumab) Cyramza criteria PA form
Dacogen (decitabine) Dacogen criteria PA form
Darzalex (aratumumab) Darzalex critera PA form
Dysport (abobotulinumtoxin A) Dysport criteria PA form
Elaprase (idursulfase) Elaprase criteria PA form
Eloctate (Antihemophilic Factor (Recombinant), Fc Fusion Protein)  Eloctate criteria PA form
Empliciti (elotuzumab) Empliciti criteria PA form
Entereg (alvimopan) Entereg criteria PA form
Entyvio (vedolizumab) Entyvio criteria PA form
Epogen (epoetin) Epogen criteria PA form
Erwinaze (asparaginase) Erwinaze criteria PA form
Ethyol (amifostine) Ethyol criteria PA form
Euflexxa (hyaluronate sodium)  Viscosupplements criteria PA form
Evomela (melphalan) Evomela criteria PA form
Exondys 51 (eteplirsen) Exondys 51 criteria PA form
Fabrazyme (agalsidase) Fabrazyme criteria PA form
Feraheme (ferumoxytol) Fereheme criteria PA form
Fotolyn (pralatrexate) Fotolyn criteria PA form
Gel-One (cross-linked hyaluronate) Viscosupplements criteria PA form
Gelsyn-3 (hyaluronate sodium)  Viscosupplements criteria PA form
Genvisc (hyaluronate sodium)  Viscosupplements criteria PA form
Glassia (alpha-1 proteinase inhibitor) Glassia criteria PA form
Halaven (eribulin) Halaven criteria PA form
Hizentra (immunoglobulin SCIG) Hizentra criteria PA form
Hyalgan (sodium hyaluronate) Viscosupplements criteria PA form
Hymovis (hyaluronic acid) Viscosupplements criteria PA form
HyQvia (immune globulin) HyQvia criteria PA form
Ilaris (canakinumab) Ilaris criteria PA form
Imfinzi (durvalumab) Imfinzi criteria PA form
Imlygic (talimogene laherparepvec) Imlygic criteria PA form
Immunoglobulin IVIG and SCIG Immunoglobulin IVIG and SCIG criteria PA form
Inflectra (infliximab-dyyb) Inflectra criteria PA form
Injectafer (ferric carboxymaltose) Injectafer criteria PA form
Intron A (interferon alpha-2b) Intron A criteria PA form
Istodax (romidepsin) Istodax criteria PA form
Ixempra (ixabepilone) Ixempra criteria PA form
Jevtana (cabazitaxel) Jevtana criteria PA form
Kadcyla (ado-trastuzumab emtansine) Kadcyla criteria PA form
Kalbitor (ecallantide) Kalbitor criteria PA form
Kanuma (sebelipase alfa) Kanuma criteria PA form
Kepivance (palifermin) Kepivance criteria PA form
Keytruda (pembrolizumab) Keytruda criteria PA form
Kineret (anakinra) Kineret criteria PA form
Krystexxa (pegloticase) Krystexxa criteria PA form
Kyprolis (carfilzomib) Kyprolis criteria PA form
Lartruvo (olaratumab) Lartruvo criteria PA form
Lemtrada (alemtuzumab) Lemtrada criteria PA form
Lumizyme (alglucosidase alfa) Lumizyme criteria PA form
Mircera (methoxy polyethylene glycol-epoetin beta) Mircera criteria PA form
Monovisc (hyaluronate sodium) Viscosupplements criteria PA form
Mozobil (plerixafor) Mozobil criteria PA form
Myobloc (botulinum toxin B) Myobloc criteria PA form
Myozyme (aglucosidase alfa) Myozyme criteria PA form
Naglazyme (galsulfase) Naglazyme criteria PA form
NovoSeven (human coagulation factor VIIa) NovoSeven criteria PA form
Nplate (romiplostim) Nplate criteria PA form
Nucala (mepolizumab) Nucala criteria PA form
Ocrevus (Ocrelizumab) Ocrevus criteria PA form
Ontak (denileukin diftitox) Ontak criteria PA form
Opdivo (nivolumab) Opdivo criteria PA form
Orencia (abatacept) Orencia criteria PA form
Orthovisc (hyaluronic acid) Viscosupplements criteria PA form
Panhematin (hemin) Panhematin criteria PA form
Perjeta (pertuzumab) Perjeta criteria PA form
Plasma volume expander Plasma volume expander criteria PA form
Portrazza (necitumumab) Portrazza criteria PA form
Procrit (epoetin) Procrit criteria PA form
Prolastin (alpha-1 proteinase inhibitor) Prolastin criteria PA form
Prolia (denosumab) Prolia criteria PA form
Qutenza (capsaicin) Qutenza criteria PA form
Radicava (edaravone) Radicava criteria PA form
Remicade (infliximab) Remicade criteria PA form
Retisert (fluocinolone acetonide) Retisert criteria PA form
Rituxan (rituximab) Rituxan criteria PA form
Ruconest (C1 esterase inhibitor[recombinant]) Ruconest criteria PA form
Sandostatin (octreotide) Sandostatin criteria PA form
Simponi (golimumab) Simponi criteria PA form
Simpon Aria (golimumab) Simponi criteria PA form
Soliris (eculizumab) Soliris criteria PA form
Somatuline Depot (lanreotide) Somatuline Depot criteria PA form
Spinraza (nusinersen) Spinraza criteria PA form
Standard criteria - brand with generic available Standard criteria - brand with generic available PA form
Standard criteria - compounds Standard criteria - compounds PA form
Standard Criteria - PA with no criteria and off-label Standard Criteria - PA with no criteria and off-label PA form
Stelara (ustekinumab) Stelara criteria PA form
Supartz (hyaluronic acid) Viscosupplements criteria PA form
Supprelin LA (histrelin) Supprelin LA criteria PA form
Sylvant (siltuximab) Sylvant criteria PA form
Synagis (palivizumab) Synagis criteria

Synagis Enrollment Form

Synercid (dalfopristin/quinupristin) Synercid criteria PA form
Synribo (omacetaxine mepesuccinate) Synribo criteria PA form
Synvisc and Synvisc-One (hyaluronic acid) Viscosupplements criteria PA form
Tecentriq (atezolizumab) Tecentriq criteria PA form
Testopel (testosterone) Testopel criteria PA form
Thrombate III (antithrombin III) Thrombate III criteria PA form
Treanda (bendamustine hydrochloride) Treanda criteria PA form
Tygacil (tigecycline) Tygacil criteria PA form
Tysabri (natalizumab) Tysabri criteria PA form
Vectibix (panitumumab) Vectibix criteria PA form
Vidaza (azacitidine) Vidaza criteria PA form
Vpriv (velaglucerase) Vpriv criteria PA form
Xeomin (incobotulinumtoxin A) Xeomin criteria PA form
Xgeva (denosumab) Xgeva criteria PA form
Xiaflex (collagenase clostridium histolyticum) Xiaflex criteria PA form
Xigris (drotrecogin alfa) Xigris criteria PA form
Xofigo (radium Ra 223 dichloride) Xofigo criteria

PA form

Xolair (omalizumab) Xolair criteria PA form
Yervoy (ipilimumab) Yervoy criteria PA form
Yondelis (trabectedin) Yondelis criteria PA form
Zaltrap (ziv-aflibercept) Zaltrap criteria PA form
Zemaira (alpha-1 antiproteinase inhibitor) Zemaira criteria PA form
Zinplava (bezlotoxumab) Zinplava criteria PA form
Zostavax (zoster vaccine live) Zostavax criteria PA form
Zyvox (linezolid) Zyvox criteria PA form