Pharmacy Help Desk: 1-877-209-1264, Provider PA Help Desk: 1-877-207-1126

Additional Therapeutic Criteria

File Description Date
Additional Therapeutic Criteria Effective September 20, 2023 207.93 KB 2023/09/22
Additional Therapeutic Criteria Effective May 24, 2023 198.9 KB 2023/05/22
Additional Therapeutic Criteria Effective May 5, 2023 198.25 KB 2023/05/04
Additional Therapeutic Criteria Effective March 14, 2023 195.44 KB 2023/03/14
Additional Therapeutic Criteria Effective January 01, 2023 221.06 KB 2022/12/23
Additional Therapeutic Criteria Effective November 04, 2022 221.83 KB 2022/11/04
Additional Therapeutic Criteria Effective September 16, 2022 222.3 KB 2022/09/16
Additional Therapeutic Criteria Effective June 8, 2022 219.79 KB 2022/06/08
Additional Therapeutic Criteria Effective April 11, 2022 215.21 KB 2022/04/11
Additional Therapeutic Criteria Effective March 31, 2022 216.52 KB 2022/03/31
Additional Therapeutic Criteria Effective March 21, 2022 221.2 KB 2022/03/22
Additional Therapeutic Criteria Effective January 1, 2022 243.81 KB 2021/12/31
Additional Therapeutic Criteria Effective October 22, 2021 261.81 KB 2021/10/18
Additional Therapeutic Criteria Effective June 16, 2021 208.65 KB 2021/06/16
Additional Therapeutic Criteria Effective February 24, 2021 193.91 KB 2021/02/22
Additional Therapeutic Criteria Effective January 1, 2021 193.82 KB 2020/12/31
Additional Therapeutic Criteria Effective October 8, 2020 168.65 KB 2020/10/08
Additional Therapeutic Criteria Effective August 10, 2020 163.75 KB 2020/08/10
Additional Therapeutic Criteria Effective February 26, 2020 131.25 KB 2020/03/03
Additional Therapeutic Criteria Effective January 1, 2020 110.27 KB 2019/12/31
Additional Therapeutic Criteria Effective September 18, 2019 130.9 KB 2019/09/18
Additional Therapeutic Criteria Effective July 22, 2019 128.53 KB 2019/07/25
Additional Therapeutic Criteria Effective May 16, 2019 110 KB 2019/05/17
Additional Therapeutic Criteria Effective March 12, 2019 130.91 KB 2019/03/12
Additional Therapeutic Criteria Effective January 1, 2019 174.83 KB 2018/12/31
Additional Therapeutic Criteria Effective September 27, 2018 171.39 KB 2018/09/27
Additional Therapeutic Criteria Effective July 17, 2018 170.11 KB 2018/07/18
Additional Therapeutic Criteria Effective March 14, 2018 131.37 KB 2018/03/14
Additional Therapeutic Criteria Effective January 24, 2018 131.31 KB 2018/01/25
Additional Therapeutic Criteria Effective January 1, 2018 114.17 KB 2018/01/02
Additional Therapeutic Criteria Effective September 29, 2017 131.01 KB 2017/09/29
Additional Therapeutic Criteria Effective July 3, 2017 130.56 KB 2017/07/05
Additional Therapeutic Criteria Effective May 30, 2017 127.26 KB 2017/05/30
Additional Therapeutic Criteria Effective April 7, 2017 63.48 KB 2017/04/07
Additional Therapeutic Criteria Effective January 1, 2017 60.23 KB 2016/12/22
Additional Therapeutic Criteria Effective Augutst 31, 2016 60.69 KB 2016/09/01

Archive Files