Clinical Prior Authorization
The following clinical prior authorizations have been implemented for Medicaid members, consistent with the Vendor Drug Program:
- Acthar Gel (PDF)
- ADD/ADHD Agents (PDF)
- Aliskiren-Containing Agents (Except Valturna) (PDF)
- Allergen Extracts – Oralair (PDF)
- Amantadine ER (PDF)
- Androgenic Agents (PDF)
- Antiemetics (PDF)
- Antipsychotics (PDF)
- Anxiolytics and Sedatives/Hypnotics (ASHs) (PDF)
- Arikayce (PDF)
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Acute Treatment) (PDF)
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Chronic) (PDF)
- Carisoprodol-Containing Agents (PDF)
- CNS Stimulants (PDF)
- Colchicine Agents (PDF)
- Copaxone (PDF)
- Cough/Cold Medication (PDF)
- Cyclobenzaprine (PDF)
- Cymbalta (PDF)
- Cystic Fibrosis Agents (PDF)
- Cytokine and CAM Antagonists (PDF)
- Desmopressin (PDF)
- Dextromethorphan Overutilization (PDF)
- Diacomit (Stiripentol) (PDF)
- Diclofenac (PDF)
- Dipeptidyl Peptidase-4 (PDF)
- Dopamine Agonists (PDF)
- Doxylamine/Pyridoxine (PDF)
- Dupixent (PDF)
- Emflaza (PDF)
- Enzymes (PDF)
- Epidiolex (PDF)
- Erythropoiesis-Stimulating Agents (PDF)
- Evrysdi (Risdiplam) (PDF)
- Fentanyl (PDF)
- Forteo (PDF)
- Gabapentin Agents- Horizant and Gralise (PDF)
- Gaucher’s Disease Agents (PDF)
- GI Motility Agents (PDF)
- Glucagon-Like Peptide (GLP-1) Receptor Agonists (PDF)
- Growth Hormone Products (PDF)
- Hemady (Dexamethasone) (PDF)
- Hepatitis C Antiviral Agents (PDF)
- Hereditary Angioedema (PDF)
- Hyperlipidemia Agents (PDF)
- Imiquimod (PDF)
- Increlex (PDF)
- Inhaled Antibiotics (PDF)
- Keveyis (PDF)
- Leukotriene Modifiers (PDF)
- Lidoderm (Lidocaine) Patch (PDF)
- Lovaza (PDF)
- Lyrica (PDF)
- Makena (PDF)
- Monoclonal Antibody Agents for Asthma (PDF)
- Multiple Sclerosis (MS) Agents (PDF)
- Nitazoxanide (PDF)
- Nuedexta (PDF)
- Nuplazid (PDF)
- Opioid Policy Criteria (PDF)
- Ophthalmic Immunomodulators (PDF)
- Oriahnn (Elagolix, Estradiol, and Norethinedrone) (PDF)
- Orilissa (PDF)
- Oxervate (PDF)
- Palforzia (PDF)
- Phenergan/Phenergan Containing Products (Promethazine) (PDF)
- Phosphate Binders (PDF)
- Phosphodiesterase Type 5 (PDE-5) Inhibitors (PDF)
- Proton Pump Inhibitors (PDF)
- Propylthiouracil (PDF)
- Pulmonary Arterial Hypertension (PDF)
- Ranexa (PDF)
- Savella (PDF)
- SGLT2 Inhibitor Agents (PDF)
- Sickle Cell Disease Agents (PDF)
- Suboxone/Subutex (PDF)
- Symlin (PDF)
- Synagis (PDF)
- Thiazolidinediones (PDF)
- Topical Acne Agents (PDF)
- Topical Immunomodulators (PDF)
- Transthyretin Agents (PDF)
- Urea Cycle Disorder Agents (PDF)
- Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors (PDF)
- Wakix (Pitolisant) (PDF)
- Xifaxan (PDF)
- Xyrem/Xywav (PDF)
- Zelboraf (PDF)
The following clinical prior authorizations have not been implemented for Medicaid members at this time. Once implemented, a link to the clinical edit criteria will be provided.
- Alprazolam/Carisoprodol/Hydrocodone
- Altabax
- Carisoprodol Overuse
- Cox-2 Inhibitors
- Drug Regimen Optimization
- Duplicate Therapy
- Ketorolac (Toradol)
- Opiate Overutilization
- Oxycontin (Narcotic Analgesic)
- Plavix