Clinical Prior Authorization
The following clinical prior authorizations have been implemented for Medicaid members, consistent with the Vendor Drug Program:
- Actiq (Oral Transmucosal Fentanyl)
- ADD/ADHD Agents
- Allergen Extracts - Grastek, Oralair, Ragwitek TM
- Alinia (Nitazoxanide)
- Amitiza (Lubiprostone)
- Antipsychotics
- Antiemetics
- Byetta
- Carisoprodol Overuse
- Cough/Cold Medication
- Cyclobenzaprine
- Cymbalta
- Cystic Fibrosis Agents
- Cytokine and CAM Antagonists
- Desmopressin
- Dextromethorphan Overutilization
- Duragesic (Fentanyl Transdermal)
- Erythropoiesis-Stimulating Agents
- Growth Hormone Products
- H.P.Acthar Gel
- Hepatitis C Virus
- Imiquimod
- Increlex
- Januvia
- Leukotriene Modifiers
- Makena
- Opiate Overutilization
- PCSK9 Inhibitors
- Phenergan/Phenergan Containing Products (Promethazine)
- Propylthiouracil
- Ranexa
- Relistor
- Revatio
- Suboxone/Subutex
- Symlin
- Synagis
- Thiazolidinediones
- Topical Immunomodulators
- Victoza
- Xifaxan
- Xyrem
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.
- Actemra
- Agents for Gauchers
- Agents for Hereditary Angioedema
- Aliskiren-Containing Agents (Except Valturna)
- Alprazolam/Carisoprodol/Hydrocodone
- Altabax
- Androgenic Agents
- Anticonvulsant agent (Gabapentin)
- Anxiolytics and Sedatives/Hypnotics (ASHs)
- Copaxone
- Cox-2 Inhibitors
- Drug Regimen Optimization
- Duplicate Therapy
- Enzymes
- Fosrenol
- Injectable Pulmonary Hypertension Agents
- Ketorolac (Toradol)
- Lidocaine Patches
- Lovaza
- Oxycontin (Narcotic Analgesic)
- Plavix
- Promethazine Utilization, Age < 21
- Provigil
- Valturna
- Xenazine
- Zelboraf
Ambetter from Superior HealthPlan
Medicaid
Medicare