Clinical Prior Authorization
The following clinical prior authorizations have been implemented for Medicaid members, consistent with the Vendor Drug Program:
- Actiq (Oral Transmucosal Fentanyl) (PDF)
- ADD/ADHD Agents (PDF)
- Agents for Hereditary Angioedema (PDF)
- Aliskiren-Containing Agents (Except Valturna) (PDF)
- ​Allergen Extracts - Grastek, Oralair, Ragwitek TM (PDF)
- Alinia (Nitazoxanide) (PDF)
- Amitiza (Lubiprostone) (PDF)
- Antipsychotics (PDF)
- Antiemetics (PDF)
- Byetta (PDF)
- Carisoprodol Overuse (PDF)
- Colcrys (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)
- Diclofenac (PDF)
- Dupixent (PDF)
- Duragesic (Fentanyl Transdermal) (PDF)
- Emflaza (PDF)
- Enzymes (PDF)
- Erythropoiesis-Stimulating Agents (PDF)
- Fosrenol (PDF)
- Forteo (PDF)
- Gaucher’s Disease Agents (PDF)
- GI Motility Agents (PDF)
- Growth Hormone Products (PDF)
- H.P.Acthar Gel (PDF)
- Hepatitis C Virus (PDF)
- Imiquimod (PDF)
- Increlex (PDF)
- Januvia (PDF)
- Keveyis (PDF)
- Leukotriene Modifiers (PDF)
- Lidoderm (Lidocaine) Patch (PDF)
- Lovaza (PDF)
- Lyrica (PDF)
- Makena (PDF)
- Morphine Equivalent Dosing (MED)
- Nuedexta (PDF)
- Nuplazid (PDF)
- PCSK9 Inhibitors (PDF)
- Phenergan/Phenergan Containing Products (Promethazine) (PDF)
- Proton Pump Inhibitors (PDF)
- Propylthiouracil (PDF)
- Provigil (PDF)
- Pulmonary Arterial Hypertension (PDF)
- Ranexa (PDF)
- Relistor (PDF)
- Revatio (PDF)
- Savella (PDF)
- Suboxone/Subutex (PDF)
- Symlin (PDF)
- Synagis (PDF)
- Thiazolidinediones (PDF)
- Topical Acne Agents (PDF)
- Topical Immunomodulators (PDF)
- Victoza (PDF)
- Xifaxan (PDF)
- Xenazine (PDF)
- Xyrem (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.
- Actemra
- Alprazolam/Carisoprodol/Hydrocodone
- Altabax
- Androgenic Agents
- Anticonvulsant agent (Gabapentin)
- Anxiolytics and Sedatives/Hypnotics (ASHs)
- Cox-2 Inhibitors
- Drug Regimen Optimization
- Duplicate Therapy
- Ketorolac (Toradol)
- Opiate Overutilization
- Oxycontin (Narcotic Analgesic)
- Plavix
- Promethazine Utilization, Age < 21