Clinical Prior Authorization

The following clinical prior authorizations have been implemented for Medicaid members, consistent with the Vendor Drug Program:

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
  • Desmopressin
  • 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
  • Xenazine
  • Zelboraf

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Medicaid

Medicare