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
  • 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 

Ambetter from Superior HealthPlan

Medicaid

Medicare