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Medication Prior Authorization

 

Table of Contents

 

Prior Authorization Medication Categories

    Navigation Tips:
  1. Use the table of contents above to jump to the desired medication category, or
  2. Use “CTRL-F” to open a search box into which you can type your search term, or
  3. Scroll through the list below to find the desired medication.
  4. Clicking on the [PDL] link in the medication category header will open a new window with the current Preferred Drug List to allow you to readily search for preferred products within the category.
  5. Clicking on the [TOP] link in the medication category header will bring you back to the Table of Contents at the top of this page. 

Prior Authorization Medication Categories

​Medication
ANALGESICS [PDL] [TOP] Criteria Form(s)
​Extended Release Opioids
(generic morphine SR and generic fentanyl patch do not require PA)
20150508 20150508
​Extended Release Opioids (Historical)
(generic morphine SR and generic fentanyl patch do not require PA)
PDF Form
Fill-in
​Actiq (fentanyl) PDF ​Form
​Fentora PDF ​Form
​Hydromorphone PDF ​​​Form
Lidoderm (lidocaine) patch PDF ​Form
​Onsolis (fentanyl) – to be retired PDF ​Form
​Oxycodone, immediate release PDF ​Form
​Relistor (methylnaltrexone) PDF ​Form
​Rybix ODT ​​PDF ​Form
​Stadol (LTC, Onc, Hospice override) PDF ​Form
​​Vimovo PDF ​Form
ANTICOAGULANTS [PDL] [TOP] Criteria Form(s)
​Eliquis PDF ​Form
​​Pradaxa PDF ​Form
​​Xarelto PDF ​Form
​​
ANTIPSYCHOTICS [PDL] [TOP] Criteria Form(s)
Atypical Antipsychotic Therapeutic Duplication PDF ​Form
Atypical Antipsychotic – Exceed Quantity Limit (QL) ​Form
Atypical Antipsychotic – Child Less than 5 years old ​Form
​​
BIOLOGICS [PDL] [TOP] Criteria Form(s)
Stelara [CAM] PDF ​Form
Synagis PDF Form
​​
CYSTIC FIBROSIS ​[PDL] [TOP] Criteria Form(s)
Kalydeco PDF ​Form
TOBI Podhaler PDF​ ​Form
GASTROINTESTINAL [PDL] [TOP] Criteria Form(s)
Amitiza and Linzess PDF ​Form
​Marinol PDF ​Form
​Diclegis PDF ​​​Form
H. pylori kits PDF ​Form
​Proton Pump Inhibitors PDF Form
​Transderm Scop (scopolamine patch) PDF ​Form
GENITOURINARY [PDL] [TOP] Criteria Form(s)
Botulinum Toxin Products (JCode only) PDF Form​
Service Auth
Cialis PDF ​Form
GROWTH HORMONES [PDL] [TOP] Criteria Form(s)
​Human Growth Hormone
Form​
Serostim PDF ​Form
HEMOPHILIA [PDL] [TOP] Criteria Form(s)
​Hemophilia / Clotting Factor Form
HORMONES [TOP] Criteria Form(s)
​Egrifta PDF ​Form
​​H.P. Acthar Gel PDF ​Form
​​Human Chorionic Gonadotropin (HCG) PDF ​Form
Makena PDF ​​​Form
INFECTIOUS DISEASE [PDL] [TOP] Criteria Form(s)
Bactroban cream ​PDF ​Form
​Direct Acting Antivirals for Hepatitis C Genotype 1 ​PDF​ Form
posted 4/27/15
​Direct Acting Antivirals for Hepatitis C Genotypes 2, 3, 4 PDF​ Form
posted 4/27/15
​Hepatitis C Direct Acting Agents - Historical PDF
Update
​Nizoral (ketoconazole oral) PDF ​​​Form
Noxafil (posaconazole) PDF ​Form
Quinine PDF ​Form
Vancocin (vancomycin) ​​PDF ​Form
Xifaxan (rifaximin) PDF ​Form
​​Zyvox (linezolid) PDF Form
LIPOTROPICS [PDL] [TOP] Criteria Form(s)
Juxtapid and Kynamro PDF ​Form
​Lovaza – to be retired PDF ​Form
​Statins (HMG CoA Reductase Inhibitors) PDF ​​​Form
Vascepa and Lovaza PDF ​Form
METABOLIC [PDL] [TOP] Criteria Form(s)
Bone Resorption Inhibitors PDF ​Form
​Ergocalciferol (Vitamin D; 50,000 unit) PDF, PDF ​Form
Invokana PDF ​​​Form
Korlym PDF ​Form
Leuprolide PDF ​Form
OPIOID DEPENDENCE [PDL] [TOP] Criteria Form(s)
Suboxone and Subutex PDF Form
Fill-in
​Subsys PDF Form
Fill-in
​​
PULMONARY ARTERIAL HYPERTENSION [PDL] [TOP] Criteria Form(s)
Adcirca PDF ​Form
​Revatio PDF ​Form
​​
RESPIRATORY [PDL] [TOP] Criteria Form(s)
Daliresp [COPD] PDF ​Form
Long-acting Beta Agonist [BRONCHODILATORS] PDF ​Form
Second Generation Non-Sedating Antihistamines PDF ​​​Form
SKELETAL MUSCLE RELAXANTS [PDL] [TOP] Criteria Form(s)
Amrix PDF ​Form
Fexmid PDF ​Form
Soma PDF ​​​Form
Zanaflex PDF ​Form
OTHER, INCLUDING RECENTLY RETIRED CRITERIA [PDL] [TOP] Criteria Form(s)
​New Prescription Medications PDF ​Form
Maximum Units (QL) PDF​ ​Form
Brand Name Multisource Medications PDF ​​​Form
Botulinum Toxin Products (JCode only) PDF Form​
Service Auth
​Onfi [ANTICONV] PDF ​Form
​Vecamyl (HTN) PDF ​Form
​Berinert (HAE) PDF ​Form
​Cinryze (HAE) PDF ​Form
​Firazyr (HAE) PDF ​Form
​Ampyra [MS] PDF ​Form
​Celebrex [NSAID] PDF ​Form
​Imbruvica (ONC) PDF ​Form
​Panretin (ONC) PDF ​Form
​Zydelig (ONC) PDF ​Form
​Onsolis (fentanyl) – to be retired PDF
​Vitamin E (retired) PDF​
​Calcium (retired) PDF
​Magnesium (retired) PDF
​Victrelis (retired) PDF
Folic acid 1mg (retired)
PDF
 
Prior Authorization Staff
Magellan Clinical Call Center
1.800.331.4475 – phone
1.888.603.7696 – fax
Magellan Technical Call Center
1.800.884.3238

Xerox State Healthcare, LLC.
1.907.644.6800 1.800.770.5650
 
Provider Inquiry/Provider Services
Xerox State Healthcare, LLC.
1.907.644.6800 1.800.770.5650
 
Division of Healthcare Services
1.907.334.2400
 
Medicaid Pharmacy and Ancillary Services Unit
Drug Utilization Review Program
1.907.334.2425
Preferred Drug List Program
1.907.334.2654 ​​​​​​​​​​​
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