Medication Prior Authorization

• Drug Utilization
• Pharmacy Issues and Policy
• Pharmacy, Medications, Notices, etc. New
• Prior Authorized Drug List Effective until December 1, 2012
• Prior Authorized Drug List Effective on December 2, 2012
• Maximum Units
• Active Pharmaceutical Ingredients
• Interim Prior Authorization List
• Acthar Gel
• Actiq
• Adcirca
• Ampyra
• Amrix
• Atypical Therapeutic Duplication
• Bactroban Cream
• Berinert
• Bisphosphonate Edit
• Botulinum Toxin Products
• Brand Name Multisource Medications
• Calcium
• Celebrex
• Cialis
• Cinryze
• Daliresp
• Egrifta
• Ergocalciferol
• Extended Release Opioids Edit
• Fentora
• Fexmid
• Firazyr
• Folic Acid 1mg
• H.Pylori Kits
• Human Chorionic Gonadotropin (HCG)
• Human Growth Hormone
• Hydromorphone
• Incivek
• Kalydeco
• Korlym
• Leuprolide
• Lidoderm Patch
• Long Acting Beta Agonist
• Lovaza
• Magnesium
• Makena
• Marinol
• New Prescription Medication
• Noxafil
• Onfi
• Onsolis
• Oxy-IR
• Panretin
• Pradaxa
• Proton Pump Inhibitors (Revised)
• Quinine
• Revatio
• Rybix ODT
• Second Generation Non-Sedating Antihistamines
• Serostim
• Soma
• Stadol
• Statins (HMG CoA Reductase Inhibitors)
• Suboxone and Subutex(Prior Authorization form listed below)
• Subsys
• Synagis(Prior Authorization form listed below)
• Transderm Scop
• Vancocin
• Victrelis
• Vitamin D 50,000 units
• Vitamin E
• Xarelto
• Xifaxan
• Zanaflex Capsules
• Zyvox
• Medication Prior Authorization Form
• Medication Prior Authorization Form - Free Text Form
• Atypical TD, Exceed QL, and Child less than 5 years old Form
• Botulinum Toxin Prior Authorization Form
• Extended Release Opioid Form
• Extended Release Opioid Form - Free text Form
• Hemophilia/Clotting Factor Form
• Proton Pump Inhibitor Form
• Suboxone and Subutex Prior Authorization form
• Subuxone and Subutex Prior Authorization Form - Free Text Form
• Synagis Prior Authorization form - Free Text Form
• Zyvox Prior Authorization Form

Prior Authorization Staff

Please call Xerox State Healthcare, LLC: (907) 644-6800 or in-state toll-free number: (800) 770-5650.

Provider Inquiry/Provider Services: (907) 644-6800 (option 1) or toll-free: (800) 770-5650 (option 1, 1).

• For additional contact information, please visit the the Alaska Medicaid Assistance website

Clinical Call Center (MAP Desk)
1-800-331-4475
State of Alaska Health Care Services Pharmacy Medication Prior Authorization
1-888-603-7696 - fax

Technical Call Center
1-800-884-3238