Skip to content

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, NON-OPIOID [PDL] [TOP] Criteria Form(s)
Lidoderm (lidocaine) patch PDF
Effective thru
10/2/16

​Form
Lidoderm (lidocaine) patch PDF
Effective 10/3/16
​Form
​Lyrica (pregabalin) PDF ​Form
​​Vimovo PDF ​Form
ANALGESICS, OPIOID & REVERSAL AGENTS [PDL] [TOP] Criteria Form(s)
Additional Information for Prescribing Opioids
​Extended Release Opioids
(generic morphine SR and generic fentanyl patch do not require PA)
PDF
Effective thru
10/2/16
Form
Extended Release Opioids
(generic morphine ER, generic fentanyl patch, & Butrans patch do not require PA)
PDF
Effective 10/3/16
Form
​Actiq (fentanyl) PDF ​Form
​Fentora PDF ​Form
​Hydromorphone PDF ​​​Form
​Onsolis (fentanyl) – to be retired PDF ​Form
​Oxycodone, immediate release PDF ​Form
​Rybix ODT ​​PDF ​Form
​Stadol (LTC, Onc, Hospice override) PDF ​Form
Subsys PDF Form
Fill-in
Narcan Nasal Spray: Naloxone Opioid Overdose Treatment ​PDF ​Form
​Evzio: Naloxone Opioid Overdose Treatment ​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)
​Cosentyx PDF​ ​Form
​Lemtrada ​PDF ​Form
Stelara [CAM] PDF ​Form
​Synagis, 2016-2017 PDF ​Form
​​
CYSTIC FIBROSIS ​[PDL] [TOP] Criteria Form(s)
Kalydeco PDF
Effective thru
10/2/16
​Form
Kalydeco PDF
Effective 10/3/16
​Form
​Orkambi ​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
​Movantik ​PDF ​Form
​Proton Pump Inhibitors PDF Form
​Relistor (methylnaltrexone)
PDF ​Form
​Transderm Scop (scopolamine patch) PDF ​Form
GENITOURINARY [PDL] [TOP] Criteria Form(s)
Botulinum Toxin Products (JCode only) PDF
Effective thru
10/2/16

Form​
Service Auth
Botulinum Toxin Products (JCode only) PDF
Effective 10/3/16
Form​
Service Auth
Cialis PDF ​Form
GROWTH HORMONES [PDL] [TOP] Criteria Form(s)
​Human Growth Hormone
Form​
​Human Growth Hormone PDF
Effective 10/3/16
Form​
Serostim PDF
Effective thru
10/2/16

​Form
Serostim PDF
Effective 10/3/16
​Form
HEMOPHILIA [PDL] [TOP] Criteria Form(s)
​Hemophilia / Clotting Factor Form
HORMONES [TOP] Criteria Form(s)
​Egrifta PDF ​Form
​​H.P. Acthar Gel PDF
Effective thru
10/2/16

​Form
​​H.P. Acthar Gel PDF
Effective 10/3/16
​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​
Effective 7/1/16
Form​
​Direct Acting Antivirals for Hepatitis C Genotype 2, 3, 5, & 6
​PDF
Effective 7/1/16
Form​

​Direct Acting Antivirals for Hepatitis C Genotype 4 PDF​
Effective 7/1/16
Form​

​Nizoral (ketoconazole oral) PDF ​​​Form
Noxafil (posaconazole) PDF ​Form
Quinine PDF ​Form
Vancocin (vancomycin) ​​PDF ​Form
Xifaxan (rifaximin) PDF
Effective thru
10/2/16

​Form
Xifaxan (rifaximin) PDF
Effective 10/3/16
​Form
​​Zyvox (linezolid) PDF Form
LIPOTROPICS [PDL] [TOP] Criteria Form(s)
Juxtapid and Kynamro PDF ​Form
​Lovaza – to be retired PDF ​Form
​PCSK9 Inhibitors (Praluent and Repatha) ​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
​Extended-Release Metformin (Glumetza and Fortamet ER) ​PDF ​Form
OPIOID DEPENDENCE [PDL] [TOP] Criteria Form(s)
Suboxone and Subutex 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
​Tecfidera (dimethyl fumarate)
​PDF ​Form
​Belsomra
​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
Eliquis (retired) PDF
​Pradaxa (retired) PDF
​Xarelto (retired) ​​PDF
​Direct Acting Antivirals for Hepatitis C (retired) – Effective through 1/15/2015 PDF
Update​
​Direct Acting Antivirals for Hepatitis C Genotype 1 (retired) – Effective through 6/30/2015 ​PDF
Effective thru 6/30/15
​Direct Acting Antivirals for Hepatitis C Genotype 1 (retired) - Effective through 6/30/2016
​PDF
Effective thru 6/30/16
​Direct Acting Antivirals for Hepatitis C Genotypes 2, 3, 4 (retired) – Effective through 6/30/2016 ​PDF
Effective thru 6/30/16
​Extended Release Opioids (Historical)
(generic morphine SR and generic fentanyl patch do not require PA)
PDF Form
Fill-in
 

References for Prescribing Opioids [Top]

Important note: The links provided below are external resources not maintained by Alaska Health and Social Services.  The State of Alaska Department of Health and Social Services is not responsible for the content contained in any of the links provided below.

Morphine Equivalent Dose Calculator
 © Washington State Agency Medical Directors' Group. 2007-2015.
Interagency Guideline on Prescribing Opioids for Pain
 Washington State Agency Medical Directors' Group.  3rd Edition, June 2015.
State of Alaska Prescription Drug Monitoring Program (PDMP)
 © Health Information Designs, LLC.
CDC Guideline for Prescribing opioids for Chronic Pain
 United States, 2016.  Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
Injury Prevention & Control: Opioid Overdose
 Centers for Disease Control and Prevention (CDC). Atlanta, GA.
Resources and Tools for Prescribers. Search and Rescue: Empowering Prescribers to Identify Opioid Drug Abuse
 © 2016 Partnership for Drug-Free Kids.

Pharmacy Links [TOP]

 

Contacts [TOP]

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 ​​​​​​​​​​​
​​​​​​​​​