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Medication Prior Authorization

Table of Contents

Prior Authorization Medication Categories

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  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)
​Cambia PDF​ ​Form
​Gralise/Horizant ​PDF Form​
​Lidoderm (lidocaine) patch ​PDF
Effective 1/15/19
 ​Form
Lidoderm (lidocaine) patch ​PDF
Effective thru
10/2/16
 ​​Form
Lidoderm (lidocaine) patch ​PDF
Effective thru
1/14/19		 ​​Form
​Lyrica (pregabalin) PDF​ ​Form
​​Vimovo ​PDF ​​Form
​ ​ ​
​ANALGESICS, OPIOID & REVERSAL AGENTS [PDL] [TOP] ​Criteria ​Form(s)
​Alaska PDMP Prescribing Resources ​PDF ​
​Additional Information for Prescribing Opioids ​PDF ​
​SUPPORT Act ​PDF ​
​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​
Effective thru 1/5/20		 ​
​Hydromorphone ​PDF
Effective 1/6/20
 ​​​Form
​Onsolis (fentanyl) – to be retired ​PDF ​​Form
​Oxycodone, immediate release PDF​
Effective thru 1/5/20		 ​​Form
​Oxycodone, immediate release ​PDF
Effective 1/6/20
 ​​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)
​Crysvita ​PDF ​Form
​CGRP Inhibitors ​PDF ​Form
​Lemtrada ​PDF ​Form
Stelara [CAM] ​PDF
Effective thru
6/9/19		 ​​Form
​Stelara [CAM] ​PDF
Effective 6/10/19 		​Form
​Synagis, 2019-2020 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
Effective thru
6/9/19 		​Form
​Orkambi ​PDF
Effective 6/10/19		 ​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
Effective thru 11/19/19		 ​​Form
​Relistor (methylnaltrexone) ​PDF
Effective 11/20/19
 ​Form
​Transderm Scop (scopolamine patch) ​PDF ​​Form
​Viberzi ​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 ​PDF ​Form
​Hemlibra ​PDF ​Form
​ ​ ​
HORMONES [TOP] ​Criteria ​Form(s)
​Egrifta ​PDF ​​Form
​H.P. Acthar Gel
 PDF
Effective 1/15/19
 ​Form
​​H.P. Acthar Gel ​PDF
Effective thru
10/2/16
 ​​Form
​​H.P. Acthar Gel ​PDF
Effective thru
1/14/19		 ​​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 Chronic Hepatitis C –
All Products and Genotypes		 ​PDF
Effective thru 3/15/20		 ​Form
​Direct Acting Antivirals for Chronic Hepatitis C –
All Products and Genotypes		 PDF​
Effective 3/16/2020
 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
​Baxdela ​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)
​Evenity ​PDF ​Form
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)
Oral Buprenorphine-based Medication Assisted Therapy (MAT);
Office-Based Opioid Treatment (OBOT)
(e.g., Bunavail, Suboxone, Subutex, Zubsolv)
 ​PDF
Effective 11/12/18
​Lucemyra ​PDF Form​
​ ​​
PULMONARY ARTERIAL HYPERTENSION [PDL] [TOP] ​Criteria ​Form(s)
Adcirca ​PDF ​​Form
​Revatio ​PDF ​​Form
​ ​​
RESPIRATORY [PDL] [TOP] ​Criteria ​Form(s)
​Interleukin-5 inhibitor ​PDF ​Form
​Dupixent ​PDF ​Form
​Xolair ​PDF ​Form
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)
​Oxbryta ​PDF ​Form
​Orexin ​PDF ​Form
​Jynarque ​PDF ​Form
​Vumerity ​PDF ​Form
​Firadapse/Ruzurgi ​PDF ​Form​
​Vyndaqel/Vyndamax ​PDF ​​Form
​Corlanor ​PDF ​​Form
​Xiaflex ​PDF ​​Form
​Mavenclad ​PDF ​Form
​Mayzent ​PDF ​Form
​Emflaza ​PDF ​Form
​Sunosi ​PDF ​Form
​Benzodiazepines ​PDF Form
​Vesicular Monoamine Transporter 2 Inhibitors PDF​ ​Form
​Palynziq ​PDF Form​
​Nuedexta ​PDF Form​
​Hetlioz ​PDF ​Form
​Orilissa PDF
Effective thru
6/9/19		 ​Form
​Orilissa ​PDF
Effective 6/10/19		 ​Form
​Epidiolex ​PDF ​Form
​Xyrem ​PDF Form
​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
​Eucrisa ​PDF ​Form
​Onfi [ANTICONV] ​PDF
Effective thru 11/19/19
 ​​Form
​Onfi ​PDF
Effective 11/20/19		 ​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
​Belsomra
 ​PDF
Effective thru 6/14/20		 ​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 ​
​Cosentyx (retired) PDF​ ​Form
​Tecfidera (dimethyl fumarate) (retired)
 ​PDF ​Form
​Suboxone and Subutex (retired)
 PDF
Effective thru
11/11/18 here		 ​
​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
​Direct Acting Antivirals for Hepatitis C Genotype 1 ​PDF​
Effective
7/1/16-10/31/17
 Form​
​Direct Acting Antivirals for Hepatitis C Genotype 2, 3, 5, & 6
 ​PDF
Effective
7/1/16-10/31/17		 Form​

​Direct Acting Antivirals for Hepatitis C Genotype 4 PDF​
Effective
7/1/16-10/31/17		 Form​

Direct Acting Antivirals for Chronic Hepatitis C –
All Products and Genotypes		 PDF
Effective thru 6/9/2019
 Form​
​ ​ ​
 

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)
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
(800) 331-4475 – phone
(888) 603-7696 – fax
Magellan Technical Call Center
(800) 884-3238

Conduent State Healthcare, LLC.
(907) 644-6800, (800) 770-5650
 
Provider Inquiry/Provider Services
Conduent State Healthcare, LLC.
(907) 644-6800 (800) 770-5650
 
Division of Healthcare Services
(907) 334-2400
 
Medicaid Pharmacy and Ancillary Services Unit
Drug Utilization Review Program
(907) 334-2458​​​​​​​​​​​ / (907) 334-2425
Preferred Drug List Program
(907) 334-2458​​​​​​​​​​​ / (907) 334-2425
​​​​​​​​​​​