ANALGESICS, OPIOID & REVERSAL AGENTS

• Alaska PDMP Prescribing Resources
• Additional Information for Prescribing Opioids
• SUPPORT Act
  

• Extended Release Opioids Criteria | Form | ePA | Effective thru 10/2/16
  (generic morphine SR and generic fentanyl patch do not require PA)
• Extended Release Opioids Criteria | Form | ePA | Effective 10/3/16
  (generic morphine ER, generic fentanyl patch, & Butrans patch do not require PA)
• Actiq (fentanyl) Criteria | Form | ePA
  
• Fentora Criteria | Form | ePA
  
• Hydromorphone Criteria | Form | ePA | Effective thru 1/5/20
• Hydromorphone Criteria | Form | ePA | Effective 1/6/20
• Onsolis (fentanyl) Criteria, to be retired | Form | ePA
  
• Oxycodone Criteria, immediate release | Form | ePA | Effective thru 1/5/20
• Oxycodone Criteria, immediate release | Form | ePA | Effective 1/6/20
• Rybix ODT Criteria | Form | ePA
  
• Stadol (LTC, Onc, Hospice override) Criteria | Form | ePA
  
• Subsys Criteria | Form, Fill-in | ePA
  
• Narcan Nasal Spray: Naloxone Opioid Overdose Treatmen Criteria | Form | ePA
  
• Evzio: Naloxone Opioid Overdose Treatment Criteria | Form | ePA
  

• Atypical Antipsychotic Therapeutic Duplication Criteria  | Form | ePA 
• Atypical Antipsychotic Criteria – Exceed Quantity Limit (QL) Criteria | Form | ePA 
• Atypical Antipsychotic Criteria – Child Less than 5 years old | Form | ePA 

BIOLOGICS

• Crysvita Criteria | Form | ePA 
• CGRP Inhibitors Criteria | Form | ePA | Effective thru 11/15/20
  
• CGRP Inhibitors Criteria | Form | ePA | Effective 11/16/20
  
• Entyvio Criteria | Form | ePA
  
• Lemtrada Criteria | Form | ePA 
• Stelara Criteria [CAM] | Form | ePA | Effective thru 6/9/19
• Stelara Criteria [CAM] | Form | ePA | Effective 6/10/19
• Synagis, 2020-2021 Criteria | Form | ePA 

CYSTIC FIBROSIS

• Kalydeco Criteria | Form | ePA | Effective thru 10/2/16
• Kalydeco Criteria | Form | ePA | Effective 10/3/16
• Orkambi Criteria | Form | ePA | Effective thru 6/9/19
• Orkambi Criteria | Form | ePA | Effective 6/10/19
• TOBI Podhaler Criteria | Form | ePA 

GASTROINTESTINAL

• Amitiza and Linzess Criteria | Form | ePA 
• Marinol Criteria | Form | ePA 
• Diclegis Criteria | Form | ePA 
• H. pylori kits Criteria | Form | ePA 
• Movantik Criteria | Form | ePA 
• Proton Pump Inhibitors Criteria | Form | ePA 
• Relistor (methylnaltrexone) Criteria | Form | ePA | Effective thru 11/19/19
• Relistor (methylnaltrexone) Criteria | Form | ePA | Effective 11/20/19
• Transderm Scop (scopolamine patch) Criteria | Form | ePA 
• Viberzi Criteria | Form | ePA 

GENITOURINARY

• Botulinum Toxin Products (JCode only) Criteria | Form, Service Auth | ePA | Effective thru 10/2/16
• Botulinum Toxin Products (JCode only) Criteria | Form, Service Auth | ePA | Effective 10/3/16
• Cialis Criteria | Form | ePA 

GROWTH HORMONES

• Human Growth Hormone Criteria | Form | ePA | Effective 10/3/16
• Serostim Criteria | Form | ePA | Effective thru 10/2/16
• Serostim Criteria | Form | ePA | Effective 10/3/16

HEMOPHILIA

• Hemophilia / Clotting Factor Criteria | Form | ePA 
• Hemlibra Criteria | Form | ePA 

HORMONES

• Egrifta Criteria | Form | ePA 
• H.P. Acthar Gel Criteria | Form | ePA | Effective 1/15/19
• H.P. Acthar Gel Criteria | Form | ePA | Effective thru 10/2/16
• H.P. Acthar Gel Criteria | Form | ePA | Effective thru 1/14/19
• Human Chorionic Gonadotropin (HCG) Criteria | Form | ePA 
• Makena Criteria | Form | ePA 

INFECTIOUS DISEASE

• Bactroban Cream Criteria | Form | ePA 
• Direct Acting Antivirals for Chronic Hepatitis C Criteria –
  All Products and Genotypes | Form | ePA | Effective thru 3/15/20
• Direct Acting Antivirals for Chronic Hepatitis C Criteria –
  All Products and Genotypes | Form | ePA | Effective 3/16/2020
• Nizoral (ketoconazole oral) Criteria | Form | ePA 
• Noxafil (posaconazole) Criteria | Form | ePA 
• Quinine Criteria | Form | ePA 
• Vancocin (vancomycin) Criteria | Form | ePA 
• Xifaxan (rifaximin) Criteria | Form | ePA | Effective thru 10/2/16
• Xifaxan (rifaximin) Criteria | Form | ePA | Effective 10/3/16
• Zyvox (linezolid) Criteria | Form | ePA 
• Baxdela Criteria | Form | ePA 

LIPOTROPICS

• Dojolv Critera | Form | ePA
• Nexlatol, Nexlizet Critera | Form | ePA
• Juxtapid and Kynamro Criteria | Form | ePA 
• Lovaza Criteria – to be retired | Form | ePA 
• PCSK9 Inhibitors (Praluent and Repatha) Criteria | Form | ePA 
• Statins (HMG CoA Reductase Inhibitors) Criteria | Form | ePA 
• Vascepa and Lovaza Criteria | Form | ePA 

METABOLIC

• Evenity Criteria | Form | ePA 
• Bone Resorption Inhibitors Criteria | Form | ePA 
• Ergocalciferol Criteria (Vitamin D; 50,000 unit Criteria) | Form | ePA 
• Invokana Criteria | Form | ePA 
• Korlym Criteria | Form | ePA 
• Leuprolide Criteria | Form | ePA 
• Extended-Release Metformin (Glumetza and Fortamet ER) Criteria | Form | ePA 

OPIOID DEPENDENCE

• Oral Buprenorphine-based Medication Assisted Therapy (MAT) Criteria;
  Office-Based Opioid Treatment (OBOT) (e.g., Bunavail, Suboxone, Subutex, Zubsolv) |
  ​MAT Provider Attestation Form, Form, Fill-in | ePA | Effective 11/12/18
• Lucemyra Criteria | Form | ePA 

PULMONARY ARTERIAL HYPERTENSION

• Adcirca Criteria | Form | ePA 
• Revatio Criteria | Form | ePA 

RESPIRATORY

• Interleukin-5 inhibitor Criteria | Form | ePA  | Effective thru 1/10/21
• Interleukin-5 inhibitor Criteria | Form | ePA  | Effective 1/11/21
• Dupixent Criteria | Form | ePA 
• Xolair Criteria | Form | ePA 
• Daliresp Criteria [COPD] | Form | ePA
• Long-acting Beta Agonist Criteria [BRONCHODILATORS] | Form | ePA 
• Second Generation Non-Sedating Antihistamines Criteria | Form | ePA 

SKELETAL MUSCLE RELAXANTS

• Amrix Criteria | Form | ePA 
• Fexmid Criteria | Form | ePA 
• Soma Criteria | Form | ePA 
• Zanaflex Criteria | Form | ePA 

OTHER, INCLUDING RECENTLY RETIRED CRITERIA

• Insulin Pens Criteria | Form | ePA
  
• Palforzi Criteria | Form | ePA
  
• Reyvo Criteria | Form | ePA
  
• Apoky / Kynmob Criteria | Form | ePA
  
• Strensiq Criteria | Form | ePA
  
• Oxervate Critera | Form | ePA
  
• Oxbryta Criteria | Form | ePA 
• Orexn Criteria | Form | ePA 
• Jynarque Criteria | Form | ePA 
• Vumerity Criteria | Form | ePA 
• Firadapse/Ruzurgi Criteria | Form | ePA 
• Vyndaqel/Vyndamax Criteria | Form | ePA 
• Corlanor Criteria | Form | ePA 
• Xiaflex Criteria | Form | ePA 
• Mavenclad Criteria | Form | ePA 
• Mayzent Criteria | Form | ePA 
• Emflaza Criteria | Form | ePA 
• Sunosi Criteria | Form | ePA 
• Benzodiazepines Criteria | Form | ePA 
• Vesicular Monoamine Transporter 2 Inhibitors Criteria | Form | ePA 
• Palynziq Criteria | Form | ePA 
• Nuedexta Criteria | Form | ePA 
• Hetlioz Criteria | Form | ePA 
• Orilissa Criteria | Form | ePA | Effective thru 6/9/19
• Orilissa Criteria | Form | ePA | Effective thru 11/15/20
• Orilissa Criteria | Form | ePA | Effective 11/16/20
  
• Epidiolex Criteria | Form | ePA | Effective thru 11/15/20
• Epidiolex Criteria | Form | ePA | Effective 11/16/2020
  
• Xyrem Criteria | Form | ePA  | Effective thru 1/10/21
• Xyrem / Xywav Criteria | Form | ePA | Effective 1/11/21
• New Prescription Medications Criteria | Form | ePA 
• Maximum Units (QL) Criteria | Form | ePA 
• Brand Name Multisource Medications Criteria | Form | ePA 
• Botulinum Toxin Products Criteria (JCode only) | Form, Service Auth | ePA 
• Eucrisa Criteria | Form | ePA 
• Onfi Criteria  [ANTICONV] | Form | ePA | Effective thru 11/19/19
• Onfi Critieria | Form | ePA | Effective 11/20/19
• Vecamyl (HTN) Criteria | Form | ePA 
• Berinert (HAE) Criteria | Form | ePA 
• Cinryze (HAE) Criteria | Form | ePA 
• Firazyr (HAE) Criteria | Form | ePA 
• Ampyra Criteria  [MS] | Form | ePA 
• Celebrex Criteria [NSAID] | Form | ePA 
• Imbruvica (ONC) Criteria | Form | ePA 
• Panretin (ONC) Criteria | Form | ePA 
• Zydelig (ONC) Criteria | Form | ePA 
• Belsomra Criteria | Form | ePA | Effective thru 6/14/20
• Onsolis (fentanyl) Criteria  – to be retired | ePA 
• Vitamin E Criteria (retired) | ePA 
• Calcium Criteria  (retired) | ePA 
• Magnesium Criteria  (retired) | ePA 
• Victrelis Criteria  (retired) | ePA 
• Folic acid 1mg Criteria  (retired) | ePA 
• Eliquis Criteria  (retired) | ePA 
• Pradaxa Criteria (retired) | ePA 
• Xarelto Criteria  (retired) | ePA 
• Cosentyx Criteria  (retired) | Form | ePA 
• Tecfidera (dimethyl fumarate) Criteria  (retired) | Form | ePA 
• Suboxone and Subutex Criteria (retired) | ePA | Effective thru 11/11/18
• Direct Acting Antivirals for Hepatitis C Criteria (retired) Update | ePA | Effective through 1/15/2015
• Direct Acting Antivirals for Hepatitis C Genotype 1 Criteria (retired) | ePA | Effective through 6/30/2015
• Direct Acting Antivirals for Hepatitis C Genotype 1 Criteria (retired) | ePA | Effective through 6/30/2016
• Direct Acting Antivirals for Hepatitis C Genotypes 2, 3, 4 Criteria (retired) | ePA | Effective through 6/30/2016
• Extended Release Opioids Criteria (Historical)
  (generic morphine SR and generic fentanyl patch do not require PA) | Form, Fill-in | ePA 
• Direct Acting Antivirals for Hepatitis C Genotype 1 Criteria | Form | ePA | Effective 7/1/16-10/31/17
• Direct Acting Antivirals for Hepatitis C Genotype 2, 3, 5, & 6 Criteria | Form | ePA | Effective 7/1/16-10/31/17
• Direct Acting Antivirals for Hepatitis C Genotype 4 Criteria | Form | ePA | Effective 7/1/16-10/31/17
• Direct Acting Antivirals for Chronic Hepatitis C Criteria - All Products and Genotypes | Form | ePA | Effective thru 6/9/2019

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.