Medicaid Prior Authorization Criteria
- Adcirca
- AdvairHFA/Breo/Dulera/Symbicort
- Age Restriction
- Ampyra
- Arikayce
- Benlysta
- Braftovi
- Bryhali
- Budesonide Capsules
- Buprenorphine
- Buprenorphine Patch
- Cinqair
- Clobazam
- Cotellic
- Cresemba
- Daliresp
- Diacomit
- Diclegis
- DPP-4 Inhibitors (Gliptins)
- Dronabinol
- Dupixent 2019
- Emend
- Entresto
- Epidiolex
- Estrace
- Entyvio
- Epogen-Procrit-Retacrit
- Fasenra
- Firazyr
- Global Pulmonary Arterial Hypertension
- GLP-1 agonists
- Growth Hormone
- Haegarda
- Hepatitis C
- Hetlioz
- HP Acthar Gel
- Hypodermic Needles & Syringes
- Ibrance
- Intron
- Invega Sustenna
- Invega Trinza
- Isotretinoins
- Kalydeco
- Kanuma
- Keveyis
- Kevzara
- Kisqali, Kisqali Femara Co- Pack
- Krystexxa
- Kuvan
- Leuprlide PA Criteria
- Letairis
- Linzess
- Long Acting Opioid Prior Authorization Policy
- Lupron
- Lyrica
- Makena
- Mavyret
- Mekinist
- Mektovi
- Migraine Prevention – Calcitonin Gene Related Peptide (CGRP)
- Movantik
- Naglazyme
- Nerlynx
- New to Market
- Nexavar
- Nicotrol
- Non Formulary Criteria
- Nucala
- Nuedexta
- Nuplazid
- Nutropin NuSpin
- Orfadin-Nityr
- Orilissa
- Orkambi
- Oxervate Criteria
- Palynziq
- Prior Authorization Global Policy
- Prolia
- Promacta
- Quantity Limit Criteria
- Relistor
- Repatha
- Restasis
- Ribavirin
- Risperdal Consta
- Santyl
- SGLT2
- Short- Acting opioid Naïve
- Short Acting Opioid Post Limit Policy
- Sildenafil- Revatio Injection
- Sildenafil- Revatio Oral
- Solosec
- Soriatane
- Spinosad, Malathion
- Sporanox Capsules
- Sporanox Oral Solution
- Sprycel
- ST-Brel-Dulera-Symbicort Criteria
- Stelara
- Step Therapy Exception
- Strensiq
- Sublocade
- Symdeko
- Synagis
- Tafinlar
- Takhzyro
- Tegsedi
- Testosterone(topical-generic)
- Tobramycin Inhalation Solution
- Tretinoin
- Tysabri
- Uceris
- Valganciclovir
- Veltassa
- Verzenio
- Vimpat
- Vivitrol
- Vosevi
- Votrient
- Weight Loss
- Xeljanz, Xeljanz XR
- Xenazine
- Xifaxan
- Xolair
- Xtandi
- Xyrem
- Zelboraf
- Zytiga
- Zyvox
2019 Exchange Prior Authorization Criteria
- Acamprosate Calcium
- Actemra
- Actimmune
- Adcirca
- Adempas
- Afinitor
- Alecensa
- Ampyra
- Anabolic Steroids – Anadrol-50
- Anabolic Steroids – Oxandrin
- Antidiabetic Agents
- Antifungal Topical
- Apokyn
- Aptiom
- Aranesp
- Arcalyst
- Atypical Antipsychotics Step Therapy Policy
- Aubagio
- Avonex
- Azacitidine-Vidaza
- Banzel
- Betaseron-Extavia
- Bexarotene-Targretin
- Bosulif
- BPH Cialis
- Briviact
- Calquence
- Caprelsa
- Carbaglu
- Cayston
- Cerdelga
- Cimzia
- Cometriq
- Cosentyx
- Cystagon
- Cystaran
- Daliresp
- Decitabine-Dacogen
- Desvenlafaxine, Fetzima Step Therapy Policy
- Differin
- Dificid
- Dofetilide-Tikosyn
- DDP-IV Inhibitors
- Eligard
- Enbrel
- Epclusa
- Epogen-Procrit
- Epoprostenol-Flolan-Veletri
- Erbitux
- Erivedge
- Esbriet
- Exelon
- Farydak
- Ferriprox
- Firazyr
- Follitropins
- Forteo
- Gazyva
- Gilenya
- Glatopa
- Growth Hormone
- GSTP Acne
- GSTP Antipsychotics
- GSTP ARBs and Direct Renin Inhibitors
- GSTP Bisphosphonates
- GSTP BPH-Alpha 1 Adrenergic Blockers
- GSTP Insomnia Agents
- GSTP Nasal Steroids
- GSTP Prostaglandin Analogues
- GSTP Proton Pump Inhibitors
- GSTP SSRIs
- GSTP Urinary Antispasmodics
- Harvoni
- hCG
- Hetlioz
- High Risk Medications
- Hizentra-Hyqvia-Cuvitru
- Humira
- Ibrance
- Iclusig
- Idhifa
- Imatinib-Gleevec
- Imbruvica
- Increlex
- Inlyta
- Intron A
- Intuniv-Kapvay Step Therapy
- Isotretinoins
- Itraconazole (Onmel Tablets)
- Itraconazole (Sporanox Capsules)
- Itraconazole (Sporanox)
- Jakafi
- Jublia
- Kadcyla
- Kalydeco
- Kevzara
- Keytruda
- Kuvan
- Lamisil Oral Granules
- Lamisil Tablets
- Lenvima
- Letairis
- Leuprolide
- Lidoderm
- Lotronex
- Lupaneta
- Lupron Depot Endometriosis-Fibroid
- Lupron Depot Prostate Cancer
- Lupron Depot-PED
- Lynparza
- Lyrica, Gralise, Horizant Step Therapy Policy
- Mekinist
- Mircera
- Mitoxantrone
- Multaq
- Myalept
- Namenda
- Neulasta/Fulphila/Udenyca
- Neupogen-Granix-Zarxio-Nivestym
- Nexavar
- Nucala
- Nuedexta
- Nuplazid
- Nuvigil
- Octreotide-Sandostatin-Sandostatin LAR
- Omega-3 Fatty Acids
- Oncaspar
- Onfi
- Opsumit
- Oral-Intranasal Fentanyl Products
- Orencia
- Orenitram
- Orfadin-Nityr
- Orkambi
- Otezla
- Pegasys
- Phenylbutyrate-Buphenyl
- Pitavastatin, Rosuvastatin Step Therapy Criteria
- Plegridy
- Pomalyst
- Prolia
- Promacta
- Provigil
- Prudoxin, Zonalon Step Therapy Criteria
- Ranexa
- Rebif
- Regranex
- Repatha Enhanced
- Revlimid
- Ribavirin
- Rydapt
- Samsca
- Santyl (Collagenase)
- Savella
- Sensipar
- Serostim
- Signifor
- Sildenafil-Revatio(oral)
- Sildenafil-Revatio
- Simponi Aria
- Simponi
- Somatuline Depot
- Somavert
- Solvadi
- Soriatane
- Specialty Exceptions Marketplace Autoimmune
- Specialty Exceptions Marketplace Multiple Sclerosis
- Specialty Exceptions MKP-STD-PDPD-ACSF-VF Hepatitis C DAAs
- Specialty Exceptions STD-PDPD-MKP Growth Hormone
- Sprycel
- Stelara
- Stivarga
- Sublocade
- Sutent
- Tadalafil-Adcirca
- Tafinlar
- Tarceva
- Tecfidera
- Testosterone Products TGC
- Treprostinil-Remodulin
- Tretinoins (Topical)
- Uloric
- Vfend
- Vigabatrin-Sabril
- Vivitrol
- Vosevi
- Votrient
- Xalkori
- Xeljanz-Xeljanz XR
- Xeloda
- Xtandi
- Zejula
- Zelboraf
- Zepatier
- Xolair
- Zoledronic acid-Zometa
- Zolinza
- Zorbtive
2018 Exchange Prior Authorization Criteria
- Adcirca
- Advair/Dulera/Symbicort
- Age Restriction
- Alogliptin, Alogliptin-metformin, Alogliptin-pioglitazone
- Amitiza
- Ampyra
- Aranesp
- Arikayce
- Aubagio
- Benlysta
- BPH Cialis
- Botox
- Braftovi
- Bryhali
- Buprenorphine Patches
- Buprenorphine SL Tablet
- Cetrotide- Ganirelix
- Chlorpromazine
- Cimzia
- Cinqair
- Clobazam
- Cosentyx
- Cotellic
- Daliresp
- Diacomit
- Diclegis
- DPP-IV Inhibitors
- Dronabinol
- Dupixent 2019
- Dupixent
- Elidel
- Emend
- Entresto
- Epidiolex
- Entyvio
- Epclusa
- Epidiolex
- Epogen, Procrit
- Estrace
- Fasenra
- Fentanyl Patch, Methadone, Morphine ER
- Fingolimod- Gilenya
- Firazyr
- Follitropins
- Global Pulmonary Arterial Hypertension Criteria
- GLP-1 Agonists
- Granisetron
- Growth Hormone
- Haegarda
- HCG & Ovidrel
- Hetlioz
- HP Acthar Gel
- Hypodermic Needles & Syringes
- Ibrance
- Intron
- Invega Sustenna
- Invega Trinza
- Isotretinoins
- Itraconazole
- Jakafi
- Januvia, Janumet, Janumet XR
- Jublia
- Kalydeco
- Kanuma
- Kerydin
- Kevzara
- Kisqali Femara Co- Pack
- Krystexxa
- Kuvan
- Letairis
- Leuprolide
- Linzess
- Long Acting Opioid Prior Authorization Policy
- Lotronex
- Lupron
- Lyrica
- Makena
- Mekinist
- Mektovi
- Menotropins
- Migraine Prevention – Calcitonin Gene Related Peptide (CGRP)
- Movantik
- Naglazyme
- Nexavar
- Nicotrol
- Non Formulary Criteria
- Nucala
- Nuedexta
- Nuplazid
- Nutropin NuSpin
- Orencia
- Orilissa
- Orkambi
- Otezla
- Palynziq
- Prior Authorization Global Policy
- Prolia
- Promacta
- Quantity Limit Criteria
- Rebif
- Relistor
- Remicade, Inflectra, Renflexis
- Repatha
- Restaisis
- Ribavirin
- Risperdal Consta
- Savella
- SGLT2
- Short acting opioid naïve
- Short Acting Opioid Post Limit Policy
- Sildenafil
- Sildenafil Inj
- Soriatane
- Spinosad, Malathion
- Sporanox Capsules
- Sporanox Oral Solution
- Sprycel
- Stelara
- Step Therapy
- Strensiq
- Suboxone Film
- Symdeko
- Symlin
- Synagis
- Tafinlar
- Takhzyro
- Tegsedi
- Tecfidera
- Testosterone (topical- generic)
- Tobramycin Inhalation Solution
- Toujeo
- Tradjenta, Jentadueto, Jentodueto XR
- Tretinoins
- Tysabri
- Uceris
- Valganciclovir
- Veltassa
- Victoza, Byetta, Trulicity, Bydureon
- Vimpat
- Vivitrol
- Votrient
- Weight Loss
- Xeljanz, Xeljanz XR
- Xenazine
- Xifaxan
- Xolair
- Xtandi
- Xyrem
- Zelboraf
- Zytiga
- Zyvox