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Prior Authorization (PA)

  • Prior Authorization Archive - 2009 | 2010 | 2011 | 2012 | 2013 
  • Covered Drugs for Dual Eligible Individuals

    • Therapeutic Categories:

    • Antibiotics - Cephaloporins, Ketoconazole Oral Tablets, Skin and Soft Tissue, Special Formulations
    • Cardiovascular - Antihypertensives, Antiplatelet, Antihyperlipidemics, Clonidine Products, Revatio
    • Central Nervous System/Behavioral Health - ADHD & Narcolepsy, Alzheimer's, Antidepressants, Anti-Migraine, Anxiolytic/Hypnotic, Atypical Antipsychotics, Fibromyalgia, Multiple Sclerosis, Narcotic Analgesics, Parkinson's, Restless Leg Syndrome, Requip XL/Mirapex ER, Smoking Cessation, Substance Abuse Treatment
    • Diabetes/Endocrine - Diabetic Medications, Erythropoietin Stimulating Agents, Growth Hormone, Makena®, Testosterone
    • Gastro-Intestinal - Amitiza, Anti-emetic, Anti-Ulcer
    • Genitourinary System - Benign Prostatic Hyperplasia (BPH), Bladder Control Drugs
    • Hepatitis C - Harvoni, Incivek, Olysio, Sovaldi, Victrelis
    • Metabolic Disorders- Procysbi - Ravicti
    • Ocular/Otic - Ocular Allergy, Opthalmic Anti-Infective/Steroid, Ophthalmic Corticosteroid, Ophthalmic NSAIDs, Ophthalmic Glaucoma, Otic Anti-Infective
    • Respiratory - Asthma & COPD Inhalation Medications, Antihistamines, Leukotriene Modifiers, Nasal Allergy Sprays, Synagis, Tobi/Pulmozyme, Xolair
    • Skeletal System - Amrix & Fexmid, Bisphosonates, Forteo, Gout, NSAIDs, Skeletal Muscle Relaxants, Soma
    • Targeted Immunomodulator Agents - Botulinum toxins, Hematopoetic, Immunomodulating, Replacement Therapy, Respiratory, Skeletal
    • Topical - Antifungal, Elidel/Protopic, Lidoderm Patch, Pediculicides, Topical Antibiotic Medications, Topical Corticosteroids
    Last Modified on Dec 14, 2022
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