CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019 CLINICAL PRIOR AUTHORIZATION TABLE OF CONTENTS All medications requiring clinical prior authorization (PA) for Kansas Medicaid are listed in the table below. Please use this table to identify if a specific medication requires a clinical PA, which clinical criteria applies to the medication and which PA form should be used to request an authorization from the patient’s specific health plan (MCO/FFS). Please note, medications requiring clinical PA may also have to meet non-preferred PA criteria before the claim may be considered for payment. Refer to the Kansas Medicaid Preferred Drug List (PDL) (http://www.kdheks.gov/hcf/pharmacy/pharmacy_druglist.html ) to determine if a medication requires a non-preferred PDL PA. Use the “ctrl + F” keyboard shortcut to search for a medication or keyword within this document. BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website) Abilify Discmelt® Aripiprazole Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages Abilify Maintena® Aripiprazole Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages Abilify® Aripiprazole Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages Abstral® Fentanyl Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management AcipHex® Sprinkles™ Rabeprazole Proton Pump Inhibitor (PPI) Step Therapy Proton Pump Inhibitor (PPI) Step Therapy Actemra® Tocilizumab Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions Actiq® Fentanyl Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management Aczone® Dapsone Acne Agents - Topical Acne Agents - Topical Adasuve® Loxapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages Adcirca® Tadalafil (tablets) Pulmonary Arterial Hypertension Agents Pulmonary Arterial Hypertension Agents Adderall XR® Amphetamine/Dextroamphetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages Adderall® Amphetamine/Dextroamphetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages Adempas® Riociguat Pulmonary Arterial Hypertension Agents Pulmonary Arterial Hypertension Agents Adlyxin™ Lixisenatide Diabetic Agents Diabetic Agents Adynovate® Antihemophilic factor VIII recombinant, pegylated Hemophilia Factors - Long-Acting Hemophilia Factors - Long-Acting Adzenys ER® Amphetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages Adzenys XR-ODT® Amphetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages Afinitor® Everolimus Chemotherapy Agents Chemotherapy Agents Afrezza® Insulin human inhalation powder Insulin human inhalation powder (Afrezza®) Universal Clinical PA Form Aimovig™ Erenumab-aooe CGRP Antagonists – Step Therapy CGRP Antagonists – Step Therapy Ajovy™ Fremanezumab-vfrm CGRP Antagonists – Step Therapy CGRP Antagonists – Step Therapy Akynzeo® Netupitant/palonosetron Anti-Emetics - Neurokinin 1 (NK-1) Antagonist/NK-1 Antagonist Combinations Anti-Emetics - Neurokinin 1 (NK-1) Antagonist/NK-1 Antagonist Combinations Alli® Orlistat Weight Loss Drugs Weight Loss Drugs Alprazolam Intensol® Alprazolam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages Alprolix® Coagulation factor IX recombinant, Fc fusion protein Hemophilia Factors - Long-Acting Hemophilia Factors - Long-Acting Alunbrig™ Brigatinib Chemotherapy Agents Chemotherapy Agents
Transcript
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
CLINICAL PRIOR AUTHORIZATION TABLE OF CONTENTS
All medications requiring clinical prior authorization (PA) for Kansas Medicaid are listed in the table below. Please use this table to identify if a specific medication requires a clinical PA, which clinical criteria applies to the medication and which PA form should be used to request an authorization from the patient’s specific health plan (MCO/FFS). Please note, medications requiring clinical PA may also have to meet non-preferred PA criteria before the claim may be considered for payment. Refer to the Kansas Medicaid Preferred Drug List (PDL) (http://www.kdheks.gov/hcf/pharmacy/pharmacy_druglist.html) to determine if a medication requires a non-preferred PDL PA.
Use the “ctrl + F” keyboard shortcut to search for a medication or keyword within this document.
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website) Abilify Discmelt® Aripiprazole Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Abilify Maintena® Aripiprazole Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Abilify® Aripiprazole Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Abstral® Fentanyl Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Adderall XR® Amphetamine/Dextroamphetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Adderall® Amphetamine/Dextroamphetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Alli® Orlistat Weight Loss Drugs Weight Loss Drugs
Alprazolam Intensol® Alprazolam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Alprolix® Coagulation factor IX recombinant, Fc fusion protein Hemophilia Factors - Long-Acting Hemophilia Factors - Long-Acting
Amjevita® Adalimumab- atto Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Amoxapine Amoxapine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Amrix® Cyclobenzaprine ER Cyclobenzaprine ER (Amrix®) Universal Clinical PA Form
Anafranil® Clomipramine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Aristada® Aripiprazole lauroxil Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Aristada Initio™ Aripiprazole lauroxil Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Arymo ER® Morphine ER Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Ativan® Lorazepam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Celexa® Citalopram Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Chlorpromazine Chlorpromazine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Cimzia® Certolizumab Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Cinqair® Reslizumab Reslizumab (Cinqair®) Universal Clinical PA Form
Cinryze® C1 Esterase Inhibitor, human C1 Esterase Inhibitor, human (Cinryze®) Universal Clinical PA Form
Clonidine Clonidine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Clozaril® Clozapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Codeine Codeine Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Combunox® Oxycodone/ibuprofen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website)
Concerta® Methylphenidate HCl Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Consensi™ Amlodipine/celecoxib Amlodipine/celecoxib (Consensi™) Universal Clinical PA Form
Contrave® ER Naltrexone/Bupropion Weight Loss Drugs Weight Loss Drugs
Conzip® Tramadol ER Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Cotempla XR-ODT™ Methylphenidate HCl Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Crinone® Progesterone Progesterone (Crinone®) Universal Clinical PA Form
Cyltezo™ Adalimumab- adbm Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Cymbalta® Duloxetine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Daklinza® Daclatasvir Hepatitis C Agents Hepatitis C Agents
Dalmane® Flurazepam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Daraprim® Pyrimethamine Pyrimethamine (Daraprim®) Universal Clinical PA Form
Daytrana® Methylphenidate Transdermal Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Delatestryl® Testosterone Enanthate Testosterone Enanthate (Delatestryl®) Universal Clinical PA Form
Demerol® Meperidine Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Demser® Metyrosine Metyrosine (Demser®) Universal Clinical PA Form
Desoxyn® Methamphetamine HCl Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Dexedrine® Dextroamphetamine Sulfate Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
DextroStat® Dextroamphetamine Sulfate Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Diazepam Intensol® Diazepam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Diclegis® Doxylamine succinate/pyridoxine hydrochloride Doxylamine succinate/pyridoxine hydrochloride (Diclegis®) Universal Clinical PA Form
Effexor XR® Venlafaxine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Effexor® Venlafaxine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Elaprase® Idursulfase Idursulfase (Elaprase®) Universal Clinical PA Form
Elavil® Amitriptyline Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website)
Fanapt® Iloperidone Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Fentora® Fentanyl Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Ferriprox® Deferiprone Deferiprone (Ferriprox®) Universal Clinical PA Form
Fetzima® Levomilnacipran Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Fluphenazine Fluphenazine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Focalin XR® Dexmethylphenidate ER Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Focalin® Dexmethylphenidate Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Forfivo® XL Bupropion Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Fortamet® Metformin ER Metformin ER Metformin ER
Forteo® Teriparatide Teriparatide (Forteo®) Universal Clinical PA Form
Geodon® Ziprasidone Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Granix® Tbo-filgrastim Tbo-filgrastim (Granix®) Universal Clinical PA Form
H.P.Acthar Gel® Repository corticotropin Repository corticotropin (H.P.Acthar Gel®) Universal Clinical PA Form
Haegarda® C1 Esterase Inhibitor, human C1 Esterase Inhibitor, human (Haegarda®) Universal Clinical PA Form
Halcion® Triazolam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Haldol Decanoate® Haloperidol Decanoate Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Haldol® Haloperidol Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Harvoni® Ledipasvir/sofosbuvir Hepatitis C Agents Hepatitis C Agents
Intron A Interferon alfa-2b Interferon alfa-2b (Intron A®) Universal Clinical PA Form
Intuniv® Guanfacine ER Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Invega Sustenna® Paliperidone palmitate Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Invega Trinza® Paliperidone palmitate Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Invega® Paliperidone Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website)
Khedezla® Desvenlafaxine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Kineret® Anakinra Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Klonopin® Clonazepam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Krystexxa® Pegloticase Pegloticase (Krystexxa®) Universal Clinical PA Form
Kuvan® Sapropterin Sapropterin (Kuvan®) Universal Clinical PA Form
Kymriah® Tisagenlecleucel Tisagenlecleucel (Kymriah®) Universal Clinical PA Form
Kynamro® Mipomersen Mipomersen (Kynamro®) Universal Clinical PA Form
Leukine® Sargramostim Sargramostim (Leukine®) Universal Clinical PA Form
Levo-Dromoran® Levorphanol Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Lexapro® Escitalopram Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Librium® Chlordiazepoxide Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Lorazepam Intensol® Lorazepam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Lorcet HD® Hydrocodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Lorcet Plus® Hydrocodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Lorcet® Hydrocodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Lortab® Hydrocodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Loxitane® Loxapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Lucentis® Ranibizumab Ranibizumab (Lucentis®) Universal Clinical PA Form
Lupaneta Pack® Leuprolide/Norethindrone Leuprolide/Norethindrone (Lupaneta Pack®) Universal Clinical PA Form
Lupron® Leuprolide Leuprolide (Lupron®) Universal Clinical PA Form
Luvox CR® Fluvoxamine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Luvox® Fluvoxamine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Luxturna™ Voretigene neparvovec-rzyl Voretigene neparvovec-rzyl (Luxturna™) Universal Clinical PA Form
Lyrica CR® Pregabalin Pregabalin (Lyrica®, Lyrica CR®) Universal Clinical PA Form
Lyrica® Pregabalin Pregabalin (Lyrica®, Lyrica CR®) Universal Clinical PA Form
Makena® Hydroxyprogesterone Caproate Hydroxyprogesterone Caproate (Makena®) Universal Clinical PA Form
Maprotiline Maprotiline Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Marplan® Isocarboxazid Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Mavyret® Glecaprevir/pibrentasvir Hepatitis C Agents Hepatitis C Agents
Maxidone® Hydrocodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Mydayis® Amphetamine/Dextroamphetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Nardil® Phenelzine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Natpara® Parathyroid hormone Parathyroid hormone (Natpara®) Universal Clinical PA Form
Nefazodone Nefazodone Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Neulasta® Pegfilgrastim Pegfilgrastim (Neulasta®) Universal Clinical PA Form
Neumega® Oprelvekin Oprelvekin (Neumega®) Universal Clinical PA Form
Neupogen® Filgrastim Filgrastim (Neupogen®) Universal Clinical PA Form
Niravam ODT® Alprazolam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Norpramin® Desipramine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Nplate® Romiplostim Romiplostim (Nplate®) Universal Clinical PA Form
Nucala® Mepolizumab Mepolizumab (Nucala®) Universal Clinical PA Form
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website)
Nucynta ER® Tapentadol ER Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Nucynta® Tapentadol Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Nuedexta® Dextromethorphan/Quinidine Dextromethorphan/Quinidine (Nuedexta®) Universal Clinical PA Form
Pamelor® Nortriptyline Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website)
Panretin® Alitretinoin Retinoids Retinoids
Papain/Urea Products Papain/Urea Products Decubitus and Wound Care Products Decubitus and Wound Care Products
Papain/Urea/Chlorophyllin Products
Papain/Urea/Chlorophyllin Products Decubitus and Wound Care Products Decubitus and Wound Care Products
Parnate® Tranylcypromine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Paxil CR® Paroxetine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Paxil® Paroxetine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Pegasys® Peginterferon alfa-2a Peginterferon alfa-2a (Pegasys®) Universal Clinical PA Form
PegIntron® Peginterferon alfa-2b Peginterferon alfa-2b (PegIntron®) Universal Clinical PA Form
Pentazocine/Naloxone Pentazocine/Naloxone Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Percocet® Oxycodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Percodan® Oxycodone/aspirin Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Perphenazine Perphenazine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Perseris™ Risperidone Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Pexeva® Paroxetine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Phentermine products Phentermine products Weight Loss Drugs Weight Loss Drugs
Primlev® Oxycodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Pristiq® Desvenlafaxine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Prolia® Denosumab Denosumab (Prolia®) Universal Clinical PA Form
Promacta® Eltrombopag Eltrombopag (Promacta®) Universal Clinical PA Form
ProSom® Estazolam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Prozac® Fluoxetine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Prozac® Weekly Fluoxetine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Remeron® Mirtazapine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Remicade® Infliximab Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Restasis® Cyclosporine Cyclosporine (Restasis®) Universal Clinical PA Form
Restoril® Temazepam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Rexulti® Brexpiprazole Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Risperdal Consta® Risperidone Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Risperdal M-Tab® Risperidone Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Risperdal® Risperidone Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Ritalin LA® Methylphenidate HCl Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Ritalin® Methylphenidate HCl Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Ryzolt® Tramadol ER Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Sabril® Vigabatrin Vigabatrin (Sabril®) Universal Clinical PA Form
Saizen® Somatropin Somatropin Somatropin
Santyl® Collagenase Decubitus and Wound Care Products Decubitus and Wound Care Products
Saphris® Asenapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Savella® Milnacipran Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Saxenda® Liraglutide Weight Loss Drugs Weight Loss Drugs
Selegiline Selegiline Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Selzentry® Maraviroc Maraviroc (Selzentry®) Universal Clinical PA Form
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website)
Sensipar® Cinacalcet Cinacalcet (Sensipar®) Universal Clinical PA Form
Serax® Oxazepam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Sernivo® Betamethasone Dipropionate Betamethasone Dipropionate (Sernivo®) Universal Clinical PA Form
Seroquel XR® Quetiapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Seroquel® Quetiapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Silenor® Doxepin Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Siliq™ Brodalumab Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Simponi Aria® Golimumab Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Simponi® Golimumab Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Supprelin® LA Histrelin acetate Histrelin acetate (Supprelin® LA) Universal Clinical PA Form
Surmontil® Trimipramine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Sylatron® Peginterferon alfa-2b Peginterferon alfa-2b (Sylatron®) Universal Clinical PA Form
Symbyax® Olanzapine/Fluoxetine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
CLINICAL PA TABLE OF CONTENTS | Revised 03/08/2019
BRAND NAME GENERIC NAME PA CRITERIA (as listed on website) PA FORM (as listed on website)
Thioridazine Thioridazine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Thiothixene Thiothixene Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Tofranil® Imipramine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Tofranil® PM Imipramine Pamoate Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Tranxene-T® Clorazepate Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Trazodone Trazodone Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Trifluoperazine Trifluoperazine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Trintellix® Vortioxetine Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Triptodur® Triptorelin Triptorelin (Triptodur®) Universal Clinical PA Form
Trogarzo™ Ibalizumab-uiyk Trogarzo™ (ibalizumab-uiyk) Universal Clinical PA Form
Trokendi XR® Topiramate extended-release Topiramate extended-release (Trokendi XR®) Universal Clinical PA Form
Troxyca ER® Oxycodone/Naltrexone Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Verdrocet® Hydrocodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Versacloz® Clozapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Viekira Pak™ Ombitasvir/paritaprevir/ ritonavir and dasabuvir Hepatitis C Agents Hepatitis C Agents
Viekira XR™ Ombitasvir/paritaprevir/ ritonavir and dasabuvir Hepatitis C Agents Hepatitis C Agents
Viibryd® Vilazodone Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Vimovo® Naproxen/esomeprazole NSAID plus PPI/H2 Blocking Agents NSAID plus PPI/H2 Blocking Agents
Vivactil® Protriptyline Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Vraylar® Cariprazine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Vyvanse® Lisdexamfetamine Mental Health → ADHD Medications - Safe Use for All Ages Mental Health → ADHD Medications - Safe Use for All Ages
Wellbutrin® Bupropion Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Wellbutrin® SR Bupropion Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Wellbutrin® XL Bupropion Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Xanax XR® Alprazolam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Xanax® Alprazolam Mental Health → Benzodiazepine Medications - Safe Use for All Ages Mental Health → Benzodiazepine Medications - Safe Use for All Ages
Xartemis XR® Oxycodone/acetaminophen Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Xeljanz XR® Tofacitinib Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Xeljanz® Tofacitinib Immunomodulators for Inflammatory Conditions Immunomodulators for Inflammatory Conditions
Zinplava® Bezlotoxumab Bezlotoxumab (Zinplava®) Universal Clinical PA Form
Zohydro ER® Hydrocodone ER Opioid Products Indicated for Pain Management Opioid Products Indicated for Pain Management
Zoloft® Sertraline Mental Health → Antidepressant Medications - Safe Use for All Ages Mental Health → Antidepressant Medications - Safe Use for All Ages
Zolpimist™ Zolpidem Zolpidem (Zolpimist™) Universal Clinical PA Form
Zomacton® Somatropin Somatropin Somatropin
Zurampic® Lesinurad Lesinurad (Zurampic®) Universal Clinical PA Form
Zyprexa Relprevv® Olanzapine pamoate Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Zyprexa Zydis® Olanzapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
Zyprexa® Olanzapine Mental Health → Antipsychotic Medications - Safe Use for All Ages Mental Health → Antipsychotic Medications - Safe Use for All Ages
