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Pharmacy
Prior Authorization (PA)
Prior Authorization Archive -
2009
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2010
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2011
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2012
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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