Pharmacy prior authorization criteria and regimen review sheets
To request a drug prior authorization (PA), contact the Minnesota Health Care Programs Prescription Drug PA Agent at 866-205-2818 (phone) or 866-648-4574 (fax).
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z
A
Abilify MyCite
Actemra
Acthar Gel
Actiq-Abstral-Fentora-Lazanda-Onsolis-Subsys
Adakveo
Aduhelm
Agamree
Akynzeo
Alhemo
Alyftrek
Amondys 45
Ampyra
Amrix
Amvuttra
Annovera
Anti-Obesity Medications
Aptiom
Aqneursa
Arcapta
Arikayce
Aristada
Attruby
Austedo
Ayvakit
Azasite
B
Banzel
Baxdela
Benlysta
Beovu
Biosimilars
Bosulif
Botulinum Toxins
Brand Preferred Over Generic
Branded Drugs - DAW
Brexafemme
Brineura
Briviact
Bryhali
Bylvay
C
Camzyos
Capital and Codeine
Carisoprodol
Casgevy
CGRP Antagonists
Cholbam
Cibinqo
Cinqair
Corlanor
Crenessity
Crysvita
Cystaran
D
Daybue
Dayvigo
Desoxyn
Diabetic testing supplies
Diacomit
Dojolvi
Doptelet
Doxylamine-Pyridoxine Fixed Dose Combinations
Drugs with new or expanded indications
Duavee
Dupixent
Durysta
Duvyzat
E
Egaten
Egrifta
Elevidys
Elfabrio
Emflaza
Endari
Enjaymo
Enspryng
Eohilia
Epaned
Epidiolex
Eucrisa
Evekeo
Evenity
Evrysdi
Exondys 51
Eylea
F
Fabhalta
Fasenra
Fenofibrates
Ferriprox
Fexmid
Filsuvez
Fintepla
Fleqsuvy
Fyarro
Fycompa
G
Galafold
Gattex
Giazo
Givlaari
GnRH agonists for pubertal suppression
Gocovri
Gralise
Grandfathering Definition and Criteria
Grastek
Growth Hormone
H
Hemady
Hemangeol
Hemgenix
Hepatitis C (effective beginning 3/1/2023)
Hepatitis C (effective beginning 1/1/2025)
Hereditary Angioedema
Hetlioz and Hetlioz LQ
Hospital discharge transition fill
Hympavzi
I
Iclusig
Ilaris
Imcivree
Immunomodulators
Ingrezza
Inqovi
Intuniv
Iqirvo
Izervay
J
K
Kalydeco
Kanuma
Kapvay
Kerendia
Keveyis
Kineret
Kisunla
Korlym
Korsuva
Krintafel
L
Lemtrada
Leqembi
Lidoderm
Livdelzi
Livmarli
Livtencity
Lokelma
Lucemyra
Lucentis
Lutathera
Luxturna
M
Macrilen
Marinol
Mavenclad
Mayzent
Medication Therapy Management
Mepsevii
Miplyffa
Monjuvi
Mozobil
Mulpleta
Myalept
N
Naloxone
Nascobal
New drugs and new or nonpreferred dosage forms
Nexviazyme
Nitisinone
Novarel
Nucala
Nucynta
Nuedexta
Nulojix
Nuplazid
Nursing home transition fill
Nurtec ODT
Nuzyra
O
Ocaliva
Ocrevus
Oleptro
Omeclamox-Pac
Oncology Drugs
Ongentys
Onmel
Onpattro
Ophthalmic Antihistamines
Opiate Combinations
Opioids Long Acting Pain Management Plan
Oracea
Oralair
Oriahnn
Orilissa
Orkambi
Otrexup
Oxbryta
P
Palforzia
Palynziq
Parsabiv
PCSK9 Inhibitors
Phentolamine
PiaSky
Potiga
Prevymis
Probuphine
Prolia
Provigil, Nuvigil
Pyrukynd
Q
R
Radicava
Ragwitek
Rasuvo
Ravicti
Rayaldee
Rebyota
Recorlev
Rectiv
Retroactive eligibility
Revatio, Adcirca
Revcovi
Reyvow
Rezdiffra
Rhofade
Rivfloza
Roctavian
Rylaze
Ryplazim
Rystiggo
Ryzumvi
S
Samsca
Saphnelo
Scemblix
Scenesse
Secuado
Seroquel XR (regimen review)
Siklos
Silenor
Sinuva
Sirturo
Soliris
Solosec
Soolantra
Spevigo
Spinraza
Spravato
Strensiq
Sunosi
Susvimo
Symdeko
Synagis - MN policy 2024-2025 season
T
Tarpeyo
Tepezza
Tezspire
Trikafta
Triptan quantity limits
Trogarzo
Trokendi XR
Tryvio
Tyrvaya
Tysabri
Tzield
U
Ubrelvy
Ultomiris
Ultram ER, Ryzolt ER, ConZip
Uptravi
V
Vabysmo
Veltassa
Veozah
Vevye
Vijoice
Viltepso
Vimizim
Vivjoa
Vizimpro
Voquezna
Vowst
Voxzogo
Voydeya
Vuity
Vumerity
Vyepti
Vyjuvek
Vyndaqel & Vyndamax
Vyondys 53
Vyvgart
W
X
Xcopri
Xenazine
Xenical
Xenleta
Xenpozyme
Xermelo
Xgeva
Xifaxan
Xofluza
Xolair
Xolremdi
Xyrem
Xywav
Y
Z
Zanaflex
Zeposia
Ziana
Zilbrysq
Zinplava
Zolgensma
Zoryve Cream
Ztalmy
Zurzuvae
Zyclara
Zyprexa Relprevv