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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 | X | Y | Z

A

Abilify MyCite
Abiraterone
Acetasol
Actemra
Acthar Gel
Actiq-Abstral-Fentora-Lazanda-Onsolis-Subsys
Adakveo
Adcetris
Adempas
Admelog
Aduhelm
Afrezza
Akynzeo
Alecensa
Aliqopa
Alunbrig
Amondys 45
Ampyra
Amrix
Annovera
Anti-Obesity Medications
Antiemetics
Antifungals - oral
Aplenzin
Apriso
Aptiom
Arcapta
Arikayce
Aristada
Astagraf XL
Aubagio
Austedo
Ayvakit
Azasite
Azilect

B

Balversa
Banzel
Basaglar
Basal insulin and GLP-1 receptor agonist combination
Bavencio
Baxdela
Benlysta
Benzoyl Peroxide Combinations
Benzoyl Peroxide Products
Beovu
Besponsa
Beta-Agonist Long Acting
Beta-Agonist Short-Acting Inhalers
Bevyxxa
Biosimilars
Bisphosphonates
Blenrep
Bosulif
Botulinum Toxins
Braftovi
Brand Preferred Over Generic
Branded Drugs - DAW
Brexafemme
Brilinta
Brineura
Brisdelle
Briviact
Bryhali
Buprenorphine with naloxone and Buprenorphine 
Buprenorphine Transdermal Patch and Buccal Film
Bylvay
Bystolic

C

Cabometyx
Calquence
Capital and Codeine
Caplyta
Caprelsa
Carisoprodol
CGRP Antagonists
Cholbam
Cimzia
Cinqair
Clobetasol-Olux Foam
Cometriq
Copiktra
Coreg CR
Corlanor
Cosopt PF
Cotellic
Crysvita
Cuvposa
Cystaran

D

Daliresp
Darzalex
Dayvigo
Desoxyn
Diabetic testing supplies
Diacomit
Direct Oral Anticoagulants (DOAC)
Dojolvi
Doptelet
Doryx
Doxylamine-Pyridoxine Fixed Dose Combinations
DPP-4 Inhibitors
Duavee 
Dupixent
Durysta

E

Egaten
Egrifta
Elzonris
Emflaza
Empliciti
Emsam
Endari
Enhertu
Enspryng
Entresto
Epaned
Epidiolex
Epinephrine Auto-injectors
Epogen
Erivedge
Erleada
Erwinaze
Esbriet
Eucrisa
Evekeo
Evenity
Exkivity
Evrysdi
Exondys 51
Extina
Eylea

F

Farydak
Fasenra
Fenofibrates
Ferriprox
Fetzima
Fexmid
Fintepla
Flector patch
Fosrenol
Fulyzaq
Fycompa

G

Galafold
Gattex
Giazo
Gilenya
Gilotrif
Givlaari
GLP-1 receptor agonists
Glucagon
Glutamine_NutreStore
GnRH agonists for pubertal suppression
Gocovri
Gralise
Grandfathering Definition and Criteria
Grastek
Growth Hormone

H

Hemangeol
Hepatitis C (effective through 12/31/2020)
Hepatitis C (effective beginning 1/1/2021)
Hereditary Angioedema
Hetlioz and Hetlioz LQ
Horizant
Hospital discharge transition fill
Hydroxyprogesterone caproate

I

Ibrance
Iclusig
Idhifa
Ilaris
Imbruvica
Imlygic
Immunomodulators
Ingrezza
Inhaled steroids for asthma
Inlyta
Inqovi
Inrebic
Insulin
Interferons
Intranasal Corticosteroids
Intuniv
Invega
Iprivask
Iressa

J

Jakafi
Jublia
Juxtapid

K

Kalydeco
Kanuma
Kapvay
Kerendia
Keveyis
Keytruda
Khedezla
Kineret
Kisqali
Korlym
Krintafel
Kynamro

L

LABA-ICS Combination
LAMAs
LAMA-LABA Combination
Lamictal ODT and XR
Lamisil Granules
Lartruvo
Lemtrada
Lenvima
Libtayo
Lidoderm
Linzess
Livmarli
Livtencity
Lokelma
Lonsurf
Lorbrena
Lotronex
Lovaza (omega-3 fatty acids)
Lucemyra
Lucentis
Lumoxiti
Lupaneta Pack
Lutathera
Luvox CR
Luxturna
Luzu
Lynparza
Lyrica

M

Macrilen
Marinol
Mavenclad
Mayzent
Medication Therapy Management
Mekinist
Mektovi
Mepsevii
Metozolv ODT
Moderiba
Monjuvi
Motegrity
Movantik
Moxatag
Mozobil
Mulpleta
Myalept

N

Naftin
Naloxone
Nascobal
Natpara
Nayzilam
Nerlynx
New drugs and new or nonpreferred dosage forms
Nexviazyme
Nimotop
Ninlaro
Nitisinone
NitroMist
Noctiva
Novarel 
Nubeqa 
Nucala
Nucynta
Nucynta ER
Nuedexta
Nulojix
Nuplazid
Nursing home transition fill
Nurtec ODT
Nuzyra

O

Ocaliva
Ocrevus
Odomzo
Ofev
Oleptro
Omeclamox-Pac
Onfi
Ongentys
Onmel
Onpattro
Opdivo
Ophthalmic Antihistamines
Ophthalmic NSAIDs
Ophthalmic Quinolones
Opiate Combinations
Opioids Long Acting
Opioids Long Acting Pain Management Plan
Opioids: Opana/ER
Opsumit
Oracea
Oralair
OraPred
Orenitram ER
Oriahnn
Orilissa
Orkambi
Otezla
Otic Antibiotics/Treagan/Cetraxal
Otrexup
Oxbryta

P

Padcev
Palforzia
Palynziq
Pancreatic enzymes
Parsabiv
PCSK9 Inhibitors
Pemazyre
Phentolamine
Phesgo
Picato
Piqray
Plegridy
Polivy
Pomalyst
Ponstel
Potiga
Pretomanid
Pristiq
Probuphine
Prolia
Proton Pump Inhibitors
Provigil, Nuvigil

Q

Qbrexa
Qualaquin
Qudexy XR
Qutenza

R

Radicava
Ragwitek
Rasuvo
Rayaldee
Rayos
Reblozyl
Rectiv
Relistor
Retevmo
Retinoids for acne
Retroactive eligibility
Revatio, Adcirca
Revcovi
Reyvow
Rexulti
Rezurock
Rhopressa
Rozlytrek
Rubraca
Rydapt
Rylaze

S

Sabril
Samsca
Saphnelo
Sarclisa
Scemblix
Secuado
Sedative hypnotics
Seroquel XR (regimen review)
SGLT2 Inhibitors
Siklos
Silenor
Sinuva
Sirturo
Soliris
Solodyn
Solosec
Soma 250 mg
Soolantra
Spinraza
Spravato
Sprix
Statins
Stimulants
Stiripentol
Stivarga
Strensiq
Sublocade 
Sunosi 
Susvimo
Sylatron
Symdeko
Symproic
Synagis – MN policy 2021-2022 season

T

Tabrecta
Tagrisso
Talzenna
Tecentriq
Tecfidera
Tepezza
Testosterone
Tibsovo
Tivdak
TOBI Podhaler
Trelegy Ellipta
Treximet
Trikafta
Trintellix
Triptan quantity limits
Trodelvy
Trogarzo
Trokendi XR
Truseltiq
Tukysa
Tybost
Tysabri
TZD-Avandia

U

Ubrelvy
Uloric
Ultomiris
Ultram ER, Ryzolt ER, ConZip
Uptravi

V

Vascepa
Vecamyl
Vectical
Veltassa
Vemlidy
Venclexta
Ventavis - Tyvaso
Veregen
Verzenio
Viberzi
Viibryd
Viltepso
Vimizim
Vimpat
Vitrakvi
Vizimpro
Voxzogo
Vraylar
Vuity
Vumerity
Vusion
Vyepti
Vyndaqel & Vyndamax
Vyondys 53
Vyzulta

W

Wakix

X

Xalkori
Xcopri
Xenazine
Xenical
Xenleta
Xermelo
Xgeva
Xhance
Xifaxan
Xiidra
Xofluza
Xolair 
Xpovio 
Xtandi
Xyrem
Xywav

Y

Yervoy
Yondelis
Yutiq

Z

Zanaflex
Zejula
Zelboraf
Zelepar
Zeposia
Zepzelca
Ziana
Zinbryta
Zinplava
Zioptan
Zipsor
Zohydro
Zolgensma
Zontivity
Zorvolex
Zurampic
Zyclara
Zydelig
Zyflo
Zykadia
Zyprexa Relprevv

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