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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 (regimen review)
Abilify Maintena
ACE or ARB plus CCB Combination
Acetasol
Acthar Gel
Actiq-Abstral-Fentora-Lazanda-Onsolis-Subsys
Adcetris
Adempas
Admelog
Afrezza
Akynzeo
Alecensa
Aliqopa
Alunbrig
Ampyra
Amrix
Antiemetics
Antifungals - oral
Antihistamines
Aplenzin
Apriso
Aptiom
ARBs
Arcapta
Aristada
Astagraf XL
Aubagio
Austedo
Azasite
Azilect

B

Bactroban Cream
Banzel
Basaglar
Basal insulin and GLP-1 receptor agonist combination
Bavencio
Baxdela
Benlysta
Benzoyl Peroxide Combinations
Benzoyl Peroxide Products
Besponsa
Beta-Agonist Long Acting
Beta-Agonist Short-Acting Inhalers
Bisphosphonates
Bosulif
Botulinum Toxins
Brand Preferred Over Generic
Branded Drugs - DAW
Brilinta
Brineura
Brisdelle
Briviact
buprenorphine/naloxone
Buprenorphine Transdermal Patch and Buccal Film
Bystolic

C

Cabometyx
Calquence
Capital and Codeine
Caprelsa
Carisoprodol
Central Precocious Puberty
Cholbam
Cinqair
Clobetasol-Olux Foam
Cometriq
Coreg CR
Corlanor
Cosopt PF
Cotellic
COX-2
Cuvposa
Cystaran

D

Daliresp
Darzalex
Desoxyn
Diabetic testing supplies
Doryx
DPP-4 Inhibitors
Duavee 
Dupixent

E

Egrifta
Eliquis
Emflaza
Empliciti
Emsam
Entresto
Epaned
Epinephrine Auto-injectors
Epogen
Erivedge
Erwinaze
Esbriet
Eucrisa
Evekeo
Exondys 51
Extina

F

Farydak
Fasenra
Fenofibrates
Ferriprox
Fetzima
Fexmid
Flector patch
Fosrenol
Fulyzaq
Fycompa

G

Gattex
Gelnique
Giazo
Gilenya
Gilotrif
GLP-1 receptor agonists
Glutamine_NutreStore
Gocovri
Gralise
Grandfathering Definition and Criteria
Grastek
Growth Hormone

H

Hemangeol
Hepatitis C
Hereditary Angioedema
Hetlioz
Horizant
Hospital discharge transition fill

I

Ibrance
Iclusig
Ilaris
Imlygic
Immunomodulators
Incruse Ellipta
Ingrezza
Inhaled steroids for asthma
Inlyta
Insulin
Interferons
Intranasal Corticosteroids
Intuniv
Invega
Iprivask
Iressa

J

Jakafi
Jublia
Juxtapid

K

Kalydeco
Kanuma
Kapvay
Keveyis
Keytruda
Khedezla
Kisqali
Korlym
Kynamro

L

LABA-ICS Combination
LAMA-LABA Combination
Lamictal ODT and XR
Lamisil Granules
Lartruvo
Lemtrada
Lenvima
Lidoderm
Linzess
Lonsurf
Lotronex
Lovaza (omega-3 fatty acids)
Lupaneta Pack
Luvox CR
Luxturna
Luzu
Lynparza
Lyrica

M

Makena
Marinol
Medication Therapy Management
Mekinist
Mepsevii
Metozolv ODT
Moderiba
Movantik
Moxatag
Mozobil
Myalept
Myrbetriq

N

Naftin
Naloxone
Nascobal
Natpara
Nerlynx
New drugs and new dosage forms
Nimotop
Ninlaro
NitroMist
Non-preferred dosage forms
Novarel
Nucala
Nucynta
Nucynta ER
Nuedexta
Nulojix
Nuplazid
Nursing home transition fill

O

Ocaliva
Ocrevus
Odomzo
Ofev
Oleptro
Omeclamox-Pac
Onfi
Onmel
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
Orfadin
Orkambi
Otic Antibiotics/Treagan/Cetraxal
Otrexup

P

Pancreatic enzymes
Parsabiv
PCSK9 Inhibitors
Phentolamine
Picato
Plegridy
Pomalyst
Ponstel
Potiga
Pradaxa
Pristiq
Prolia
Proton Pump Inhibitors
Provigil, Nuvigil

Q

Qualaquin
Qudexy XR
Quinolones

R

Radicava
Ragwitek
Rapaflo
Rasuvo
Rayaldee
Rayos
Rectiv
Relistor
Retinoids for acne
Retroactive eligibility
Revatio, Adcirca
Rexulti
Rubraca

S

Sabril
Samsca
Savaysa
Sedative hypnotics
Seroquel XR (regimen review)
SGLT2 Inhibitors
Silenor
Sirturo
Sitavig
Sklice
Soliris
Solodyn
Solosec
Soma 250 mg
Soolantra
Spinraza
Sprix
Statins
Stimulants
Stiripentol
Stivarga
Strensiq
Sylatron
Symproic
Synagis – MN policy 2017-2018 season

T

Tagrisso
Tecfidera
Testosterone
TOBI Podhaler
Tobramycin Inhalation Solution
Trelegy Ellipta
Treximet
Trintellix
Triptan quantity limits
Trokendi XR
Tudorza
Tybost
Tysabri
TZD-Avandia

U

Uloric
Ultram ER, Ryzolt ER, ConZip
Uptravi

V

Vascepa
Vecamyl
Vectical
Veltassa
Vemlidy
Venclexta
Ventavis - Tyvaso
Veregen
Verzenio
Viberzi
Victoza
Viibryd
Vimizim
Vimpat
Vraylar
Vusion
Vyzulta

X

Xalkori
Xarelto
Xenazine
Xenical
Xerese
Xermelo
Xgeva
Xifaxan
Xiidra
Xolair
Xtandi
Xyrem

Y

Yervoy
Yondelis

Z

Zanaflex
Zejula
Zelboraf
Zelepar
Ziana
Zinbryta
Zinplava
Zioptan
Zipsor
Zohydro
Zontivity
Zorvolex
Zovirax Cream
Zubsolv
Zurampic
Zyclara
Zydelig
Zyflo
Zykadia
Zyprexa Relprevv
Zytiga

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