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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

Abiraterone
Abilify Maintena
ACE or ARB plus CCB Combination
Acetasol
Actemra
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
Arikayce
Aristada
Astagraf XL
Aubagio
Austedo
Azasite
Azilect

B

Bactroban Cream
Balversa
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
Bevyxxa
Bisphosphonates
Bosulif
Botulinum Toxins
Braftovi
Brand Preferred Over Generic
Branded Drugs - DAW
Brilinta
Brineura
Brisdelle
Briviact
Bryhali
Buprenorphine with naloxone and Buprenorphine 
Buprenorphine Transdermal Patch and Buccal Film
Bystolic

C

Cabometyx
Calquence
Capital and Codeine
Caprelsa
Carisoprodol
CGRP Antagonists
Cholbam
Cimzia
Cinqair
Clobetasol-Olux Foam
Cometriq
Copiktra
Coreg CR
Corlanor
Cosopt PF
Cotellic
COX-2
Crysvita
Cuvposa
Cystaran

D

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

E

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

F

Farydak
Fasenra
Fenofibrates
Ferriprox
Fetzima
Fexmid
Flector patch
Fosrenol
Fulyzaq
Fycompa

G

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

H

Hemangeol
Hepatitis C
Hereditary Angioedema
Hetlioz
Horizant
Hospital discharge transition fill
Hydroxyprogesterone caproate

I

Ibrance
Iclusig
Idhifa
Ilaris
Imbruvica
Imlygic
Immunomodulators
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
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
Lokelma
Lonsurf
Lorbrena
Lotronex
Lovaza (omega-3 fatty acids)
Lucemyra
Lumoxiti
Lupaneta Pack
Lutathera
Luvox CR
Luxturna
Luzu
Lynparza
Lyrica

M

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

N

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

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
Orilissa
Orkambi
Otezla
Otic Antibiotics/Treagan/Cetraxal
Otrexup

P

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

Q

Qbrexa
Qualaquin
Qudexy XR
Quinolones

R

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

S

Sabril
Samsca
Sedative hypnotics
Seroquel XR (regimen review)
SGLT2 Inhibitors
Siklos
Silenor
Sinuva
Sirturo
Sitavig
Sklice
Soliris
Solodyn
Solosec
Soma 250 mg
Soolantra
Spinraza
Spravato
Sprix
Statins
Stimulants
Stiripentol
Stivarga
Strensiq
Sublocade
Sylatron
Symdeko
Symproic
Synagis – MN policy 2019-2020 season

T

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

U

Uloric
Ultomiris
Ultram ER, Ryzolt ER, ConZip
Uptravi

V

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

X

Xalkori
Xenazine
Xenical
Xerese
Xermelo
Xgeva
Xhance
Xifaxan
Xiidra
Xofluza
Xolair
Xtandi
Xyrem

Y

Yervoy
Yondelis

Z

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

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