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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 | WX | Y | Z

A

Abilify MyCite
Abiraterone
Actemra
Acthar Gel
Actiq-Abstral-Fentora-Lazanda-Onsolis-Subsys
Adakveo
Adcetris
Aduhelm
Agamree
Akynzeo
Alecensa
Aliqopa
Alunbrig
Amondys 45
Ampyra
Amrix
Amvuttra
Annovera
Anti-Obesity Medications
Aptiom
Arcapta
Arikayce
Aristada
Austedo
Ayvakit
Azasite

B

Balversa
Banzel
Bavencio
Baxdela
Benlysta
Beovu
Besponsa
Beqvez
Bevyxxa
Biosimilars
Blenrep
Bosulif
Botulinum Toxins
Braftovi
Brand Preferred Over Generic
Branded Drugs - DAW
Brexafemme
Brineura
Briviact
Bryhali
Bylvay

C

Cabometyx
Calquence
Camzyos
Capital and Codeine
Caprelsa
Carisoprodol
CGRP Antagonists
Cholbam
Cibinqo
Cinqair
Cometriq
Copiktra
Corlanor
Cotellic
Crysvita
Cystaran

D

Darzalex
Daybue
Dayvigo
Desoxyn
Diabetic testing supplies
Diacomit
Dojolvi
Doptelet
Doxylamine-Pyridoxine Fixed Dose Combinations
Drugs with new or expanded indications
Duavee 
Dupixent
Durysta

E

Egaten
Egrifta
Elevidys
Elfabrio
Elzonris
Emflaza
Empliciti
Endari
Enhertu
Enjaymo
Enspryng
Eohilia
Epaned
Epidiolex
Erivedge
Erleada
Erwinaze
Eucrisa
Evekeo
Evenity
Exkivity
Evrysdi
Exondys 51
Eylea

F

Fabhalta
Farydak
Fasenra
Fenofibrates
Ferriprox
Fexmid
Filsuvez
Fintepla
Fleqsuvy
Fyarro
Fycompa

G

Galafold
Gattex
Giazo
Gilotrif
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

I

Ibrance
Iclusig
Idhifa
Ilaris
Imbruvica
Imcivree
Imlygic
Immunomodulators
Ingrezza
Inlyta
Inqovi
Inrebic
Intuniv
Iqirvo
Iressa
Izervay

J

Jakafi
Juxtapid

K

Kalydeco
Kanuma
Kapvay
Kerendia
Keveyis
Keytruda
Kimmtrak
Kineret
Kisqali
Kisunla
Korlym
Krintafel

L

Lartruvo
Lemtrada
Lenvima
Leqembi
Libtayo
Lidoderm
Livdelzi
Livmarli
Livtencity
Lokelma
Lonsurf
Lorbrena
Lucemyra
Lucentis
Lumoxiti
Lutathera
Luxturna
Lynparza

M

Macrilen
Marinol
Mavenclad
Mayzent
Medication Therapy Management
Mekinist
Mektovi
Mepsevii
Monjuvi
Mozobil
Mulpleta
Myalept

N

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

O

Ocaliva
Ocrevus
Odomzo
Oleptro
Omeclamox-Pac
Oncology Drugs
Ongentys
Onmel
Onpattro
Opdivo
Opdualag
Ophthalmic Antihistamines
Opiate Combinations
Opioids Long Acting Pain Management Plan
Oracea
Oralair
Oriahnn
Orilissa
Orkambi
Otrexup
Oxbryta

P

Padcev
Palforzia
Palynziq
Parsabiv
PCSK9 Inhibitors
Pemazyre
Pemfexy
Phentolamine
Phesgo
PiaSky
Piqray
Polivy
Pomalyst
Potiga
Probuphine
Prolia
Provigil, Nuvigil
Pyrukynd

Q

Qalsody
Qbrexa
Qutenza

R

Radicava
Ragwitek
Rasuvo
Ravicti
Rayaldee
Rebyota
Recorlev
Rectiv
Retevmo
Retroactive eligibility
Revatio, Adcirca
Revcovi
Reyvow
Rezdiffra
Rivfloza
Roctavian
Rozlytrek
Rubraca
Rydapt
Rylaze
Ryplazim
Rystiggo

S

Samsca
Saphnelo
Sarclisa
Scemblix
Scenesse
Secuado
Seroquel XR (regimen review)
Siklos
Silenor
Sinuva
Sirturo
Soliris
Solosec
Soolantra
Spevigo
Spinraza
Spravato
Stivarga
Strensiq
Sunosi 
Susvimo
Symdeko
Synagis - MN policy 2024-2025 season

T

Tabrecta
Tagrisso
Talzenna
Tarpeyo
Tecentriq
Tepezza
Tezspire
Tibsovo
Tivdak
Trikafta
Triptan quantity limits
Trodelvy
Trogarzo
Trokendi XR
Truseltiq
Tukysa
Tyrvaya
Tysabri
Tzield

U

Ubrelvy
Ultomiris
Ultram ER, Ryzolt ER, ConZip
Uptravi

V

Vabysmo
Veltassa
Venclexta
Veozah
Verzenio
Vevye
Vijoice
Viltepso
Vimizim
Vitrakvi
Vivjoa
Vizimpro
Vonjo
Voquezna
Vowst
Voxzogo
Voydeya
Vuity
Vumerity
Vyepti
Vyjuvek
Vyndaqel & Vyndamax
Vyondys 53
Vyvgart

W

Wainua
Wakix
Welireg
Winrevair

X

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

Y

Yervoy
Yondelis
Yutiq

Z

Zanaflex
Zejula
Zelboraf
Zeposia
Zepzelca
Ziana
Zilbrysq
Zinplava
Zolgensma
Zoryve Cream
Ztalmy
Zurzuvae
Zyclara
Zydelig
Zykadia
Zyprexa Relprevv

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