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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
Afrezza
Akynzeo
Alecensa
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
Benlysta
Benzoyl Peroxide Combinations
Benzoyl Peroxide Products
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
Butrans
Bystolic

C

Cabometyx
Capital and Codeine
Caprelsa
Carisoprodol
Cholbam
Cinqair
Cinryze-Berinert
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

Farxiga
Farydak
Fenofibrates
Ferriprox
Fetzima
Fexmid
Firazyr
Flector patch
Fosrenol
Fulyzaq
Fycompa

G

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

H

Hemangeol
Hepatitis C
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
Invokana
Iprivask
Iressa

J

Jakafi
Jardiance
Jublia
Juxtapid

K

Kalbitor
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
Lupron Peds – Supprelin LA
Luvox CR
Luzu
Lynparza
Lyrica

M

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

N

Naftin
Naloxone
Nascobal
Natpara
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
PCSK9 Inhibitors
Phentolamine
Picato
Plegridy
Pomalyst
Ponstel
Potiga
Pradaxa
Pristiq
Prolia
Proton Pump Inhibitors
Provigil, Nuvigil

Q

Qualaquin
Qudexy XR
Quinolones

R

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)
Silenor
Sirturo
Sitavig
Sklice
Soliris
Solodyn
Soma 250 mg
Soolantra
Spinraza
Sprix
Statins
Stimulants
Stiripentol
Stivarga
Strensiq
Sylatron
Synagis – MN policy 2017-2018 season

T

Tagrisso
Tecfidera
Testosterone
TOBI Podhaler
Tobramycin Inhalation Solution
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
Viberzi
Victoza
Viibryd
Vimizim
Vimpat
Vraylar
Vusion

X

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

Y

Yervoy
Yondelis

Z

Zanaflex
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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