Pharmacy prior authorization criteria and regimen review sheets
To request a drug prior authorization (PA), contact the Prime Therapeutics Call Center at 844-575-7887 (phone) or 866- 390-2778 (fax). Call Center hours are 24 hours a day, 7 days a week, 365 days a year.
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z
A
Actemra
Acthar Gel
Actiq-Abstral-Fentora-Lazanda-Onsolis-Subsys
Adakveo
Agamree
Akynzeo
Alhemo
Alyftrek
Amondys 45
Amrix
Amvuttra
Annovera
Antimigraine Agents, Other
Anti-Obesity Medications
Aqneursa
Arikayce
Aristada
Attruby
Austedo
Ayvakit
B
Baxdela
Benlysta
Beovu
Biosimilars
Blujepa
Bosulif
Botulinum Toxins
Brand Preferred Over Generic
Branded Drugs - DAW
Brineura
Brinsupri
Bryhali
Bylvay
C
Camzyos
Casgevy
Cholbam
Cibinqo
Cinqair
Crenessity
Crysvita
Ctexli
D
Daybue
Dayvigo
Desoxyn
Diabetic testing supplies
Diacomit
Dojolvi
Doptelet
Doxylamine-Pyridoxine Fixed Dose Combinations
Drugs with new or expanded indications
Duavee
Dupixent
Durysta
Duvyzat
E
Egaten
Egrifta
Elevidys
Elfabrio
Emflaza
Endari
Enjaymo
Enspryng
Eohilia
Epaned
Eucrisa
Evekeo
Evenity
Evrysdi
Exondys 51
Eylea
F
Fabhalta
Fasenra
Fenofibrates
Ferriprox
Fexmid
Filsuvez
Fintepla
Fleqsuvy
Fyarro
G
Galafold
Gattex
Giazo
Givlaari
GnRH agonists for pubertal suppression
Gocovri
Gralise
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
Hympavzi
I
Iclusig
Ilaris
Imaavy
Imcivree
Immunomodulators
Ingrezza
Inqovi
Iqirvo
Izervay
J
K
Kalydeco
Kanuma
Kapvay
Kerendia
Keveyis
Kineret
Kisunla
Korlym
Korsuva
Krintafel
L
Lemtrada
Leqembi
Lidoderm
Livdelzi
Livmarli
Livtencity
Lokelma
Lucemyra
Lucentis
Lutathera
Luxturna
Lynkuet
M
Macrilen
Marinol
Mavenclad
Mayzent
Medication Therapy Management
Mepsevii
Miplyffa
Monjuvi
Mulpleta
Myalept
N
Nascobal
New drugs and new or nonpreferred dosage forms
Nexviazyme
Niktimvo
Nitisinone
Novarel
Nucala
Nucynta
Nuedexta
Nulojix
Nuplazid
Nursing home transition fill
Nuzyra
O
Ocrevus
Oleptro
Omeclamox-Pac
Oncology Drugs
Ongentys
Onmel
Onpattro
Ophthalmic Antihistamines
Opiate Combinations
Opioids Long Acting Pain Management Plan
Oracea
Oralair
Oriahnn
Orilissa
Orkambi
Orlynvah
Otrexup
P
Palforzia
Palsonify
Palynziq
Papziemeos
Parsabiv
PCSK9 Inhibitors
Phentolamine
PiaSky
Potiga
Prevymis
Probuphine
Prolia
Provigil, Nuvigil
Pyrukynd
Q
Qalsody
Qbrexa
Qfitlia
Qutenza
R
Radicava
Ragwitek
Rasuvo
Ravicti
Rayaldee
Rebyota
Recorlev
Rectiv
Retroactive eligibility
Revatio, Adcirca
Revcovi
Reyvow
Rezdiffra
Rhapsido
Rhofade
Rivfloza
Roctavian
Rylaze
Ryplazim
Rystiggo
Ryzneuta
Ryzumvi
S
Samsca
Saphnelo
Scemblix
Scenesse
Secuado
Sephience
Seroquel XR (regimen review)
Siklos
Sinuva
Sirturo
Soliris
Solosec
Soolantra
Spevigo
Spinraza
Spravato
Strensiq
Sunosi
Susvimo
Symdeko
Synagis - MN policy 2024-2025 season
T
Tarpeyo
Tavalisse
Tepezza
Tezspire
Trikafta
Triptan quantity limits
Trogarzo
Trokendi XR
Tryvio
Tyrvaya
Tysabri
Tzield
U
Ultomiris
Ultram ER, Ryzolt ER, ConZip
V
Vabysmo
Vanrafia
Veltassa
Veozah
Vevye
Vijoice
Viltepso
Vimizim
Vivjoa
Vizimpro
Voquezna
Vowst
Voxzogo
Voydeya
Vuity
Vumerity
Vyepti
Vyjuvek
Vykat XR
Vyndaqel & Vyndamax
Vyondys 53
Vyvgart
W
Wainua
Wakix
Wayrilz
Weight Management Agents
Winrevair
X
Xenleta
Xenpozyme
Xermelo
Xgeva
Xifaxan
Xolair
Xolremdi
Xyrem
Xywav
Y
Z
Zanaflex
Zelsuvmi
Zeposia
Ziana
Zilbrysq
Zinplava
Zolgensma
Zoryve foam or cream, 0.3%
Ztalmy
Zurzuvae
Zyclara
Zyprexa Relprevv