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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
    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
    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
    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

    Farxiga
    Farydak
    Fenofibrates
    Ferriprox
    Fetzima
    Fexmid
    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
    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
    Invokana
    Iprivask
    Iressa

    J

    Jakafi
    Jardiance
    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
    Luzu
    Lynparza
    Lyrica

    M

    Makena
    Marinol
    Medication Therapy Management
    Mekinist
    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)
    Silenor
    Sirturo
    Sitavig
    Sklice
    Soliris
    Solodyn
    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

    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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