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Prior Authorization (PA)

Prior Authorization Archive - 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015

Covered Drugs for Dual Eligible Individuals

Therapeutic Categories:

  • Anti-Infectives - Cephaloporins, Ketoconazole Oral Tablets, Skin and Soft Tissue, Special Formulations
  • Biologics - Botulinum toxins, Hematopoetic, Immunomodulating, Replacement Therapy, Respiratory, Skeletal
  • Cardiovascular - Anticoagulants, Antihypertensives, Antiplatelet, Antihyperlipidemics, Clonidine Products, Hereditary Angioedema, Pulmonary Arterial Hypertension, Revatio
  • Central Nervous System/Behavioral Health - ADHD & Narcolepsy, Alzheimer's, Antidepressants, Anti-Migraine, Anxiolytic/Hypnotic, Atypical Antipsychotics, Fibromyalgia, Multiple Sclerosis, Narcotic Analgesics, Parkinson's, Restless Leg Syndrome, Requip XL/Mirapex ER, Smoking Cessation, Substance Abuse Treatment
  • Diabetes/Endocrine - Diabetic Medications, Erythropoietin Stimulating Agents, Growth Hormone, Makena®, Testosterone
  • Gastro-Intestinal - Amitiza, Anti-emetic, Anti-Ulcer, Bowel Prep
  • Genitourinary System - Benign Prostatic Hyperplasia (BPH), Bladder Control Drugs
  • Hemophilia - Adynovate, Alprolix, Coagadex, Corifact, Eloctate, Idelvion, Obizur, Tretten
  • Hepatic Disorders - Daklinza, Harvoni, Incivek, Olysio, Sovaldi, Technivie, Victrelis, Viekira Pak, Zepatier
  • Metabolic Disorders- Procysbi, Ravicti, Strensiq
  • Ocular/Otic - Ocular Allergy, Opthalmic Anti-Infective/Steroid, Ophthalmic Corticosteroid, Ophthalmic NSAIDs, Ophthalmic Glaucoma, Otic Anti-Infective
  • Oncologic Therapies - Afinitor, Halaven, Ixempra, Kadcyla, Perjeta, Tykerb 
  • Respiratory - Asthma & COPD Inhalation Medications, Antihistamines, Leukotriene Modifiers, Nasal Allergy Sprays, Pulmonary Arterial Hypertension, Pulmonary Fibrosis, Synagis, Tobi/Pulmozyme, Xolair
  • Skeletal System - Amrix & Fexmid, Bisphosonates, Forteo, Gout, NSAIDs, Skeletal Muscle Relaxants, Soma
  • Special Formulations - Millipred®, Veripred 20®
  • Topical - Antifungal, Elidel/Protopic, Lidoderm Patch, Pediculicides, Topical Antibiotic Medications, Topical Corticosteroids
Last Modified on Dec 14, 2022