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DHSS Reorganization
>
Department of Health
>
Health Care Services
>
Retired Criteria
Page Content
Retired Criteria
Belsomra Criteria
|
Form
|
ePA
|
Effective thru 6/14/20
Benlysta Criteria
|
Form
|
ePA
Botulinum Toxin Products (JCode only) Criteria
|
Form
,
Service Auth
|
ePA
|
Effective thru 10/2/16
Calcium Criteria
(retired) |
ePA
Celebrex Criteria
(retired) [
NSAID
] |
Form
|
ePA
CGRP Inhibitors Criteria
|
Form
|
ePA
|
Effective thru 11/15/20
Cosentyx Criteria
(retired) |
Form
|
ePA
Diclegis Criteria
|
Form
|
ePA |
Effective thru 5/31/22
Eliquis Criteria
(retired) |
ePA
Entyvio Criteria
|
Form
|
ePA
Effective thru 2/28/23
Epidiolex Criteria
|
Form
|
ePA
|
Effective thru 11/15/20
Eucrisa Criteria
(retired) |
Form
|
ePA
|
Effective thru 3/14/21
Eucrisa Criteria
(retired)|
Form
|
ePA
|
Effective 3/15/21
Firadapse/Ruzurgi Criteria
|
Form
|
ePA |
Effective thru 1/1/23
Folic acid 1mg Criteria
(retired) |
ePA
Hepatitis C Direct Acting Antivirals for Chronic Hepatitis C Criteria - All Products and Genotypes
|
Form
|
ePA
|
Effective 1/4/22
Hetlioz Criteria
|
Form
|
ePA
H.P. Acthar Gel Criteria
|
Form
|
ePA
|
Effective thru 10/2/16
H.P. Acthar Gel Criteria
|
Form
|
ePA
|
Effective thru 1/14/19
Human Growth Hormone Criteria
|
Form
|
ePA
|
Effective through 1/1/23
Hydromorphone Criteria
|
Form
|
ePA
|
Effective thru 1/5/20
Interleukin-5 inhibitor Criteria
|
Form
|
ePA
|
Effective thru 1/10/21
Interleukin-5 Inhibitors Criteria
|
Form
|
ePA
|
Effective thru 3/1/22
Jynarque Criteria
|
Form
|
ePA
|
Effective thru 5/31/22
Kalydeco Criteria
|
Form
|
ePA
|
Effective thru 10/2/16
Lidoderm (lidocaine) patch Criteria
(retired) |
Form
|
ePA
|
Effective thru 10/2/16
Lidoderm (lidocaine) patch Criteria
(retired) |
Form
|
ePA
|
Effective thru 10/2/16
Lidoderm (lidocaine) patch Criteria
(retired) |
Form
|
ePA
|
Effective thru 10/2/16
Long-acting Beta Agonist Criteria
[
BRONCHODILATORS
]
(retired)
|
Form
|
ePA
Lovaza Criteria
|
Form
|
ePA
|
Effective thru 3/14/21
Magnesium Criteria
(retired) |
ePA
MAT Provider Attestation Form
,
Form
|
ePA
|
Effective thru 5/31/23
Makena Criteria
|
Form
|
ePA
Mayzent Criteria
|
Form
|
ePA
Onfi Criteria
|
Form
|
ePA
Effective 3/1/23
Onfi Criteria
[
ANTICONV
] |
Form
|
ePA
|
Effective thru 11/19/19
Onsolis (fentanyl) Criteria
|
Form
|
ePA
Opzelura Criteria
|
Form
|
ePA
Oral Buprenorphine-based Medication Assisted Therapy (MAT) Criteria;
Office-Based Opioid Treatment (OBOT) (e.g., Bunavail, Suboxone, Subutex, Zubsolv)
|
Effective thru 5/31/23
Orexn Criteria
|
Form
|
ePA
|
Effective thru 5/31/22
Orilissa, Orihann, Myfembree Criteria
|
Form
|
ePA
|
Orkambi Criteria
|
Form
|
ePA
|
Effective thru 6/9/19
Oxbryta Criteria
|
Form
|
ePA
Oxycodone Criteria,
immediate release
|
Form
|
ePA
|
Effective thru 1/5/20
Pradaxa Criteria
(retired) |
ePA
Proton Pump Inhibitors Criteria
(retired)
|
Form
|
ePA
Relistor (methylnaltrexone) Criteria
|
Form
|
ePA
|
Effective thru 11/19/19
Second Generation Non-Sedating Antihistamines Criteria
(retired) |
Form
|
ePA
Serostim Criteria
|
Form
|
ePA
|
Effective thru 10/2/16
Soliris, Ultomiris Criteria
|
Form
|
ePA
|
Stelara Criteria
[
CAM
] |
Form
|
ePA
|
Effective thru 6/9/19
Suboxone and Subutex Criteria
(retired) |
ePA
|
Effective thru 11/11/18+
Tecfidera (dimethyl fumarate) Criteria
(retired) |
Form
|
ePA
TOBI Podhaler Criteria
(retired) |
Form
|
ePA
Vancocin (vancomycin) Criteria
(retired) |
Form
|
ePA
Vascepa and Lovaza Criteria
|
Form
|
ePA
|
Effective thru 3/14/21
Victrelis Criteria
(retired) |
ePA
Vitamin E Criteria
(retired) |
ePA
Xarelto Criteria
(retired) |
ePA
Xifaxan (rifaximin) Criteria
|
Form
|
ePA
|
Effective thru 10/2/16
Xyrem Criteria
|
Form
|
ePA
|
Effective thru 1/10/21
Zyvox (linezolid) Criteria
(retired)
|
Form
|
ePA
Return to the
Medication Prior Authorization page
.
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