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State of Alaska

Department of Health > Health Care Services > Retired Criteria

Retired Criteria

Amitiza and Linzess Criteria | Form | ePA | Effective thru 12/31/23
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
Corlanor Criteria (retired) | Form | ePA
Cosentyx Criteria (retired) | Form | ePA
Diclegis Criteria | Form | ePA | Effective thru 5/31/22
Eliquis Criteria (retired) | ePA
Entyvio Criteria | Form | ePA | Effective thru 12/31/23
Entyvio Criteria | Form | ePAEffective 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
Interleukin-5 Inhibitor Criteria (Nucala, Cinqair, Fasenra) | Form | ePA | Effective 1/11/21
Jynarque Criteria | Form | ePA | Effective thru 5/31/22
Kalydeco Criteria | Form | ePA | Effective thru 10/2/16
Kerendia Criteria | Form | ePA | Effective thru 12/31/23
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 | ePAEffective 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
PCSK9 Inhibitors (Praluent and Repatha) Criteria | Form | ePA
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 |
Sphingosine 1-phosphate receptor modulators Criteria | Form | ePA
Stelara Criteria [CAM] | Form | ePA | Effective thru 6/9/19
Strensiq Criteria | Form | ePA | Effective thru 12/31/23
Suboxone and Subutex Criteria (retired) | ePA | Effective thru 11/11/18+
Synagis, 2023-2024 Criteria | Form | ePA
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
Vesicular Monoamine Transporter 2 Inhibitors Criteria
(Austedo, Austedo XR, Ingrezza, Xenazine) | Form | ePA
Victrelis Criteria (retired) | ePA
Vitamin E Criteria (retired) | ePA
Xarelto Criteria (retired) | ePA
Xifaxan (rifaximin) Criteria | Form | ePA | Effective thru 10/2/16
Xolair Criteria (retired) | Form | ePA
Xolair Criteria (retired) | Form | ePA | Effective 11/1/22
Xyrem Criteria | Form | ePA | Effective thru 1/10/21
Zyvox (linezolid) Criteria(retired) | Form | ePA

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