Medication Prior Authorization

Table of Contents

• Drug Lookup Tool
• 90 Day Generic Med List (eff. 5-18-2014)
• Prior Authorization Med List
• Interim Prior Authorization List
• Maximum Units Med List (eff. through 6-9-2019)
• Maximum Units Med List (eff. 6-10-2019)
• Maximum Units Med List (eff. 9-17-2021)
  
• Preferred Drug List effective 3/1/2023 (Legend: How to Read the PDL)
• General Medication Prior Authorization Fill-in Form
• Cost Exceeds Maximum Prior Authorization Form
  
• Information About Your Prescription Drug Benefits and Prior Authorization - Pamphlet
• Pharmacy Links
• Contacts
• Sign up for email updates

Prior Authorization Medication Categories

• Analgesics, non-opioid
• Analgesics, opioid & reversal agents
  
• Antipsychotics
• Biologics
• Cystic Fibrosis
• Gastrointestinal
• Genitourinary
• Growth Hormones
• Hemophilia
• Hormones
• Infectious disease
• Lipotropics
• Metabolic
• Opioid dependence
• Pulmonary Arterial Hypertension (PAH)
• Respiratory (Asthma, COPD, Allergy)
• Skeletal muscle relaxants
• Other, including retired criteria

Navigation Tips:

1. Use the table of contents above to jump to the desired medication category, or
2. Use “CTRL-F” to open a search box into which you can type your search term, or
3. Scroll through the list below to find the desired medication.
4. Clicking on the [PDL] link in the medication category header will open a new window with the current Preferred Drug List to allow you to readily search for preferred products within the category.
5. Clicking on the [TOP] link in the medication category header will bring you back to the Table of Contents at the top of this page.

Prior Authorization Medication Categories

ANALGESICS, NON-OPIOID

• Cambia Criteria | Form | ePA
• Gralise/Horizant Criteria | Form | ePA
• Lyrica (pregabalin) Criteria | Form | ePA
  
• Vimovo Criteria | Form | ePA
  

ANALGESICS, OPIOID & REVERSAL AGENTS

• Alaska PDMP Prescribing Resources
  
• Additional Information for Prescribing Opioids
• SUPPORT Act

• Extended Release Opioids Criteria | Form | ePA | Effective 10/3/16
  
• Actiq (fentanyl) Criteria | Form | ePA
  
• Fentora Criteria | Form | ePA
  
• Hydromorphone Criteria | Form | ePA | Effective thru 1/5/20
• Hydromorphone Criteria | Form | ePA | Effective 1/6/20
• Onsolis (fentanyl) Criteria, to be retired | Form | ePA
  
• Oxycodone Criteria, immediate release | Form | ePA | Effective thru 1/5/20
• Oxycodone Criteria, immediate release | Form | ePA | Effective 1/6/20
• Rybix ODT Criteria | Form | ePA
  
• Stadol (LTC, Onc, Hospice override) Criteria | Form | ePA
  
• Subsys Criteria | Form | ePA
  
• Narcan Nasal Spray: Naloxone Opioid Overdose Treatmen Criteria | Form | ePA
  
• Evzio: Naloxone Opioid Overdose Treatment Criteria | Form | ePA
  

ANTIPSYCHOTICS

• Atypical Antipsychotic Therapeutic Duplication Criteria | Form | ePA
  • Atypical Antipsychotic Criteria – Exceed Quantity Limit (QL) Criteria | Form | ePA
  • Atypical Antipsychotic Criteria – Child Less than 5 years old | Form | ePA

BIOLOGICS

• Leqembi Criteria | Form | ePA
• Tzield Criteria | Form | ePA
• Aduhelm Criteria | Form | ePA
• Crysvita Criteria | Form | ePA
• CGRP Inhibitors Criteria | Form | ePA | Effective thru 11/15/20
  
• CGRP Inhibitors Criteria | Form | ePA | Effective 11/16/20
  
• Entyvio Criteria | Form | ePA | Effective 3/1/23
• Entyvio Criteria | Form | ePA Effective thru 2/28/23
• Infliximab Criteria | Form | ePA
• Lemtrada Criteria | Form | ePA
• Stelara Criteria [CAM] | Form | ePA | Effective thru 6/9/19
• Stelara Criteria [CAM] | Form | ePA | Effective 6/10/19
• Synagis, 2022-2023 Criteria | Form | ePA

CYSTIC FIBROSIS

• Kalydeco Criteria | Form | ePA | Effective thru 10/2/16
• Kalydeco Criteria | Form | ePA | Effective 10/3/16
• Orkambi Criteria | Form | ePA | Effective thru 6/9/19
• Orkambi Criteria | Form | ePA | Effective 6/10/19

GASTROINTESTINAL

• Amitiza and Linzess Criteria | Form | ePA
• Marinol Criteria | Form | ePA
• Diclegis Bonjesta Criteria | Form | ePA
• Diclegis Criteria | Form | ePA | Effective thru 5/31/22
• H. pylori kits Criteria | Form | ePA
• Movantik Criteria | Form | ePA
• Relistor (methylnaltrexone) Criteria | Form | ePA | Effective thru 11/19/19
• Relistor (methylnaltrexone) Criteria | Form | ePA | Effective 11/20/19
• Transderm Scop (scopolamine patch) Criteria | Form | ePA
• Viberzi Criteria | Form | ePA

GENITOURINARY

• Botulinum Toxin Products (JCode only) Criteria | Form, Service Auth | ePA | Effective thru 10/2/16
• Botulinum Toxin Products (JCode only) Criteria | Form, Service Auth | ePA | Effective 10/3/16
• Cialis Criteria | Form | ePA
• Mytesi Criteria | Form | ePA

GROWTH HORMONES

• Human Growth Hormone Criteria | Form | ePA |  Effective 1/2/23
  
• Human Growth Hormone Criteria | Form | ePA | Effective through 1/1/23
• Serostim Criteria | Form | ePA | Effective thru 10/2/16
• Serostim Criteria | Form | ePA | Effective 10/3/16
• Voxzogo Criteria |
  

HEMOPHILIA

• Hemophilia / Clotting Factor Criteria | Form | ePA
• Hemlibra Criteria | Form | ePA

HORMONES

• Egrifta Criteria | Form | ePA
• H.P. Acthar Gel Criteria | Form | ePA | Effective 1/15/19
• 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 Chorionic Gonadotropin (HCG) Criteria | Form | ePA
• Makena Criteria | Form | ePA

INFECTIOUS DISEASE

• Hepatitis C Direct Acting Antivirals for Chronic Hepatitis C Criteria - All Products and Genotypes | Form | ePA | Effective 1/4/2022
• Hepatitis C Direct Acting Antivirals for Chronic Hepatitis C Criteria - All Products and Genotypes | Form | ePA | Patient Readiness Assessment Attestation Form | Effective 6/1/2022
  
• Bactroban Cream Criteria | Form | ePA
• Nizoral (ketoconazole oral) Criteria | Form | ePA
• Noxafil (posaconazole) Criteria | Form | ePA
• Quinine Criteria | Form | ePA
• Xifaxan (rifaximin) Criteria | Form | ePA | Effective thru 10/2/16
• Xifaxan (rifaximin) Criteria | Form | ePA | Effective 10/3/16
• Baxdela Criteria | Form | ePA

LIPOTROPICS

• Myalept Criteria | Form | ePA
• Evkeeza Critera | Form | ePA
• Dojolv Critera | Form | ePA
• Nexlatol, Nexlizet Critera | Form | ePA
• Juxtapid and Kynamro Criteria | Form | ePA
• Leqvio Criteria |Form | ePA |
  
• Lovaza Criteria – to be retired | Form | ePA | Effective thru 3/14/21
• PCSK9 Inhibitors (Praluent and Repatha) Criteria | Form | ePA
• Statins (HMG CoA Reductase Inhibitors) Criteria | Form | ePA
• Vascepa and Lovaza Criteria | Form | ePA | Effective 3/15/21
• Vascepa and Lovaza Criteria | Form | ePA | Effective thru 3/14/21

METABOLIC

• Prolia, Xgeva Criteria | Form | ePA
• Reclast, Zometa Criteria | Form | ePA
• Imcivree Criteria | Form | ePA
• Evenity Criteria | Form | ePA
• Bone Resorption Inhibitors Criteria | Form | ePA
• Ergocalciferol Criteria (Vitamin D; 50,000 unit Criteria) | Form | ePA
• Invokana Criteria | Form | ePA
• Korlym Criteria | Form | ePA
• Leuprolide Criteria | Form | ePA
• Extended-Release Metformin (Glumetza and Fortamet ER) Criteria | Form | ePA

OPIOID DEPENDENCE

• Oral Buprenorphine-based Medication Assisted Therapy (MAT) Criteria;
  Office-Based Opioid Treatment (OBOT) (e.g., Bunavail, Suboxone, Subutex, Zubsolv) |
  MAT Provider Attestation Form, Form | ePA | Effective 11/12/18
• Lucemyra Criteria | Form | ePA

PULMONARY ARTERIAL HYPERTENSION

• Opsumit Criteria | Form | ePA
• Uptravi Criteria | Form | ePA
• Inhaled Prostacycline Mimetic Criteria | Form | ePA
• Adcirca Criteria | Form | ePA
• Revatio Criteria | Form | ePA

RESPIRATORY

• Esbriet Criteria | Form | ePA
• Ofev Criteria | Form | ePA
• Interleukin-5 inhibitor Criteria | Form | ePA | Effective thru 1/10/21
• Interleukin-5 inhibitor Criteria | Form | ePA | Effective 1/11/21
• Interleukin-5 Inhibitors Criteria | Form | ePA | Effective thru 3/1/22
• Dupixent Criteria | Form | ePA
• Dupixent Criteria | Form | ePA | Effective 11/1/2022
  
• Xolair Criteria | Form | ePA
• Xolair Criteria | Form | ePA | Effective 11/1/2022
  
• Daliresp Criteria [COPD] | Form | ePA

SKELETAL MUSCLE RELAXANTS

• Amrix Criteria | Form | ePA
• Fexmid Criteria | Form | ePA
• Soma Criteria | Form | ePA
• Zanaflex Criteria | Form | ePA

OTHER, INCLUDING RECENTLY RETIRED CRITERIA

• Cholbam Criteria | Form | ePA
• Spravato Criteria | Form | ePA |
  
• Empaveli Criteria | Form | ePA |
  
• Tepezza Criteria | Form | ePA |
  
• Spinal Muscular Atrophy (Spinraza, Evrysdi) Criteria | Form | ePA |
• Zulresso Criteria | Form | ePA |
• Soliris, Ultomiris Criteria | Form | ePA |
• Soliris, Ultomiris Criteria | Form | ePA | Effective 11/1/2022
• DMD Antisense Oligonucleotides Criteria | Form | ePA |
  
• Krystexxa Criteria | Form | ePA |
  
• Ocrevus Criteria | Form | ePA
• Sphingosine 1-phosphate receptor modulators Criteria | Form | ePA
• Benlysta Criteria | Form | ePA
• Benlysta Criteria | Form | ePA | Effective 11/1/2022
  
• Opzelura Criteria | Form | ePA
• Opzelura Criteria | Form | ePA | Effective 11/1/2022
  
• Lybalvi Criteria | Form | ePA
• Kerendia Criteria | Form | ePA
• Verquvo Criteria | Form | ePA
• Isturisa Criteria | Form | ePA
• Lupkynis Criteria | Form | ePA
• Wakix Criteria | Form | ePA
• Fintepla Criteria | Form | ePA
• Kesimpta Criteria | Form | ePA
• Xcopri Criteria | Form | ePA
• Insulin Pens Criteria | Form | ePA
  
• Palforzi Criteria | Form | ePA
  
• Reyvo Criteria | Form | ePA
  
• Apoky / Kynmob Criteria | Form | ePA
  
• Strensiq Criteria | Form | ePA
  
• Oxervate Critera | Form | ePA
  
• Oxbryta Criteria | Form | ePA
• Oxbryta Criteria | Form | ePA | Effective 11/1/2022
  
• Orexin Antagonist Criteria | Form | ePA | Effective 6/1/22
  
• Orexn Criteria | Form | ePA | Effective thru 5/31/22
  
• Jynarque Samsca Criteria | Form | ePA | Effective 6/1/22
  
• Jynarque Criteria | Form | ePA | Effective thru 5/31/22
• Vumerity Criteria | Form | ePA
• Firadapse/Ruzurgi Criteria | Form | ePA | Effective thru 1/1/23
• Firadapse/Ruzurgi Criteria | Form | ePA | Effective 1/2/23
  
• Vyndaqel/Vyndamax Criteria | Form | ePA
• Corlanor Criteria | Form | ePA
• Xiaflex Criteria | Form | ePA
• Mavenclad Criteria | Form | ePA
• Mayzent Criteria | Form | ePA
• Mayzent Criteria | Form | ePA | Effective 11/1/2022
  
• Emflaza Criteria | Form | ePA
• Sunosi Criteria | Form | ePA
• Benzodiazepines Criteria | Form | ePA
• Vesicular Monoamine Transporter 2 Inhibitors Criteria | Form | ePA
• Palynziq Criteria | Form | ePA
• Nuedexta Criteria | Form | ePA
• Hetlioz Criteria | Form | ePA
• Hetlioz Criteria | Form | ePA | Effective 5/1/2022
• Orilissa, Orihann, Myfembree Criteria | Form | ePA |
• Orilissa, Orihann, Myfembree Criteria | Form | ePA | Effective 11/1/2022
• Epidiolex Criteria | Form | ePA | Effective thru 11/15/20
• Epidiolex Criteria | Form | ePA | Effective 11/16/2020
  
• Xyrem Criteria | Form | ePA | Effective thru 1/10/21
• Xyrem / Xywav Criteria | Form | ePA | Effective 1/11/21
• New Prescription Medications Criteria | Form | ePA
• Maximum Units (QL) Criteria | Form | ePA
• Brand Name Multisource Medications Criteria | Form | ePA
• Botulinum Toxin Products Criteria (JCode only) | Form, Service Auth | ePA
• Onfi Criteria | Form | ePA Effective 3/1/23
• Onfi Criteria [ANTICONV] | Form | ePA | Effective thru 11/19/19
• Onfi Critieria | Form | ePA | Effective 11/20/19
• Vecamyl (HTN) Criteria | Form | ePA
• Berinert (HAE) Criteria | Form | ePA
• Cinryze (HAE) Criteria | Form | ePA
• Firazyr (HAE) Criteria | Form | ePA
• Ampyra Criteria [MS] | Form | ePA
• Imbruvica (ONC) Criteria | Form | ePA
• Panretin (ONC) Criteria | Form | ePA
• Zydelig (ONC) Criteria | Form | ePA
• Belsomra Criteria | Form | ePA | Effective thru 6/14/20
• Onsolis (fentanyl) Criteria – to be retired | ePA
  
  
• Proton Pump Inhibitors Criteria (retired) | Form | ePA
• Long-acting Beta Agonist Criteria [BRONCHODILATORS] (retired) | Form | ePA
• Zyvox (linezolid) Criteria (retired) | Form | ePA
• Vancocin (vancomycin) Criteria (retired) | Form | ePA
  
• Vitamin E Criteria (retired) | ePA
• Calcium Criteria (retired) | ePA
• Magnesium Criteria (retired) | ePA
• Victrelis Criteria (retired) | ePA
• Folic acid 1mg Criteria (retired) | ePA
• Eliquis Criteria (retired) | ePA
• Pradaxa Criteria (retired) | ePA
• Xarelto Criteria (retired) | ePA
• Cosentyx Criteria (retired) | Form | ePA
• Tecfidera (dimethyl fumarate) Criteria (retired) | Form | ePA
• Suboxone and Subutex Criteria (retired) | ePA | Effective thru 11/11/18+
  
• Second Generation Non-Sedating Antihistamines Criteria (retired) | Form | ePA
• 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
• Eucrisa Criteria (retired)| Form | ePA | Effective 3/15/21
• Eucrisa Criteria (retired) | Form | ePA | Effective thru 3/14/21
• TOBI Podhaler Criteria (retired) | Form | ePA
• Celebrex Criteria (retired) [NSAID] | Form | ePA
  

References for Prescribing Opioids [Top]

Important note: The links provided below are external resources not maintained by the State of AlaskaDepartment of Health. The State of Alaska Department of Health is not responsible for the content contained in any of the links provided below.

Morphine Equivalent Dose Calculator
© Washington State Agency Medical Directors' Group. 2007-2015.
Interagency Guideline on Prescribing Opioids for Pain
Washington State Agency Medical Directors' Group. 3rd Edition, June 2015.
State of Alaska Prescription Drug Monitoring Program (PDMP)
CDC Guideline for Prescribing opioids for Chronic Pain
United States, 2016. Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
Injury Prevention & Control: Opioid Overdose
Centers for Disease Control and Prevention (CDC). Atlanta, GA.
Resources and Tools for Prescribers. Search and Rescue: Empowering Prescribers to Identify Opioid Drug Abuse
© 2016 Partnership for Drug-Free Kids.
ASAM: Provider's Clinical Support System
ASAM: Provider's Clinical Support System - Mentoring

Pharmacy Links [TOP]

• Drug Utilization Program Overview
• Preferred Drug List Program Overview
• Alaska DHCS Medicaid Homepage
• State of Alaska Public Notice Website
• Alaska Administrative Code, Title 7 Part 8
• Alaska State Statutes
• CMS Medicaid Drug Rebate Program
• CMS Medicaid Pharmacy Drug Pricing (NADAC files)
• Alaska Medicaid Provider Billing Manuals
• Alaska Medicaid Health Enterprise Pharmacy site

Contacts [TOP]

Prior Authorization Staff

Magellan Clinical Call Center
800-331-4475 – phone
888-603-7696 – fax

Magellan Technical Call Center
800-884-3238

Conduent State Healthcare, LLC.
907-644-6800, 800-770-5650

Provider Inquiry/Provider Services

Conduent State Healthcare, LLC.
907-644-6800, 800-770-5650

Division of Healthcare Services
907-334-2400

Medicaid Pharmacy and Ancillary Services Unit

Drug Utilization Review Program
907-334-2458, 907-334-2425

Preferred Drug List Program
907-334-2458, 907-334-2425