Prior Authorization Medication List

Overview 

Prior authorization medication lists and medication categories required for Alaska Medical Assistance: Alaska Medicaid, and Denali KidCare.

Program information

Maximum Units Med Lists over 25 months old are accessible via the Alaska State Libraries Archive & Museums digital collections portal.

Prior authorization lists

• Drug Lookup Tool
• Prior Authorization Med List
• Interim Prior Authorization List  (effective 01/17​/25)
• Maximum Units Med List  (effective 4/21/23)
• Maximum Units Med List (effective 9/15/23)
• Maximum Units Med List (effective 4/19/24)
• Maximum Units Med List (effective 2/25/25)
• Preferred Drug List  (effective 03/1/25) (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
• Electronic Prior Authorization (ePA) 

Prior authorization medications

ANALGESICS, NON-OPIOID

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

ANALGESICS, OPIOID & REVERSAL AGENTS

• Alaska PDMP Prescribing Resources
• Actiq (fentanyl) Criteria | Form
• Evzio: Naloxone Opioid Overdose Treatment Criteria | Form
• Extended Release Opioids Criteria | Form | Effective 10/3/16
• Fentora Criteria | Form 
• Hydromorphone Criteria | Form | Effective 1/6/20
• Oxycodone Criteria, immediate release | Form | Effective 1/6/20
• Narcan Nasal Spray: Naloxone Opioid Overdose Treatmen Criteria 
• Rybix ODT Criteria | Form 
• Stadol (LTC, Onc, Hospice override) Criteria | Form 
• Subsys Criteria | Form 

ANTIPSYCHOTICS

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

BIOLOGICS

• Adbry Criteria | Form
• Aduhelm Criteria | Form
• Bimzelx Criteria | Form
• CGRP Inhibitors (i.e. fremaexumab, ubrogepant, etc.) Criteria | Form | Effective 11/16/20
• Crysvita Criteria | Form 
• Entyvio Criteria | Form | Effective 1/1/24
• Infliximab (Avsola, Inflectra, Remicade, & Renflexis) Criteria | Form 
• Kevzara Criteria | Form
• Lemtrada Criteria | Form
• Leqembi Criteria | Form
• Skyclarys Criteria | Form 
• Stelara Criteria |  Form | Effective 11/01/24
• Synagis, 2024-2025 Criteria | Form
• Tezspire Criteria | Form 
• Tzield Criteria | Form 

CELL AND GENE THERAPY

• Beqvez_Criteria
• Elevidys Criteria | Form 
• Hemgenix Criteria | Form
• Roctavian Criteria | Form
• Vyjuvek Criteria | Form
• Zolgensma Criteria | Form 

CYSTIC FIBROSIS

• Kalydeco Criteria | Form | Effective 10/3/16
• Orkambi Criteria | Form | Effective 6/10/19

GASTROINTESTINAL

• Amitiza and Linzess Criteria | Form
• Diclegis Bonjesta Criteria | Form
• H. Pylori Kits (Helidac, Pylera, Prevpac, Omeclamox-Pak) Criteria | Form
• Marinol Criteria | Form
• Movantik Criteria | Form |
• Relistor (methylnaltrexone) Criteria | Form | Effective 11/20/19
• Transderm Scop (scopolamine patch) Criteria | Form 
• Viberzi Criteria | Form

GENITOURINARY

• Cialis Criteria | Form
• Mytesi Criteria | Form

GROWTH HORMONES

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

HEMOPHILIA

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

HORMONES

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

INFECTIOUS DISEASE

• Bactroban Cream Criteria | Form 
• Baxdela Criteria | Form
• Hepatitis C Direct Acting Antivirals for Chronic Hepatitis C Criteria - All Products and Genotypes | Form | Patient Readiness Assessment Attestation Form | Effective 6/1/22
• Nizoral (ketoconazole oral) Criteria | Form
• Noxafil (posaconazole) Criteria | Form
• Quinine Criteria | Form
• Xifaxan (rifaximin) Criteria | Form | Effective 10/3/16

LIPOTROPICS

• Evkeeza Critera | Form
• Dojolv Critera | Form
• Juxtapid and Kynamro Criteria | Form
• Leqvio Criteria |Form
• Myalept Criteria | Form
• Nexlatol, Nexlizet Critera | Form
• PCSK9 Inhibitors (Praluent and Repatha) Criteria | Form Effective 3/1/24
• Statins (HMG CoA Reductase Inhibitors) Criteria | Form
• Vascepa and Lovaza Criteria | Form Effective 3/15/21

METABOLIC

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

OPIOID DEPENDENCE

• Lucemyra Criteria | Form
•  Oral Buprenorphine-based Medication Assisted Therapy Office-Based Opioid Treatment |  Attestation | Form Effective 6/1/23

PULMONARY ARTERIAL HYPERTENSION

• Adcirca Criteria | Form
• Inhaled Prostacycline Mimetic (Tyvaso, Ventavis) Criteria | Form
• Opsumit Criteria | Form
• Revatio Criteria | Form
• Uptravi Criteria | Form

RESPIRATORY

• Daliresp Criteria | Form
• Dupixent Criteria | Form Effective 11/1/22
• Esbriet Criteria | Form
• Interleukin-5 Inhibitor Criteria (Nucala, Cinqair, Fasenra) | Form Effective 3/1/24
• Ofev Criteria | Form
• Xolair Criteria | Form Effective 6/1/24

SKELETAL MUSCLE RELAXANTS

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

OTHER

• Ampyra Criteria | Form
• Apoky / Kynmob Criteria | Form
• Benlysta Criteria | Form Effective 11/1/22
• Benzodiazepines Criteria | Form
• Berinert (HAE) Criteria | Form
• Botulinum Toxin Products (JCode Only), (Botox, Dysport, Myobloc, Xeomin) Criteria |       Form | Service Auth | Effective 6/1/24
• Brand Name Multisource Medications Criteria | Form
• Briumvi Criteria | Form
• Cholbam Criteria | Form
• Cinryze (HAE) Criteria | Form
• Corlanor Criteria | Form Effective 6/1/24
• DMD Antisense Oligonucleotide (Exondys 51, Amondys 45, Vyondys 53, Viltepso) Criteria | Form
• Emflaza Criteria | Form
• Empaveli Criteria | Form
• Epidiolex Criteria | Form Effective 11/16/20
• Fabhalta | Form
• Fintepla Criteria | Form
• Firadapse/Ruzurgi Criteria | Form Effective 1/2/23
• Firazyr (HAE) Criteria | Form
• Hetlioz Criteria | Form Effective 5/1/22
• Imbruvica (ONC) Criteria | Form
• Insulin Pens Criteria | Form
• Isturisa Criteria | Form
• Jynarque Samsca Criteria | Form Effective 6/1/22 
• Kerendia Criteria | Form Effective 1/1/24
• Kesimpta Criteria | Form
• Krystexxa Criteria | Form
• Lupkynis Criteria | Form
• Lybalvi Criteria | Form
• Mavenclad Criteria | FormForm
• Mayzent Criteria | Form Effective 11/1/22
• New Prescription Medications Criteria | Form
• Nuedexta Criteria | Form
• Ocrevus Criteria | Form
• Onfi Critieria | Form Effective 11/20/19
• Opzelura Criteria | Form Effective 11/1/22
• Orexin Antagonist (Belsomera, Dayvigo, Quviviq) Criteria | Form Effective 6/1/22
• Orilissa, Orihann, Myfembree Criteria | Form | Effective 11/1/22
• Oxbryta Criteria | Form | Effective 11/1/22
• Oxervate Critera | Form
• Palforzi Criteria | Form
• Palynziq Criteria | Form
• Panretin (ONC) Criteria | Form
• Qutenza Criteria | Form
• Reyvow Criteria | Form
• Rystiggo Criteria
• Soliris, Ultomiris Criteria | Form Effective 11/1/22
• Sphingosine 1-phosphate receptor modulators Criteria | Form | Effective 3/1/24
• Spinal Muscular Atrophy (Spinraza, Evrysdi) Criteria | Form
• Spravato Criteria | Form
• Strensiq Criteria | Form | Effective 1/1/24
• Sunosi Criteria | Form
• Tepezza Criteria | Form
• Vecamyl (HTN) Criteria | Form
• Veozah Criteria
• Verquvo Criteria | Form
• Vesicular Monoamine Transporter 2 Inhibitors Criteria
  (Austedo, Austedo XR, Ingrezza, Xenazine) | Form | Effective 11/1/23
• Vumerity Criteria | Form
• Vyndaqel/Vyndamax Criteria | Form
• Wakix Criteria | Form
• Xcopri Criteria | Form
• Xiaflex Criteria | Form
• Xyrem / Xywav Criteria | Form | Effective 1/11/21
• Zilbrysq Criteria | Form
• Ztalmy Criteria | Form
• Zulresso Criteria | Form
• Zurzuvae Criteria | Form
• Zydelig (ONC) Criteria | Form

References for prescribing opioids

Important note: The links provided below are external resources not maintained by the State of Alaska Department of Health (DOH). DOH 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 PainWashington State Agency Medical Directors' Group. 3rd Edition, June 2015
• State of Alaska Prescription Drug Monitoring Program (PDMP)CDC Guideline for Prescribing opioids for Chronic PainUnited States, 2016. Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep 2016;65(No. RR-1):1–49. 
• Injury Prevention & Control: Opioid OverdoseCenters 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 

• 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

Resources