Retired Prior Authorization Medication

Alaska Medicaid General Prior Authorization form

AK General PA Form

Prime Therapeutics’ Preferred Method for Prior Authorization Requests website.

Amitiza and Linzess Criteria

Effective thru 12/31/23

Belsomra Criteria

Effective thru 6/14/20

 Bimzelx Criteria

Benlysta Criteria

Botulinum Toxin Products (JCode only) Criteria

Effective thru 10/2/16

Calcium Criteria (retired)

 Celebrex Criteria (retired)

CGRP Inhibitors Criteria

Effective thru 11/15/20

Corlanor Criteria (retired)

Cosentyx Criteria (retired)

Diclegis Criteria

Effective thru 5/31/22

Dupixent Criteria

Dupixent Criteria

Effective 11/1/22

Eliquis Criteria (retired)

Entyvio Criteria

Effective thru 12/31/23

Entyvio Criteria

Effective thru 2/28/23

Epidiolex Criteria 

Effective thru 11/15/20

Eucrisa Criteria (retired) 

Effective thru 3/14/21

Eucrisa Criteria (retired)

Effective 3/15/21

Firadapse/Ruzurgi Criteria

Effective thru 1/1/23

Folic acid 1mg Criteria (retired)

Hepatitis C Direct Acting Antivirals for Chronic Hepatitis C Criteria - All Products and Genotypes

Effective 1/4/22

Hetlioz Criteria

H.P. Acthar Gel Criteria 

Effective thru 10/2/16

H.P. Acthar Gel Criteria

Effective thru 1/14/19

Human Growth Hormone Criteria

Effective through 1/1/23

Hydromorphone Criteria

Effective thru 1/5/20

Interleukin-5 inhibitor Criteria

Effective thru 1/10/21

Interleukin-5 Inhibitors Criteria

 Effective thru 3/1/22

Interleukin-5 Inhibitor Criteria (Nucala, Cinqair, Fasenra)

Effective 1/11/21

Jynarque Criteria

Effective thru 5/31/22

Kalydeco Criteria

Effective thru 10/2/16

Kerendia Criteria

Effective thru 12/31/23

Lidoderm (lidocaine) patch Criteria (retired)

Effective thru 10/2/16

Lidoderm (lidocaine) patch Criteria (retired) 

Effective thru 10/2/16

Lidoderm (lidocaine) patch Criteria (retired)

Effective thru 10/2/16

Long-acting Beta Agonist Criteria (retired)

Lovaza Criteria

Effective thru 3/14/21

Magnesium Criteria (retired)

MAT Provider Attestation Form

Effective thru 5/31/23

Makena Criteria

Mayzent Criteria

Ocrevus Criteria

Onfi Criteria

Effective 3/1/23

Onfi Criteria 

Effective thru 11/19/19

Onsolis (fentanyl) Criteria

Opzelura Criteria

Oral Buprenorphine-based Medication Assisted Therapy (MAT) Criteria; Office-Based Opioid Treatment (OBOT) (e.g., Bunavail, Suboxone, Subutex, Zubsolv)

 Effective thru 5/31/23

Orexin Criteria 

Effective thru 5/31/22

Orilissa, Orihann, Myfembree Criteria

Orkambi Criteria

Effective thru 6/9/19

Oxbryta Criteria

Oxycodone Criteria, immediate release

 Effective thru 1/5/20

PCSK9 Inhibitors (Praluent and Repatha) Criteria

Pradaxa Criteria (retired)

Proton Pump Inhibitors Criteria (retired)

Relistor (methylnaltrexone) Criteria

Effective thru 11/19/19

Second Generation Non-Sedating Antihistamines Criteria (retired)

Serostim Criteria

Effective thru 10/2/16

Soliris, Ultomiris Criteria

Sphingosine 1-phosphate receptor modulators Criteria

Stelara Criteria 

Effective thru 6/9/19

Strensiq Criteria

Effective thru 12/31/23

Suboxone and Subutex Criteria (retired)

Effective thru 11/11/18

Synagis, 2023-2024 Criteria

Tecfidera (dimethyl fumarate) Criteria (retired)

TOBI Podhaler Criteria (retired)

Vancocin (vancomycin) Criteria (retired)

Vascepa and Lovaza Criteria

Effective thru 3/14/21

Vesicular Monoamine Transporter 2 Inhibitors Criteria Austedo, Austedo XR, Ingrezza, Xenazine) 

Victrelis Criteria (retired)

Vitamin E Criteria (retired)

Xarelto Criteria (retired)

Xifaxan (rifaximin) Criteria

Effective thru 10/2/16

Xolair Criteria (retired)

Xolair Criteria (retired)

Effective 11/1/22

Xyrem Criteria

Effective thru 1/10/21

Zyvox (linezolid) Criteria (retired)