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 (effective 11/1/24)
  
• Maximum Units Med List over 25 months old are accessible via the Alaska State Libraries Archives & Museums digital collections portal.
• Maximum Units Med List (effective through 4/20/23)
• Maximum Units Med List (effective 4/21/23)
• Maximum Units Med List (effective 9/15/23)
  
• Maximum Units Med List (effective 4/19/24)
• Preferred Drug List (effective 11/1/24)  (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
• Cell and Gene Therapy
• Gastrointestinal
• Genitourinary
• Growth Hormones
• Hemophilia
• Hormones
• Infectious disease
• Lipotropics
• Metabolic
• Opioid dependence
• Pulmonary Arterial Hypertension (PAH)
• Respiratory (Asthma, COPD, Allergy)
• Skeletal muscle relaxants
• Other criteria
• 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.
5. 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.
7. 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

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

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

CELL AND GENE THERAPY

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

CYSTIC FIBROSIS

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

GASTROINTESTINAL

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

GENITOURINARY

• Cialis Criteria | Form | ePA
• Mytesi Criteria | Form | ePA

GROWTH HORMONES

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

HEMOPHILIA

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

HORMONES

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

INFECTIOUS DISEASE

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

LIPOTROPICS

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

METABOLIC

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

OPIOID DEPENDENCE

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

PULMONARY ARTERIAL HYPERTENSION

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

RESPIRATORY

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

SKELETAL MUSCLE RELAXANTS

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

OTHER

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

• Archive of Retired Criteria
  

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

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

Prime Therapeutics Technical Call Center
800-884-3238

HMS (Healthcare Management Solutions, LLC)
907-644-6800, 800-770-5650

Provider Inquiry/Provider Services

HMS (Healthcare Management Solutions, 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