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2020 Medicaid Preapproval Criteria 2020 Medicaid Preapproval Criteria ABILIFY MAINTENA ................................................................................................................................................................ 10 ACTHAR HP ............................................................................................................................................................................ 11 ACTIMMUNE ......................................................................................................................................................................... 13 ADAGEN & REVCOVI ............................................................................................................................................................. 14 ADCIRCA ................................................................................................................................................................................ 15 ADEMPAS .............................................................................................................................................................................. 16 AFINITOR ............................................................................................................................................................................... 18 AFINITOR DISPERZ ................................................................................................................................................................. 19 ALDURAZYME ........................................................................................................................................................................ 20 ALGLUCOSIDASE ALFA ........................................................................................................................................................... 21 ALPHA-1 PROTEINASE INHIBITORS ....................................................................................................................................... 22 AMPYRA ................................................................................................................................................................................ 23 AMIFAMPRIDINE ................................................................................................................................................................... 24 ANTIEMETICS ........................................................................................................................................................................ 26 ANTIHEMOPHILIC FACTORS .................................................................................................................................................. 28 ARCALYST .............................................................................................................................................................................. 30 ARISTADA .............................................................................................................................................................................. 31 ARIKAYCE ............................................................................................................................................................................... 32 ATGAM .................................................................................................................................................................................. 33 ATRYN .................................................................................................................................................................................... 34 AUBAGIO ............................................................................................................................................................................... 35 AUSTEDO ............................................................................................................................................................................... 36 AVONEX ................................................................................................................................................................................. 37 AZEDRA ................................................................................................................................................................................. 38 BANZEL .................................................................................................................................................................................. 39 BELEODAQ ............................................................................................................................................................................. 40 BENLYSTA .............................................................................................................................................................................. 41 1 BESPONSA ............................................................................................................................................................................. 42 BETASERON ........................................................................................................................................................................... 43 BEVACIZUMAB ...................................................................................................................................................................... 44 BLINCYTO .............................................................................................................................................................................. 45 BONJESTA & DICLEGIS ........................................................................................................................................................... 46 BOTOX ................................................................................................................................................................................... 47 BRINEURA .............................................................................................................................................................................. 49 CABLIVI .................................................................................................................................................................................. 50 CALQUENCE........................................................................................................................................................................... 51 C1 ESTERASE INHIBITOR ........................................................................................................................................................ 52 CARBAGLU ............................................................................................................................................................................. 53 CAYSTON ............................................................................................................................................................................... 54 CERDELGA ............................................................................................................................................................................. 55 CEREZYME ............................................................................................................................................................................. 56 CGRP Inhibitors ..................................................................................................................................................................... 57 CHOLBAM .............................................................................................................................................................................. 59 CINQAIR IV ............................................................................................................................................................................ 60 COAGADEX ............................................................................................................................................................................ 61 COMPOUNDED MEDICATIONS ............................................................................................................................................. 62 CONTINUOUS GLUCOSE MONITORS ..................................................................................................................................... 63 CORLANOR ............................................................................................................................................................................ 64 CRESEMBA ............................................................................................................................................................................. 65 CRYSVITA ............................................................................................................................................................................... 66 CYSTADANE ........................................................................................................................................................................... 67 CYSTAGON ............................................................................................................................................................................
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