CLINICAL PRIOR AUTHORIZATION (PA) TABLE of CONTENTS Medications Requiring Clinical Prior Authorization (PA) for Kansas Medicaid Are Listed in the Table Below

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CLINICAL PRIOR AUTHORIZATION (PA) TABLE OF CONTENTS Medications requiring Clinical Prior Authorization (PA) for Kansas Medicaid are listed in the table below. Please use this table to identify if a specific medication requires Clinical PA and which Clinical PA criteria and PA form should be used to request an authorization from the patient’s specific health plan (MCO/FFS). Please note, medications requiring Clinical PA may also have to meet Non-preferred PDL PA criteria before the claim may be considered for payment. Products listed in red font have criteria updated since the last posting. For drugs that are new to the market and not listed in the table, please click the following medication hold link for further information: http://www.kdheks.gov/hcf/pharmacy/medication_hold_review.htm

Use the “ctrl + F” keyboard shortcut to search for a medication or keyword within this document. BRAND NAME GENERIC NAME PA CRITERIA PA FORM Idecabtagene https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chimeric_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chim Abecma® vicleucel Antigen_Receptor_T-Cell_Therapy_Agents.pdf eric_Antigen_Receptor_T-Cell_Therapy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Abilify Discmelt® Aripiprazole tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Abilify http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Aripiprazole Maintena® tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Abilify MyCite® Aripiprazole tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Abilify® Aripiprazole tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Abrilada™ Adalimumab-afzb Ulcerative Colitis Agents Plaque Psoriasis Agents Ulcerative Colitis Agents FORM Plaque Psoriasis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Abstral® Fentanyl _Criteria.pdf d_PA_FORM.pdf Adult Rheumatoid Arthritis Agents Juvenile Idiopathic Arthritis Adult Rheumatoid Arthritis FORM Juvenile Idiopathic Arthritis Agents Actemra® Tocilizumab Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Actiq® Fentanyl _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Adasuve® Loxapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Adcetris Brentuximab vedotin _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Adcirca® Tadalafil (tablets) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf Amphetamine/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Adderall XR® Dextroamphetamine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Amphetamine/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Adderall® Dextroamphetamine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Adempas® Riociguat _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Adhansia XR™ Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Adlyxin™ Lixisenatide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Antihemophilic factor VIII http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemo Adynovate® recombinant, Acting_Hemophilia_Factors_PA_Criteria.pdf philia_Factors_Long-Acting_PA_Form.pdf pegylated http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Adzenys ER® Amphetamine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Adzenys XR- http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Amphetamine ODT® dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Afinitor® Everolimus _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Insulin human http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Afrezza_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Afrezza® inhalation powder _Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Aimovig™ Erenumab-aooe Prophylaxis_Agents_PA_Criteria.pdf aine_Prophylaxis_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Ajovy™ Fremanezumab-vfrm Prophylaxis_Agents_PA_Criteria.pdf aine_Prophylaxis_Agents_PA_Form.pdf Netupitant/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- palonosetron (oral) http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neuro Akynzeo® emetics%20NK- Fosnetupitant/ kinin_1_NK1_antagonist_combo.pdf 1_antagonists_and_NK1_combinations_PA_Criteria.pdf palonosetron (IV) https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Alecensa Alectinib hcl _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Lo http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Wt_lo Alli® Orlistat ss_Drugs_PA_Criteria.pdf ss_inital_renewal.pdf Alprazolam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Alprazolam Intensol® pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf Coagulation factor IX http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemo Alprolix® recombinant, Fc Acting_Hemophilia_Factors_PA_Criteria.pdf philia_Factors_Long-Acting_PA_Form.pdf fusion protein https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Alunbrig™ Brigatinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Aminosalicylate Aminosalicylate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif sodium sodium is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Consti Amitiza® Lubiprostone Constipation_Agents_PA_Criteria.pdf pation_agents_step_therapy.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis FORM Ankylosing Spondylitis Agents Crohn's Disease Agents Juvenile Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents FORM Amjevita® Adalimumab- atto Idiopathic Arthritis Agents Plaque Psoriasis Agents Juvenile Idiopathic Arthritis Agents FORM Plaque Psoriasis Agents Ulcerative Colitis Agents FORM Ulcerative Colitis Agents FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Duchenne https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Duch Amondys 45™ Casimersen _Muscular_Dystrophy_Agents_PA_Criteria.pdf enne_Muscular_Dystrophy_Agents_PA_Form.pdf

sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Testosterone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Androderm® Transdermal d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf Testosterone Topical http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica AndroGel® Gel d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf Benzhydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Apadaz® Acetaminophen _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepre Aplenzin® Bupropion epressant_Medications_PA_FORM.pdf ssant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Aptensio XR® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Alpha1-Proteinase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Alpha_1_P http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Alpha Aralast NP® Inhibitor (Human) roteinase_Inhibitor_PA_Criteria.pdf 1_proteinase_inhibitor.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Aranesp® Darbepoetin alfa _Auxiliary_Treatment_Agents_PA_Criteria.pdf logy_Auxiliary_Treatment_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Carbinoxa http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Carbin Arbinoxa® Carbinoxamine mine_Products_Step_Therapy_PA_Criteria.pdf oxamine_Products_Step_Therapy_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Arcalyst_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Arcalyst® Rilonacept A_Criteria.pdf sal_PA_Form.pdf Amikacin oral http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Arikayce® inhalation Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Aristada Initio™ Aripiprazole lauroxil tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Aristada® Aripiprazole lauroxil tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Arranon Nelarabine _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Arymo ER® Morphine ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Ativan® Lorazepam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Aubagio® Teriflunomide clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Monoamin http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Mono Austedo™ Deutetrabenzine e_Depletor_PA_Criteria.PDF amine_Depletor_VMAT2_Inhibitors_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Avinza® Morphine ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Avonex® Interferon beta-1a clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf Ulcerative Colitis Agents Plaque Psoriasis Agents Psoriatic Ulcerative Colitis Agents FORM Plaque Psoriasis Agents FORM Avsola™ Infliximab Arthritis Agents Psoriatic Arthritis Agents FORM Testosterone Topical http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Axiron® Solution d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Ayvakit Avapritinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Monomethyl http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Bafiertam® Fumarate clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Balversa Erdafitinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Banzel® Rufinamide Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Bavencio® Avelumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Belbuca® Buprenorphine _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Belrapzo Bendamustine _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benlysta_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Benlysta® Belimumab A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Betaseron® Interferon beta-1b clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Bicnu Carmustine _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Immune globulin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Bivigam® (human) intravenous lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Blincyto® Blinatumomab

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Doxylamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diclegis_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Bonjesta® succinate/ _Criteria.pdf sal_PA_Form.pdf Pyridoxine HCl https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Bosulif Bosutinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr aine_Prophylaxis_Agents_PA_Form.pdf Botox® OnabotulinumtoxinA Migraine Prophylaxis Agents Botulinum Toxins http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Bo tulinum_Toxins_HP.pdf

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Brand Medical (Generic Drug https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brand_Me https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Bran Necessity Required) dical_Necessity_PA_Criteria.pdf d_Medical_Necessity_PA_Form.pdf Lisocabtagene https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chimeric_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chim Breyanzi® maraleucel Antigen_Receptor_T-Cell_Therapy_Agents.pdf eric_Antigen_Receptor_T-Cell_Therapy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brineura_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Brineura™ Cerliponase, alfa A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brisdelle__ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Brisdelle® Paroxetine PA_Criteria.pdf sal_PA_Form.pdf Sodium http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Buphenyl_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Buphenyl® phenylbutyrate PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Butrans® Buprenorphine _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Bydureon® Exenatide ER Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Bydureon® https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Exenatide ER BCise™ Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Byetta® Exenatide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Cabometyx® Cabozantinib

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Calquence® Acalabrutinib

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Caplyta® Lumateperone tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Capstat® Capreomycin is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf Immune globulin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Carimune NF® (human) intravenous lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Celexa® Citalopram sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Re http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/enzy Cerdelga® Eliglustat placement_Therapy_PA_Criteria.pdf me_replacement_therapy.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Re http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/enzy Cerezyme® Imiglucerase placement_Therapy_PA_Criteria.pdf me_replacement_therapy.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Canna Cesamet® Nabilone emetics_Cannabinoid_PA_Criteria.pdf binoid_antiemetics.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Chlorpromazine Chlorpromazine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis FORM Cimzia® Certolizumab Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents FORM Psoriasis Agents Plaque Psoriasis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Ag http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Asthm Cinqair® Reslizumab ents_PA_Criteria.pdf a_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neuro Cinvanti™ Aprepitant (IV) emetics%20NK- kinin_1_NK1_antagonist_combo.pdf 1_antagonists_and_NK1_combinations_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Clonidine Clonidine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Clozaril® Clozapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Codeine Codeine _Criteria.pdf d_PA_FORM.pdf Oxycodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Combunox® Ibuprofen _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Concerta® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Amlodipine/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Consensi_S http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Consensi™ Celecoxib tep_Therapy_PA_Criteria.pdf sal_PA_Form.pdf Naltrexone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Lo http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Wt_lo Contrave® ER Bupropion ss_Drugs_PA_Criteria.pdf ss_inital_renewal.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Conzip® Tramadol ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Copaxone® Glatiramer clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf Psoriatic Arthritis Agents Ankylosing Spondylitis Agents Psoriatic Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Cosentyx® Secukinumab Plaque Psoriasis Agents Plaque Psoriasis Agents FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Cotellic® Cobimetinib

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Cotempla http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Methylphenidate HCl XR-ODT™ dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Crinone_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Crinone® Progesterone A_Criteria.pdf sal_PA_Form.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Juvenile FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents Cyltezo™ Adalimumab- adbm Idiopathic Arthritis Agents Plaque Psoriasis Agents FORM Juvenile Idiopathic Arthritis Agents FORM Plaque Psoriasis Ulcerative Colitis Agents Agents FORM Ulcerative Colitis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Cymbalta® Duloxetine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Cyramza Ramucirumab _Agents_PA_Criteria.pdf logy_Auxiliary_Treatment_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Dalmane® Flurazepam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Daraprim_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Daraprim® Pyrimethamine PA_Criteria.pdf sal_PA_Form.pdf Daratumumab & https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Darzalex Faspro Hyaluronidase _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Darzalex® Daratumumab

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Methylphenidate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Daytrana® Transdermal dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Testosterone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Testostero http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Delatestryl® Enanthate ne_Injectable_PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Demerol® Meperidine _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Demser_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Demser® Metyrosine A_Criteria.pdf sal_PA_Form.pdf Methamphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Desoxyn® HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Dextroamphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Dexedrine® sulfate dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Dextroamphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD DextroStat® sulfate dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Diacomit® Stiripentol Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf Diazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Diazepam Intensol® pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf Doxylamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diclegis_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Diclegis® succinate/ _Criteria.pdf sal_PA_Form.pdf Pyridoxine HCl http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Dihydrocodeine Dihydrocodeine _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Dilaudid® Hydromorphone _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Doral® Quazepam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf Drizalma http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Duloxetine Sprinkle™ sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Ibuprofen/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/NSAID_plu http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/NSAID Duexis® Famotidine s_PPI-H2_Blocking_Agents_Step_Therapy_PA_Criteria.pdf _PPI_H2.pdf Atopic Dermatitis Agents PA; Atopic Dermatitis PA FORM Dupixent® Dupilumab Asthma Agents PA Asthma Agents PA FORM

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Duragesic Fentanyl transdermal _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Dyanavel XR® Amphetamine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Intranasal_ Azelastine/ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Dymista® Antihistamine- Fluticasone sal_PA_Form.pdf Corticosteroid_Agents_Step_Therapy_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Botulinum http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Bo Dysport® AbobotulinumtoxinA _Toxins_PA_Criteria.pdf tulinum_Toxins_HP.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Effexor XR® Venlafaxine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Effexor® Venlafaxine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Elaprase_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Elaprase® Idursulfase A_Criteria.PDF sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Elavil® Amitriptyline sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Re http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/enzy Elelyso® Taliglucerase alfa placement_Therapy_PA_Criteria.pdf me_replacement_therapy.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Atopic_Der http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Atopic Elidel® Pimecrolimus matitis_Agents_PA_Criteria.pdf _Dermatitis_Agents_PA_Form.pdf Antihemophilic factor VIII http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemo Eloctate® recombinant, Fc Acting_Hemophilia_Factors_PA_Criteria.pdf philia_Factors_Long-Acting_PA_Form.pdf fusion protein https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Elyxyb Celecoxib Acute_Treatment_Agents_PA_Criteria.pdf aine_Acute_Treatment_Agents_PA_Form.pdf Morphine/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Embeda® Naltrexone _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neuro Emend® Aprepitant (oral) emetics%20NK- kinin_1_NK1_antagonist_combo.pdf 1_antagonists_and_NK1_combinations_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neuro Emend® Fosaprepitant (IV) emetics%20NK- kinin_1_NK1_antagonist_combo.pdf 1_antagonists_and_NK1_combinations_PA_Criteria.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Duchenne https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Duch Emflaza® Deflazacort

_Muscular_Dystrophy_Agents_PA_Criteria.pdf enne_Muscular_Dystrophy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Emgality™ Galcanezumab-gnlm Prophylaxis_Agents_PA_Criteria.pdf aine_Prophylaxis_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Empliciti® Elotuzumab

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

Oxycodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Endocet® Acetaminophen _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neuromye https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neur Enspryng Satralizumab litis_Optica_Spectrum_Disorder_NMOSD_Agents_PA_Criteria. omyelitis_Optica_Spectrum_Disorder_NMOSD_Agents_PA_Form.pdf pdf Crohn's Disease Agents Entyvio® Vedolizumab Crohn’s Disease Agents FORM Ulcerative Colitis Agents FORM Ulcerative Colitis Agents Sofosbuvir/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepat Epclusa® Velpatasvir _PA_Criteria.pdf itis_C_Agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Epidiolex® Cannabidiol Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Epogen® Epoetin alfa _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Erbitux Cetuximab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Erelzi™ Etanercept-szzs Ankylosing Spondylitis Agents Juvenile Idiopathic Arthritis FORM Ankylosing Spondylitis Agents FORM Juvenile Idiopathic Agents Plaque Psoriasis Agents Arthritis Agents FORM Plaque Psoriasis Agents FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Erivedge Vismodegib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Erleada Apalutamide _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Asparaginalse hhttps://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncolog Erwinaze logy_Agents_PA_Form.pdf erwinia chrysanthemi y_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Esbriet® Pirfenidone

Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf Antihemophilic factor VIII http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemo Esperoct® recombinant, Acting_Hemophilia_Factors_PA_Criteria.pdf philia_Factors_Long-Acting_PA_Form.pdf PEGylated Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Juvenile Idiopathic Eticovo™ Etanercept Ankylosing Spondylitis Agents Juvenile Idiopathic Arthritis Arthritis Agents FORM Plaque Psoriasis Agents FORM Agents Plaque Psoriasis Agents

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Atopic_Der http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Atopic Eucrisa® Crisaborole matitis_Agents_PA_Criteria.pdf _Dermatitis_Agents_PA_Form.pdf https://kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_Requ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Evenity™ Romosozumab irements_PA_Criteria.pdf um_Requirements_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hyperchol https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hype Evkeeza™ Evinacumab-dgnb esterolemia_Agents_PA_Criteria.pdf rcholesterolemia_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Spinal_M https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Spina Evrysdi™ Risdiplam uscular_Atrophy_PA_Criteria.pdf l_Muscular_Atrophy_PA_Form.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Exalgo® Hydromorphone ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exjade_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Exjade® Deferasirox _Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Duchenne https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Duch Exondys 51™ Eteplirsen

_Muscular_Dystrophy_Agents_PA_Criteria.pdf enne_Muscular_Dystrophy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Extavia® Interferon beta-1b clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Re http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/enzy Fabrazyme® Agalsidase beta placement_Therapy_PA_Criteria.pdf me_replacement_therapy.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Fanapt® Iloperidone tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Farxiga® Dapagliflozin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Farydak® Panobinostat _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Ag http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Asthm Fasenra™ Benralizumab ents_PA_Criteria.pdf a_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Fazaclo® Clozapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Fentora® Fentanyl _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ferriprox_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Ferriprox® Deferiprone PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Fetzima® Levomilnacipran sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac Finacea® Azelaic acid gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf https://kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_Requ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Fintepla® Fenfluramine irements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Firazyr_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Firazyr® Icatibant _Criteria.pdf sal_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Flebogamma Immune globulin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav DIF® (human) intravenous lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf Epoprostenol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Flolan® (injection) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Fluphenazine Fluphenazine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Dexmethylphenidate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Focalin XR® ER dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Focalin® Dexmethylphenidate dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Forfivo® XL Bupropion sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Fortamet® Metformin ER Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Teriparatid http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Forteo® Teriparatide e_Forteo_Criteria.pdf sal_PA_Form.pdf Testosterone Topical http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Fortesta® Gel d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Fulphila® Pegfilgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Fuzeon® Enfuvirtide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Fuzeon.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Re http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/enzy Galafold® Migalastat placement_Therapy_PA_Criteria.pdf me_replacement_therapy.pdf Gammagard Immune globulin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav S/D® (human) intravenous lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf Immune globulin (human) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Gammagard® intravenous/ lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf subcutaneous Immune globulin (human) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Gammaked® intravenous/ lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf subcutaneous Immune globulin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Gammaplex® (human) intravenous lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf Immune globulin (human) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Gamunex-C® intravenous/ lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf subcutaneous https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Gavreto Pralsetinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Gazyva Obinutuzumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_H http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somat Genotropin® Somatropin ormone_PA_Criteria.pdf ropin_products.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Geodon® Ziprasidone tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Gilenya® Fingolimod clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Gilotrif® Afatinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Alpha1-Proteinase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Alpha_1_P http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Alpha Glassia® Inhibitor (Human) roteinase_Inhibitor_PA_Criteria.pdf 1_proteinase_inhibitor.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Glatopa® Glatiramer clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Gleevec Imatinib mesylate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Glumetza® Metformin ER Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Empagliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Glyxambi® Linagliptin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Nitroglycerin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nitroglycer http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Nitrog GoNitro® sublingual powder in_Sublingual_Step_Therapy_PA_Criteria.pdf lycerin_Step_Therapy_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Granix® Tbo-filgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf Repository http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/HP_Acthar http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer H.P.Acthar Gel® Corticotropin __PA_Criteria.pdf sal_PA_Form.pdf Adult Rheumatoid Arthritis Agents Crohn's Disease Agents Adult Rheumatoid Arthritis Agents FORM Crohn’s Disease Agents Hadlima™ Adalimumab-bwwd Ulcerative Colitis Agents Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM Plaque Psoriasis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Halcion® Triazolam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf Haldol Haloperidol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Decanoate® Decanoate tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Haldol® Haloperidol tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Ledipasvir/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepat Harvoni® Sofosbuvir _PA_Criteria.pdf itis_C_Agents.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Herceptin® Trastuzumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Herceptin® Trastuzumab & https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Hylecta hyaluronidase-oysk _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Hycet® Acetaminophen _Criteria.pdf d_PA_FORM.pdf Hydrocodone/ Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Ibuprofen Ibuprofen _Criteria.pdf d_PA_FORM.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Juvenile FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents Hyrimoz™ Adalimumab Idiopathic Arthritis Agents Plaque Psoriasis Agents Ulcerative FORM Juvenile Idiopathic Arthritis Agents FORM Plaque Psoriasis Colitis Agents Agents FORM Ulcerative Colitis Agents FORM

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Hysingla ER® Hydrocodone ER _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Ibrance® Palbociclib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Iclusig Ponatinib hcl _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Coagulation factor IX recombinant, http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemo Idelvion® albumin fusion Acting_Hemophilia_Factors_PA_Criteria.pdf philia_Factors_Long-Acting_PA_Form.pdf protein (rIX-FP) https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Idhifa® Enasidenib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

Ilaris® Canakinumab Juvenile Idiopathic Arthritis Agents Juvenile Idiopathic Arthritis Agents FORM

Ilumya® Tildrakizumab-asmn Plaque Psoriasis Agents Plaque Psoriasis Agents FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Imbruvica® Ibrutinib

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Mecasermin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Increlex®

rinfabate Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Infergen_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Infergen® Interferon alfacon-1 A_Criteria.pdf sal_PA_Form.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Inflectra® Infliximab-dyyb FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents Psoriasis Agents FORM Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM Ulcerative Colitis Agents http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Monoamin http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Mono Ingrezza® Valbenazine e_Depletor_PA_Criteria.PDF amine_Depletor_VMAT2_Inhibitors_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Inlyta Axitinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IntronA_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Intron A Interferon alfa-2b _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Intuniv® Guanfacine ER dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Invega Paliperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Sustenna® palmitate tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Paliperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Invega Trinza® palmitate tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Invega® Paliperidone tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Canagliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Invokamet XR® Metformin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Canagliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Invokamet® Metformin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Invokana® Canagliflozin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Isonarif® Rifampin/Isoniazid is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Ixempra Ixabepilone _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents Ixifi™ Infliximab-qbtx Psoriasis Agents FORM Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM Ulcerative Colitis Agents http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jadenu_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Jadenu® Deferasirox _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jakafi_PA_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Jakafi® Ruxolitinib Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Jardiance® Empagliflozin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jetrea_PA_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Jetrea® Ocriplasmin Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Jevtana Cabazitaxel _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Antihemophilic factor VIII http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemo Jivi® recombinant, Acting_Hemophilia_Factors_PA_Criteria.pdf philia_Factors_Long-Acting_PA_Form.pdf PEGylated http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Jornay PM™ Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hyperchol https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hype Juxtapid® Lomitapide

esterolemia_Agents_PA_Criteria.pdf rcholesterolemia_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Kadcyla Ado-trastuzumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Kadian ER® Morphine ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kalbitor_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Kalbitor® Ecallantide A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Kalydeco® Ivacaftor Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Kanjinti Trastuzumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kanuma_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Kanuma® Sebelipase alfa A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Kapvay® Clonidine ER dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Carbinoxa http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Carbin Karbinal ER™ Carbinoxamine ER mine_Products_Step_Therapy_PA_Criteria.pdf oxamine_Products_Step_Therapy_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Kesimpta® Ofatumumab clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf Kevzara® Sarilumab Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Keytruda® Pembrolizumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Khedezla® Desvenlafaxine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf

Kineret® Anakinra Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Kisqali Femara Ribociclib -letrozole _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Kisqali® Ribociclib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Kisqali® Femara https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Ribociclib/Letrozole Co-pack _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Klonopin® Clonazepam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pegloticase http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Krystexxa® Pegloticase _Krystexxa.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kuvan_PA_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Kuvan® Sapropterin criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chimeric_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chim Kymriah® Tisagenlecleucel

Antigen_Receptor_T-Cell_Therapy_Agents.pdf eric_Antigen_Receptor_T-Cell_Therapy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kynamro_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Kynamro® Mipomersen A_Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Kyprolis® Carfilzomib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Lartruvo® Olaratumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Latuda® Lurasidone tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Lazanda® Fentanyl _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Lemtrada® Alemtuzumab clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Lenvima Lenvatinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Ambrisentan http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Letairis® (tablets) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Leukine® Sargramostim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Levo-Dromoran® Levorphanol _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Lexapro® Escitalopram sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Librium® Chlordiazepoxide pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Consti Linzess® Linaclotide Constipation_Agents_PA_Criteria.pdf pation_agents_step_therapy.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Lonsurf Trifluridine-tipiracil _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Lorazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Lorazepam Intensol® pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Lorbrena Lorlatinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Lorcet HD® Acetaminophen _Criteria.pdf d_PA_FORM.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Lorcet Plus® Acetaminophen _Criteria.pdf d_PA_FORM.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Lorcet® Acetaminophen _Criteria.pdf d_PA_FORM.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Lortab® Acetaminophen _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Loxitane® Loxapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lucentis_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Lucentis® Ranibizumab A_Criteria.pdf sal_PA_Form.pdf Leuprolide/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupaneta_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Lupaneta Pack® Norethindrone Pack_PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupron_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Lupron® Leuprolide _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Luvox CR® Fluvoxamine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Luvox® Fluvoxamine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Voretigene http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Luxturna_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Luxturna™ Neparvovec-rzyl A_Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Lynparza™ Olaparib

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lyrica_CR_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Lyrica CR® Pregabalin PA_Criteria.pdf sal_PA_Form.pdf Hydroxyprogesteron http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Makena_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Makena® e Caproate A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Maprotiline Maprotiline sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Canna Marinol® Dronabinol emetics_Cannabinoid_PA_Criteria.pdf binoid_antiemetics.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Marplan® Isocarboxazid sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Matulane Procarbazine _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Mavenclad® Cladribine clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf Glecaprevir/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepat Mavyret® Pibrentasvir _PA_Criteria.pdf itis_C_Agents.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Maxidone® Acetaminophen _Criteria.pdf d_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Mayzent® Siponimod clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Mekinist® Trametinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Mektovi™ Binimetinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Metadate CD® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Metadate ER® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Methadone Methadone _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Methylin® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac MetroCream® Metronidazole gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac Metrogel® Metronidazole gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac MetroLotion® Metronidazole gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac Mirvaso® Brimonidine gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi MorphaBond® Morphine ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Morphine IR Morphine IR _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Consti Motegrity™ Prucalopride Constipation_Agents_PA_Criteria.pdf pation_agents_step_therapy.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Motofen_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Motofen® Difenoxin/Atropine A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Ind http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/opioid Movantik® Naloxegol uced_Constipation_Agents_PA_Criteria.pdf _induced_constipation.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Mozobil® Plerixafor _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi MS Contin® Morphine ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Myambutol® Ethambutol is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Mycobutin® Rifabutin is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf Amphetamine/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Mydayis® Dextroamphetamine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Rimabotulinumtoxin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Botulinum http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Bo Myobloc® B _Toxins_PA_Criteria.pdf tulinum_Toxins_HP.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Nardil® Phenelzine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Testosterone nasal http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Natesto® gel d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Natpara_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Natpara® Parathyroid hormone A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Nefazodone Nefazodone sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Nerlynx Neratinib maleate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Neulasta® Pegfilgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf Neulasta® https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Pegfilgrastim Onpro® _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Neupogen® Filgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Nexavar Sorafenib tosylate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hyperchol https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hype Nexletol™ Bempedoic Acid esterolemia_Agents_PA_Criteria.pdf rcholesterolemia_Agents_PA_Form.pdf Bempedoic https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hyperchol https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hype Nexlizet™ Acid/Ezetimibe esterolemia_Agents_PA_Criteria.pdf rcholesterolemia_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Niazid® Isoniazid is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Niazid-B6® Isoniazid/Pyridoxine is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Ninlaro® Ixazomib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Niravam ODT® Alprazolam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf Nitroglycerin Nitroglycerin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nitroglycer http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Nitrog sublingual spray sublingual spray in_Sublingual_Step_Therapy_PA_Criteria.pdf lycerin_Step_Therapy_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Nivestym Filgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf Non-Rebate Non-rebate eligible https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Us https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Eligible OUD OUD drugs e_Disorder_Agents_PA_Criteria.pdf d_Use_Disorder_Agents_PA_Form.pdf Drugs Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Norco® Acetaminophen _Criteria.pdf d_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_H http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somat Norditropin® Somatropin ormone_PA_Criteria.pdf ropin_products.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac Noritate® Metronidazole gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Norpramin® Desipramine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nplate_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Nplate® Romiplostim _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Ag http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Asthm Nucala® Mepolizumab ents_PA_Criteria.pdf a_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Nucynta ER® Tapentadol ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Nucynta® Tapentadol _Criteria.pdf d_PA_FORM.pdf Dextromethorphan/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Nuedexta®

Quinidine Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Nurtec™ODT™ Rimegepant Acute_Treatment_Agents_PA_Criteria.pdf aine_Acute_Treatment_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_H http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_ Nutropin® Somatropin ormone_PA_Criteria.pdf PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Nydrazid® Isoniazid is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Nyvepria™ Pegfilgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ocaliva_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Ocaliva® Obeticholic Acid _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Ocrevus™ Ocreblizumab clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf Immune globulin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Octagam® (human) intravenous lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Ofev® Nintedanib

Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Ogivri Trastuzumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

Olumiant® Baricitinib Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_H http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somat Omnitrope® Somatropin ormone_PA_Criteria.pdf ropin_products.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Oncaspar Pegaspargase _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Onfi® Clobazam

Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf

Ivacaftor Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Osphena® Ospemifene

Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf Otezla® Apremilast Psoriatic Arthritis Agents Plaque Psoriasis Agents Psoriatic Arthritis Agents FORM Plaque Psoriasis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Oxaydo® Oxycodone _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi OxyContin® Oxycodone ER _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Ozempic® Semaglutide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Padcev Enfortumab vedotin _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Pamelor® Nortriptyline sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Papain/Urea Papain/Urea http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Wound_Ca http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_De Products Products re_PA_Criteria.pdf cubitus_28578_Activated_Traditional.pdf Papain/Urea/ Papain/Urea/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Wound_Ca http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_De Chlorophyllin Chlorophyllin re_PA_Criteria.pdf cubitus_28578_Activated_Traditional.pdf Products Products http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Parnate® Tranylcypromine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Calcimimet http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Calci Parsabiv® Etelcalcetide ics_PA_Criteria.pdf mimetic_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Paser Granules® Aminosalicylic acid is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Paxil CR® Paroxetine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Paxil® Paroxetine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Pentazocine/ Pentazocine/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Naloxone Naloxone _Criteria.pdf d_PA_FORM.pdf Oxycodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Percocet® Acetaminophen _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Percodan® Oxycodone/Aspirin _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Perjeta Pertuzumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Perphenazine Perphenazine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Perseris™ Risperidone tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Pexeva® Paroxetine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Phentermine Phentermine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Lo http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Wt_lo products products ss_Drugs_PA_Criteria.pdf ss_inital_renewal.pdf Pertuzumab, https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Phesgo trastuzumab, & _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf hyaluronidase-zzxf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Piqray Alpelisib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Plegridy® Interferon beta-1a clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Polatuzumab https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Polivy vedotin-piiq _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Pomalyst Pomalidomide _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hyperchol https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hype Praluent® Alirocumab

esterolemia_Agents_PA_Criteria.pdf rcholesterolemia_Agents_PA_Form.pdf Ziconotide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Prialt_PA_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Prialt® intrathecal infusion Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Priftin® Rifapentine is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf Oxycodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Primlev® Acetaminophen _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Pristiq® Desvenlafaxine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Immune globulin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_G http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intrav Privigen® (human) intravenous lobulins_IVIGs_PA_Criteria.pdf enous_Immune_globulin.pdf Dextroamphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD ProCentra® sulfate dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Procrit® Epoetin alfa _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf Alpha1-Proteinase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Alpha_1_P http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Alpha Prolastin C® Inhibitor (Human) roteinase_Inhibitor_PA_Criteria.pdf 1_proteinase_inhibitor.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Prolia® Denosumab Oncology Auxiliary Drugs

y_Treatment_Agents_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Promacta_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Promacta® Eltrombopag PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo ProSom® Estazolam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Atopic_Der http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Atopic Protopic® Tacrolimus matitis_Agents_PA_Criteria.pdf _Dermatitis_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Provenge® Sipuleucel-T _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Prozac® Fluoxetine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Prozac® Weekly Fluoxetine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Pyrazinamide Pyrazinamide is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf Phentermine/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Lo http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Wt_lo Qsymia® Topiramate ss_Drugs_PA_Criteria.pdf ss_inital_renewal.pdf Dapagliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Qtern® Saxagliptin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Dapagliflozin/Metfor https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Qternmet XR® min/Saxagliptin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Qualaquin_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Qualaquin® Quinine PA_Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Qudexy XR® Topiramate ER Prophylaxis_Agents_PA_Criteria.pdf aine_Prophylaxis_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Quillichew ER™ Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Quillivant XR® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Radicava_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Radicava® Edaravone A_Criteria.pdf sal_PA_Form.pdf Short ragweed pollen http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ragwitek_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Ragwitek® allergen extract PA_Criteria.pdf sal_PA_Form.pdf Glycerol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ravicti_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Ravicti® phenylbutyrate _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Rebif® Interferon beta-1a clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf Coagulation factor IX http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemo Rebinyn® recombinant, glycol- Acting_Hemophilia_Factors_PA_Criteria.pdf philia_Factors_Long-Acting_PA_Form.pdf pegylated http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Regranex_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Regranex® Becaplermin PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Relexxii™ Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Ind http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/opioid Relistor® Methylnaltrexone uced_Constipation_Agents_PA_Criteria.pdf _induced_constipation.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Remeron® Mirtazapine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Remicade® Infliximab FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents Psoriasis Agents FORM Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM Ulcerative Colitis Agents Treprostinil http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Remodulin® (injection) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents Renflexis® Infliximab-abda Psoriasis Agents FORM Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM Ulcerative Colitis Agents https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hyperchol https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hype Repatha® Evolocumab

esterolemia_Agents_PA_Criteria.pdf rcholesterolemia_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Restasis_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Restasis® Cyclosporine A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Restoril® Temazepam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Retacrit® Epoetin alfa _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf Sildenafil (injection, http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Revatio® oral suspension, _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf tablets) https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Revlimid® Lenalidomide _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Rexulti® Brexpiprazole tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ Reyvow™ Lasmiditan aine_Acute_Treatment_Agents_PA_Form.pdf Acute_Treatment_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac Rhofade® Oxymetazoline gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Riabni Rituximab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Rifadin® Rifampin is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Rifamate® Rifampin/Isoniazid is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf Rifampin/Isoniazid/P http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Rifater® yrazinamide is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rilutek_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Rilutek® Riluzole _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Rimactane® Rifampin is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf Rinvoq™ Upadacitinib Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM Risperdal http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Risperidone M-Tab® tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Risperdal http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Risperidone Consta® tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Risperdal® Risperidone tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Ritalin LA® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Ritalin® Methylphenidate HCl dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Ruxience Rituximab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Rybelsus® Semaglutide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Rydapt® Midostaurin _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Carbinoxa http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Carbin Ryvent™ Carbinoxamine mine_Products_Step_Therapy_PA_Criteria.pdf oxamine_Products_Step_Therapy_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Ryzolt® Tramadol ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sabril_PA_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Sabril® Vigabatrin Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_H http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somat Saizen® Somatropin ormone_PA_Criteria.pdf ropin_products.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Sandostatin Lar Octreotide _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Wound_Ca http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_De Santyl® Collagenase re_PA_Criteria.pdf cubitus_28578_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Saphris® Asenapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Savella® Milnacipran sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Lo http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Wt_lo Saxenda® Liraglutide ss_Drugs_PA_Criteria.pdf ss_inital_renewal.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Secuado® Asenapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Ertugliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Segluromet™ Metformin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Selzentry.p http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Selzentry® Maraviroc df sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Calcimimet http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Calci Sensipar® Cinacalcet ics_PA_Criteria.pdf mimetic_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Serax® Oxazepam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf Betamethasone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sernivo_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Sernivo® dipropionate _Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Seroquel XR® Quetiapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Seroquel® Quetiapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Serostim® Somatropin Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf

Siliq™ Brodalumab Plaque Psoriasis Agents Plaque Psoriasis Agents FORM Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Simponi Aria® Golimumab FORM Juvenile Idiopathic Arthritis Agents FORM Juvenile Idiopathic Arthritis Agents

Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Simponi® Golimumab Ankylosing Spondylitis Agents FORM Ankylosing Spondylitis Agents FORM Ulcerative Colitis Agents Ulcerative Colitis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Sinequan® Doxepin sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Sirturo® Bedaquiline is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Plaque_Ps http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Plaqu Skyrizi® Risankizumab oriasis_Agents_PA_Criteria.pdf e_Psoriasis_Agents_PA_Form.pdf Insulin glargine/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Soliqua® Lixisenatide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neuromye https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neur Soliris® Eculizumab litis_Optica_Spectrum_Disorder_NMOSD_Agents_PA_Criteria. omyelitis_Optica_Spectrum_Disorder_NMOSD_Agents_PA_Form.pdf pdf Soma Compound Carisoprodol/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soma_PA_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Cariso with Codeine® Aspirin/Codeine Criteria.pdf prodol_Containing_Products_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Soma http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soma_PA_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Cariso Carisoprodol/Aspirin Compound® Criteria.pdf prodol_Containing_Products_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soma_PA_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Cariso Soma® Carisoprodol Criteria.pdf prodol_Containing_Products_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Somavert_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Somavert® Pegvisomant PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_A http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosac Soolantra® Ivermectin gents_PA_Criteria.PDF ea_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepat Sovaldi® Sofosbuvir _PA_Criteria.pdf itis_C_Agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Spinal_Mu http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Spinal Spinraza® Nusinersen scular_Atrophy_PA_Criteria.pdf _Muscular_Atrophy_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Spravato® Esketamine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Sprycel Dasatinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Steglatro™ Ertugliflozin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Ertugliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Steglujan™ Sitagliptin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Psoriatic Arthritis Agents FORM Crohn’s Disease Agents FORM Plaque Psoriatic Arthritis Agents Crohn's Disease Agents Plaque Stelara® Ustekinumab Psoriasis Agents FORM Ulcerative Colitis Agents FORM Psoriasis Agents Ulcerative Colitis Agents

https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Stivarga® Regorafenib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Strattera® Atomoxetine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Strensiq_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Strensiq® Asfotase alfa A_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Striant® Testosterone buccal d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Subsys® Fentanyl _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Us https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Subutex® Buprenorphine e_Disorder_Agents_PA_Criteria.pdf d_Use_Disorder_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Narcol Sunosi® Solriamfetol _Agents_PA_Criteria.pdf epsy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Supprelin_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Supprelin® LA Histrelin acetate LA_PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Surmontil® Trimipramine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf

Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Sympazan™ Clobazam Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Ind http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/opioid Symproic® Naldemedine uced_Constipation_Agents_PA_Criteria.pdf _induced_constipation.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Synagis_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Sy Synagis® Palivizumab

_Criteria.pdf nagis_HP.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Canna Syndros® Dronabinol emetics_Cannabinoid_PA_Criteria.pdf binoid_antiemetics.pdf Empagliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Synjardy XR® Metformin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Empagliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Synjardy® Metformin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Syprine_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Syprine® Trientine _Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tabrecta Capmatinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tafinlar® Dabrafenib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tagrisso® Osimertinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Taltz® Ixekizumab Psoriatic Arthritis Agents Plaque Psoriasis Agents Psoriatic Arthritis Agents FORM Plaque Psoriasis Agents FORM https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Talzenna Talazoparib tosylate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tarceva Erlotinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Oxycodone/Naloxon http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Targiniq ER® e _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tasigna Nilotinib hcl _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Brexucabtagene https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chimeric_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chim Tecartus™ autoleucel Antigen_Receptor_T-Cell_Therapy_Agents.pdf eric_Antigen_Receptor_T-Cell_Therapy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tecentriq® Atezolizumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Tecfidera® Dimethyl fumarate clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Tenex® Guanfacine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf Testosterone Topical http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Testim® Gel d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Testopel_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Testopel® Testosterone implant A_Criteria.pdf sal_PA_Form.pdf Testosterone Testosterone Powder http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Powder for for Compounding d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf Compounding http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_H http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somat Tev-Tropin® Somatropin ormone_PA_Criteria.pdf ropin_products.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Thioridazine Thioridazine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Thiothixene Thiothixene tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tibsovo® Ivosidenib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Tofranil® Imipramine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Tofranil® PM Imipramine pamoate sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Tracleer® Bosentan (tablets) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Tranxene-T® Clorazepate pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Trazimera Trastuzumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Trazodone Trazodone sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculos http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rif Trecator® Ethionamide is_Agents_PA_Criteria.pdf ampin_and_TB_15381_Activated_Traditional.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Trelstar® Triptorelin

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Tremfya™ Guselkumab Plaque Psoriasis Agents Psoriatic Arthritis Agents Plaque Psoriasis Agents FORM Psoriatic Arthritis Agents FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Trifluoperazine Trifluoperazine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf Empagliflozin/linaglip https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Trijardy XR® tin/metformin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Elexacaftor/tezacafto http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Trikafta™ r/ivacaftor Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Trintellix® Vortioxetine sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Triptodur_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Triptodur® Triptorelin PA_Criteria.pdf sal_PA_Form.pdf Sacituzumab https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Trodelvy govitecan _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Trogarzo_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Trogarzo™ Ibalizumab-uiyk A_Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Trokendi XR® Topiramate ER Prophylaxis_Agents_PA_Criteria.pdf aine_Prophylaxis_Agents_PA_Form.pdf Oxycodone/naltrexo http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Troxyca® ER ne _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Consti Trulance® Plecanatide Constipation_Agents_PA_Criteria.pdf pation_agents_step_therapy.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Trulicity® Dulaglutide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Adult Rheumatoid Arthritis Agents Truxima® Rituximab https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology Adult Rheumatoid Arthritis Agents FORM Oncology Agents PA FORM _Agents_PA_Criteria.pdf Trypsin/Balsam Trypsin/Balsam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Wound_Ca http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_De Peru/Castor Oil Peru/Castor Oil re_PA_Criteria.pdf cubitus_28578_Activated_Traditional.pdf Products Products https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tukysa Tucatinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Tykerb Lapatinib ditosylate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Tysabri® Natalizumab Crohn's Disease Agents Multiple Sclerosis Agents Crohn’s Disease Agents FORM Multiple Sclerosis Agents FORM Treprostinil http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Tyvaso® (inhalation solution) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Ubrelvy Ubrogepant Acute_Treatment_Agents_PA_Criteria.pdf aine_Acute_Treatment_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Udenyca® Pegfilgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf Tramadol/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Ultracet® Acetaminophen _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Ultram ER Tramadol ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Ultram® Tramadol _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neuromye https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neur Uplizna Inebilizumab litis_Optica_Spectrum_Disorder_NMOSD_Agents_PA_Criteria. omyelitis_Optica_Spectrum_Disorder_NMOSD_Agents_PA_Form.pdf pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Uptravi® Selexipag _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Valium® Diazepam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Valstar Valrubicin _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti- http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neuro Varubi® Rolapitant emetics%20NK- kinin_1_NK1_antagonist_combo.pdf 1_antagonists_and_NK1_combinations_PA_Criteria.pdf https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology Vectibix Panitumumab logy_Agents_PA_Form.pdf _Agents_PA_Criteria.pdf

Epoprostenol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Veletri® (injection) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Venclexta® Venetoclax _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Iloprost http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmo Ventavis® (inhalation solution) _Hypertension_Agents_PA_Criteria.pdf nary_arterial_hypertension_agents.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Verdrocet® Acetaminophen _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Versacloz® Clozapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Verzenio™ Abemaciclib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Vesicare LS™ Solifenacin Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Viberzi® Eluxadoline

Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Vicodin ES® Acetaminophen _Criteria.pdf d_PA_FORM.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Vicodin HP® Acetaminophen _Criteria.pdf d_PA_FORM.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Vicodin® Acetaminophen _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Victoza® Liraglutide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Ombitasvir/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepat Viekira Pak™ Paritaprevir/Ritonavi _PA_Criteria.pdf itis_C_Agents.pdf r and Dasabuvir http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Viibryd® Vilazodone sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Duchenne https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Duch Viltepso™ Viltolarsen _Muscular_Dystrophy_Agents_PA_Criteria.pdf enne_Muscular_Dystrophy_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Naproxen/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/NSAID_plu http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/NSAID Vimovo® Esomeprazole s_PPI-H2_Blocking_Agents_Step_Therapy_PA_Criteria.pdf _PPI_H2.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Vitrakvi Larotrectinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Vivactil® Protriptyline sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf Testosterone Topical http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_an http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topica Vogelxo® Gel d_Buccal_Androgen_PA_Criteria.pdf l_buccal_androgen_hormone_agents.pdf Sofosbuvir/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepat Vosevi™ Velpatasvir/ _PA_Criteria.pdf itis_C_Agents.pdf Voxilaprevir https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Votrient Pazopanib hcl _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Re http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/enzy VPRIV® Velaglucerase alfa placement_Therapy_PA_Criteria.pdf me_replacement_therapy.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Vraylar® Cariprazine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Vumerity™ Diroximel Fumarate clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Migraine_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Migr Vyepti™ Eptinezumab Prophylaxis_Agents_PA_Criteria.pdf aine_Prophylaxis_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Duchenne https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Duch Vyondys 53™ Golodirsen _Muscular_Dystrophy_Agents_PA_Criteria.pdf enne_Muscular_Dystrophy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Vyvanse® Lisdexamfetamine dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Narcol Wakix® Pitolisant _Agents_PA_Criteria.pdf epsy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Wellbutrin® Bupropion sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Wellbutrin® SR Bupropion sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Wellbutrin® XL Bupropion sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Xalkori® Crizotinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Xanax XR® Alprazolam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiaze http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzo Xanax® Alprazolam pine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf diazepine_Mental_Health_FORM.pdf Oxycodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Xartemis XR® Acetaminophen _Criteria.pdf d_PA_FORM.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Xeljanz® Tofacitinib FORM Ulcerative Colitis Agents FORM Juvenile Idiopathic Arthritis Ulcerative Colitis Agents Juvenile Idiopathic Arthritis Agents Agents FORM Psoriatic Arthritis Agents FORM Ulcerative Colitis Agents FORM Xeljanz® XR Tofacitinib Psoriatic Arthritis Agents Ulcerative Colitis Agents

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Monoamin http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Mono Xenazine® Tetrabenazine e_Depletor_PA_Criteria.PDF amine_Depletor_VMAT2_Inhibitors_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Lo http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Wt_lo Xenical® Orlistat ss_Drugs_PA_Criteria.pdf ss_inital_renewal.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Botulinum http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Bo Xeomin® IncobotulinumtoxinA _Toxins_PA_Criteria.pdf tulinum_Toxins_HP.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Xermelo® Telotristat

Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Xgeva® Denosumab _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf Collengenase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xiaflex_PA http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Xiaflex® clostridium

_Criteria.pdf sal_PA_Form.pdf histolyticum Dapagliflozin/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Xigduo XR® Metformin Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf Lifitegrast http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xiidra_PA_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Xiidra® ophthalmic solution Criteria.pdf sal_PA_Form.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Xodol® Acetaminophen _Criteria.pdf d_PA_FORM.pdf Radium Ra 223 https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Xofigo® dichloride _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Ag http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Asthm Xolair® Omalizumab

ents_PA_Criteria.pdf a_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Xospata Gilteritinib fumarate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Xtampza ER® Oxycodone ER _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Xtandi Enzalutamide _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Insulin degludec/ https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetes_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diab Xultophy® Liraglutide Mellitus_Type_2_Agents_PA_Criteria.pdf etes_Mellitus_Type_2_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Narcol Xyrem® Sodium oxybate _Agents_PA_Criteria.pdf epsy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Narcol Xywav™ Oxybate Salts _Agents_PA_Criteria.pdf epsy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Yervoy Ipilimumab _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM Axicabtagene https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chimeric_ https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chim Yescarta™

Ciloleucel Antigen_Receptor_T-Cell_Therapy_Agents.pdf eric_Antigen_Receptor_T-Cell_Therapy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Yonsa Abiraterone acetate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aspirin- http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Yosprala® Aspirin/Omeprazole PPI_Combination_Step_Therapy_PA_Criteria.pdf sal_PA_Form.pdf Hydrocodone/ http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Zamicet® Acetaminophen _Criteria.pdf d_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Zejula® Niraparib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Zarxio® Filgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Zelboraf® Vemurafenib

_Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Alpha1-Proteinase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Alpha_1_P http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Alpha Zemaira® Inhibitor (Human) roteinase_Inhibitor_PA_Criteria.pdf 1_proteinase_inhibitor.pdf Dextroamphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Me http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD Zenzedi® sulfate dications_Safe_Use_for_All_Ages_PA_Criteria.pdf _Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepat Zepatier® Elbasvir/Grazoprevir _PA_Criteria.pdf itis_C_Agents.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_S http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multi Zeposia® Ozanimod clerosis_Agents_PA_Criteria.pdf ple_Sclerosis_Agents_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology_Auxiliar Ziextenzo™ Pegfilgrastim _Auxiliary_Treatment_Agents_PA_Criteria.pdf y_Treatment_Agents_PA_Criteria.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zinplava_P http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Zinplava® Bezlotoxumab A_Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Zirabev Bevacizumab-bvzr _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioi Zohydro ER® Hydrocodone ER _Criteria.pdf d_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Spinal_Mu http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Spinal Zolgensma® Onasemnogene scular_Atrophy_PA_Criteria.pdf _Muscular_Atrophy_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Zolinza Vorinostat _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepres http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antid Zoloft® Sertraline sant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf epressant_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zolpimist_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Zolpimist™ Zolpidem PA_Criteria.pdf sal_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_H http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somat Zomacton® Somatropin ormone_PA_Criteria.pdf ropin_products.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021 BRAND NAME GENERIC NAME PA CRITERIA PA FORM http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_ http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minim Zorbtive® Somatropin Requirements_PA_Criteria.pdf um_Requirements_PA_Form.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zurampic_ http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Univer Zurampic® Lesinurad PA_Criteria.pdf sal_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Zydelig® Idelalisib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Zykadia® Certinib _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf Zyprexa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Olanzapine pamoate Relprevv® tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Zyprexa Zydis® Olanzapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsycho http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antips Zyprexa® Olanzapine tic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf ychotic_Medications_PA_FORM.pdf https://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oncology https://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Onco Zytiga Abiraterone acetate _Agents_PA_Criteria.pdf logy_Agents_PA_Form.pdf

CLINICAL PA TABLE OF CONTENTS | Revised 06.18.2021