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2020 Medicaid Preapproval Criteria 2020 Medicaid Preapproval Criteria ABILIFY MAINTENA ................................................................................................................................................................ 11 ACNE AGENTS........................................................................................................................................................................ 13 ACTHAR HP ............................................................................................................................................................................ 14 ACTIMMUNE ......................................................................................................................................................................... 16 ADCIRCA ................................................................................................................................................................................ 17 ADEMPAS .............................................................................................................................................................................. 18 ADENOSINE DEAMINASE (ADA) REPLACEMENT ................................................................................................................... 20 AFAMELANOTIDE .................................................................................................................................................................. 21 AFINITOR ............................................................................................................................................................................... 23 AFINITOR DISPERZ ................................................................................................................................................................. 24 AGALSIDASE BETA ................................................................................................................................................................. 25 ALGLUCOSIDASE ALFA ........................................................................................................................................................... 26 ALPHA-1 PROTEINASE INHIBITORS ....................................................................................................................................... 27 AMBRISENTAN ...................................................................................................................................................................... 28 AMPYRA ................................................................................................................................................................................ 29 AMIFAMPRIDINE ................................................................................................................................................................... 30 ANTIEMETICS ........................................................................................................................................................................ 32 ANTIHEMOPHILIC FACTORS .................................................................................................................................................. 34 ANTITHROMBIN .................................................................................................................................................................... 36 ANTITHYMOCYTE .................................................................................................................................................................. 37 ALPELISIB ............................................................................................................................................................................... 38 APOMORPHINE ..................................................................................................................................................................... 39 ARCALYST .............................................................................................................................................................................. 40 ARISTADA .............................................................................................................................................................................. 41 ARIKAYCE ............................................................................................................................................................................... 42 ATEZOLIZUMAB ..................................................................................................................................................................... 43 AUBAGIO ............................................................................................................................................................................... 44 1 AUSTEDO ............................................................................................................................................................................... 45 AVONEX ................................................................................................................................................................................. 46 AZTREONAM ......................................................................................................................................................................... 47 BEDAQUILINE ........................................................................................................................................................................ 48 BELINOSTAT .......................................................................................................................................................................... 49 BELIMUMAB .......................................................................................................................................................................... 50 BENRALIZUMAB .................................................................................................................................................................... 51 BETASERON ........................................................................................................................................................................... 53 BEVACIZUMAB ...................................................................................................................................................................... 54 BEXAROTENE ......................................................................................................................................................................... 55 BIMATOPROST IMPLANT....................................................................................................................................................... 56 BLINATUMOMAB .................................................................................................................................................................. 58 BONJESTA & DICLEGIS ........................................................................................................................................................... 59 BOSENTAN ............................................................................................................................................................................ 60 BOTOX ................................................................................................................................................................................... 61 BUROSUMAB ......................................................................................................................................................................... 63 CAPLACIZUMAB ..................................................................................................................................................................... 64 C1 ESTERASE INHIBITOR ........................................................................................................................................................ 65 CARBAGLU ............................................................................................................................................................................. 66 CANNABIDIOL ........................................................................................................................................................................ 67 CENOBAMATE ....................................................................................................................................................................... 68 CERDELGA ............................................................................................................................................................................. 69 CERLIPONASE ALFA ............................................................................................................................................................... 70 CGRP INHIBITORS .................................................................................................................................................................. 71 CHELATING AGENTS .............................................................................................................................................................. 74 CHOLBAM .............................................................................................................................................................................
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