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2019 Medicaid Preapproval Criteria

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2019 Medicaid Preapproval Criteria 2019 Medicaid Preapproval Criteria ABILIFY MAINTENA ................................................................................................................................................................ 13 ACTHAR HP ............................................................................................................................................................................ 14 ACTIMMUNE ......................................................................................................................................................................... 16 ADAGEN & REVCOVI ............................................................................................................................................................. 17 ADCIRCA ................................................................................................................................................................................ 18 ADEMPAS .............................................................................................................................................................................. 19 AFINITOR ............................................................................................................................................................................... 21 AFINITOR DISPERZ ................................................................................................................................................................. 22 ALDURAZYME ........................................................................................................................................................................ 23 ALGLUCOSIDASE ALFA ........................................................................................................................................................... 24 ALPHA-1 PROTEINASE INHIBITORS ....................................................................................................................................... 25 AMPYRA ................................................................................................................................................................................ 26 AMIFAMPRIDINE ................................................................................................................................................................... 27 ANTIEMETICS ........................................................................................................................................................................ 29 ANTIHEMOPHILIC FACTORS .................................................................................................................................................. 31 ARCALYST .............................................................................................................................................................................. 33 ARISTADA .............................................................................................................................................................................. 34 ARIKAYCE ............................................................................................................................................................................... 35 ATGAM .................................................................................................................................................................................. 36 ATRYN .................................................................................................................................................................................... 37 AUBAGIO ............................................................................................................................................................................... 38 AUSTEDO ............................................................................................................................................................................... 39 AVASTIN ................................................................................................................................................................................ 40 AVONEX ................................................................................................................................................................................. 41 AZEDRA ................................................................................................................................................................................. 42 BANZEL .................................................................................................................................................................................. 43 BELEODAQ ............................................................................................................................................................................. 44 1 BENLYSTA .............................................................................................................................................................................. 45 BESPONSA ............................................................................................................................................................................. 46 BETASERON ........................................................................................................................................................................... 47 BLINCYTO .............................................................................................................................................................................. 48 BONJESTA & DICLEGIS ........................................................................................................................................................... 49 BOTOX ................................................................................................................................................................................... 50 BRINEURA .............................................................................................................................................................................. 52 CABLIVI .................................................................................................................................................................................. 53 CALQUENCE .......................................................................................................................................................................... 54 C1 ESTERASE INHIBITOR ........................................................................................................................................................ 55 CARBAGLU ............................................................................................................................................................................. 56 CAYSTON ............................................................................................................................................................................... 57 CERDELGA ............................................................................................................................................................................. 58 CEREZYME ............................................................................................................................................................................. 59 CGRP Inhibitors ..................................................................................................................................................................... 60 CHOLBAM .............................................................................................................................................................................. 62 CIMZIA ................................................................................................................................................................................... 63 CINQAIR IV ............................................................................................................................................................................ 66 COAGADEX ............................................................................................................................................................................ 67 COMPOUNDED MEDICATIONS ............................................................................................................................................. 68 CONTINUOUS GLUCOSE MONITORS ..................................................................................................................................... 69 CORLANOR ............................................................................................................................................................................ 70 CRESEMBA ............................................................................................................................................................................. 71 CRYSVITA ............................................................................................................................................................................... 72 CYSTADANE ..........................................................................................................................................................................
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