2020 Medicaid Preapproval Criteria ABILIFY MAINTENA ................................................................................................................................................................ 10 ACTHAR HP ............................................................................................................................................................................ 11 ACTIMMUNE ......................................................................................................................................................................... 13 ADCIRCA ................................................................................................................................................................................ 14 ADEMPAS .............................................................................................................................................................................. 15 ADENOSINE DEAMINASE (ADA) REPLACEMENT ................................................................................................................... 17 AFINITOR ............................................................................................................................................................................... 18 AFINITOR DISPERZ ................................................................................................................................................................. 19 ALDURAZYME ........................................................................................................................................................................ 20 ALGLUCOSIDASE ALFA ........................................................................................................................................................... 21 ALPHA-1 PROTEINASE INHIBITORS ....................................................................................................................................... 22 AMPYRA ................................................................................................................................................................................ 23 AMIFAMPRIDINE ................................................................................................................................................................... 24 ANTIEMETICS ........................................................................................................................................................................ 26 ANTIHEMOPHILIC FACTORS .................................................................................................................................................. 28 ARCALYST .............................................................................................................................................................................. 30 ARISTADA .............................................................................................................................................................................. 31 ARIKAYCE ............................................................................................................................................................................... 32 ATGAM .................................................................................................................................................................................. 33 ATRYN .................................................................................................................................................................................... 34 AUBAGIO ............................................................................................................................................................................... 35 AUSTEDO ............................................................................................................................................................................... 36 AVONEX ................................................................................................................................................................................. 37 AZEDRA ................................................................................................................................................................................. 38 BANZEL .................................................................................................................................................................................. 39 BELINOSTAT .......................................................................................................................................................................... 40 BENLYSTA .............................................................................................................................................................................. 41 1 BESPONSA ............................................................................................................................................................................. 42 BETASERON ........................................................................................................................................................................... 43 BEVACIZUMAB ...................................................................................................................................................................... 44 BLINCYTO .............................................................................................................................................................................. 45 BONJESTA & DICLEGIS ........................................................................................................................................................... 46 BOTOX ................................................................................................................................................................................... 47 BRINEURA .............................................................................................................................................................................. 49 CABLIVI .................................................................................................................................................................................. 50 C1 ESTERASE INHIBITOR ........................................................................................................................................................ 51 CARBAGLU ............................................................................................................................................................................. 52 CAYSTON ............................................................................................................................................................................... 53 CERDELGA ............................................................................................................................................................................. 54 CGRP Inhibitors ..................................................................................................................................................................... 55 CHOLBAM .............................................................................................................................................................................. 57 CINQAIR IV ............................................................................................................................................................................ 58 COAGADEX ............................................................................................................................................................................ 59 COMPOUNDED MEDICATIONS ............................................................................................................................................. 60 CONTINUOUS GLUCOSE MONITORS ..................................................................................................................................... 61 CORLANOR ............................................................................................................................................................................ 62 CRESEMBA ............................................................................................................................................................................. 63 CRIZANLIZUMAB ................................................................................................................................................................... 64 CRYSVITA ............................................................................................................................................................................... 65 CYSTADANE ........................................................................................................................................................................... 66 CYSTAGON ............................................................................................................................................................................. 67 DALIRESP ............................................................................................................................................................................... 68 DEFIBROTIDE