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Prior authorization
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#	Item
271	BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover p Add to Reading List Source URL: www.dhhr.wv.gov Language: English - Date: 2011-06-10 09:21:51 Morphinans Anti-acne preparations Alcohols Phenols Combination drugs Tramadol Benzoyl peroxide Sulfacetamide/sulfur Codeine Chemistry Organic chemistry Medicine
272	BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover p Add to Reading List Source URL: www.dhhr.wv.gov Language: English - Date: 2013-06-19 16:52:38 Anti-acne preparations Alcohols Phenols Ketones Tramadol Benzoyl peroxide Clindamycin Codeine Hydrocodone Chemistry Organic chemistry Morphinans
273	BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover p Add to Reading List Source URL: www.dhhr.wv.gov Language: English - Date: 2014-10-10 09:42:36 Anti-acne preparations Alcohols Phenols Combination drugs Clindamycin Tramadol Sulfacetamide/sulfur Benzoyl peroxide Codeine Chemistry Organic chemistry Morphinans
274	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Chantix (varenicline) Patient name:_______________________________Medicaid ID #:________________________________ Prescriber Name:________________Prescriber NPI# Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:15 Organic chemistry Stimulants Technology Benzazepines Pyrazines Varenicline Nicotine Fax Nicotinic agonists Chemistry Smoking cessation
275	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION BUTRANS (buprenorphine) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescriber NPI#:_____ Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:15 Anesthesia Drug rehabilitation Ethers Buprenorphine Pain management Opioid Analgesic Kappa Opioid receptor Medicine Pain Morphinans
276	BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA This is not an all-inclusive list of available covered drugs and includes only managed categories. Refer to cover p Add to Reading List Source URL: www.dhhr.wv.gov Language: English - Date: 2011-09-02 13:46:04 Morphinans Anti-acne preparations Alcohols Phenols Combination drugs Tramadol Benzoyl peroxide Sulfacetamide/sulfur Codeine Chemistry Organic chemistry Medicine
277	BUREAU FOR MEDICAL SERVICES WEST VIRGINIA MEDICAID PREFERRED DRUG LIST WITH PRIOR AUTHORIZATION CRITERIA THERAPEUTIC PREFERRED AGENTS Add to Reading List Source URL: www.dhhr.wv.gov Language: English - Date: 2010-12-03 12:26:05 Morphinans Combination drugs Anti-acne preparations Ketones Alcohols Hydrochlorothiazide Oxycodone Clindamycin Codeine Chemistry Organic chemistry Pharmacology
278	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM ENBREL (enteracept) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescriber N Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:16 Anatomy Arthritis Autoimmune diseases Immunosuppressants Psoriasis Biologic Etanercept Psoriatic arthritis Rheumatoid arthritis Medicine Health Rheumatology
279	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM ADAGEN (pegademase bovine) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Presc Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:15 Pharmacology Clinical pharmacology Medical prescription Patient safety Eli Lilly and Company Methadone Pharmacy Fax Adenosine Medicine Chemistry Pharmaceutical sciences
280	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM CEREZYME (imiglucerase) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescrib Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:15 Clinical pharmacology Health Medical prescription Patient safety Imiglucerase Pharmacy Medical necessity Ohio Automated Rx Reporting System Pharmaceutical sciences Medicine Pharmacology

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