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Prior authorization
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#	Item
291	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM EMSAM (selegiline transdermal) Patient name:_______________________________Medicaid ID #:________________________________ Prescriber Name:________________Prescr Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:16 Technology Emsam Selegiline Antidepressant Medicaid Fax Medical necessity Monoamine oxidase inhibitors Pharmacology Medicine
292	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 12:26:03 Morphinans Combination drugs Anti-acne preparations Alcohols Phenols Tramadol Benzoyl peroxide Clindamycin Codeine Chemistry Organic chemistry Pharmacology
293	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 Add to Reading List Source URL: www.dhhr.wv.gov Language: English - Date: 2010-12-03 12:26:00 Anti-acne preparations Combination drugs Morphinans Ketones Phenols Tramadol Clindamycin Hydromorphone Sulfacetamide/sulfur Chemistry Organic chemistry Pharmacology
294	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: 2014-09-19 15:45:33 Anti-acne preparations Alcohols Phenols Combination drugs Clindamycin Tramadol Sulfacetamide/sulfur Benzoyl peroxide Codeine Chemistry Organic chemistry Morphinans
295	An Independent Licensee of the Blue Cross and Blue Shield Association Prior Authorization Requirements Effective: [removed] Add to Reading List Source URL: www.azbluemedicare.com Language: English - Date: 2014-10-01 01:42:15 Biology Anemia Leflunomide Etanercept Erythropoietin Disease-modifying antirheumatic drug Infliximab Anakinra Rheumatoid arthritis Medicine Immunosuppressants Pharmacology
296	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION Colchicine (Cholcrys, Mitigare) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescriber NP Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-10-20 16:29:14 Arthritis Rheumatology Acetamides Alkaloids Colchicine Ketones Gout Allopurinol Non-steroidal anti-inflammatory drug Chemistry Organic chemistry Medicine
297	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: 2012-04-17 12:28:43 Alcohols Phenols Euphoriants Anti-acne preparations Tramadol Benzoyl peroxide Tapentadol Codeine Sulfacetamide/sulfur Chemistry Organic chemistry Morphinans
298	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: 2013-12-30 10:27:00 Anti-acne preparations Alcohols Phenols Combination drugs Tramadol Clindamycin Sulfacetamide/sulfur Benzoyl peroxide Valsartan Chemistry Organic chemistry Morphinans
299	Prior Authorization of Power Mobility Devices (PMDs) Demonstration Updated Fact Sheet • The Medicare Fee-for-Service Prior Authorization of Power Mobility Device (PMD) Add to Reading List Source URL: www.cms.gov Language: English - Date: 2014-05-23 14:11:43 Healthcare in the United States Medicare Medicaid Government Wheelchair TRICARE Health United States Federal assistance in the United States Healthcare reform in the United States Presidency of Lyndon B. Johnson
300	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM EMEND-(aprepitant) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescriber NP Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:16 Antiemetics Oncology Chemotherapy regimens Aprepitant Lactams Morpholines Dolasetron Chemotherapy Cisplatin Chemistry Medicine Organic chemistry

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