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Prior authorization
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#	Item
331	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Adult Acne 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
332	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 12:25:59 Morphinans Combination drugs Anti-acne preparations Ketones Amines Sulfacetamide/sulfur Hydrochlorothiazide Benzoyl peroxide Clindamycin Chemistry Organic chemistry Pharmacology
333	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: 2011-03-30 14:17:14 Morphinans Anti-acne preparations Alcohols Phenols Combination drugs Tramadol Benzoyl peroxide Sulfacetamide/sulfur Codeine Chemistry Organic chemistry Medicine
334	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 12:25:59 Morphinans Combination drugs Anti-acne preparations Ketones Amines Benzoyl peroxide Hydrochlorothiazide Clindamycin Sulfacetamide/sulfur Chemistry Organic chemistry Pharmacology
335	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: 2014-02-27 08:48:35 Anti-acne preparations Alcohols Phenols Combination drugs Tramadol Clindamycin Benzoyl peroxide Sulfacetamide/sulfur Valsartan Chemistry Organic chemistry Morphinans
336	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: 2011-03-03 15:53:04 Anti-acne preparations Morphinans Combination drugs Alcohols Phenols Sulfacetamide/sulfur Clindamycin Hydromorphone Tramadol Chemistry Organic chemistry Medicine
337	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 17:20:01 Biology Anemia Leflunomide Etanercept Disease-modifying antirheumatic drug Infliximab Anakinra Rheumatoid arthritis Adalimumab Medicine Immunosuppressants Pharmacology
338	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: 2013-05-29 11:23:02 Anti-acne preparations Alcohols Phenols Ketones Tramadol Benzoyl peroxide Clindamycin Codeine Hydrocodone Chemistry Organic chemistry Morphinans
339	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM BOTULINUM TOXINS 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 Neurotoxins Biology Anatomy Migraine Hyperhidrosis Spasmodic torticollis Medicine Plastic surgery Botulinum toxin
340	PA Criteria Prior Authorization Group Drug Names Covered Uses Exclusion Criteria Required Medical Information Add to Reading List Source URL: www.bcidaho.com Language: English - Date: 2014-10-07 11:43:51 Pharmaceutical sciences Eli Lilly and Company Pharmaceuticals policy Clinical pharmacology Amines Food and Drug Administration Methadone Antipsychotic Clozapine Chemistry Medicine Pharmacology

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