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Prior authorization
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#	Item
341	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Arixtra – Non-Traditional Medicaid (fondaparinux sodium) Patient name:__________________________________________Medicaid ID #:______________________________ Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:15 Fondaparinux Medicaid Medical necessity Health Medicine Heparins Deep vein thrombosis Enoxaparin sodium
342	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: 2014-09-08 09:44:58 Alcohols Phenols Anti-acne preparations Combination drugs Tramadol Clindamycin Benzoyl peroxide Codeine Sulfacetamide/sulfur Chemistry Organic chemistry Morphinans
343	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: 2010-12-06 11:35:35 Morphinans Combination drugs Ketones Anti-acne preparations Alcohols Benzoyl peroxide Tramadol Sulfacetamide/sulfur Codeine Chemistry Organic chemistry Pharmacology
344	Prior Authorization of Power Mobility Devices (PMDs) Demonstration Fact Sheet The Medicare Fee-for-Service Prior Authorization of Power Mobility Device (PMD) demonstration will implement a Prior Authorization process for Add to Reading List Source URL: www.cms.gov Language: English - Date: 2014-01-08 14:44:34 Healthcare in the United States Medicare Health Medicaid TRICARE Wheelchair Government United States Federal assistance in the United States Healthcare reform in the United States Presidency of Lyndon B. Johnson
345	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: 2012-05-29 10:03:18 Phenols Alcohols Anti-acne preparations Euphoriants Tramadol Benzoyl peroxide Tapentadol Sulfacetamide/sulfur Codeine Chemistry Organic chemistry Morphinans
346	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM 72 Hour Emergency Supply (to be completed and submitted ONLY by the dispensing pharmacy) Patient name:___________________________________Medicaid ID #:_______ Add to Reading List Source URL: medicaid.utah.gov Language: English - Date: 2014-08-07 16:26:15 Medicinal chemistry Pharmacy Pharmaceuticals policy Medicaid Ohio Automated Rx Reporting System Medical prescription Medicine Pharmaceutical sciences Health
347	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION AMPYRA (dalfampridine) 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 Medicine Organ failure Creatinine Guanidines Metabolism Renal function Renal failure Epileptic seizure Anatomy Renal physiology Biology
348	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: 2014-03-21 08:47:33 Morphinans Anti-acne preparations Phenols Alcohols Combination drugs Tramadol Clindamycin Benzoyl peroxide Sulfacetamide/sulfur Chemistry Organic chemistry Medicine
349	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: 2014-06-13 08:24:46 Anti-acne preparations Alcohols Phenols Combination drugs Clindamycin Tramadol Sulfacetamide/sulfur Benzoyl peroxide Codeine Chemistry Organic chemistry Morphinans
350	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: 2014-09-30 10:26:58 Anti-acne preparations Alcohols Phenols Combination drugs Clindamycin Tramadol Sulfacetamide/sulfur Benzoyl peroxide Codeine Chemistry Organic chemistry Morphinans

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