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Virginia Medicaid Pharmacy Services

Service Authorizations

Service Authorizations

Class name (if the entire class has an edit PDL or Clinical) Revised date
Class name (if the entire class has an edit PDL or Clinical) Revised date
Aid Cat35 02/2015
Anti-Allergens (Oral) 06/2017
Antiemetic/Antivertigo 06/2017
Anti-Obesity Drugs 08/2015
Antifungal (Oral) 06/2017
Antipsychotics In Children Less Than 18 Years 11/2016
Bowel Disorder 06/2017
Buprenorphine (Oral) 06/2017
Dose Optimization 10/2016
General request form 12/2012
Growth Hormone 06/2017
Hepatitis C Antivirals 06/2017
Hepatitis C Therapy Patient Treatment Agreement 11/2016
Hereditary Angioedema (HAE) 06/2017
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors 06/2017
Proton Pump Inhibitors 11/2016
Short & Long Acting Opioid 06/2017
Short & Long Acting Opioid Daily Dose Limit 06/2017
Stimulants/ADHD Meds in Children Less Than FDA Indicated Age & over 18 07/2015
Topical Onychomycosis Agents 03/2016
Drugs name (if select drugs within the class requires a SA) Revised date
Drugs name (if select drugs within the class requires a SA) Revised date
Alecensa® 03/2016
Ampyra® 08/2012
Cerdelga™ 11/2014
Cotellic® 03/2016
Elelyso™, Korlym™ or Potiga™ 12/2012
Erivedge® or Odomzo® 11/2015
Esbriet® or Ofev® 11/2014
Exjade®, Ferriprox® or Jadenu™ 08/2015
Farydak® 05/2015
Forteo® or Tymlos™ 06/2017
Fulyzaqtm®, Ravicti® or Signifor® 09/2013
Gilotrif™ 01/2014
Ibrance® 03/2016
Iclusig ™ 03/2016
Imbruvica™ 08/2015
Jakafi™ or Promacta® 08/2015
Juxtapid™ or Kynamro™ 05/2013
Kalydeco™ or Orkambi® 08/2015
Lonsurf® 03/2016
Lenvima™ 08/2015
Lynparza™ 08/2015
Mekinist™ or Tafinlar® 01/2014
Methadone 12/2016
Mirvaso® 03/2014
Natpara® 08/2015
Ninlaro® 03/2016
Northera™ 11/2014
Otrexup™ 06/2017
Revlimid® 01/2016
Sivextro™ 08/2014
Soma®/carisoprodol 08/2012
Soolantra® 08/2015
Synagis® 09/2016
Tagrisso® 03/2016
Triumeq® 11/2014
Valchlor™ 01/2014
Xalkori® or Zelboraf® 08/2013
Xeljanz™ 05/2013
Zydelig® 11/2014
Zykadia™ 08/2014
Zyvox® 08/2014

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