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Virginia Medicaid Pharmacy Services

Service Authorizations

Service Authorizations

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File Name
File Name
VA Medicaid Request for Service Authorization Bowel Disorder Medications
VA Medicaid Request for Service Authorization Growth Hormone
VA Medicaid Request for Service Authorization Antiemetic/Antivertigo Medications
VA Medicaid Request for Service Authorization Hereditary Angiodema (HAE) Medications
VA Medicaid Request for Service Authorization Stimulants/ADHD Medications Prescribed for Children Less Than FDA Indicated Age
VA Medicaid Request for Service Authorization Antifungal Medications
VA Medicaid Request for Service Authorization Eliquis ™
VA Medicaid Request for Service Authorization Xeljanz ™
VA Medicaid Request for Service Authorization Iclusig ™ or Linzess ™
VA Medicaid Request for Service Authorization Juxtapid ™ or Kynamro ™
VA Medicaid Request for Service Authorization Elelyso ™, Korlym ™ or Potiga ™
VA Medicaid Request for Service Authorization Xarelto ®
VA Medicaid Request for Service Authorization Zelboraf ® OR Xalkori ® Products
VA Medicaid Request for Service Authorization Soma ®/Carisoprodol Products
VA Medicaid Request for Service Authorization Oral Buprenorphine Products
VA Medicaid Request for Service Authorization DUR Medications Onfi ™
VA Medicaid Request for Service Authorization Methadone
VA Medicaid Request for Service Authorization Kalydeco ™ OR Jakafi ™
VA Medicaid Request for Service Authorization Ferriprox ® OR Promacta ®
VA Medicaid Request for Service Authorization Cialis ®
VA Medicaid Request for Service Authorization for an Atypical Antipsychotic in Children Less Than 6 Year
VA Medicaid Request for Service Authorization Synagis ®
VA Medicaid Request for Service Authorization Pradaxa ®
VA Medicaid Request for Service Authorization Forteo ®
VA Medicaid Request for Service Authorization Narcotic Lozenge
VA Medicaid Request for Service Authorization Long Acting Narcotics
VA Medicaid Request for Service Authorization Ampyra ®
VA Medicaid Request for Service Authorization Dose Optimization
VA Medicaid Request for Service Authorization Proton Pump Inhibitors (PPI)
VA Medicaid Request for Drug Service Authorization
VA Medicaid Request for Service Authorization Ketek ®
VA Medicaid Request for Service Authorization Anti-Obesity Drugs

Last Updated on: 03/12/2014