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Virginia Medicaid Pharmacy Services

Service Authorizations

Service Authorizations

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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
Antiemetic/Antivertigo 01/2014
Anti-Obesity Drugs 02/2014
Antifungal (Oral) 05/2013
Antipsychotics In Children Less Than 13 Years 06/2014
Bowel Disorder 01/2014
Buprenorphine (Oral) 02/2015
Dose Optimization 08/2012
General request form 12/2012
Growth Hormone 001/2014
Hepatitis C Antivirals 8/2014
Hepatitis C Antivirals - Appendix A 12/2014
Hereditary Angioedema (HAE) 01/2014
Long Acting Narcotics 08/2012
Narcotic Lozenge 08/2012
Proton Pump Inhibitors 12/2012
Stimulants/ADHD Medications in Children Less Than FDA Indicated Age 01/2014
Topical Onychomycosis Agents 08/2014
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
Ampyra® 08/2012
Cerdelga™ 11/2014
Cialis® 08/2012
Elelyso™, Korlym™ or Potiga™ 12/2012
Eliquis™ 01/2014
Ferriprox® or Promacta® 08/2013
Forteo® 08/2012
Fulyzaqtm®, Ravicti® or Signifor® 09/2013
Gilotrif™ 01/2014
Iclusig ™ 06/2014
Imbruvica™ 01/2014
Jakafi™ or Kalydeco™ 08/2014
Juxtapid™ or Kynamro™ 05/2013
Ketek® 08/2012
Luzu® 03/2014
Mekinist™ or Tafinlar® 01/2014
Methadone 08/2012
Mirvaso® 03/2014
Northera™ 11/2014
Onfi™ 01/2014
Otrexup™ 03/2014
Pradaxa® 12/2012
Revlimid® 01/2014
Sivextro™ 08/2014
Soma®/carisoprodol 08/2012
Synagis® 08/2014
Triumeq® 11/2014
Valchlor™ 01/2014
Xalkori® or Zelboraf® 08/2013
Xarelto® 02/2014
Xeljanz™ 05/2013
Zydelig® 11/2014
Zykadia™ 08/2014
Zyvox® 08/2014