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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
Antiemetic/Antivertigo 01/2014
Anti-Obesity Drugs 08/2015
Antifungal (Oral) 05/2013
Antipsychotics In Children Less Than 18 Years 07/2015
Bowel Disorder 12/2016
Buprenorphine (Oral) 12/2016
Dose Optimization 10/2016
General request form 12/2012
Growth Hormone 01/2014
Hepatitis C Antivirals 12/2016
Hereditary Angioedema (HAE) 03/2016
Long Acting Opioids 12/2016
Long Acting & Short Acting Opioids Daily Dose Limit 12/2016
Oral Anticoagulants 07/2015
Proton Pump Inhibitors 03/2016
Short Acting Opioids 12/2016
Stimulants/ADHD Meds in Children Less Than FDA Indicated Age & over 18 07/2015
Topical Onychomycosis Agents 03/2016
Transmucosal Immediate Release Fentanyl 07/2015
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
Cialis® 08/2012
Cotellic® 03/2016
Elelyso™, Korlym™ or Potiga™ 12/2012
Entresto™ 01/2016
Erivedge® or Odomzo® 11/2015
Esbriet® or Ofev® 11/2014
Exjade®, Ferriprox® or Jadenu™ 08/2015
Farydak® 05/2015
Forteo® 08/2012
Fulyzaqtm®, Ravicti® or Signifor® 09/2013
Gilotrif™ 01/2014
Ibrance® 03/2016
Iclusig ™ 03/2016
Imbruvica™ 08/2015
Kalydeco™ or Orkambi® 08/2015
Jakafi™ or Promacta® 08/2015
Juxtapid™ or Kynamro™ 05/2013
Ketek® 08/2012
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
Onfi™ 01/2014
Otrexup™ 03/2014
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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