Currentpriority healthPolicy N/A

Priority Health Medicaid Pharmacy Prior Authorizations

This part of Priority Health Medicaid Pharmacy Prior Authorizations lists preferred and non-preferred medications across multiple therapeutic classes and the prior authorization (PA) criteria, duration limits, quantity limits, age limits, and medication-specific exceptions for non-preferred agents included in Part 3 of 7 of the formulary/PA matrix.

Policy Summary

Payerpriority health

PolicyPriority Health Medicaid Pharmacy Prior Authorizations

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit PA for non-preferred medications and include documentation meeting the listed criteria (e.g., allergy, contraindication, therapeutic failure, or medication-specific requirements).

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

30+Therapeutic classes covered in this part

ManyNon-preferred agents requiring PA

90High MME threshold

7Opioid-naïve short-acting supply limit (days)

CommonGeneral PA criteria prevalence

What this bulletin covers

Part 3 of 7 of the Medicaid Pharmacy PA matrix lists preferred and non-preferred medications across many therapeutic classes (30+ classes referenced) and is mixed in coverage stance (preferred agents often no PA; many non-preferred agents require PA).

Therapeutic classes covered include biologic immunomodulators, opioids, insulins, weight-loss agents (GLP‑1 and non‑GLP1), anticoagulants, antifungals, antivirals, respiratory controllers, migraine agents, PCSK9/lipotropics, ophthalmics, dermatologic biologics, and many others (numerous drug‑class sections and specific agents are enumerated throughout).

General PA logic repeats across classes: approvals for non‑preferred agents are commonly granted when allergy/contraindication/serious adverse reaction to preferred medications, the patient is clinically intolerant or would deteriorate if switched, or there is therapeutic failure after specified trials of preferred agents (trial lengths vary by class).

Recurring operational themes include explicit PDL bypass allowances in defined situations (e.g., inability to swallow, unique FDA indication), frequent duration limits (commonly 1 year), product-specific quantity limits, and specialist-prescribing or baseline testing requirements for many biologics and specialty agents.

Representative drug listings (preferred vs non-preferred)

Preferred Agents (No Prior Authorization required) - select examples present in this partmixedCovered

	Humalog® 50/50 kwikpens
	Humulin® 70/30 Kwikpens, vials
	Lantus® pens, vials (preferred basal insulin example)
	Lev emir® pens, vials (preferred basal insulin example)
	atorvastatin
	ezetimibe
	azithromycin
	azelastine (nasal, ophthalmic)
	ciprofloxacin, moxifloxacin, ofloxacin (ophthalmic)

Non-Preferred Agents (Prior Authorization required) - select examples present in this partmixedExperimental

	Humalog® 75/25 pens
	Novolog® 70/30 pens, vials
	Basaglar® kwikpens, tempo pens
	Praluent®
	Repatha®
	Nexletol®
	Nexlizet®
	Icosapent Ethyl
	Celebrex® (celecoxib) - non-preferred listing
	Vumerity®

1–10 of 12

1/2

Agents where PDL criteria do not apply (coverage governed by separate lipid criteria)mixed

	Omega-3 Acid Ethyl Esters (adjunct for TG ≥500 mg/dL)
	NEXLETOL® (bempedoic acid)
	NEXLIZET® (bempedoic acid/ezetimibe)
	ICOSAPENT ETHYL

No CPT/HCPCS/ICD-10 codes listed in this partmixed

No codes listed

No procedure/drug codes listed in this partmixed

No codes listed

No specific procedure/billing codes listed in this partmixed

No codes listed

General non-preferred PA criteria (applies across classes)

General Non-Preferred Agent PA Criteria (recurring across multiple classes)

Covered when ANY of the following are met:

note":"Specify subtype and prior therapies tried with dates and outcomes."},{"text":"For migraine therapies (acute and preventive, including triptans oral/injectable/nasal and other acute agents): documentation of diagnosis (episodic or chronic), trial and failure or contraindication to preferred acute and/or preventive agents as appropriate (including one-month or two-week trial variations where clinically specified).","note":"Document frequency of attacks, prior preventive trials, and response."},{"text":"For antihypertensive combinations (ACEI+ARB combos, ARB/ARB-combinations, beta-blocker combinations): documentation that monotherapy or preferred combination therapy was tried and was ineffective or not tolerated; or necessity for fixed-dose combination for adherence where medically appropriate.","note":"List prior agents, doses, and outcomes."},{"text":"For lipid and cardiovascular agents (PCSK9 inhibitors, bile salts): documentation of LDL goals, statin intolerance or maximally tolerated therapy, and lipid panel results supporting need for non-preferred agent.","note":"Include recent lipid panel values and statin trial history."},{"text":"For hematologic agents (ESA, colony stimulating factors): documentation meets condition-specific criteria (CKD, chemotherapy-induced anemia, MDS, AIDS, pre-op) including relevant labs, transfusion history, and dosing justification per program guidance.","note":"Attach hemoglobin, neutrophil counts, or other labs as required."},{"text":"For growth hormone agents: documentation of approved indication, required testing (as per Growth Hormone Required Testing Information), and pediatric-specific limits where applicable.","note":"Include testing dates and results."},{"text":"For GLP‑1 therapies (including MACE/MASH/OSA indications, Wegovy®, and diabetes-specific uses): documentation of indication-specific criteria, baseline cardiovascular risk or weight/MASH/OSA measures, prior therapy trials as required, and renewal criteria documentation (weight loss response, continued benefit, safety monitoring).","note":"Provide baseline weight, A1c, MACE history as applicable, and prior GLP-1 use."},{"text":"For dermatologic immunomodulators and topical products (e.g., Opzelura®, topical antifungals, topical vitamin D analogs, calcineurin inhibitors): documentation of diagnosis severity, prior topical/systemic therapy trials (including high‑potency steroid trials), and pediatric dosing/quantity limits when applicable.","note":"Include body surface area or quantity justification for larger supplies."},{"text":"For ophthalmic agents, nasal sprays (Dymista®, Ryaltris®, Xhance®), and unique delivery products: clinical rationale for non-preferred choice and documentation of failure/intolerance to preferred alternatives or necessity based on prior surgical history or anatomic considerations.","note":"Include ENT/ophthalmology consultation notes when available."},{"text":"For biologic immunomodulators across diseases (AS, GCA, Crohn’s disease incl. pediatric products Yuflyma/Yusimry, HS, JIA agents, nr-axSpA, plaque psoriasis, RA, UC, uveitis): meet disease-specific entry criteria (disease activity measures, prior csDMARD or steroid trials, site-of-care and prescriber specialty requirements), and provide documentation of prior biologic use and reason for switching if applicable.","note":"Specify disease, prior treatments, objective measures (e.g., CDAI, BASDAI, PASI), and age if pediatric."},{"text":"For antivirals (oral, influenza, topical) including NEFFY® epinephrine exceptions and agent-specific criteria: diagnosis confirmation, timing of therapy relative to symptom onset where relevant (e.g., influenza), and documentation of prior therapies or risk factors necessitating the non-preferred agent.","note":"Include symptom onset date and diagnostic test results if applicable."},{"text":"For agents treating urologic, BPH (5‑alpha reductase inhibitors, alpha blockers), or combination urology products: documentation of lower urinary tract symptom severity, prior trials, and specific contraindications to preferred agents.","note":"Include IPSS score or equivalent when available."},{"text":"For opioids and controlled substances (including long‑acting and short‑acting): documentation of chronic pain diagnosis, prior treatment plan, opioid risk mitigation (treatment agreement, PDMP check), and justification for non-preferred formulation or long‑acting agent (include MME calculations).","note":"Attach opioid treatment documentation and PDMP check date."},{"text":"For quantity limits, agent-specific bypass (e.g., LIKMEZ® metronidazole bypass, NEFFY® epinephrine specific rules), or single‑use/short-course agents (e.g., AEMCOLO®): include indication, prior therapy, and justification for exceeding standard quantity limits or bypassing usual step edits.","note":"Provide clinical rationale and any required safety monitoring."},{"text":"For medications with age or formulation exceptions (e.g., ASMANEX® TWISTHALER age limit exceptions, Norliqva/Katerzia exceptions for CCBs): document age, prior trials, and clinical justification for exception to standard age restrictions."},{"text":"For ocular, dermatologic, or other agents with established quantity/age limits or safety checks: include required monitoring documentation and rationale for override.","note":"Include prior authorization forms or monitoring test dates."}]}

Class- and product-specific PA criteria (selected highlights)

Selected Class-Specific Non-Preferred PA Criteria (key classes and medication-specific rules)

Medication-specific non-preferred PA rules for selected key classes. Each block below renders the criteria tree for the titled class from the brief.

Entresto / Sacubitril-Valsartan

Non-Preferred Agent PA Criteria: Allergy to the preferred medications; OR Contraindication or drug to drug interaction with the preferred medications; OR History of unacceptable side effects; OR Therapeutic failure on one preferred medication

Anticoagulants

Anticoagulant PA Criteria: Allergy/contraindication/unacceptable side effects OR Therapeutic failure on one preferred medication
Pradaxa oral pellets pediatric and VTE-specific rules apply

Antifungals (systemic and specific agents)

Quantity, duration and age/weight limits (operational)

Product	Limit type	Value	Source note
Entresto Sprinkles	Quantity limit	60 capsules per 30 days	Allow PDL bypass if unable to swallow; Qty limit 60 caps/30d
Elyxyb	Quantity limit	14 doses per 30 days (67.2 mL)	Acute migraine non-preferred quantity: 14 doses/30d
Reyvow	Quantity limit	8 tablets per 30 days	Acute migraine non-preferred quantity: 8 tabs/30d
Zavzpret	Quantity limit	8 nasal devices per 30 days	Acute migraine non-preferred quantity: 8 devices/30d
Vivjoa	Quantity limit	18 tablets per treatment course	Vivjoa: 18 tablets per treatment course; one-time approval for recurrent VVC
Pradaxa Oral Pellets	Age limit	Patient must be 11 years old or younger	Pradaxa Oral Pellets: patient must be ≤11 years; attestation for VTE use if applicable
Noxafil suspension	Max age	Maximum patient age = 17 years	Noxafil 300 mg suspension packets: max patient age 17 years
Vusion	Max age	Maximum patient age = 16 years	Vusion topical: max patient age 16 years
Hemangeol	Max age	Maximum age of 1 year	Hemangeol (propranolol) oral solution: max age = 1 year
Tremfya	Pediatric weight requirement	Patient must be ≥40 kg (and ≥6 years) for psoriasis indication	Tremfya: pediatric weight requirement ≥40 kg for ages ≥6
NEFFY (epinephrine)	Patient weight	Patient weighs ≥30 kg	NEFFY: patient weight requirement ≥30 kg
High MME	Threshold	>90 MME/day	Total daily MME > 90 MME/day requires review and attestations
Opioid-naïve short-acting limit	Supply limit	7 days	Claims >7-day supply for opioid‑naïve patients (no opioid in past 180 days) will deny for PA
Entresto Sprinkles (again)	Bypass note	PDL bypass allowed if inability to swallow tablets	Entresto Sprinkles: allow PDL bypass if patient unable to swallow tablets; Qty 60/30d

What providers must do

Prior Authorization

Prior authorization required for non-preferred agents

Prior authorization is required for non-preferred agents. Submit a completed prior authorization request and supporting clinical documentation showing the patient meets at least one of the approved criteria for the requested medication (diagnosis, age, prior therapy trials, specialty prescriber when required, relevant labs or testing). Requests lacking the required documentation or failing to demonstrate an approved criterion may be denied.

Submit a completed Medicaid Pharmacy Prior Authorization form.
Provide documentation demonstrating at least one approved criterion is met (diagnosis, age, trial history, labs, specialty prescriber if required).
Include any specific attestations required for the drug class (see documentation callouts below).

Billing Rule

Product-specific quantity and duration limits

Coding and billing guidance (operational reminders)

This part contains numerous billing/operational impacts: quantity limits and duration limits are enforced (many examples provided, e.g., Entresto Sprinkles 60 capsules/30 days, typical approval length 1 year), and PA approvals require submission of documentation of trials, labs, specialist consults, or attestations as specified by agent.

Opioid-related billing rules: total daily MME > 90 MME/day triggers additional review and required attestations/documentation; claims for short-acting opioids exceeding a 7‑day supply for opioid‑naïve patients (no opioid claim in prior 180 days) will deny for PA.

Note: code_groups for this part show no CPT/HCPCS/ICD‑10 codes listed (the part contains drug NDC/name-level entries and many medication-specific rules). Do not invent CPT/HCPCS/ICD‑10 codes when populating — only include codes actually present in the source.

Billing Rule

Short-acting opioid 7-day limit enforcement

Short‑acting opioid prescriptions for opioid‑naïve patients are limited to a 7‑day supply. Claims for more than a 7‑day supply for patients with no opioid claim in the prior 180 days will deny for PA. Highlight denial risk when requesting >7 days for opioid‑naïve patients and ensure MME and high‑risk documentation requirements are met for higher daily MME exposures.

Opioid‑naïve short‑acting supply limit: >7 days will deny for PA

Definitions and operational terms

PDL bypass — Allowance to bypass preferred drug list trial requirements under specific clinical circumstances (e.g., inability to swallow tablets, unique FDA indication).

PDL — Preferred Drug List (used here to indicate preferred medications).

High MME — Total daily Morphine Milligram Equivalent greater than 90 MME/day requiring additional review and documentation.

PDL — Preferred Drug List (duplicate entry in source).

Effective and review dates

No effective/review dates provided in this part.

Policy Summary

Payerpriority health

PolicyPriority Health Medicaid Pharmacy Prior Authorizations

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit PA for non-preferred medications and include documentation meeting the listed criteria (e.g., allergy, contraindication, therapeutic failure, or medication-specific requirements).

On This Page

Non-Preferred Agent PA Criteria (general repeated rule across many classes)

Non-Preferred Agent PA Criteria — general repeated rule (used across many classes). Capture any of the following variations where specified by class-specific rules:

ANY of the following

One-month trial of a preferred agent with documentation of inadequate response or intolerance.
Used for some acute/short‑term therapies or where clinical guidance specifies a 4‑week trial.
Two-week trial of a preferred agent with documentation of inadequate response or intolerance.
Used for certain rapid-onset therapies or where shorter trial is clinically appropriate.
90-day (three‑month) trial of a preferred agent at adequate dose with documented lack of efficacy or intolerance.
Common for chronic therapies where 90 days is considered adequate to assess response.
Trial and failure of at least two preferred agents from different subclasses within the same therapeutic class where required (e.g., multiple biologic mechanisms, multiple triptans, multiple antihistamines).
Document agent names, doses, durations, and reasons for failure.
Step therapy alternative required unless prescriber documents contraindication, intolerance, allergy, or prior therapeutic failure to the step therapy agent(s).
Attach documentation of contraindication or failure.
Requirement for specialist prescriber (e.g., neurologist, rheumatologist, pulmonologist, gastroenterologist, cardiologist) when specified by disease-specific criteria; referral/consultation notes required where applicable.
Include specialty consult note or attestation of collaboration.
Age-specific trial variations (pediatric shorter trials, adult longer trials) or pediatric-specific limits/requirements (juvenile-specific limits).
Provide patient age and justification for shorter/longer trial length.
For acute infections/antibiotics: indication-appropriate duration trial or intolerance to first-line agents (culture/sensitivity data supportive when available).
Specify culture/sensitivity or rationale for selection.
For immunomodulators/biologics: when switching within class, documentation of primary nonresponse, secondary loss of response, or intolerance to prior biologic; include therapeutic drug monitoring or anti‑drug antibody data when available.
Provide prior biologic therapy dates and reason for change.
For quantity/step edits: documentation why standard quantity limits are insufficient (e.g., weight-based dosing, specific indication requiring higher supply, or frequency of dosing).
Attach dosing calculation and prescribing rationale.
For agents with REMS or required enrollment programs: prescriber attests to enrollment and patient education as required prior to approval.
Provide REMS enrollment confirmation if applicable.
Medical necessity based on disease severity measures (e.g., PASI for psoriasis, CDAI for Crohn’s, BASDAI for axSpA, AIMS for tardive dyskinesia) when specified by the medication or disease criteria.
Include baseline and on‑therapy scores for continuation reviews.
For MACE/MASH/OSA GLP‑1 indications and renewals: documentation of initial indication criteria and meeting renewal thresholds (e.g., percentage weight loss, glycemic control, OSA improvement).
Include baseline and follow-up measures as required by the indication.
Exceptions such as LIKMEZ® bypass, NEFFY® specific epinephrine rules, AEMCOLO® single‑course criteria, or agent-specific product limits must be documented per the agent-specific notes (include agent name and rationale).
Attach agent-specific justification and any relevant test results or prior authorization forms.

Antifungal PA Criteria: Allergy/contraindication/unacceptable side effects OR Trial and failure with one month of one preferred medication OR Serious illness resulting in immunocompromised status
See agent-specific entries for BREXAFEMME, CRESEMBA, VIVJOA

Biologic Immunomodulators (AS, GCA, Crohn's, HS) - broad biologics entry

General biologic PA criteria: Allergy/contraindication/unacceptable side effects OR patient clinically stable such that switching would cause deterioration OR therapeutic failure with one preferred medication in the same subclass
Bypass allowed for unique FDA-approved indications
Crohn's specific example (Zymfentra): ZYMFENTRA (infliximab-dyyb): Patient ≥18; Diagnosis moderate to severe Crohn's disease; Prescriber attests patient completed IV induction with an infliximab product; Prescribed by/consult with gastroenterologist
Duration: 1 year

Weight Loss Agents (non-GLP1 and GLP1)

Non-GLP1 Initial: Prescriber attests single-class use; age/BMI criteria and lifestyle/medical attestations per brief
Renewal documentation: adolescents - maintained/improved BMI percentile; adults - maintained ≥5% weight loss
GLP1 Initial: Allergy/contraindication/history of unacceptable side effects or trial/failure with all five types of preferred medications OR documented failure of all five; prescriber attestations re: single-agent use, prior interventions, used to avert bariatric surgery; Age/ BMI requirements as specified
Duration: 6 months

GLP-1s for MACE/MASH/OSA and Zepbound criteria

Wegovy for MACE initial: Prescriber attests no concurrent GLP1 or non-GLP1 weight loss med or DPP-4 inhibitor, patient ≥18, BMI ≥27, established cardiovascular disease, other attestations re: contraindications and treatment plan
Renewal: maintained ≥5% weight loss
Wegovy for MASH: Prescriber attests noncirrhotic MASH with F2-F3 fibrosis, BMI and concurrency attestations similar to MACE; Renewal: maintained ≥5% weight loss
Zepbound for OSA (preferred): Prescriber attests no concurrent GLP1 or non-GLP1 weight loss med or DPP-4 inhibitor, patient ≥18, BMI ≥27, documented moderate to severe OSA; Renewal: maintained ≥5% weight loss
Preferred agent PA criteria apply

Opioids - MME rules and PA criteria: Total daily MME >90 requires extensive review and attestations; short-acting opioid 7-day limit for opioid-naïve patients; PA criteria include age limits (≥12 for codeine/tramadol), allergy/contraindication/unacceptable side effects, therapeutic failure durations (one week for long-acting, one week each with two preferred meds for short-acting non-preferred) and MME documentation requirements

Initial high MME exceptions (cancer, sickle cell, hospice, exempt LTC) bypass requirements; otherwise prescriber must attest to risk assessment, pain agreement, MAPS review, non-opioid interventions, toxicology, naloxone counseling, and provide current opioid regimen and MME calculation

Product-specific quantity and duration limits are enforced. Requests must adhere to the product limits published on the Medicaid ADL and any additional limits in this criteria document. Common examples include 1-year and 6-month authorization periods where specified; some products have shorter initial durations (eg, 60 days, 3 months) or numeric quantity limits (capsules, doses, milligrams) that must be observed.

Examples of common durations: Initial authorization often 6 months or 1 year; some agents limited to 60 days, 3 months, or other product-specific time frames.
Quantity limits (per fill or per year) on certain products must be followed; prescribers must justify requests exceeding published limits.
Renewal requests must document clinical response and continue to meet criteria to receive continuation authorization for the established timeframe.

Documentation Required

Documentation and attestations required (include diagnosis, age, labs, specialty prescriber, trial history, BMI/weight as applicable)

Clinical documentation requirements and attestations vary by agent. Include the required fields listed below when submitting a PA: diagnosis, patient age, relevant labs/testing (with dates and values), prescriber specialty (if required), previous trial history with dates/doses, and measurements such as BMI or weight when applicable.

Clinical documentation for migraine prevention PA: include diagnosis, patient age, prior migraine prophylaxis trials and outcomes, prescriber specialty if required, and relevant baseline headache frequency data.
Weight loss agent attestations and measurements: include diagnosis (eg, obesity, weight-related condition), current weight, height, BMI, documentation of prior weight management attempts, and attestation of indication (weight loss or metabolic/GLP-1 indication) as applicable.
Biologic disease-specific requirements: include confirmatory testing/diagnosis, prior conventional therapy trials, prescriber specialty (eg, dermatology, rheumatology, gastroenterology), and baseline disease activity measures.
Baseline testing/labs required for certain agents: include specific lab test names, dates, and numeric results (eg, hepatitis screening, CBC, LFTs, pregnancy test when indicated).
Growth hormone testing and documentation requirements: include diagnosis, growth charts, baseline IGF-1 and other endocrine testing, specialist prescriber (pediatric endocrinologist) attestation, and patient's growth velocity data.
ESA/Jesduvroq/Vafseo required labs: include hemoglobin, iron studies (ferritin, TSAT), renal function, and dates/values to support use.
Opioid high MME documentation and attestations: include current MME calculation, indication, documentation of risk-benefit discussion, treatment plan for monitoring, and any required state prescription drug monitoring program (PDMP) checks.
Pradaxa Oral Pellets pediatric and VTE use: include pediatric diagnosis justification, age, weight-based dosing rationale, and VTE indication details per product labeling.
GLP-1 and weight/metabolic indications attestations: specify whether request is for weight management or metabolic/diabetes indication and include relevant clinical measures (A1c if diabetes, BMI if weight management) and prior therapy trials as required.
Montelukast form/age justification: include indication, patient age, and justification if formulation or age differs from standard recommendations.
Ophthalmic renewal requirements (Eysuvis): include evidence of continued benefit, ocular exam findings, and any adverse events since prior authorization.
Statin/PCSK9 lab documentation: include LDL-C values with dates, prior statin therapy history, and prescriber specialty when required.
Quantity and age limits enforcement: clearly document patient age and justify any request that exceeds age or quantity limits specified in the ADL or criteria.

Prior Authorization

Bypass allowances and specialty prescriber requirement for growth hormone agents

PDL (preferred drug list) trial requirements may be bypassed in specified scenarios. Examples include documented intolerance or contraindication to preferred agents, clinically urgent situations, or when clinical documentation shows prior failure despite adequate trials. Include supporting documentation demonstrating the reason for bypass.

Bypass allowed for documented allergy/intolerance or contraindication to all formulary alternatives.
Bypass may be granted if trialing preferred agents would be medically inappropriate (provide clinical rationale).
For growth hormone agents, a specialist prescriber (pediatric endocrinologist) is required for initial requests and must submit the specific growth hormone testing and documentation described above.

If total daily MME >90, submit required high‑MME documentation and attestations to avoid denial