Clinical pa table of contents - Kansas Department of Health ...€¦ · CLINICAL PA TABLE OF CONTENTS | Revised 06/10/2020 CLINICAL PRIOR AUTHORIZATION (PA) TABLE OF CONTENTS Medications

CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020

CLINICAL PRIOR AUTHORIZATION (PA) TABLE OF CONTENTS

Medications requiring Clinical Prior Authorization (PA) for Kansas Medicaid are listed in the table below. Please use this table to identify if a specific medication requires Clinical PA and which Clinical PA criteria and PA form should be used to request an authorization from the patient’s specific health plan (MCO/FFS). Please note, medications requiring Clinical PA may also have to meet Non-preferred PDL PA criteria before the claim may be considered for payment. Products listed in red font have criteria updated since the last posting. For drugs that are new to the market and not listed in the table, please click the following medication hold link for further information: http://www.kdheks.gov/hcf/pharmacy/medication_hold_review.htm Use the “ctrl + F” keyboard shortcut to search for a medication or keyword within this document.

BRAND NAME GENERIC NAME PA CRITERIA PA FORM

Abilify Discmelt®

Aripiprazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf

Abilify Maintena®

Aripiprazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Abilify® Aripiprazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Abilify MyCite® Aripiprazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Abstral® Fentanyl http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioid_PA_FORM.pdf

Actemra® Tocilizumab Adult Rheumatoid Arthritis Agents Juvenile Idiopathic Arthritis Agents

Adult Rheumatoid Arthritis FORM Juvenile Idiopathic Arthritis Agents FORM

Actiq® Fentanyl http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Adasuve® Loxapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Adcirca® Tadalafil (tablets) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary_Hypertension_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Pulmonary_arterial_hypertension_agents.pdf

Adderall XR® Amphetamine/ Dextroamphetamine

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD_Medications_PA_FORM.pdf

Adderall® Amphetamine/ Dextroamphetamine



Adempas® Riociguat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary_Hypertension_Agents_PA_Criteria.pdf


Adlyxin™ Lixisenatide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diabetic_Agents_PA_FORM.pdf

Adynovate® Antihemophilic factor VIII recombinant, pegylated

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Long-Acting_Hemophilia_Factors_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hemophilia_Factors_Long-Acting_PA_Form.pdf

Adzenys ER® Amphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


http://www.kdheks.gov/hcf/pharmacy/medication_hold_review.htm

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf
















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Adult_Rheumatoid_Arthritis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Juvenile_Idiopathic_Arthritis_Agents_PA_Criteria.pdf


http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Adult_Rheumatoid_Arthritis_Agents_PA_Form.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Juvenile_Idiopathic_Arthritis_Agents_PA_Form.pdf










http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary_Hypertension_Agents_PA_Criteria.pdf
















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf














Adzenys XR-ODT®

Amphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Afinitor® Everolimus http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf

Afrezza® Insulin human inhalation powder

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Afrezza_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf

Aimovig™ Erenumab-aooe http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/CGRP_Antagonists_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/CGRP_Antagonists_PA_Form.pdf

Ajovy™ Fremanezumab-vfrm

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/CGRP_Antagonists_PA_Criteria.pdf


Akynzeo® Netupitant/ palonosetron (oral) Fosnetupitant/ palonosetron (IV)

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics%20NK-1_antagonists_and_NK1_combinations_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neurokinin_1_NK1_antagonist_combo.pdf

Alli® Orlistat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Loss_Drugs_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Wt_loss_inital_renewal.pdf

Alprazolam Intensol®

Alprazolam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzodiazepine_Mental_Health_FORM.pdf

Alprolix® Coagulation factor IX recombinant, Fc fusion protein



Alunbrig™ Brigatinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Aminosalicylate sodium

Aminosalicylate sodium

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rifampin_and_TB_15381_Activated_Traditional.pdf

Amitiza® Lubiprostone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-Constipation_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Constipation_agents_step_therapy.pdf

Amjevita® Adalimumab- atto Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Juvenile Idiopathic Arthritis Agents Plaque Psoriasis Agents Ulcerative Colitis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents FORM Juvenile Idiopathic Arthritis Agents FORM Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM

Amoxapine Amoxapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antidepressant_Medications_PA_FORM.pdf

Amrix® Cyclobenzaprine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Amrix_PA_Criteria.pdf


Anafranil® Clomipramine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Androderm® Testosterone Transdermal

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_and_Buccal_Androgen_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topical_buccal_androgen_hormone_agents.pdf

AndroGel® Testosterone Topical Gel







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf





















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Loss_Drugs_PA_Criteria.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf
















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-Constipation_Agents_PA_Criteria.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Psoriatic_Arthritis_Agents_PA_Criteria.pdf


http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ankylosing_Spondylitis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Crohns_Disease_Agents_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Plaque_Psoriasis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ulcerative_Colitis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Psoriatic_Arthritis_Agents_PA_Form.pdf


http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Ankylosing_Spondylits_Agents_PA_Form.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Crohns_Disease_Agents_PA_Form.pdf


http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Plaque_Psoriasis_Agents_PA_Form.pdf


http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Ulcerative_Colitis_Agents_PA_Form.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Amrix_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Amrix_PA_Criteria.pdf

















Apadaz® Benzhydrocodone/ Acetaminophen



Aptensio XR® Methylphenidate HCl



Aralast NP® Alpha1-Proteinase Inhibitor (Human)

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Alpha_1_Proteinase_Inhibitor_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Alpha1_proteinase_inhibitor.pdf

Arbinoxa® Carbinoxamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Carbinoxamine_Products_Step_Therapy_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Carbinoxamine_Products_Step_Therapy_PA_Form.pdf

Arcalyst® Rilonacept http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Arcalyst_PA_Criteria.pdf


Arikayce® Amikacin oral inhalation

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Arikayce_PA_Criteria.pdf


Arimidex® Anastrozole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aromatase_Inhibitors_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Aromatase_Inhibitors_17628_Activated_Traditional.pdf

Aristada® Aripiprazole lauroxil http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Aristada Initio™ Aripiprazole lauroxil http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Aromasin® Exemestane http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aromatase_Inhibitors_PA_Criteria.pdf


Arymo ER® Morphine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Ativan® Lorazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Aubagio® Teriflunomide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Multiple_Sclerosis_Agents_PA_FORM.pdf

Austedo™ Deutetrabenzine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Monoamine_Depletor_PA_Criteria.PDF

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Monoamine_Depletor_VMAT2_Inhibitors_PA_Form.pdf

Avinza® Morphine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Avonex® Interferon beta-1a http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Axiron® Testosterone Topical Solution



Banzel® Rufinamide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Banzel_PA_Criteria.pdf


Bavencio® Avelumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Belbuca® Buprenorphine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Benlysta® Belimumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benlysta_PA_Criteria.pdf














http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Carbinoxamine_Products_Step_Therapy_PA_Criteria.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Arcalyst_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Arcalyst_PA_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aromatase_Inhibitors_PA_Criteria.pdf
























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Monoamine_Depletor_PA_Criteria.PDF
















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Banzel_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Banzel_PA_Criteria.pdf











http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benlysta_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benlysta_PA_Criteria.pdf





Betaseron® Interferon beta-1b http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Bivigam® Immune globulin (human) intravenous

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Immune_Globulins_IVIGs_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Intravenous_Immune_globulin.pdf

Blincyto® Blinatumomab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Bonjesta® Doxylamine succinate/ Pyridoxine HCl

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diclegis_PA_Criteria.pdf


Botox® OnabotulinumtoxinA

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Botulinum_Toxins_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Botulinum_Toxins_HP.pdf

Braftovi™ Encorafenib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Brineura™ Cerliponase, alfa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brineura_PA_Criteria.pdf


Brisdelle® Paroxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brisdelle__PA_Criteria.pdf


Buphenyl® Sodium phenylbutyrate

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Buphenyl_PA_Criteria.pdf


Butrans® Buprenorphine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Bydureon® Exenatide ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Bydureon® BCise™

Exenatide ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Byetta® Exenatide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Cabometyx® Cabozantinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Calquence® Acalabrutinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Capstat® Capreomycin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Carimune NF® Immune globulin (human) intravenous



Celexa® Citalopram http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Cerdelga® Eliglustat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Replacement_Therapy_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/enzyme_replacement_therapy.pdf

























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brineura_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brineura_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brisdelle__PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brisdelle__PA_Criteria.pdf











































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Replacement_Therapy_PA_Criteria.pdf






Cerezyme® Imiglucerase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Replacement_Therapy_PA_Criteria.pdf


Cesamet® Nabilone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics_Cannabinoid_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Cannabinoid_antiemetics.pdf

Chlorpromazine

Chlorpromazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Cimzia® Certolizumab Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Psoriasis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents FORM Plaque Psoriasis Agents FORM

Cinqair® Reslizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Asthma_Agents_PA_Form.pdf

Cinvanti™ Aprepitant (IV) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics%20NK-1_antagonists_and_NK1_combinations_PA_Criteria.pdf


Clonidine Clonidine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Clozaril® Clozapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Codeine Codeine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Combunox® Oxycodone/ Ibuprofen



Concerta® Methylphenidate HCl



Consensi™ Amlodipine/ Celecoxib

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Consensi_Step_Therapy_PA_Criteria.pdf


Contrave® ER Naltrexone/ Bupropion



Conzip® Tramadol ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Copaxone® Glatiramer http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Cosentyx® Secukinumab Psoriatic Arthritis Agents Ankylosing Spondylitis Agents Plaque Psoriasis Agents

Psoriatic Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Plaque Psoriasis Agents FORM

Cotellic® Cobimetinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Cotempla XR-ODT™

Methylphenidate HCl



Crinone® Progesterone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Crinone_PA_Criteria.pdf






http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics_Cannabinoid_PA_Criteria.pdf



















https://gcc01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.kdheks.gov%2Fhcf%2Fpharmacy%2Fpdl_authorization_forms%2FAsthma_Agents_PA_Form.pdf&data=02%7C01%7CAnnette.Grant%40ks.gov%7C4c5dc8b3e1c8420cc82108d7ba2cfb11%7Cdcae8101c92d480cbc43c6761ccccc5a%7C0%7C0%7C637182574655727427&sdata=oEyReVVWtaiN02gGXHQcS4YDoLy74twDUyyy0USV8ZY%3D&reserved=0


























































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Crinone_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Crinone_PA_Criteria.pdf





Cyltezo™ Adalimumab- adbm Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Juvenile Idiopathic Arthritis Agents Plaque Psoriasis Agents Ulcerative Colitis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents FORM Juvenile Idiopathic Arthritis Agents FORM Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM

Cymbalta® Duloxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Dalmane® Flurazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Daraprim® Pyrimethamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Daraprim_PA_Criteria.pdf


Darzalex® Daratumumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Daytrana® Methylphenidate Transdermal



Delatestryl® Testosterone Enanthate

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Testosterone_Injectable_PA_Criteria.pdf


Demerol® Meperidine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Demser® Metyrosine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Demser_PA_Criteria.pdf


Desoxyn® Methamphetamine HCl



Dexedrine® Dextroamphetamine sulfate



DextroStat® Dextroamphetamine sulfate



Diazepam Intensol®

Diazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Diclegis® Doxylamine succinate/ Pyridoxine HCl



Dihydrocodeine Dihydrocodeine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Dilaudid® Hydromorphone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Doral® Quazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Drizalma Sprinkle™

Duloxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Duexis® Ibuprofen/ Famotidine

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/NSAID_plus_PPI-H2_Blocking_Agents_Step_Therapy_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/NSAID_PPI_H2.pdf



























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Daraprim_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Daraprim_PA_Criteria.pdf



















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Demser_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Demser_PA_Criteria.pdf













































Dupixent® Dupilumab Atopic Dermatitis Agents PA; Asthma Agents PA

Atopic Dermatitis PA FORM Asthma Agents PA FORM

Duragesic Fentanyl transdermal



Dyanavel XR® Amphetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Dymista® Azelastine/ Fluticasone

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Intranasal_Antihistamine-Corticosteroid_Agents_Step_Therapy_PA_Criteria.pdf


Dysport® AbobotulinumtoxinA



Effexor XR® Venlafaxine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Effexor® Venlafaxine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Elaprase® Idursulfase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Elaprase_PA_Criteria.PDF


Elavil® Amitriptyline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Elelyso® Taliglucerase alfa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Replacement_Therapy_PA_Criteria.pdf


Elidel® Pimecrolimus http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Atopic_Dermatitis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Atopic_Dermatitis_Agents_PA_Form.pdf

Eloctate® Antihemophilic factor VIII recombinant, Fc fusion protein



Embeda® Morphine/ Naltrexone



Emend® Aprepitant (oral) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics%20NK-1_antagonists_and_NK1_combinations_PA_Criteria.pdf


Emend® Fosaprepitant (IV) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics%20NK-1_antagonists_and_NK1_combinations_PA_Criteria.pdf


Emflaza® Deflazacort http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Emflaza_PA_Criteria.PDF


Emgality™ Galcanezumab-gnlm http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/CGRP_Antagonists_PA_Criteria.pdf


http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Atopic_Dermatitis_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Agents_PA_Criteria.pdf




























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Elaprase_PA_Criteria.PDF

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Elaprase_PA_Criteria.PDF

































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Emflaza_PA_Criteria.PDF

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Emflaza_PA_Criteria.PDF









Empliciti® Elotuzumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Emsam® Selegiline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Enbrel® Etanercept Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Juvenile Idiopathic Arthritis Agents Plaque Psoriasis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Juvenile Idiopathic Arthritis Agents FORM Plaque Psoriasis Agents FORM

Endocet® Oxycodone/ Acetaminophen



Entyvio® Vedolizumab Crohn's Disease Agents Ulcerative Colitis Agents

Crohn’s Disease Agents FORM Ulcerative Colitis Agents FORM

Epclusa® Sofosbuvir/ Velpatasvir

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Hepatitis_C_Agents.pdf

Erelzi™ Etanercept-szzs Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Juvenile Idiopathic Arthritis Agents Plaque Psoriasis Agents


Esbriet® Pirfenidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IPF_Treatments_PA_Criteria.pdf


Esperoct® Antihemophilic factor VIII recombinant, PEGylated



Eticovo™ Etanercept Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Juvenile Idiopathic Arthritis Agents Plaque Psoriasis Agents


Eucrisa® Crisaborole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Atopic_Dermatitis_Agents_PA_Criteria.pdf


Exalgo® Hydromorphone ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Exjade® Deferasirox http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exjade_PA_Criteria.pdf


Exondys 51™ Eteplirsen http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exondys_51_PA_Criteria.pdf


Extavia® Interferon beta-1b http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Fabrazyme® Agalsidase beta http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Replacement_Therapy_PA_Criteria.pdf


Fanapt® Iloperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf














































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IPF_Treatments_PA_Criteria.pdf




























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exjade_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exjade_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exondys_51_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exondys_51_PA_Criteria.pdf

















Farxiga® Dapagliflozin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Farydak® Panobinostat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Fasenra™ Benralizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Agents_PA_Criteria.pdf


Fazaclo® Clozapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Femara® Letrozole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aromatase_Inhibitors_PA_Criteria.pdf


Fentora® Fentanyl http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Ferriprox® Deferiprone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ferriprox_PA_Criteria.pdf


Fetzima® Levomilnacipran http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Finacea® Azelaic acid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosacea_Agents_PA_Form.pdf

Firazyr® Icatibant http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Firazyr_PA_Criteria.pdf


Flebogamma DIF®

Immune globulin (human) intravenous



Flolan® Epoprostenol (injection)



Fluphenazine Fluphenazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Focalin XR® Dexmethylphenidate ER



Focalin® Dexmethylphenidate



Forfivo® XL Bupropion http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Fortamet® Metformin ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Metformin_ER_Step_Therapy.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Metformin_ER.pdf

Forteo® Teriparatide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Teriparatide_Forteo_Criteria.pdf


Fortesta® Testosterone Topical Gel



Fuzeon® Enfuvirtide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Fuzeon.pdf http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ferriprox_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ferriprox_PA_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Firazyr_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Firazyr_PA_Criteria.pdf



























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Metformin_ER_Step_Therapy.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Teriparatide_Forteo_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Teriparatide_Forteo_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Fuzeon.pdf





Galafold® Migalastat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Replacement_Therapy_PA_Criteria.pdf


Gammagard S/D®

Immune globulin (human) intravenous



Gammagard® Immune globulin (human) intravenous/ subcutaneous



Gammaked® Immune globulin (human) intravenous/ subcutaneous



Gammaplex® Immune globulin (human) intravenous



Gamunex-C® Immune globulin (human) intravenous/ subcutaneous



Genotropin® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somatropin_products.pdf

Geodon® Ziprasidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Gilenya® Fingolimod http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Gilotrif® Afatinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Glassia® Alpha1-Proteinase Inhibitor (Human)



Glatopa® Glatiramer http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Glumetza® Metformin ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Metformin_ER_Step_Therapy.pdf


Glyxambi® Empagliflozin/ Linagliptin



GoNitro® Nitroglycerin sublingual powder

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nitroglycerin_Sublingual_Step_Therapy_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Nitroglycerin_Step_Therapy_PA_Form.pdf

Granix® Tbo-filgrastim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Granix_PA_Criteria.pdf


H.P.Acthar Gel® Repository Corticotropin

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/HP_Acthar__PA_Criteria.pdf


























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf




































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Granix_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Granix_PA_Criteria.pdf









Hadlima™ Adalimumab-bwwd Adult Rheumatoid Arthritis Agents Crohn's Disease Agents Ulcerative Colitis Agents

Adult Rheumatoid Arthritis Agents FORM Crohn’s Disease Agents FORM Ulcerative Colitis Agents FORM

Halcion® Triazolam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Haldol Decanoate®

Haloperidol Decanoate



Haldol® Haloperidol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Harvoni® Ledipasvir/ Sofosbuvir



Herceptin® Trastuzumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Hetlioz® Tasimelteon http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hetlioz_PA_Criteria.pdf


Hizentra® Immune globulin (human) subcutaneous



Humatrope® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf


Humira® Adalimumab Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Juvenile Idiopathic Arthritis Agents Plaque Psoriasis Agents Ulcerative Colitis Agents


Hycet® Hydrocodone/ Acetaminophen



Hydrocodone/ Ibuprofen

Hydrocodone/ Ibuprofen



Hyrimoz™ Adalimumab Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Juvenile Idiopathic Arthritis Agents Plaque Psoriasis Agents Ulcerative Colitis Agents


Hysingla ER® Hydrocodone ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Ibrance® Palbociclib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Idelvion® Coagulation factor IX recombinant, albumin fusion protein (rIX-FP)






























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hetlioz_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hetlioz_PA_Criteria.pdf






































































Idhifa® Enasidenib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Ilaris® Canakinumab Juvenile Idiopathic Arthritis Agents Juvenile Idiopathic Arthritis Agents FORM

Ilumya® Tildrakizumab-asmn Plaque Psoriasis Agents Plaque Psoriasis Agents FORM

Imbruvica® Ibrutinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Imfinzi™ Durvalumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Increlex® Mecasermin rinfabate

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Increlex_PA_Criteria.pdf


Infergen® Interferon alfacon-1 http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Infergen_PA_Criteria.pdf


Inflectra® Infliximab-dyyb Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Psoriasis Agents Ulcerative Colitis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Crohn’s Disease Agents FORM Plaque Psoriasis Agents FORM Ulcerative Colitis Agents FORM

Ingrezza® Valbenazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Monoamine_Depletor_PA_Criteria.PDF


Intron A Interferon alfa-2b http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IntronA_PA_Criteria.pdf


Intuniv® Guanfacine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Invega Sustenna®

Paliperidone palmitate



Invega Trinza® Paliperidone palmitate



Invega® Paliperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Invokamet XR® Canagliflozin/ Metformin



Invokamet® Canagliflozin/ Metformin



Invokana® Canagliflozin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Isonarif® Rifampin/Isoniazid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Ixifi™ Infliximab-qbtx Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Psoriasis Agents Ulcerative Colitis Agents






















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Infergen_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Infergen_PA_Criteria.pdf






















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IntronA_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IntronA_PA_Criteria.pdf




















































Jadenu® Deferasirox http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jadenu_PA_Criteria.pdf


Jakafi® Ruxolitinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jakafi_PA_Criteria.pdf


Jardiance® Empagliflozin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Jetrea® Ocriplasmin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jetrea_PA_Criteria.pdf


Jivi® Antihemophilic factor VIII recombinant, PEGylated



Jornay PM™ Methylphenidate HCl



Juxtapid® Lomitapide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Juxtapid_PA_Criteria.pdf


Kadian ER® Morphine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Kalbitor® Ecallantide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kalbitor_PA_Criteria.pdf


Kalydeco® Ivacaftor http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_Requirements_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Minimum_Requirements_PA_Form.pdf

Kanuma® Sebelipase alfa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kanuma_PA_Criteria.pdf


Kapvay® Clonidine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Karbinal ER™ Carbinoxamine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Carbinoxamine_Products_Step_Therapy_PA_Criteria.pdf


Kevzara® Sarilumab Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM

Keytruda® Pembrolizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Khedezla® Desvenlafaxine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Kineret® Anakinra Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM

Kisqali® Ribociclib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Kisqali® Femara Co-pack

Ribociclib/Letrozole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Klonopin® Clonazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jadenu_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jadenu_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jakafi_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jakafi_PA_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jetrea_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jetrea_PA_Criteria.pdf











http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Juxtapid_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Juxtapid_PA_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kalbitor_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kalbitor_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Minimum_Requirements_PA_Criteria.pdf


https://gcc01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.kdheks.gov%2Fhcf%2Fpharmacy%2Fpdl_authorization_forms%2FMinimum_Requirements_PA_Form.pdf&data=02%7C01%7CAnnette.Grant%40ks.gov%7C4c5dc8b3e1c8420cc82108d7ba2cfb11%7Cdcae8101c92d480cbc43c6761ccccc5a%7C0%7C0%7C637182574655727427&sdata=dHm3VVFIYUJEkdfvRXZkeBoW2%2FWBoWQ9AlldRm1AiM8%3D&reserved=0


http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kanuma_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kanuma_PA_Criteria.pdf





































Krystexxa® Pegloticase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pegloticase_Krystexxa.pdf


Kuvan® Sapropterin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kuvan_PA_criteria.pdf


Kymriah® Tisagenlecleucel http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kymriah_PA_Criteria.PDF


Kynamro® Mipomersen http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kynamro_PA_Criteria.pdf


Kyprolis® Carfilzomib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Lartruvo® Olaratumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Latuda® Lurasidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Lazanda® Fentanyl http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Lemtrada® Alemtuzumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Letairis® Ambrisentan (tablets)



Leukine® Sargramostim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Leukine_Criteria.pdf


Levo-Dromoran®

Levorphanol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Lexapro® Escitalopram http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Librium® Chlordiazepoxide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Linzess® Linaclotide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-Constipation_Agents_PA_Criteria.pdf


Lorazepam Intensol®

Lorazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Lorcet HD® Hydrocodone/ Acetaminophen



Lorcet Plus® Hydrocodone/ Acetaminophen



Lorcet® Hydrocodone/ Acetaminophen



Lortab® Hydrocodone/ Acetaminophen



Loxitane® Loxapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pegloticase_Krystexxa.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pegloticase_Krystexxa.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kuvan_PA_criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kuvan_PA_criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kymriah_PA_Criteria.PDF

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kymriah_PA_Criteria.PDF



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kynamro_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kynamro_PA_Criteria.pdf



























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Leukine_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Leukine_Criteria.pdf













































Lucentis® Ranibizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lucentis_PA_Criteria.pdf


Lupaneta Pack® Leuprolide/ Norethindrone

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupaneta_Pack_PA_Criteria.pdf


Lupron® Leuprolide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupron_PA_Criteria.pdf


Luvox CR® Fluvoxamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Luvox® Fluvoxamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Luxturna™ Voretigene Neparvovec-rzyl

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Luxturna_PA_Criteria.pdf


Lynparza™ Olaparib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Lyrica CR® Pregabalin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lyrica_CR_PA_Criteria.pdf


Makena® Hydroxyprogesterone Caproate

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Makena_PA_Criteria.pdf


Maprotiline Maprotiline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Marinol® Dronabinol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics_Cannabinoid_PA_Criteria.pdf


Marplan® Isocarboxazid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Mavenclad® Cladribine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Mavyret® Glecaprevir/ Pibrentasvir



Maxidone® Hydrocodone/ Acetaminophen



Mayzent® Siponimod http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Mekinist® Trametinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Mektovi™ Binimetinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Metadate CD® Methylphenidate HCl



Metadate ER® Methylphenidate HCl



Methadone Methadone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lucentis_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lucentis_PA_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupron_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupron_PA_Criteria.pdf



















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lyrica_CR_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lyrica_CR_PA_Criteria.pdf

























































Methylin® Methylphenidate HCl



MetroCream® Metronidazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


Metrogel® Metronidazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


MetroLotion® Metronidazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


Mirvaso® Brimonidine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


MorphaBond® Morphine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Morphine IR Morphine IR http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Motegrity™ Prucalopride http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-Constipation_Agents_PA_Criteria.pdf


Motofen® Difenoxin/Atropine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Motofen_PA_Criteria.pdf


Movantik® Naloxegol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Induced_Constipation_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/opioid_induced_constipation.pdf

Mozobil® Plerixafor http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Mozobil_PA_Criteria.pdf


MS Contin® Morphine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Myambutol® Ethambutol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Mycobutin® Rifabutin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Mydayis® Amphetamine/ Dextroamphetamine



Myobloc® RimabotulinumtoxinB



Nardil® Phenelzine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Natesto® Testosterone nasal gel



Natpara® Parathyroid hormone

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Natpara_PA_Criteria.pdf


Nefazodone Nefazodone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Neulasta® Pegfilgrastim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neulasta_PA_Criteria.pdf


































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Motofen_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Motofen_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Induced_Constipation_Agents_PA_Criteria.pdf




http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Mozobil_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Mozobil_PA_Criteria.pdf







































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neulasta_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neulasta_PA_Criteria.pdf





Neupogen® Filgrastim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neupogen_Criteria.pdf


Niazid® Isoniazid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Niazid-B6® Isoniazid/Pyridoxine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Ninlaro® Ixazomib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Niravam ODT® Alprazolam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Nitroglycerin sublingual spray

Nitroglycerin sublingual spray



Norco® Hydrocodone/ Acetaminophen



Norditropin® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf


Noritate® Metronidazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


Norpramin® Desipramine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Nplate® Romiplostim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nplate_PA_Criteria.pdf


Nucala® Mepolizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Agents_PA_Criteria.pdf


Nucynta ER® Tapentadol ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Nucynta® Tapentadol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Nuedexta® Dextromethorphan/ Quinidine

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nuedexta_PA_Criteria.pdf


Nutropin® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf


Nydrazid® Isoniazid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Ocaliva® Obeticholic Acid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ocaliva_PA_Criteria.pdf


Ocrevus™ Ocreblizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Octagam® Immune globulin (human) intravenous



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neupogen_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neupogen_Criteria.pdf







































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nplate_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nplate_PA_Criteria.pdf

























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ocaliva_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ocaliva_PA_Criteria.pdf













Ofev® Nintedanib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IPF_Treatments_PA_Criteria.pdf


Olumiant® Baricitinib Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM

Omnitrope® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf


Onfi® Clobazam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Onfi_PA_Criteria.pdf


Onivyde® Irinotecan http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Opana ER® Oxymorphone ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Opana ER® Oxymorphone ER (crush-resistant)



Opana® Oxymorphone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Opdivo® Nivolumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Opsumit® Macitentan http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary_Hypertension_Agents_PA_Criteria.pdf


Oralair® Sweet Vernal, Orchard, Perennial Rye, Timothy, Kentucky Blue Grass mixed pollens allergens extract

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Oralair_PA_Criteria.pdf


Oramorph® Morphine ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Orap® Pimozide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Orencia® Abatacept Psoriatic Arthritis Agents, Adult Rheumatoid Arthritis Agents Juvenile Idiopathic Arthritis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM Juvenile Idiopathic Arthritis Agents FORM

Orenitram® Treprostinil (tablets ER)



Orilissa™ Elagolix http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Orilissa_PA_Criteria.pdf


Orkambi® Lumacaftor/ Ivacaftor



Osphena® Ospemifene http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Osphena_PA_Criteria.pdf


Otezla® Apremilast Psoriatic Arthritis Agents Plaque Psoriasis Agents Psoriatic Arthritis Agents FORM Plaque Psoriasis Agents FORM











http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Onfi_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Onfi_PA_Criteria.pdf


















































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Orilissa_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Orilissa_PA_Criteria.pdf





http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Osphena_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Osphena_PA_Criteria.pdf









Oxaydo® Oxycodone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


OxyContin® Oxycodone ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Ozempic® Semaglutide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Pamelor® Nortriptyline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Papain/Urea Products

Papain/Urea Products

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Wound_Care_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Decubitus_28578_Activated_Traditional.pdf

Papain/Urea/ Chlorophyllin Products

Papain/Urea/ Chlorophyllin Products



Parnate® Tranylcypromine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Parsabiv® Etelcalcetide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Calcimimetics_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Calcimimetic_Agents_PA_Form.pdf

Paser Granules®

Aminosalicylic acid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Paxil CR® Paroxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Paxil® Paroxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Pentazocine/ Naloxone

Pentazocine/ Naloxone



Percocet® Oxycodone/ Acetaminophen



Percodan® Oxycodone/Aspirin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Perphenazine Perphenazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Perseris™ Risperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Pexeva® Paroxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Phentermine products

Phentermine products



Plegridy® Interferon beta-1a http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Praluent® Alirocumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/PCSK9_inhibitor_therapy_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/PCSK_9_inhibitor.pdf





























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Calcimimetics_PA_Criteria.pdf
















































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/PCSK9_inhibitor_therapy_PA_Criteria.pdf






Prialt® Ziconotide intrathecal infusion

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Prialt_PA_Criteria.pdf


Priftin® Rifapentine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Primlev® Oxycodone/ Acetaminophen



Pristiq® Desvenlafaxine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Privigen® Immune globulin (human) intravenous



ProCentra® Dextroamphetamine sulfate



Prolastin C® Alpha1-Proteinase Inhibitor (Human)



Prolia® Denosumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Prolia_PA_Criteria.pdf


Promacta® Eltrombopag http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Promacta_PA_Criteria.pdf


ProSom® Estazolam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Protopic® Tacrolimus http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Atopic_Dermatitis_Agents_PA_Criteria.pdf


Provenge® Sipuleucel-T http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Prozac® Fluoxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Prozac® Weekly Fluoxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Pyrazinamide Pyrazinamide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Qsymia® Phentermine/ Topiramate



Qtern® Dapagliflozin/ Saxagliptin



Qualaquin® Quinine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Qualaquin_PA_Criteria.pdf


Qudexy XR® Topiramate ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topiramate_ER_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Topriamate_ER_PA_Form.pdf

Quillichew ER™ Methylphenidate HCl































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Prolia_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Prolia_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Promacta_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Promacta_PA_Criteria.pdf



































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Qualaquin_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Qualaquin_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topiramate_ER_PA_Criteria.pdf










Quillivant XR® Methylphenidate HCl



Radicava® Edaravone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Radicava_PA_Criteria.pdf


Ragwitek® Short ragweed pollen allergen extract

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ragwitek_PA_Criteria.pdf


Ravicti® Glycerol phenylbutyrate

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ravicti_PA_Criteria.pdf


Rebif® Interferon beta-1a http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Rebinyn® Coagulation factor IX recombinant, glycol-pegylated



Regranex® Becaplermin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Regranex_PA_Criteria.pdf


Relexxii™ Methylphenidate HCl



Relistor® Methylnaltrexone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Induced_Constipation_Agents_PA_Criteria.pdf


Remeron® Mirtazapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Remicade® Infliximab Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Psoriasis Agents Ulcerative Colitis Agents


Remodulin® Treprostinil (injection)



Renflexis® Infliximab-abda Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Crohn's Disease Agents Plaque Psoriasis Agents Ulcerative Colitis Agents


Repatha® Evolocumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/PCSK9_inhibitor_therapy_PA_Criteria.pdf


Restasis® Cyclosporine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Restasis_PA_Criteria.pdf


Restoril® Temazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Revatio® Sildenafil (injection, oral suspension, tablets)







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Radicava_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Radicava_PA_Criteria.pdf



















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Regranex_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Regranex_PA_Criteria.pdf





















































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Restasis_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Restasis_PA_Criteria.pdf













Revlimid® Lenalidomide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Rexulti® Brexpiprazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Rhofade® Oxymetazoline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


Rifadin® Rifampin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Rifamate® Rifampin/Isoniazid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Rifater® Rifampin/Isoniazid/Pyrazinamide



Rilutek® Riluzole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rilutek_PA_Criteria.pdf


Rimactane® Rifampin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Rinvoq™ Upadacitinib Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM

Risperdal Consta®

Risperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Risperdal M-Tab®

Risperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Risperdal® Risperidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Ritalin LA® Methylphenidate HCl



Ritalin® Methylphenidate HCl



Rituxan Hycela®

Rituximab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Rituxan® Rituximab Adult Rheumatoid Arthritis Agents Chemotherapy Agents Adult Rheumatoid Arthritis Agents FORM Chemotherapy Agents FORM

Rosadan® Metronidazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


Roxanol® Morphine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Roxicet® Oxycodone/ Acetaminophen



Roxicodone Intensol®

Oxycodone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Roxicodone® Oxycodone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rilutek_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rilutek_PA_Criteria.pdf



























































Roxybond® Oxycodone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Rubraca™ Rucaparib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Rydapt® Midostaurin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Ryvent™ Carbinoxamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Carbinoxamine_Products_Step_Therapy_PA_Criteria.pdf


Ryzolt® Tramadol ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Sabril® Vigabatrin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sabril_PA_Criteria.pdf


Saizen® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf


Santyl® Collagenase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Wound_Care_PA_Criteria.pdf


Saphris® Asenapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Savella® Milnacipran http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Saxenda® Liraglutide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Loss_Drugs_PA_Criteria.pdf


Segluromet™ Ertugliflozin/ Metformin



Selzentry® Maraviroc http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Selzentry.pdf http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf

Sensipar® Cinacalcet http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Calcimimetics_PA_Criteria.pdf


Serax® Oxazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Sernivo® Betamethasone dipropionate

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sernivo_PA_Criteria.pdf


Seroquel XR® Quetiapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Seroquel® Quetiapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Siliq™ Brodalumab Plaque Psoriasis Agents Plaque Psoriasis Agents FORM

Simponi Aria® Golimumab Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM

Simponi® Golimumab Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ankylosing Spondylitis Agents Ulcerative Colitis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Ulcerative Colitis Agents FORM





















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sabril_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sabril_PA_Criteria.pdf



























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Selzentry.pdf










































Sinequan® Doxepin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Sirturo® Bedaquiline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Skyrizi® Risankizumab Plaque Psoriasis Agents Plaque Psoriasis Agents FORM

Soliqua® Insulin glargine/ Lixisenatide



Soliris® Eculizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soliris_PA_Criteria.pdf


Soma Compound with Codeine®

Carisoprodol/ Aspirin/Codeine

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soma_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Carisoprodol_Containing_Products_PA_Form.pdf

Soma Compound®

Carisoprodol/Aspirin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soma_PA_Criteria.pdf


Soma® Carisoprodol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soma_PA_Criteria.pdf


Somavert® Pegvisomant http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Somavert_PA_Criteria.pdf


Soolantra® Ivermectin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rosacea_Agents_PA_Criteria.PDF


Sovaldi® Sofosbuvir http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C_PA_Criteria.pdf


Spravato® Esketamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Spinraza® Nusinersen http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Spinal_Muscular_Atrophy_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Spinal_Muscular_Atrophy_PA_Form.pdf

Steglatro™ Ertugliflozin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Steglujan™ Ertugliflozin/ Sitagliptin



Stelara® Ustekinumab Psoriatic Arthritis Agents Crohn's Disease Agents Plaque Psoriasis Agents

Psoriatic Arthritis Agents FORM Crohn’s Disease Agents FORM Plaque Psoriasis Agents FORM

Stivarga® Regorafenib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Strattera® Atomoxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Strensiq® Asfotase alfa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Strensiq_PA_Criteria.pdf


Striant® Testosterone buccal http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topical_and_Buccal_Androgen_PA_Criteria.pdf
















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soliris_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soliris_PA_Criteria.pdf















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Somavert_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Somavert_PA_Criteria.pdf















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Spinal_Muscular_Atrophy_PA_Criteria.pdf




























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Strensiq_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Strensiq_PA_Criteria.pdf









Subsys® Fentanyl http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Subutex® Buprenorphine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Buprenorphine_for_Opioid_Dependence_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Buprenorphine_products_opiod_addic.pdf

Sunosi® Solriamfetol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Narcolepsy_Agents_PA_Form.pdf

Supprelin® LA Histrelin acetate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Supprelin_LA_PA_Criteria.pdf


Surmontil® Trimipramine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Symbyax® Olanzapine/ Fluoxetine

Antipsychotic Medications - Safe Use for All Ages Antidepressant Medications -Safe Use for All Ages

Antipsychotic Medications - Safe Use for All Ages PA FORM Antidepressant Medications -Safe Use for All Ages FORM

Symdeko™ Tezacaftor/ Ivacaftor



Symproic® Naldemedine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_Induced_Constipation_Agents_PA_Criteria.pdf


Synagis® Palivizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Synagis_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS

_Synagis_HP.pdf

Syndros® Dronabinol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics_Cannabinoid_PA_Criteria.pdf


Synjardy XR® Empagliflozin/ Metformin



Synjardy® Empagliflozin/ Metformin



Syprine® Trientine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Syprine_PA_Criteria.pdf


Tafinlar® Dabrafenib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Tagrisso® Osimertinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Taltz® Ixekizumab Psoriatic Arthritis Agents Plaque Psoriasis Agents Psoriatic Arthritis Agents FORM Plaque Psoriasis Agents FORM

Targiniq ER® Oxycodone/Naloxone



Tecentriq® Atezolizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Tecfidera® Dimethyl fumarate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Tenex® Guanfacine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf






http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Buprenorphine_for_Opioid_Dependence_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Buprenorphine_for_Opioid_Dependence_PA_Criteria.pdf



https://gcc01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.kdheks.gov%2Fhcf%2Fpharmacy%2Fpdl_authorization_forms%2FNarcolepsy_Agents_PA_Form.pdf&data=02%7C01%7CAnnette.Grant%40ks.gov%7C4c5dc8b3e1c8420cc82108d7ba2cfb11%7Cdcae8101c92d480cbc43c6761ccccc5a%7C0%7C0%7C637182574655717469&sdata=95O9atIdZ2%2BOfIlobTET5MMwjJUlMEI5eYU3XUeyoik%3D&reserved=0


http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Supprelin_LA_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Supprelin_LA_PA_Criteria.pdf

















http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Synagis_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Synagis_PA_Criteria.pdf

https://gcc01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.kdheks.gov%2Fhcf%2Fpharmacy%2Fpdl_authorization_forms%2FKS_Synagis_HP.pdf&data=02%7C01%7Cannette.grant%40ks.gov%7C4ed78085b7f94a59b92e08d803e9341b%7Cdcae8101c92d480cbc43c6761ccccc5a%7C0%7C1%7C637263647433620564&sdata=onuv%2FU4TgEioBAmr0o0uaM%2BoftUI%2FPQym73rASIMi6s%3D&reserved=0

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http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Syprine_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Syprine_PA_Criteria.pdf

































Testim® Testosterone Topical Gel



Testopel® Testosterone implant

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Testopel_PA_Criteria.pdf


Testosterone Powder for Compounding

Testosterone Powder for Compounding



Tev-Tropin® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf


Thioridazine Thioridazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Thiothixene Thiothixene http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Tibsovo® Ivosidenib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Tofranil® Imipramine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Tofranil® PM Imipramine pamoate



Tracleer® Bosentan (tablets) http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary_Hypertension_Agents_PA_Criteria.pdf


Tranxene-T® Clorazepate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Trazodone Trazodone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Trecator® Ethionamide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Tuberculosis_Agents_PA_Criteria.pdf


Trelstar® Triptorelin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Tremfya™ Guselkumab Plaque Psoriasis Agents Plaque Psoriasis Agents FORM

Trifluoperazine Trifluoperazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Trikafta™ Elexacaftor/tezacaftor/ivacaftor



Trintellix® Vortioxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Triptodur® Triptorelin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Triptodur_PA_Criteria.pdf


Trogarzo™ Ibalizumab-uiyk http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Trogarzo_PA_Criteria.pdf


Trokendi XR® Topiramate ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Topiramate_ER_PA_Criteria.pdf






































































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Triptodur_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Triptodur_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Trogarzo_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Trogarzo_PA_Criteria.pdf









Trulance® Plecanatide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-Constipation_Agents_PA_Criteria.pdf


Trulicity® Dulaglutide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Truxima® Rituximab Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM

Trypsin/Balsam Peru/Castor Oil Products

Trypsin/Balsam Peru/Castor Oil Products



Tysabri® Natalizumab Crohn's Disease Agents Multiple Sclerosis Agents Crohn’s Disease Agents FORM Multiple Sclerosis Agents FORM

Tyvaso® Treprostinil (inhalation solution)



Ultracet® Tramadol/ Acetaminophen



Ultram ER Tramadol ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Ultram® Tramadol http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Uptravi® Selexipag http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pulmonary_Hypertension_Agents_PA_Criteria.pdf


Valium® Diazepam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Varubi® Rolapitant http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Anti-emetics%20NK-1_antagonists_and_NK1_combinations_PA_Criteria.pdf


Veletri® Epoprostenol (injection)



Venclexta® Venetoclax http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Ventavis® Iloprost (inhalation solution)



Verdrocet® Hydrocodone/ Acetaminophen



Versacloz® Clozapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Verzenio™ Abemaciclib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Viberzi® Eluxadoline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Viberzi_PA_Criteria.pdf


Vicodin ES® Hydrocodone/ Acetaminophen










































































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Viberzi_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Viberzi_PA_Criteria.pdf









Vicodin HP® Hydrocodone/ Acetaminophen



Vicodin® Hydrocodone/ Acetaminophen



Victoza® Liraglutide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diabetic_Agents_PA_Criteria.pdf


Viekira Pak™ Ombitasvir/ Paritaprevir/Ritonavir and Dasabuvir



Viibryd® Vilazodone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Vimovo® Naproxen/ Esomeprazole



Vivactil® Protriptyline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Vogelxo® Testosterone Topical Gel



Vosevi™ Sofosbuvir/ Velpatasvir/ Voxilaprevir



VPRIV® Velaglucerase alfa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Enzyme_Replacement_Therapy_PA_Criteria.pdf


Vraylar® Cariprazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Vumerity™ Diroximel Fumarate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Multiple_Sclerosis_Agents_PA_Criteria.pdf


Vyvanse® Lisdexamfetamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Wakix® Pitolisant http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy_Agents_PA_Criteria.pdf


Wellbutrin® Bupropion http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Wellbutrin® SR Bupropion http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Wellbutrin® XL Bupropion http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Xalkori® Crizotinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Xanax XR® Alprazolam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf




















































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy_Agents_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy_Agents_PA_Criteria.pdf

























Xanax® Alprazolam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benzodiazepine_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Xartemis XR® Oxycodone/ Acetaminophen



Xeljanz® Tofacitinib Psoriatic Arthritis Agents Adult Rheumatoid Arthritis Agents Ulcerative Colitis Agents

Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM Ulcerative Colitis Agents FORM

Xeljanz® XR Tofacitinib Psoriatic Arthritis Agents Psoriatic Arthritis Agents FORM

Xenazine® Tetrabenazine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Monoamine_Depletor_PA_Criteria.PDF


Xenical® Orlistat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Weight_Loss_Drugs_PA_Criteria.pdf


Xeomin® IncobotulinumtoxinA



Xermelo® Telotristat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xermelo_PA_Criteria.pdf


Xgeva® Denosumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xgeva_PA_Criteria.pdf


Xiaflex® Collengenase clostridium histolyticum

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xiaflex_PA_Criteria.pdf


Xifaxan® Rifaximin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xifaxan_PA_Criteria.pdf


Xigduo XR® Dapagliflozin/ Metformin



Xiidra® Lifitegrast ophthalmic solution

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xiidra_PA_Criteria.pdf


Xodol® Hydrocodone/ Acetaminophen



Xofigo® Radium Ra 223 dichloride



Xolair® Omalizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Asthma_Agents_PA_Criteria.pdf


Xtampza ER® Oxycodone ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Xultophy® Insulin degludec/ Liraglutide



Xyrem® Sodium oxybate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Narcolepsy_Agents_PA_Criteria.pdf


Yescarta™ Axicabtagene Ciloleucel

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Yescarta_PA_Criteria.pdf


Yosprala® Aspirin/Omeprazole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aspirin-PPI_Combination_Step_Therapy_PA_Criteria.pdf































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xermelo_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xermelo_PA_Criteria.pdf



http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xgeva_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xgeva_PA_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xifaxan_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xifaxan_PA_Criteria.pdf



































http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aspirin-PPI_Combination_Step_Therapy_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Aspirin-PPI_Combination_Step_Therapy_PA_Criteria.pdf





Zamicet® Hydrocodone/ Acetaminophen



Zejula® Niraparib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Zelboraf® Vemurafenib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Zemaira® Alpha1-Proteinase Inhibitor (Human)



Zenzedi® Dextroamphetamine sulfate



Zepatier® Elbasvir/Grazoprevir http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hepatitis_C_PA_Criteria.pdf


Zinplava® Bezlotoxumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zinplava_PA_Criteria.pdf


Zohydro ER® Hydrocodone ER http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Opioid_PA_Criteria.pdf


Zolgensma® Onasemnogene http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Spinal_Muscular_Atrophy_PA_Criteria.pdf


Zoloft® Sertraline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antidepressant_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Zolpimist™ Zolpidem http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zolpimist_PA_Criteria.pdf


Zomacton® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf


Zurampic® Lesinurad http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zurampic_PA_Criteria.pdf


Zydelig® Idelalisib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Zykadia® Certinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Chemotherapy_Agents_PA_Criteria.pdf


Zyprexa Relprevv®

Olanzapine pamoate http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Zyprexa Zydis® Olanzapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


Zyprexa® Olanzapine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Antipsychotic_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf


























http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zinplava_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zinplava_PA_Criteria.pdf













http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zolpimist_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zolpimist_PA_Criteria.pdf







http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zurampic_PA_Criteria.pdf

http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zurampic_PA_Criteria.pdf























Documents

Clinical pa table of contents - Kansas Department of Health ...€¦ · CLINICAL PA TABLE OF CONTENTS | Revised 06/10/2020 CLINICAL PRIOR AUTHORIZATION (PA) TABLE OF CONTENTS Medications