Medicaid Program

The Clinical Prior Authorization (PA) Program was implemented to improve quality and manage drug classes that have been identified as requiring additional monitoring.  This program is also intended as a means of ensuring that drugs are being prescribed for the right patients and for the appropriate reasons, while still monitoring drug expenditures.  

Clinical Prior Authorization Request Forms

• Anti-Obesity Medication (pdf - 1 page)
• Bowel Disorders (pdf - 1 page)
• Brand Name Drug Approval (1 page)
• Byetta ® (pdf - 1 page)
• CNS Stimulant/ADHD Medication Approval  (pdf - 1 page)

• Combination Benzoyl Peroxide and Clindamycin Products (pdf - 1 page)

• Cymbalta ® (pdf - 1 page)

• Dipeptidyl Peptidase - 4 Inhibitors & Combination Medications (pdf -1 page)
• Direct Renin Inhibitor Medications (pdf - 1 page)
• Growth Hormone (pdf - 1 page)
• Hemotopoietic Agents  (pdf - 1 page)
• Hyaluronic Acid Derivatives Injection (pdf - 1 page)
• Inhaled Insulin (pdf - 1 page)
• Legend Topical NSAIDS (pdf - 1 page) 
• Lyrica ® (pdf - 1 page)
• Onychomycosis Agents Approval  (pdf - 1 page) 
• Oral Isotretinoin (pdf - 1 page)
• Oxycontin (pdf- 1 page)
• Proton Pump Inhibitor Approval (pdf - 1 page)
• Receptor Selective NSAID Authorization (pdf - 1 page)
• Spiriva ®  (pdf - 1 page)
• Suboxone® (pdf - 1 page)
• Symlin ® (pdf - 1 page)
• Synagis (pdf - 1 page)
• Systemic Immunomodulators (pd - 1 page)
• Topical Immunomodulators (pdf - 1 page)
• Transmucosal Analgesic(pdf - 1 page)  
• Xenical ®  (pdf - 1 page)
• Xolair ® (pdf - 1 page)

QUESTIONS & ANSWERS

1.  How do I request a prior authorization?

Requests for prior authorization must be initiated by the prescriber and may be initiated via phone, fax or mail.  The First Health phone number is (866) 675-7755 and the fax number is (888) 603-7696.

2.  How are the clinical criteria determined?

The Pharmacy and Therapeutics Advisory Committee (PTAC) recommends the specific clinical criteria.  The PTAC is composed of practicing pharmacists, physicians and nurses.

3.  How often are the drugs and clinical criteria reviewed?

DHHS periodically reviews the drugs and the clinical criteria.  Updates to the list of drugs and the clinical criteria are made in accordance with current clinical practices.

4.  Who can I contact for more information?

For more information or assistance prescribers may call the First Health Services Clinical Call Center at: (866)-675-7755.

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