Drugs Requiring PA

Some prescription drugs may require certification, also known as prior authorization, in order to be covered. These drugs have detailed criteria that must be met before prior authorization can be granted. It is very important to make sure that prior authorization has been granted before going to the pharmacy. Please review the State Health Plan's prior authorization policies. Below is a list of the drugs and drug classes that require prior authorization:
  • Alpha Interferons
  • Antifungal Agents
    • Lamisil and Sporanox
    • Noxafil
    • Vfend
  • Antinarcoleptic Agents (Provigil)
  • Appetite Suppressants and Weight Loss Agents
  • Bisphosphonates
    • Actonel
    • Actonel with Calcium
  • Certolizumab (Cimzia)
  • Clostridium Botulinum Neurotoxins (Botox, Myobloc)
  • COX2 Inhibitors (Celebrex)
  • Fentanyl (Actiq and Fentora)
  • Fertility Agents
  • Growth Stimulating Drugs
  • Immunomodulators
    • Revlimid
    • Thalomid
  • Multiple Sclerosis Agents
  • Non-Sedating Antihistamines
  • Omalizumab (Xolair)
  • Proton Pump Inhibitors
    • Aciphex
    • Prevacid
    • Protonix
  • Psoriasis Agents
  • Rheumatoid Arthritis Agents
    • Leflunomide (Arava)
    • Etanercept (Enbrel)
    • Adalimumab (Humira)
    • Anakinra (Kineret)
    • Infliximab (Remicade)
    • Abatacept (Orencia)
    • Rituximab (Rituxan)
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
    • Lexapro
    • Luvox CR
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
    • Effexor XR
    • Pristiq
  • Sildenafil (Revatio)
Additionally, some prescription drugs may be subject to quantity limits, based on criteria developed by the State Health Plan or its representative. Prior approval is required before excess quantities of certain drugs will be covered. If you need quantities in excess of the limit for a drug that is subject to quantity limits, it is important to make sure your provider has received prior authorization before you go to the pharmacy. Below is a list of the drugs that require prior authorization for exceeding quantity limits:
  • Migraine Medications
    • Imitrex
    • Zomig/ZMT
    • Amerge
    • Maxalt/MLT
    • Axert
    • Frova
    • Relpax
    • Migranal NS)
    • Treximet
  • Proton Pump Inhibitors
    • Prilosec
    • Aciphex
    • Nexium
    • Prevacid
    • Protonix
  • Sedative Hypnotic Agents
    • Rozerem
    • Sonata
    • Ambien
    • Ambien CR
    • Lunesta
The State Health Plan or its representative may change the list of prescription drugs from time to time. To initiate a prior authorization request of your prescription drugs, your physician may call Medco at 1-800-753-2851, or obtain a prior authorization review form and fax it directly to Medco at the number listed on the form.

If you disagree with a decision made during the prescription drug prior authorization process, you have the right to request that the State Health Plan or its representative review the decision through the grievance process. The grievance process is voluntary and may be requested by the member or an authorized representative acting on the member's behalf. Visit the PPO plan grievance page.