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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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf
Abilify® 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 MyCite® 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioid_PA_FORM.pdf
Adasuve® 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/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.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
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
Adempas® Riociguat 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
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/pdl_authorization_forms/ADHD_Medications_PA_FORM.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Adzenys XR-ODT®
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/pdl_authorization_forms/ADHD_Medications_PA_FORM.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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/CGRP_Antagonists_PA_Form.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
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
Alunbrig™ Brigatinib 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
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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Anafranil® Clomipramine 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
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/Topical_and_Buccal_Androgen_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/topical_buccal_androgen_hormone_agents.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Apadaz® Benzhydrocodone/ Acetaminophen
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
Aptensio XR® Methylphenidate HCl
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
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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Arikayce® Amikacin oral inhalation
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Arikayce_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf
Aristada Initio™ Aripiprazole lauroxil 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
Aromasin® Exemestane 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
Arymo ER® Morphine ER 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
Ativan® Lorazepam 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Opioid_PA_FORM.pdf
Avonex® Interferon beta-1a 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
Axiron® Testosterone Topical Solution
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
Banzel® Rufinamide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Banzel_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Bavencio® Avelumab 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
Belbuca® Buprenorphine 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
Benlysta® Belimumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Benlysta_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Betaseron® Interferon beta-1b 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf
Bonjesta® Doxylamine succinate/ Pyridoxine HCl
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diclegis_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf
Brineura™ Cerliponase, alfa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brineura_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Brisdelle® Paroxetine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Brisdelle__PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Buphenyl® Sodium phenylbutyrate
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Buphenyl_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Butrans® Buprenorphine 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
Bydureon® Exenatide ER 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
Bydureon® BCise™
Exenatide ER 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
Byetta® Exenatide 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
Cabometyx® Cabozantinib 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
Calquence® Acalabrutinib 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
Capstat® Capreomycin 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
Carimune NF® 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
Celexa® Citalopram 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
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
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Cerezyme® Imiglucerase 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Neurokinin_1_NK1_antagonist_combo.pdf
Clonidine Clonidine 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
Clozaril® Clozapine 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
Codeine Codeine 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
Combunox® Oxycodone/ Ibuprofen
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
Concerta® Methylphenidate HCl
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
Consensi™ Amlodipine/ Celecoxib
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Consensi_Step_Therapy_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Contrave® ER Naltrexone/ Bupropion
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
Conzip® Tramadol ER 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
Copaxone® Glatiramer 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf
Cotempla XR-ODT™
Methylphenidate HCl
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
Crinone® Progesterone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Crinone_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Page 6
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antidepressant_Medications_PA_FORM.pdf
Dalmane® Flurazepam 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
Daraprim® Pyrimethamine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Daraprim_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Darzalex® Daratumumab 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
Daytrana® Methylphenidate Transdermal
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
Delatestryl® Testosterone Enanthate
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Testosterone_Injectable_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Demerol® Meperidine 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
Demser® Metyrosine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Demser_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Desoxyn® Methamphetamine HCl
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
Dexedrine® Dextroamphetamine sulfate
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
DextroStat® Dextroamphetamine sulfate
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
Diazepam Intensol®
Diazepam 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
Diclegis® Doxylamine succinate/ Pyridoxine HCl
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Diclegis_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Dihydrocodeine Dihydrocodeine 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
Dilaudid® Hydromorphone 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
Doral® Quazepam 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
Drizalma Sprinkle™
Duloxetine 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
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
Page 7
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Dupixent® Dupilumab Atopic Dermatitis Agents PA; Asthma Agents PA
Atopic Dermatitis PA FORM Asthma Agents PA FORM
Duragesic Fentanyl transdermal
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
Dyanavel XR® 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/pdl_authorization_forms/ADHD_Medications_PA_FORM.pdf
Dymista® Azelastine/ Fluticasone
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Intranasal_Antihistamine-Corticosteroid_Agents_Step_Therapy_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Dysport® AbobotulinumtoxinA
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
Effexor XR® Venlafaxine 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
Effexor® Venlafaxine 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
Elaprase® Idursulfase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Elaprase_PA_Criteria.PDF
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Elavil® Amitriptyline 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
Elelyso® Taliglucerase alfa 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
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
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
Embeda® Morphine/ Naltrexone
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
Emend® Aprepitant (oral) 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
Emend® Fosaprepitant (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
Emflaza® Deflazacort http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Emflaza_PA_Criteria.PDF
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Emgality™ Galcanezumab-gnlm 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
Page 8
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Empliciti® Elotuzumab 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
Emsam® Selegiline 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
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
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
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
Psoriatic Arthritis Agents FORM Adult Rheumatoid Arthritis Agents FORM Ankylosing Spondylitis Agents FORM Juvenile Idiopathic Arthritis Agents FORM Plaque Psoriasis Agents FORM
Esbriet® Pirfenidone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IPF_Treatments_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Esperoct® 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
Eticovo™ 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
Eucrisa® Crisaborole 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
Exalgo® Hydromorphone ER 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
Exjade® Deferasirox http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exjade_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Exondys 51™ Eteplirsen http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Exondys_51_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Extavia® Interferon beta-1b 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
Fabrazyme® Agalsidase beta 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
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/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf
Page 9
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Farxiga® Dapagliflozin 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
Farydak® Panobinostat 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
Fasenra™ Benralizumab 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
Fazaclo® Clozapine 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
Femara® Letrozole 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
Fentora® 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
Ferriprox® Deferiprone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ferriprox_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Fetzima® Levomilnacipran 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
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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Flebogamma DIF®
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
Flolan® Epoprostenol (injection)
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
Fluphenazine Fluphenazine 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
Focalin XR® Dexmethylphenidate ER
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
Focalin® Dexmethylphenidate
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
Forfivo® XL Bupropion 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
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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Fortesta® Testosterone Topical Gel
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
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
Page 10
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Galafold® Migalastat 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
Gammagard S/D®
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
Gammagard® Immune globulin (human) intravenous/ subcutaneous
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
Gammaked® Immune globulin (human) intravenous/ subcutaneous
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
Gammaplex® 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
Gamunex-C® Immune globulin (human) intravenous/ subcutaneous
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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf
Gilenya® Fingolimod 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
Gilotrif® Afatinib 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
Glassia® 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
Glatopa® Glatiramer 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
Glumetza® 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
Glyxambi® Empagliflozin/ Linagliptin
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
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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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/download/KS_Medicaid_Universal_PA_Form.pdf
Page 11
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Benzodiazepine_Mental_Health_FORM.pdf
Haldol Decanoate®
Haloperidol Decanoate
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
Haldol® Haloperidol 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
Harvoni® Ledipasvir/ Sofosbuvir
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
Herceptin® Trastuzumab 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
Hetlioz® Tasimelteon http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Hetlioz_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Hizentra® Immune globulin (human) subcutaneous
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
Humatrope® 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
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
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
Hycet® Hydrocodone/ Acetaminophen
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
Hydrocodone/ Ibuprofen
Hydrocodone/ Ibuprofen
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
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
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
Hysingla ER® Hydrocodone ER 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
Ibrance® Palbociclib 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
Idelvion® Coagulation factor IX recombinant, albumin fusion protein (rIX-FP)
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
Page 12
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Idhifa® Enasidenib 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf
Imfinzi™ Durvalumab 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
Increlex® Mecasermin rinfabate
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Increlex_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Infergen® Interferon alfacon-1 http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Infergen_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Monoamine_Depletor_VMAT2_Inhibitors_PA_Form.pdf
Intron A Interferon alfa-2b http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IntronA_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Intuniv® Guanfacine ER 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
Invega Sustenna®
Paliperidone palmitate
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
Invega Trinza® Paliperidone palmitate
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
Invega® Paliperidone 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
Invokamet XR® Canagliflozin/ Metformin
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
Invokamet® Canagliflozin/ Metformin
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
Invokana® Canagliflozin 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
Isonarif® Rifampin/Isoniazid 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
Ixifi™ Infliximab-qbtx 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
Page 13
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Jadenu® Deferasirox http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jadenu_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Jakafi® Ruxolitinib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jakafi_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Jardiance® Empagliflozin 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
Jetrea® Ocriplasmin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Jetrea_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Jivi® 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
Jornay PM™ Methylphenidate HCl
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
Juxtapid® Lomitapide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Juxtapid_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Kadian ER® Morphine ER 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
Kalbitor® Ecallantide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kalbitor_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Kapvay® Clonidine ER 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
Karbinal ER™ Carbinoxamine ER 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf
Khedezla® Desvenlafaxine 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf
Kisqali® Femara Co-pack
Ribociclib/Letrozole 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
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/pdl_authorization_forms/Benzodiazepine_Mental_Health_FORM.pdf
Page 14
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Krystexxa® Pegloticase http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Pegloticase_Krystexxa.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Kuvan® Sapropterin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kuvan_PA_criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Kymriah® Tisagenlecleucel http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kymriah_PA_Criteria.PDF
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Kynamro® Mipomersen http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Kynamro_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Kyprolis® Carfilzomib 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
Lartruvo® Olaratumab 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
Latuda® Lurasidone 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
Lazanda® 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
Lemtrada® Alemtuzumab 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
Letairis® Ambrisentan (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
Leukine® Sargramostim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Leukine_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Levo-Dromoran®
Levorphanol 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
Lexapro® Escitalopram 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
Librium® Chlordiazepoxide 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
Linzess® Linaclotide 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
Lorazepam Intensol®
Lorazepam 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
Lorcet HD® Hydrocodone/ Acetaminophen
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
Lorcet Plus® Hydrocodone/ Acetaminophen
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
Lorcet® Hydrocodone/ Acetaminophen
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
Lortab® Hydrocodone/ Acetaminophen
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
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/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf
Page 15
CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Lucentis® Ranibizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lucentis_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Lupaneta Pack® Leuprolide/ Norethindrone
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupaneta_Pack_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Lupron® Leuprolide http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lupron_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Luvox CR® Fluvoxamine 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
Luvox® Fluvoxamine 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
Luxturna™ Voretigene Neparvovec-rzyl
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Luxturna_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Lynparza™ Olaparib 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
Lyrica CR® Pregabalin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Lyrica_CR_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Makena® Hydroxyprogesterone Caproate
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Makena_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Maprotiline Maprotiline 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
Marinol® Dronabinol 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
Marplan® Isocarboxazid 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
Mavenclad® Cladribine 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
Mavyret® Glecaprevir/ Pibrentasvir
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
Maxidone® Hydrocodone/ Acetaminophen
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
Mayzent® Siponimod 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
Mekinist® Trametinib 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
Mektovi™ Binimetinib 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
Metadate CD® Methylphenidate HCl
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
Metadate ER® Methylphenidate HCl
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
Methadone Methadone 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
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Methylin® Methylphenidate HCl
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
MetroCream® Metronidazole 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
Metrogel® Metronidazole 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
MetroLotion® Metronidazole 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
Mirvaso® Brimonidine 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
MorphaBond® Morphine ER 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
Morphine IR Morphine IR 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
Motegrity™ Prucalopride 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
Motofen® Difenoxin/Atropine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Motofen_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
MS Contin® Morphine ER 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
Myambutol® Ethambutol 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
Mycobutin® Rifabutin 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
Mydayis® 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
Myobloc® RimabotulinumtoxinB
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
Nardil® Phenelzine 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
Natesto® Testosterone nasal gel
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
Natpara® Parathyroid hormone
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Natpara_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Nefazodone Nefazodone 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
Neulasta® Pegfilgrastim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neulasta_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
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Neupogen® Filgrastim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Neupogen_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Niazid® Isoniazid 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
Niazid-B6® Isoniazid/Pyridoxine 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
Ninlaro® Ixazomib 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
Niravam ODT® 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
Nitroglycerin sublingual spray
Nitroglycerin sublingual spray
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
Norco® Hydrocodone/ Acetaminophen
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
Norditropin® 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
Noritate® Metronidazole 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
Norpramin® Desipramine 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
Nplate® Romiplostim http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nplate_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Nucala® Mepolizumab 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
Nucynta ER® Tapentadol ER 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
Nucynta® Tapentadol 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
Nuedexta® Dextromethorphan/ Quinidine
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Nuedexta_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Nutropin® Somatropin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Growth_Hormone_PA_Criteria.pdf
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rifampin_and_TB_15381_Activated_Traditional.pdf
Ocaliva® Obeticholic Acid http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ocaliva_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Ocrevus™ Ocreblizumab 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
Octagam® 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
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
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Ofev® Nintedanib http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/IPF_Treatments_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Somatropin_products.pdf
Onfi® Clobazam http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Onfi_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Onivyde® Irinotecan 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
Opana ER® Oxymorphone ER 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
Opana ER® Oxymorphone ER (crush-resistant)
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
Opana® Oxymorphone 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
Opdivo® Nivolumab 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
Opsumit® Macitentan 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
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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Oramorph® Morphine ER 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
Orap® Pimozide 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
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)
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
Orilissa™ Elagolix http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Orilissa_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Orkambi® Lumacaftor/ 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
Osphena® Ospemifene http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Osphena_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Otezla® Apremilast Psoriatic Arthritis Agents Plaque Psoriasis Agents Psoriatic Arthritis Agents FORM Plaque Psoriasis Agents FORM
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Oxaydo® Oxycodone 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
OxyContin® Oxycodone ER 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
Ozempic® Semaglutide 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
Pamelor® Nortriptyline 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
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
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
Parnate® Tranylcypromine 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/KS_Rifampin_and_TB_15381_Activated_Traditional.pdf
Paxil CR® Paroxetine 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
Paxil® Paroxetine 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
Pentazocine/ Naloxone
Pentazocine/ Naloxone
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
Percocet® Oxycodone/ Acetaminophen
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
Percodan® Oxycodone/Aspirin 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
Perphenazine Perphenazine 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
Perseris™ Risperidone 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
Pexeva® Paroxetine 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
Phentermine products
Phentermine products
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
Plegridy® Interferon beta-1a 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
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
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Prialt® Ziconotide intrathecal infusion
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Prialt_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Priftin® Rifapentine 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
Primlev® Oxycodone/ Acetaminophen
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
Pristiq® Desvenlafaxine 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
Privigen® 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
ProCentra® Dextroamphetamine sulfate
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
Prolastin C® 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
Prolia® Denosumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Prolia_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Promacta® Eltrombopag http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Promacta_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
ProSom® Estazolam 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
Protopic® Tacrolimus 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
Provenge® Sipuleucel-T 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
Prozac® Fluoxetine 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
Prozac® Weekly Fluoxetine 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
Pyrazinamide Pyrazinamide 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
Qsymia® Phentermine/ Topiramate
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
Qtern® Dapagliflozin/ Saxagliptin
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
Qualaquin® Quinine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Qualaquin_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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/ADHD_Medications_Safe_Use_for_All_Ages_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/ADHD_Medications_PA_FORM.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Quillivant XR® Methylphenidate HCl
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
Radicava® Edaravone http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Radicava_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Ragwitek® Short ragweed pollen allergen extract
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ragwitek_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Ravicti® Glycerol phenylbutyrate
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Ravicti_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Rebif® Interferon beta-1a 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
Rebinyn® Coagulation factor IX recombinant, glycol-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
Regranex® Becaplermin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Regranex_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Relexxii™ Methylphenidate HCl
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
Relistor® Methylnaltrexone 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
Remeron® Mirtazapine 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
Remicade® Infliximab 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
Remodulin® Treprostinil (injection)
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
Renflexis® Infliximab-abda 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
Repatha® Evolocumab 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
Restasis® Cyclosporine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Restasis_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Restoril® Temazepam 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
Revatio® Sildenafil (injection, oral suspension, 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
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
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Revlimid® Lenalidomide 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
Rexulti® Brexpiprazole 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
Rhofade® Oxymetazoline 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
Rifadin® Rifampin 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
Rifamate® Rifampin/Isoniazid 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
Rifater® Rifampin/Isoniazid/Pyrazinamide
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
Rilutek® Riluzole http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Rilutek_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Rimactane® Rifampin 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf
Risperdal M-Tab®
Risperidone 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
Risperdal® Risperidone 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
Ritalin LA® Methylphenidate HCl
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
Ritalin® Methylphenidate HCl
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
Rituxan Hycela®
Rituximab 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Rosacea_Agents_PA_Form.pdf
Roxanol® Morphine 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
Roxicet® Oxycodone/ Acetaminophen
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
Roxicodone Intensol®
Oxycodone 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
Roxicodone® Oxycodone 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
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Roxybond® Oxycodone 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
Rubraca™ Rucaparib 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
Rydapt® Midostaurin 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
Ryvent™ 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
Ryzolt® Tramadol ER 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
Sabril® Vigabatrin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sabril_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Saizen® 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
Santyl® Collagenase 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
Saphris® Asenapine 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
Savella® Milnacipran 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
Saxenda® Liraglutide 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
Segluromet™ Ertugliflozin/ Metformin
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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Calcimimetic_Agents_PA_Form.pdf
Serax® Oxazepam 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
Sernivo® Betamethasone dipropionate
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Sernivo_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Seroquel XR® Quetiapine 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
Seroquel® Quetiapine 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
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
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Sinequan® Doxepin 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
Sirturo® Bedaquiline 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
Skyrizi® Risankizumab Plaque Psoriasis Agents Plaque Psoriasis Agents FORM
Soliqua® Insulin glargine/ 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
Soliris® Eculizumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Soliris_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Carisoprodol_Containing_Products_PA_Form.pdf
Soma® Carisoprodol 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
Somavert® Pegvisomant http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Somavert_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Soolantra® Ivermectin 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
Sovaldi® Sofosbuvir 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
Spravato® Esketamine 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Diabetic_Agents_PA_FORM.pdf
Steglujan™ Ertugliflozin/ Sitagliptin
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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Chemotherapy_Agents_PA_Form.pdf
Strattera® Atomoxetine 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
Strensiq® Asfotase alfa http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Strensiq_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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/pdl_authorization_forms/topical_buccal_androgen_hormone_agents.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Subsys® 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
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
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Surmontil® Trimipramine 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
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
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
Symproic® Naldemedine 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Cannabinoid_antiemetics.pdf
Synjardy XR® Empagliflozin/ Metformin
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
Synjardy® Empagliflozin/ Metformin
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
Syprine® Trientine http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Syprine_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Tafinlar® Dabrafenib 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
Tagrisso® Osimertinib 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
Taltz® Ixekizumab Psoriatic Arthritis Agents Plaque Psoriasis Agents Psoriatic Arthritis Agents FORM Plaque Psoriasis Agents FORM
Targiniq ER® Oxycodone/Naloxone
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
Tecentriq® Atezolizumab 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
Tecfidera® Dimethyl fumarate 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
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/pdl_authorization_forms/ADHD_Medications_PA_FORM.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Testim® Testosterone Topical Gel
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
Testopel® Testosterone implant
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Testopel_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Testosterone Powder for Compounding
Testosterone Powder for Compounding
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
Tev-Tropin® 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
Thioridazine Thioridazine 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
Thiothixene Thiothixene 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
Tibsovo® Ivosidenib 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
Tofranil® Imipramine 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
Tofranil® PM Imipramine pamoate
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
Tracleer® Bosentan (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
Tranxene-T® Clorazepate 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
Trazodone Trazodone 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
Trecator® Ethionamide 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
Trelstar® Triptorelin 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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf
Trikafta™ Elexacaftor/tezacaftor/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
Trintellix® Vortioxetine 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
Triptodur® Triptorelin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Triptodur_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Trogarzo™ Ibalizumab-uiyk http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Trogarzo_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Trokendi 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
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Trulance® Plecanatide 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
Trulicity® Dulaglutide 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
Truxima® Rituximab Adult Rheumatoid Arthritis Agents Adult Rheumatoid Arthritis Agents FORM
Trypsin/Balsam Peru/Castor Oil Products
Trypsin/Balsam Peru/Castor Oil 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
Tysabri® Natalizumab Crohn's Disease Agents Multiple Sclerosis Agents Crohn’s Disease Agents FORM Multiple Sclerosis Agents FORM
Tyvaso® Treprostinil (inhalation solution)
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
Ultracet® Tramadol/ Acetaminophen
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
Ultram ER Tramadol ER 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
Ultram® Tramadol 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
Uptravi® Selexipag 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
Valium® Diazepam 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
Varubi® Rolapitant 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
Veletri® Epoprostenol (injection)
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
Venclexta® Venetoclax 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
Ventavis® Iloprost (inhalation solution)
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
Verdrocet® Hydrocodone/ Acetaminophen
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
Versacloz® Clozapine 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
Verzenio™ Abemaciclib 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
Viberzi® Eluxadoline http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Viberzi_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Vicodin ES® Hydrocodone/ Acetaminophen
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
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Vicodin HP® Hydrocodone/ Acetaminophen
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
Vicodin® Hydrocodone/ Acetaminophen
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
Victoza® Liraglutide 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
Viekira Pak™ Ombitasvir/ Paritaprevir/Ritonavir and Dasabuvir
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
Viibryd® Vilazodone 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
Vimovo® Naproxen/ Esomeprazole
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
Vivactil® Protriptyline 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
Vogelxo® Testosterone Topical Gel
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
Vosevi™ Sofosbuvir/ Velpatasvir/ Voxilaprevir
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
VPRIV® Velaglucerase alfa 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
Vraylar® Cariprazine 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
Vumerity™ Diroximel Fumarate 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
Vyvanse® Lisdexamfetamine 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
Wakix® Pitolisant 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
Wellbutrin® Bupropion 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
Wellbutrin® SR Bupropion 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
Wellbutrin® XL Bupropion 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
Xalkori® Crizotinib 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
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/pdl_authorization_forms/Benzodiazepine_Mental_Health_FORM.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Xanax® 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
Xartemis XR® Oxycodone/ Acetaminophen
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
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
http://www.kdheks.gov/hcf/pharmacy/pdl_authorization_forms/Monoamine_Depletor_VMAT2_Inhibitors_PA_Form.pdf
Xenical® 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
Xeomin® IncobotulinumtoxinA
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
Xermelo® Telotristat http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xermelo_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Xgeva® Denosumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xgeva_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Xiaflex® Collengenase clostridium histolyticum
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xiaflex_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Xifaxan® Rifaximin http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xifaxan_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Xigduo XR® Dapagliflozin/ Metformin
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
Xiidra® Lifitegrast ophthalmic solution
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Xiidra_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Xodol® Hydrocodone/ Acetaminophen
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
Xofigo® Radium Ra 223 dichloride
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
Xolair® Omalizumab 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
Xtampza ER® Oxycodone ER 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
Xultophy® Insulin degludec/ Liraglutide
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
Xyrem® Sodium oxybate 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
Yescarta™ Axicabtagene Ciloleucel
http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Yescarta_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.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/download/KS_Medicaid_Universal_PA_Form.pdf
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CLINICAL PA TABLE OF CONTENTS | Revised 08/01/2020
BRAND NAME GENERIC NAME PA CRITERIA PA FORM
Zamicet® Hydrocodone/ Acetaminophen
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
Zejula® Niraparib 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
Zelboraf® Vemurafenib 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
Zemaira® 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
Zenzedi® Dextroamphetamine sulfate
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
Zepatier® Elbasvir/Grazoprevir 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
Zinplava® Bezlotoxumab http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zinplava_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Zohydro ER® Hydrocodone ER 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
Zolgensma® Onasemnogene 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
Zoloft® Sertraline 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
Zolpimist™ Zolpidem http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zolpimist_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Zomacton® 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
Zurampic® Lesinurad http://www.kdheks.gov/hcf/pharmacy/PA_Criteria/Zurampic_PA_Criteria.pdf
http://www.kdheks.gov/hcf/pharmacy/download/KS_Medicaid_Universal_PA_Form.pdf
Zydelig® Idelalisib 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
Zykadia® Certinib 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
Zyprexa Relprevv®
Olanzapine pamoate 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
Zyprexa Zydis® 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/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.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/pdl_authorization_forms/Antipsychotic_Medications_PA_FORM.pdf