Prior Authorization Criteria N - Z
Prior Authorization (PA) Request Process Guide - Updated October 20, 2011
The Georgia Department of Community Health establishes the guidelines for drugs requiring a Prior Authorization (PA) in the Georgia Medicaid Fee-for-Service/PeachCare for Kids® Outpatient Pharmacy Program. To view the summary of guidelines for coverage, please select the drug or drug category from the list below.
Drug/Drug Category by Alphabetical listing (A-M | N - Z)
- NSAID and COX II - Updated 03/01/12
- Nasal Steroids - Updated 10/6/11
- Neotic - Updated 3/25/11
- Nexiclon
- Niacor - Updated 3/25/11
- Nitrofurantoin
- Nucort - Updated 1/24/11
- Nucynta - Updated 12/7/11
- Nuedexta
- Nutridox - Updated 1/24/11
- Octreotide Injection - Updated 1/24/11
- Oforta - Updated 1/24/11
- Oleptro - Updated 3/25/11
- Opana and Opana ER - Updated 11/9/11
- Ophthalmic Antivirals
- Ophthalmic Beta Blockers - Updated 3/25/11
- Ophthalmic NSAID - Updated 11/9/11
- Ophthalmic Quinolones - Updated 7/28/11
- Ophthalmics for Allergy Conjunctivitis - Updated 8/17/11
- Ophthalmic Steroid Antibiotic Combination
- Oracea - Updated 1/24/11
- Oral Contraceptives - Updated 03/21/12
- Orapred ODT - Updated 1/24/11
- Orencia - Updated 10/6/11
- Ovace - Updated 8/17/11
- Oxycodone IR QLL Criteria - Posted 04/17/12
- Pamine_FQ - Updated 1/24/11
- Panretin - Updated 1/24/11
- Parcopa - Updated 1/24/11
- Pediaderm AF
- Pediaderm HC - Updated 1/24/11
- Pediaderm TA
- Pegylated Interferons - Updated 1/4/12
- Phenelzine
- Phosphate Binders - Updated 12/7/11
- Phosphodiesterase 5 Inhibitors - Updated 8/17/11
- Picato - Posted 04/17/12
- Piperacillin Tazobactam - Updated 11/9/11
- Polyethylene Glycol - Updated 1/24/11
- Pradaxa
- Prandimet - Updated 1/24/11
- Prenatal Vitamins - Updated 1/24/11
- Primaxin - Updated 1/24/11
- Promacta - Updated 1/24/11
- Propafenone ER - Posted 05/10/12
- Prostacyclin Analogs - Updated 1/24/11
- Prostaglandin Agonists - Updated 04/17/12
- Protease Inhibitors for Hepatitis C - Updated 04/17/12
- Proton Pump Inhibitors - Updated 10/6/11
- Proton Pump Inhibitors PA Request Form - Updated 3/15/10
- Quinolones - Updated 05/02/12
- Ranexa - Updated 1/24/11
- Regranex - Updated 1/24/11
- Requip XL - Updated 3/25/11
- Rectiv - Posted 04/17/12
- Retisert - Updated 1/24/11
- Ribavirin Products - Updated 3/25/11
- Salkera - Updated 2/1/11
- Scabicides - Updated 05/09/12
- Sedative Hypnotics - Updated 3/28/11
- Selective Serotonin Reuptake Inhibitors (SSRI) - Updated 03/21/12
- Serostim - Updated 1/14/09
- Serotonin and Norepinephrine Reuptake Inhibitors - Updated 04/17/12
- Serotonin Receptor Agonists (Triptans) - Updated 10/6/11
- Short Acting Narcotics - Updated 04/17/12
- Silenor - Updated 2/1/11
- Skeletal Muscle Relaxants - Updated 04/17/12
- Sodium Sulfacetamide - Updated 5/5/10
- Solodyn - Updated 3/25/11
- Somatuline Depot - Updated 7/11/08
- Sprycel - Updated 7/11/08
- Statins and Lipid Lowering Agents - Updated 03/01/12
- Statin PA Appeal Form
- Suboxone and Subutex - Updated 2/1/11
- Sutent - Updated 8/23/11
- Symlin
- Synagis PA Request Form - Updated 9/20/11
- Synagis PA Summary - Updated 02/28/12
- Taclonex - Updated 3/28/11
- Tarceva - Updated 2/1/08
- Tasigna - Updated 7/11/08
- Teflaro - Updated 02/14/12
- Temodar - Updated 7/11/08
- Thiazolidinediones and Combination Products - Updated 04/17/12
- Thyroid Supplement - Posted 03/21/12
- Tindamax - Updated 7/7/08
- TNF Immunomodulators - Updated 11/9/11
- Topical Anti-Acne - Updated 01/05/12
- Topical Corticosteroid - Updated 04/17/12
- Topical Corticosteroid Potency List - Updated 04/17/12
- Topical Estrogens - Updated 7/28/11
- Topical Immunomodulators - Updated 7/11/08
- Topical Ketoconazole - Updated 12/7/11
- Topical NSAIDs
- Topical Testosterone - Updated 6/2/11
- Tranexamic Acid - Posted 02/29/12
- Transmucosal Fentanyl Citrate - Updated 6/2/11
- Trelstar - Updated 8/18/10
- Triamcinolone Injection
- Tribenzor
- Trimipramine - Posted 02/29/12
- Twynsta
- Tygacil - Updated 09/02/2011
- Tysabri - Updated 10/30/08
- Tyzeka
- Uloric - Updated 2/2/11
- Ultravate PAC - Updated 2/2/11
- Urea Products - Updated 2/2/11
- Urinary Tract Antispasmotics - Updated 05/09/12
- Urocit K
- Valacyclovir - Updated 05/09/12
- Valcyte Solution
- Vectical
- Vibativ
- Victoza
- Viibryd
- Vitamin D and ESRD Products - Updated 6/2/11
- Vitamin E - Updated 7/11/08
- Vivitrol - Updated 3/28/11
- Votrient - Updated 3/28/11
- Vusion - Updated 2/2/11
- Xalkori
- Xarelto - Updated 02/14/12
- Xenical - Updated 2/2/11
- Xenazine - Updated 2/2/11
- Xerese - Updated 2/2/11
- Xifaxan - Updated 2/2/11
- Xolair - Updated 2/2/11
- Xyrem - Updated 2/2/11
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