Prior Authorization Criteria N - Z

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)

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

• Narcotic Fill Limit - Posted 04/01/13
• Narcotics Long Acting - Updated 7/8/19
• Nasal Antihistamines - Updated 8/22/19
• Nasal Steroids - Updated 02/09/24
• Natpara - Posted 05/26/16
• Neuropathic Pain - Updated 02/12/24
• Northera - Posted 03/30/16
• NSAID and COX II  - Updated 02/12/24
• NSAIDs, Topical - Updated 02/05/24
• Nuedexta

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• Ocaliva - Posted 06/13/18
• Oncology Oral-Breast - Posted 12/10/19
• Oncology Oral-Hematologic - Updated 08/18/23
• Oncology Oral-Ovarian - Updated 8/14/19
• Oncology Oral - Other - Posted 02/12/24
• Oncology Oral-Lung - Updated 02/06/24
• Oncology Oral-Prostate - Updated 02/12/24
• Oncology Oral-Renal - Posted 02/06/24
• Ophthalmics for Allergic Conjunctivitis - Updated 02/12/24
• Ophthalmic Antibiotics - Updated 01/27/20
• Ophthalmics Anti-inflammatories - Updated 08/17/23
• Ophthalmics Anti-inflammatories Immunomodulators - Updated 05/31/22
• Ophthalmic Antivirals  - Posted 03/12/15
• Ophthalmic Glaucoma Agents - Updated 02/06/24
• Ophthalmic Steroid Antibiotic Combination - Posted 07/2/19
• Ophthalmics for Neurotrophic Keratitis - Posted 8/26/19
• Opiate Dependence Treatments - Posted 02/06/24
• Opioid MME Maximum PA Form - Updated 10/4/19
• Otic Antibiotics - Posted 1/27/20
• Oxazolidinones  - Posted 05/06/16

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• Palynziq - Posted 8/26/19
• Pancreatic Enzymes - Updated 07/17/23
• Panretin - Updated 1/24/11
• Parenteral Nutrition Products -Posted Updated 08/26/19
• Pheochromocytoma Agents - Posted 10/15/21
• Phosphate Binders - Updated 02/05/24
• Pituitary Suppressive Agents - Updated 04/02/24
• Pleuromutilin Antibiotics - Posted 12/07/20
• Potassium Binders - Posted 06/06/22
• Potassium Lodide  - Posted 02/05/25
• Primary Hyperoxaluria Agents - Posted 10/15/21
• Primary Periodic Paralysis Agents  - Posted 02/12/24
• Procysbi - Posted 11/22/13
• Proton Pump Inhibitors - Updated 12/01/20
  • Proton Pump Inhibitors PA Request Form - Updated 11/04/20
• Pulmonary Artery Hypertension Agents - Updated 02/06/24
• Pulmonary Fibrosis Agents - Updated 02/09/24
• Pyridostigmine - Posted 12/10/19
• Pyruvate Kinase Deficiency Agents - Posted 02/09/24

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• Quinolones - Updated 9/27/18

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• Ranolazine - Updated 08/18/23
• Rectiv  - Posted 04/17/12
• Regranex  - Updated 1/24/11

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• Santyl - Posted 02/06/13
• Sedative Hypnotics - Updated 02/06/24
• Sickle Cell Agents - Updated 04/01/22
• Signifor - Posted 06/28/19
• Sirturo - Posted 11/22/13
• Skeletal Muscle Relaxants - Updated 02/06/24
• Spinal Muscular Atrophy Agents - Updated 10/26/23
• ​ Stimulants and Related Agents - Updated 02/06/24
• Strensiq - Posted 05/26/16
• Synagis Policy for RSV Season '23-'24  - Posted 09/07/23
  • Synagis - PA Summary  - Updated 10/03/23
  • Synagis - PA Request Form - Updated 09/07/23
  • Synagis - MAR - Updated 9/13/18
  • Synagis - FAQ - Posted 9/6/18
• Synribo - Updated 01/19/18

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• Tetracyclines - Updated 07/23/21
• Thiola - Posted 12/10/19
• Thrombopoiesis Stimulating Proteins  - Updated 08/17/23
• Thyroid Hormones - Updated 02/12/24
• Tobacco Cessation - Updated 08/2/18
  • Tobacco Cessation PA Request Form - Updated 12/12/18
• Tobramycin Inhaled - Updated 06/28/17
• Topical Antineoplastic and Genital Warts - Updated 02/09/24
• Topical NSAIDs  - Updated 07/03/19
• Transmucosal Fentanyl  - Updated 11/30/20
• Trelstar - Updated 8/18/10

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• Ulcerative Colitis Agents - Posted 8/22/19
• Urea Cycle Disorders Oral  - Posted 02/06/24
• Urea Products - Updated 2/2/11
• Urinary Anti-infectives - Updated 02/12/24
• Urocit K  - Updated 02/25/14
• Uterine Disorder Treatments - Posted 04/02/24

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• Vaginal Estrogen Preparations - Posted 07/05/22
• Vasodilators, Coronary - Updated 08/10/21
• Vecamyl - Posted 02/24/14
• Vitamin D and ESRD Products - Updated 09/08/21
• Vimizim - Posted 03/30/16
• Vyjuvek - Posted 02/06/24
• Vyndaqel-Vyndamax - Posted 1/8/20

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• Xenical - Updated 9/27/18
• Xospata - Posted 7/10/19
• Xyrem - Updated 09/27/18

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