Prior Authorization Criteria N - Z

pharmacy

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

Narcolepsy Agents - Posted 09/03/25
Narcotic Fill Limit - Posted 09/03/25
Narcotics Long Acting - Updated 7/8/19
Nasal Antihistamines - Posted 09/03/25
Nasal Steroids - Posted 09/03/25
Natpara - Posted 05/26/16
Neurogenic Orthostatic Hypotension Agents - Posted 09/03/25
Neuropathic Pain - Posted 09/03/25
Niemann-Pick Disease Agents - Posted 09/08/25
Northera - Posted 03/30/16
NSAID and COX II - Posted 09/03/25
NSAIDs, Topical - Posted 09/03/25
Nuedexta
Nutritionals Triglycerides - Posted 09/03/25

Octreotide and Related Agents - Posted 09/03/25
Oncology Oral-Breast - Posted 09/08/25
Oncology Oral-Hematologic - Posted 09/08/25
Oncology Oral-Ovarian - Posted 09/08/25
Oncology Oral - Other - Posted 09/08/25
Oncology Oral-Lung - Posted 09/08/25
Oncology Oral-Prostate - Posted 09/08/25
Oncology Oral-Renal - Posted 09/03/25
Oncology Oral-Skin - Posted 09/03/25
Opfolda - Posted 09/08/25
Ophthalmics for Allergic Conjunctivitis - Posted 09/08/25
Ophthalmic Antibiotics - Posted 09/03/25
Ophthalmics Anti-inflammatories - Posted 09/03/25
Ophthalmics Anti-inflammatories Immunomodulators - Posted 09/08/25
Ophthalmic Antivirals - Posted 09/08/25
Ophthalmic Glaucoma Agents - Posted 09/08/25
Ophthalmic Steroid Antibiotic Combination - Posted 09/03/25
Ophthalmics Demodex Blepharitis - Posted 09/08/25
Ophthalmics for Neurotrophic Keratitis - Posted 09/08/25
Opiate Dependence Treatments - Posted 09/08/25
Opioid MME Maximum PA Form - Posted 09/03/25
Otic Antibiotics - Posted 09/08/25
Oxazolidinones - Posted 09/04/25

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

Quinolones - Updated 9/27/18

Ranolazine - Posted 09/05/25
Rectiv - Posted 09/05/25
Regranex - Updated 1/24/11

Santyl - Posted 02/06/13
Sedative Hypnotics - Posted 09/05/25
Sickle Cell Agents - Posted 09/05/25
Signifor - Posted 06/28/19
Sirturo - Posted 11/22/13
Skeletal Muscle Relaxants - Posted 09/05/25
Sohonos - Posted 09/05/25
Spinal Muscular Atrophy Agents - Posted 09/05/25
Stem Cell Mobilizers - Posted 09/05/25
Stimulants and Related Agents - Posted 09/05/25
Strensiq - Posted 09/05/25
Sulfonamides - Posted 09/05/25
Synagis Policy for RSV Season '24-'25 - Posted 09/05/25
- Synagis - PA Summary - Posted 09/05/25
- Synagis - PA Request Form - Posted 09/05/25
- Synagis - MAR - Updated 9/13/18
- Synagis - FAQ - Posted 9/6/18
Synribo - Posted 09/05/25

Tetracyclines - Posted 09/05/25
Thiola - Posted 09/05/25
Thrombopoiesis Stimulating Proteins - Posted 09/05/25
Thyroid Hormones - Posted 09/05/25
Tobacco Cessation - Posted 09/05/25
- Tobacco Cessation PA Request Form - Posted 09/05/25
Tobramycin Inhaled - Updated 06/28/17
Topical Antineoplastic and Genital Warts - Posted 09/05/25
Topical NSAIDs - Updated 07/03/19
Transmucosal Fentanyl - Posted 09/05/25
Transthyretin Amloidosis Agents - Posted 09/05/25
Trelstar - Updated 8/18/10

Ulcerative Colitis Agents - Posted 09/05/25
Urea Cycle Disorders Oral - Posted 09/05/25
Urea Products - Updated 2/2/11
Urinary Anti-infectives - Posted 09/05/25
Urocit K - Posted 09/08/25
Uterine Disorder Treatments - Posted 09/08/25

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Vaginal Estrogen Preparations - Posted 09/08/25
Vasodilators, Coronary - Posted 09/08/25
Vasopressor Receptor Antagonists - Posted 09/08/25
Vecamyl - Posted 09/08/25
Vitamin D and ESRD Products - Posted 09/08/25
Vimizim - Posted 09/08/25
Vyjuvek - Posted 02/06/24
Vyndaqel-Vyndamax - Posted 1/8/20

Wound Care Products - Posted 09/08/25

Xenical - Updated 9/27/18
Xyrem - Updated 09/27/18