Prior Authorization Process and Criteria

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.

If the drug cannot be located by name or if you are unsure of the drug category in which the drug is located, please see the attached Prior Authorization (PA) Cross Reference document for assistance.

Prior Authorization (PA) Cross Reference Alphabetical by Therapeutic Class -- Updated 11/15/24

Prior Authorization (PA) Cross Reference Alphabetical by Drug Name - Updated 11/15/24

Prior Authorization (PA) Request Process Guide - Updated 12/20/23

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

• ACE Inhibitors and Combinations - Updated 03/21/19
• Acne and Rosacea Agents Topical - Updated 08/17/23
• Acromegaly Agents - Updated 06/28/19
• Aliskiren and Combinations - Updated 06/29/17
• Alzheimer Agents - Updated 02/06/24
• Amyotrophic Lateral Sclerosis Agents - Updated 9/27/23
• Analgesics, Narcotics Long - Updated 07/17/23
• Analgesics, Narcotics Short - Updated 02/09/24
• Analgesics, Salicylates - Posted 2/20/20
• Androgenic Agents Injectable - Posted 8/14/19
• Androgenic Agents Oral - Updated 02/12/24
• Androgenic Agents Topical - Updated 09/08/21
• Angiotensin Modulators  - Posted 07/03/24
• Angiotensin Receptor Blockers and Combinations  - Updated 07/03/24
• Anthelmintics - Updated 12/11/19
• Antiallergens, Oral - Updated 02/06/24
• Antiarrhythmics, Oral PA Summary - Posted 11/24/20
• Antibiotics, GI - Updated 02/06/24
• Antibiotics, Inhaled - Updated 07/17/23
• Antibiotics, Other - Posted 02/09/24
• Antibiotics, Topical - Posted 01/28/21
• Antibiotics, Vaginal - Updated 08/08/24
• Anticholinergics-Antispasmodics - Updated 02/09/24
• Anticoagulants  - Updated 08/10/21
• Anticonvulsants - Posted 02/28/25
• Antidepressants - Updated 06/06/24
• Antidiabetic Agents  - Updated 10/01/24
• Antidiarrheals - Updated 02/06/24
• Antiemetics/Antivertigo Agents  - Updated 07/03/24
• Antifibrinolytic Agents - Updated 02/05/24
• Antifungals Injectable - Updated 10/28/24
• Antifungals Oral - Updated 10/01/24
• Antifungals Topical - Posted 2/21/20
• Antihistamines - Updated 08/17/23
• Antihistamines Nasal - Posted 6/27/19
• Antihyperlipidemics, Other – Posted 02/04/25
• Antihypertensives Sympatholytics - Posted 08/17/23
• Antihyperuricemics  - Updated 07/17/23
• Antimalarials  - Updated 06/18/19
• Antimigraine Agents, Other - Updated 07/03/24
• Antimigraine Agents, Triptans - Posted 12/01/20
• Antiparkinson Agents - Updated 07/23/21
• Antiparasitics, Topical - Updated 02/06/24
• Antiplatelet Drugs - Updated 08/22/19
• Antiprotozoals - Updated 10/28/24
• Antipruritics Topical - Posted 7/3/19
• Antipsoriatic Agents - Updated 12/27/24
• Antivirals General - Posted 05/22/24
• Antivirals Oral - Updated 02/05/24
• Antivirals Topical - Posted 6/19/19
• Anxiolytics Benzodiazepines and Barbiturates - Updated 02/06/24
• Asthma and COPD Agents - Updated 08/14/24
• Atypical Antipsychotics - Updated 11/04/24
  • Atypical Antipsychotic PA Request Form  - Updated 10/28/24
• Augmentin Products - Posted 08/02/18
• Aztreonam - Updated 05/19/17

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• Basal Cell Carcinoma Agents - Posted 05/06/16
• Beta Blockers - Updated 10/01/24
• Bile Acid Sequestrants - Updated 12/03/15
• Bile Salts - Posted 03/21/25
• Biologic Immunomodulators  - Posted 03/21/25
• Bladder Relaxant Preparations - Updated 07/03/24
• Bone Resorption Suppression - Updated 09/08/21
• BPH Agents - Updated 02/09/24

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• Calcium Channel Blockers - Updated 02/09/24
• Capecitabine - Posted 09/21/15
• Carbapenem Injectable  - Posted 05/22/24
• Cardiovascular Other - Posted 08/17/23
• Celestone Soluspan - Updated 12/27/10
• Cephalosporins Related Antibiotics - Updated 12/12/24
• Cephalosporins, Injectable - Updated 12/13/24
• Chelating Agents - Updated 04/02/24
• Clonidine TTS - Updated 3/7/11
• Colony Stimulating Factors - Updated 03/06/24
• Complement Inhibitors - Posted 02/28/25
• Compounded Drugs - Posted 02/09/24
• Compound PA Request Form - Updated 12/12/18
• Contraceptives - Updated 02/09/24
• Corlanor - Posted 01/3/20
• Corticosteroid Combinations - Updated 10/18/17
• Corticosteroids Topical - Updated 02/06/24
• Corticotropin - Posted 02/28/25
• Corvita - Updated 01/19/18
• Crinone - Updated 12/27/10
• Cystic Fibrosis, Oral  - Updated 02/06/24

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• Daurismo - Posted 6/28/19
• Daybue - Posted 04/0824
• Diabetic Supplies, Insulin Pens  - Updated 05/20/24
• Diarrhea Agent - Posted 07/10/17
• Digoxin - Posted 02/05/24
• Disposable Insulin Delivery System - Posted 02/12/24
• Diuretics - Updated 07/14/23
• Duchenne Muscular Dystrophy Treatments - Posted 01/08/25

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• Egrifta  - Updated 06/28/17
• Elaprase - Updated 12/27/10
• Enzymes for Gaucher Disease - Updated 01/27/15
• Enzyme Inhibitors Systemic - Updated 02/06/24
• Epinephrine Injection - Updated 02/06/24
• Epoetin - Updated 01/31/19
• Estrogen Agents, Oral-Transdermal  - Updated 12/01/20
• Etoposide - Updated 7/10/19

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• Fabry Disease Agents - Posted 6/28/19
• Fibric Acid Derivatives - Updated 08/2/18
• Firmagon - Updated 04/11/13

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• Gattex - Updated 02/09/24
• GI Motility, Chronic PA - Updated 10/01/24
• Glucocorticoids Oral - Updated 12/12/24
• Glycopeptides  - Posted 06/10/16
• Growth Factors - Posted 07/17/23
• Growth Hormones - Updated 07/03/24

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• H. Pylori Agents  - Updated 01/08/25
• H2 Antagonists - Updated 12/01/20
• Hemophilia Treatment - Updated 02/06/24
• Hepatitis B Agents - Updated 7/10/19
• Hepatitis C Agents - Updated 02/03/23
  • Hepatitis C Retreatment Form - Updated 7/23/19
• ​HAE Treatments  - Updated 10/15/21
• Hereditary Transthyretin Amyloidosis Agents - Updated 12/12/24
• HIV-AIDS Medications - Updated 07/03/24
• HP Acthar - Updated 04/3/17
• Hyaluronidase - Updated 1/18/11
• Hyperhidrosis Agent - Posted 8/14/19
• Hyperoxaluria Agents - Posted 12/12/24
• Hypoglycemics Insulin and Related Agents - Updated 07/14/23
• Hypophosphatemia Treatments - Posted 11/30/20

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• Imcivree - Posted 02/12/24
• Immune Globulin - Updated 02/12/24
• Immunomodulators, Lupus - Updated 09/01/22
• Immunomodulators, Topical - Updated 08/17/23
• Immunosuppressives Oral - Updated 6/27/19
• Increlex - Updated 1/18/11
• Invanz - Updated 1/18/11
• Iron, Oral - Posted 02/01/21
• Iron Parenteral - Updated 08/18/23
• Isotretinoin - Updated 10/28/13

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• Jynarque - Posted 9/28/18
• Korlym  - Posted 05/23/12

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• Lambert-Eaton Myasthenic Syndrome Agents - Updated 02/06/24
• Lanoxin - Posted 04/09/14
• Laxatives and Cathartics - Updated 08/18/23
• Leukotriene Modifiers - Updated 12/11/19
• Lipotropics, Other - Updated 08/10/21
• Lipotropics, Statins - Posted 02/28/25
  • Lipotropics, Satins PA Appeal Form - Posted 2/20/20

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• Macrolides-Ketolides  - Updated 02/20/20
  • ​ Universal 17-P Auth Form - Updated 10/30/18
• Megace ES - Updated 03/30/16
• Melanoma Agents - Updated 1/23/19
• Metabolic Dysfunction Associated Steatohepatitis - Posted 01/08/25
• Methotrexate_Products - Updated 07/02/24
• Milrinone
• Miscellaneous Analgesics - Updated 07/17/23
• Movement Disorder - Updated 02/06/24
• Mozobil - Updated 1/24/11
• Multiple Sclerosis Agents - Updated 02/12/24
• Myalept - Updated 08/20/15

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