
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
Prior
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 -
Afinitor
- Updated 08/23/19 -
Aliskiren
and Combinations - Updated 06/29/17 -
Alzheimer
Agents - Updated 08/18/2023 -
Amyotrophic
Lateral Sclerosis - Posted 6/28/19 -
Anabolic
Steroids/Androgens - Updated 03/31/16 -
Analgesics,
Narcotics Long - Updated 07/17/23 -
Analgesics,
Narcotics Short - Updated 09/21/21 -
Analgesics,
Salicylates - Posted 2/20/20 -
Androgenic
Agents Injectable - Posted 8/14/19 -
Androgenic
Agents Oral - Posted 8/14/19 -
Androgenic
Agents Topical - Updated 09/08/21 -
Angiotensin
Modulators - Posted 07/17/23 -
Angiotensin
Receptor Blockers and Combinations - Updated 07/05/22 -
Anthelmintics
- Updated 12/11/19 -
Antiallergens,
Oral - Posted 01/28/21 -
Antiarrhythmics,
Oral PA Summary - Posted 11/24/20 -
Antibiotics,
GI - Updated 09/21/21 -
Antibiotics,
Inhaled - Updated 07/17/23 -
Antibiotics,
Topical - Posted 01/28/21 -
Antibiotics,
Vaginal - Updated 07/17/23 -
Anticholinergics-Antispasmodics
- Updated 09/21/21 -
Anticoagulants
- Updated 08/10/21 -
Anticonvulsants
- Updated 07/05/22 -
Antidepressants
- Updated 08/18/23 -
Antidiabetic
Agents - Updated 07/14/23 -
Antidiarrheals
- Posted 12/07/20 -
Antiemetics/Antivertigo
Agents - Updated 08/18/23 -
Antifibrinolytic
Agents - Posed 11/30/20 -
Antifungals
Injectable - Posted 2/21/20 -
Antifungals
Oral - Updated 07/14/23 -
Antifungals
Topical - Posted 2/21/20 -
Antihistamines
- Updated 08/17/23 -
Antihistamines
Nasal - Posted 6/27/19 -
Antihypertensives
Sympatholytics - Posted 08/17/23 -
Antihyperuricemics
- Updated 07/17/23 -
Antimalarials
- Updated 06/18/19 -
Antimigraine
Agents, Other - Updated 07/17/23 -
Antimigraine
Agents, Triptans - Posted 12/01/20 -
Antiparkinson
Agents - Updated 07/23/21 -
Antiparasitics,
Topical - Updated 09/21/21 -
Antiplatelet
Drugs - Updated 08/22/19 -
Antiprotozoals
- Updated 08/10/21 -
Antipruritics
Topical - Posted 7/3/19 -
Antipsoriatic Agents
- Updated 08/18/23 -
Antivirals
Oral - Posted 1/3/20 -
Antivirals
Topical - Posted 6/19/19 -
Anxiolytics
Benzodiazepines and Barbiturates - Updated 8/22/19 -
Asthma
and COPD Agents - Updated 02/01/21 -
Atypical
Antipsychotics - Updated 10/11/22-
Atypical
Antipsychotic PA Request Form - Revised 10/12/22
-
Atypical
-
Augmentin
Products - Posted 08/02/18 -
Aztreonam
- Updated 05/19/17
-
Balversa
- Posted 10/3/19 -
Basal
Cell Carcinoma Agents - Posted 05/06/16 -
Beta
Blockers - Updated 08/22/19 -
Bile
Acid Sequestrants - Updated 12/03/15 -
Bile
Salts - Posted 09/08/21 -
Biologic
Immunomodulators - Updated 01/06/23 -
Bladder
Relaxant Preparations - Updated 09/21/21 -
Bone
Resorption Suppression - Updated 09/08/21 -
BPH
Agents - Updated 2/20/20
-
Cabometyx
- Posted 06/18/19 -
Calcium
Channel Blockers - Posted 1/3/20 -
Capecitabine
- Posted 09/21/15 -
Carbaglu
- Updated 8/17/11 -
Carbapenems
- Posted 09/09/16 -
Cardiovascular
Other - Posted 08/17/23 -
Celestone
Soluspan - Updated 12/27/10 -
Cephalosporins
Related Antibiotics - Posted 2/20/20 -
Cephalosporins,
Injectable - Posted 2/20/20 -
Chelating
Agents - Updated 01/3/20 -
Chenodal
- Posted 01/23/19 -
Cholbam
- Posted 05/06/16 -
Clonidine
TTS - Updated 3/7/11 -
Colony
Stimulating Factors - Updated 08/17/23 -
Compound
PA Request Form - Updated 12/12/18 -
Contraceptives
- Updated 12/01/20 -
Corlanor
- Posted 01/3/20 -
Corticosteroid
Combinations - Updated 10/18/17 -
Corticosteroids
Oral - Updated 12/1/19 -
Corticosteroids
Topical - Updated 09/08/21 -
Corvita
- Updated 01/19/18 -
Crinone
- Updated 12/27/10 -
Cystic
Fibrosis, Oral - Updated 08/17/23 -
Cytomegalovirus
Agents - Posted 6/27/19
-
Daurismo
- Posted 6/28/19 -
Diabetic
Supplies, Insulin Pens - Updated 07/17/23 -
Diarrhea
Agent - Posted 07/10/17 -
Diuretics
- Updated 07/14/23
-
Egrifta
- Updated 06/28/17 -
Elaprase
- Updated 12/27/10 -
Emflaza
Prior Authorization Request Form - Updated 12/12/18 -
Enzymes
for Gaucher Disease - Updated 01/27/15 -
Enzyme
Inhibitors Systemic - Posted 10/15/21 -
Epinephrine
Injection - Updated 12/10/19 -
Epoetin
- Updated 01/31/19 -
Estrogen
Agents, Oral-Transdermal - Updated 12/01/20 -
Etoposide
- Updated 7/10/19
-
Fabry
Disease Agents - Posted 6/28/19 -
Fibric
Acid Derivatives - Updated 08/2/18 -
Firmagon
- Updated 04/11/13
-
Gattex
- Posted 04/16/13 -
GI
Motility, Chronic PA - Updated 08/17/23 -
Glycopeptides
- Posted 06/10/16 -
Growth
Factors - Posted 07/17/23 -
Growth
Hormones - Updated 05/31/22
-
H.
Pylori Agents - Updated 12/01/20 -
H2
Antagonists - Updated 12/01/20 -
Hemophilia
Treatment - Updated 07/17/23 -
Hepatitis
B Agents - Updated 7/10/19 -
Hepatitis
C Agents - Updated 02/03/23-
Hepatitis
C Retreatment Form - Updated 7/23/19
-
Hepatitis
-
HAE
Treatments - Updated 10/15/21 -
Hereditary
Transthyretin Amyloidosis Agents - Posted 9/6/19 -
HIV-AIDS Medications
- Updated 07/17/23 -
HP
Acthar - Updated 04/3/17 -
Hyaluronidase
- Updated 1/18/11 -
Hyperhidrosis
Agent - Posted 8/14/19 -
Hypoglycemics
Insulin and Related Agents - Updated 07/14/23 -
Hypophosphatemia
Treatments - Posted 11/30/20
-
Immune Globulin
- Updated 08/22/19 -
Immunomodulators,
Lupus - Updated 09/01/22 -
Immunomodulators,
Topical - Updated 08/17/23 -
Immunosuppressives
Oral - Updated 6/27/19 -
Increlex
- Updated 1/18/11 -
Inlyta
- Updated 07/10/18 -
Invanz
- Updated 1/18/11 -
Iron,
Oral - Posted 02/01/21 -
Iron
Parenteral - Updated 08/18/23 -
Isotretinoin
- Updated 10/28/13
-
Lambert-Eaton
Myasthenic Syndrome Agents - Posted 12/11/19 -
Lanoxin
- Posted 04/09/14 -
Laxatives
and Cathartics - Updated 08/18/23 -
Leukotriene
Modifiers - Updated 12/11/19 -
Lidocaine
Topical Products - Updated 08/23/19 -
Lipopeptides
- Posted 6/28/19 -
Lipotropics,
Other - Updated 08/10/21 -
Lipotropics,
Statins - Posted 12/01/20-
Lipotropics,
Satins PA Appeal Form - Posted 2/20/20
-
Lipotropics,
-
Lonsurf
- Posted 07/10/19
-
Macrolides-Ketolides
- Updated 02/20/20 -
Makena
- Updated 11/01/16 -
Universal
17-P Auth Form - Updated 10/30/18
-
Universal
-
Megace
ES - Updated 03/30/16 -
Melanoma
Agents - Updated 1/23/19 -
Methotrexate_Products
- Posted 10/12/17 -
Milrinone
-
Miscellaneous
Analgesics - Updated 07/17/23 -
Movement
Disorder - Updated 04/19/22 -
Mozobil
- Updated 1/24/11 -
Multiple
Sclerosis Agents - Updated 08/18/23 -
Myalept
- Updated 08/20/15