Prior Authorization Process and Criteria

Pharmacist

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 -- Updated 12/29/20

Prior Authorization (PA) Request Process Guide - Updated 1/30/20

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 12/01/20
• Acromegaly_Agents - Updated 06/28/19
• Afinitor - Updated 08/23/19
• Aliskiren and Combinations - Updated 06/29/17
• Allergic Rhinitis Sublingual Immunotherapy  -- Posted 01/06/15
• Alpha -1 Proteinase Inhibitors - Updated 04/10/14
• Alzheimer Agents - Updated 1/24/2020
• Amyotrophic Lateral Sclerosis - Posted 6/28/19
• Anabolic Steroids/Androgens - Updated 03/31/16
• Analgesics, Narcotics Long - Posted 1/3/20
• Analgesics, Narcotics Short - Updated 12/07/20
• Analgesics, Salicylates - Posted 2/20/20
• Androgenic Agents Injectable - Posted 8/14/19
• Androgenic Agents Oral - Posted 8/14/19
• Androgenic Agents Topical - Updated 02/20/20
• Angiotensin Receptor Blockers and Combinations  - Updated 12/07/20
• Anthelmintics - Updated 12/11/19
• Antiandrogens - Updated 8/23/19
• Antiarrhythmics, Oral PA Summary - Posted 11/24/20
• Antibiotics, GI - Posted 11/30/20
• Antibiotics, GI - Posted 2/20/20
• Antibiotics, Vaginal - Updated 12/01/20
• Anticholinergics-Antispasmodics - Updated 2/20/20
• Anticoagulants  - Updated 1/24/20
• Anticonvulsants - Updated 11/30/20
• Antidepressants - Updated 12/01/20
• Antidiabetic Agents  - Updated 12/07/20
• Antidiarrheals - Posted 12/07/20
• Antiemetics/Antivertigo Agents  - Updated 12/07/20
• Antifibrinolytic Agents - Posed 11/30/20
• Antifungals Injectable - Posted 2/21/20
• Antifungals Oral - Posted 2/21/20
• Antifungals Topical - Posted 2/21/20
• Antihistamines - Posted 06/18/19
• Antihistamines Nasal - Posted 6/27/19
• Antihyperuricemics - Posted 11/30/20
• Antimalarials  - Updated 06/18/19
• Antimigraine Agents, Other - Updated 12/01/20
• Antimigraine Agents, Triptans - Posted 12/01/20
• Antiparkinson Agents - Updated 12/01/20
• Antiparasitics, Topical - Updated 12/01/20
• Antiplatelet Drugs - Updated 08/22/19
• Antiprotozoals - Updated 11/30/20
• Antipruritics Topical - Posted 7/3/19
• Antipsoriatic Agents - Updated 06/26/19
• Antivirals Oral - Posted 1/3/20
• Antivirals Topical - Posted 6/19/19
• Anxiolytics Benzodiazepines and Barbiturates - Updated 8/22/19
• Arikayce - Posted 6/27/19
• Asthma and COPD Agents - Updated 01/3/20
• Atypical Antipsychotics - Updated 1/24/20
  • Atypical Antipsychotics Prior Authorization Request Form - Updated 11/04/20
• Augmentin Products - Posted 08/02/18
• Aztreonam - Updated 05/19/17

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• Balversa - Posted 10/3/19
• Basal Cell Carcinoma Agents - Posted 05/06/16
• Beta Blockers - Updated 08/22/19
• BiDil - Updated 12/22/10
• Bile Acid Sequestrants - Updated 12/03/15
• Biologic Immunomodulators  - Updated 12/01/20
• Bladder Relaxant Preparations - Posted 6/27/19
• Bone Ossification Suppression - Updated 06/05/18
• BPH Agents - Updated 2/20/20

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• 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
• 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 1/24/20
• Compound PA Request Form - Updated 12/12/18
• Contraceptives - Updated 12/01/20
• Copiktra - Posted 6/27/19
• Corlanor - Posted 01/3/20
• Corticosteroid Combinations - Updated 10/18/17
• Corticosteroids Oral - Updated 12/1/19
• Corticosteroids Topical - Posted 12/10/19
• Corvita - Updated 01/19/18
• Crinone - Updated 12/27/10
• Cystic Fibrosis, Oral  - Updated 12/01/20
• Cytomegalovirus Agents  - Posted 6/27/19

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• Daurismo - Posted 6/28/19
• Diabetic Supplies, Insulin Pens  - Updated 12/07/20
• Diarrhea Agent - Posted 07/10/17
• Diuretics - Updated 12/07/20

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• 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
• Epinephrine Injection - Updated 12/10/19
• 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
• Femring QLL  - Posted 05/02/12
• Fibric Acid Derivatives - Updated 08/2/18
• Firmagon - Updated 04/11/13

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• Gattex - Posted 04/16/13
• GI Motility, Chronic PA - Updated 12/01/20
• Glycopeptides  - Posted 06/10/16
• Gonadotropin Releasing Hormone - Posted 6/28/19
• Growth Hormones - Updated 06/28/17

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• H. Pylori Agents  - Updated 12/01/20
• H2 Antagonists - Updated 12/01/20
• Hemophilia Treatment - Updated 12/07/20
  • ​ Hemlibra Prior Authorization Form - Updated 8/5/19
• Hepatitis B Agents - Updated 7/10/19
• Hepatitis C Agents - Updated 07/23/19
  • Hepatitis C Retreatment Form - Updated 7/23/19
• ​HAE Treatments  - Updated 1/17/20
• Hereditary Transthyretin Amloidosis Agents - Posted 9/6/19 
• HIV-AIDS Medications - Updated 12/07/20
• HP Acthar - Updated 04/3/17
• Hyaluronidase - Updated 1/18/11
• Hyperhidrosis Agent - Posted 8/14/19
• Hyperkalemia Agents - Posted 6/18/19
• Hypoglycemics Insulin and Related Agents - Updated 12/07/20
• Hypophosphatemia Treatments - Posted 11/30/20

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• Immune Globulin - Updated 08/22/19
• Immunosuppressives Oral - Updated 6/27/19
• Increlex - Updated 1/18/11
• Inlyta  - Updated 07/10/18
• Invanz - Updated 1/18/11
• Iron Parenteral - Updated 09/27/18
• Isotretinoin - Updated 10/28/13

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• Jynarque - Posted 9/28/18

• Keveyis - Posted 05/05/16
• Korlym  - Posted 05/23/12

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• Lambert-Eaton Myasthenic Syndrome Agents - Posted 12/11/19
• Lanoxin - Posted 04/09/14
• Laxatives and Cathartics - Posted 12/10/19
• Leukotriene Modifiers - Updated 12/11/19
• Lidocaine Topical Products - Updated 08/23/19
• Lipopeptides - Posted 6/28/19
• Lipotropics, Other - Posted 2/20/20
• Lipotropics, Statins - Posted 12/01/20
  • Lipotropics, Satins PA Appeal Form - Posted 2/20/20
• Lonsurf - Posted 07/10/19

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• Macrolides-Ketolides  - Updated 02/20/20
• Makena - Updated 11/01/16
  • ​ Universal 17-P Auth Form - Updated 10/30/18
• Megace ES - Updated 03/30/16
• Melanoma Agents - Updated 1/23/19
• Methotrexate_Products - Posted 10/12/17
• Milrinone
• Miscellaneous Analgesics - Updated 06/28/19
• Movement Disorder - Updated 1/27/20
• Mozobil - Updated 1/24/11
• Multiple Sclerosis Agents - Updated 12/02/20
• Myalept - Updated 08/20/15

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