Prior Authorization Criteria N - Z

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.

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
• Naloxone Products - Posted 09/14/16 
• Nasal Steroids - Updated 7/02/19
• Natpara - Posted 05/26/16
• Neuropathic Pain - Updated 04/18/22
• Nexavar - Posted 7/10/19
• Northera - Posted 03/30/16
• NSAID and COX II  - Updated 06/18/19
• NSAIDs, Topical - Posted 1/27/20
• Nuedexta

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• Ocaliva - Posted 06/13/18
• Oncology Oral-Breast - Posted 12/10/19
• Oncology Oral-Hematologic - Updated 10/15/21
• Oncology Oral-Ovarian - Updated 8/14/19
• Oncology Oral Lung - Updated 10/15/21
• Oncology Oral-Prostate - Posted 10/15/21
• Ophthalmics for Allergic conjunctivitis - Posted 08/23/19
• Opthalmic Antibiotics - Updated 01/27/20
• Ophthalmics Anti-inflammatories - Updated 02/01/21
• Ophthalmics Anti-inflammatories Immunomodulators - Updated 05/31/22
• Ophthalmic Antivirals  - Posted 03/12/15
• Ophthalmic Glaucoma Agents - Updated 02/01/21
• Ophthalmic Steroid Antibiotic Combination - Posted 07/2/19
• Ophthalmics for Neurotrophic Keratitis - Posted 8/26/19
• Opiate Dependence Agents - Updated 06/03/22
• Opioid MME Maximum PA Form - Updated 10/4/19
• Orfadin - Posted 10/13/16
• Otic Antibiotics - Posted 1/27/20
• Oxazolidinones  - Posted 05/06/16

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• Palynziq - Posted 8/26/19
• Pancreatic Enzymes - Updated 07/05/22
• Panretin - Updated 1/24/11
• Parenteral Nutrition Products -Posted Updated 08/26/19
• Pheochromocytoma Agents - Posted 10/15/21
• Phosphate Binders - Updated 12/10/19
• Pituitary Suppressive Agents - Updated 05/30/22
• Pleuromutilin Antibiotics - Posted 12/07/20
• Potassium Binders - Posted 06/06/22
• Primary Hyperoxaluria Agents - Posted 10/15/21
• 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 10/15/21
• Pulmonary Fibrosis Agents - Updated 01/27/20
• Pyridostigmine - Posted 12/10/19

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• Quinolones - Updated 9/27/18

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• Ranolazine - Posted 1/3/20
• Ravicti - Posted 06/28/19
• Rectiv - Posted 04/17/12
• Regranex  - Updated 1/24/11

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• Santyl - Posted 02/06/13
• Sedative Hypnotics - Updated 01/26/22
• Serostim - Updated 1/14/09
• Sickle Cell Agents - Updated 04/01/22
• Signifor - Posted 06/28/19
• Sirturo - Posted 11/22/13
• Skeletal Muscle Relaxants - Updated 02/20/20
• Spinal Muscular Atrophy Agents - Posted 04/26/21
• ​ Stimulants and Related Agents - Updated 03/01/22
• Stivarga - Updated 10/12/17
• Strensiq - Posted 05/26/16
• Sutent - Updated 07/10/18
• Synagis Policy for RSV Season '22-'23  - Posted 11/14/22
  • Synagis - PA Summary  - Updated 10/05/21
  • Synagis - PA Request Form - Updated 10/04/21
  • Synagis - MAR - Updated 9/13/18
  • Synagis - FAQ - Posted 9/6/18
• Synribo - Updated 01/19/18

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• Temozolomide - Posted 7/8/19
• Tetracyclines - Updated 07/23/21
• Thiola - Posted 12/10/19
• Thrombopoiesis Stimulating Proteins  - Updated 02/01/21
• Thyroid Hormones - Updated 10/15/21
• 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 07/03/19
• Topical NSAIDs  - Updated 07/03/19
• Transmucosal Fentanyl  - Updated 11/30/20
• Trelstar - Updated 8/18/10
• Turalio - Posted 1/3/20
• Tygacil - Updated 09/02/2011
• Tyzeka

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• Ulcerative Colitis Agents - Posted 8/22/19
• Urea Products - Updated 2/2/11
• Urinary Antiinfectives - Updated 02/21/20
• Urocit K  - Updated 02/25/14

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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
• Vitrakvi - Posted 7/10/19
• Vimizim - Posted 03/30/16
• Votrient - Updated 08/22/12
• 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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