For pharmacy prior authorization criteria for specific agents, please see documents posted at
- Coverage Details and Specific Drugs PA – See below for specific drug prior authorization request forms. If you do not find the form you need for a specific drug, use the Standard Request Form.
- Prior Authorization Request – you may need prior authorization for a specific drug. Refer to the Preferred Drug List (PDL)/Clinical Coverage Policy 9A, Over-The-Counter Products (OTC) for coverage details.
If a prior authorization is needed for a specific drug, use one of the following forms: (under development)
The state Medicaid policy for the Physician Administered Drug Plan may be found at this link.
- Physician Administered Drug Program (PDP) – Covers primarily injectable drugs or biologics purchased and given by a medical professional in an office or outpatient setting.
- PDP catalog – This is a list of covered drugs and biologics with approved indications and restrictions. Click here to view the PDP catalog.
- Off-label use – PDP requests can be submitted for off-label use. These requests should include the intended use of the drug.
Submit requests for PDP off-label uses via the Provider Portal.