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Drug Specific Prior Authorizations 2024 (Medicaid/CHIP)

Drugs listed on this page require prior authorization from Health Partners (Medicaid) and KidzPartners (CHIP).

Please note that there are different prior authorization forms for Jefferson Health Plans' Medicare and ACA plans. Forms are also sent to different fax numbers.

If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Using the appropriate form will help assure that we have the information necessary to make a decision about your request.

2024 Non-PDL Prior Authorizations:

Corticotropin Injection Gel

Non-Preferred Drug (non-PDL)

Quantity Limit Exceptions

Sapropterin Dehydrochloride

Zoryve 0.3% Foam

2024 PDL Prior Authorizations:

Acne Agents – Oral

Acne Agents – Topical

Alcohol Use Disorder Agents

Alzheimer’s Agents

Analgesics – Non-Opioid Barbituate Combinations

Analgesics – Opioid Long-Acting

Analgesics – Opioid Short-Acting

Androgenic Agents

Angiotensin Modulators

Angiotensin Modulators – Combinations

Antianginal Agents

Antibiotics – GI and Related Agents

Antibiotics - Inhaled

Antibiotics – Topical

Anticonvulsants

Antidepressants - Other

Antidepressants – SSRIs

Antiemetics – Antivertigo Agents

Antifibrotic Respiratory Agents

Antifungals – Oral

Antifungals – Topical

Antihemophilia Agents

Antihistamines – Minimally Sedating

Antihypertensives – Sympatholytic

Antihyperuricemics

Antiparasitics – Topical

Antiparkinson’s Agents

Antipsoriatics – Oral

Antipsoriatics – Topical

Antivirals – CMV

Antivirals – Herpes

Antivirals – Influenza

Benign Prostatic Hyperplasia (BPH) Treatments

Bladder Relaxant Preparations

Blood Glucose Meters and Test Strips

Bone Density Regulators

Botulinum Toxins

Bronchodilators – Beta Agonist

Calcium Channel Blockers

Colony Stimulating Factors

Continuous Glucose Monitors (CGM)

Contraceptives – Oral

Contraceptives – Other

Cytokine and CAM Antagonists

Dry Eye Treatments

Enzyme Replacements – Gaucher Disease

Epinephrine – Self-Injected

Erythropoiesis Stimulating Proteins

Fluoroquinolones – Oral

GI Motility Agents – Chronic

Glucocorticoids - Inhaled

Glucocorticoids - Oral

Growth Hormones

H. Pylori Treatments

Hematopoietic Mixtures

Hepatitis B Agents

Hepatitis C Agents

Hereditary Angioedema Agents (HAE)

Histamine 2 Receptor Blockers

HIV-AIDS Antiretrovirals

Hypoglycemia Treatments

Hypoglycemics - Alpha Glucosidase Inhibitors

Hypoglycemics – Incretin Mimetics

Hypoglycemics – Insulins and Related Agents

Hypoglycemics – Meglitinides

Hypoglycemics – Metformins

Hypoglycemics – SGLT-2 Inhibitors

Hypoglycemis – Sulfonylureas

Hypoglycemis – TZDs

Immunomodulators – Atopic Dermatitis

Immunomodulators – Topical

Immunosuppressives – Oral

Intra-Articular Hyaluronates

Intranasal Rhinitis Agents

Iron – Chelating Agents

Iron – Parenteral

Leukotriene Modifiers

Lipotropics – Other

Lipotropics – Statins

Local Topical Anesthetics

Macular Degeneration Agents

Methotrexate Products

Migraine Acute Treatment Agents

Migraine Prevention Agents

Monoclonal Antibodies

Multiple Sclerosis Agents

Neuropathic Pain Agents

Obesity Treatment Agents

Oncology Agents – Breast Cancer

Oncology Agents – Oral

Ophthalmics - Allergic Conjunctivitis

Ophthalmics – Antibiotics

Ophthalmics – Antibiotic Steriod Combo

Ophthalmics – Anti-inflammatories

Ophthalmics – Glaucoma

Opioid Dependence Treatments

Opioid Overdose Agents

Otic Antibiotics

Pancreatic Enzymes

Phosphate Binders

Pituitary Suppressive Agents - LHRH

Platelet Aggregation Inhibitors

Potassium Removing Agents

Prenatal Vitamins

Progestational Agents

Proton Pump Inhibitors

Pulmonary Arterial Hypertension Agents - Oral & Inhaled

Sedative Hypnotics

Sickle Cell Anemia Agents

Skeletal Muscle Relaxants

Smoking Cessation Agents

Steroids – Topical

Stimulants and Related Agents

Thalidomide and Derivatives

Thrombopoietics

Thyroid Hormones

Tubeless Insulin Delivery Devices

Ulcerative Colitis Agents

Urea Cycle Disorder Agents

Urinary Anti-Infectives

Vaginal Anti-Infectives

Vitamin D Analogs

VMAT2 Inhibitors