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New Hampshire Medicaid

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Documents

Fax Forms
Title Revision Date
Title Revision Date
Adenosine Triphosphate-Citrate Lyase Medications Prior Authorization Drug Approval Form 07/12/2022
Allergen Extract Medications Prior Authorization Drug Approval Form 08/13/2021
Anti-Fungal Medication for Onychomycosis Prior Authorization/Non-Preferred Drug Approval Form 07/12/2022
Asthma/Allergy Immunomodulators Prior Authorization Drug Approval Form 07/12/2022
Atopic Dermatitis Prior Authorization Drug Approval Form 07/12/2022
Benign Prostatic Hyperplasia Prior Authorization/Non-Preferred Drug Approval Form 08/13/2021
Bowel Disorder Drugs Prior Authorization Drug Approval Form 08/13/2021
Brand Name Multiple Source Prescription Drugs Prior Authorization/Non-Preferred Drug Approval Form 07/12/2022
Buprenorphine/Naloxone and Buprenorphine (Oral) Prior Authorization Drug Approval Form 07/12/2022
Calcitonin Gene-Related Peptide (CGRP) Inhibitor Prior Authorization Drug Approval Form 01/14/2022
Carisoprodol and Combination Medications Prior Authorization Drug Approval Form 07/12/2022
CNS Stimulant and ADHD/ADD Medication Prior Authorization Drug Approval Form 07/12/2022
Codeine for Pediatric Use Prior Authorization Drug Approval Form 01/14/2022
Convenience Kits Prior Authorization Drug Approval Form 01/14/2022
Direct Renin Inhibitors and Combinations Prior Authorization Drug Approval Form 08/13/2021
Duchenne Muscular Dystrophy Medications Prior Authorization Drug Approval Form 08/13/2021
Duloxetine Prior Authorization Drug Approval Form 07/12/2022
Dupixent Prior Authorization Drug Approval Form 01/14/2022
Evrysdi Prior Authorization Drug Approval Form 08/13/2021
Fibromyalgia Prior Authorization Drug Approval Form 07/12/2022
Growth Hormones Prior Authorization Drug Approval Form 07/12/2022
Hematopoietic Agent Prior Authorization Drug Approval Form 08/13/2021
Hepatitis C Medications Prior Authorization Drug Approval Form 01/14/2022
Hetlioz Prior Authorization Drug Approval Form 07/12/2022
Horizant Prior Authorization Drug Approval Form 07/12/2022
Hyaluronic Acid Derivatives Injection Prior Authorization Drug Approval Form 01/14/2022
Inhaled Insulin Medications Prior Authorization Drug Approval Form 07/12/2022
Juxtapid Prior Authorization Drug Approval Form 01/14/2022
Long Acting Opioid Analgesics Prior Authorization Drug Approval Form 07/12/2022
Methadone Prior Authorization Drug Approval Form 02/24/2021
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease Prior Authorization Drug Approval Form 07/12/2022
Morphine Milligram Equivalent (MME) Prior Authorization Drug Approval Form 07/12/2022
Movement Disorder Medications Prior Authorization Drug Approval Form 07/12/2022
New Drug Product Medication Request Prior Authorization Drug Approval Form 07/12/2022
Non-Preferred Drug Approval Form 04/09/2019
Oral Isotretinoin Medications Prior Authorization Drug Approval Form 07/12/2022
Pregabalin Prior Authorization Drug Approval Form 07/12/2022
Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) Prior Authorization Drug Approval Form 07/12/2022
Psychoactive Medications for Children (5 years of age or younger) Prior Authorization Drug Approval Form 07/12/2022
Psychotropic Medications Duplicate Therapy (6 years of age or older) Prior Authorization Drug Approval Form 07/12/2022
Pulmonary Arterial Hypertension (Phosphodiesterase type-5 (PDE-5) Inhibitors only) Prior Authorization/Non-Preferred Drug Approval Form 01/14/2022
Rho Kinase Inhibitor Prior Authorization Drug Approval Form 01/14/2022
Second-Line Antifungal Prior Authorization Drug Approval Form 07/12/2022
Short Acting Fentanyl Analgesic Prior Authorization Drug Approval Form 08/13/2021
Spinraza Prior Authorization Drug Approval Form 01/14/2022
Spravato Prior Authorization Drug Approval Form 08/13/2021
Stromectol Prior Authorization Drug Approval Form 01/14/2022
Symlin Prior Authorization Drug Approval Form 07/12/2022
Synagis Prior Authorization Drug Approval Form 07/12/2022
Systemic Immunomodulators Medications Prior Authorization Drug Approval Form 07/12/2022
Verquvo Prior Authorization Drug Approval Form 07/12/2022
Vuity Prior Authorization Drug Approval Form 07/12/2022
Weight Management Prior Authorization Drug Approval Form 01/14/2022
Zolgensma Prior Authorization Drug Approval Form 07/12/2022

Clinical PA Criteria
Title Date
Title Date
Adenosine Triphosphate-Citrate Lyase Criteria 07/12/2022
Allergen Extract Criteria 08/13/2021
Anti-Fungal Medication for Onychomycosis Criteria 07/12/2022
Asthma/Allergy Immunomodulator Criteria 07/12/2022
Atopic Dermatitis Criteria 07/12/2022
Benign Prostatic Hyperplasia Criteria 08/13/2021
Bowel Disorders/GI Motility, Chronic Criteria 08/13/2021
Brand Name Multiple Source Prescription Drug Product Criteria 07/12/2022
Buprenorphine/Naloxone and Buprenorphine (Oral) Criteria 07/12/2022
Calcitonin Gene-Related Peptide (CGRP) Inhibitor Criteria 01/14/2022
Carisoprodol and Combination Medication Criteria 07/12/2022
CNS Stimulant and ADHD/ADD Medications Criteria 07/12/2022
Codeine for Pediatric Use Criteria 01/14/2022
Convenience Kits Criteria 01/14/2022
Direct Renin Inhibitor and Combination Criteria 08/13/2021
Duchenne Muscular Dystrophy Criteria 08/13/2021
Duloxetine Criteria 07/12/2022
Dupixent Criteria 01/14/2022
Evrysdi Criteria 08/13/2021
Fibromyalgia Criteria 07/12/2022
Hematopoietic Agent Criteria 08/13/2021
Hepatitis C Criteria 01/14/2022
Hetlioz Criteria 07/12/2022
Horizant Criteria 07/12/2022
Human Growth Hormones Criteria 07/12/2022
Hyaluronic Acid Derivatives Injection Criteria 01/14/2022
Inhaled Insulin Criteria 07/12/2022
Juxtapid Criteria 01/14/2022
Long-Acting Opioid Analgesic Criteria 07/12/2022
Methadone (Pain Management Only) Criteria 07/12/2022
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease Criteria 07/12/2022
Morphine Milligram Equivalent Criteria 07/12/2022
Movement Disorders Criteria 07/12/2022
New Drug Product Criteria 07/12/2022
Oral Isotretinoin Criteria 07/12/2022
Pregabalin Criteria 07/12/2022
Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Criteria 07/12/2022
Psychoactive Medication for Children (5 Years of Age or Younger) Criteria 07/12/2022
Psychotropic Medication Duplicate Therapy (Patients 6 Years and Older) Criteria 07/12/2022
Pulmonary Arterial Hypertension Criteria Phosphodiesterase Type 5 (PDE-5) Inhibitors Only 01/14/2022
Rho Kinase Inhibitor Criteria 01/14/2022
Second-Line Antifungal Criteria 07/12/2022
Short-Acting Fentanyl Analgesic Criteria 08/13/2021
Spinraza (nusinersen) Criteria 01/14/2022
Spravato Criteria 08/13/2021
Stromectol Criteria 01/14/2022
Symlin Criteria 07/12/2022
Synagis Criteria 07/12/2022
Systemic Immunomodulator Criteria 07/12/2022
Verquvo Criteria 07/12/2022
Vuity Criteria 07/12/2022
Weight Management Criteria 01/14/2022
Zolgensma Criteria 07/12/2022