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PA Criteria

North Dakota Department of Human Services now requires Prior Authorization for the following drugs. All criteria algorithims are in .pdf format. In order to view and print these documents correctly, we recommend downloading the latest version of Acrobat Reader™.

• ACE-I / ARB / Renin Inhibitor Criteria

• Actoplus met Criteria

• Aczone Criteria

• Ampyra Criteria

• Amrix Criteria

• Antihistamine Criteria

• Asacol Criteria

• Blood Factor Products Criteria

• Carisoprodol Criteria

• Clorpres Criteria

• COX-II / Name Brand NSAID Criteria

• Gilenya Criteria

• Growth Hormone Criteria

• Immunomodulators Criteria

• Ketek Criteria 

• Livalo Criteria

• Metozolv Criteria

• Moxatag Criteria

• Narcotic Criteria

• Nexiclon

• Nucynta Criteria

• Nuedexta

• Nuvigil Criteria

• ODT Preparations Criteria

• Ophthalmic Anti-Infectives

• Oracea Criteria 

• Oravig Criteria

• Oxycontin Criteria

• PPI Criteria

• Qualaquin Criteria

• Ribapak Criteria

• Relistor Criteria 

• Revatio / Adcirca Criteria 

• Sancuso Criteria

• Sedative Hypnotic Criteria

• Short-Acting HFA Beta2 Agonists Criteria

• Solodyn Criteria 

• Soma 250mg Criteria 

• Suboxone/Subutex Criteria

• Tobacco Cessation Criteria

• Topical Anesthetics Criteria

• Topical Ketoconazole Agents

• Tramadoler Criteria

• Triptan Criteria

• Uloric Criteria

• Vusion Criteria

• Xenical Criteria

• Xolair Criteria

• Xyrem Criteria

• Zanaflex Criteria

• Zyclara Criteria