Minnesota Health Care Programs and SeniorSelect

› New Step Therapy Programs effective 5/1/09

› Pharmacy Utilization Management Programs and Changes effective 9/1/09

Formularies

›    UCare OTC Medication Formulary
›    Minnesota Health Care Programs Formulary

Physician Certification Prior Authorization Forms

›    UCare Prior Authorization Criteria for Minnesota Health
Care Programs

Prior authorization requests may be submitted by phone or fax directly to RxAmerica using the forms below.

Prior Authorization forms (For Minnesota Health Care Programs and SeniorSelect Only)

›  Actiq^® (fentanyl)
›  Amphetamines
› Aranesp® (darbopoeitin alfa)
›  Avonex® and Rebif® (interferon beta - 1a)
›  Banzel® (rufinamide)
›  Betaseron® (interferon beta - 1b)
›  Byetta® (exenatide)
›  Celebrex® (celecoxib)
›  Copaxone® (glatiramer)
›  DDAVP®, Minirin® (desmopressin acetate)
›  Enbrel® (etanercept)
›  Epogen® and Procrit® (epoeitin alfa)
›  Humira® (adalimumab)
›  Kineret® (anakinra)
›  Provigil® (modafinil)
›  Sancuso® (granisetron)
›  Stimate® (desmopressin acetate)
›  Tretinoin
›  Xenazine® (tetrabenazine)
›  Xenical® (orlistat)
›  Xolair® (omalizumab)
›  Zyvox® (linezolid)

Step Therapy Exception:

›    Non-Sedating Antihistamine Step Therapy
›    Proton Pump Inhibitor Step Therapy
›    Other Step Therapy

Quantity Limit Exception:

›    High Dose Proton Pump Inhibitor
›    Quantity Override Request Form

Non-Formulary Exception:

›    Non-Formulary Request Form

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