Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -1- EA Codes and Criteria List
Expedited Authorization
Codes and Criteria Table
What is new in this version of the expedited
authorization list?
Effective for dates of service on and after December 1, 2021, the Health Care Authority (HCA)
will implement the following changes:
Product
Code
Criteria
isotretinoin
001
Removed
002
Removed
003
Removed
004
Removed
005
Removed
What is expedited authorization (EA)?
(WAC 182-530-3200(4))
The expedited authorization process is designed to eliminate the need to request authorization
from HCA. The intent is to establish authorization criteria and associate these criteria with
specific codes, enabling providers to create an “EA” number when appropriate.
How is an EA number created?
To bill HCA for drugs that meet the expedited authorization criteria on the following pages, the
pharmacist must create an 11-digit EA number. The first 8 digits of the EA number must be
85000000. The last 3 digits must be the code number of the diagnosis/condition that meets the
EA criteria.
Example: The 11-digit EA number for Accutane (for the treatment of "severe,
recalcitrant acne rosacea in adults unresponsive to conventional therapy") would be
85000000002 (85000000 = first eight digits, 002 = diagnosis/condition code).
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -2- EA Codes and Criteria List
Reminder: EA numbers are only for drugs listed in this table. EA numbers are not valid for any
of the following:
• Other drugs requiring authorization through the Prescription Drug Program
• Waiving the State Maximum Allowable Cost (SMAC) or Automated Maximum Allowable
Cost (AMAC) price.
• Authorizing the third or fifth fill in the month.
Note: Use of an EA number does not exempt claims from edits, such as per-calendar-month
prescription limits or early refills.
EA guidelines:
Diagnoses - Diagnostic information may be obtained from the prescriber, client, client’s
caregiver, or family member to meet the conditions for EA. Drug claims submitted without an
appropriate diagnosis/condition code for the dispensed drug are denied.
Unlisted Diagnoses - If the drug is prescribed for a diagnosis/condition, or age that does not
appear on the EA list, additional justification is required. The pharmacist must request
authorization by either one of the following:
Phone 1-800-562-3022
Fax 1-866-668-1214
Documentation - Dispensing pharmacists must write both of the following on the original
prescription:
The full name of the person who provided the diagnostic information
The diagnosis/condition and/or the criteria code from the attached table
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -3- EA Codes and Criteria List
Drug
Code
Criteria
90-day supply
required
090
The prescription is written for less than a 90-day supply.
Aciphex®
(rabeprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Adderall®/XR
(amphetamine salt
combo)
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Alpha-agonists
076
Change in prescribed alpha agonist or change in dose of
prescribed alpha agonist. Total dose of all currently prescribed
alpha agonists does not exceed:
• 0.2mg clonidine equivalent dose for patient age 4 – 5
years of age; or
• 0.3mg clonidine equivalent dose for patient age 6 - 8
years of age; or
• 0.4mg clonidine equivalent dose for patient age 9 - 17
years of age.
Clonidine equivalent dose: 1mg guanfacine = 0.1mg clonidine.
amphetamine salt
combo/XR
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Anoro Ellipta®
(umeclidinium-
vilanterol)
150
Diagnosis of COPD.
Arcapta™
Neohaler™
(indacaterol)
150
Diagnosis of COPD.
Second Generation
Antipsychotics
(Atypical
Antipsychotics)
(Generics First)
Abilify®
(aripiprazole)
aripiprazole
clozapine
Clozaril®
(clozapine)
Fanapt®
(iloperidone)
Geodon®
400
Continuation of therapy.
401
Patient is not a new start.
402
History of hyperprolactinemia.
403
History of extrapyramidal symptoms (EPS).
404
Pharmacy has chart note on file documenting patient’s refusal of
a generic atypical antipsychotic, or their request for a specific
atypical antipsychotic.
405
Prescribed for a diagnosis which is not FDA indicated for any
preferred generic AAP.
406
Patient in Crisis.
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -4- EA Codes and Criteria List
Drug Code Criteria
(ziprasidone HCl)
Invega™
(paliperidone)
Latuda®
(lurasidone HCl)
olanzapine
quetiapine
Risperdal®
(risperidone)M-tab
risperidone
Saphris®
(asenapine)
Seroquel®
(quetiapine) /XR
Ziprasidone
Zyprexa®
(olanzapine)
Zydis®
barbiturates
180
Prescribed for a diagnosis other than cancer, chronic mental
health disorders, or epilepsy.
Bevespi
Aerosphere™
(glycopyrrolate-
formoterol fumarate)
150
Diagnosis of COPD.
Blood Glucose Test
Strips
263
Gestational Diabetes (any quantity necessary up to two months
post-delivery)
264
Insulin-dependent diabetic (age 21 and older, up to 100 strips
and 100 lancets per month)
265
Insulin-dependent diabetic (age 20 and younger, up to 300 strips
and 300 lancets per month)
266
Patient had diabetes prior to pregnancy (any quantity necessary
up to two months post-delivery)
Brovana®
(arformoterol)
150
Diagnosis of COPD.
buprenorphine
077
buprenorphine monotherapy for pregnant clients. Limited to 32
mg per day, 28 days at a time for up to 12 months.
buprenorphine
078
buprenorphine monotherapy for non-pregnant clients while prior
authorization is initiated. Limited to 32mg per day, 7 days at a
time for up to 14 days every 6 months.
bupropion SR/XL
014
Not for smoking cessation.
Concerta®
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -5- EA Codes and Criteria List
Drug Code Criteria
(methylphenidate
HCl)
or Attention Deficit Disorder ADD).
contraceptives
(oral, transdermal,
and intra-vaginal)
364
Prescriber is unwilling to change dispensed quantity to twelve-
month supply.
365
Patient does not want twelve-month supply.
366
Pharmacy is unwilling to dispense twelve-month supply.
Daytrana®
(methylphenidate
HCl) transdermal
patch
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Descovy®
(emtricitabine/tenof
ovir alafenamide)
006
Continuation of pre-exposure prophylaxis (PrEP) therapy.
Dexedrine SA®
(d-amphetamine)
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Dexilant®
(dexlansoprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Dexmethylphenidate
/SA
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Diclegis®
(doxylamine-
pyridoxine)
129
Treatment of nausea and vomiting of pregnancy in women who
do not respond to conservative management.
Dulera®
(mometasone
furoate-formoterol
fumarate)
151
Diagnosis of moderate to severe asthma.
esomeprazole
magnesium
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
esomeprazole
strontium
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Focalin®/XR
(dexmethylphenidat
e)
075
Diagnosis of attention deficit hyperactivity disorder (ADHD) or
Attention deficit disorder (ADD)
Gonadotropin-
releasing Hormone
(GnRH) Agonists
Eligard (leuprolide)
Fensolvi
(leuprolide)
Lupron
103
GnRH therapy for puberty suppression in adolescents diagnosed
with gender dysphoria AND a pediatric endocrinologist or other
clinician experienced in pubertal assessment has determined
hormone treatment to be appropriate.
This code will not override prior authorization for brands with
generic equivalents or non-preferred products unless client has
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -6- EA Codes and Criteria List
Drug Code Criteria
Depot/Depot-Ped
(leuprolide)
Supprelin LA
(histrelin)
Triptodur
(triptorelin)
Vantas (histrelin)
Zoladex (goserlin)
met tried and failed criteria.
Gonadotropin-
releasing Hormone
(GnRH) Agonists
Eligard (leuprolide)
Fensolvi
(leuprolide)
Lupron
Depot/Depot-Ped
(leuprolide)
Supprelin LA
(histrelin)
Triptodur
(triptorelin)
Vantas (histrelin)
Zoladex (goserlin)
104
For clients 18 years of age and older:
• GnRH therapy for the treatment of gender dysphoria.
For clients 17 years of age and under:
• GnRH therapy for the treatment of gender dysphoria;
AND
• A pediatric endocrinologist or other clinician
experienced in pubertal assessment has determined
hormone treatment to be appropriate.
This code will not override prior authorization for brands with
generic equivalents or non-preferred products unless client has
met tried and failed criteria.
HIV combinations
Biktarvy®
(bictegravir/emtricit
abine/tenofovir
alafenamide)
Cimduo
(lamivudine and
tenofovir disoproxil
fumarate)
Descovy®
(emtricitabine/tenof
ovir alafenamide)
Dovato
(dolutegravir/lamiv
udine)
efavirenz/lamivudin
e/tenofovir
disoproxil
007
Continuation of antiviral treatment.
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -7- EA Codes and Criteria List
Drug Code Criteria
HIV combinations
cont.
Juluca
dolutegravir/rilpivir
ine)
Symtuza®
(darunavir/cobicista
t/emtricitabine/tenof
ovir alafenamide)
Temixys™
(lamivudine/tenofovi
r disoproxil)
Triumeq
(abacavir
600mg/dolutefravir
50mg/lamivudine
300mg)
007
Continuation of antiviral treatment.
Incruse Ellipta®
(umeclidinium
bromide)
150
Diagnosis of COPD.
Intron A®
(interferon
alpha-2b
recombinant)
030
Diagnosis of hairy cell leukemia in patients 18 years of age and
older.
031
Diagnosis of recurring or refractory condyloma acuminate
(external genital/perianal area) for intralesional treatment in
patients 18 years of age and older.
032
Diagnosis of AIDS-related Kaposi’s sarcoma in patients 18
years of age and older.
033
Diagnosis of chronic hepatitis B in patients 1 year of age and
older.
107
Diagnosis of malignant melanoma in patients 18 years of age
and older.
109
Treatment of chronic hepatitis C in patients 18 years of age and
older.
135
Diagnosis of follicular non-Hodgkin’s lymphoma in patients 18
years of age and older.
Lancets
263
Gestational Diabetes (up to two months post delivery)
264
Insulin-dependent diabetic (age 21 and older)
265
Insulin-dependent diabetic (age 20 and younger)
266
Patient had diabetes prior to pregnancy
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -8- EA Codes and Criteria List
Drug Code Criteria
lansoprazole
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Metadate ®/ER
(methylphenidate
HCl)
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Methadone
products
540
Client is in active cancer treatment, hospice care, palliative care,
or other end-of-life care. This code will override the 18 or 42
doses, and the chronic use (42 days in a 90-day period) limit, but
NOT the 120 MME limit.
methylphenidate
/LA/SR/OSM
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Methylin®
/XR/chewable/
solution
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Nephro-vite®,
Nephro-Vite® Rx,
and Nephron® FA
096
Treatment of patients with renal disease.
Nexium®
Nexium® granules
(esomeprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
omeprazole
OTC/RX
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
omeprazole-sodium
bicarbonate
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Opioid products
(excludes
injectable/IV)
containing:
benzhydrocodone
buprenorphine (pain
indications only)
butorphanol
codeine
dihydrocodeine
fentanyl
hydrocodone
hydromorphone
levorphanol
meperidine
540
Client is in active cancer treatment, hospice care, palliative care,
or other end-of-life care. This code will override the 18 or 42
doses, and the chronic use (42 days in a 90 day period) limit, but
NOT the 120 MME limit.
541
Prescriber has indicated “EXEMPT” on the prescription. This
code will override the 18 or 42 doses, but NOT the chronic use
(42 days in a 90 day period) limit or the 120 MME limit.
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -9- EA Codes and Criteria List
Drug Code Criteria
morphine
oxycodone
oxymorphone
pentazocine
tapentadol
tramadol
oxandrolone
Before any code is allowed, there must be an absence of all of
the following:
a) Hypercalcemia;
b) Nephrosis;
c) Carcinoma of the breast;
d) Carcinoma of the prostate; and
e) Pregnancy.
110
Treatment of unintentional weight loss in patients who have had
extensive surgery, severe trauma, chronic infections (such as
AIDS wasting), or who fail to maintain or gain weight for no
conclusive pathophysiological cause.
111
To compensate for the protein catabolism due to long-term
corticosteroid use.
112
Treatment of bone pain due to osteoporosis.
pantoprazole
sodium
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Perforomist®
(formoterol
fumarate)
150
Diagnosis of COPD.
Prevacid®
(lansoprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Prevacid®
SoluTab™
(lansoprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Prilosec OTC®
Prilosec® Rx
(omeprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Protonix®
(pantoprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -10- EA Codes and Criteria List
Drug Code Criteria
Protonix® Pak
(pantoprazole)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Pulmozyme®
(dornase alpha)
053
Diagnosis of cystic fibrosis and the patient is 5 years of age or
older.
rabeprazole sodium
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Rectiv®
(nitroglycerin)
081
Treatment of anal fissures.
Rena-Vite®
Rena-Vite RX®
(folic acid-vit B
comp W-C)
096
Treatment of patients with renal disease.
Riomet®
(metformin) oral
solution
086
Inability to swallow oral tablets or capsules.
Ritalin®/LA
(methylphenidate
HCl)
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD).
Savella®
(milnacipran HCl)
066
Treatment of fibromyalgia.
Seebri Neohaler®
(glycopyrrolate)
150
Diagnosis of COPD.
Serevent®
Diskus®
(salmeterol)
150
Diagnosis of COPD.
Stiolto®
(tiotropium
bromide-olodaterol)
150
Diagnosis of COPD.
Striverdi®
(olodaterol)
150
Diagnosis of COPD.
SymlinPen®
(pramlintide
acetate)
267
Diagnosis of type 1 diabetes.
Testosterone
therapy
Aveed (testosterone
undecanoate)
AndroDerm
(testosterone
102
For clients 18 years of age and older:
• Testosterone therapy for the treatment of gender
dysphoria.
For clients 17 years of age and under:
• Testosterone therapy for the treatment of gender
dysphoria; AND
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -11- EA Codes and Criteria List
Drug Code Criteria
transdermal patch)
testosterone
cypionate IM
testosterone
transdermal gel
1.62%
Xyosted
(testosterone
enanthate)
• A pediatric endocrinologist or other clinician
• experienced in pubertal assessment has determined
hormone treatment to be appropriate.
This code will not override prior authorization for brands with
generic equivalents or non-preferred products unless client has
met tried and failed criteria.
Tudorza®
Pressair®
(aclidinum bromide)
150
Diagnosis of COPD.
Utibron Neohaler®
(indacaterol-
glycopyrrolate)
150
Diagnosis of COPD.
Vancomycin
oral
069
Diagnosis of clostridium difficile toxin and one of the following:
a) The patient has failed to respond after 2 days of
metronidazole treatment; or
b) The patient is intolerant to metronidazole; or
c) Metronidazole is contraindicated due to drug-drug
interaction(s).
Vyvanse®
(lisdexamfetamine
dimesylate)
075
Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)
or Attention Deficit Disorder ADD
Wellbutrin
SR® and XL®
(bupropion HCl)
014
Not for smoking cessation.
Zegerid®
(omeprazole-sodium
bicarbonate)
079
Diagnosis of H. pylori with ulcer present. Limited to 28 units for
14 days for initial fill.
Zyprexa
Relprevv®
(olanzapine
pamoate)
070
All of the following must apply:
a) There is an appropriate DSM IV diagnosis with a
psychotic disorder;
b) Patient is 18 to 65 years of age;
c) Patient has established tolerance to oral olanzapine prior to
initiating Zyprexa Relprevv®;
d) Zyprexa Relprevv ® will be administered only in a
registered healthcare facility with ready access to
emergency response services, and the patient will be
Prescription Drug Program
(Rev. 12/13/2021) (Eff. 12/01/2021) -12- EA Codes and Criteria List
Drug Code Criteria
monitored for at least 3 hours after injection for
delirium/sedation syndrome prior to release; and
e) Dose is not more than 300mg every 2 weeks or 405mg
every 4 weeks.
