AMOXICILLIN/CLAVULANATE PA SUMMARY
Augmentin Suspension 250-62.5mg/5mL
NON-PREFERRED Amoxicillin/Clavulanate Suspension Generic 250-62.5mg/mL
LENGTH OF AUTHORIZATION: 1 Year
Submit documentation of allergies, contraindications, drug-drug
interactions, or show a history of intolerable side effects to the inactive
ingredients in brand name Augmentin Suspension (preferred medication).
Exceptions to these conditions of coverage are considered through the
prior authorization process.
The Prior Authorization process may be initiated by calling SXC Health
Solutions at 1-866-525-5827.
PA and APPEAL PROCESS:
For online access to the PA process please go to www.ghp.georgia.gov,
select the Provider Information tab, click on “view full text” in the
Pharmacy Services box, click on “Prior Approval Process” in the list on
QUANTITY LEVEL LIMITATIONS:
For online access to the current Quantity Level Limit please go to
www.ghp.georgia.gov, select Provider Information, click on “view full
list” in the Medicaid Provider Manuals box then select Pharmacy Services
from the list shown.