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The Prior Authorization Process

Formulary Covered Outpatient Medications

Prior authorization requests for covered outpatient medications are processed through Express Scripts, Inc. (ESI). ESI is the pharmacy benefits manager for Maryland Physicians Care. Call ESI directly at 800-753-2851 or fax the appropriate form, found below under Prior-Authorization Forms for Outpatient Pharmacy Medications Processes Through ESI, 877-251-5896.

Non-Formulary Exception Process

To support routine non-Formulary pharmacy authorization decisions, MPC uses guidelines based on FDA-approved indications, evidence-based clinical literature, recognized off-label use supported by peer-reviewed clinical studies, and member’s benefit design, which are applied based on individual members.

The Non-Formulary Guideline is used to evaluate authorization requests for which there are not specific guidelines. A request may be authorized if the medications is deemed to be medically necessary for any of the following reasons:

  • Up to two (2) formulary drugs (when available) in the same theraputic category have been utilized for an adequate trial and have not been effective OR
  • Formulary drugs in the same therapeutic category are contra-indicated OR
  • There is no therapeutic alternative listed on the Formulary.

To request a non-formulary exception, call the prior authorization team at Express Scripts, Inc. at 1-800-753-2851.

Specialty Medications

Prior authorization review for specialty medications is based on the pharmacy benefit used for the distribution of the medication. Therefore, refer to the MPC Specialty Medication List (PDF) to determine the appropriate process for specialty medication prior authorization requests.

Oncology Medications

Prior Authorization for medications related to an oncology treatment regimen will be processed by Eviti. Your office can sign up for training at https://connect.eviti.com to learn how to access the web based system. If you have any additional questions, please call Eviti, Inc., our oncology vendor, at 1-888-678-0990 (toll free).

Request for authorization for oncology medications off-label use will be processed through Maryland Physicians Care.

Hepatitis C Medications

Hepatitis C drug prior authorizations are processed by MPC's Pharmacy Department using the Maryland Department of Health (MDH) Hepatitis C clinical criterial. Fax the completed MDH Hepatitis C Prior Authorization Form with clinical information to 866-207-7231.

Prior-Authorization Forms for Outpatient Pharmacy Medications Processed Through ESI

PA Forms for Outpatient Pharmacy
Medications Starting with Letters A through K

PA Forms for Outpatient Pharmacy 
Medications Starting with Letters L through Z

Prior-Authorization for Medications Processed Through Maryland Physicians Care

Prior Authorization for drugs in the list directly below, as well as drugs for Hepatitis C, should be sent to Maryland Physicians Care using this alternate fax form (PDF).

  • Abatacept INJ
  • Abobotulinum toxin A
  • Acthar HP Gel
  • Adalimumab 20mg INJ
  • Administration and Supply of Tositumomab, 450mg
  • Ado=Trastuzumab EMT 1mg INJ
  • Adynovate Factor VIII Recom
  • Aflibercept INJ
  • Agalsidase Beta 1mg INJ
  • Aldesleukin INJ
  • Alefacept, 0.5mg INJ
  • Alemtuzumab 1mg INJ
  • Alglucerase Per 10 Units INJ
  • Alglucosidase Alfa INJ
  • Alpha 1 Proteinase Inhibitor
  • Amifostine 500mg INJ
  • Antihemophilic VII VWF Comp
  • Anti-Inhibitor Per IU
  • Antithrombin III (Human) Per IU
  • Antithrombin Recombinant
  • Apomorphine Hydrochloride, 1mg INJ
  • Aripiprazole Lauroxil IM
  • Arsenic Trioxide INJ
  • Asparaginase, NOS
  • Azacitidine 1mg INJ
  • Azathioprine Oral Tab 50mg 100 EA
  • Basiliximab 20mg INJ
  • BCG (Intravesical) Per Installation
  • Belatacept INJ
  • Belimumab INJ
  • Belinostat 10mg INJ
  • Bendamustine INJ
  • Beta Interferon IM 1mcg INJ
  • Beta Interferon SQ 1mcg INJ
  • Bevacizumab 10mg INJ
  • Bevacizumab Injection
  • Bleomycin Sulfate INJ
  • Blinatumomab 1mcg INJ
  • Bortezomib 0.1mg INJ
  • Brentuximab Vedotin INJ
  • Brineura 
  • C1 Esterase INHIB Ruconest 10U INJ
  • C1 Esterase, Berinert
  • C1 Esterase, Cinryze
  • Cabazitaxel INJ
  • Canakinumab INJ
  • Carboplatin INJ
  • Carfilzomib 1mg INJ
  • Carmustine INJ
  • Catheter TA Drug- Coated Non-Laser
  • Cerdelga
  • Certolizumab Pegol INJ 1mg
  • Certolizumab Pegol INJ 1mg
  • Cetuximab 10mg INJ
  • Cholbam
  • Cisplatin 10mg INJ
  • Cladribine Per 1mg INJ
  • Clofarabine 1mg INJ
  • Collagenase, Clost Hist INJ
  • Corticotropin to 40 Units INJ
  • Cyclosporin, Parenteral, 250mg
  • Cytarabine HCL 100mg INJ
  • Cytarabine Liposome INJ
  • Cytomegalovirus Immune Globulin Human- IV Use
  • Cytomegalovirus Immune Globulin IV Per Vial INJ
  • Dacarbazine 100mg
  • Daclatasvir (Daklinza)
  • Daclizumab Parenteral 25mg
  • Dactinomycin INJ
  • Daklinza (Daclatasvir)
  • Dalteparin Sodium Per 2500 IU INJ
  • Darbepoetin Alfa 1 Microgram for ESRD on Dialysis INJ
  • Darbepoetin Alfa 1 Microgram Non-ESRD Use INJ
  • Daunorubicin Citrate INJ
  • Daunorubicin INJ
  • Decitabine, 1mg INJ
  • Deferoxamine Mesylate 500mg per 5 CC INJ
  • Degareliz INJ
  • Denosumab INJ
  • Dexamethasone Intra Implant
  • Dexrazoxane Hydrochloride per 250mg INJ
  • Dibenzyline
  • Docetaxel INJ
  • Dornase Alfa Non-Comp Unit
  • Doxorubicin HCL INJ
  • Doxorubicin INJ 10mg
  • Drug or Biological Not Otherwise Classified Part B Drug Comp ACQ Prog (CAP)
  • Ecallantide INJ
  • Eculizumab INJ
  • Elliotts’ B Solution 1ml INJ
  • Elosulfase Alfa, INJ
  • Enfuvirtide, 1mg INJ
  • Enoxaparin Sodium 0.5mg INJ
  • Epclusa (Sofosbuvir/velpatasvir)
  • Epoetin Alfa for Non-ESRD Use 1000 Units INJ
  • Epoetin Alfa, 100 U (for ESRD on Dialysis) INJ
  • Epoetin Beta ESRD Use
  • Epoetin Beta NON-ESRD Use
  • Epoprostenol 0.5mg INJ
  • Eribulin Mesylate INJ
  • Erwinaze INJ
  • Etanercept, 25mg INJ
  • Euflexxa INJ Per Dose
  • Exondys
  • Factor IX (Anti-Hemophilic Factor, Purefied, Non-Recombinant) Per IU
  • Factor IX Complx Per IU
  • Factor IX FC Fusion Recomb
  • Factor IX Recombinan Rixubix
  • Factor IX Recombinant NOS
  • Factor VII (Anti-Hemophilic Factor Human) Per IU
  • Factor VII A Antihemophilic Factor Recombinant/1mcg
  • Factor VIII (Anti-Hemophilic Factor (Porcine)), P
  • Factor VIII FC Fusion Per IU INJ
  • Factor VIII Per IU INJ
  • Factor VIII Recomb Novoeight
  • Factor VIII Recombinant NOS
  • Factor XIII Anti-Hem Factor
  • Factor XIII Recomb A Subunit
  • Ferumoxytol, ESRD Use
  • Ferumoxytol, Non-ESRD
  • Filgrastim G-CSF 1mcg INJ
  • Filgrastim G-CSF Bio Sim INJ
  • Filgrastin G-CSF Bio Sim INJ
  • Flebogamma INJ
  • Floxuridine INJ
  • Fludarabine Phosphate INJ
  • Fluorouracil INJ
  • Fondaparinux Sodium 0.5mg INJ
  • Fulvestrant 25mg INJ
  • Galsulfase, 1mg INJ
  • Gamma Globulin IM 1CC INJ
  • Gamma Globulin IM Over 10CC INJ
  • Gammagard Liquid INJ
  • Gammaplex INJ
  • Gamunex-C/Gammaked
  • Gattex
  • Gel-One
  • Gemcitabine HCL INJ
  • Gemtuzumab Ozogamicin INJ
  • Glassia Injection
  • Glatiramer Acetate, 20mg INJ
  • Glucarpidase
  • Golimumab for IV Use 1mg
  • Goserelin Acetate Implant Per 3.6mg
  • Harvoni (Ledipasvir/sofosbuvir)
  • Hemin, 1mg INJ
  • Hemophilia Clotting Factor NOC
  • Hizentra INJ
  • Human Fibrinogen Conc INJ
  • Human IG SC
  • Humate-P INJ
  • Hyalgan/Supartz INJ Per Dose
  • Hydroxyprogesterone Caproate
  • Ibandronate Sodium, 1mg INJ
  • Icatibant INJ
  • Idarubicin HCL INJ
  • Idursulfase INJ
  • Ifosfamide INJ
  • IG/Hyaluronidase 100mg IG INJ
  • Iloprost Non-Comp Unit Dose
  • Imm Glob Bivigam, 500mg INJ
  • Immune Globulin Human- IM Use
  • Immune Globulin Human- IV Use
  • Immune Globulin, Powder
  • Immunosuppressive Drug, Not Otherwise Classified
  • Implant Ganciclovir 4.5mg Long-Acting
  • Imported Lipodox INJ
  • Imuglucerase INJ
  • Incobotulinum toxin A
  • Indium IN-111 Ibritumomab Tiuxetan Diagnostic/Study Dose up to 5
  • Infliximab, 10mg INJ
  • Interferon Alfa-2A INJ
  • Interferon Alfa-2B INJ
  • Interferon Alfacon-1 INJ
  • Interferon Alfa-N3 INJ
  • Interferon Beta- 1B Per 0.25mg Admin Phys Superv
  • Interferon Beta-1A INJ
  • Interferon Gamma 1-B INJ
  • Iodine I-131 Tositumomab Diagnostic/Study Dose
  • Irinotecan INJ
  • Irinotecan Liposome INJ
  • IVIG Non-Lyophilized, NOS
  • IVIG Privigen 500mg INJ
  • Ixabepilone INJ
  • Kalydeco
  • Korlym
  • Kuvan
  • Lanreotide INJ
  • Laronidase 0.1mg INJ
  • Ledipasvir/sofosbuvir (Harvoni)
  • Leuprolide Acetate For Depot Suspension 7.5mg
  • Leuprolide Acetate Per 1mg
  • Leuprolide Acetate Per 3.75mg INJ
  • Lumizyme INJ
  • Lymphocyte Immune Globulin
  • Lymphocyte Immune/Antithymocyte Globulin 5ml EA
  • Mecasermin, 1mg INJ
  • Mechlorethamine HCL INJ
  • Melphalen Oral 2mg
  • Mepolizumab INJ
  • Methylnaltrexone INJ
  • Mitomycin INJ
  • Mitoxantrone Hydrochloride Per 5mg INJ
  • Monovisc INJ Per Dose
  • Mycophenolate Mofetil, Oral, 250mg
  • Mycophenolic Acid Oral 180mg
  • Naltrexone, Depot Form, 1mg INJ
  • Natalizumab INJ
  • Necitumumab INJ
  • Nelarabine, 50mg INJ
  • Nesiritide 0.1mg INJ
  • Nivolumab 1mg INJ
  • NJ Bulking Agent Anal Canal
  • NOC Drugs, Inhalation Solution Admin Through DME
  • Not Otherwise Classified Antineoplastic Drugs
  • Nuwiq Factor VIII Recomb
  • Obinutuzumab INJ
  • Octagam INJ
  • Octreotide, Depot Form for IM INJ, 1mg INJ
  • Octreotide, Non-Depot Form for SC or IV INJ 25mg INJ
  • Ofatumumab INJ
  • Olanzapine Long-Acting INJ
  • Olysio (Simeprevir)
  • Omacetaxine MEP, 0.01mg INJ
  • Omalizumab 5mg INJ
  • Ombitasvir/paritaprevir/ritonavir (Technivie)
  • Onabotulinum toxin A INJ
  • Oprelvekin 5mg INJ
  • Opthalmic Mitomycin
  • Orfadin
  • Orkambi
  • Orthovisc INJ Per Dose
  • Oxaliplatin, 0.5mg INJ
  • Paclitaxel INJ
  • Palifermin 50mcg INJ
  • Paliperidone Palmitate INJ
  • Palitaxel Protein-Bound Particles 1mg INJ
  • Panitumumab INJ
  • Paricalcitol 1mcg INJ
  • Paritaprevir/ritonavir/ombitasvir plus dasabuvir (Viekira Pak/Viekira XR)
  • Pasireotide Long Acting 1mg INJ
  • Peg Interferon Alfa-2B/10
  • Pegademase Bovine 25 IU INJ
  • Pegaptanib Sodium 0.3mg INJ
  • Pegaspargase INJ
  • Pegfilgrastim, 6mg INJ
  • Peginesatide INJ
  • Pegloticase INJ
  • Pegylated Interferon Alfa-2A 180mcg/ml INJ
  • Pembrolizumab 1mg INJ
  • Pemetrexed 10mg INJ
  • Pentostatin INJ
  • Pertuzumab 1mg INJ
  • Plerixafor INJ
  • Porfimer Sodium INJ
  • Pralatrexate INJ
  • Prescription Drug, Oral, Chemotherapeutic NOS
  • Prescription Drug, Oral, Non-Chemotherapeutic NOS
  • Procysbi
  • Protein C Concentrate
  • PRT CC Kcentra Per I.U. FCT IX ACTV
  • Ramucirumab 5mg INJ
  • Ranibizumab INJ
  • Rasburicase, 0.5mg INJ
  • Respiratory Syncytial Virus Immune Globulin
  • RHO D Immune Globulin IV Human 100 IU INJ
  • Rhophylac INJ
  • Rilonacept INJ
  • Rimabotulinum toxin B INJ
  • Risperidone Long Acting 0.5mg INJ
  • Rituximab INJ
  • Romidepsin INJ
  • Romiplostim INJ
  • SabrilSargramostin (GM-CSF)/50mcg INJ
  • Siltuximax 10mg INJ
  • Simeprevir (Olysio)
  • Sipleucel-T Auto CD54+
  • Sofosbuvir (Sovaldi)
  • Sofosbuvir/velpatasvir (Epclusa)
  • Somatropin 1mg INJ
  • Sovaldi (Sofosbuvir)
  • Strensiq
  • Streptozocin INJ
  • Supprelin LA Implant
  • Synvisc or Synvisc-One
  • Tacrolimis EX Rel Oral 0.1mg
  • Tacrolimus Parenteral 5mg
  • Taliglucerace Alfa 10U INJ
  • Talimogene Laherparepvec INJ
  • TBO-Filgrastim 1mcg INJ
  • Technivie (Ombitasvir/Paritaprevir/Ritonavir)
  • Televancin INJ
  • Temozolomide INJ
  • Temozolomide Oral 5mg
  • Temsirolimus INJ
  • Teniposide 50mg INJ
  • Teriparatide 10mcg INJ
  • Thiotepa INJ
  • Thyrotropin 0.9mg Prov 1.1 Vial INJ
  • Tinzaparin Sodium, 1000 IU INJ
  • Tobramycin, Inhal Sol, FDA Approved, Non-Comp, Unit Dose, Administered Through DME
  • Tocilizumab INJ
  • Trastuzumab INJ
  • Treprostinil 1mg INJ
  • Treprostinil, Non-Comp Unit
  • Triptorelin Pamoate 3.75mg INJ
  • Unclassified Biologics
  • Unclassified Drugs
  • Uptravi
  • Ustekinumab INJ
  • Valrubicin INJ
  • Vantas Implant
  • Vedolizumab 1mg INJ
  • Velaglucerase Alfa
  • Verteporfin 0.1mg INJ
  • Viekira Pak/Viekira XR (Paritaprevir/Ritonavir/Ombitasvir plus Dasabuvir)
  • Vinblastine Sulfate INJ
  • Vincristine Sulfate 1mg
  • Vincristing Sul Lip 1mg INJ
  • Vinorelbine Tartrate INJ
  • Vivaglobin, INJ
  • Wilate Injection
  • Xyntha INJ
  • Zavesca
  • Ziconotide 1mcg INJ
  • Ziv-Aflibercept 1mg INJ
  • Zoledronic Acid 1mg