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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 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



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
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
Certolizumab Pegol INJ 1mg
Certolizumab Pegol INJ 1mg
Cetuximab 10mg INJ
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
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
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
Gemcitabine HCL INJ
Gemtuzumab Ozogamicin INJ
Glassia Injection
Glatiramer Acetate, 20mg INJ
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
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
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
Protein C Concentrate
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
Sargramostin (GM-CSF)/50mcg INJ
Siltuximax 10mg INJ
Simeprevir (Olysio)
Sipleucel-T Auto CD54+
Sofosbuvir (Sovaldi)
Sofosbuvir/velpatasvir (Epclusa)
Somatropin 1mg INJ
Sovaldi (Sofosbuvir)
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
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
Ziconotide 1mcg INJ
Ziv-Aflibercept 1mg INJ
Zoledronic Acid 1mg