Prior Authorization for Medications

MPC Pharmacy Rx Prior Authorization Process:

Prior authorization requests for covered outpatient medications are processed by the MPC Pharmacy Department. The MPC Pharmacy PA department can be reached directly at 1-888-258-8250. Providers are encouraged to continue to submit electronic prior authorizations (ePA) via their existing vendor (i.e. CoverMyMeds/Surescript). To find the appropriate prior authorization form, see the list below for the prior authorization forms for outpatient pharmacy medications. Please fax completed prior authorization forms, with supporting clinical documentation, to the MPC Pharmacy PA department at 1-833-896-0656.

Please note that behavioral health and abuse deterrent medications are “carved out” from MPC and are payable as fee-for-service (FFS) through Maryland Medical Assistance. Refer to the following link to the Maryland Department of Health formulary to confirm coverage under FFS: MDH BH Formulary

Prior Authorization Pharmacy Forms

MPC Medical Benefit Drug Prior Authorization Request Process (Buy & Bill)

Prior authorization for medications reviewed by Maryland Physicians Care must be submitted using the
Medical Benefit Drug Prior Authorization Form.

For MPC Clinical Policies click here

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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 no specific guidelines. A request may be authorized if the medications are deemed to be medically necessary for any of the following reasons:

• up to two (2) formulary drugs (when available) in the same therapeutic category have been utilized for an adequate trial and have not been effective,
• 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 MPC Pharmacy PA Department at 1-888-258-8250.

Specialty Medications

Prior authorization review for specialty medications is based on the pharmacy benefit used for the distribution of the medication.

Oncology Medications

Eviti will process prior Authorization for medications related to an oncology treatment regimen. 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 criteria. Fax the completed MDH Hepatitis C Prior Authorization Form with clinical information to 800-953-8856.

 

MPC Pharmacy Prior Authorization Search Tool

Using the look-up tool, providers can confirm which medications are covered under the pharmacy benefit and which medications require prior authorization.

For medications covered under the medical benefit, please use the MPC Prior Authorization form: Medical Benefit Drug Prior Auth Form.

Formulary Search Tool

Name	Formulary Status	Eviti PA	MPC PA	90 Day