Prior Authorization for Medications

ESI Prior Authorization Process:

Prior authorization requests for covered outpatient medications are processed through Express Scripts, Inc. (ESI). ESI is the pharmacy benefits manager for Maryland Physicians Care. Providers can access the Formulary Search Tool to find additional information about medications or call ESI directly at 1-800-753-2851. To find the appropriate Prior Auth form, look below under Prior-Authorization Forms for Outpatient Pharmacy Medications Processed Through ESI.

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 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.

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.

 

Prior Authorization Forms for Outpatient Pharmacy Medications Processed Through ESI

MPC/Eviti Pharmacy Prior Authorization Search Tool

Using our look-up tool, providers easily find if medications require authorization.

Medications requiring MPC Prior Authorization use the Medical Benefit Drug Prior Auth Form.

Name	Formulary Status	Eviti PA	MPC PA	90 Day