Prior Authorization for Medications
Pharmacy Prior Authorization Search Tool
Using our look-up tool, providers easily find if medications require authorization.
All non-formulary medications require Prior Authorization. Submit this form for review.
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.
Prior authorization for medications reviewed by Maryland Physicians Care must be submitted using the Medical Rx Determination Form.
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.
Prior authorization review for specialty medications is based on the pharmacy benefit used for the distribution of the medication.
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.