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. Show
 MPC Medical Benefit Drug Prior Authorization Request Process (Buy & Bill)Prior authorization for medications reviewed by Maryland Physicians Care must be submitted using the For MPC Clinical Policies click here
Non-Formulary Exception ProcessTo 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:
To request a non-formulary exception, call the prior authorization team at Express Scripts, Inc. at 1-800-753-2851. Specialty MedicationsPrior authorization review for specialty medications is based on the pharmacy benefit used for the distribution of the medication. Oncology MedicationsEviti 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 MedicationsHepatitis 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. How do I get prior authorization for Express Scripts?Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.
Why does Express Scripts require prior authorization?Express Scripts, the TRICARE pharmacy contractor, sometimes needs more information from your doctor about your prescription before it can be covered by your plan. Express Scripts uses this information to help control costs. They also must make sure the medication is an effective treatment.
What are three drugs that require prior authorization?Most common prescription drugs requiring preauthorization:
Androgel. Aripiprazole. Copaxone. Crestor.
How can I make my prior authorization faster?16 Tips That Speed Up The Prior Authorization Process. Create a master list of procedures that require authorizations.. Document denial reasons.. Sign up for payor newsletters.. Stay informed of changing industry standards.. Designate prior authorization responsibilities to the same staff member(s).. |
Express scripts prior authorization form 2022 pdf
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