MHCP Enrolled Providers – Pharmacies

Preferred Brands [Generics that are PA’d] (Updated 2/1/2017)

Preferred Brand

Generic Requires Prior Authorization

Adderall XR

mixed amphetamine salts

Aggrenox

aspirin/dipyridamole

Aldara

imiquimod 5% cream

Androgel

testosterone gel pump

Benzaclin

clindamycin/benzoyl peroxide

Copaxone 20mg

Glatopa

Diastat

diazepam rectal

Differin 0.1% and 0.3% (gel and cream)

adapalene 0.1% and 0.3% (gel and cream)

Gleevec

imatinib

Kitabis (inhalation)

tobramycin (inhalation)

Patanol

olopatadine 0.1%

Protopic

tacrolimus ointment

Provigil

modafinil

Pulmicort inhalation solution

budesonide inhalation

Renvela

sevelamer carbonate

Ritalin LA

methylphenidate ER

Seroquel XR

quetiapine ER

Zetia

ezetimibe


List of Drugs Requiring PA (Updated 4/28/2015)

The following is a list of drugs that require prior authorization for fee-for-service MHCP eligible recipients.

Branded drugs that are subject to MAC pricing also require PA.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |

5-HTP

A

ABILIFY MAINTENA

AMBIEN CR

ABSTRAL

AMOXICILLIN ER

ACANYA

AMPYRA

ACCU-CHEK

AMRIX

ACCU-CHEK ADVANTAGE

AMTURNIDE

ACCU-CHEK AVIVA

ANDRODERM

ACCU-CHEK AVIVA PLUS

ANDROGEL

ACCU-CHEK COMFORT CURVE

ANORO ELLIPTA

ACCU-CHEK COMPACT

ANTARA

ACCU-CHEK SMARTVIEW

ANZEMET

ACCU-CHEK VOICEMATE

APIDRA

ACCUTREND GLUCOSE

APLENZIN

ACETASOL HC

APRISO

ACIPHEX SPRINKLE

APTIOM

ACTEMRA

ARBINOXA

ACTIMMUNE

ARCAPTA NEOHALER

ACTIQ

ARNUITY ELLIPTA

ACTIVE Q

ASPIRIN BUFFERED

ACTONEL

ASSURE 4

ACTOPLUS MET XR

ASSURE PLATINUM

ACURA METER KIT

ASSURE PRO

ACURA PLUS

ASTAGRAF XL

ACURA STARTER KIT

ASTEPRO

ACURA TEST STRIPS

ATACAND

ACUVAIL

ATACAND HCT

ACZONE

ATELVIA

ADAPALENE

ATRALIN

ADCETRIS

AUBAGIO

ADCIRCA

AVALIDE

ADEMPAS

AVANDIA

ADOXA

AVAPRO

ADVOCATE BLOOD GLUCOSE MONITOR

AVELOX

ADVOCATE REDI-CODE

AVELOX ABC PACK

ADVOCATE REDI-CODE+

AVINZA

ADVOCATE TEST STRIP

AVITA

AFREZZA

AXIRON

AGAMATRIX AMP

AZASITE

AKYNZEO

AZELASTINE HCL

ALUVEA

AZILECT

ALVESCO

AZOR

B

BACTROBAN

BONIVA

BACTROBAN NASAL

BOSULIF

BANZEL

BOTOX

BECONASE AQ

BP

BELSOMRA

BPO

BENICAR

BREEZE 2

BENICAR HCT

BREO ELLIPTA

BENLYSTA

BRILINTA

BENZEPRO

BRINTELLIX

BENZOYL PEROXIDE

BRISDELLE

BERINERT

BROMFENAC SODIUM

BESIVANCE

BROVANA

BG-STAR

BUDESONIDE

BINOSTO

BUNAVAIL

BLOOD GLUCOSE METER

BUPRENORPHINE HCL

BLOOD GLUCOSE MONITOR

BUPRENORPHINE-NALOXONE

BLOOD GLUCOSE MONITOR KIT

BUTRANS

BLOOD GLUCOSE MONITORING

BYDUREON

BLOOD GLUCOSE TEST

BYDUREON PEN

BLOOD GLUCOSE TEST STRIP

BYSTOLIC

BLOOD-GLUCOSE METER

 

C

CALCITRIOL

CLEVER CHOICE TEST STRIPS

CAMBIA

CLEVER CHOICE VOICE+ TST STRIP

CANDESARTAN CILEXETIL

CLINDACIN ETZ

CAPITAL W-CODEINE

CLINDACIN PAC

CAPRELSA

CLINDAMYCIN PHOS-BENZOYL PEROX

CARESENS N

CLINDAMYCIN-BENZOYL PEROXIDE

CARESENS N VOICE

CLOBETASOL EMOLLIENT

CARISOPRODOL

CLOBETASOL EMULSION

CARISOPRODOL COMPOUND

CLOBETASOL PROPIONATE

CARISOPRODOL COMPOUND-CODEINE

CLONIDINE HCL ER

CARISOPRODOL-ASPIRIN

CO Q10

CARISOPRODOL-ASPIRIN-CODEINE

CO Q-10

CELEBREX

COENZYME Q10

CELECOXIB

COMETRIQ

CENTANY AT

CONTOUR

CERDELGA

CONTOUR LINK

CESAMET

CONTOUR NEXT

CHOICEDM CLARUS

CONTOUR NEXT EZ

CHOICEDM CLARUS TEST STRIPS

CONTOUR NEXT LINK

CHOICEDM G20

CONTOUR NEXT USB

CHROMAGEN

CONTOUR USB

CIMZIA

CONTROL

CINRYZE

CONTROL G3

CIPRO XR

CONZIP

CITRACAL PRENATAL + DHA

COPAXONE

CLARINEX

COREG CR

CLARINEX-D 12 HOUR

CORVITA 150

CLEANSE & TREAT PLUS

COSENTYX (2 SYRINGES)

CLEAR CARE

COSENTYX PEN

CLEVER CHEK BLOOD GLUCOSE SYST

COSENTYX PEN (2 PENS)

CLEVER CHOICE

COSENTYX SYRINGE

CLEVER CHOICE BLOOD GLUC SYS

COSOPT PF

CLEVER CHOICE HD GLUCOSE SYST

CREATINE

CLEVER CHOICE MICRO

CUVPOSA

CLEVER CHOICE MICRO TEST STRIP

CYCLOBENZAPRINE HCL

CLEVER CHOICE PRO

CYSTARAN

CLEVER CHOICE TALK

 

D

DALIRESP

DIDGET

DESLORATADINE

DORYX

DESONATE

DOXYCYCLINE HYCLATE

DESVENLAFAXINE ER

DOXYCYCLINE MONOHYDRATE

DESVENLAFAXINE FUMARATE ER

DRONABINOL

DEXILANT

DUAC

DEXPAK

DUAVEE

DEXTROAMPHETAMINE SULFATE

DUEXIS

DEXTROAMPHETAMINE-AMPHET ER

DUOPA

DIABETIC.COM STARTER

DURAGESIC

DIACOMIT

DUTOPROL

DIAZEPAM

DYMISTA

DICLEGIS

DYSPORT

DICLOFENAC SODIUM

 

E

EASY CHECK

ELIQUIS

EASY CHECK TEST STRIP

EMADINE

EASY GLUCO G2

EMBEDA

EASY PLUS

EMBRACE

EASY PLUS II

EMSAM

EASY STEP

ENBREL

EASY TALK

ENTYVIO

EASY TOUCH

ENVISION

EASY TOUCH GLUCOSE MONITOR

EPA

EASY TRAK

EPANED

EASYGLUCO

EPIDUO

EASYGLUCO PLUS

EPINASTINE HCL

EASYMAX

ERIVEDGE

EASYMAX 15

ERTACZO

EASYMAX L

ERWINAZE

EASYMAX N

ESBRIET

EASYMAX NG

ESCAVITE

EASYMAX V

ESOMEPRAZOLE MAGNESIUM

EASYMAX V SPEAKING

ESOMEPRAZOLE STRONTIUM

EASYMAX V2

ESZOPICLONE

EASYPLUS

EVAMIST

EASYPLUS R13N

EVEKEO

EASYPLUS V

EVENCARE

ECLIPSE

EVENCARE G2

EDARBI

EVENCARE G3

EDARBYCLOR

EVOLUTION BLOOD GLUCOSE METER

EDLUAR

EVOLUTION TEST STRIPS

EGRIFTA

EVZIO

ELEMENT BLOOD GLUCOSE METER

EXALGO

ELEMENT COMPACT

EXTAVIA

ELEMENT PLUS

EXTINA

ELEMENT TEST STRIPS

EZ SMART

ELESTAT

EZ SMART PLUS

F

FABIOR

FORA TEST STRIP

FARXIGA

FORA V10

FELBAMATE

FORA V12

FENOFIBRATE

FORA V20

FENOFIBRIC ACID

FORA V22

FENTANYL

FORA V30A

FENTANYL CITRATE

FORACARE GD20

FENTORA

FORACARE GD40

FERRIPROX

FORACARE GD40A

FETZIMA

FORACARE GD40B

FEXMID

FORFIVO XL

FIBRICOR

FORTESTA

FIFTY50 TEST STRIP

FORTISCARE BLOOD GLUCOSE SYST

FIRAZYR

FORTISCARE GLUCOSE TEST STRIPS

FISH OIL

FOSRENOL

FLECTOR

FREESTYLE FLASH SYSTEM

FLO-PRED

FREESTYLE FREEDOM

FLUVOXAMINE MALEATE ER

FREESTYLE FREEDOM LITE

FONDAPARINUX SODIUM

FREESTYLE INSULINX

FORA D10

FREESTYLE INSULINX TEST STRIPS

FORA D15C

FREESTYLE LITE METER

FORA D15G

FREESTYLE LITE STRIPS

FORA D15Z

FREESTYLE LITE TEST STRIPS

FORA D20

FREESTYLE SIDEKICK II

FORA G20

FREESTYLE SYSTEM

FORA G30A

FREESTYLE TEST STRIPS

FORA G71A

FULYZAQ

FORA G90

FYCOMPA

G

G-4

GLUCOCARD EXPRESSION

GABAPENTIN

GLUCOCARD VITAL

GATIFLOXACIN

GLUCOCARD VITAL SENSOR

GATTEX

GLUCOCOM BLOOD GLUCOSE

GDRIVE

GLUCOCOM GLUCOSE

GE100 BLOOD GLUCOSE SYSTEM

GLUCOLAB

GE100 BLOOD GLUCOSE TEST STRIP

GLUCOSE TEST STRIP

GELNIQUE

GLUMETZA

GENERESS FE

GLYXAMBI

GENOTROPIN

GMATE TEST STRIPS

GIAZO

GMATE VOICE METER

GILENYA

GMATE VOICE STARTER

GILOTRIF

GRALISE

GLUCO NAVII

GRANISETRON HCL

GLUCOCARD 01

GRASTEK

GLUCOCARD 01 SENSOR PLUS

GUANFACINE HCL ER

GLUCOCARD 01-MINI

 

H

H.P. ACTHAR

HUMIRA

HALFLYTELY-BISACODYL

HUMIRA PEDIATRIC CROHN'S

HALONATE

HUMULIN 70/30 KWIKPEN

HARVONI

HUMULIN 70-30

HEMANGEOL

HUMULIN N

HETLIOZ

HUMULIN N KWIKPEN

HORIZANT

HUMULIN R

HUMALOG

HYDROCODONE-ACETAMINOPHEN

HUMALOG MIX 50/50

HYDROCODONE-IBUPROFEN

HUMALOG MIX 50-50

HYDROCORTISONE-ACETIC ACID

HUMALOG MIX 75-25

HYDROMORPHONE ER

HUMATROPE

HYSINGLA ER

I

IBANDRONATE SODIUM

INFINITY TEST STRIPS

IBG-STAR

INLYTA

IBRANCE

INTERMEZZO

IBUDONE

INTUNIV

ICLUSIG

INVEGA

ILARIS

INVOKAMET

IMIQUIMOD

INVOKANA

INCIVEK

IPRIVASK

INCRUSE ELLIPTA

IRBESARTAN

INFINITY

IRBESARTAN-HYDROCHLOROTHIAZIDE

J

JADENU

JANUMET XR

JAKAFI

JARDIANCE

JALYN

JUBLIA

K

KADIAN

KEYNOTE PRO

KALBITOR

KEYTRUDA

KALYDECO

KHEDEZLA

KAPVAY

KINERET

KAZANO

KORLYM

KETOCONAZOLE

KUVAN

KETODAN

KYNAMRO

KEYNOTE

 

L

LAMICTAL ODT

LIBERTY TEST STRIPS

LAMICTAL ODT (BLUE)

LIDOCAINE

LAMICTAL ODT (GREEN)

LIDODERM

LAMICTAL ODT (ORANGE)

LIDOVIR

LAMICTAL XR

LIFE MEDICAL STARTER

LAMICTAL XR (BLUE)

LIMBREL525

LAMICTAL XR (GREEN)

LINZESS

LAMICTAL XR (ORANGE)

LIPOFEN

LAMISIL

LIPTRUZET

LAMIVUDINE-ZIDOVUDINE

LIQ-10

LAMOTRIGINE ER

LIVALO

LAMOTRIGINE ODT

LO MINASTRIN FE

LANSOPRAZOLE

LOFIBRA

L-ARGININE

LORTAB

LASTACAFT

LOTREL

LAYOLIS FE

LOTRONEX

LAZANDA

LOVAZA

L-CITRULLINE

LUNESTA

LEMTRADA

LUPANETA PACK

LENVIMA

LUPRON DEPOT-PED

LEVALBUTEROL CONCENTRATE

LUVOX CR

LEVOCETIRIZINE DIHYDROCHLORIDE

LUZU

LEVOFLOXACIN

LYNPARZA

LIBERTY BLOOD GLUCOSE METER

LYRICA

LIBERTY MONITOR

 

M

MAGNACET

MINOCYCLINE HCL

MAKENA

MIRAPEX ER

MAR-COF CG

MIRCERA

MARINOL

MODAFINIL

MAXICHLOR PSE

MODERIBA

MAXIDONE

MOMEXIN

MAXIMA

MORPHINE SULFATE ER

MEFENAMIC ACID

MOVANTIK

MEKINIST

MOXATAG

METHYLIN

MOXEZA

METHYLPHENIDATE ER

MOXIFLOXACIN HCL

METHYLPHENIDATE HCL

MOZOBIL

METHYLPHENIDATE LA

MS CONTIN

METOCLOPRAMIDE HCL ODT

MULTIGEN

METOZOLV ODT

MULTIGEN FOLIC

MICARDIS

MULTIGEN PLUS

MICARDIS HCT

MUPIROCIN

MICRO

MYALEPT

MICRODOT

MYGLUCOHEALTH

MICRODOT XTRA

MYRBETRIQ

MINASTRIN 24 FE

 

N

NAFTIN

NORDITROPIN NORDIFLEX

NAMENDA XR

NORETHINDRONE-ETHIN ESTRADIOL

NASCOBAL

NORETHIN-ETH ESTRA FERROUS FUM

NATESTO

NORTHERA

NATPARA

NOVA MAX BLOOD GLUCOSE METER

NATROBA

NOVA MAX GLUCOSE TEST STRIPS

NATROL 5-HTP

NOVAMAX PLUS

NEPHROCAPS QT

NOVAREL

NESINA

NUCYNTA

NEUAC

NUCYNTA ER

NEURONTIN

NUEDEXTA

NEUTEK 2TEK TEST STRIPS

NULOJIX

NIMODIPINE

NUTRESTORE

NITROGLYCERIN

NUTROPIN AQ

NITROLINGUAL

NUTROPIN AQ NUSPIN

NITROMIST

NUVIGIL

NORDITROPIN FLEXPRO

 

O

OFEV

OPANA ER

OLEPTRO ER

OPSUMIT

OLUX

OPTIUM

OLUX-E

OPTIUM EZ

OLYSIO

OPTIVAR

OMECLAMOX-PAK

OPTUMRX

OMEGA-3 ACID ETHYL ESTERS

ORACEA

OMEPRAZOLE-SODIUM BICARBONATE

ORALAIR

OMNARIS

ORAPRED ODT

OMNITROPE

ORAVIG

ON CALL PLUS METER

ORENCIA

ON CALL PLUS TEST STRIP

ORENITRAM ER

ON CALL VIVID METER

ORFADIN

ON CALL VIVID TEST STRIP

OSENI

ONDANSETRON ODT

OTEZLA

ONE TOUCH BASIC SYSTEM

OTREXUP

ONETOUCH ULTRA TEST STRIPS

OXECTA

ONETOUCH ULTRALINK

OXISTAT

ONETOUCH ULTRAMINI

OXTELLAR XR

ONETOUCH VERIO

OXYCODONE HCL ER

ONETOUCH VERIO IQ

OXYCODONE HCL-IBUPROFEN

ONETOUCH VERIO SYNC

OXYCONTIN

ONEXTON

OXYMORPHONE HCL

ONFI

OXYMORPHONE HCL ER

ONMEL

OZURDEX

OPANA

 

P

PACNEX HP

PREGNYL

PACNEX LP

PREMIUM BLOOD GLUCOSE

PACNEX MX

PREMIUM BLOOD GLUCOSE TEST

PANCREAZE

PREMIUM V10

PAPAVERINE HCL

PRESTIGE

PAZEO

PRESTIGE METER

PEGASYS

PRESTIGE SMART SYSTEM

PENNSAID

PRESTIGE SMART SYSTEM IQ

PERFOROMIST

PRESTIGE VALUE PACK

PERTZYE

PRESTO PRO

PEXEVA

PREVACID

PHARMACIST CHOICE

PRILOSEC

PHENTOLAMINE MESYLATE

PRIMLEV

PICATO

PRISTIQ ER

PLEGRIDY

PROAIR RESPICLICK

PLEGRIDY PEN

PROCENTRA

PNV-DHA PLUS

PRODIGY

PNV-IRON

PRODIGY AUTOCODE

POMALYST

PRODIGY AUTOCODE PRO

PONSTEL

PRODIGY NO CODING

POTIGA

PRODIGY POCKET

PR BENZOYL PEROXIDE

PRODIGY POCKET PRO

PRADAXA

PRODIGY VOICE

PRAMIPEXOLE ER

PRODIGY VOICE PRO

PRECISION

PROLENSA

PRECISION PCX

PROLIA

PRECISION PCX PLUS

PROTONIX

PRECISION POINT OF CARE

PROVENGE

PRECISION Q-I-D

PROVIGIL

PRECISION XTRA

PURE L-CITRULLINE

PREDNISOLONE SODIUM PHOSPHATE

PYLERA

Q

QNASL

QUININE SULFATE

QNASL CHILDREN

QUINTET

QUALAQUIN

QUINTET AC

QUDEXY XR

QUTENZA

QUILLIVANT XR

 

R

RAGWITEK

REVEAL BLOOD GLUCOSE METER

RAPAFLO

REVEAL TEST STRIP

RASUVO

RHINOCORT AQUA

RAYOS

RIBAPAK

RECTIV

RIBASPHERE

REFUAH PLUS

RIGHTEST GM100 SYSTEM

RELION CONFIRM

RIGHTEST GM300 SYSTEM

RELION CONFIRM-MICRO

RIGHTEST GM550 SYSTEM

RELION MICRO

RIGHTEST GS100 TEST STRIPS

RELION PRIME

RIGHTEST GS300 TEST STRIPS

RELION PRIME TEST STRIPS

RIGHTEST GS550 TEST STRIPS

RELISTOR

RIGHTSOURCE

REMICADE

RISEDRONATE SODIUM

REPREXAIN

ROPINIROLE HCL

REQUIP XL

RUCONEST

RETIN-A MICRO PUMP

RYBIX ODT

REVATIO

RYTARY

S

SABRIL

SOLODYN

SAFYRAL

SOLUS V2

SAIZEN

SOLUS V2 TEST STRIPS

SAMSCA

SOMA

SANCUSO

SOOLANTRA

SAVAYSA

SOTYLIZE

SE BPO

SOVALDI

SE-NATAL 19

SPINOSAD

SEROSTIM

SPIRIVA RESPIMAT

SIDEKICK

SPRIX

SILDENAFIL

STELARA

SILDENAFIL CITRATE

STIVARGA

SILENOR

STRIANT

SIMBRINZA

SUBOXONE

SIMPONI

SUBSYS

SIMPONI ARIA

SUMATRIPTAN

SIRTURO

SUMAVEL DOSEPRO

SITAVIG

SUPPRELIN LA

SKLICE

SURE EDGE BLOOD GLUCOSE METER

SMART CARESENS N

SURE EDGE TEST STRIPS

SMARTDIABETES XPRES

SURECHEK TEST STRIPS

SMARTEST EJECT

SURESTEP

SMARTEST PERSONA

SURESTEP PRO

SMARTEST PRONTO

SURE-TEST EASYPLUS MINI

SMARTEST PROTEGE

SYLATRON

SMARTEST SMART CODE

SYLATRON 4-PACK

SMARTEST TALKING

SYNAGIS

SMARTEST TEST

SYNAREL

SOLIRIS

 

T

TACHOSIL

TOBI PODHALER

TACROLIMUS

TOBRAMYCIN

TANZEUM

TOLTERODINE TARTRATE ER

TARKA

TOPIRAMATE ER

TAZORAC

TOUJEO SOLOSTAR

TD GOLD BLOOD GLUCOSE MONITOR

TRAMADOL HCL ER

TD GOLD TEST STRIP

TRANDOLAPRIL-VERAPAMIL ER

TD GOLD VOICE GLUCOSE MONITOR

TREXIMET

TECFIDERA

TRIBENZOR

TELCARE

TRIGLIDE

TELCARE BGM

TROKENDI XR

TELMISARTAN

TRUE METRIX BLOOD GLUCOSE MTR

TELMISARTAN-AMLODIPINE

TRUE METRIX GLUCOSE TEST STRIP

TELMISARTAN-HYDROCHLOROTHIAZID

TRUE2GO BLOOD GLUCOSE SYSTEM

TEST N'GO

TRUERESULT BLOOD GLUCOSE SYSTM

TESTIM

TRUETEST TEST STRIPS

TESTOPEL

TRUETRACK BLOOD GLUCOSE SYSTEM

TESTOSTERONE

TRUETRACK SMART SYSTEM

TEV-TROPIN

TRUETRACK TEST STRIP

TEXACORT

TRULICITY

THERAPENTIN-60

TUDORZA PRESSAIR

THERAPENTIN-90

TWYNSTA

TIMOPTIC OCUDOSE

TYBOST

TIZANIDINE HCL

TYSABRI

TL 4.25% BPO MX

TYVASO

TOBI

 

U

ULORIC

ULTRATRAK PRO

ULTIMA

ULTRATRAK ULTIMATE

ULTRAM ER

ULTRESA

ULTRATRAK

UNISTRIP1

V

VANCOMYCIN HCL

VICTORY

VARIZIG

VICTOZA 2-PAK

VASCEPA

VICTOZA 3-PAK

VECAMYL

VICTRELIS

VECTICAL

VIEKIRA PAK

VELTIN

VIIBRYD

VENLAFAXINE HCL ER

VIMIZIM

VENTAVIS

VIMOVO

VERAMYST

VIMPAT

VEREGEN

VIOKACE

VERSACLOZ

VITAFOL-PN

VICODIN

VOCAL POINT

VICODIN ES

VOGELXO

VICODIN HP

VUSION

W

WAVESENSE AMP

WAVESENSE PRESTO

WAVESENSE JAZZ

 

X

XALKORI

XODOL 10-300

XARELTO

XODOL 5-300

XELJANZ

XODOL 7.5-300

XENAZINE

XOLAIR

XENICAL

XOPENEX HFA

XEOMIN

XTANDI

XERESE

XYLON 10

XGEVA

XYREM

XIFAXAN

XYZAL

Y

YERVOY

 

Z

ZANAFLEX

ZORBTIVE

ZELAPAR

ZORVOLEX

ZELBORAF

ZOVIRAX

ZENZEDI

ZUBSOLV

ZETONNA

ZUPLENZ

ZIANA

ZYCLARA

ZIOPTAN

ZYDELIG

ZIPSOR

ZYFLO CR

ZOFRAN

ZYKADIA

ZOFRAN ODT

ZYMAXID

ZOHYDRO ER

ZYPREXA RELPREVV

ZOLPIDEM TARTRATE ER

ZYTIGA

ZONTIVITY

 
Rate/Report this page Report/Rate this page