MHCP Enrolled Providers Pharmacies

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