Pharmacy

Formulary (covered medication list)

You now have the ability to use the new Formulary Search Tool to find out which medications are on the formulary drug lists. You can search by drug name or drug class. The search tool will show formulary status, generic alternatives and if there are any requirements, such as prior authorization, quantity limits or age limits. The formularies can change.

Download the Mercy Care Formulary

Formulary updates

January 2021

Additions:

• Levonorgest-Eth Estrad 91-Day TABLET 0.15-0.03 &0.01 MG
• Norethin Ace-Eth Estrad-FE Tablet 1-20 MG-MCG(24)
• Benzoyl Peroxide 6% Cleanser
• Clind Ph-Benzoyl Perox 1.2-5%
• Detrol 1 MG Tablet
• Detrol 2 MG Tablet
• Detrol LA 2 MG Capsule
• Detrol LA 4 MG Capsule
• Esomeprazole DR 10 Mg Packet (Age Limit)
• Esomeprazole DR 20 Mg Packet (Age Limit)
• Esomeprazole DR 40 Mg Packet (Age Limit)
• Esomeprazole Mag DR 40 Mg Cap
• Fish Oil EC 1,000 Mg Softgel
• Krill Oil 300 Mg Softgel
• Kyleena 19.5 Mg System
• Norethin Ace-Eth Estrad-FE Tablet Chewable 1-20 MG-MCG(24)
• Mirena 52 Mg System
• Nadolol 20 Mg Tablet (Age Limit)
• Nadolol 40 Mg Tablet (Age Limit)
• Nadolol 80 Mg Tablet (Age Limit)
• Nuvaring Vaginal Ring
• Plan B One-Step Tablet 1.5mg
• Pantoprazole Sodium Packet 40 MG Oral (Age Limit)
• Protonix 40 Mg Suspension (Age Limit)
• Retacrit Inj 20000uni (Prior Authorization Required)
• Retin-A 0.025% Cream
• Retin-A 0.05% Cream
• Retin-A 0.1% Cream
• Retin-A 0.025% Gel
• Retin-A 0.01% Gel
• Rufinamide Sus 40mg/ml (Prior Authorization Required)
• Skyla 13.5 Mg System
• SM Omega 3-6-9 Softgel
• Toviaz ER 4 Mg Tablet
• Toviaz ER 8 Mg Tablet

Removals:

• Adapalene 0.1% Cream
• Amantadine 100 Mg Tablet
• Carbidopa 25 Mg Tablet
• Carbidopa-Levo 25-100 Mg ODT
• Carbidopa-Levo 25-250 Mg ODT
• Carbidopa-Levodopa 100 Mg-Enta
• Carbidopa-Levodopa 125 Mg-Enta
• Carbidopa-Levodopa 150 Mg-Enta
• Carbidopa-Levodopa 200 Mg-Enta
• Carbidopa-Levodopa 50 Mg-Enta
• Carbidopa-Levodopa 75 Mg-Enta
• Ciclopirox 0.77% Topical Susp
• Colestipol HCl Granules
• Colestipol HCl Granules Packet
• Ella 30 Mg Tablet
• Erythromycin 2% Pads
• Erythromycin 2% Gel
• Etonogestrel-Ethinyl Estradiol Ring 0.12-0.015 MG/24HR Vaginal
• Flavoxate HCl 100 Mg Tablet
• Fluvastatin ER 80 Mg Tablet
• Fluvastatin Sodium 20 Mg Cap
• Fluvastatin Sodium 40 Mg Cap
• Niacin 500 Mg Tablet
• Omeprazole Dr 20 Mg Tablet
• Omeprazole Mag Dr 20.6 Mg Cap
• Banzel Sus 40mg/ml
• Selegiline HCl 5 Mg Capsule
• Selegiline HCl 5 Mg Tablet
• Sod Sulfacetamide 10% Shampoo
• Sodium Sulfacetamide 10% Wash
• Solifenacin 10 Mg Tablet
• Solifenacin 5 Mg Tablet
• Sulfacetamide Sod 10% Top Susp
• Tazarotene 0.1% Cream
• Tolterodine Tartrate Tablet 1 MG Oral
• Tolterodine Tartrate Tablet 2 MG Oral
• Tolterodine Tartrate ER Capsule Extended Release 24 Hour 2 MG Oral
• Tolterodine Tartrate ER Capsule Extended Release 24 Hour 4 MG Oral
• Tretinoin Cream 0.025 %
• Tretinoin Cream 0.05 %
• Tretinoin Cream 0.1 %
• Tretinoin Gel 0.01 %
• Tretinoin Gel 0.025 %
• Trospium Chloride 20 Mg Tablet
• Trospium Chloride ER 60 Mg Cap
• Verapamil ER PM 100 Mg Capsule
• Verapamil ER PM 200 Mg Capsule
• Verapamil ER PM 300 Mg Capsule

Other Updates:

• Detrol 1 Mg Tablet (Removed Step Therapy)
• Detrol 2 Mg Tablet (Removed Step Therapy)
• Detrol LA 2 Mg Capsule (Removed Step Therapy)
• Detrol LA 4 Mg Capsule (Removed Step Therapy)
• Ezetimibe 10 Mg Tablet (Removed Step Therapy)
• Lansoprazole ODT 15 Mg Tablet (Removed Prior Authorization, Added Age Limit)
• Lansoprazole ODT 30 Mg Tablet (Removed Prior Authorization, Added Age Limit)
• Montelukast Sod 4 Mg Granules (Updated Age Limit)
• Retin-A 0.01% Gel (Removed Step Therapy)
• Retin-A 0.025% Cream (Removed Step Therapy)
• Retin-A 0.025% Gel (Removed Step Therapy)
• Retin-A 0.05% Cream (Removed Step Therapy)
• Retin-A 0.1% Cream (Removed Step Therapy)
• Rosuvastatin Calcium 10 Mg Tab (Removed Step Therapy)
• Rosuvastatin Calcium 20 Mg Tab (Removed Step Therapy)
• Rosuvastatin Calcium 40 Mg Tab (Removed Step Therapy)
• Rosuvastatin Calcium 5 Mg Tab (Removed Step Therapy)
• Sevelamer Carbonate 800 Mg Tab (Removed Prior Authorization)

 

December 2020

Additions:

• None

Removals:

• None

Other Updates:

• None

 

November 2020

Additions:

• Cetirizine Cap 10mg
• Dimethyl Fum Cap 120mg DR (Quantity Level Limit, Prior Authorization Required)
• Dimethyl Fum Cap 240mg DR (Quantity Level Limit, Prior Authorization Required)
• Dimethyl Fumarate Capsule DR Starter Pack 120 Mg & 240 Mg (Quantity Level Limit, Prior Authorization Required)
• Diphenhydramine Chw 12.5mg
• Emtricitabin Cap 200mg
• Guaifenesin Tab 400mg
• Levocetirizi Sol 2.5mg/5
• Levocetirizi Tab 5mg
• Nebulizers
• Phenylephrine Tab 10mg
• Saline Gel Nasal

Removals:

• Emtriva Cap 200mg
• Tamiflu Cap 30mg
• Tamiflu Cap 45mg
• Tamiflu Cap 75mg
• Tamiflu Susp 6mg/ml
• Tecfidera Cap DR 120mg
• Tecfidera Cap DR 240mg
• Tecfidera Capsule DR Starter Pack 120 Mg & 240 Mg

Other Updates:

• Linaclotide capsules (Step Therapy Updated)

 

October 2020

Additions:

• Advair Diskus 100-50 mcg/dose (Step Therapy Required)
• Advair Diskus 250-50 mcg/dose (Step Therapy Required)
• Advair Diskus 500-50 mcg/dose (Step Therapy Required)
• Ajovy Inj 225/1.5 (Prior Authorization Required)
• Ajovy Syn 225/1.5 (Prior Authorization Required)
• Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300 Mg
• Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300 Mg
• Flovent Disk Aer 100mcg
• Flovent Disk Aer 250mcg
• Flovent Disk Inh 50mcg
• Humalog Jr Inj 100/ml
• Humulin 5's Pen 70/30kwp
• Humulin N Pen U-100kwp
• Dulera Aerosol 50-5mcg (Step Therapy Required)

Removals:

• Aimovig Inj 70mg/ml
• Aimovig Pen 140mg/ml
• Artificial Tears 1% Solution
• Dyanavel XR Sus 2.5mg/ml
• Insulin Lispro Junior Kwikpen
• Insulin Lispro Protamine Mix Kwikpen
• Novolin 70/30 Vial
• Psyllium Powder 30%
• Psyllium Powder 33%
• Psyllium Powder 49%
• Quillichew Chw 20mg ER
• Quillichew Chw 30mg ER
• Quillichew Chw 40mg ER
• Quillivantxr Sus 25mg/5ml
• Symfi Lo Tablet 400-300-300mg
• Symfi Tablet 600-300-300mg
• Symjepi Inj 0.15mg
• Symjepi Inj 0.3mg

Other Updates:

• None

 

September 2020

Additions:

• Cyclophosph Cap 25mg
• Cyclophosph Cap 50mg
• Erivedge Cap 150mg (Prior Authorization Required)
• Abiraterone Tab 250mg (Prior Authorization Required)
• Venclexta Tab 10mg (Prior Authorization Required)
• Venclexta Tab 50mg (Prior Authorization Required)
• Venclexta Tab 100mg (Prior Authorization Required)
• Venclexta Tab Start Pk (Prior Authorization Required)
• Tafinlar Cap 50mg (Prior Authorization Required)
• Tafinlar Cap 75mg (Prior Authorization Required)
• Rydapt Cap 25mg (Prior Authorization Required)
• Mekinist Tab 0.5mg (Prior Authorization Required)
• Mekinist Tab 2mg (Prior Authorization Required)
• Gilotrif Tab 20mg (Prior Authorization Required)
• Gilotrif Tab 30mg (Prior Authorization Required)
• Gilotrif Tab 40mg (Prior Authorization Required)
• Alecensa Cap 150mg (Prior Authorization Required)
• Zykadia Cap 150mg (Prior Authorization Required)
• Jakafi Tab 5mg (Prior Authorization Required)
• Jakafi Tab 10mg (Prior Authorization Required)
• Jakafi Tab 15mg (Prior Authorization Required)
• Jakafi Tab 20mg (Prior Authorization Required)
• Jakafi Tab 25mg (Prior Authorization Required)
• Kalydeco Tab 150mg (Prior Authorization Required)
• Kalydeco Pak 25mg (Prior Authorization Required)
• Kalydeco Pak 50mg (Prior Authorization Required)
• Kalydeco Pak 75mg (Prior Authorization Required)
• Ofev Cap 100mg (Prior Authorization Required)
• Ofev Cap 150mg (Prior Authorization Required)
• Austedo Tab 6mg (Prior Authorization Required)
• Austedo Tab 9mg (Prior Authorization Required)
• Austedo Tab 12mg (Prior Authorization Required)
• Soliris Inj 10mg/Ml (Prior Authorization Required)
• Lenvima Cap 4mg (Prior Authorization Required)
• Lenvima Cap 8 Mg (Prior Authorization Required)
• Lenvima Cap 10 Mg (Prior Authorization Required)
• Lenvima Cap 12mg (Prior Authorization Required)
• Lenvima Cap 20 Mg (Prior Authorization Required)
• Lenvima Cap 14 Mg (Prior Authorization Required)
• Lenvima Cap 18 Mg (Prior Authorization Required)
• Lenvima Cap 24 Mg (Prior Authorization Required)
• Repatha Push Inj 420/3.5 (Prior Authorization Required)
• Repatha Inj 140mg/ml (Prior Authorization Required)
• Xolair Inj 75/0.5 (Prior Authorization Required)
• Xolair Inj 150mg/ml (Prior Authorization Required)
• Symdeko Tab 50-75mg (Prior Authorization Required)
• Symdeko Tab 100-150 (Prior Authorization Required)

Removals:

• None

Other Updates:

• None

 

August 2020

Additions:

• Diclofenac Sodium Soln 1.5% (Quantity Level Limit, Step Therapy Required)
• Ibrance Cap 100mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Cap 125mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Cap 75mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Tab 100mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Tab 125mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Tab 75mg (Prior Authorization Required, Quantity Level Limit)
• Temixys 300-300 (Quantity Level Limit)
• Lynparza Tab 100mg (Prior Authorization Required, Quantity Level Limit)
• Lynparza Tab 150mg (Prior Authorization Required, Quantity Level Limit)
• Solifenacin Succinate Tab 10 Mg (Quantity Level Limit, Step Therapy Required)
• Solifenacin Succinate Tab 5 Mg (Quantity Level Limit, Step Therapy Required)
• Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)

Removals:

• Fluorouracil Cream 0.5%
• Naproxen Sodium Tab 275 Mg
• Tolmetin Sodium Cap 400
• Tolmetin Sodium Tab 200
• Tolmetin Sodium Tab 600

Other Updates:

• Symtuza Tab (Added Prior Authorization)
• Testosterone TD Soln 30 Mg/Act (Added Quantity Level Limit)
• Testosterone Gel 1.62% (Added Quantity Level Limit)
• Candesartan Cilexetil Tab 4 Mg (Added Step Therapy)
• Candesartan Cilexetil Tab 8 Mg (Added Step Therapy)
• Candesartan Cilexetil Tab 16 Mg (Added Step Therapy)
• Candesartan Cilexetil Tab 32 Mg (Added Step Therapy)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 Mg (Added Step Therapy)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 Mg (Added Step Therapy)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 Mg (Added Step Therapy)
• Fluvastatin Sodium Cap 20 Mg (Added Step Therapy)
• Fluvastatin Sodium Cap 40 Mg (Added Step Therapy)
• Carbamide Peroxide 6.5% Otic Soln (Added Quantity Level Limit)
• Betamethasone Dipropionate Augmented Cream 0.05% (Added Quantity Level Limit)
• Lidocaine Oint 5% (Changed Quantity Level Limit)

 

July 2020

Additions:

• None

Removals:

• Videx EC Cap 125mg
• Videx Ped Pow 2gm
• Videx Sol 4gm
• Zaclir Lot 8%

Other Updates:

• None

 

June 2020

Additions:

• Alahist D Tab
• Dovato Tab 50-300mg (Quantity Level Limit)
• Gvoke Hypopen Inj (Quantity Level Limit)
• Phenazopyridine Tab 95 Mg

Removals:

• None

Other Updates:

• None

 

May 2020

Additions:

• Dexameth Pho Inj 20mg/5ml
• Dexameth Pho Mdv 10mg/ml
• Dexameth Pho Via 120mg/30
• Dexamethason Via 10mg/ml
• Dexamethason Via 4mg/ml
• Everolimus Tab 0.25mg (Prior Authorization Required)
• Everolimus Tab 0.5mg (Prior Authorization Required)
• Everolimus Tab 0.75mg (Prior Authorization Required)
• Pyrimethamine Tab 25mg (Prior Authorization Required)

Removals:

• Daraprim Tab 25mg
• Zortress Tablet 0.25mg
• Zortress Tablet 0.5mg
• Zortress Tablet 0.75mg

Other Updates:

• None

 

April 2020

Additions:

• Erlotinib Hcl Tab 100 Mg (Prior Authorization Required)
• Erlotinib Hcl Tab 25 Mg (Prior Authorization Required)
• Ferrous Fumarate Tab 325 Mg
• Forteo Inj 600 Mcg/2.4ml (Prior Authorization Required)
• Glycerin Suppos 2.1 Gm
• Ibandronate Sodium 150 Mg Tab
• Imatinib Mesylate 100 Mg Tab (Prior Authorization Required)
• Imatinib Mesylate 400 Mg Tab (Prior Authorization Required)
• Mesalamine Cap ER 24hr 0.375 Gm (Quantity Level Limit)
• Nevirapine Susp 50 Mg/5ml
• Orkambi Granules 100-125 Mg (Prior Authorization Required)
• Orkambi Granules 200-125 Mg (Prior Authorization Required)
• Orkambi Tab 100-125 Mg (Prior Authorization Required)
• Orkambi Tab 200-125 Mg (Prior Authorization Required)
• Omeprazole Tablet Delayed Release Disintegrating 20 Mg (Quantity Level Limit)
• Prolia Syringe 60 Mg/Ml (Prior Authorization Required)
• Tramadol Hcl Tab 100mg (Quantity Level Limit)
• Zinc Oxide Oint 40%

Removals:

• Apriso Cap ER 24Hr 0.375GM
• Bivigam Solution
• Carimune Nf Inj
• Diphenhydramine HCl Liquid 6.25 Mg/mL
• Ferrous Sulfate Syrup 300 Mg/5ml (60 Mg/5ml Elemental)
• Gleevec Tab
• Konsyl Daily Fiber Packet 100%
• Levalbuterol HCL Sol Nebulizer
• Polyethylene Glycol 3350 Oral Packet
• Sennosides Tab 17.2 Mg
• Sodium Bicarbonate Powder
• Tarceva Tab
• Viramune Susp 50mg/ml

Other Updates:

• Valacyclovir Tab 1gm (Termed Quantity Limit)
• Valacyclovir Tab 500mg (Termed Quantity Limit)

 

March 2020

Additions:

• None

Removals:

• Fluoritab Dro 0.125mg
• Prenatal Without A Vit W/ Fe Fumarate-Folic

Other Updates:

• None

 

February 2020

Additions:

• Bimatoprost Sol 0.03% (Step Therapy Required)
• Ethinyl Estradiol 0.015mg and Etonogestrel 0.12mg Ring
• Everolimus Tab 2.5mg (PA Required)
• Everolimus Tab 5mg (PA Required)
• Everolimus Tab 7.5mg (PA Required)
• Flebogamma Dif 5% Vial (PA Required)
• Hydrocortisone 1% Ointment
• Travoprost Dro 0.004% (PA Required)
• Triamcinolone 0.05% Ointment

Removals:

• Afinitor Tab 2.5mg
• Afinitor Tab 5mg
• Afinitor Tab 7.5mg
• First-Vanco Sol 25mg/ml
• First-Vanco Sol 50mg/ml
• Kyleena
• Methyclothiazide Tab 5mg
• Mirena
• NuvaRing 0.12-0.015mg/24hr
• Phospholine (Echothiophate Iodide) Opth Solution 0.125%
• Rabeprazole EC 20 Mg Cap
• Skyla
• Travatan Z Solution 0.004%

Other Updates:

• Combigan Sol 0.2/0.5% (Added Quantity Level Limit)
• Ibandronate Inj 3mg/3ml (Added Quantity Level Limit)
• Levofloxacin Sol 0.5% (Added Quantity Level Limit)
• Memantine Tab HCl 10mg (Added Quantity Level Limit)
• Memantine Tab HCl 5mg (Added Quantity Level Limit)
• Tazarotene Cre 0.1% (Added Step Therapy Required)

 

January 2020

Additions:

• Anusol-HC Cream 2.5%
• Calc Acetate Tab 667mg
• Clobetasol Gel 0.05% (Quantity Level Limit)
• Derma-Smoothe/FS Oil 0.01% Body
• Derma-Smoothe/FS Oil 0.01% Scalp
• Eszopiclone Tab 1mg (Age Limit, Quantity Level Limit)
• Eszopiclone Tab 2mg (Age Limit, Quantity Level Limit)
• Eszopiclone Tab 3mg (Age Limit, Quantity Level Limit)
• Imitrex Spr 20mg/ACT (Quantity Level Limit)
• Imitrex Spr 5mg/ACT (Quantity Level Limit)
• Metoprolol Tab 37.5mg
• Sevelamer Tab 800mg
• Zomig Spr 2.5mg (Quantity Level Limit)
• Zomig Spr 5mg (Quantity Level Limit)

Removals:

• Calc Acetate Tab 668mg
• Clobetasol Lot 0.05%
• Fluocinolone Acet Oil 0.01% Body
• Fluocinolone Acet Oil 0.01% Sc
• Nadolol Tab 20mg
• Nadolol Tab 40mg
• Nadolol Tab 80mg
• Nadolol/Bend Tab 40-5mg
• Renagel Tab 800mg
• Renagel Tab 400mg
• Renvela Tab 800mg
• Scalpicin Sol 1%
• Sumatriptan Inj 6mg/0.5
• Sumatriptan  Spr 20mg/Act
• Sumatriptan  Spr 5mg/Act
• Verapamil Cap 360mg Sr

Other Updates:

• None

Pharmacy prior authorization guidelines

Some prescriptions require prior authorization from Mercy Care before they can be filled. Requests for medications requiring Prior Authorization (PA) will be reviewed based on the PA Guidelines/Criteria for that medication.

Medications that do not have a specific PA guideline will follow the Non-Formulary Medication Guideline. Additional information may be required on a case-by-case basis to allow for adequate review.

• Mercy Care Prior Authorization Guidelines (effective 12.01.2020)
• Botulinum Toxins (effective 04.01.2020)
• Colony Stimulating Factors (effective 08.18.2020)
• Cytokine and CAM Antagonists (effective 09.01.2020)
• Growth Hormone  (effective 04.01.2020)
• Hemophilia (effective 02.04.2019)
• Hepatitis C (effective 01.30.2020)
• Hereditary Angioedema (effective 04.01.2020)
• Immune Globulins (effective 04.01.2020)
• Injectable Osteoporosis Agents(effective 04.01.2020)
• Multiple Sclerosis (effective 12.01.2020)
• Opioids (effective 08.18.2020)
• Opioids 5-Day Supply Limit
• Smoking Cessation
• Step Therapy Prior Authorization Guidelines
• Spravato (effective 06.22.2020)
• Sublocade (effective 04.01.2020)

Pharmacy prior authorization forms

Mercy Care requires prior authorization for certain drugs on the Preferred Drug List and for all non-formulary drug requests.

You may now request prior authorization by calling 602-263-3000 or toll-free 1-800-624-3879, or you may print the required prior authorization form below and fax it along with supporting clinical notes to 1-800-854-7614.

If the drug you are requesting is not listed, please use the Non-Formulary PA request form. Most drugs will require use of the Non-Formulary PA form. If you would like a prior authorization request form faxed to you, please contact the Mercy Care Pharmacy Prior Authorization team at 602-263-3000 or toll free 1-800-624-3879.

These are fax forms for drugs in our prior authorization program. Select the drug name to download the prior authorization request form.

• Universal Pharmacy Prior Authorization Request Form
• Botulinum Toxins  
• Calcitonin Gene-Related Peptide Receptor Antagonists  Updated 12.03.2020
• Clozapine Under 18 Years Old
• Colony Stimulating Factors  (ex: Neupogen, Fulphila, Udencya)  
• Concomitant Antidepressant
• Concomitant Antipsychotic 
• Corlanor 
• Cystic Fibrosis  
• Cytokine and CAM Antagonists (ex: Enbrel, Humira) 
• Dalfampridine (Ampyra)  
• Daraprim (Pyrimethamine)  
• DPP4-Inhibitors 
• Dupixent  
• Egrifta  
• Emflaza 
• Entresto  
• Epidiolex  
• Erythropoiesis Stimulating Agents  
• Gonadotropin Releasing Hormone Analogs 
• Growth Hormone (Genotropin, Norditropin)  
• Hemophilia  
• Hepatitis C  
• Hyaluronic Acid Derivatives  
• Hyperlipidemia Medications
• Idiopathic Pulmonary Fibrosis Agents 
• Increlex 
• Injectable Osteoporosis (Tymlos, Evenity, Forteo, Prolia, zoledronic acid) 
• Interleukin-5 Antagonists 
• Interferons  
• Janus Associated Kinase Inhibitors (Inrebic, Jakafi) 
• Long Acting Antipsychotic Injectables Under 18 Years Old 
• Monoamine Depletors (Austedo, Ingrezza, tetrabenazine)  
• Multiple Sclerosis Agents  
• Opioids  
• Platelet Inhibitors  (Brilinta and Zontivity)  
• Premarin Vaginal Cream
• Pulmonary Arterial Hypertension Agents  (Tracleer, Letairis, Adcirca, Sildenafil, Revatio susp)  
• Savella
• Somatostatin Analogs (Sandostatin, Sandostatin LAR Depot, Signifor, Signifor LAR, Somatuline Depot, Octreotide)  
• Spinraza  
• Spravato   
• Sublocade 
• Testosterone  
• Thrombopoiesis Stimulating Products (Promacta, Nplate, Tavalisse)  
• Xolair  
• Xyrem 

Electronic Prior Authorization (ePA)

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

• Time saving
  • Decreasing paperwork, phone calls and faxes for requests for prior authorization
• Quicker Determinations
  • Reduces average wait times, resolution often within minutes
• Accommodating & Secure
  • HIPAA compliant via electronically submitted requests Getting started is easy. Choose ways to enroll:
  • No cost required! Let us help get you started!

• Visit the CoverMyMeds® website
• Call CoverMyMeds® toll-free at 866-452-5017
• Visit the SureScripts website
• Call SureScripts toll-free at 866-797-3239

Billing Information:

BIN: 610591

PCN: ADV

Group: RX8805

Over-the-counter product list

Over-the-counter product list

Specialty drugs

How to order specialty drugs for patients CVS Caremark Specialty Pharmacy offers medications that are not often available at local pharmacies for a variety of conditions, such as cancer, hemophilia, immune deficiency, multiple sclerosis and rheumatoid arthritis.

Specialty medications require prior authorization before they can be filled and delivered. These medications can be delivered to the provider’s office, member’s home or other location as requested.

For providers who prefer to purchase the specialty drug and bill through the member’s Medical Insurance:

• Call 602-263-3000 or toll-free at 1-800-624-3879 to initiate prior authorization for the requested specialty medication. 

 For providers who prefer to bill through the member’s Pharmacy Insurance directly: 

Complete the applicable Pharmacy Prior Authorization form and fax it to 1-800-854-7614.

Click here for the Specialty Drug List

CVS/Coram pharmacy enrollment form

Adding a new drug to the formulary

You work with patients every day, and there may be times when you believe we should add a drug to the formulary. If you want to ask for a change to Mercy Care’s Preferred Drug List (PDL), include the following information in your request:

• Basic product information
• Indications for use
• Therapeutic advantage
• Which drug(s) it would replace in the current PDL
• Any supporting literature from medical journals

The requesting physician may be invited to attend the Pharmacy and Therapeutics Committee meeting to support the PDL addition request and answer questions.

Requests should be sent to: Aetna Corporate Pharmacy Director 4500 E. Cotton Center Blvd. Phoenix, AZ 85040

Controlled Substance Prescription Monitoring Program (CSPMP)

The Controlled Substance Prescription Monitoring Program (CSPMP) is a program developed to promote public health and welfare by detecting diversion, abuse, and misuse of prescription medications classified as controlled substances.  Every physician who possesses DEA registration is required to also possess a CSPMP registration.

• Step 1: Register
• Register for CSPMP.  Click on ‘Register now’ and fill out the ‘New Registration’ information.
• Step 2: Verify
• After you submit the registration form, you will receive a verification email with your CSPMP ID number and verification code.
• Follow the email link to verify your email address.
• Step 3: Login
• Once you login, you will then be able to complete your registration profile with your CSPMP ID and DEA number.

Fill out the ‘Registration Details’ and certify that the application is complete and accurate, then ‘Print Certificate’.