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Commonwealth Coordinated Care Plus
(CCC Plus)

Pharmacy Program

 



Preferred Drug List 

Preferred Drug List (PDL) Search
Preferred Drug List
(PDF 1.92 MB) 

1/1/2018 PDL Update (PDF 159.71 KB)

Pharmacy Prior Authorization Forms

 

View the current pharmacy prior authorization forms below  

 

 

 

  • Actimmune (PDF 75.34 KB)
  • ADHD Medications, Non-Stimulant (PDF 74.01 KB)
  • ADHD Medications, Stimulant (PDF 73.43 KB)
  • Alecensa (PDF 66.61 KB)
  • Alfa Interferons (PDF 72.48 KB)
  • Anthelmintics (PDF 67.33 KB)
  • Anti-Allergens (PDF 73.1 KB)
  • Antipsychotic Medications for Children (PDF 72.12 KB)
  • Biltricide (PDF 66.57 KB)
  • Bosulif (PDF 71.07 KB)
  • Buphenyl (PDF 66.16 KB)
  • Cabometyx (PDF 67.28 KB)
  • Caprelsa (PDF 72.07 KB)
  • Carbaglu (PDF 66.51 KB)
  • Carisoprodol Products (PDF 75.58 KB)
  • Celebrex (PDF 71.46 KB)
  • Cephalosporins (PDF 68.07 KB)
  • Cialis (PDF 66.62 KB)
  • Colcrys (PDF 67.75 KB)
  • Colony Stimulating Factors (PDF 90.3 KB)
  • Complera (PDF 71.44 KB)
  • Copper Chelating Agents (PDF 71.14 KB)
  • Cotellic (PDF 73.85 KB)
  • Cystaran (PDF 67.06 KB)
  • Daliresp (PDF 113.17 KB)
  • Daraprim (PDF 72.55 KB)
  • Deferasirox Products (Exjade / Jadenu) (PDF 74.65 KB)
  • Dermatologic Acne Agents (PDF 67.27 KB)
  • Diabetes Hypoglycemics (Symlin) (PDF 67.27 KB)
  • Dronabinol (PDF 72.49 KB)
  • Dry Eye Disease (PDF 73.23 KB)
  • Emflaza (PDF 65.98 KB)
  • Enstilar (PDF 67.47 KB)
  • Entresto (PDF 66.67 KB)
  • Erivedge (PDF 71.48 KB)
  • Farydak (PDF 71.37 KB)
  • Forteo / Tymlos (PDF 74.88 KB)
  • Gattex (PDF 67.21 KB)
  • General Non-Preferred Medications (PDF 66.4 KB)
  • Genvoya (PDF 71.55 KB)
  • GI Antibiotics (PDF 74.53 KB)
  • GI Motility (PDF 80.98 KB)
  • Gilotrif (PDF 72.96 KB)
  • Gleevec (PDF 73.26 KB)
  • Gonadotropin-Releasing Hormone Agonists (PDF 80.34 KB)
  • Growth Hormone (PDF 74.92 KB)
  • Hemangeol (PDF 66.32 KB)
  • Hereditary Angioedema Agents (PDF 74.54 KB)
  • Hepatitis C (PDF 125.18 KB)
  • Hetlioz (PDF 66.92 KB)
  • Hycamtin (PDF 70.68 KB)
  • Ibrance (PDF 71.48 KB)
  • Iclusig (PDF 71.86 KB)
  • Idiopathic Pulmonary Fibrosis (IPF) Agents (PDF 72 KB)
  • Ilaris (PDF 74.59 KB)
  • Imbruvica (PDF 71.87 KB)
  • Increlex (PDF 78.21 KB)
  • Inhaled Antibiotics (Tobi Podhaler) (PDF 66.74 KB)
  • Inlyta (PDF 71.98 KB)
  • Iressa (PDF 70.68 KB)
  • Isotrentinoin (PDF 79.84 KB)
  • Jakafi (PDF 71.33 KB)
  • Juxtapid / Kynamro (PDF 67.88 KB)
  • Kalydeco (PDF 72.04 KB)
  • Korlym (PDF 71.1 KB)
  • Kuvan (PDF 66.9 KB)
  • Lenvima (PDF 74.13 KB)
  • Long Acting Beta Adrenergics (PDF 67.58 KB)
  • Lonsurf (PDF 72.1 KB)
  • Lynparza (PDF 72.11 KB)
  • Lyrica (PDF 66.36 KB)
  • Lysteda (PDF 66.88 KB)
  • Macrolides / Ketolides (PDF 72.75 KB)
  • Mekinist (PDF 71.33 KB)
  • Mepron (PDF 71.67 KB)
  • Methadone (PDF 97.51 KB)
  • Mozobil (PDF 70.99 KB)
  • MS Agents (PDF 74.92 KB)
  • Nexavar (PDF 77.05 KB)
  • Ninlaro (PDF 71.14 KB)
  • Nuedexta (PDF 71.05 KB)
  • Nuplazid (PDF 66.57 KB)
  • Odomzo (PDF 70.92 KB)
  • Omega-3 Fatty Acid Agents (PDF 67.78 KB)
  • Onfi (PDF 67.19 KB)
  • Opioid Dependency (PDF 73.89 KB)
  • Opioid Medications (PDF 168.8 KB)
  • Orfadin (PDF 71.06 KB)
  • Orkambi (PDF 72.24 KB)
  • Ortrexup (PDF 71.95 KB)
  • Oxybutynin ER / Ditropan XL (PDF 66.6 KB)
  • Pancreatic Enzymes (PDF 72.27 KB)
  • Panretin (PDF 67.14 KB)
  • PCSK9 Inhibitors (PDF 90.91 KB)
  • Phosphodiesterase 5 Inhibitors (Adcirca / Sildenafil / Revatio) (PDF 72.09 KB)
  • Platelet Inhibitors (Durlaza / Yosprala / Zontivity) (PDF 73.14 KB)
  • Pomalyst (PDF 71.68 KB)
  • Promacta (PDF 73.39 KB)
  • Proton Pump Inhibitors (PDF 71.78 KB)
  • Provigil / Nuvigil (PDF 71.53 KB)
  • Pulmozyme (PDF 71.14 KB)
  • Quinolones (PDF 68.18 KB)
  • Ranexa (PDF 66.94 KB)
  • Ravicti (PDF 72.23 KB)
  • Rectiv (PDF 66.76 KB)
  • Revlimid (PDF 75.08 KB)
  • Rubraca (PDF 71.28 KB)
  • Savaysa (PDF 67.95 KB)
  • Sensipar (PDF 72.16 KB)
  • Sernivo (PDF 67.52 KB)
  • SGLT-2 Inhibitors (PDF 71.95 KB)
  • Signifor (PDF 71.47 KB)
  • Somavert (PDF 72.7 KB)
  • Soriatane (PDF 80.75 KB)
  • Specialty Medication Cover Sheet (PDF 72.32 KB)
  • Sprycel (PDF 70.88 KB)
  • Stivarga (PDF 73.32 KB)
  • Strensiq (PDF 70.63 KB)
  • Stribild (PDF 71.5 KB)
  • Sutent (PDF 80.61 KB)
  • Synagis (PDF 225.02 KB)
  • Tafinlar (PDF 71.16 KB)
  • Tarceva (PDF 73.98 KB)
  • Targretin (PDF 66.97 KB)
  • Tasigna (PDF 73.07 KB)
  • Temodar (PDF 76.43 KB)
  • Thalomid (PDF 74.07 KB)
  • Topical NSAIDs (PDF 71.44 KB)
  • Tykerb (PDF 73.4 KB)
  • Veltassa (PDF 77.46 KB)
  • Venclexta (PDF 71.07 KB)
  • Votrient (PDF 76.05 KB)
  • Xalkori (PDF 71.48 KB)
  • Xeljanz (PDF 119.07 KB)
  • Xenazine (PDF 71.8 KB)
  • Xolair (PDF 81.06 KB)
  • Zelboraf (PDF 71.71 KB)
  • Zolinza (PDF 67 KB)
  • Zurampic (PDF 71.73 KB)
  • Zydelig (PDF 72.07 KB)
  • Zykadia (PDF 71.18 KB)
  • Zytiga (PDF 66.86 KB)
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