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Commonwealth Coordinated Care Plus
(CCC Plus)

Pharmacy Program

 



Preferred Drug List 

Preferred Drug List (PDL) Search
Preferred Drug List
(PDF 1.85 MB) 

 

Pharmacy Prior Authorization Forms

 

View the current pharmacy prior authorization forms below.   

 

  • Actimmune (PDF 75.34 KB)
  • Alecensa (PDF 66.61 KB)
  • Alfa Interferons (PDF 72.48 KB)
  • Anthelmintics (PDF 67.33 KB)
  • Anti-Allergens (PDF 73.1 KB)
  • Antipsychotics in 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 71.36 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 135.02 KB)
  • Hemangeol (PDF 66.32 KB)
  • Hereditary Angioedema Agents (PDF 74.54 KB)
  • Hepatitis C (PDF 125.52 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 66.83 KB)
  • Inlyta (PDF 71.98 KB)
  • Iressa (PDF 70.68 KB)
  • Isotrentinoin (PDF 79.84 KB)
  • Jakafi (PDF 71.33 KB)
  • Kalydeco (PDF 72.04 KB)
  • Korlym (PDF 71.1 KB)
  • Kuvan (PDF 66.9 KB)
  • Lenvima (PDF 74.13 KB)
  • Lonsurf (PDF 72.1 KB)
  • Lynparza (PDF 72.11 KB)
  • Lyrica (PDF 66.36 KB)
  • Lysteda (PDF 66.88 KB)
  • Macrolides and 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)
  • 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 154.28 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)
  • 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 and 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 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)
  • Stimulants / ADHD Medications (PDF 72.93 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)