Drug Formulary

icon PDF 2022 Medicare-Medicaid Plan/Dual Options Drug Formulary

icon PDF 2023 Medicare-Medicaid Plan/Dual Options Drug Formulary 

Additional Pharmacy Benefit Information

2022

icon PDF Prior Authorization for Pharmacy

icon PDF Prior Authorization Grid

icon PDF Step Therapy Grid

icon PDF How to Request a Redetermination

2023

icon PDF Prior Authorization for Pharmacy

icon PDF Prior Authorization Grid

icon PDF Step Therapy Grid

icon PDF How to Request a Redetermination

 

NOTE: As of April 1, 2023, New Century Health performs Oncology services on behalf of Molina Healthcare for pharmacy benefit medications only when they are submitted as part of a combined regimen for oncology. If you have a request that includes both medical and pharmacy benefit drugs, submit your Prior Authorization request directly to New Century Health via the NCH provider portal: my.newcenturyhealth.com or you may call New Century Health at (888) 999-7713.

 

Click here if one of your patients is looking for the Coverage Determination Request Form, Direct Member Reimbursement Form, or other member forms.

 

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