MedStar Family Choice has approved a wide variety of prescription medications available for our physicians to prescribe. MedStar Family Choice also pays for many over-the-counter (OTC) medications.

High-Cost Medication List - MedStar Family Choice (MFC) will require Prior Authorization (PA) for high-cost medications regardless of place of service (i.e., PA is required in ALL outpatient and inpatient settings). High-cost medications are expected to have an annual cost of greater than $500,000 per year. Prescribers MUST contact MFC before administration. Failure to do so will result in non-payment. Post-administration retrospective requests for authorization will NOT be accepted for review. WITHOUT PRIOR AUTHORIZATION, YOU WILL NOT BE REIMBURSED. NO EXCEPTIONS.

High-Cost Medication Prior Authorization Table

MedStar Family Choice covers a 90-day supply of most chronic medications at retail pharmacies and through mail order. Click here for more information on medications available for a 90-day supply and how to register MedStar Family Choice members for mail order pharmacy.

Approved drugs are listed in the sections below:

  • MedStar Family Choice Formulary

  • Recent Formulary Updates: a comprehensive list of formulary changes made at each quarterly Pharmacy and Therapeutics Committee meeting. 

  • MedStar Family Choice covers many common over-the-counter (OTC) products. You are encouraged to prescribe OTC products when clinically appropriate. A prescription is required, and refills are permitted.  OTC products are no longer listed individually on the formulary documents as coverage is comprehensive.  Products are subject to category specific cost thresholds to guide brand selection to fiscally responsible products when comparable products are available.

    This is inclusive of durable medical equipment such as blood pressure monitors and at-home diabetic testing machines and supplies.

    Condoms and emergency contraception do not require a prescription.

  • Prior Authorization Table and Step Therapy: a comprehensive listing of all medications requiring prior authorization and step therapy with criteria necessary for approval.

For those medications that require prior authorization, please submit a request (see link below for the form) to MedStar Family Choice. Requests must include clinical documentation that supports the medical need for the specific medication.

 

If a physician feels it medically necessary to prescribe a medication not on the formulary, the physician may submit a request (see link below for the form) to MedStar Family Choice. Requests must include clinical documentation that supports the medical need for that specific medication.

 

Physicians may call MedStar Family Choice at 410-933-2200, or fax requests to 410-933-2274.

Clinical Criteria for Hepatitis C Medications, Opioid Medications and Synagis

 

Prior Authorization Forms:

There are certain categories of medications that are covered by the Maryland Department of Health. Mental health medications and some seizure medications are not the responsibility of MedStar Family Choice. Please review the Maryland Department of Health preferred drug list for the listing of covered medications.

A list of mental health medications can be found on the Maryland Department of Health Medicaid Pharmacy Program website.

For the most up-to-date pharmaceutical recall information, please visit the U.S. Food and Drug Administration website at https://www.fda.gov/Drugs/DrugSafety/DrugRecalls/default.htm.

For additional information, please see the Provider Frequently Asked Questions.

Information current as of: