Drug Formulary

icon PDF 2024 Medicare-Medicaid Plan/Dual Options Drug Formulary

Additional Pharmacy Benefit Information

icon PDF 2024 Prior Authorization Grid

icon PDF 2024 Step Therapy Grid

icon PDF 2024 Medicare Part D Drug (J-Code) Step Therapy Grid

icon PDF Request for Medicare Prescription Drug Coverage Determination

icon PDF Request for Redetermination of Medicare Prescription Drug Denial

icon PDF Direct Member Reimbursement Form


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 call New Century Health at (888) 999-7713.


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