Magellan Complete Care of Arizona (MCC of AZ) appreciates your commitment and dedication to serving our Arizona Medicaid members. To make it easier for you to focus on providing great care to our MCC of AZ members, we’ve compiled our provider forms all in one place for you to access.
Click on the link to the forms you need, then download a copy and follow the instructions on the form.
AHCCCS Drug List
AHCCCS Acute and Long-Term Care Drug List
MCC of AZ Drug List
MCC of AZ Searchable Drug List
Crisis Response Network
Crisis Response Network Provider Submission Portal
Network Management Forms
Utilization Management
Utilization Management Prior Authorization
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J Code Prior Authorization Changes
Effective September 1, 2020, the following medications require prior authorization:
J CODE |
J CODE DESCRIPTION |
J1599 |
INJECTION, IMMUNE GLOBULIN (IVIG) |
J9042 |
INJECTION, BRENTUXIMAB VEDOTIN, 1MG (ADCETRIS) |
J9228 |
INJECTION, IPILIMUMAB, 1 MG (YERVOY) |
J9271 |
INJECTION, PEMBROLIZUMAB, 1 MG (KEYTRUDA) |
J9312 |
INJECTION, RITUXIMAB, 10 MG (RITUXAN) |
Q5116 |
INJECTION, TRASTUZUMAB-QYYP, 10 MG (BIOSIMILAR TO TRAZIMERA) |
J9355 |
INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG (TRAZIMERA) |
J1930 |
INJECTION, LANREOTIDE, 1MG (SOMATULINE) |
J9043 |
INJECTION, CABAZITAXEL, 1MG (JEVTANA) |
J3101 |
INJECTION, TENECTEPLASE (TNKASE) |
J9305 |
INJECTION, PEMETREXED, 10 MG (ALIMTA) |
J9039 |
INJECTION, BLINATUMOMAB (BLINCYTO) |
EPSDT
EPSDT Tracking Forms
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Weekly Missed Provider Appointments Form
Weekly Missed Provider Appointments Form
Other
Other MCC of AZ Forms
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Archived
Archived MCC of AZ Forms