Provider Forms

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 Lists

AHCCCS Acute and Long-Term Care Drug List

MCC of AZ Drug List

Utilization Management

Utilization Management Prior Authorization

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)

Weekly Missed Provider Appointments Form

Weekly Missed Provider Appointments Form