skip to content
Primary navigation

Non-Preferred Dosage Form

DrugDrugs with multiple dosage forms

January 2018

Authorization will be granted if the recipient has had a documented: 

  • Allergic reaction to a specific inactive ingredient in the preferred drug
  • Adverse reaction to a specific inactive ingredient in the preferred drug
  • Therapeutic success while taking a nonpreferred drug and therapeutic failure while taking the preferred drug
  • Supporting documentation must be provided at the time of request

Prescribers must: 

  • List the specific drug being requested, including:
    • dosage form
    • strength
    • use directions
  • Document when the preferred drug was tried and the length of the trial period 
  • Provide specific clinical documentation of therapeutic failure on the preferred drug whenever possible
  • Describe the medical problem caused by the preferred drug. Stomach ache and other non-descript symptoms are not adequate rationale

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

back to top