Prior Authorization
Prior authorization is one of FutureScripts’ utilization management procedures. It requires that providers receive approval from FutureScripts before prescribing certain medications. This safeguard ensures that the drug prescribed is clinically appropriate for the plan participant and encourages the use of generic or lower-cost brand-name drugs as an alternative. Prior authorization also ensures that drugs prescribed for off-label use are done so in accordance with U.S. Food and Drug Administration guidelines.
To determine which drugs require prior authorization, please refer to the
FutureScripts Select Drug Formulary Guide, or download the applicable request form below, and fax it to
1-888-671-5285 (toll-free): *
ADHD Agents Quantity Limit Prior Authorization Form
Analgesic Medications (Celebrex®, Mobic®, Ultram® ER, Flector patch®, Voltaren gel®, Ryzolt® and Zipsor®)
Anti-Infective Agents (Zmax™, Zyvox®, Oracea®, and Noxafil)
Arthritis/Psoriasis Agents (Enbrel®, Kineret®, Humira®, Amevive™, Raptiva®, Simponi®, Cimzia®, and Actemra®)
Bisphosphonate Agents
Botulinium Toxins (Type A & B)
Diabetic Agents (Actoplus Met, Actoplus Met XR, Byetta®, Glumetza®, Non-preferred Insulins, Prandimet®, Symlin®, Tradjenta, and Victoza)
Diabetic Test Strips (LifeScan One Touch®, Accu-Check®)
Direct Ship Injectable Form
Effient®
Erectile Dysfunction Agents (Viagra®, Caverject®/Edex®, MUSE®, Levitra®, Cialis® and Staxyn®)
Exjade®/Ferriprox®
Fanapt®/Invega®/Latuda®
Forteo™ (Tepriparatide [rDNA origin] Injection)
General Pharmacy (Gender Edit, Quantity Edit, Age Edit, Prior Authorization)
Growth Hormones
Hepatitis C Agents (Incivek, Victrelis)
Hyalganates (Synvisc®, Supartz®, Hyalgan®, Euflexxa®, Orthovisc®, and Synvisc-One®)
Lyrica® (pregabalin)/Pristiq®/Savella®/Aplenzin®/Gralise®
Medicare Administrative for Part B/D Coverage
Migraine Agents
Non-Formulary Exception Request
Oral Chemotherapy Agents
Proton Pump Inhibitors
Provigil® (modafinil)/Nuvigil® (armodafinil)
Renvela®
Synagis® (palivizumab)
Suboxone Subutex
Vyvanse®/Intuniv®/Daytrana®/Kapvay®
Xolair® (omalizumab)