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.
NaviNet®
Log on to the NaviNet portal to view an up-to-date list of which drugs require prior authorization, submit a prior authorization request for determination, or take advantage of other helpful features.
Or download the applicable request form below, and fax it to 215-241-3073 (local) or 1-888-671-5285 (toll-free): *
Analgesic Medications (Celebrex®, Mobic®, and Ultram® ER)
Anti-Infective Agents (Avidoxy®, Avidoxy DK®, Zmax™, Zyvox®, Noxafil®,Oracea®, and Nutridox®)
Arthritis/Psoriasis Agents (Enbrel®, Kineret®, Humira®, Amevive™, Raptiva®, and Simponi®)
Bisphosphonate Agents
Botulinium Toxins (Type A & B)
Cesamet®
Controlled Substances (Fentora®, Opana®, Nucynta®, Magnacet®, Actiq®, Opana ER®, Onsolis®, and Fentanyl Citrate)
Daytrana® (Methylphenidate transdermal system)
Diabetic Agents (Byetta®, Exubera®, Glumetza®, Janumet®, Januvia®, Prandimet®, Onglyza®, and Symlin®)
Diabetic Test Strips (LifeScan One Touch®, Accu-Check®)
Direct Ship Injectable Form
Effient®
Erectile Dysfunction Agents (Viagra®, Caverject®/Edex®, MUSE®, Levitra®, and Cialis®)
Exjade®
Forteo™ (Tepriparatide [rDNA origin] Injection)
General Pharmacy (Gender Edit, Quantity Edit, Age Edit, Prior Authorization)
Growth Hormones
Lipitor® (atorvastatin)/Caduet® (amlodipine/atorvastatin)/Vytorin® (ezetimibe/simvastatin)/Crestor® (rosuvastatin calcium)
Lyrica® (pregabalin)/Cymbalta® (duloxetine)/Pristiq®/Savella®/Aplenzin®/Saphris®
Migraine Agents
Mozobil® (plerixafor)
Non-Formulary Exception Request
Oral Antihypertensive Agents
Oral Chemotherapy Agents (Afinitor®, Gleevec®, Hycamtin®, Votrient®, Iressa®, Nexavar®, Revlimid®, Sprycel®, Sutent®, Tarceva®, Tasigna®, Temodar®, Thalomid®, Tykerb®, and Zolinza®)
Paliperidone (Invega®)/Quetiapine fumarate (Seroquel XR®)
Proton Pump Inhibitors (Aciphex®, Nexium®, Prevacid®, Prevacid NapraPAC®, Protonix®,Pylera®, Zegerid ®, Prilosec® Suspension, and Kapidex®)
Provigil® (modafinil)/Nuvigil® (armodafinil)
Renvela®
Revatio™ (sildenafil)/Adcirca (tadalifil)
Singulair®
Taclonex®
Vyvanse®/Intuniv®
Xolair® (omalizumab)