Submitting a prior authorization request via electronic prior authorization (ePA)
To simplify your experience with prior authorization, save time and ensure you have the most up to date criteria, please submit your prior authorization request to FutureScripts through either of the following online portals:
Submit via fax using the form below.
Please download the applicable request form below and fax it to 1-888-671-5285 or email it to us.* Please refer to your plan specific website to access the plan formulary.
If a drug specific form is not listed in the A-Z section, please select the "Other" section which has the general fax form and other administrative forms.
- ledipasvir/sofosbuvir (generic Harvoni)
- Lenvima
- Lidocaine patch
- Lidoderm
- Lonsurf
- Lopreeza
- Lorbrena
- Lorzone
- Lunesta
- Lynparza
Other forms
- General Fax Form
- B vs. D Fax Form
- Duplicate Long-Acting Opioid Use Form
- Hospice Fax Form
- Intradialytic Parenteral Nutrition (IDPN)/Intraperitoneal Nutrition (IPN)/Parenteral Nutrition (TPN) Form
- Morphine Equivalent Dose
- Opioid - 7 Days Supply Limit
- Opioid-APAP Combination Use Form
- Opioid-Benzodiazepine Combination Use Form
- Opioid-Medication Assisted Treatment (MAT) Combination Use Form
- Opioid-Prenatal Combination Use Form
- Tier Lowering Exception Form
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