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.
- Abiraterone acetate (generic Zytiga)
- Abraxane
- Aciphex
- Aciphex Sprinkle
- Actemra
- Actemra ACTPen
- Activase
- Activella
- Adapalene
- Adapalene-benzoyl peroxide
- Adcetris
- Adcirca
- Adderall
- Adderall XR
- Adempas
- Adhansia XR
- Adlyxin
- Adlyxin Starter Pack
- Admelog
- Admelog SoloStar
- Adriamycin
- Adrucil
- Adzenys ER
- Adzenys XR-ODT
- Aerospan
- Afinitor
- Aimovig
- Ajovy
- Aklief
- Albuterol nebulizer solution
- Alecensa
- Alimta
- Aliqopa
- Alkeran Injection
- Allzital
- Alora
- Altreno
- Alunbrig
- Alvesco
- Alyq
- Amabelz
- Ambien
- Ambien CR
- Ambrisentan
- Amphetamine-dextroamphetamine ER
- Ampyra
- Amrix
- Androderm
- Androgel
- Androgel Pump
- Angeliq
- Apidra
- Apidra Solostar
- Aptensio XR
- Aralast NP
- Aranesp
- Armodafinil
- Armonair
- Arranon
- Arsenic trioxide
- Arzerra
- Asceniv
- Ascomp
- Ascomp with Codeine
- Asmanex HFA
- Asmanex Twisthaler
- Asparlas
- Atacand
- Atacand HCT
- Ativan
- Atralin
- Auryxia
- Austedo
- Avalide
- Avapro
- Avastin
- Aveed
- Avita
- Azacitidine
- Balversa
- Basaglar
- Bavencio
- Beleodaq
- Benicar
- Benicar HCT
- Benztropine injection
- Benztropine tablet
- Besponsa
- Bexarotene
- Bicnu
- Bijuva
- Bivigam
- Bleomycin
- Blincyto
- Boniva Injection
- Bosentan (generic Tracleer)
- Bosulif
- Botox
- Braftovi
- Brukinsa
- Busulfan
- Busulfex
- Butalbital-acetaminophen
- Butalbital-acetaminophen-caffeine
- Butalbital-acetaminophen-caffeine-codeine
- Butalbital-aspirin-caffeine
- Butalbital-aspirin-caffeine-codeine
- Byetta
- Cabometyx
- Calcitonin nasal spray
- Calcitriol Injection
- Calcium gluconate injection
- Calcium gluconate tablet
- Calcium gluconate/dextrose injection
- Calcium gluconate/sodium chloride injection
- Calquence
- Cambia
- Camptosar
- Caprelsa
- Carboplatin
- Carimune NF
- Carisoprodol
- Carisoprodol-aspirin
- Carisoprodol-aspirin-codeine
- Carmustine
- Carnitor Injection
- Cetacaine
- Chlordiazepoxide
- Chlorzoxazone
- Cialis 2.5mg and 5mg
- Cimzia
- Cisplatin
- Cladribine
- Climara
- Climara Pro
- Clindamycin-Tretinoin
- Clolar
- Combipatch
- Cometriq
- Concerta
- Copiktra
- Cosentyx
- Cosmegen
- Cotellic
- Cotempla XR-ODT
- Cozaar
- Crestor
- Cyclobenzaprine
- Cyclobenzaprine ER
- Cyramza
- Cytarabine
- Dacarbazine
- Dacogen
- Daklinza
- dalfampridine ER (generic Ampyra)
- Darzalex
- Daunorubicin
- Daurismo
- Daytrana
- Decitabine
- Deferoxamine
- Depocyt
- Depo-testosterone
- Desferal
- Desoxyn
- Dexedrine
- Dexilant
- Dexmethylphenidate
- Dexmethylphenidate ER
- Dexrazoxane
- Dextroamphetamine ER capsule
- Diclofenac gel 3%
- Diclofenac patch
- Differin
- Digitek
- Digoxin
- Digox
- Dilaudid
- Diovan
- Diovan HCT
- Dipyridamole
- Divigel
- Docefrez
- Docetaxel
- Dolophine
- Doptelet
- Dotti
- Doxil
- Doxorubicin
- Dronabinol
- Duexis
- Dupixent
- Duragesic
- Dyanavel XR
- Dysport
- Edarbi
- Edarbyclor
- Edluar
- Elestrin
- Ellence
- Elzonris
- Emgality
- Empliciti
- Enbrel
- Enhertu
- Entyvio
- Epclusa
- Epiduo
- Epiduo Forte
- Epirubicin
- Epogen
- Erbitux
- Erivedge
- Erleada
- Erlotinib hydrochloride (generic Tarceva)
- Erwinaze
- Esbriet
- Esgic
- Esomeprazole Strontium
- Estrace
- Estradiol-norethindrone acetate
- Estradiol patch
- Estradiol tablet
- Estrogel
- Estropipate
- Eszopiclone
- Etopophos
- Etoposide injection
- Evamist
- Evekeo ODT
- Evenity
- Everolimus
- Evomela
- Farxiga
- Farydak
- Fasenra
- Febuxostat
- Femhrt
- Fentanyl patch
- Fexmid
- Fiasp
- Fiasp FlexTouch
- Fioricet
- Fioricet with Codeine
- Fiorinal
- Fiorinal with Codeine
- Flebogamma DIF
- Flector Patch
- Floxuridine injection
- Fludara (fludarabine phosphate)
- Fluorouracil
- Focalin
- Focalin XR
- Folotyn
- Fortamet
- Forteo
- Fortesta
- Fyavolv
- Halaven
- Harvoni
- Heparin sodium
- Herceptin
- Herceptin Injection
- Herceptin hylecta
- Hetlioz
- Hizentra
- H.P. Acthar
- Humalog
- Humalog Junior Kwikpen
- Humalog Kwikpen
- Humalog MIX 50/50
- Humalog MIX 50/50 Kwikpen
- Humalog MIX 75/25
- Humalog MIX 75/25 Kwikpen
- Humatrope
- Humira
- Humulin 70/30
- Humulin 70/30 Kwikpen
- Humulin N
- Humulin N Kwikpen
- Humulin R
- Humulin R U-500
- Humulin R U-500 Kwikpen
- Hycamtin Injection
- Hydromorphone
- Hydroxyprogesterone Caproate (1.25 gm/5ml only)
- Hydroxyzine hydrochloride
- Hydroxyzine pamoate
- Hyzaar
- Ibandronate sodium injection
- Ibrance
- Iclusig
- Idamycin (idarubicin)
- Idhifa
- Ifex (ifosfamide)
- Imatinib mesylate
- Imbruvica
- Imfinzi
- Imitrex Injection
- Indomethacin ER
- Inflectra
- Infugem
- Ingrezza
- Inlyta
- Inrebic
- Insulin Lispro
- Insulin Lispro Kwikpen
- Intermezzo
- Intrarosa
- Ipratropium-albuterol nebulizer solution
- Ipratropium nebulizer solution
- Iressa
- Irinotecan
- Istodax
- Ixempra Kit
- Marqibo
- Marinol
- Mavyret
- Mekinist
- Mektovi
- Melphalan injection
- Menostar
- Metadate CD
- Metadate ER 20mg tab
- Metaxall
- Metaxalone
- Metformin ER (generic Fortamet, generic Glumetza)
- Methadone
- Methamphetamine
- Methocarbamol injection
- Methocarbamol tablet
- Methylin
- Methylphenidate CD
- Methylphenidate ER tablet
- Methylphenidate LA
- Miacalcin Injection
- Miacalcin nasal spray
- Mimvey
- Mimvey Lo
- Minivelle
- Mitomycin
- Mitoxantrone
- Modafinil
- Morphabond ER
- Morphine sulfate ER/CR
- MS Contin
- Mustargen
- Mvasi
- Mydayis
- Mylotarg
- Octagam
- Odomzo
- Ofev
- Olumiant
- Olysio
- Omeppi
- Omeprazole-Sodium Bicarbonate
- Omnitrope
- Oncaspar
- Ondansetron
- Ondansetron ODT
- Onivyde
- Opana
- Opdivo
- Opsumit
- Orencia
- Orenitram
- Orphenadrine-aspirin-caffeine
- Orphenadrine Citrate ER
- Orphenadrine CR
- Orphengesic Forte
- Oseni
- Otezla
- Oxaydo
- Oxaliplatin
- Oxervate
- Oxycodone ER
- Oxycodone tablet
- Oxycontin
- Oxymorphone
- Ozempic
- Paclitaxel
- Padcev
- Pamidronate Injection
- Panzyga
- Paricalcitol Injection
- Percocet
- Perjeta
- Phenadoz suppository
- Photofrin
- Piqray
- Polivy
- Pomalyst
- Portrazza
- Praluent
- Prefest
- Premarin injection
- Premarin tablet
- Prevacid
- Prilosec
- Primlev
- Privigen
- Procentra
- Procrit
- Prolia
- Promethazine
- Promethegan suppository
- Protamine
- Protonix
- Provenge
- Proventil HFA
- Provigil
- Pulmicort Flexhaler
- Tadalafil (generic Adcirca)
- Tadalafil 2.5mg and 5mg (generic Cialis)
- Tafinlar
- Tagrisso
- Tarceva
- Targretin
- Tasigna
- Taxotere
- Tecentriq
- Temodar Injection
- Tencon
- Teniposide
- Testim
- Testosterone (Generic Androgel, Androgel Pump, Fortesta)
- Testosterone cypionate
- Testosterone enanthate
- Tetrabenazine
- Thalomid
- Theracys
- Thiotepa
- Tibsovo
- Tice BCG
- Toposar
- Topotecan
- Torisel
- Totect
- Tracleer
- Tradjenta
- Tranxene
- Travatan Z
- Treanda
- Tremfya
- Tretinoin
- Tretinoin Microsphere
- Trintellix
- Trisenox
- Trulance
- Tudorza
- Turalio
- Tykerb
- Tymlos
- Tyvaso
- Valium
- Vanatol LQ
- Vanatol S
- Vancomycin injection
- Vancomycin/dextrose injection
- Vancomycin/sodium chloride injection
- Vantas
- Vectibix
- Velcade
- Venclexta
- Ventavis
- Ventolin HFA
- Verzenio
- Vibativ
- Vidaza
- Viekira
- Viibryd
- Vimovo
- Vinblastine
- Vincasar PFS
- Vincristine
- Vinorelbine
- Vistaril
- Vitrakvi
- Vivelle-Dot
- Vizimpro
- Vogelxo
- Vogelxo pump
- Vosevi
- Votrient
- Vyndamax
- Vyndaqel
- Vyvanse
- Vyxeos
- Vyzulta
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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