Select Formulary
Prior Authorization is required for coverage of certain prescribed covered drugs that have been approved by the U.S. Food and Drug Administration (FDA) for specific medical conditions. The approval criteria was developed and endorsed by the Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.
To determine which commercial 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): *
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.
- Abilify
- Abilify Mycite
- Absorica
- Acanya
- Aciphex
- Actemra
- Acticlate
- Aczone
- Adcirca
- Adderall
- Addyi
- Adempas
- Adipex-P
- Adlyxin
- Admelog
- Admelog SoloStar
- Advate
- Adynovate
- Adzenys ER
- Adzenys XR
- Aerospan
- Afinitor
- Afrezza
- Afstyla
- Aimovig
- Airduo RespiClick
- Ajovy
- Aktipak
- Alecensa
- Almotriptan
- Alphanate
- Alphanine SD
- Alprolix
- Altabax
- Altreno
- Alunbrig
- Alvesco
- Ambien
- Ambien CR
- Amerge
- Amitiza
- Ampyra
- Amrix ER
- Anaprox DS
- Androderm
- Androgel
- Apadaz
- Apidra
- Aplenzin
- Aptensio XR
- Arakoda
- Arcalyst
- Arikayce
- Armodafinil
- Armonair RespiClick
- Arnuity Ellipta
- Arthrotec
- Atacand
- Atacand HCT
- Ativan
- Atralin
- Austedo
- Auvi-Q
- Avalide
- Avapro
- Aveed
- Avidoxy
- Axert
- Axiron
- Azelex
- Azor
- Cabometyx
- Calcipotriene-betamethasone ointment
- Calquence
- Capex
- Caprelsa
- Carac
- Carbaglu
- Caverject
- Cayston
- Celebrex
- Cerdelga
- Chantix
- Cholbam
- Cialis
- Ciclodan
- Cimzia
- Cinryze
- Cleocin T
- Clindagel
- Clindamycin-benzoyl peroxide 1%-5%
- Clobex
- Cloderm
- Coagadex
- Colcrys
- Cometriq
- Compound Products
- Concerta
- Contrave ER
- Copiktra
- Cordran
- Corifact
- Corlanor
- Cosentyx
- Cotellic
- Cotempla XR-ODT
- Cozaar
- Cresemba capsule
- Crestor
- Cuprimine
- Cutivate
- Cyanocobalamin Injection
- Cystaran
- Dalfampridine ER (generic Ampyra)
- Daklinza
- Daypro
- Daytrana
- Depo-testosterone
- Derma-smoothe
- Desonate
- Desowen
- Desoxyn
- Dexedrine
- Dexilant
- DHE - dihydroergotamine Injection
- Diabetic Test Strips
- Diacomit
- Dibenzyline
- Diclegis
- Diclofenac 3% gel
- Didrex
- Diethylpropion
- Diethylpropion ER
- Differin
- Dihydroergotamine nasal spray
- Diovan
- Diovan HCT
- Doptelet
- Doral
- Doryx DR
- Duac
- Duexis
- Dulera
- Dupixent
- Durlaza
- Duzallo
- Dyanavel XR
- Dymista
- EC-Naprosyn
- Ecoza
- Edarbi
- Edarbyclor
- Edex
- Edluar
- Effexor XR
- Eletriptan
- Elidel
- Elmiron
- Eloctate
- Emflaza
- Emgality
- Enbrel
- Endari
- Enstilar
- Entresto
- Epclusa
- Epidiolex
- Erivedge
- Erleada
- Ertaczo
- Esbriet
- Esomeprazole magnesium
- Esomeprazole strontium
- Eszopiclone
- Eucrisa
- Evekeo
- Evoclin
- Evzio
- Exelderm
- Exforge
- Exforge HCT
- Exjade
- Extavia
- Extina
- Mavenclad
- Mavyret
- Maxalt, Maxalt MLT
- Mayzent
- Mekinist
- Mektovi
- Metadate CD
- Metformin ER (generic Glumetza)
- Methotrexate Injection
- Micardis
- Micardis HCT
- Migranal
- Minastrin 24 FE
- Minocin
- Minolira
- Mitigare
- Mobic
- Modafinil
- Mometasone nasal spray
- Monoclate P
- Monodox
- Mononine
- Motegrity
- Mulpleta
- Muse
- Myalept
- Mydayis
- Mytesi
- Palynziq
- Pandel
- Penlac
- Pennsaid
- Phendimetrazine
- Phendimetrazine ER
- Phenoxybenzamine
- Phentermine
- Picato
- Plixda
- Pomalyst
- Praluent
- Prenatal Vitamins
- Prevacid
- Prilosec
- Prinivil
- Pristiq
- Proctocort suppository
- Procysbi
- Profilnine
- Promacta
- Protonix
- Protopic
- Proventil HFA
- Provigil
- Prozac
- Pulmicort Flexhaler
- Safyral
- Saizen
- Samsca
- Saphris
- Saxenda
- Segluromet
- Sernivo
- Serostim
- Seysara
- Skyrizi
- Signifor
- Sildenafil (generic Revatio)
- Silenor
- Siliq
- Simponi
- Simponi Aria
- Sirturo
- Sivextro tablet
- Skelaxin
- Solaraze
- Soliqua
- Solodyn
- Soma
- Sonata
- Sovaldi
- Sprycel
- Staxyn
- Steglatro
- Steglujan
- Stelara
- Stendra
- Stivarga
- Strattera
- Strensiq
- Striant
- Sumatriptan
- Sumatriptan-naproxen
- Sumavel DosePro
- Sutent
- Sylatron
- Symdeko
- Symlin Pen
- Symproic
- Synalar
- Syprine
- Taclonex ointment & suspension
- Tadalafil (generic Adcirca)
- Tadalafil (generic Cialis)
- Tafinlar
- Tagrisso
- Takhzyro
- Taltz
- Talzenna
- Tarceva
- Targadox
- Targretin Gel
- Tasigna
- Tavalisse
- Technivie
- Tegsedi
- Tekturna
- Tekturna HCT
- Temodar
- Temozolomide
- Tenoretic
- Tenormin
- Testim
- Testosterone (transdermal)
- Testosterone cypionate
- Testosterone enanthate
- Tetrabenazine
- Thalomid
- Thiola
- Tibsovo
- Tirosint
- Topamax Sprinkle
- Topicort
- Toviaz
- Tracleer
- Tradjenta
- Tremfya
- Tretten
- Treximet
- Tribenzor
- Trintellix
- Trulance
- Tudorza
- Twynsta
- Tykerb
- Tymlos
- Tyvaso
- Zanaflex
- Zavesca
- Zegerid
- Zejula
- Zelboraf
- Zembrace Symtouch
- Zepatier
- Zestril
- Zetia
- Zetonna
- Ziana
- Zioptan
- Zipsor
- Zmax
- Zolinza
- Zolmitriptan
- Zolmitriptan orally disintegrating
- Zoloft
- Zolpidem
- Zolpidem ER
- Zolpimist
- Zomacton
- Zomig, Zomig ZMT
- Zorbtive
- ZTlido
- Zurampic
- Zyban
- Zydelig
- Zykadia
- Zypitamag
- Zytiga
- Zyvox
Other forms
- General Fax Form
- Formulary Exception Fax Form
- Cost Share Exception for Preventative Medications
- Opioid Management - Buprenorphine/naloxone (Bunavail®/Suboxone®/Zubsolv®) and Buprenorphine (Subutex®)
- Opioid Management - Butalbital Containing Headache Products
- Opioid Management - Cough & Cold Products
- Opioid Management - Morphine Milligram Equivalent (MME) > 90 mg/day, Long-acting opioids, Short-acting opioids for short term Use, and Quantity
- Opioid Management- Short-acting opioids for continuation beyond 30 days
- Opioid Management - Transmucosal Immediate Release Fentanyl (TIRF) Products
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