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.
- Absorica
- Acanya
- Aciphex
- Actemra
- Acticlate
- Aczone
- Adcirca
- Adderall
- Adempas
- Adhansia XR
- Adipex-P
- Admelog
- Admelog SoloStar
- Aerospan
- Afinitor
- Aimovig
- Ajovy
- Aklief
- Aktipak
- Alecensa
- Almotriptan
- Altreno
- Alunbrig
- Alvesco
- Ambien
- Ambien CR
- Ambrisentan
- Amerge
- Amitiza
- Androderm
- Androgel
- Apexicon E
- Apidra
- Aptensio XR
- Arcalyst
- Armodafinil
- Armonair RespiClick
- Arnuity Ellipta
- Atacand
- Atacand HCT
- Atralin
- Avalide
- Avapro
- Aveed
- Avidoxy
- Axiron
- Azelex
- Azor
- Cabometyx
- Calquence
- Capex
- Caprelsa
- Cequa
- Chantix
- Cialis
- Ciclodan
- Cimzia
- Cleocin T
- Clindagel
- Clindamycin-benzoyl peroxide 1%-5%
- Clobex
- Clocortolone
- Cloderm
- Colchicine
- Cometriq
- Compound Products
- Concerta
- Continuous Glucose Monitoring System (Dexcom products, Medtronic products)
- Contrave ER
- Copiktra
- Cordran
- Cosentyx
- Cotellic
- Cozaar
- Crestor
- Cutivate
- Cyanocobalamin Injection
- Daklinza
- Daurismo
- Depo-testosterone
- Derma-smoothe
- Desonate
- Desowen
- Desoxyn
- Dexedrine
- Dexilant
- Diabetic Test Strips and Meters
- Diclofenac epolamine patch
- Diclofenac 3% gel
- Didrex
- Diethylpropion
- Diethylpropion ER
- Differin
- Diflorasone
- Diovan
- Diovan HCT
- Doryx DR
- Doxycycline hyclate DR
- Duac
- Duexis
- Dulera
- Dupixent
- Dymista
- Tadalafil (generic Adcirca)
- Tadalafil (generic Cialis)
- Tafinlar
- Tagrisso
- Taltz
- Talzenna
- Tarceva
- Targadox
- Targretin capsule
- Tasigna
- Tekturna
- Tekturna HCT
- Temodar
- Temozolomide
- Tepmetko
- Testim
- Testosterone (transdermal)
- Testosterone cypionate
- Testosterone enanthate
- Thalomid
- Tibsovo
- Tirosint
- Topicort
- Tosymra
- Tracleer
- Tradjenta
- Tremfya
- Tresiba Flextouch
- Treximet
- Tribenzor
- Trintellix
- Trulance
- Turalio
- Twynsta
- Tykerb
- Tymlos
- Tyvaso
Other forms
- General Fax Form
- Formulary Exception Fax Form
- CNS Stimulants - High Cumulative Dose
- 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