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 Select Drug Formulary Guide, or download the applicable request form below, and fax it to 1-888-671-5285 (toll-free): *
Forms
- General Fax Form
- Acute Migraine Agents
- CNS Stimulants - High Cumulative Dose
- Immune Modulating Therapy
- Opioid Management - Buprenorphine/naloxone (Bunavail®/Suboxone®/Zubsolv®) and Buprenorphine (Subutex®)
- 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
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