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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): *