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Premium Formulary

The Premium Formulary is a partially-closed formulary. The Premium Formulary is considered partially-closed because it excludes coverage of some brand-name drugs that do not offer a clear clinical advantage over other less costly brand or generic alternatives. Most other prescription drugs are on the formulary including specialty medications. Some medications may be subject to utilization management programs to ensure appropriate clinical use and cost efficiency. The formulary structure features medications generics (with the lowest copayments), preferred and non-preferred brand-name drugs.

To determine which commercial drugs require prior authorization, please refer to the
Premium Non-Specialty Prior Authorization List or the Premium Specialty Prior Authorization and Quantity Limit List, 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.



 

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A-Z drug-specific forms

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z  | Other

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A

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