Value 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 Value 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. Please refer to the Formulary Exception Fax Form to request a formulary exception for a non formulary drug on the Value Formulary.
- Actemra
- Adcirca
- Addyi
- Adempas
- Admelog
- Admelog SoloStar
- Advate
- Adynovate
- Afinitor
- Afinitor Disperz
- Afstyla
- Aimovig
- Ajovy
- Aktipak
- Alecensa
- Almotriptan
- Alphanate
- Alphanine SD
- Alprolix
- Altabax
- Alunbrig
- Alvesco
- Amphetamine (generic Evekeo)
- Ampyra
- Apidra
- Arcalyst
- Arikayce
- Armodafinil
- Atripla
- Austedo
- Auvi-Q
- Aveed
- Cabometyx
- Calquence
- Caprelsa
- Carac
- Carbaglu
- Caverject
- Cayston
- Cerdelga
- Chantix
- Cholbam
- Cimzia
- Cinryze
- Clocortolone
- Cloderm
- Coagadex
- Cometriq
- Compound Products
- Continuous Glucose Monitoring System (Dexcom products, Medtronic products)
- Contrave
- Copiktra
- Corifact
- Corlanor
- Cosentyx
- Cotellic
- Cresemba
- Cuprimine
- Cyanocobalamin injection
- Cystagon
- Cystaran
- Tadalafil (generic Adcirca)
- Tadalafil (generic Cialis)
- Tafinlar
- Tagrisso
- Takhzyro
- Taltz
- Talzenna
- Targretin gel
- Tasigna
- Tavalisse
- Tegsedi
- Tekturna
- Tekturna HCT
- Temozolomide
- Testosterone cypionate
- Testosterone enanthate
- Testosterone gel
- Testosterone topical solution
- Tetrabenazine
- Thalomid
- Thiola
- Tibsovo
- Tirosint
- Toviaz
- Tracleer
- Tremfya
- Tretten
- Trintellix
- Tykerb
- Tymlos
- Tyvaso
Other forms
- General Fax Form
- Formulary Exception Fax Form
- CNS Stimulants - High Cumulative Dose
- Opioid Management - Buprenorphine/naloxone (Suboxone/Zubsolv) and Buprenorphine
- 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