Prior Authorization Forms
Certain medications require prior authorization or medical necessity. To download a prior authorization form for a non-formulary medication, please click on the appropriate link below.
Please note that the form must be approved before medication can be dispensed.
Prior Authorization Forms for Non-Formulary Medications
- Accrufer (Ferric Maltol)
- Actemra (Tocilizumab)
- Addyi (Filbanserin)
- Adempas (Riociguat)
- Adlyxin, Byetta, Bydureon, Victoza
- Advair HFA
- Agamree (Vamorolone)
- Aimovig (Erenumab-aooe)
- Ajovy (Fremanezumab-vfrm)
- Aklief (Trifarotene)
- Alecensa, Alunbrig and Zykadia
- Altoprev (Lovastatin ER)
- Alvaiz (Eltrombopag)
- Amitiza (Lubiprostone)
- Amzeeq (Minocycline)
- Androderm, AndroGel, Natesto, Testim, Testosterone 1.62% gel, & Vogelxo
- Anti-Obesity Agents: Benzphetamine, Diethylpropion, Phendimetrazine IR and SR, Phentermine
- Aspruzyo Sprinkles (Ranolazine ER Granule)
- Augtyro (Repotrectinib)
- Austedo (Deutetrabenazine)
- Auvelity (Dextromethorphan HBr and Bupropion HCL)
- Auvi-Q (Epinephrine)
- Balversa (Erdafitinib)
- Basal Insulin Analogs: Basaglar, Semglee, Semglee (YFGN), Insulin Glargine-YGFN, Insulin Glargine and Solostar, Rezvoglar
- Basal Insulin Analogs (Levemir and Levemir Flextouch)
- Belsomra (Suvorexant), Dayvigo (Lemborexant), Quvivq (Daridorexant)
- Belviq (Lorcaserin)
- Benlysta (Belimumab)
- Benzoyl Peroxide Products
- Bepreve (Bepotastine), Emadine (Emedastine), Lastacaft (Alcaftadine)
- Bimzelx (Bimekizumab-bkzx)
- Braftovi (Encorafenib)
- Brand Name Over Generic
- Breo Ellipta (Fluticasone/Vilanterol)
- Brukinsa (Zanubrutinib)
- Butrans (Buphrenorphine Transdermal System)
- Bystolic (Nebivolol)
- Calquence (Acalabrutinib)
- Cambia (Diclofenac Potassium Powder Packets)
- Caplyta (Lumateperone)
- Cialis (Tadalafil)
- Cimzia (Certolizumab)
- Compounded Medications
- Continuous Glucose Monitor (CGM): Freestyle Libre and Dexcom
- Contrave (Naltrexone SR and Bupropion SR)
- Copiktra (Duvelisib)
- Cordran (Flurandrenolide)
- Corlanor (Ivabradine)
- Cosentyx (Secukinumab)
- Cotempla XR ODT (Methylphenidate)
- Cycloset (Bromocriptine)
- Cequa (Cyclosporine 0.09%), Restasis (Cyclosporine 0.05% multi-dose), Xiidra (Lifitegrast 5%) ophthalmic solution
- Darolutamide (Nubeqa)
- Denavir (Penciclovir)
- Diclegis (Doxylamine and Pyridoxine)
- Diflorasone Diacetate
- Duexis (Ibuprofen/Famotidine) and Vimovo (Esomperazole/Naproxen)
- Dulera (Mometasone/Fomoterol)
- Duloxetine DR capsules (Drizalma Sprinkle)
- Dupixent (Dupilumab)
- Dutasteride (Avodart)
- Emflaza (Deflazacort)
- Emgality 100mg (Galcanezumab-gnlm)
- Emgality 120mg (Galcanezumab-gnlm)
- Enstilar, Taclonex, Wynzora (Calcipotriene-betamethasone)
- Entyvio Pen (Vedolizumab)
- Enbrel (Etanercept)
- Eohilia (Budesonide oral susp)
- Epidiolex (Cannabidiol)
- Erleada (Apalutamide)
- Esbriet (Pirfenidone)
- Eucrisa (Crisaborole)
- Eysuvis (Loteprednol)
- Fasenra (Benralizumab)
- Febuxostat (Uloric)
- Fenofibrate (Fenoglide) 120 mg tablet
- Fertility Agents (Injectable Gonadotropins Only)
- Fetzima (Levomilnacipran XR)
- Fibric Acid Derivatives
- Filsuvez (Birch triterpenes)
- Firdapse (Amifampridine)
- Fintepla (Fenfluramine Oral Solution)
- Forteo
- Fortesta (testosterone 2% topical gel)
- Fruzaqla (Fruquintinib)
- Gemtesa (vibegron)
- Gilenya (Fingolimod)
- Gocovri (amantadine ER)
- Gralise (gabapentin ER)
- Growth Hormone
- Hepatitis C Medications
- Hetlioz, Hetlioz LQ (tasimelteon)
- H.P. Acthar Gel
- Horizant (gabapentin enacarbil)
- Humira (adalimumab)
- Ibrance
- Idhifa (Enasidenib) and Tibsovo (Ivosidenib)
- Ilumya
- Imbruvica
- Ingrezza
- Inhaled Corticosteroids (Aerospan, Alvesco, Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler, Pulmicort Flexhaler, QVAR, QVAR Redihaler)
- Inrebic (Fedratinib)
- Inqovi (Decitabine/ Cedazuridine)
- Intrarosa (Prasterone)
- Invokamet, Invokamet XR, Xigduo XR, and Segluromet
- Invokana, Farxiga, Steglatro, Inpefa, and Steglujan
- Istradefylline (Nourianz)
- Iwilfin (Eflornithine)
- Iyuzeh (Latanoprost)
- Jalyn (Dutasteride/Tamsulosin)
- Janumet (Sitagliptin and Metformin immediate-release) and Janumet XR (Sitagliptin and Metformin extended-release)
- Januvia (Sitagliptin)
- Jatenzo, Kyzatrex, Tlando (Testosterone Undecanoate Capsules)
- Jaypirca (Pirtobrutinib)
- Jesduvroq (Daprodustat)
- Jornay (Methylphenidate HCl ER) and Azstarys (Serdexmethylphenidate/Dexmethylphenidate)
- Jublia (Efinaconazole) and Kerydin (Tavaborole)
- Jylamvo, Xatmep (Methotrexate) Oral Solution
- Jynarque (Tolvaptan)
- Kalydeco (Ivacaftor)
- Kapspargo (Metoprolol Succ ER Capsules)
- Kazano, Jentadueto, Jentadueto XR, and Kombiglyze XR PA
- Kerendia (Finerenone)
- Kevzara (Sarilumab)
- Kineret (Anakinra)
- Kisqali (Ribociclib)
- Letairis (Ambrisentan) and Opsumit (Macitentan)
- Levothyroxine Solution (Ermeza, Thyquidity, Tirosint-SOL)
- Levorphanol (Levo-Dromoran)
- Likmez (Metronidazole) Oral Suspension
- Linzess (Linaclotide)
- Liptruzet (Atorvastatin and Ezetimibe)
- Lescol XL (Fluvastatin extended-release), Livalo (Pitavastatin), Zypitamag (Pitavastatin magnesium)
- Lomaira (Phentermine)
- Lonhala Magnair (Glycopyrrolate)
- Lovaza (Omega-3-acid ethyl esters)
- Lumakras (Sotorasib)
- Lynparza (Olaparib)
- Lyrica and Lyrica CR (Pregabalin)
- Mavenclad (Cladribine)
- Mecasermin (Increlex)
- Mekinist (trametinib)
- Mektovi (Binimetinib)
- Migraine Agents: Nasal Triptans (Zomig)
- Miebo (Perfluorohexyloctane)
- Minocycline ER, Ximino ER, Coremino ER, Minolira ER, Seysara
- Motegrity (Prucalopride)
- Motpoly XR (Lacosamide ER)
- Mounjaro (Tirzepatide) and Ozempic (Semaglutide)
- Movantik (Naloxegol)
- Mydaysis (Mixed Amphetamine Salts ER)
- Myrbetriq (Mirabegron)
- Myrbetriq Granules (Mirabegron)
- Namenda XR (Memantine)
- Namzaric (Donepezil and Memantine)
- Nasal Allergy Drugs
- Nerlynx (Neratinib)
- Neulasta, Ziextenzo, Nyvepria
- Neupogen (Filgrastim), Zarxio (Filgrastim-sndz)
- Neupro (Rotigotine)
- Nesina, Oseni, Tradjenta, and Onglyza
- Newer Sedative Hypnotics (Ambien CR, Edluar, Intermezzo, Lunesta, Rozerem, Silenor, Zolpimist)
- Newly Approved Innovator Drugs
- Nexletol (Bempedoic Acid) and Nexlizet (Bempedoic Acid and Ezetimibe)
- Ninlaro (Ixazomib)
- Nocdurna (Desmopressin Acetate)
- Noctiva (Desmopressin Nasal Spray)
- Non-Preferred Migraine Agents: Oral Triptans
- Northera (Droxidopa)
- Nucala (Mepolizumab)
- Nucynta ER (Tapentadol ER)
- Nuplazid (Pimavanserin)
- Nurtec ODT (Rimegepant)
- Ocaliva (Obeticholic Acid)
- Odactra (House Dust Mite Allergen Extract)
- Ofev (Nintedanib Esylate)
- Ogsiveo (Nirogacestat)
- Ojjaara (Momelotinib)
- Olumiant (Baricitinib)
- Omnipod and Omnipod DASH
- Omnipod 5 kits and pods
- Opzelura (Ruxolitinib)
- Oracea (Doxycycline)
- Oral Bisphosphonates (Actonel, Atelvia, Binosto, Fosamax Plus D)
- Orencia (Abatacept)
- Orgovyx (Relugolix)
- Oriahnn (Elagolix/Estradiol/Norethindrone), Myfembree (Relugolix/Estradiol/Norethindrone)
- Orkambi (Ivacaftor/Lumacaftor)
- Otezla (Apremilast)
- Detrol (Tolterodine IR), Enablex (Darifenacin), Gelnique (Oxybutynin gel), Oxytrol (Oxybutynin transdermal patch), Sanctura XR (Trospium ER), Toviaz (Fesoterodine), Vesicare (Solifenacin)
- Oxervate (Cenegermin-bkbj)
- Pennsaid (Diclofenac 2% Solution)
- Pexidartinib (Turalio)
- Pliaglis (Lidocaine-Tetracaine 7%-7%)
- Piqray (Alpelisib)
- Pomalyst (Pomalidomide)
- Praluent (Alirocumab)
- Pramlintide (Symlin)
- Pristiq (Desvenlafaxine Succ ER) and Khedezla (Desvenlafaxine ER)
- Proton Pump Inhibitors: Nexium, Aciphex, and generics
- Proton Pump Inhibitors: Prevacid ODT and Zegerid suspension
- Proton Pump Inhibitors: Prevacid, Zegerid, and generics
- Qbrexza (Glycopyrronium)
- Qelbree (viloxazine)
- Qsymia (Phentermine/Topiramate ER)
- Qualaquin (Quinine Sulfate)
- Qudexy XR (Topiramate ER) and Trokendi XR (Topiramate ER)
- Qulipta (Atogepant)
- Rapaflo (Silodosin)
- Rayos (Prednisone DR)
- Relistor (Methylnaltrexone)
- Renin Angiotensin Antihypertensive Agents (RAAs)
- Repatha (Evolocumab)
- Restasis (Cyclosporine 0.05%) Single Dose
- Revlimid (Lenalidomide)
- Rexulti (Brexpiprazole)
- Reyvow (Lasmiditan)
- Rinvoq (Upadacitinib)
- Rivfloza (Nedosiran)
- Rocklatan (Netarsudil) and Rhopressa (Netarsudil and Latanoprost)
- Rozlytrek (Entrectinib)
- Ryaltris (Olopatadine HCl/Mometasone furoate)
- Rybelsus (Semaglutide oral tablet)
- Rytary (Carbidopa/Levodopa)
- Safinamide (Xadago)
- Savella (Milnacipran)
- Self-Monitoring Blood Glucose System (SMBGS) Glucose Test Strips
- Simponi (Golimumab)
- Skyrizi (Risankizumab) on-body injector
- Skyrizi (risankizumab) auto-injector & prefilled syringe
- Skytrofa (Lonapegsomatropin-tcgd)
- Solaraze (Diclofenac 3%)
- Soliqua (Lixisenatide/Insulin glargine)
- Sotyktu (Deucravacitinib)
- Stelara (Ustekinumab)
- Stendra (Avanafil)
- Subcutaneous Immunoglobulins (SCIG)
- Sucraid (Sacrosidase) Oral Solution
- Sulfacetamide and Sulfacetamide Sodium/Sulfur
- Symbicort (Budesonide/Formoterol)
- Symdeko (Tezacaftor-Ivacaftor)
- Symproic (Naldemedine)
- Synjardy and Synjardy XR (Empagliflozin/Metformin)
- Tafinlar (Dabrafenib)
- Taltz (Ixekizumab)
- Tavalisse (Fostamatinib)
- Tazorac (Tazarotene 0.05% and 0.1% gel, Tazarotene 0.05% cream)
- Tecfidera (Dimethyl Fumarate)
- Testosterone cypionate and enanthate
- Tetracyclines
- Tezspire (Tezepelumab-ekko)
- Thiazolidinediones (TZDs, Actos, Actoplus Met, Actoplus Met XR, Duetact, Avandia, Avandament, and Avandaryl)
- Tiopronin IR / Tiopronin DR (Thiola / Thiola EC)
- Topical Acne and Rosacea Agents: Azelex and Finacea (azelaic acid)
- Topical Acne and Rosacea Agents: Dapsone Products
- Topical Acne and Rosacea Agents: Metronidazole Products
- Topical Acne and Rosacea Agents: Retinoids and Combinations
- Topical Acne and Rosacea Agents: Rhofade, Mirvaso and Soolantra
- Toujeo (Insulin Glargine)
- Tracleer (bosentan)
- Tremfya (guselkumab)
- Tresiba
- Trikafta (elexacaftor-tezacaftor-ivacaftor)
- Trintellix (vortioxetine)
- Trulance (plecanatide) and Ibsrela (tenapanor)
- Trulicity (Dulaglutide)
- Truqap (Capivasertib)
- Tymlos
- Tyrvaya (varenicline tartrate)
- Ubrogepant (Ubrelvy)
- USFHP Standard PA Form
- V-Go Disposable Insulin Delivery Device
- Vascepa
- Velsipity (Etrasimod)
- Venclexta (venetoclax)
- Veozah (fezolinetant)
- Verzenio
- Viagra (Sildenafil)
- Viberzi (Eluxadoline)
- Vilazodone (Viibryd)
- Vitrakvi (Larotrectinib) Capsules and Oral Solution
- Vowst (fecal microbiota spores, live-brpk)
- Voquezna (Vonoprazan)
- Vtama (Tapinarof 1% Cream)
- Vyndamax (Tafamidis) and Vyndaqel (Tafamidis Meglumine)
- Vyleesi (Bremelanotide injection)
- Vytorin
- Vyvanse
- Vyzulta
- Wainua (Eplontersen)
- Wakix (pitolisant)
- Wegovy (Semaglutide), Saxenda (Liraglutide), Zepbound (Tirzepatide)
- Welireg (Belzutifan)
- Winlevi (clascoterone)
- Xalkori (Crizotinib) Capsules and Pellets
- Xdemvy (Lotilaner)
- Xeljanz and Xeljanz XR
- Xenical (orlistat)
- Xermelo (Telotrisat ethyl)
- Xhance (Fluticasone Propionate 93 mcg Nasal Spray)
- Xifaxan 200mg
- Xifaxan 550mg
- Xolair (omalizumab)
- Xpovio (selinexor)
- Xphozah (Tenapanor)
- Xtandi (enzalutamide)
- Xultophy (Insulin degludec/liraglutide)
- Xyosted (testosterone enanthate)
- Xyrem (sodium oxybate) & Xywav (calcium, potassium & sodium oxybate salts)
- Yonsa (Abiraterone)
- Yupelri (Revefenacin)
- Zejula (niraparib)
- Zelboraf (vemurafenib)
- Zembrace Symtouch
- Zeposia (ozanimod)
- Zerviate (cetirizine)
- Zilbrysq (Zilucoplan Sodium)
- Zoryve (roflumilast 0.3%)
- Zurzuvae (Zuranolone)
- Zymfentra (Infliximab-dyyb)
- Zytiga (Abiraterone Acetate)
US Family Health Plan
