Drug Formulary
Prior Authorization Submission
Certain covered drugs that have been approved by the FDA for specific medical conditions require prior authorization. The approval criteria were 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.
Prior Authorization Criteria
A request form must be completed for all medications requiring prior authorization. The forms below are available in PDF format. Current prior authorization medications are:
- Analgesic Medications (Celebrex®, Mobic®, and Ultram ER®)
- Arthritis/Psoriasis agents (Enbrel®, Kineret®, Humira®, Amevive® and Raptiva®)
- Botulinum Toxins (Type A and B)
- Diabetic Agents (Exubera®, Byetta®, and Symlin®)
- Direct Ship Injectable Form
- Erectile Dysfuntion Medications (Viagra®, Caverject®/Edex®, MUSE®, Levitra®, and Cialis®)
- Fentora®/Opana®/Opana Er®
- Forteo® Injection
- Growth Hormone Enrollment Form
- Lyrica® (pregabalin)/Cymbalta® (duloxetine)
- Medicare Administrative Prior authorization for Part B/D
- Migraine Agents
- Oral chemotherapy agents (Thalomid®, Gleevec®, Sprycel®, Iressa®, Tarceva®, Sutent®, Nexavar®, and Revlimid®)
- Proton Pump Inhibitors (Aciphex®, Nexium®, Prevacid®, Prevacid NapraPAC®, and Protonix®)
- Provigil® (modafenil)
- Synagis® (palivizumab)
- Xolair® (omalizumab)
- Zavesca®(miglustat) and Revatio® (sildenafil)
- Non-Preferred Exception Request
- General Pharmacy Prior Authorization Form
Request Form Instructions
Providers:
Download a Coverage Determination Form:
Coverage Determination Form for Enrollees
Coverage Determination Form for Providers
Coverage Determination Instructions
- When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will be faxed back to your office for completion, which will delay the review process.
- Fax completed forms to the FutureScripts® Secure for review. Make sure you include your office telephone and fax number.
- You will be notified by fax if the request is approved. You and your patient will receive a denial letter if the request is denied.
- If you have not gotten a response after two business days from submitting complete information, contact the Provider Services Department. Information regarding expedited requests.
Members:
- Take the appropriate request form to your physician to be completed.
- You or your physician may fax the completed form to the FutureScripts Secure for review.
- If you have not gotten a response after two business days from your provider submitting complete information, contact the provider who requested the prior approval on your behalf.
- If you have questions, please contact Member Services at the number listed on the back of your identification card.
FutureScripts Secure fax numbers:
- 215-241-3073 inside local Philadelphia area
- 888-671-5285 toll-free outside the local calling area
Tiered cost-sharing exceptions
Physicians, on behalf of members, may request coverage of a non-preferred medication, at the preferred formulary copay. The physician should complete the Non-preferred Exception Request Form providing detail to support use of the non-preferred medication and fax the request to 215-241-3073 or 1-888-671-5285. The Non-preferred Exception Request Form can also be obtained by calling 1-888-678-7015 (Option #3).
If the non-preferred request is approved, the drug will be processed at the appropriate formulary benefit copay. If the request is denied, the member and physician will receive a denial letter that explains the appeal process. The member may still receive benefits for the drug at the non-preferred copay or coinsurance.
