Medical Necessity Forms
Certain medications require prior authorization or medical necessity. To download a medical necessity 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.
Medical Necessity Forms for Non-Formulary Medications
- Adcirca
- Adrenergic Beta-blockers (ABAs) (Bystolic)
- Andro Gel and Axiron
- Anzemet, Sancuso, and Zuplenz
- Aplenzin
- Atelvia (Risedronate delayed release tablet)
- Avandia, Avandamet, Avandaryl
- Avodart
- Belbuca
- Beyaz, Natazia, Safyral
- Calcium Channel Non-dihydropyridines (Verelan, Verelan PM, Covera HS, and CardizemLA)
- Cardura XL (doxazosin extended-release)
- Cialis (tadalafil), Levitra (vardenafil), and Staxyn (vardenafil)
- Cycloset (bromocriptine)
- Cymbalta (Duloxetine)
- Daytrana, Focalin, Focalin XR
- Dihydropyridine Calcium Channel Blockers
- Estrostep Fe
- Extavia (interferon beta-1b)
- Extended-Cycle Oral Contraceptives
- Fanapt, Latuda, and Saphris
- Fortamet and Glumetza (metformin extended-release)
- Gralise (gabapentin ER) and Horizant (gabapentin enacarbil ER)
- Growth Hormone Products (Genotropin, Humatrope, Omnitrope, Saizen)
- Inhaled Corticosteroids (ICSs)
- Interferon alfacon-1 (Infergen)
- Ketek (telithromycin) and Zmax (azithromycin sustained release suspension)
- Leukotriene Modifiers, (Zyflo and Zyflo CR)
- Levemir FlexPen (insulin detemir pen device)
- Livalo (pitavastatin)
- Loestrin 24 Fe and Lo Loestrin Fe
- Lybrel
- Metformin ER (Generic for Fortamet and Glumetza)
- Lyrica (Pregabalin)
- Nasal Antihistamines
- Newer Antihistamine Agents (Clarinex, Clarinex D and Xyzal)F
- Nexium
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
- Nucynta (tapentadol)
- Nuvigil (Armodafinil)
- Oleptro (Trazodone Extended-release)
- Onglyza (saxagliptin) and Kombiglyze XR (saxagliptin + metformin)
- Ophthalmic Glaucoma Agents Azopt, Betimol, Istalol, Travatan/Travatan Z, and Zioptan
- Osteoporosis Agent (Miacalcin)
- Ovcon 35 and Femcon Fe
- Overactive Bladder (OAB) Medications
- Oxecta (oxycodone immediate-release)
- Paxil CR, Prozac Weekly, and Sarafem
- Pristiq (Desvenlafaxine)
- Rapaflo (silodosin)
- Ryzolt, Ultram ER, and Tramadol ER
- Savella (Milnacipran)
- Self-Monitoring Blood Glucose System Test Strips (SMBGS) Glucose Test Strips
- Short-Acting Beta Agonists – Maxair (Pirbuterol)
- Soliqua
- Sumavel DosePro (sumatriptan needle-free injection)
- Targeted Immunomodulatory Biologics (TIBs) – (Cimzia, Enbrel, Kineret, Simponi)
- Tekamlo (aliskiren and amlodipine)
- Topical Antifungals
- Tribenzor (olmesartan – amlodipine – HCTZ)
- Triptan Agents (Amerge, Axert, and Frova)
- Viibryd (Vilazodone)
- Vyvanse
- Welchol (colesevelam)
- Xultophy