Downloadable Forms
To download a medical necessity form for a non-formulary medication, please click on the appropriate link below:
- Adrenergic Beta-blockers (ABAs) (Bystolic)
- Ambien CR, Rozerem, and Sonata
- Antiemetics (Anzemet and Sancuso)
- Antilipidemic Drugs II (Antara, Tricor, Lovaza)
- Avandia, Avandamet, Avandaryl
- Cialis (Tadalafil) and Viagra (Sildenafil)
- Cymbalta (Duloxetine)
- Dihydropyridine Calcium Channel Blockers
- Growth Hormone Products (Genotropin, Humatrope, Omnitrope, Saizen)
- Ketek (telithromycin) and Zmax (azithromycin sustained release suspension)
- Inhaled Corticosteroids
- Lexapro (Escitalopram)
- Lyrica (Pregabalin)
- Paxil CR, Prozac Weekly, and Sarafem
- Proton Pump Inhibitors (Aciphex, Dexilant, Prevacid, Protonix, and Zegerid)
- Rapaflo (silodosin)
- Short-Acting Beta Agonists (SABAs)
- Targeted Immunomodulatory Biologics (TIB’s) (Cimzia, Enbrel, Kineret, and Simponi)
- Topical Antifungals
- Triptan Agents (Amerge, Axert, and Frova)
- Verelan, Verelan PM, Covera HS, and Cardizem LA
Prior Authorization Forms for Non-Formulary Medications
To download a prior authorization form for a non-formulary medication, please click on the appropriate link below:
- Adalimumab (Humira)
- Advicor, Altoprev, Caduet, Lescol, Lescol XL, Livalo, Simcor
- Amevive (Alefacept)
- Anakinra (Kineret)
- Armodafinil (Nuvigil)
- BPH Beta Blocker (Jalyn and Rapaflo)
- Brand Name Over Generic
- Cimzia (Certolizumab pegol)
- Crestor (Rosuvastatin)
- Cymbalta (Duloxetine)
- DPP-4 Inibitors (Januvia, Janumet, Kombiglyze XR, and Onglyza)
- Etanercept (Enbrel)
- Exenatide (Byetta)
- Fertility Agents (Injectable Gonadotropins Only)
- Fertility Agents (Injectable Gonadotropins Only)
- Growth Hormone
- Levitra and Staxyn (Vardenafit)
- Mecasermin (Increlex)
- Newer Sedative Hypnotics
- PDE-5 Inhibitors (Cialis, Levitra, Viagra, and Staxyn)
- Pramlintide (Symlin)
- Proton Pump Inhibitor
- Renin Angiotensin Antihypertensive Agents (RAAs) (Amturnide, Atacand, Atacand HCT, Avapro, Avalide, Azor, Benicar, Benicar HCT, Edarbi, Tekamlo, Tekturna, Tekturna HCT, Teveten, Teveten HCT, Tribenzor, and Valturna)
- Simponi (Golimumab)
- Topical Antifungals
- Thiazolidinediones (TZDs)
- Victoza