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