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Medication Request Forms (MRF) and Clinical Coverage Criteria

Please note: Criteria are applicable for Commercial members, except as indicated.

Medication
Medication Request Forms* (MRF) and
Clinical Coverage Criteria*
Abstral
(fentanyl citrate)
Actemra
(tocilizumab)
Acthar
(corticotropin)
Actiq (fentanyl citrate)
Adcirca
(tadalafil)
Afrezza
(human insulin regular)
Ambien2
(zolpidem)
Ambien CR2
(zolpidem CR)
Amerge2
(naratriptan)
Androderm
(testosterone transdermal)
Androgel
(testosterone 1%)
Aplenzin
(bupropion)
Aranesp
(darbepoetin)
Atralin1
(tretinoin topical)
Avita1
(tretinoin)
Axert2
(almotriptan)
Axiron
(testosterone)
Belsomra
(suvorexant)
Botox
(botulinum toxin A)
Brintellix2
(vortioxetine hydrobromide)
Bydureon2
(exenatide microspheres)
Byetta2
(exenatide)
Celexa2
(citalopram)
Cialis1
(tadalafil)
ciclodan 8% solution
(ciclopirox)
ciclopirox 8.0% solution
Cimzia
(certolizumab pegol)
Cinryze
(C1 Inhibitor (human))
Corlanor
(ivabradine hcl)
Cosentyx
(secukinumab)
Cymbalta2
(duloxetine)
Delatestryl
(testosterone)
Depo-Testosterone
(testosterone)
Desvenlafaxine ER2
(desvenlafaxine)
Diabetic Test Strips
Differin1
(adapalene)
Duexis
(ibuprofen/famotidine)
Dysport
(abobotulinum toxin A)
Edluar2
(zolpidem)
Effexor2
(venlafaxine)
Effexor XR2
(venlafaxine XR)
Egrifta
(tesamorelin)

Elidel
(pimecrolimus)

EMLA1
(lidocaine/ prilocaine)
Enbrel
(etanercept)
Entresto
(sacubitril/valsartan)
Epiduo1
(adepalene/benzoyl peroxide)
Epiduo Forte (adapalene/benzoyl peroxide)
Epogen
(epoetin alpha)
Fabior
(tazarotene)
fentora
(fentanyl citrate)
Fetzima2
(levomilnacipran hydrochloride)
Fluoxetine 60mg tabs
(fluoxetine)
Follistim AQ2
(follitropin beta)
Forfivo XL2
(bupropion)
Formulary Exception Request Form
Forteo
(teriparatide)
Fortesta
(testosterone)
Frova2
(frovatriptan)
Fulyzaq2
(crofelemer)
Gattex
(teduglutide)
Genotropin
(somatropin)

Harvoni
(ledipasvir/ sofosbuvir)
Hetlioz
(tasimelteon)
Humatrope
(somatropin)
Humira
(adalimumab)
Hysingla ER
(hydrocodone bitartrate)
Ilaris
(canakinumab)
Imitrex tabs2
(sumatriptan)
Increlex
(mecasermin recombinant)

Injectable MRF

Intermezzo2
(zolpidem tartrate subl tab)
itraconazole
(itraconazole)
Jublia
(efinaconazole)
Kalydeco
(ivacaftor)
Kerydin
(tavaborole)
Khedezla2
(desvenlafaxine)
Kineret
(anakinra)
Lamisil
(terbinafine)
Lamisil Granules
(terbinafine granules)
Lazanda
(fentanyl citrate)
Levitra1
(vardenafil)
Lexapro2
(escitalopram)

lidocaine/ prilocaine1

Liptruzet1
(ezetimibe/atorvastatin)
Lunesta2
(eszopiclone)
Luvox CR2
(fluvoxamine)
Lyrica2
(pregabalin)
Maxalt2
(rizatriptan)
Maxalt MLT2
(rizatriptan; oral-disintegrating tablet)
modafinil
(modafinil)
Myobloc
(botulinum toxin B)
Natesto
(testosterone, nasal gel)

Nesina2
(alogliptin benzoate)

Norditropin
(somatropin)

Norditropin Nordiflex
(somatropin)

Nutropin
(somatropin)
Nutropin AQ
(somatropin)
Nutropin AQ Nuspin
(somatropin)
Nuvigil
(armodafinil)
Olysio
(simeprevir sodium)
Omnitrope
(somatropin)
Onfi
(clobazam)
Onglyza2
(saxagliptin)
Onmel
(itraconazole)
Orencia
(abatacept)
Orkambi
(lumacaftor/ivacaftor)
Otezla
(apremilast)
Paxil2
(paroxetine)
Paxil CR2
(paroxetine)
Pedipirox-4
(ciclopirox 8.0% solution)
Penlac
(ciclopirox)
Pexeva2
(paroxetine)
Pristiq2
(desvenlafaxine)
Procrit
(epoetin alpha)
Protopic
(tacrolimus)
Provigil
(modafinil)
Prozac2
(fluoxetine)
Prozac Weekly2
(fluoxetine hcl)
Revatio
(sildenafil citrate)

Retin-A1
(tretinoin)

Retin-A Micro1
(tretinoin)
Rozerem2
(ramelteon)

Saizen
(somatropin)

Sarafem2
(fluoxetine)
Savella
(milnacipran)
Selfemra2
(fluoxetine)
Serostim
(somatropin)
Silenor 2
(doxepin)
Simponi
(golimumab)
Solodyn
(minocycline)
Sovaldi
(sofosbuvir)
Sonata2
(zaleplon)
Sporanox
(itraconazole)
Staxyn1
(vardenafil)
Stelara
(ustekinumab)
Stendra1
(avanfil)
Striant
(testosterone)
Subsys
(fentanyl citrate spray)
Synagis
(palivizumab)
Tanzeum
(albiglutide)
Tazorac1
(tazarotene)
terbinafine HCL
Testim
(testosterone 1%)
Tev-Tropin
(somatropin)
Tretin-X1
(tretinoin)

tretinoin1

Treximet (sumatriptan/naproxen)
Trulicity
(dulaglutide)
Viekira Pak
ombitasvir/ paritaprevir/ ritonavir/ dasabuvir
Veltin1
(clindamycin/tretinoin)
Venlafaxine ER
(venlafaxine er)
Viagra 1
(sildenafil)
Victoza 2
(liraglutide)
Viibryd 2
(vilazodone)
Vimovo (naproxen/esomeprazole mag)
Vogelxo
(testosterone)
Wellbutrin2
(bupropion)
Wellbutrin SR2
(bupropion ER)
Wellbutrin XL2
(bupropion)
Xeljanz
(tofacitinib citrate)
Xeomin
(incobotulinum toxin A)
Xolair
(omalizumab)
Ziana1
(tretinoin)
Zohydro ER
(hydrocodone bitartrate)
Zoloft2
(sertraline)
Zolpimist2
(zolpidem)
Zomig2
(zolmatriptan)
Zomig ZMT2
(zolmatriptan)
Zorbtive
(somatropin)
Zyvox
(linezolid)

Key

1 Prior Authorization is required only when quantity limitation or restriction is exceeded

2 Prior Authorization is required only when Step Therapy requirement is not met


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Quantity limitations

Not available through the Mail Service Program

Medications not covered