Harvard Pilgrim Health Care - Medication Request Forms (MRF) and Clinical Coverage Criteria 3-Tier

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	Home > Providers > Pharmacy > Premium 3-Tier Prescription Drug Program > Medication Prior Authorization 3-Tier > Medication Request Forms (MRF) and Clinical Coverage Criteria 3-Tier

Beginning November 2016, Massachusetts providers should use the Massachusetts Standard Form for Medication Prior Authorization Requests to request coverage for most drugs that require prior authorization. Please refer to our drug specific criteria for details related to required information.

Providers in all other service states should continue to use the drug-specific Medication Request Forms (MRF). Completed forms should be faxed to MedImpact Healthcare Systems at 888-807-6643. If you have any questions regarding this process, please contact MedImpact's Customer Service at 800-788-2949.

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

Medication	Medication Request Forms* (MRF) and Clinical Coverage Criteria*
Abstral (fentanyl citrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Actemra (tocilizumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Acthar (corticotropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Actiq (fentanyl citrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Addyi (flibanserin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Adcirca (tadalafil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Adlyxin	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Afrezza (human insulin regular)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
AirDuo Respiclick⁴ (fluticasone/salmeterol)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Aktipak⁴ (erythromycin/benzoyl peroxide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Akynzeo³ (netupitant/ palonosetron)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Alogliptan benzoate (alogliptan benzoate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Ambien² (zolpidem)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Alunbrig ⁴ (brigatinib)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Ambien CR² (zolpidem CR)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Amerge² (naratriptan)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Androderm (testosterone transdermal)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Androgel (testosterone 1%)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Aplenzin (bupropion)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Aralast (alpha 1-proteinase inhibitor)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Aranesp (darbepoetin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Armodafinil (armodafinil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Atralin¹ (tretinoin topical)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Austedo⁴ (deutetrabenazine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
AUVI-Q (epinephrine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Avita¹ (tretinoin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

Axert² (almotriptan)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Axiron (testosterone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Basaglar Kwikpen (insulin glargine, hum.rec. anlog)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Belsomra (suvorexant)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Bepreve³ (bepotastine besilate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Botox (botulinum toxin A)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Briviact (brivaracetam)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Bydureon² (exenatide microspheres)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Byetta² (exenatide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Carac³ (fluorouracil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Celexa² (citalopram)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Cialis¹ (tadalafil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
ciclodan 8% solution (ciclopirox)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Cimzia (certolizumab pegol)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Cinryze (C1 Inhibitor (human))	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
clindamycin/tretinoin (clindamycin/tretinoin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Compound Exceptions	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Corlanor (ivabradine hcl)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Cosentyx (secukinumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Cresemba³ (isavuconazonium sulfate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Cuprimine (penicillamine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Cymbalta² (duloxetine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

Daklinza (daclatasvir)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Daraprim (pyrimethamine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Delatestryl (testosterone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Depen (penicillamine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Depo-Testosterone (testosterone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Dermapak Plus (tretinoin 0.025%)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Dexilant³ (dexlansoprazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Diabetic Test Strips	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Diclofenac sodium	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Differin¹ (adapalene)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Duavee³ (conjugated estrogens/ bazedoxifene)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Duexis (ibuprofen/ famotidine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Dupixent (dupilumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Durlaza (aspirin ER)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Dysport (abobotulinum toxin A)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Edluar² (zolpidem)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Effexor/XR² (venlafaxine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Egrifta (tesamorelin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Elidel (pimecrolimus)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Emflaza (deflazacort)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Enbrel (etanercept)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Entresto (sacubitril/ valsartan)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Epclusa (sofosbuvir/ velpatasvir)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Epiduo¹ (adepalene/ benzoyl peroxide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Epiduo Forte (adapalene/ benzoyl peroxide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Epogen (epoetin alpha)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Ertaczo³ (sertaconazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Esomeprazole magnesium (esomeprazole magnesium)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Eucrisa⁴ (crisabarole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Evzio (naloxone HCl)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Eylea (aflibercept)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

Fabior (tazarotene)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Farxiga³ (dapagliflozin propanediol)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
fentora (fentanyl citrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Fetzima² (levomilnacipran hydrochloride)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Fluoroplex³ (fluorouracil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Fluorouracil³	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Fluoxetine 60mg tabs (fluoxetine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Follistim AQ² (follitropin beta)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Formulary Exception Request Form	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Forteo (teriparatide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Fortesta (testosterone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Frova² (frovatriptan)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Gattex (teduglutide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Genotropin (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Glumetza (metformin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Harvoni (ledipasvir/ sofosbuvir)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Hemangeol³ (propranolol HCL)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Hetlioz (tasimelteon)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Humatrope (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Humira (adalimumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Ilaris (canakinumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Imitrex tabs² (sumatriptan)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Increlex (mecasermin recombinant)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Ingrezza⁴ (valbenazine tosylate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Injectable MRF	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Intermezzo² (zolpidem tartrate subl tab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Irenka (duloxetine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
itraconazole (itraconazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Jublia (efinaconazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

Kalydeco (ivacaftor)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Kerydin (tavaborole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Keveyis³ (dichlorphenamide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Kevzara⁴ (sarilumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Khedezla² (desvenlafaxine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Kineret (anakinra)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Kisqali (ribociclib succinate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Kisqali Femara Co-Pack (ribociclib succinate/letrozole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Lazanda (fentanyl citrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Levitra¹ (vardenafil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Lexapro² (escitalopram)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Lipitor (atorvastatin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Lunesta² (eszopiclone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Luvox CR² (fluvoxamine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Luzu³ (luliconazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Lyrica² (pregabalin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Maxalt/ MLT² (rizatriptan; oral disintegrating tablet)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Mentax³ (butenafine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Minitran³ (nitroglycerin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Mircera (methoxy peg-epoetin beta)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Mirvaso³ (brimonidine tartrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
modafinil (modafinil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Myobloc (botulinum toxin B)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Mytesi (crofelemer)	MRF (Non-MA providers) MA Standard PA Form NH Standard PA form Criteria

Natesto (testosterone, nasal gel)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Neo-Synalar³ (neomycin/fluocinolone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Nesina² (alogliptin benzoate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Nexium (esomeprazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Norditropin/ Nordiflex (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Novolog/Mix 70/30 (insulin aspart)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Novolin N/R/70/30 (human insulin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Nuplazid (pimavanserin tartrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Nutropin/ AQ/ AQ Nuspin (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Nuvigil (armodafinil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Ocaliva (obethicholic acid)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Olysio (simeprevir sodium)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Omnitrope (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Onfi (clobazam)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Onglyza² (saxagliptin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Onmel (itraconazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Onzetra Xsail (sumariptan succinate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Orencia (abatacept)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Orkambi (lumacaftor/ ivacaftor)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Otezla (apremilast)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Paxil/ CR² (paroxetine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Pedipirox-4 (ciclopirox 8.0% solution)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Penlac (ciclopirox)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Pennsaid (diclofenac sodium)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Pexeva² (paroxetine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Picato³ (ingenol mebutate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Plegridy³ (peginterferon beta-1A)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Plegridy Pen³ (peginterferon beta-1A)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Praluent (alirocumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Pristiq² (desvenlafaxine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Procrit (epoetin alpha)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Prolastin (alpha 1-proteinase inhibitor)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Prolia (denosumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Protopic (tacrolimus)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Provigil (modafinil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Prozac/ Weekly² (fluoxetine/ fluoxetine hcl)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

Rayaldee (calcifediol)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Rayos (prednisone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Relistor (methylnaltrexone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Repatha (evolocumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Revatio (sildenafil citrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Rescula (unoprostone isopropyl)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Retin-A/ Micro¹ (tretinoin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Rexulti (brexpiprazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Rhofade (oxymetazoline hcl)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Rozerem² (ramelteon)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Rydapt⁴ (midostaurin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Rytary (carbidopa/ levodopa)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Saizen (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Sarafem² (fluoxetine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Savella (milnacipran)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Selfemra² (fluoxetine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Serostim (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Silenor ² (doxepin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Siliq⁴ (broadalumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Simponi (golimumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Sirturo³ (bedaquiline fumarate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Solaraze³ (diclofenac sodium)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Soliqua	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Solodyn (minocycline)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Sovaldi (sofosbuvir)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Sonata² (zaleplon)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Sporanox (itraconazole)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Staxyn¹ (vardenafil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Stelara (ustekinumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Stendra¹ (avanfil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Striant (testosterone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Striverdi Respimat³ (olodaterol)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Subsys (fentanyl citrate spray)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Synagis (palivizumab)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Syprine (trientine hydrochloride)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

Taltz (ixekizumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tanzeum (albiglutide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tazorac¹ (tazarotene)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Technivie (ombitasvir/ paritaprevir/ ritonavir)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Testim (testosterone 1%)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tev-Tropin (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tresiba (insulin degludec)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tresiba Flextouch (insulin degludec)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tretin-X¹ (tretinoin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
tretinoin¹	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Treximet (sumatriptan/ naproxen)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Trintellix² (vortioxetine hydrobromide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Trulance (plecanatide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Trulicity (dulaglutide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tuzistra XR³ (chlorpheniramine/ codeine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Tymlos⁴ (abaloparatide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Uptravi (selexipag)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Viekira Pak (ombitasvir/ paritaprevir/ ritonavir/ dasabuvir)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Velphoro³ (sucroferric oxyhydroxide)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Veltin¹ (clindamycin/tretinoin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Venlafaxine ER (venlafaxine er)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Viagra ¹ (sildenafil)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Victoza ² (liraglutide)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Viibryd ² (vilazodone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Vimovo (naproxen/ esomeprazole mag)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Vivlodex (meloxicam)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Vogelxo (testosterone)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Vraylar (cariprazine)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Wellbutrin/ SR/ XL² (bupropion/ bupropion ER)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

Xadago⁴ (safinamide mesylate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xeljanz (tofacitinib citrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xeomin (incobotulinum toxin A)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xermelo (telotristat etiprate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xgeva (denosumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xigduo XR³ (dapagliflozin/metformin HCL)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xolair (omalizumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xtampza ER (oxycodone myristate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Xultophy (insulin degludec/ liraglutide)	MRF MA Standard PA form NH Standard PA form Criteria
Zejula⁴ (niraparib tosylate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zemaira (alpha 1-proteinase inhibitor)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zembrace (sumatriptan- subcutaneous)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zepatier (elbasvir/ grazoprevir)	MRF (Non-MA providers) MA Standard PA form (Coming soon) NH Standard PA form Criteria
Ziana¹ (tretinoin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zinbryta (daclizumab)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zohydro ER (hydrocodone bitartrate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zoloft² (sertraline)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zolpimist² (zolpidem)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zomig/ ZMT² (zolmatriptan)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zontivity³ (vorapaxar sulfate)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zorbtive (somatropin)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria
Zurampic (lesinurad)	MRF (Non-MA providers) MA Standard PA form NH Standard PA form Criteria

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

³ Prior Authorization is required for Value formulary only

⁴ Prior Authorization is required for Premium formulary only

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