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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)
Addyi
(flibanserin)
Adcirca
(tadalafil)
Afrezza
(human insulin regular)
Alogliptan benzoate
(alogliptan benzoate)
Ambien2
(zolpidem)
Ambien CR2
(zolpidem CR)
Amerge2
(naratriptan)
Androderm
(testosterone transdermal)
Androgel
(testosterone 1%)
Aplenzin
(bupropion)
Aralast
(alpha 1-proteinase inhibitor)
Aranesp
(darbepoetin)
Armodafinil
(armodafinil)
Atralin1
(tretinoin topical)
Avita1
(tretinoin)
Axert2
(almotriptan)
Axiron
(testosterone)
Belsomra
(suvorexant)
Botox
(botulinum toxin A)
Briviact
(brivaracetam)
Bydureon2
(exenatide microspheres)
Byetta2
(exenatide)
Celexa2
(citalopram)
Cerezyme
(imiglucerase)
Cialis1
(tadalafil)
ciclodan 8% solution
(ciclopirox)
ciclopirox 8.0% solution
Cimzia
(certolizumab pegol)
Cinryze
(C1 Inhibitor (human))
Corlanor
(ivabradine hcl)
Cosentyx
(secukinumab)
Cymbalta2
(duloxetine)
Daklinza
(daclatasvir)
Delatestryl
(testosterone)
Depo-Testosterone
(testosterone)
Dermapak Plus
(tretinoin 0.025%)
Desvenlafaxine ER2
(desvenlafaxine)
Diabetic Test Strips
Differin1
(adapalene)
Duexis
(ibuprofen/famotidine)
Durlaza
(aspirin ER)
Dysport
(abobotulinum toxin A)
Edluar2
(zolpidem)
Effexor/XR2
(venlafaxine)
Egrifta
(tesamorelin)
Elelyso
(taliglucerase)

Elidel
(pimecrolimus)

Enbrel
(etanercept)
Entresto
(sacubitril/valsartan)
Epiduo1
(adepalene/benzoyl peroxide)
Epiduo Forte (adapalene/benzoyl peroxide)
Epogen
(epoetin alpha)
Esomeprazole magnesium (esomeprazole magnesium)
Evzio
(naloxone HCl)
Eylea
(aflibercept)
Fabior
(tazarotene)
fentora
(fentanyl citrate)
Fetzima2
(levomilnacipran hydrochloride)
Fluoxetine 60mg tabs
(fluoxetine)
Follistim AQ2
(follitropin beta)
Formulary Exception Request Form
Forteo
(teriparatide)
Fortesta
(testosterone)
Frova2
(frovatriptan)
Fulyzaq2
(crofelemer)
Gattex
(teduglutide)
Genotropin
(somatropin)

Glumetza
(metformin)
Harvoni
(ledipasvir/ sofosbuvir)
Hetlioz
(tasimelteon)
Humatrope
(somatropin)
Humira
(adalimumab)
Ilaris
(canakinumab)
Imitrex tabs2
(sumatriptan)
Increlex
(mecasermin recombinant)

Injectable MRF

Intermezzo2
(zolpidem tartrate subl tab)
Irenka
(duloxetine)
itraconazole
(itraconazole)
Jublia
(efinaconazole)
Kalydeco
(ivacaftor)
Kerydin
(tavaborole)
Khedezla2
(desvenlafaxine)
Kineret
(anakinra)
Lazanda
(fentanyl citrate)
Levitra1
(vardenafil)
Lexapro2
(escitalopram)
Lumizyme
(alglucosidase alfa)
Lunesta2
(eszopiclone)
Luvox CR2
(fluvoxamine)
Lyrica2
(pregabalin)
Maxalt/ MLT2
(rizatriptan; oral-disintegrating tablet)
modafinil
(modafinil)
Myobloc
(botulinum toxin B)
Myozyme
(alglucosidase)
Natesto
(testosterone, nasal gel)

Nesina2
(alogliptin benzoate)

New To Market Drugs
Nexium
(esomeprazole)
Norditropin/ Nordiflex
(somatropin)
Nplate
(romiplostim)
Nuplazid
(pimavanserin tartrate)
Nutropin/ AQ/ AQ Nuspin
(somatropin)
Nuvigil
(armodafinil)
Ocaliva
(obethicholic acid)
Olysio
(simeprevir sodium)
Omnitrope
(somatropin)
Onfi
(clobazam)
Onglyza2
(saxagliptin)
Onmel
(itraconazole)
Onzetra Xsail
(sumariptan succinate)
Orencia
(abatacept)
Orkambi
(lumacaftor/ivacaftor)
Otezla
(apremilast)
Paxil/ CR2
(paroxetine)
Pedipirox-4
(ciclopirox 8.0% solution)
Penlac
(ciclopirox)
Pennsaid
(diclofenac sodium)
Pexeva2
(paroxetine)
Praluent
(alirocumab)

Pristiq2
(desvenlafaxine)
Procrit
(epoetin alpha)
Prolastin
(alpha 1-proteinase inhibitor)
Prolia
(denosumab)
Protopic
(tacrolimus)
Provigil
(modafinil)
Prozac/ Weekly2
(fluoxetine/ fluoxetine hcl)
Rayos
(prednisone)
Repatha
(evolocumab)

Revatio
(sildenafil citrate)

Retin-A/ Micro1
(tretinoin)

Rexulti
(brexpiprazole)
Rozerem2
(ramelteon)
Rytary
(carbidopa/levodopa)

Saizen
(somatropin)

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

tretinoin1

Treximet
(sumatriptan/naproxen)
Trintellix2
(vortioxetine hydrobromide)
Trulicity
(dulaglutide)
Uptravi
(selexipag)
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)
Vivlodex
(meloxicam)
Vogelxo
(testosterone)
Vpriv
(velaglucerase alfa)
Vraylar
(cariprazine)
Wellbutrin/ SR/ XL2
(bupropion/ bupropion ER)
Xeljanz
(tofacitinib citrate)
Xeomin
(incobotulinum toxin A)
Xgeva
(denosumab)
Xolair
(omalizumab)
Xtampza ER
(oxycodone myristate)
Zecuity
(sumatriptan-transdermal)
Zemaira
(alpha 1-proteinase inhibitor)
Zembrace
(sumatriptan-subcutaneous)
Zepatier
(elbasvir/grazoprevir)
Ziana1
(tretinoin)
Zohydro ER
(hydrocodone bitartrate)
Zoloft2
(sertraline)
Zolpimist2
(zolpidem)
Zomig/ ZMT2
(zolmatriptan)
Zorbtive
(somatropin)

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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