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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
Medication Request Forms (MRF) and Clinical Coverage Criteria

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

A-E F-J K-O P-S T-Z

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
(buproprion)
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))
Cosentyx
(secukinumab)
Cymbalta2
(duloxetine)
Delatestryl
(testosterone)
Depo-Testosterone
(testosterone)
Desvenlafaxine ER2
(desvenlafaxine)
Diabetic Test Strips
Differin1
(adapalene)
Dysport
(abobotulinum toxin A)
Edluar2
(zolpidem)
Effexor2
(venlafaxine)
Effexor XR2
(venlafaxine XR)
Egrifta
(tesamorelin)

Elidel
(pimecrolimus)
EMLA1
(lidocaine/ prilocaine)
Enbrel
(etanercept)
Epiduo1
(adepalene/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)
Ilaris
(canakinumab)
Imitrex tabs2
(sumatriptan)
Increlex
(mecasermin recombinant)

Injectable MRF
Intermezzo2
(zolpidem tartrate subl tab)
itraconazole
(itraconazole)
Januvia2
(sitagliptin)
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)

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)
Otezla (PA not required until 4/1/2015)
(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)
Victrelis
(boceprevir)
Viibryd 2
(vilazodone)
Vogelxo
(testosterone)
Vytorin2
(ezetimibe/simvastatin)
10/10 and 10/20 only
Wellbutrin2
(bupropion)
Wellbutrin SR2
(bupropion ER)
Wellbutrin XL2
(bupropion)
Xeljanz
(tofacitinib citrate)
Xeomin
(incobotulinum toxin A)
Xolair
(omalizumab)
ZetiaST2
(ezetimibe)
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

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