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Prior Authorization

Certain covered drugs that have been approved by the FDA for specific medical conditions require prior authorization. The approval criteria were developed and endorsed by the Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Download the prior authorization criteria.

A request form must be completed for all medications requiring prior authorization. The forms below are available in PDF format. Current prior authorization medications are:

Request form instructions

Providers:
  1. When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will be faxed back to your office for completion, which will delay the review process.
  2. Fax completed forms to FutureScripts® Secure for review. Make sure you include your office telephone and fax number on the form.
  3. You will be notified by fax if the request is approved. You and your patient will receive a denial letter if the request is denied.
  4. If you have not received a response after 72 hours from submitting complete information, contact FutureScripts Secure. Information regarding expedited requests.
Members:
  1. Take the appropriate request form to your physician to be completed.
  2. You or your physician may fax the completed form to FutureScripts Secure for review.
  3. If you have not received a response from your provider after two business days, contact the provider who requested the prior approval on your behalf.
  4. If you have questions, please contact Customer Service at the number listed on the back of your identification card.

FutureScripts Secure fax numbers:

  • 215-241-3073 inside local Philadelphia area
  • 888-671-5285, toll-free outside the local calling area

Tiered cost-sharing exceptions

Physicians, on behalf of members, may request coverage of a non-formulary medication, at the preferred formulary copay. The physician should complete the Non-formulary Exception Request Form providing detail to support use of the non-preferred medication and fax the request to 215-241-3073 or 1-888-671-5285. The Non-preferred Exception Request Form can also be obtained by calling 1-888-678-7015 (Option #3).

If the non-preferred request is approved, the drug will be processed at the appropriate formulary benefit copay. If the request is denied, the member and physician will receive a denial letter that explains the appeal process. The member may still receive benefits for the drug at the non-preferred copay or coinsurance.