This pre-authorization form allows members to initiate a request for a non-formulary medication.
The pharmacy department will review your request and process.
The following criteria will be used when reviewing a request:
- The member has failed a trial of preferred and standard medications.
These medications should include:
- Drugs in the same therapeutic class as the requested drug
- Other recognized drug therapies for the medical condition
- Drugs on the preferred and standard list are contraindicated for this member.