Us Family Health Plan Pharmacy Program Medical Necessity Form For Topical Antifungals Page 3
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4US Family Health Plan Pharmacy Program Medical Necessity Form
for Topical Antifungals
Page 1 of 2
This form applies to the US Family Health Plan Mail Order Pharmacy and the US Family Health Plan Retail Pharmacy programs. This form must be completed and signed by
the prescriber.
Formulary topical antifungals available at the formulary copay include butenafine (Mentax), clotrimazole, ketoconazole, miconazole,
naftifine (Naftin), and nystatin. Topical formulations of ciclopirox (Loprox), econazole (Spectazole), oxiconazole (Oxistat),
sertaconazole (Ertaczo), sulconazole (Exelderm), and miconazole 0.25% / zinc oxide 15% (Vusion) are non-formulary, but
available to most beneficiaries at the non-formulary cost share. The non-formulary designation applies to both the brand name
and generic versions of these medications.
You do NOT need to complete this form in order for non-active duty beneficiaries (spouses, dependents, and retirees) to obtain non-
formulary medications at the non-formulary cost share. The purpose of this form is to provide information that will be used to determine
if the use of a non-formulary medication instead of a formulary medication is medically necessary. If a non-formulary medication is
determined to be medically necessary, non-active duty beneficiaries may obtain it at the formulary cost share.
• The provider may call: 1-877-880-7007
or the completed form may be faxed to:1-617-562-5296
• The patient may attach the completed form to the prescription and mail
it to: ATTN: Pharmacy, 77 Warren St, Brighton, MA 02135
Step
Please complete patient and physician information
(Please Print)
1
Patient Name:
Physician Name:
Address:
Address:
Sponsor ID #
Phone #:
Date of Birth:
Secure Fax #:
Step
Please indicate which medication is being prescribed:
1.
2
□
ciclopirox (Loprox)
Please go to Question 2
□
econazole (Spectazole)
□
oxiconazole (Oxistat)
□
sertaconazole (Ertaczo)
□
sulconazole (Exelderm)
□
miconazole 0.25% / zinc oxide 15% (Vusion)
Please go to Question 3
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