Prior authorization forms
- Aranesp® request form (PDF)
- Enbrel® or Humira® for treating arthritis request form (PDF)
- Enbrel® or Humira® for treating psoriasis request form (PDF)
- Epogen® request form (PDF)
- Euflexxa®, Synvisc®/Hyalgan® injection request form (PDF)
- Forteo®, Boniva® Injection, Prolia®, or Reclast® prior authorization form (PDF)
- FUZEON® coverage determination form (PDF)
- Hepatitis C prior authorization form (PDF)
- Long-acting injectable atypical antipsychotics request form (PDF)
- Lupron® replacement request form (PDF)
- Miscellaneous chemotherapy medication request form (PDF)
- Miscellaneous injectable drug request form (PDF)
- Miscellaneous patient self-administered injectable and specialty drug request form (PDF)
- Myobloc®, Dysport®, Xeomin®, or Botox® request form (PDF)
- Patient self-administered growth hormone request form (PDF)
- Peg-Intron or Pegasys & Ribavirin & VICTRELIS or INCIVEK for hepatitis C treatment request form (PDF)
- Procrit® request form (PDF)
- Remicade® request form (PDF)
- Suboxone®/Subutex® prior authorization form (PDF)
- Synagis® request form (PDF)
- Tysabri® office administration request form (PDF)
- White blood cell stimulators request form (PDF)
i.e. Leukine or Neupogen
- XOLAIR prior authorization form (PDF)