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Specialty / Injectable Prior Authorization Forms

• Aranesp Request Form (PDF)

• Botox or Myobloc Request Form (PDF)

• Chemotherapy Drug Request Form (PDF)

• Forteo Request Form (PDF)

• Fuzeon HIV RNA Tracking Form (PDF)

• Fuzeon Medication History Form (PDF)

• Fuzeon Procedure and Required Information Form (PDF)

• Growth Hormone Request Form (PDF)

• Hyaluronic Acid Derivatives Request Form (Euflexxa/Synvisc) (PDF)

• Long-Acting Inject able Atypical Antipsychotics (PDF)

• Pegasys/Ribavirin, Peg-Intron, or Non Pegylated Interferons for Hepatitis C Treatment Request Form (PDF)

• Procrit Request Form (PDF)

• Remicade Request Form (PDF)

• Self-Administered and Specialty Drugs Order Form (PDF)

• Self Injectable Biological for Treating Arthritis (i.e. Enbrel® or Humira®) Request Form

• Self Injectable Biological for Treating Psoriasis, Psoriatic Arthritis or Ankylosing Spondylitis (Enbrel® and Humira®) (PDF)

• Serostim Request Form (PDF)

• Specialty / Injectable Drug Request Form (PDF)

• Suboxone®/Subutex® Prior Authorization Form (PDF)

• Tysabri Request Form (Natalizumab) (PDF)

• White Blood Cell Stimulators (Leukine®, Neupogen®, Neulasta®) (PDF)

• Xolair Request Form (PDF)

• Zoladex® or Lupron® Physician Request Form (PDF)