Specialty/Injectable Request Forms

• Patient Self-Administered Injectable and Specialty Drugs Request Form (PDF)

• Aranesp® Request Form (PDF)

• Botulinum Toxins Request Form (PDF)

• Chemotherapy/Antiemetic Drug Replacement/Request Form (PDF)

• Erythropoietin (Epogen®) Required Documentation for Approval of Monthly Doses Greater Than 50,000 Units (PDF)

• Forteo®, Boniva® Injection, & Reclast® Prior Authorization Request Form (PDF)

• Fuzeon® Prior Authorization Procedure & Required Information Form (PDF)

• Fuzeon® Medication History Form (PDF)
  Documenting failure to oral anti-retroviral therapy.

• Fuzeon® HIV RNA Tracking Form (PDF)

• Patient Self-Administered Growth Hormone Request Form (PDF)

• Hepatitis C Treatment Prior Authorization Form (PDF)
  Peg-Intron/Ribavirin

• Physician Administered Hyaluronic Acid Derivatives Request Form (PDF)
  i.e. Euflexxa/Synvisc Injection

• Injectable Drug Replacement / Request Form (PDF)
  For Physician's Office

• Ixempra Physician Request Form (PDF)

• Kuvan Physician Request Form (PDF)

• Long Acting Injectable Atypical Antipsychotics Request Form (PDF)
  Risperdal Consta/Invega Sustenna

• Lupron® Replacement Request Form (PDF)

• Procrit® Request Form (PDF)

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

• Request Form for Self Injectable Biologicals for Treating Psoriasis, Ankylosing Spondylitis or Psoriatic Arthritis (PDF)
  i.e. Enbrel, Humira

• Serostim® Prior Authorization Request Form (PDF)

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

• Synagis® Request Form (PDF)

• Tysabri® (Natalizumab) Office Administration Request Form (PDF)

• White Blood Cell Stimulators Request Form (PDF)
  i.e. Leukine or Neupogen

• Xolair® Prior Authorization Request Form (PDF)