Specialty Prior Authorization Forms
Note: Prior authorization is no longer needed for 17P (PDF)
A – F
- Aranesp® request form (PDF)
- Biological (self-injectable) for arthritis request form (PDF)
- Biologicals (self-injectable) for psoriasis, psoriatic arthritis request form (PDF)
- Chemotherapy coverage determination form (PDF)
- Erythropoietin (Epogen®; monthly) approval form (PDF)
- Forteo®, Reclast®, Prolia®, or Boniva® injection request form (PDF)
- Fuzeon® medication history form (PDF)
- Fuzeon PA procedure and required information form (PDF)
G – I
- Growth hormone (patient self-administered) request form (PDF)
- Hemophilia drug request form (PDF)
- Hepatitis C prior authorization request form (PDF)
- HIV RNA tracking form while receiving Fuzeon (PDF)
- Hyaluronic acid derivatives (physician-administered) request form (PDF)
- Infusible biological medications prior authorization request form (PDF)
- Injectable and specialty drugs (patient self-administered) request form (PDF)
- Injectable drug replacement / request form (PDF)
- Ixempra® request form (PDF)
J – R
- Juxtapid®/Kynamro® request form (PDF)
- Kuvan® request form (PDF)
- Long-acting injectable atypical antipsychotics request form (PDF)
- Lupron® replacement request form (PDF)
- Myobloc®, Botox®, or Dysport® request form (PDF)
- Opioid Containing Products Request Form (PDF)
- Opioid dependence agents request form (PDF)
- Oral oncology medication request form (PDF)
- PROCRIT® request form (PDF)