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)
  • Hepatitis C prior authorization criteria (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)

S – Z

• SEROSTIM® prior authorization request form (PDF)
• Synagis® request form (PDF)
• Tasigna® request form (PDF)
• Tysabri® office administration request form (PDF)
• White blood cell stimulators request form (PDF)
• XOLAIR® prior authorization request form (PDF)