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NEW!
SYNAGIS PRESCRIPTION DRUG FORM
PRESCRIPTION DRUG PROGRAM MAIL SERVICE FORM
ICORE HEALTHCARE DRUG ORDER FORM (Non-PA Drugs)
ICORE HEALTHCARE ORAL CHEMOTHERAPY PRESCRIPTION FORM
Out of Network Prescription Reimbursement Form.
For reimbursement of a prescription purchased out of the service area, please download and print this form. Prescription Claim Form (PDF)
Review request for newly approved drugs and quantity limitations
If a physician requests an FDA approved medication for a non-FDA approved disease state/condition, or dosing schedule, you must submit at least 3 peer-reviewed journal articles or abstracts; a national or published Clinical Guideline; and/or published information regarding current standard of care.
Review Process
Our providers may initiate the review request by completing our Medication Request Form below or by contacting member services at (800) 310-2835 and having the form faxed directly to the office.
Pharmacy Prior-Authorization Forms
These PDF formatted forms are to be used by participating physicians and pharmacy providers to obtain coverage of the following medications.
Use the scroll arrows at the left to see the entire list.
Actiq® (Fentanyl Lozenge)
Amevive® (alefacerpt)
Angiotensin II Receptor Antagonist Step Therapy
Aranesp® (darbepoetin alfa)
Atralin (tretinoin)
Botox (botulinum toxin Type A)
Celebrex (celecoxib)
Cerezyme (imiglucerase)
Differin ® (adapalene)
Elaprase ® (idursulfase)
Enbrel® (etanercept)
Epogen (epoetin alfa)
Fabrazyme (agalsidase beta)
Flolan (epoprostenol)
Forteo (teriparatide)
Gleevec ® (Imatinib)
Growth Hormone (Adult)
Growth Hormone (Pediatric)
Humira (adalimumab)
Kineret (anakinra)
Leukine (sargramostim)
Meridia (sibutramine)
Mobic (meloxicam)
Nexavar ( sorafenib tosylate)
Noxafil ® (posaconazole)
Orencia ® (abatacept)
Pegasys (peginterferon alfa-2a)
PEG-Intron (peginterferon alfa-2b)
Procrit (epoetin alfa)
Provigil (Modafinil)
Raptiva (efalizumab)
Remicade (infliximab)
Remodulin (treprostinil)
Revatio (sildenafil)
Revlimid ® (lenalidomide)
Retin-A® (tretinoin)
Rituxan ® (rituximab)
Singulair (montelukast)
Sprycel ® (dasatinib)
Suboxone (buprenorphine/Naloxone)
Subutex (buprenorphine)
Sutent (sunitinib malate)
Symlin (pramlintide)
Tasigna (nilotinib)
Tazorac ® (tazarotene)
Tracleer (Bosentan)
Tretin-X® (tretinoin)
Tykerb® (lapatinib)
Tysabri ® (natalizumab)
Ventavis (iloprost)
Vfend (voriconazole)
Xenical (orlistat)
Xolair (omalizumab)
Zolinza ® (vorinostat)
Zorbtive (somatropin)
Zyvox (linezolid)
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