Review Process for requests to bypass Step Therapy, Quantity Limit and Brand restrictions
Our providers may initiate the review request by completing our Medication Request Form (located in the Drug Formulary) or by contacting member services at (800) 310-2835 and having the form faxed directly to the office.

To ensure that you are submitting the correct form, please search the requested drug on our online Drug Formulary to obtain the appropriate prior-authorization form.

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.

Please click on the form that you need and it will open in PDF format so you can print it.
If you need acrobat reader please click here to download it.

MEDICATION LIST Q & A

Personal Medication Profile

PRESCRIPTION DRUG PROGRAM MAIL SERVICE FORM
FORMULARIO DEL SERVICIO POR CORREO DEL PROGRAMA DE MEDICAMENTOS RECETADOS

ICORE HEALTHCARE DRUG ORDER FORM (Non-PA Drugs)

ICORE HEALTHCARE ORAL CHEMOTHERAPY PRESCRIPTION FORM

HNE MEDICARE ADVANTAGE PART B FORM

HNE MEDICARE ADVANTAGE PART D 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)