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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)

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.

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