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Rx Review Forms
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 Review Request Form or by contacting provider services and having the form faxed directly to them at 1-800-310-2835.
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), for the DX of psoriasis
Enbrel, for the DX of rheumatoid arthritis,polyarticular juvenile rheumatoid arthritis or psoriatic arthritis.
Epogen (epoetin alfa)
Exubera ® (insulin human inhalation powder)
Fabrazyme (agalsidase beta)
Flolan (epoprostenol)
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)
Procrit (epoetin alfa)
Provigil (Modafinil)
Raptiva (efalizumab)
Remicade (infliximab)
Remodulin (treprostinil)
Revatio (sildenafil)
Revlimid ® (lenalidomide)
Retin-A® (tretinoin)
Rituxan ® (rituximab)
Singulair (montelukast)
Soliris ® (eculizumab)
Sprycel ® (dasatinib)
Sutent (sunitinib malate)
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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