List of Forms

Request for Step Therapy Exception Form

Request For Step Therapy Exception

Request for Quantity Limit Exception Form

Request For Quantity Limit Exception

Request for Coverage of a Non-Formulary Drug Form

Request For Coverage Of A Non-Formulary Drug

Request for a Lower Co-pay (Tiering Exception Form)

Request For A Lower Co-pay (Tiering Exception)

Quantity Limit Exception Form

Abilify® (aripiprazole)

Geodon® (ziprasidone)

Risperidone

Seroquel® (quetiapine)

Zyprexa® (olanzapine)

Prior Authorization Request Form

Abatacept (Orencia®)

Afinitor® (severolimus)

Alkeran

Amevive® (alefacept)

Amnesteem®, Claravis®, Sotret®, Accutane® (isotretinoin) Capsules

Antiemetics

Aralast®, Prolastin®, Zemaira® (human Alpha-1 Proteinase Inhibitor)

Bleomycin

Campath® (alemtuzumab)

Celebrex® (celecoxib)

Cerezyme® (imiglucerase)

Cyklokapron® (tranexamic Acid)

Declomycin® (demeclocycline)

Elitek® (Rasburicase)

Emsam® (selegiline Transdermal System)

Enbrel® (etanercept)

Eraxis® (anidulafungin), Cancidas® (caspofungin), And Mycamine® (micafungin)

Exjade® (deferasirox)

Faslodex® (fulvestrant)

Fentanyl Citrate Buccal Lollipop, Actiq®, Fentora®, Opana ER®, Opana®

Forteo® (teriparatide)

Gleevec® (imatinib)

Growth Hormones

Hexalen® (altretamine )

Humira® (adalimumab)

Humulin R U-500® (Insulin Regular 500 Units/mL)

Immunosuppressives Used In Organ Rejection

Infusion Drugs

Inhalation Solutions

Intravenous Immune Globulins

Intron A® (interferon Alpha 2-b)

Itraconazole

Ketek® (telithromycin)

Kineret® (anakinra)

Kuvan® (sapropterin)

Lamictal®, Lamictal Starter Kit®, Lamictal Dispersable Tabs® (lamotrigine)

Lamisil® (terbinafine)

Leukine® (Sargramostim)

Lotronex® (alosetron)

Lovaza® (omega-3 Acid Ethyl Esters)

Lupron Depot®, Lupron Depot-Ped®, Leuprolide, Eligard®, Zoladex®, Viadur®

Naglazyme® (galsulfase)

Namenda® (memantine) Oral Solution

Neupogen® (filgrastim) & Neulasta® (pegfilgrastim)

Nexavar® (sorafenib)

Nexium® (esomeprazole)

Novantrone® (mitoxantrone)

Noxafil® (posaconazole)

Ontak® (denileukin Diftitox)

Oral Hepatitis B Drugs

Oxandrin® (oxandrolone)

Oxycontin® (oxycodone Extended-release)

Oxymetholone

PEG Intron® (Peginterferon Alpha 2-b Injection)

Pegasys® (peginterferon Alpha 2-a Injection)

Penlac® (Ciclopirox)

Prior Authorization Form

Procrit®, Epogen® (Epoetin) And Aranesp® (Darbepoetin)

Proleukin® (aldesleukin)

Promacta® (eltrombopag)

Provigil® (modafinil)

Pulmicort Respules® (budesonide)

Pulmozyme® (dornase Alfa)

Qualaquin® (Quinine Sulfate)

Raptiva® (efalizumab)

Rebetol®, CopegusTM (ribavirin)

Rebif®, Avonex® (interferon Beta-1a), Betaseron® (interferon Beta-1b) & Copaxone® (glatiramer Acetate)

Regranex® (becaplermin)

Remicade® (infliximab)

Revatio® (sildenafil)

Revlimid® (lenalidomide)

Rilutek® (Riluzole)

Rituxan® (rituximab)

Roferon A® (interferon Alpha 2-a)

Sensipar® (cinacalcet)

Somatuline® (lanreotide Acetate), Sandostatin® And Sandostatin LAR® Depot (octreotide), Somavert® (pegvisomant)

Sutent® (sunitinib)

Tarceva® (erlotinib)

Targretin® (bexarotene) Capsules

Targretin® (bexarotene) Gel

Thalomid® (thalidomide)

Topamax® (topiramate) Tablets

Total Parenteral Nutrition

Trelstar® (triptorelin)

Trisenox® (arsenic Trioxide)

Twinrix®, Engerix-B®, Recombivax®

Tykerb® (lapatinib)

Valcyte® (valganciclovir)

Velcade® (bortezomib)

Vesanoid® (tretinoin)

Vfend® (voriconazole)

Vidaza® (azacitidine)

Vimpat® (lacosamide) Oral Tablets

Vistide® (cidofovir)

Vivitrol® (naltrexone)

Xenical® (orlistat)

Xolair® (omalizumab)

Zolinza® (vorinostat)

Criteria Forms

Aranesp Albumin Free Sure

Lamictal Chewable Dispersible

Norditropin Cartridge

Norditropin Nordiflex Pen

Peg-intron Redipen Pak 4

Sandostatin Lar Depot