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Specialty/Injectable Request Forms

Adobe PDF Patient Self-Administered Injectable and Specialty Drugs Request Form
Adobe PDF Aranesp® Request Form
Adobe PDF Avastin® (bevacizumab) Request Form
Adobe PDF Botox® Request Form
Adobe PDF Chemotherapy Drug Replacement/Request Form
Adobe PDF Erbitux® (cetuximab) Request Form (for 100mg/ 50-ml vials)
Adobe PDF Forteo® Prior Authorization Request Form
Adobe PDF Fuzeon® Prior Authorization Procedure & Required Information Form
Adobe PDF Fuzeon® Medication History Form (Documenting failure to oral anti-retroviral therapy)
Adobe PDF Fuzeon® HIV RNA Tracking Form
Adobe PDF Patient Self-Administered Growth Hormone Request Form
Adobe PDF Physician Administered Hyaluronic Acid Derivatives Request Form (ie Synvisc®/Hyalgan® Injection)
Adobe PDF Injectable Drug Replacement / Request Form - For Physician’s Office
Adobe PDF Ixempra Physician Request Form
Adobe PDF Lupron® Replacement Request Form
Adobe PDF Myobloc® Physician Request Form
Adobe PDF Nexavar® Physician Request Form
Adobe PDF Procrit® Request Form
Adobe PDF Request Form for Self Injectable Biological for Treating Arthritis (i.e. Enbrel, Humira).
Adobe PDF Request Form for Self Injectable Biologicals for Treating Psoriasis, Ankylosing Spondylitis or Psoriatic Arthrits (i.e. Enbrel, Humira).
Adobe PDF Risperdal-Consta® (Risperidone) Request Form (for 12.5mg/2ml, 25 mg/2ml, 37.5 mg/2ml, 50 mg/2ml)
Adobe PDF Serostim® Prior Authorization Request Form
Adobe PDF Suboxone/Subutex Pharmacy Prior Authorization Form
Adobe PDF Sutent® Physician Request Form
Adobe PDF Synagis® Request Form
Adobe PDF Tasigna® Physician Request Form
Adobe PDF Tykerb® Physician Request Form
Adobe PDF Tysabri® (Natalizumab) Office Administration Request Form
Adobe PDF Xeloda® Physician Request Form
Adobe PDF Xolair® Prior Authorization Request Form
Adobe PDF Zoladex® Replacement Request Form