Pharmacy

• Member Benefits
• Find a Pharmacy
• Printable List of Pharmacies
• Searchable Formulary
• Printable Formulary
• Printable Specialty Formulary
• Formulary Changes 2013
• Pharmacy Services
• Prior Authorization
• Transition Supply of Medication
• Pharmacy and Therapeutics Committee

Pharmacy - Specialty Injectable Forms

• Aranesp® Request Form (PDF)

• Enbrel® or Humira® for Treating Arthritis Request Form (PDF)

• Enbrel® or Humira® for Treating Psoriasis Request Form (PDF)

• Epogen® Request Form (PDF)

• Euflexxa®, Synvisc®/Hyalgan® Injection Request Form (PDF)

• Forteo®, Boniva® Injection, Prolia®, or Reclast® Prior Authorization Form (PDF)

• FUZEON® Coverage Determination Form (PDF)

• Long-Acting Injectable Atypical Antipsychotics Request Form (PDF)

• Lupron® Replacement Request Form (PDF)

• Miscellaneous Chemotherapy Medication Request Form (PDF)

• Miscellaneous Injectable Drug Request Form (PDF)

• Miscellaneous Patient Self-Administered Injectable & Specialty Drug Request Form (PDF)

• Myobloc®, Dysport®, Xeomin®, or Botox® Request Form (PDF)

• Patient Self-Administered Growth Hormone Request Form (PDF)

• Peg-Intron or Pegasys & Ribavirin & VICTRELIS or INCIVEK for Hepatitis C Treatment Request Form (PDF)

• Procrit® Request Form (PDF)

• Remicade® Request Form (PDF)

• Suboxone®/Subutex® Prior Authorization Form (PDF)

• Synagis® Request Form (PDF)

• Tysabri® Office Administration Request Form (PDF)

• White Blood Cell Stimulators Request Form (PDF)
  i.e. Leukine or Neupogen

• XOLAIR Prior Authorization Form (PDF)