Indiana University Health Plans
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Prior Authorization Specialty Request Forms

Click on the form name below to download in PDF format.

Adobe PDF icon Aranesp Request Form
Adobe PDF icon Botox Request Form
Adobe PDF icon Self Injectable Biological Request Form for Treating Arthritis (i.e. Enbrel, Humira)
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Self Injectable Biological Request Form for Treating Psoriasis, Psoriatic Arthritis or Ankylosing Spondylitis (i.e. Enbrel, Humira)

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Chemotherapy Drug Request Form

Adobe PDF icon Forteo Request Form
Adobe PDF icon Patient Self-Administered Growth Hormone Request Form
Adobe PDF icon Home Infusion Therapies Request Form
Adobe PDF icon Patient Self-Administered Injectable and Specialty Drugs Request Form
Adobe PDF icon Leukine Request Form
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Lupron Request Form

Adobe PDF icon Myobloc Request Form
Adobe PDF icon Neupogen Request Form
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Self Injectable Non Pegylated Interferons Request Form (for Hepatitis C treatment) 

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Self Injectable Pegasys Interferons Request Form (for Hepatitis C treatment)

Adobe PDF icon Self Injectable Peg-Intron Interferons Request Form (for Hepatitis C treatment)
Adobe PDF icon Procrit Request Form
Adobe PDF icon Self Injectable Ribavirin Interferons Request Form (for Hepatitis C treatment)
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Remicade Request Form

Adobe PDF icon Risperdal-Consta Request Form
Adobe PDF icon Serostim Prior Authorization Request Form
Adobe PDF icon Xolair Prior Authorization Request Form
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Zoladex Request Form

Providers who would to like to check on the status of a prior authorization request they have submitted should contact our Provider Help Desk:

Telephone: 1-866-907-7088

Members who would to like to check on the status of a prior authorization request submitted by their doctor should contact our Member Services Department 8:00 a.m. to 8:00 p.m., seven days a week:

Telephone: 1-866-907-1587
TTY/TDD: 1-800-743-3333

 
 
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Last Modified: Friday, December 20, 2013 3:27:24 PM
Pending CMS Approval
IU Health Plans is a Medicare Advantage organization with a Medicare contract.