Prior Authorization Specialty Request Forms

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

	Aranesp Request Form
	Botox Request Form
	Self Injectable Biological Request Form for Treating Arthritis (i.e. Enbrel, Humira)
	Self Injectable Biological Request Form for Treating Psoriasis, Psoriatic Arthritis or Ankylosing Spondylitis (i.e. Enbrel, Humira)
	Chemotherapy Drug Request Form
	Forteo Request Form
	Patient Self-Administered Growth Hormone Request Form
	Home Infusion Therapies Request Form
	Patient Self-Administered Injectable and Specialty Drugs Request Form
	Leukine Request Form
	Lupron Request Form
	Myobloc Request Form
	Neupogen Request Form
	Self Injectable Non Pegylated Interferons Request Form (for Hepatitis C treatment)
	Self Injectable Pegasys Interferons Request Form (for Hepatitis C treatment)
	Self Injectable Peg-Intron Interferons Request Form (for Hepatitis C treatment)
	Procrit Request Form
	Self Injectable Ribavirin Interferons Request Form (for Hepatitis C treatment)
	Remicade Request Form
	Risperdal-Consta Request Form
	Serostim Prior Authorization Request Form
	Xolair Prior Authorization Request Form
	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