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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 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 Sutent® Physician Request Form
Adobe PDF Synagis® Request Form
Adobe PDF Tykerb® Physician Request Form
Adobe PDF Xeloda® Physician Request Form
Adobe PDF Xolair® Prior Authorization Request Form
Adobe PDF Zoladex® Replacement Request Form
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