Request for Quantity Limit Exception Form

Request For Quantity Limit Exception

Request for Coverage of a Non-Formulary Drug Form

Request For Coverage Of A Non-Formulary Drug

Request for a Lower Co-pay (Tiering Exception Form)

Request For A Lower Co-pay (Tiering Exception)

Quantity Limit Exception Form

Abilify® (aripiprazole)

Geodon® (ziprasidone)

Risperdal® (risperidone)

Seroquel® (quetiapine)

Zyprexa® (olanzapine)

Prior Authorization Request Form

Antiemetics

Celebrex® (celecoxib)

Cyklokapron® (Tranexamic Acid)

Emsam® (selegiline Transdermal System)

Faslodex® (fulvestrant)

Forteo® (teriparatide)

Growth Hormones

Humira® (adalimumab)

Immunosuppressives Used In Organ Rejection

Infusion Drugs

Inhalation Solutions

Iressa® (gefitinib)

Lovaza® (Omega-3 Acid Ethyl Esters)

Megace ES® And Megestrol Acetate

Namenda® (memantine) Oral Solution

Nefazodone (Serzone®) Tablets

Neupogen® (filgrastim) & Neulasta® (pegfilgrastim)

Neupro® (Rotigotine) Transdermal Patches

Nexavar® (sorafenib)

Oxandrin® (oxandrolone)

Oxycontin® OR Oxycodone Extended-Release Tablets

PEG Intron® (Peginterferon Alpha 2-b Injection)

Pegasys® (Peginterferon Alpha 2-a Injection)

Piroxicam (Feldene®)

Pulmicort Respules® (Budesonide)

Pulmozyme® (dornase Alfa)

Raptiva® (efalizumab)

Regranex® (becaplermin)

Remicade® (infliximab)

Revatio® (sildenafil)

Revlimid® (lenalidomide)

Rilutek® (Riluzole)

Risperdal Consta®

Rituxan® (Rituximab)

Roferon A® (interferon Alpha 2-a)

Somavert® (Pegvisomant)

Sprycel® (dasatinib)

Sutent® (sutinib)

Tarceva® (erlotinib)

Terbinafine

Testosterone Cypionate & Enanthate (Depo-Testosterone®, Delatestryl®), Buccal Testosterone (Striant®), Testosterone Pellets (Testopel®)

Thalomid® (Thalidomide)

Total Parenteral Nutrition

Twinrix®, Engerix-B®, Recombivax®

Tykerb® (lapatinib)

Valcyte® (valganciclovir)

Xolair® (omalizumab)

Zolinza® (vorinostat)