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

Amevive® (alefacept)

Anabolic Steroids (Nandrolone Decanoate & Oxymetholone (Anadrol-50®)

Emsam® (selegiline Transdermal System)

Enbrel® (etanercept)

Exjade® (Deferasirox)

Faslodex® (fulvestrant)

Forteo® (teriparatide)

Gleevec® (Imatinib)

Growth Hormones

Hepsera® (adefovir )

Hexalen® (Altretamine )

Humira® (adalimumab)

Immunosuppressives Used In Organ Rejection

Infusion Drugs

Inhalation Solutions

Intron A® (interferon Alpha 2-b)

Isotretinoin (Amnesteem®, Claravis®, Sotret®, Accutane®) Capsules

Kineret® (anakinra)

Lovaza® (Omega-3 Acid Ethyl Esters)

Megace ES® And Megestrol Acetate

Neupogen® (filgrastim) & Neulasta® (pegfilgrastim)

Nexavar® (sorafenib)

Oxycontin® OR Oxycodone Extended-Release Tablets

Procrit®, Epogen® (Epoetin) And Aranesp® (Darbepoetin)

Provigil® (modafinil)

Pulmicort Respules® (Budesonide)

Pulmozyme® (dornase Alfa)

Raptiva® (efalizumab)

Rebif®, Avonex® (interferon Beta-1a), Betaseron® (interferon Beta-1b) & Copaxone® (glatiramer Acetate)

Remicade® (infliximab)

Revatio® (sildenafil)

Revlimid® (lenalidomide)

Rilutek® (Riluzole)

Risperdal Consta®

Roferon A® (interferon Alpha 2-a)

Somavert® (Pegvisomant)

Sprycel® (dasatinib)

Sutent® (sutinib)

Tarceva® (erlotinib)

Targretin® (Bexarotene Oral)

Terbinafine

Thalomid® (Thalidomide)

Valcyte® (valganciclovir)

Zolinza® (vorinostat)