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)

Amitriptyline HCl (Elavil®) Tablets 75mg, 100mg & 150mg

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

Antiemetics

Bleomycin

Campath® (Alemtuzumab)

Celebrex® (celecoxib)

Cyklokapron® (Tranexamic Acid)

Elitek® (Rasburicase)

Emsam® (selegiline Transdermal System)

Enbrel® (etanercept)

Exjade® (Deferasirox)

Exubera® (Insulin Inhalation)

Faslodex® (fulvestrant)

Faslodex® (fulvestrant)

Forteo® (teriparatide)

Gleevec® (Imatinib)

Growth Hormones

Hepsera® (adefovir )

Hexalen® (Altretamine )

Humira® (adalimumab)

Humulin R U-500® (Insulin Regular 500 Units/mL)

Immunosuppressives Used In Organ Rejection

Infusion Drugs

Inhalation Solutions

Intravenous Immune Globulins

Intron A® (interferon Alpha 2-b)

Iressa® (gefitinib)

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

Kineret® (anakinra)

Lovaza® (Omega-3 Acid Ethyl Esters)

Megace ES® And Megestrol Acetate

Naglazyme® (Galsulfase)

Namenda® (memantine) Oral Solution

Nefazodone (Serzone®) Tablets

Neupogen® (filgrastim) & Neulasta® (pegfilgrastim)

Neupro® (Rotigotine) Transdermal Patches

Nexavar® (sorafenib)

Nexium® (esomeprazole)

Novantrone® (Mitoxantrone)

Ontak® (Denileukin Diftitox)

Oxandrin® (oxandrolone)

Oxycontin® OR Oxycodone Extended-Release Tablets

PEG Intron® (Peginterferon Alpha 2-b Injection)

Pegasys® (Peginterferon Alpha 2-a Injection)

Piroxicam (Feldene®)

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

Proleukin® (Aldesleukin)

Provigil® (modafinil)

Pulmicort Respules® (Budesonide)

Pulmozyme® (dornase Alfa)

Raptiva® (efalizumab)

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

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)

Targretin® (Bexarotene Oral)

Terbinafine

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

Thalomid® (Thalidomide)

Total Parenteral Nutrition

Trisenox® (Arsenic Trioxide)

Twinrix®, Engerix-B®, Recombivax®

Tykerb® (lapatinib)

Valcyte® (valganciclovir)

Velcade® (Bortezomib)

Vidaza® (Azacitidine)

Xolair® (omalizumab)

Zolinza® (vorinostat)