Prior Authorization Specialty Request Form

	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 like to submit a prior authorization request may either contact our Provider Help Desk at 1-866-205-0749, or use our Patient Self-Administered Injectable and Specialty Drugs Request Form. Please answer all questions on the form and fax to the phone number listed on the form.

Providers wishing to check on the status of a prior authorization request they have submitted should contact our provider help desk:

Telephone: 1-866-205-0749

Members wishing to check on the status of a prior authorization request submitted by their doctor should contact our Member Services Department 8:00 a.m. - 8:00 p.m., seven days a week:

Telephone: 1-877-661-6230 (Press 2)
TTY/TDD: 1-800-735-2929