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Home > Provider Center > Prior Authorization Process > Prior Authorization Specialty Request Forms

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Prior Authorization Specialty Request Form

	Aranesp Request Form
	Botox Request Form
	Enbrel Self Injectable Biological Request Form (For Treating Arthritis)
	Forteo Request Form
	Fuzeon Lab Tracking Form
	Fuzeon Medication History Form
	Fuzeon Prior Authorization Request Form
	Patient Self-Administered Growth Hormone Request Form
	Home Infusion Therapies Request Form
	Humira Self Injectable Biological Request Form (For Treating Arthritis)
	Patient Self-Administered Injectable and Specialty Drugs Request Form
	Kineret Self Injectable Biological Request Form (For Treating Arthritis)
	Leukine 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)
	Risperdal-Consta Request Form
	Serostim Prior Authorization Request Form
	Xolair Prior Authorization Request Form

Providers who would like to submit a prior authorization request may either contact our Provider Help Desk at 1-888-684-5502, 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: 1-888-684-5502

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

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Last Modified: Monday, December 03, 2007 10:59:28 AM
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