Health Care Professional Forms
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Applications and forms for health care professionals and their patients
Coordination of Benefits
Dispute and Appeals
Employee Assistance Program (EAP)
ERA/EFT
Medicare
Network Applications
National Provider Identifier (NPI)
Patient Specific
Pharmacy
Physician Communications
Provider Demographic Updates
Specialty Pharmacy Medications
General Medication Request
Crohns/Ulcerative Colitis Medication Request
Enzyme Replacement Medication Request
Growth Hormone Medication Request
Hemophilia Medication Request
Hepatitis C Medication Request
HIV/AIDS Medication Request
Immune Globulin Medication Request
Infertility Medication Request
Osteoporosis Medication Request
Psoriasis Medication Request
Rheumatoid/Psoriatic/Juvenile Arthritis and Ankylosing Spondylitis Medication Request
Synagis Medication Request
Synagis® Reorder Form
Transplant Medication Request
Viscosupplementation Medication Request
Vivitrol Reorder Form
Specialty Pharmacy Precertification
Abatacept (Orencia®) Precertification Request
Adalimumab (Humira®) Precertification Request
Alefacept (Amevive®) Precertification Request
Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request
Anakinra (Kineret®) Precertification Request
Antiemetic Injectable Medication Precertification Request
Apremilast (Otezla®) Medication Precertification Request
Belimumab (Benlysta®) Injectable Medication Precertification Request
Botulinum Toxins Medication Precertification Request
Brentuximab vedotin (Adcetris®) Injectable Medication Precertification Request
Cabazitaxel (Jevtana®) Injectable Medication Precertification Request
Certolizumab (Cimzia®) Precertification Request
Cetuximab (Erbitux) Injectable medication precertification Request
Denosumab (Prolia, Xgeva) Medication Precertification Request
Eculizumab (Soliris®) Medication Precertification Request
Enzyme Replacement Precertification Request
EPO/Dialysis medication precertification Request
Etanercept (Enbrel®) Precertification Request
Golimumab (Simponi®) Precertification Request
Growth Hormone Medication Request (Adult)
Growth Hormone Medication Request (Pediatric)
Hep C Medication Precertification Request
Hereditary Angioedema Medication Precertification Request
Hydroxyprogesterone Caproate (Makena®) Medication Precertification Request
Immune Globulin (IG) Therapy Medication Precertification Request
Infertility Medication Precertification Request (Female)
Infertility Medication Precertification Request (Male)
Infliximab (Remicade®) Precertification Request
Insulin-Like Growth Factor-1 Injectable Medication Precertification Request
Interferon gamma (Actimmune®) Injectable Medication Precertification Request
Ipilimumab (Yervoy®) Injectable Medication Precertification Request
Multiple Sclerosis Medication Precertification Request
Obinutuzumab (Gazyva™) Injectable Medication Precertification Request
Omalizumab (Xolair®) Medication Precertification
Osteoporosis Precertification Request
Palivizumab (Synagis®) Injectable Medication Precertification Request
Panitumumab (Vectibix) Injectable medication precertification Request
Pegloticase (Krystexxa®) Injectable Medication Precertification Request
Pembrolizumab (Keytruda®) Injectable Medication Precertification Request
Provenge Medication Precertification Request
Pulmonary Arterial Hypertension Precertification Request
Radium-223 dichloride (Xofigo) Injectable Medication Precertification Request
Repository Corticotropin (H.P Acthar Gel) Injectable Medication Precertification Request
Rituximab (Rituxan®) Precertification Request
Teduglutide(Gattex®)Injectable Medication Precertification Request
Tocilizumab (Actemra®) Precertification Request
Tofacitinib (XeljanzTM) Medication Precertification Request
Trastuzumab (Herceptin), Ado-Trastuzumab (Kadcyla) and Pertuzumab (Perjeta) Injectable Medication Precertification Request
Ustekinumab (Stelara®) Precertification Request
Vedolizumab (Entyvio®) Injectable Medication Precertification Request
Viscosupplementation Injectable Medications Precertification Request
Ziv-Aflibercept (Zaltrap®) Injectable Medication Precertification Request
Specialty Pharmacy Precertification (Individual Plans)
Abatacept (Orencia®) Injectable Medication Precertification Request
Adalimumab (Humira®) Injectable Medication Precerification Request
Adult Growth Hormone Injectable Medication Precertification Request
Alefacept (Amevive®) Injectable Medication Precertification Request
Anakinra (Kineret®) Injectable Medication Precertification Request
Apremilast (Otezla®) Medication Precertification Request
Certolizumab pegol (Cimzia®) Injectable Medication Precertification Request
Entanercept (Enbrel®) Injectable Medication Precertification Request
Forteo Injectable Medication Precertification Request
Multiple Sclerosis Medication Precertification Request
Pediatric Growth Hormone Injectable Medication Precertification Request
Pulmonary Arterial Hypertension Medication Precertification Request
Tocilizumab (Actemra®) Injectable Medication Precertification Request
Tofacitinib (Xeljanz™) Medication Precertification Request
Ustekinumab (Stelara®) Injectable Medication Precertification Request
Vedolizumab (Entyvio®) Injectable Medication Precertification Request
State Specific
