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Health Care Professional Forms

Legal Notices: Health benefits and health insurance plans contain exclusions and limitations.

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Applications and forms for health care professionals and their patients.

Part D prescription drug prior authorizations and exceptions

General Prior Authorization

Aranesp^® (darbepoetin alfa)

Hepatitis C

Lidocaine Products

Linezolid (generic Zyvox^®)

Modafinil (generic Provigil^®) and Armodafinil

Ondansetron (oral generic Zofran^®)

Procrit^® (epoetin alfa)

Regranex^® (becaplermin)

Sildenafil (generic Revatio^®)

Topical testosterone

Tracleer^® (bosetan)

Zolpidem (generic Ambien^®)

Tier exception (cost-share reduction) request