Drug Authorization Forms

HUM
  • A Drug Special Authorization form is required when a pharmacy receives a denial for an electronic drug claim that requires prior authorization. The pharmacy will receive a message indicating that the drug must be authorized. The pharmacy can then print the appropriate form(s) that corresponds to the special authorization drug.
  •  
  •  
  •  
  •  

DUPIXENT (ASTHMA) / DUPILUMAB (ASTHMA) DUPIXENT (ATOPIC DERMATITIS) / DUPILUMAB (ATOPIC DERMATITIS)
DUPIXENT (CRSWNP) / DUPILUMAB (CRSWNP) ENTYVIO (CROHNS) / VEDOLIZUMAB (CROHNS)
ENTYVIO (UC) / VEDOLIZUMAB (UC) HUMIRA (AS) / ADALIMUMAB (AS)
HUMIRA (CROHNS) / ADALIMUMAB (CROHNS) HUMIRA (HS) / ADALIMUMAB (HS)
HUMIRA (JIA) / ADALIMUMAB (JIA) HUMIRA (PA) / ADALIMUMAB (PA)
HUMIRA (PSORIASIS) / ADALIMUMAB (PSORIASIS) HUMIRA (RA) / ADALIMUMAB (RA)
HUMIRA (UC) / ADALIMUMAB (UC) HUMIRA (UVEITIS) / ADALIMUMAB (UVEITIS)
LORBRENA (NSCLC) / LORLATINIB (NSCLC) OCREVUS (PPMS) / OCRELIZUMAB (PPMS)
OCREVUS (RRMS) / OCREVUS (RRMS) OZEMPIC / SEMAGLUTIDE
REMICADE (AS) / INFLIXIMAB (AS) REMICADE (CROHNS) / INFLIXIMAB (CROHNS)
REMICADE (PA) / INFLIXIMAB (PA) REMICADE (PSORIASIS) / INFLIXIMAB (PSORIASIS)
REMICADE (RA) / INFLIXIMAB (RA) REMICADE (UC) / INFLIXIMAB (UC)
STELARA (CROHNS) / USTEKINUMAB (CROHNS) STELARA (PA) / USTEKINUMAB (PA)
STELARA (PSORIASIS) / USTEKINUMAB (PSORIASIS) STELARA (UC) / USTEKINUMAB (UC)
TAGRISSO / OSIMERTINIB TRIKAFTA / ELEXACAFTOR/TEZACAFTOR/IVACAFTOR/ IVACAFTOR


Requires Adobe Acrobat Reader
Get Adobe Reader