Forms

Commercial Pharmacy Prior Authorization Forms

• Amevive
• Amitiza
• Amphetamine
• Arava
• Boniva
• Byetta
• Elidel
• Forteo
• Lamisil
• Medical Exception Request
• Provigil
• Protopic
• Restasis
• Sporanox
• Symlin
• Synagis
• Tracleer
• Xolair

Miscellaneous Forms

• CuraScript Enrollment Form
• Provider Demographic Form
• Springfield Medical Exception Request
• New Beginnings Pregnancy Risk Screening
• Payment Refund Notification Form
• Bill Name & Tax ID Change (W9)
• Primary Care Designation

Referral Forms

• Laredo Referral
• St. John's Referral
• Mercy MedicareADVANTAGE in Partnership with St. John's Referral
• Springfield Prior Authorization

Medicare Part D Pharmacy Prior Authorization Forms

• Acne - Tretinoin
• Afinitor
• Aranesp
• Chantix
• Cimzia
• Differin
• Enbrel
• EPO
• Forteo
• Growth Hormones
• Humira
• Increlex
• Infergen
• Itraconazole
• IVIG
• Lamisil - terbinafine
• Lidoderm
• Neulasta
• Neupogen
• Neurtrophil
• Octreotide
• Oxzandrin
• Pegasys
• Pegintron
• Provigil
• Remicade
• Revatio
• Revlimid
• Ribavirin
• Rituxan
• Sandostatin LAR
• Somatuline Depot
• Somavert
• testosterones - Androderm
• Thalomid
• Topical Ulcers - Regranex
• Xenaxine
• Xolair