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Pharmacy
User: Visitor July 25, 2008
Pharmacy Images
Provider Help Desk: (p) 888-420-9711 (f) 800-408-1088 | Member Help Desk: (p) 866-796-2463 (f) 207-287-8601
Prior Authorization (PA) Helpdesk (for Provider PA inquiries): (p) 888-445-0497 (f) 888-879-6938

PA - Prior Authorization Forms Archive

(click column headers to sort)
Name Description Date
Erectile Dysfunction Erectile Dysfunction 40 kB #10530  10/5/2005
Flumist (copy) Flumist (copy) 39 kB #10610  1/12/2006
Fuzeon Fuzeon 30 kB   10/5/2005
Neupogen Leukine Neupogen Leukine 34 kB   10/5/2005
Subjective Global Assessment (SGA) Subjective Global Assessment (SGA) 28 kB   10/5/2005
Syringe Filling Syringe Filling 26 kB   10/5/2005
Vivitrol (copy) Vivitrol (copy) 33 kB   11/22/2006
Zofran Zofran 34 kB #30810  11/4/2005
Symlin (copy) Symlin (copy) 39 kB #301501  11/6/2007
Sensipar (copy) Sensipar (copy) 32 kB #30115  11/6/2007
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 96 kB #30110  11/6/2007
Remicade/Kineret (copy) Remicade/Kineret (copy) 98 kB #10510  11/6/2007
Raptiva Amevive (copy) Raptiva Amevive (copy) 34 kB #20910  11/6/2007
Provigil (copy) Provigil (copy) 33 kB #20710  11/6/2007
Phosphate Binders (copy) Phosphate Binders (copy) 28 kB #20720  11/6/2007
Non Sedating Antihistamines (copy) Non Sedating Antihistamines (copy) 32 kB #20530  11/6/2007
Multi Antipsychotic - Clinical PA (copy) Multi Antipsychotic - Clinical PA (copy) 34 kB #20440  11/6/2007
Miscellaneous Non Preferred (copy) Miscellaneous Non Preferred (copy) 29 kB #20420  11/6/2007
Four (4) Brand PA Form (copy) Four (4) Brand PA Form (copy) 36 kB #10600  11/6/2007
EPO (copy) EPO (copy) 36 kB #10520  11/6/2007
Dose Consolidation (copy) Dose Consolidation (copy) 33 kB #10420   11/6/2007
Cox II Inhibitors (copy) Cox II Inhibitors (copy) 30 kB #10310  11/6/2007
Brand Drugs (copy) Brand Drugs (copy) 53 kB #10220  11/6/2007
Synagis Respigam (copy) Synagis Respigam (copy) 74 kB #30120  11/15/2007
Zyvox (copy) Zyvox (copy) 33 kB #30820  1/2/2008
Oral Anabolic Steroid (copy) Oral Anabolic Steroid (copy) 31 kB #20600  1/17/2008
Growth Hormone (copy) Growth Hormone (copy) 123 kB #10710  1/17/2008
Byetta (copy) Byetta (copy) 33 kB #10230  1/2/2008
Antifungals (copy) Antifungals (copy) 159 kB #10120  1/17/2008
Synvisc (copy) Synvisc (copy) 37 kB #30130  2/27/2008
Botox - Myobloc (copy) Botox - Myobloc (copy) 42 kB #10210  2/27/2008
MS Agents (copy) MS Agents (copy) 91 kB #20430  4/17/2008
Narcotics (copy) Narcotics (copy) 118 kB #20510  7/3/2008
Acute Migraine (copy) Acute Migraine (copy) 270 kB #10110  7/3/2008