Submit via fax using the form below.
Please download the applicable request form below and fax it to 1-888-671-5285 or email it to us.* Please refer to your plan specific website to access the plan formulary.
If a drug specific form is not listed in the A-Z section, please select the "Other" section which has the general fax form and other administrative forms.
- Abelcet
- Abilify Mycite
- Abilify tablet
- Abiraterone acetate (generic Zytiga)
- Abraxane
- Abstral
- Acetylcysteine nebulizer solution
- Aciphex
- Aciphex Sprinkle
- Actemra
- Actemra ACTPen
- Acticlate
- Actiq
- Activase
- Activella
- Actonel
- Adapalene
- Adapalene-benzoyl peroxide
- Adcetris
- Adcirca
- Adderall
- Adderall XR
- Adempas
- Adhansia XR
- Adlyxin
- Adlyxin Starter Pack
- Admelog
- Admelog SoloStar
- Adriamycin
- Adrucil
- Adzenys ER
- Adzenys XR-ODT
- Aerospan
- Afinitor
- Afrezza
- Aimovig
- Ajovy
- Albuterol nebulizer solution
- Aldurazyme
- Alecensa
- Alimta
- Aliqopa
- Alkeran Injection
- Alkeran tablet
- Allzital
- Alora
- Altabax
- Altoprev
- Altreno
- Alunbrig
- Alvesco
- Alyq
- Amabelz
- Ambien
- Ambien CR
- Ambrisentan
- Amerge
- Amitriptyline
- Amphetamine (generic Evekeo)
- Amphetamine-dextroamphetamine ER
- Ampyra
- Amrix
- Anadrol-50
- Anafranil
- Androderm
- Androgel
- Androgel Pump
- Angeliq
- Anzemet
- Apadaz
- Apidra
- Apidra Solostar
- Aplenzin
- Aprepitant
- Aptensio XR
- Aralast NP
- Aranesp
- Arikayce
- Armodafinil
- Armonair
- Arranon
- arsenic trioxide
- Arymo ER
- Arzerra
- Ascomp
- Ascomp with Codeine
- Asmanex HFA
- Asmanex Twisthaler
- Astagraf XL
- Atacand
- Atacand HCT
- Atelvia
- Ativan
- Atralin
- Atgam
- Auryxia
- Austedo
- Avalide
- Avapro
- Avastin
- Aveed
- Avita
- Avycaz
- Axert
- Azacitidine
- Azasan
- Azathioprine
- Azor
- Balversa
- Basaglar
- Bavencio
- Beconase AQ
- Belbuca
- Beleodaq
- Belsomra
- Benicar
- Benicar HCT
- Benlysta
- Benzhydrocodone-acetaminophen
- Benztropine injection
- Benztropine tablet
- Berinert
- Besponsa
- Bexarotene
- Bicnu
- Bijuva
- Binosto
- Bivigam
- Bleomycin
- Blincyto
- Boniva Injection
- Boniva tablet
- Bosentan (generic Tracleer)
- Bosulif
- Botox
- Braftovi
- Brompheniramine
- Brovana
- Budesonide Nebulizer Suspension
- Bupropion ER 450mg
- Busulfan
- Busulfex
- Butalbital-acetaminophen
- Butalbital-acetaminophen-caffeine
- Butalbital-acetaminophen-caffeine-codeine
- Butalbital-aspirin-caffeine
- Butalbital-aspirin-caffeine-codeine
- Byetta
- Cabometyx
- Calcitonin nasal spray
- Calcitriol capsule/oral solution
- Calcitriol Injection
- Calcium gluconate injection
- Calcium gluconate tablet
- Calcium gluconate/dextrose injection
- Calcium gluconate/sodium chloride injection
- Calquence
- Cambia
- Camptosar
- Capacet
- Capecitabine
- Caprelsa
- Carbaglu
- Carbinoxamine
- Carboplatin
- Carimune NF
- Carisoprodol
- Carisoprodol-aspirin
- Carisoprodol-aspirin-codeine
- Carmustine
- Carnitor Injection
- Carnitor SF
- Carnitor tablet/oral solution
- Cayston
- Celebrex
- Celexa
- Cellcept
- Cerdelga
- Cerezyme
- Cesamet
- Cetacaine
- Chlordiazepoxide
- Chlordiazepoxide-amitriptyline
- Chlorpropamide
- Chlorzoxazone
- Cholbam
- Cialis 2.5mg and 5mg
- Cimzia
- Cinqair
- Cinryze
- Cisplatin
- Cladribine
- Clemastine
- Climara
- Climara Pro
- Clindamycin-Tretinoin
- Clolar
- Clomipramine
- Clonidine ER
- Coly-Mycin M
- Colistimethate (generic Coly-Mycin M)
- Combipatch
- Cometriq
- Concerta
- ConZip
- Copiktra
- Corlanor
- Cosentyx
- Cosmegen
- Cotellic
- Cotempla XR-ODT
- Cozaar
- Cresemba
- Crestor
- Crinone
- Cromolyn nebulizer solution
- Crysvita
- Cubicin
- Cuprimine
- Cyclobenzaprine
- Cyclobenzaprine ER
- Cyclophosphamide
- Cyclosporine modified
- Cyramza
- Cystaran
- Cytarabine
- Dacarbazine
- Dacogen
- Daklinza
- dalfampridine ER (generic Ampyra)
- Dalvance
- Daptomycin
- Darzalex
- Daunorubicin
- Daurismo
- Daytrana
- Decitabine
- Deferasirox
- Deferoxamine
- Demerol
- Demerol injection
- Depocyt
- Depo-testosterone
- Desferal
- Desoxyn
- Detrol
- Detrol LA
- Dexedrine
- Dexilant
- Dexmethylphenidate
- Dexmethylphenidate ER
- Dexrazoxane
- Dextroamphetamine ER capsule
- Diacomit
- Diclofenac gel 3%
- Diclofenac patch
- Dicyclomine
- Dicyclomine injection
- Differin
- Dificid
- Digitek
- Digoxin
- Digoxin injection
- Digox
- Dilaudid
- Diovan
- Diovan HCT
- Dipyridamole
- Ditropan XL
- Divigel
- Docefrez
- Docetaxel
- Dolophine
- Doptelet
- Doryx
- Dotti
- Doxepin
- Doxil
- Doxorubicin
- Dronabinol
- Duexis
- Dupixent
- Duragesic
- Durlaza
- Duzallo
- Dyanavel XR
- Dymista
- Dysport
- Edarbi
- Edarbyclor
- Edluar
- Egrifta
- Elaprase
- Elavil
- Elelyso
- Elestrin
- Ellence
- Embeda
- Emend
- Emflaza
- Emgality
- Empliciti
- Emsam
- Enablex
- Enbrel
- Endari
- Entyvio
- Envarsus XR
- Epclusa
- Epidiolex
- Epiduo
- Epiduo Forte
- Epirubicin
- Epogen
- Epoprostenol sodium
- Erbitux
- Ergoloid Mesylates
- Erivedge
- Erleada
- Erlotinib hydrochloride (generic Tarceva)
- Erwinaze
- Esbriet
- Esgic
- Esomeprazole injection
- Esomeprazole Strontium
- Estrace
- Estradiol-norethindrone acetate
- Estradiol patch
- Estradiol tablet
- Estropipate
- Eszopiclone
- Etopophos
- Etoposide injection
- Etoposide capsule
- Eucrisa
- Evamist
- Evekeo
- Evekeo ODT
- Evenity
- Evomela
- Exalgo
- Exforge
- Exforge HCT
- Exjade
- Exondys 51
- Extavia
- Ezallor Sprinkle
- Fabrazyme
- Fanapt
- Fanapt Titration Pack
- Farxiga
- Farydak
- Fasenra
- Febuxostat
- Femhrt
- Fentanyl citrate buccal tablet
- Fentanyl citrate lozenge
- Fentanyl patch
- Fentora
- Ferriprox
- Fetzima
- Fetzima Titration Pack
- Fexmid
- Fiasp
- Fiasp FlexTouch
- Fioricet
- Fioricet with Codeine
- Fiorinal
- Fiorinal with Codeine
- Firazyr
- Firdapse
- Flebogamma DIF
- Flector Patch
- FloLipid
- Floxuridine injection
- Fludara (fludarabine phosphate)
- Fluorouracil
- Flurazepam
- Focalin
- Focalin XR
- Folotyn
- Forfivo XL
- Fortamet
- Forteo
- Fortesta
- Fosamax
- Fosamax Plus D
- Frova
- Fyavolv
- Galafold
- Gamastan SD
- Gammagard Liquid
- Gammagard S/D
- Gammaked
- Gammaplex
- Gamunex-C
- Gattex
- Gazyva
- Gelnique
- Gemzar (gemcitabine)
- Gengraf
- Genotropin
- Gilotrif
- Gliadel Wafer
- Glassia
- Gleevec
- Gleostine
- Glucovance
- Glumetza
- Glyburide
- Glyburide-metformin
- Glyburide micronized
- Glynase
- Gocovri
- Gralise
- Granisetron
- Grastek
- Guanfacine ER
- Haegarda
- Halaven
- Harvoni
- Hepatitis B Vaccine
- Heparin sodium
- Herceptin
- Herceptin Injection
- Herceptin hylecta
- Hetlioz
- Hizentra
- Horizant
- H.P. Acthar
- Humalog
- Humalog Junior Kwikpen
- Humalog Kwikpen
- Humalog MIX 50/50
- Humalog MIX 50/50 Kwikpen
- Humalog MIX 75/25
- Humalog MIX 75/25 Kwikpen
- Humatrope
- Humira
- Humulin 70/30
- Humulin 70/30 Kwikpen
- Humulin N
- Humulin N Kwikpen
- Humulin R
- Humulin R U-500
- Humulin R U-500 Kwikpen
- Hycamtin Injection
- Hycamtin capsule
- Hydromorphone
- Hydromorphone ER
- Hydroxyprogesterone Caproate (1.25 gm/5ml only)
- Hydroxyprogesterone injection
- Hydroxyzine hydrochloride
- Hydroxyzine injection
- Hydroxyzine pamoate
- Hysingla ER
- Hyzaar
- Ibandronate sodium injection
- Ibandronate tablet
- Ibrance
- Iclusig
- Idamycin (idarubicin)
- Idhifa
- Ifex (ifosfamide)
- Ilaris
- Ilumya
- Imatinib mesylate
- Imbruvica
- Imfinzi
- Imipramine hydrochloride
- Imipramine pamoate
- Imitrex
- Imitrex Injection
- Imuran
- Imvexxy
- Inbrija
- Increlex
- Indomethacin capsule
- Indomethacin ER
- Indocin oral suspension
- Inflectra
- Infugem
- Ingrezza
- Inlyta
- Inrebic
- Insulin Lispro
- Insulin Lispro Kwikpen
- Intermezzo
- Intrarosa
- Intuniv
- Ipratropium-albuterol nebulizer solution
- Ipratropium nebulizer solution
- Iressa
- Irinotecan
- Istodax
- Ixempra Kit
- Lanoxin
- Lanoxin injection
- Lartruvo
- Latuda
- Lazanda
- ledipasvir/sofosbuvir (generic Harvoni)
- Lemtrada
- Lenvima
- Lescol
- Lescol XL
- Letairis
- Levalbuterol Nebulizer Solution
- Levocarnitine Injection
- Levocarnitine tablet/oral solution
- Lexapro
- Libtayo
- Lidocaine patch
- Lidocaine-prilocaine cream
- Lidoderm
- Linezolid injection
- Linezolid Tablet & Suspension
- Lipitor
- Lipodox 50
- Lonhala Magnair
- Lonsurf
- Lopreeza
- Lorbrena
- Lorzone
- Lumizyme
- Lunesta
- Lynparza
- Lyrica CR
- Makena
- Margesic
- Marqibo
- Marinol
- Marten-Tab
- Mavenclad
- Mavyret
- Mayzent
- Maxalt
- Maxalt MLT
- Mekinist
- Mektovi
- Melphalan injection
- Melphalan tablet
- Menostar
- Meperidine
- Meperidine injection
- Meprobamate
- Metadate CD
- Metadate ER 20mg tab
- Metaxall
- Metaxalone
- Metformin ER (generic Fortamet, generic Glumetza)
- Methadone
- Methamphetamine
- Methocarbamol injection
- Methocarbamol tablet
- Methotrexate- Chemotherapy Use
- Methotrexate- Transplant Use
- Methylin
- Methylphenidate CD
- Methylphenidate ER tablet
- Methylphenidate LA
- Miacalcin Injection
- Miacalcin nasal spray
- Micardis
- Micardis HCT
- Mimvey
- Mimvey Lo
- Minivelle
- Minocin capsule
- Minocin injection
- Minocycline ER
- Minolira
- Mitomycin
- Mitoxantrone
- Modafinil
- Monodox
- Morphabond ER
- Morphine sulfate ER/CR
- Mozobil
- MS Contin
- Mulpleta
- Mustargen
- Mvasi
- Myalept
- Mycophenolate mofetil
- Mydayis
- Myfortic (mycophenolic acid)
- Myleran
- Mylotarg
- Myobloc
- Mytesi
- Nalocet
- Nasonex
- Natesto
- Natpara
- Navelbine
- Neoral
- Nerlynx
- Nesina
- Nexavar
- Nexium
- Nexium Injection
- Ninlaro
- Nipent
- Norditropin FlexPro
- Norethindrone acetate-ethinyl estradiol
- Norgesic Forte
- Nortriptyline
- Novolin R
- Novolin R Relion
- Novolog
- Noxafil
- Nubeqa
- Nucala
- Nucynta
- Nucynta ER
- Nuedexta
- Nulojix
- Nuplazid
- Nutropin AQ Nuspin
- Nuvigil
- Nuzyra injection
- Nuzyra tablet
- Ocaliva
- Ocrevus
- Octagam
- Odactra
- Odomzo
- Ofev
- Olumiant
- Olysio
- Omeppi
- Omeprazole-Sodium Bicarbonate
- Omnaris
- Omnitrope
- Oncaspar
- Ondansetron
- Ondansetron ODT
- Onivyde
- Onpattro
- Onzetra
- Opana
- Opana ER
- Opdivo
- Opsumit
- Oracea
- Oralair
- Orbactiv Injection
- Orencia
- Orenitram
- Orilissa
- Orkambi
- Orphenadrine-aspirin-caffeine
- Orphenadrine Citrate ER
- Orphenadrine CR
- Orphenadrine Injection
- Orphengesic Forte
- Oseni
- Osmolex ER
- Osphena
- Otezla
- Otrexup
- Oxaydo
- Oxaliplatin
- Oxervate
- Oxycodone ER
- Oxycodone tablet
- Oxycontin
- Oxymorphone
- Oxymorphone ER
- Oxytrol
- Ozempic
- Paclitaxel
- Palynziq
- Pamelor
- Pamidronate Injection
- Panzyga
- Parafon Forte DSC
- Paricalcitol Injection
- Paxil
- Paxil CR
- Pentazocine-Naloxone
- Percocet
- Perjeta
- Perphenazine-Amitriptyline
- Pexeva
- Phenadoz suppository
- Phenergan injection
- Phenergan suppository
- Photofrin
- Picato
- Piqray
- Pomalyst
- Portrazza
- Praluent
- Pravachol
- Prefest
- Premarin tablet
- Prevacid
- Prilosec
- Primlev
- Privigen
- Procentra
- Procrit
- Procysbi
- Prograf
- Prolastin-C
- Prolia
- Promethazine
- Promethazine injection
- Promethegan suppository
- Promethazine VC
- Prophylactic Vaccines
- Protamine
- Protonix
- Provenge
- Proventil HFA
- Provigil
- Prozac
- Prozac weekly
- Pulmicort Flexhaler
- Pulmicort respules
- Pulmozyme
- Rabeprazole
- Radicava
- Ragwitek
- Rapamune
- Rasuvo
- Ravicti
- Rayaldee
- Relexxii
- Relion R
- Relistor tablet
- Relpax
- Remicade
- Remodulin
- Repatha
- Requip XL
- Rescula
- Restoril
- Retin-A
- Retin-A Micro
- Revatio
- Revlimid
- Rexulti
- Rhopressa
- Ritalin
- Ritalin LA
- Rituxan
- Rituxan Hycela
- Robaxin Injection
- Robaxin tablet
- Rocaltrol capsule/oral solution
- Rocaltrol Injection
- Roxicodone tablet
- RoxyBond
- Rozlytrek
- Ruconest
- Rydapt
- Ryvent
- Saizen
- Samsca
- Sancuso
- Sandimmune
- Saphris
- Savella
- Seconal
- Segluromet
- Serostim
- Signifor
- Signifor LAR
- Sildenafil
- Silenor
- Siliq
- Simponi
- Simponi Aria
- Simulect
- Sirolimus
- Sirturo
- Sivextro Injection
- Sivextro Tablet
- Skyrizi
- sofosbuvir/velpatasvir (generic Epclusa)
- Soliqua
- Solodyn
- Soma
- Sonata
- Sovaldi
- Sprix
- Sprycel
- Steglatro
- Steglujan
- Stelara
- Stivarga
- Strensiq
- Striant
- Subsys
- Sumatriptan injection
- Sumavel DosePro
- Surmontil
- Sutent
- Sylatron
- Symdeko
- Symlin, Symlin Pen
- Symproic
- Sylvant
- Synagis
- Synera patch
- Synercid Injection
- Synribo
- Tacrolimus
- Tadalafil (generic Adcirca)
- Tadalafil 2.5mg and 5mg (generic Cialis)
- Tafinlar
- Tagrisso
- Takhyzro
- Taltz
- Tanzeum
- Tarceva
- Targadox
- Targretin
- Tasigna
- Tavalisse
- Taxotere
- Tecentriq
- Technivie
- Teflaro Injection
- Tegsedi
- Tekturna
- Tekturna HCT
- Temodar capsule
- Temodar Injection
- Temozolomide
- Tencon
- Teniposide
- Testim
- Testosterone (Generic Androgel, Androgel Pump, Fortesta)
- Testosterone cypionate
- Testosterone enanthate
- Tetrabenazine
- Thalomid
- Theracys
- Thiotepa
- Tibsovo
- Tice BCG
- Tigan
- Tivorbex
- TOBI
- TOBIPodhaler
- Tofranil
- Toposar
- Topotecan
- Torisel
- Totect
- Tracleer
- Tradjenta
- Tranxene
- Travatan Z
- Treanda
- Tremfya
- Treprostinil injection
- Tretinoin
- Tretinoin Microsphere
- Trexall- Chemotherapy Use
- Trexall- Transplant Use
- Treximet
- Trihexyphenidyl
- Trimethobenzamide
- Trimipramine
- Trintellix
- Triptodur
- Trisenox
- Trogarzo
- Trulance
- Tudorza
- Turalio
- Twynsta
- Tykerb
- Tymlos
- Tysabri
- Tyvaso
- Valchlor
- Valium
- Vanatol LQ
- Vancomycin injection
- Vancomycin/dextrose injection
- Vancomycin/sodium chloride injection
- Vantas
- Varubi
- Vecamyl
- Vectibix
- Velcade
- Venclexta
- Ventavis
- Ventolin HFA
- Verzenio
- Vibativ
- Vibramycin
- Vidaza
- Viekira
- Viibryd
- Vimovo
- Vinblastine
- Vincasar PFS
- Vincristine
- Vinorelbine
- Vistaril
- Vitrakvi
- Vivelle-Dot
- Vizimpro
- Vogelxo
- Vogelxo pump
- Vosevi
- Votrient
- Vpriv
- Vraylar
- Vyndamax
- Vyndaqel
- Vyvanse
- Vyxeos
- Vyzulta
- Zaleplon
- Zaltrap
- Zanosar
- Zavesca
- Zebutal
- Zegerid
- Zejula
- Zelboraf
- Zemaira
- Zembrace SymTouch
- Zemplar
- Zenzedi
- Zepatier
- Zerbaxa injection
- Zetonna
- Zevalin Y-90
- Ziana
- Zinbryta
- Zinecard
- Zinplava
- Zioptan
- Zipsor
- Zmax
- Zocor
- Zofran
- Zofran ODT
- Zohydro ER
- Zoladex
- Zolinza
- Zoloft
- Zolpidem
- Zolpidem ER
- Zolpidem sublingual tablet
- Zolpimist
- Zomacton
- Zomig
- Zomig ZMT
- Zorbtive
- Zortress
- Zorvolex
- ZTlido
- Zurampic
- Zydelig
- Zykadia
- Zypitamag
- Zytiga
- Zyvox Injection
- Zyvox Tablet & Suspension
Other forms
- General Fax Form
- B vs. D Fax Form
- Duplicate Long-Acting Opioid Use Form
- Hospice Fax Form
- Intradialytic Parenteral Nutrition (IDPN)/Intraperitoneal Nutrition (IPN)/Parenteral Nutrition (TPN) Form
- Morphine Equivalent Dose
- Opioid - 7 Days Supply Limit
- Opioid-APAP Combination Use Form
- Opioid-Benzodiazepine Combination Use Form
- Opioid-Medication Assisted Treatment (MAT) Combination Use Form
- Opioid-Prenatal Combination Use Form
- Tier Lowering Exception Form
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