WebTrade Name Dosage Form Strength Tier Drug Description Azathioprine *generic equivalent of Azasan/Imuran tablet 50 mg,75 mg,100 mg Tier 1 immunosuppressan t drugs Basaglar Kwikpen u-100 insulin pen (ml) 100/ml (3) Tier 2 insulin therapy Benazepril HCL *generic equivalent of Lotensin tablet 5mg, 10 mg, 20 mg, 40 mg Tier 1 ace inhibitors Web1. Submit a separate form for each medication. 2. Complete ALL information on the form. NOTE: The prescribing physician (PCPor Specialist) should, in most cases, complete the form. 3. Please provide the physician address as it is required for physician notification. 4. Fax the completed form and all clinical documentation to 1-866-240-8123
Highmark Expanding Medical Injectable Drug Program, …
WebHighmark Blue Cross Blue Shield West Virginia Specialty Drug Request Form Once completed, please fax this form to Walgreens at 1-877-231-8302. Please use a separate form for each drug. Print, type, or WRITE LEGIBLY and complete form in full. Walgreens will contact Highmark WV for authorization, if necessary. Walgreens can be reached at (888 ... WebSPECIALTY DRUG REQUEST FORM Once completed, please fax this form to1-866-240-8123. To view our formularies on-line, please visit our Web site at the addresses listed above. Please use a separate form for each drug. Print, type or WRITE LEGIBLY and complete form in full. If approved, the payor will forward to the exclusive specialty vendor. portsmouth city parking
Provider Resource Center
WebMedical Specialty Drug Authorization Request Form . Please print, type or write legibly in … WebCystic fibrosis prescription referrals may be sent to any of our locations as well as our dedicated cystic fibrosis pharmacy. If you are unsure where to send a prescription to, please call us at 855-244-2555. Address. E-prescribing Name. Canton, MI. 41460 Haggerty Circle South. Canton, MI 48188. Phone: 888-282-5166. Fax: 888-570-4700. Web1. Submit a separate form for each medication. 2. Complete ALL information on the form. … optus tower locations