Prescription Drug Forms

Mail Order Form - Coming Soon

Use this form to order medication through our mail order service Walgreens Mail Service.  If you need additional information or assistance please call Pharmacy Customer Service at the phone number on your ID card.

Coverage Determination Form

You must contact us if you would like to request a coverage determination by completing and returning this form.

Coverage Redetermination Form

You must contact us if you would like to request a coverage redetermination by completing this form

2010 Step Therapy Protocol

Step therapy protocol information

Quantity Limits

Quantity limits on prescription drugs

2009 Prior Authorization Criteria

Prior Authorization Criteria Information

2010 Prior Authorization Criteria

Prior Authorization Criteria Information

Prior Authorization Forms

• Actiq
• Anticoagulant
• Apokyn
• Avonex/Betaseron/Rebif
• Copaxone
• Enbrel
• Formulary Exception
• Forteo
• General Prior Authorization
• Gleevec
• Hepatitis C
• Humira
• Immunosuppresant
• Itraconazole
• Neupogen/Leukine/Neulasta
• Oxycontin
• Procrit/Aranesp
• Quantity Exception
• Revlimid
• Symlin
• Tarceva
• Testosterone
• Thalomid
• Tier Cost Sharing Exception Form
• Tracleer
• Xolair
• Zavesca