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Pharmacy Forms

Mail Order Pharmacy

  • Postal Prescription Services (PPS) Form for HIP
 

Pharmacy Prior Authorization Quick Reference Guide

  • Pharmacy Prior Authorization Quick Reference Guide for Hoosier Healthwise and HIP


Pharmacy Appeals Coversheet

  • Pharmacy Appeals Coversheet for Hoosier Healthwise and HIP


Medication Request Forms for Hoosier Healthwise and HIP

  • Brand Medically Necessary Medication
  • Actemra
  • Antipsychotics
  • Benzodiazepine and Opioid Concurrent Therapy PA Request Form
  • Buprenorphine/naloxone (Bunavail, Suboxone Films, and Zubsolv)
  • BZD/Sedative Hypnotic Therapeutic Duplication Medical Necessity
  • Cimzia
  • CNS Stimulant Therapeutic Duplication Medical Necessity
  • Corlanor
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  • Kineret
  • MS Interferons (Avonex, Betaseron, Extavia, Plegridy, Rebif)
  • Opioid Analgesic Medical Necessity
  • Orencia SC
  • Otezla
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  • Stelara
  • Synagis
  • Xeljanz
  • Medication Request Form (MRF) for all other drugs
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Page updated 10/18/2019 | Copyright © 2007-2019 MDwise, Inc. All Rights Reserved

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