List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.

List of Specialty drugs only. These drugs may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

This claim form should be completed when an individual whose plan design includes mandatory generic is applying for coverage for the full cost of the brand name drug.

This form is to be completed when an individual is accessing the coverage navigation service for assistance applying to government and/or manufacturer sponsored programs for Specialty Drug coverage.

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

This form is to be completed when enrolling new employees or changing existing coverage information.

This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.

Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.