RX Forms

We have made it simple for you!  To begin the enrollment process:

  1. Search by either the product name or the therapy name below.
  2. Print the PDF version of the Enrollment Form.
  3. Fax the completed form, signed by the prescriber back to us at the fax number indicated on the PDF.
THERAPY NAMEMEDICATION NAMEPRESCRIBING INFORMATION
Hepatitis C Harvoni www.harvoni.com
Hepatitis C Moderiba www.moderiba.com
Hepatitis C Olysio www.olysio.com
Hepatitis C Peg-Intron www.merck.com
Hepatitis C Pegasys www.gene.com
Hepatitis C RibaPak www.ribapak.com
Hepatitis C Sovaldi hcp.sovaldi.com
Hepatitis C Technivie www.rxabbvie.com
Hepatitis C Viekira www.viekira.com
Hepatitis C Zepatier www.zepatier.com
Hepatitis C Daklinza www.daklinza.com
OncologyTarceva® www.tarceva.com
OncologyTargreti® targretin.com
OncologyTasigna® www.us.tasigna.com
OncologyTemoda® www.merck.com
OncologyTykerb® www.us.tykerb.com
OncologyXalkori® www.xalkori.com
OncologyXeloda® http://www.gene.com
OncologyXtandi® www.xtandi.com
OncologyZelboraf® www.gene.com
OncologyZolinza® www.merck.com
OncologyZydelig® https://www.zydelig.com
OncologyZytiga® https://www.zytiga.com
Oncology Afinitor® www.afinitor.com
Oncology Erivedge®www.erivedge.com
OncologyBosulif®www.bosulif.com
OncologyFareston® www.fareston.com
OncologyGleevec®http://www.gleevec.com
OncologyHycamtin®www.pharma.us.novartis.com
OncologyIclusig®www.iclusigrems.com
OncologyInlyta®www.inlyta.com
OncologyLonsurf®www.lonsurf.com
OncologyMekinist®tafinlarmekinist.com
OncologyMozibil®www.mozobil.com
OncologySprycel®www.sprycel.com
OncologyStivarga®www.stivarga-us.com
OncologyStivarga®tafinlarmekinist.com
OncologyTafinlar®www.pharma.us.novartis.com
OncologyImbruvica® www.imbruvica.com
OncologyJakafi® www.jakafi.com
OncologyNexavar® www.nexavar.com
OncologyPomalyst® www.pomalystrems.com
OncologyRevlimid® www.revlimid.com
OncologySutent® www.sutent.com
OncologyThalomid® www.thalomid.com
OncologyVotrient® www.us.votrient.com
Mental HealthAbilify Maintenawww.abilifymaintena.com
Rheumatoid Arthritis (RA)Actemrahttps://www.actemra.com
Pulmonary Arterial HypertensionAdcircawww.adcirca.com
Hypoactive (low) Sexual Desire Disorder (HSDD)Addyiwww.addyi.com
Irritable Bowel Syndrome (IBS)Amitizawww.amitiza.com
HIV/AIDSAptivusboehringer-ingelheim.com
AnemiaAranesphttp://pi.amgen.com/
AnticoagulantArixtrahttp://ca.gsk.com
Organ TransplantAstagraf XLhttps://www.astellas.us
HIV/AIDSAtriplawww.atripla.com
Multiple Sclerosis (MS)Avonexhttps://www.avonex.com
Hepatitis BBaracludebms.com
Weight LossBelviqhttp://www.belviq.com
Organ TransplantCellceptwww.cellcept.com
Crohn's DiseaseCimziawww.cimzia.com
Rheumatoid Arthritis (RA)Cimziawww.cimzia.com
HIV/AIDSCombivirwww.viivhealthcare.com
HIV/AIDSComplerawww.complera.com
Weight LossContravehttps://www.contrave.com/
Multiple Sclerosis (MS)Copaxonewww.copaxone.com
Cystic FibrosisCreonwww.creon.com
HIV/AIDSCrixivanwww.crixivan.com
AntibioticDificidwww.dificid.com
HIV/AIDSEdurantwww.edurant.com
HIV/AIDSEmtrivawww.gilead.com
PsoriasisEnbrelhttp://pi.amgen.com
Rheumatoid Arthritis (RA)Enbrelhttps://www.enbrel.com
PsoriasisEnstilarhttp://www.enstilar.com
Crohn's DiseaseEntyviowww.entyvio.com
Organ TransplantEnvarsus XRwww.envarsusxr.com
HIV/AIDSEpivirwww.viivhealthcare.com
Hepatitis BEpivir HBVwww.gsksource.com
AnemiaEpogenhttp://pi.amgen.com
HIV/AIDSEpzicomwww.gsksource.com
OsteoarthritisEuflexxahttp://www.euflexxa.com
OsteoporosisForteowww.forteo.com
AnticoagulantFragminwww.pfizer.ca
HIV/AIDSFuzeonwww.gene.com
OsteoarthritisGel-Onehttp://www.zimmer.com
ANYGeneral RX FormFRDspecialtyrx.com
Growth HormoneGenotropinwww.genotropin.com
Multiple Sclerosis (MS)Gilenyawww.gilenya.com
Hepatitis BHBIGwww.merck.com
Hepatitis BHepserawww.gilead.com
Crohn's DiseaseHumirahttps://www.humira.com/
PsoriasisHumirahttp://www.accessdata.fda.gov
Rheumatoid Arthritis (RA)Humirahttps://www.humirapro.com
OsteoarthritisHyalganhttp://www.hyalgan.com
Cystic FibrosisHyper-Sal 7%www.pari.com
HIV/AIDSIntelencewww.intelence.com
Mental HealthInvega Sustennawww.invegasustenna.com
HIV/AIDSInvirasewww.gene.com
HIV/AIDSIsentresswww.isentress.com
HIV/AIDSKaletrawww.kaletra.com
Cystic FibrosisKalydecowww.kalydeco.com
Rheumatoid Arthritis (RA)Kineretwww.kineretrx.com
AnemiaLeukinehttp://www.leukine.com
HIV/AIDSLexivawww.viivhealthcare.com
Irritable Bowel Syndrome (IBS)Linzesswww.linzess.com
AnticoagulantLovenoxhttp://products.sanofi.us
EndometriosisLupaneta Packwww.lupanetapack.com
EndometriosisLupron Depotwww.lupron.com
Preterm birthMakenahttp://www.makena.com
Opioid-Induced Constipation (OIC)Movantikwww.movantik.com
Organ TransplantMyfortichttps://www.pharma.us.novartis.com
Organ TransplantNeoralhttps://www.pharma.us.novartis.com
AnemiaNeulastahttp://pi.amgen.com
AnemiaNeumegawww.pfizer.com
AnemiaNeupogenwww.neupogen.com
Growth HormoneNordiflexwww.norditropin.com
Growth HormoneNorditropinwww.norditropin.com
HIV/AIDSNorvirwww.norvir.com
Chronic Immune Thrombocytopenic Purpura (ITP)Nplatehttp://pi.amgen.com
Growth HormoneNutropin AQwww.nutropin.com
Rheumatoid Arthritis (RA)Orenciawww.orenciahcp.com
OsteoarthritisOrthovischttps://www.depuysynthes.com
PsoriasisOtezlahttp://www.otezla.com
Rheumatoid Arthritis (RA)Otezlahttp://www.otezla.com
PsoriasisOtrexuphttp://www.otrexup.com
Rheumatoid Arthritis (RA)Otrexuphttp://www.otrexup.com
Cystic FibrosisPancreazehttp://www.pancreaze.net/
Hepatitis BPeg-Intronwww.merck.com
Hepatitis BPegasyswww.gene.com
Actinic KeratosisPicatohttp://www.picato.com
Hypercholesterolemia (HeFH)Praluentwww.praluent.com
HIV/AIDSPrezistawww.prezista.com
AnemiaProcritwww.procrit.com
Organ TransplantPrografhttps://www.prograf.com
OsteoporosisProliawww.prolia.com
Chronic Immune Thrombocytopenic Purpura (ITP)Promactahttps://www.pharma.us.novartis.com
Cystic FibrosisPulmozymewww.pulmozyme.com
Weight LossQsymiahttps://qsymia.com
Organ TransplantRapamunehttp://www.pfizer.com
Multiple Sclerosis (MS)Rebifwww.rebif.com
Opioid-Induced Constipation (OIC)Relistorwww.relistor.com
Crohn's DiseaseRemicadewww.remicade.com
Rheumatoid Arthritis (RA)Remicadehttp://www.remicade.com
Hypercholesterolemia (HeFH)Repathawww.repatha.com
HIV/AIDSRescriptorwww.viivhealthcare.com
HIV/AIDSRetrovirwww.viivhealthcare.com
Pulmonary Arterial HypertensionRevatiowww.revatio.com
HIV/AIDSReyatazwww.reyataz.com
Mental HealthRisperdal Constawww.risperdalconsta.com
Growth HormoneSaizenhttp://www.saizenus.com/
NauseaSancusowww.sancuso.com
Organ TransplantSandimmunehttps://www.pharma.us.novartis.com
Weight LossSaxendahttps://www.saxenda.com/
HIV/AIDSSelzentrywww.selzentryhcp.com
Rheumatoid Arthritis (RA)Simponihttps://www.simponihcp.com
Skin InfectionSivextrohttp://sivextro.com
Actinic KeratosisSolarazehttp://pharmaderm.com
PsoriasisStelarahttp://www.stelarainfo.com
Hypophosphatasia (HPP)Strensiqwww.strensiq.com
HIV/AIDSStribildwww.stribild.com
OsteoarthritisSupartzwww.supartzfx.com
HIV/AIDSSustivabms.com
OsteoarthritisSynviscwww.synviscone.com
OsteoarthritisSynvisc Onewww.synviscone.com
PsoriasisTaclonexhttp://www.taclonex.com
HIV/AIDSTivicaywww.tivicay.com
Cystic FibrosisTobiwww.pharma.us.novartis.com
HIV/AIDSTriumeqwww.triumeq.com
HIV/AIDSTrizivirwww.viivhealthcare.com
HIV/AIDSTruvadawww.truvada.com
HIV/AIDSTybostwww.gilead.com
Hepatitis BTyzekawww.pharma.us.novartis.com
Ulcerative Colitis (UC)Ucerishttps://www.uceris.com
HIV/AIDSVidexbms.com
HIV/AIDSViraceptwww.viivhealthcare.com
HIV/AIDSViramuneus.boehringer-ingelheim.com
Hepatitis BVireadwww.viread.com
HIV/AIDSVireadwww.viread.com
Rheumatoid Arthritis (RA)Xeljanzra.xeljanz.com
Weight LossXenicalhttp://www.gene.com
Irritable Bowel Syndrome with Diarrhea (IBS-D)Xifaxanwww.salix.com
Cystic FibrosisZenpepwww.zenpep.com
HIV/AIDSZerithttp://www.bms.com
HIV/AIDSZiagenwww.viivhealthcare.com
Organ TransplantZortresshttp://www.saveonmyprescription.com
Mental HealthZyprexa Relprevv
www.zyprexarelprevvprogram.com
AntibioticZyvoxwww.zyvox.com
X