WebSep 14, 2024 · Members can obtain mail order forms for maintenance drugs by calling the Member Service telephone number on their ID card. Once a member places an order, the member's information remains on file. Any subsequent refills do not require an order form. WebHome ... Live Chat

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WebProvider Forms, select . Miscellaneous Forms, and then select the form titled . Request for Non-Formulary Drug Coverage. Table 3. Additions to the Specialty Tier Copay Option . Note: The specialty tier does not apply to Highmark Delaware Healthcare Reform members; see Highmark Delaware’s online Provider Resource Center and access the Pharmacy 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 desert willow potted plant

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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 WebJun 2, 2024 · A Highmark prior authorization form is a document used to determine whether a patient’s prescription cost will be covered by their Highmark health insurance plan. A physician must fill in the form with the … WebSpecialty Pharmacy Network To help keep prescription drug costs affordable for our … desert willow trees for sale