Specialty Pharmacy Management

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Our Specialty Pharmacy

Benefits for Providers

Condition Specific Programs

Provider Frequently Asked Questions (FAQ)

Ordering Specialty Medications

Prior Authorization

Enrollment Fax Forms

Medical Assistance Program

Specialty Drugs We Dispense

Enrollment Fax Forms

Enrollment Fax Forms

Generic Order Form (PDF)

Acthar Enrollment Form (Microsoft Office Word file)

Aldurazyme Enrollment Form (Microsoft Office Word file)

Alpha1 Proteinase Inhibitor Enrollment Form (Microsoft Office Word file)

Avastin Enrollment Form (Microsoft Office Word file)

Bleeding Disorder (Microsoft Office Word file)

Botulinum Toxin Enrollment Form (Microsoft Office Word file)

Cerezyme Enrollment Form (Microsoft Office Word file)

Cimzia Enrollment Form (Microsoft Office Word file)

Cytogam Enrollment Form (Microsoft Office Word file)

Fabrazyme Enrollment Form (Microsoft Office Word file)

Fertitlity Enrollment Form (Microsoft Office Word file)

Nutropin Patient Authorization and Notice of Release of Information (PDF)

Genotropin Patient Authorization Form (PDF)

Hepatitis C (Microsoft Office Word file)

Herceptin Enrollment Form (Microsoft Office Word file)

Hyaluronan Injection (Microsoft Office Word file)

Intravenous Immune Globulin (Microsoft Office Word file)

Letairis Enrollment Materials (PDF)

Lupron Enrollment Form (Microsoft Office Word file)

Macugen Lucentis Enrollment Form (Microsoft Office Word file)

Mirena Enrollment Form (Microsoft Office Word file)

Multiple Sclerosis (Microsoft Office Word file)

Myozyme Enrollment Form (Microsoft Office Word file)

Orencia Enrollment Form (Microsoft Office Word file)

Prialt Enrollment Form (Microsoft Office Word file)

Remicade Enrollment Form (Microsoft Office Word file)

RSV Prophylaxis Enrollment Form (Microsoft Office Word file) If you are a provider or member in California, please visit the list of pre-service medical review request forms on the provider section of bluecrossca.com to access the appropriate RSV Prophylaxis Enrollment Form.

Simponi Enrollment Form (Microsoft Office Word file)

Synagis Refill Form (Microsoft Office Word file)

Transplant (PDF)

Tysabri Enrollment Form (Microsoft Office Word file)

Vivaglobin Enrollment Form (Microsoft Office Word file)

Xolair Enrollment Form (Microsoft Office Word file)