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1. Select Form

There are two ways a request can be created:

  • Drug Specific Form - These forms will ask you a few questions about the drug. Completion of this form makes it more likely your request will be reviewed accurately and quickly. It is highly recommended to complete this form where available.
  • General Form - Can be used for any drug, but does not ask any drug specific questions.


2. Complete Form


Each form will require some basic information (patient name, DOB, prescriber, pharmacy). 

  • Drug Specific Form - Medical records are not required, but highly recommended to be submitted with the request.
  • General Form - Some type of documentation will be required with the request.


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