Providers are required to provide HIRSP with various types of information. This section of the HIRSP Web site provides important forms to assist with this requirement. Forms are in PDF format for ease of printing.
| Recent Notifications/Updates | Download |
|---|---|
| 2008 HIRSP Provider Rates (xls file - 6.7 MB) | 6.7 MB xls |
| HIRSP Expanded Pharmacy Networks |
 145 KB |
| Navitus SpecialtyRx Notice |
36 KB |
| Commonly Prescribed Specialty Pharmacy Products |
56 KB |
| Applications and Enrollment | Download |
|---|---|
| HIPAA Privacy Authorization for Use or Disclosure Form |
68 KB
|
| Pharmacy Forms | Download |
|---|---|
| Formulary (Will link to Pharmacy Benefit Administrator's Web site: Navitus) | Visit Navitus |
| HIRSP Prescription Drug Claim |
24 KB |
| Commonly Prescribed Specialty Pharmacy Products |
57 KB |
| Therapeutic Interchange Reimbursement for Navitus Network Pharmacies |
220 KB |
| Common Medications Approved for Tablet Splitting by the Navitus Pharmacy & Therapeutics (P&T) Committee |
627 KB |
| Patient Referral/Medication Request Form | 216 KB |
| Prior Authorization Forms | Download |
|---|---|
| Prior Authorization Forms (Will link to Pharmacy Benefit Administrator's Web site: Navitus) | Visit Navitus |
| Prior Authorization Process (Will link to Pharmacy Benefit Administrator's Web site: Navitus) | Visit Navitus |
| Prior Authorization Form for Compounded Drugs |
23 KB
|