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 PDF Icon 145 KB
Navitus SpecialtyRx Notice PDF Icon 36 KB
Commonly Prescribed Specialty Pharmacy Products PDF Icon 56 KB
Applications and Enrollment Download
HIPAA Privacy Authorization for Use or Disclosure Form PDF Icon 68 KB
Pharmacy Forms Download
Formulary (Will link to Pharmacy Benefit Administrator's Web site: Navitus) Visit Navitus
HIRSP Prescription Drug Claim PDF Icon 24 KB
Commonly Prescribed Specialty Pharmacy Products PDF Icon 57 KB
Therapeutic Interchange Reimbursement for Navitus Network Pharmacies PDF Icon 220 KB
Common Medications Approved for Tablet Splitting by the Navitus Pharmacy & Therapeutics (P&T) Committee PDF Icon 627 KB
Patient Referral/Medication Request Form PDF Icon 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 PDF Icon 23 KB