Forms and Documents for Protopic
We've provided a number of different forms and letters to help you.
Forms for Benefit Verification and Patient Assistance Requests are no longer available on this site. For your convenience Benefit Verification Requests and Patient Assistance Requests can now be submitted conveniently online via Astellas eService
If you don't see a form you need, please contact us at 1-800-477-6472.
- Blue Cross Blue Shield of Florida Prior Approval Form (PDF - 306 KB)
- Illinois Medicaid Prior Authorization Form (PDF - 718 KB)
- Kentucky Spirit Prior Approval Form (PDF - 39 KB)
- Patient Authorization to Disclose Health Information (HIPAA) (PDF - 123 KB)
- Sample Letter of Medical Necessity (PDF - 191 KB)
- Sample Letter of Denial Appeal (PDF - 219 KB)
- Sample Letter of Medicare Carrier Advisory Letter (PDF - 197 KB)
- Wellcare Prior Approval Form (PDF - 48 KB)
Some forms and documents provided on this Web site are not the property of Astellas Pharma US, LLC, and may be subject to change.
