Special Pharmacy Network Enrollment Forms

1 Specialty Pharmacy Network SYNAGIS Enrollment Forms Specialty Pharmacy Link Link toto Enrollment Enrollment form form Specialty Pharmacy Portal AcariaHealth (including Exactus SP) Enrollment Enrollment form form Click Here Accredo Enrollment Enrollment form form Click Here Advance Pharmacy Solutions Enrollment Enrollment form form Alliance/ walgreens / prime alliancerx walgreens prime Enrollment Enrollment form form Amber Specialty Pharmacy Enrollment Enrollment form form CVS Specialty Pharmacy Enrollment Enrollment form form Duncan Specialty Pharmacy Enrollment Enrollment form form Elixir Specialty Pharmacy Enrollment Enrollment form form Exactus Specialty Humana SpecialtyPharmacy Pharmacy Enrollment Enrollment form form HumanaPharmacy Hy-Vee Specialty Solutions Pharmacy Enrollment Enrollment form form Hy-Vee Pharmacy Lumicera SpecialtySolutions Pharmacy Enrollment Enrollment form form Lumicera Specialty Pharmacy Magellan Enrollment Enrollment form form Magellan Optum Specialty Specialty Pharmacy Pharmacy Enrollment Enrollment form form Optum Specialty

2 Perform RX Specialty Pharmacy Pharmacy Enrollment Enrollment form form Perform US Bioservices RX Specialty Specialty Pharmacy Pharmacy Enrollment Enrollment form form Click Here US Bio Vital Care Specialty Specialty Pharmacy Pharmacy Enrollment Enrollment form form Click Here Vital Care (State Specialty of LA. Pharmacy only) Enrollment Enrollment form form Walmart Specialty Pharmacy Enrollment Enrollment form form SYNAGIS Copay Enrollment Enroll here! Parent/Caregiver HIPAA Consent form Parent/Caregiver Consent Form If you have questions, call SYNAGIS CONNECT at 1-833-SYNAGIS (1-833-796-2447) or contact your Field Reimbursement Senior Manager. Sobi, Inc., and SYNAGIS CONNECT do not guarantee coverage or reimbursement for SYNAGIS. This document is designed to provide general guidance and offer direction. Coverage and reimbursement decisions are made by insurance companies following the receipt of claims.

3 A Benefits Investigation is required to determine if SYNAGIS is processed as a Pharmacy or medical benefit. SYNAGIS CONNECT is a registered trademark of Arexis AB c/o Swedish Orphan Biovitrum AB (publ). 2021 Swedish Orphan Biovitrum. All rights reserved. PP-12308 08/21. SYNAGIS and SYNAGIS CONNECT are registered trademarks of Arexis AB c/o Swedish Orphan Biovitrum AB (publ). 2021 Swedish Orphan Biovitrum. All rights reserved.