Prior authorization forms

Download and print the most commonly requested prior authorization fax forms for commercial and FEP procedures, injectable drugs (office administered and home self-administered) and oral/topical drugs, choosing from the lists below. You need Adobe Reader to view the forms.

Blue Shield 65 Plus forms

Prior Authorization/Coverage Determination Form (PDF, 125 KB)

Prescription drug prior authorization and step therapy exception request forms

Office drugs prior authorization request (PDF, 301 KB)

Home Self-Administered Injectable Drug authorization request (PDF, 288 KB)

Oral/Topical Drugs (PDF, 288 KB)

Procedure authorization request forms