Download and print the most commonly requested prior authorization fax forms for procedures, injectable drugs (office administered and home self-administered) and oral/topical drugs, choosing from the lists below..

Blue Shield of California Promise Health Plan, Medi-Cal and Cal MediConnect

Find authorization and referral forms

Blue Shield Medicare

Non-Formulary Exception and Quantity Limit Exception (PDF, 129 KB)

Prior Authorization/Coverage Determination Form (PDF, 136 KB)

Prior Authorization Generic Fax Form (PDF, 173 KB)

Prior Authorization Urgent Expedited Fax Form (PDF, 126 KB)

Tier Exception (PDF, 109 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

Commercial procedures / HCPCS
Actigraphy
Advanced Imaging
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Auditory Brainstem Implant
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
Bariatric Surgery
Bioengineered Skin and Soft Tissue Substitutes
Biofeedback as a Treatment of Urinary Incontinence in Adults
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)
Breast Implant Management
Cellular Immunotherapy for Prostate Cancer
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Clinical Trial (for any indication)
Computed Tomography to Detect Coronary Artery Calcification
Continuous Passive Motion in the Home Setting
Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Dental Anesthesia
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Elective Invasive Coronary Angiography (ICA)
Elective Percutaneous Coronary Intervention (PCI)
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
Esophageal pH Monitoring
External Insulin Infusion Pump
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Extracranial Carotid Artery Stenting
Functional Neuromuscular Electrical Stimulation
Gender Reassignment Surgery
Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
Gene Variants (PALB2, CHEK2 and ATM) Associated With Breast Cancer in Individuals at High Breast Cancer Risk
General Request
Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
Genetic Testing for Cardiac Ion Channelopathies
Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
Genetic Testing for Diagnosis and Management of Mental Health Conditions
Genetic Testing for Inherited Thrombophilia
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic Testing for Mitochondrial Disorders
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Home Health Care
Hyperbaric Oxygen Therapy
Hysterectomy Surgery for Benign Conditions
Implantable Cardioverter Defibrillator
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Intensity Modulated Radiation Therapy (Generic IMRT)
Intensity-Modulated Radiotherapy of the Breast and Lung
Intensity-Modulated Radiotherapy of the Prostate
Intensity-Modulated Radiotherapy: Abdomen and Pelvis
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
Intensity-Modulated Radiotherapy: Central Nervous System Tumors
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
Intraoperative Radiotherapy
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms
Knee Arthroscopy
Knee Arthroscopy in Knee Osteoarthritis
Knee Braces (Custom)
Lumbar Spine Surgery
Magnetic Resonance Spectroscopy
Magnetoencephalography/Magnetic Source Imaging
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Microprocessor Controlled Lower Limb Prostheses
Microwave and Locoregional Laser Tumor Ablation
Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Negative Pressure Wound Therapy in the Outpatient Setting
Neuropsychological Testing
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
Nonpharmacologic Treatment of Rosacea
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Orthognathic Surgery
Orthopedic Applications of Platelet-Rich Plasma
Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti
Partial Thickness Rotator Cuff Tears and Acromioplasty Subacromial Decompression
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Physical Therapy- Applies to eBay only
Pneumatic Compression Pumps for Treatment of Lymphedema and Venus Ulcers
Power Wheelchairs and Power Operated Vehicles for Permanent Use
Radiation Oncology
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Reconstructive Services
Reduction Mammaplasty
Reproductive Techniques
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Spine and Pain Management
Subtalar Arthroereisis
Surgical Deactivation of Headache Trigger Sites
Surgical Treatment of Femoroacetabular Impingement
Surgical Treatment of Gynecomastia
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Total Artificial Hearts and Implantable Ventricular Assist Devices
Total Hip Arthroplasty for Adults
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Treatment of Hyperhidrosis
Treatment of Varicose Veins Venous Insufficiency
Urgent Expedited Request
Wearable Cardioverter Defibrillators
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
Whole Gland Cryoablation of Prostate Cancer
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
Procedures for Federal Employee Program members
ABA Therapy
Actemra
Actimmune
Adcetris
Adcirca
Adempas
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Afinitor
Afrezza
Aldurazyme
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Artificial Intervertebral Disc-Cervical Spine
Artificial Intervertebral Disc-Lumbar Spine
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
Automated Percutaneous and Endoscopic Discectomy
Avastin
Axial Lumbosacral Interbody Fusion
Balloon Ostial Dilation for the Treatment of Chronic Rhinosinusitis
Bariatric Surgery
Bio-Engineered Skin And Soft Tissue Substitutes
Biofeedback
Biventricular Pacemakers for the Treatment of Heart Failure
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Bone Mineral Density Studies
Bone Morphogenetic Protein
Botox
Brachytherapy for Clinically Localized Prostate Cancer
Brachytherapy for Oncologic Indications
Cardiac Applications of Positron Emission Scanning
Cardiovascular Risk Panels
Catheter Ablation for Cardiac Arrhythmias
Cervical Spinal Fusion
Chromoendoscopy as an Adjunct to Colonoscopy
Cleft Palate Dental Related Services
Clinical Trial (for any indication)
Cochlear and Auditory Brainstem Implants
Cognitive Rehabilitation
Congenital Anomalies
Cranial Electrotherapy Stimulation
Cryosurgical Ablation of Miscellaneous Solid Tumors
Deep Brain Stimulation
Dermatologic Applications of Photodynamic Therapy
Detection of Circulating Tumor Cells
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Diagnosis and Treatment of Sacroiliac Joint Pain
Discectomy
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography
Electrical Bone Growth Stimulation
Emend
Endoscopic Injection
Endoscopic Radiofrequency Ablation
Enhanced External Counterpulsation
Entyvio
Epidural Steroid Injections for Back Pain
Epogen Procrit
Extension of Benefits
External Insulin Infusion Pump
Facet Arthroplasty
Facet Joint Denervation
Facet Joint Injections and Facet Joint Nerve Blocks
Functional Neuromuscular Electrical Stimulation
Gastrointestinal Motility and Manometry Testing
Gender Reassignment Surgery
Gene Expression Profiling for Managing Breast Cancer Treatment
General Anesthesia for Dental Procedures
General Request
Genetic Testing for Cadasil Syndrome
Genetic Testing for Colorectal Cancer
Genetic Testing for Hereditary Breast and/or Ovarian Cancer
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Hospice
Hyaluronic Acid Agents
Hyperbaric Oxygen Therapy
IMRT Abdomen and Pelvis
IMRT Breast and Lung
IMRT Central Nervous
IMRT Generic
IMRT Head and Neck or Thyroid
IVIG Immune Globulin
Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis
Immune Cell Function Assay
Implantable Cardioverter Defibrillator
Implantable Middle Ear and Bone-Anchored Hearing Aids
Implantation of Intrastromal Corneal Ring Segments
Incontinence Treatment System
Ingestible pH and Pressure Capsule
Injectable Bulking Agent
Inpatient Residential Treatment
Intraoperative Radiotherapy
KRAS, NRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer
Knee Braces
Laminectomy
Lower Limb Prostheses
Lumbar Spinal Fusion
Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
Manipulation Under Anesthesia
Medical Injectable Drug
Microprocessor-Controlled Prostheses for the Lower Limb
Miscellaneous Applications of PET
Monitored Anesthesia Care
Negative Pressure Wound Therapy in the outpatient setting
Neuromuscular and Functional Electrical Stimulation
Neuropsychological Testing
Oncologic Applications of PET Scanning
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures)
Oral Maxillofacial Procedures
Orthognathic Surgery
Orthopedic Applications of Platelet-Rich Plasma
Orthoptic Training for the Treatment of Vision or Learning Disabilities
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Diseases
Panniculectomy, Abdominoplasty and Surgical Management of Diastasis Recti
Percutaneous Vertebroplasty and Sacroplasty
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Positron Emission Tomography (PET)
Power Wheelchair
Prolia
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors
Reduction Mammaplasty for Breast-Related Symptoms
Regional Sympathetic Blocks
Remicade
Rituxan
Sacroiliac Joint Injections
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Sinuva
Skilled Nursing Facility (standard option plan ONLY)
Spinal Cord Stimulation
Surgical Treatment of Bilateral Gynecomastia
Surgical Treatment of Morbid Obesity (Benefit)
Temporomandibular Joint Dysfunction
Transcranial Magnetic Stimulation
Transurethral Radiofrequency
Treatment of Varicose Veins Venous Insufficiency
UVPP UPPP
Urgent Request for Prior Authorization
Virtual Colonoscopy Computed Tomography Colonography
Wearable Cardioverter Defibrillator
Wireless Capsule Endoscopy
Xgeva